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Purpose The purpose of this paper is to determine the food safety knowledge and practices of the Iranian consumers and also its association with socio-demographic characteristics. Design/methodology/approach In the present cross-sectional and population-based study, the validated food safety questionnaires applied to 1,500 participants who were selected through multistage stratified cluster sampling from the capital city and regional area of East-Azerbaijan – Iran. The Student t-test and analysis of variance and linear regression were used for statistical analysis. Findings Although the overall percentages of mean score for knowledge (77.66 percent) and self-reported practice (70.77 percent) were good, there was a low level of awareness and self-reported practice in some subsections such as optimal heating/cooling temperature, proper thawing techniques and eating raw egg. Female and married respondents had significantly higher mean knowledge score than males (pp=0.04). Residents of regional areas acted more safely than capital city residents (p=0.01). Research limitations/implications Despite the good knowledge of some respondents regarding food safety, their food safety practices were poor. It can thus be suggested that the future studies have better focus on investigating the perceived barriers of consumers about food safety practices. Practical implications Although the mean knowledge and practice regarding food safety of Iranian consumers was good, yet there is the lack of knowledge and practice on some important factors related to food poisonings such as eating raw or lightly cooked egg or improper heating/thawing practices. So, it is important to develop proper food safety education programs emphasizing on these issues. According to lower food safety knowledge and practice of low-educated, single and male respondents, the educational programs should mainly focus on these groups. Originality/value For the development of effective food safety education programs in Iran, learning about the basic knowledge and practice of consumers is essential; however, there is limited data that directly tackles this issue in Iran.

This study investigated public trust in health services in Tabriz, Islamic Republic of Iran. A crosssectional household study was conducted in 2014, using random cluster sampling. A total of 1050 households were enrolled in the study and a valid questionnaire was used to collect data through interviews. The mean score for public trust in health services in Tabriz (out of 100) was 53.91 ± 13.7. People had most trust in professional expertise and lowest in macro-level policy. Specialists, pharmacy doctors and nurses were the health providers that enjoyed the highest levels of trust. It is concluded that public trust in health services in Tabriz is low and policy-makers need to employ appropriate policies to improve patients' experience of health services.ثقة الجمهور بالخدمات الصحية في تبريز بجمهورية إيران الإسلامية.جعفر صادق تبريزي، محمد سعادتي، همايون صادقي- بازركاني، ليلى عابدي، رقية علي بابائي.لقد استقصت هذه الدراسة ثقة الجمهور بالخدمات الصحية في تبريز بجمهورية إيران الإسامية. حيث أجريت دراسة أسَيّة مقطعية في عام 2014 ، استُخدم فيها اختبار العينة العنقودي العشوائي. وقد سُجِّل في الدراسة ما مجموعه 1050 أسرة، واستُخدم استبيان ذو مصدوقية لجمع البيانات عن طريق إجراء مقابات. فكان متوسط الدرجات المحرزة بخصوص ثقة الجمهور بالخدمات الصحية في تبريز 53.91 ± 13.7 (من كل 100). وقد منح الناس أعى درجات الثقة للخرة المهنية وأدنى الدرجات لسياسات الصعيد الكلي. وكان الاختصاصيون ودكاترة الصيدلة والممرضات مقدمي الرعاية الصحية الذين تمتعوا بأعى مستويات الثقة. يستنتج من ذلك أن ثقة الجمهور بالخدمات الصحية في تبريز منخفضة، وأن صانعي السياسات بحاجة إلى توظيف سياسات مناسبة لتحسن معاناة المرضى من الخدمات الصحية.Confiance du public iranien dans les services de santé : données recueillies à Tabriz (République islamique d'Iran).La présente étude visait à étudier la confiance du public dans les services de santé de Tabriz, en République islamique d’Iran. Une étude transversale des ménages a été conduite en 2014, à l’aide d’un sondage aléatoire par grappe. Un total de 1050 ménages ont participé à l’étude, et un questionnaire validé a été utilisé pour collecter des données au cours d’entretiens. Le score moyen de la confiance du public dans les services de santé à Tabriz (sur un échantillon de 100 individus) était de 53,91 ± 13,7. Les individus faisaient davantage confiance à l’expertise professionnelle et se fiaient moins aux politiques concernant les soins de santé dans leur ensemble. Les spécialistes, les docteurs en pharmacie et les personnels infirmiers étaient les prestataires de santé qui jouissaient des taux de confiance les plus élevés. En conclusion, on peut dire que la confiance du public dans les services de santé à Tabriz est basse et que les responsables politiques doivent recourir à des politiques appropriées pour améliorer l’expérience des services de santé vécue par les patients.

Background: program evaluation is an integral and expected component in the development of any healthcare program. It helps decision-makers to base their decisions on facts. Objective: This paper analyzes the effect of accreditation on three indicators related to patient safety and hospital care quality in ICU wards of an Iranian teaching hospital. Methods: This interventional study was accomplished based on executive management and scientific methods such as plan-do-check-act (PDCA) cycle and audit to improve quality and safety. We used data reported from ICU wards of the hospital to analyze the effect of accreditation on the three selected indicators. (SPSS) version 22.00 was used for the statistical analysis. Results: In total, 6997 patients were analyzed. The accreditation interventions appeared to be effective at reducing pressure ulcer incidence average (from an average of 6.8 percent to 4.1 percent) (p=0.045). The accreditation also. The average stay of the patients during the study also positively changed from an average of 1.58 days to 10.13 days (1.45 improvements)(p=0.0303). In relation to hospital acquired infection but, unexpectedly, its effect on hospital was negative, then it considerably increased and rose from 1.5 percent to 8.1 percent (p=0.001). However this increasing was due to enhanced infection incident report system. Conclusion: hospital accreditation has presented ample opportunity a significant positive effect on hospitals.

Objective: The relationship between serum 25-hydroxy-vitamin D and within normal range liver enzymes in a population-based study in the northwest of Iran was investigated. Method: This cross-sectional study was comprised of 700 apparently healthy Iranian adults (287 men & 413 women) who participated in the major lifestyle promotion project (LPP) conducted in East Azarbaijan-Iran in 2015. The ultraviolet method and chemiluminescent immunoassay technology were respectively used for determination of the serum levels of liver enzymes (alanine aminotransferase (ALT) and aspartate aminotransferase (AST)) and 25-hydroxy-vitamin D. The one-way ANOVA and the linear regression analysis were used for statistical analysis. Results: There were not significant differences in mean ALT and AST levels regarding different serum 25-hydroxy- vitamin D status. In the unadjusted model, serum 25-hydroxy-vitamin D was significantly associated with ALT (p = 0.008). The participants in the fourth quartile of 25-hydroxy-vitamin D had significantly higher level of ALT compared with participants in the first quartile (p = 0.002). After adjustment for age, sex, BMI, waist circumference, fasting blood glucose, lipid profile, and dietary vitamin D, this association remained significant. For AST, in the unadjusted model, the association between serum 25-hydroxy-vitamin D and AST was marginally significant (p = 0.08). The participants in the third quartile of 25-hydroxy-vitamin D had significantly higher levels of AST compared with participants in the first quartile (p = 0.01). Conclusion: According to results, there was a positive association between 25-hydroxy-vitamin D and ALT in individuals without liver diseases. Additional prospective studies were needed to confirm this observation and also elucidate the underlying mechanisms.

Background and Objectives: Monitoring of health organizations by the regulatory bodies is crucial to ensure high performance of health system. Although Iranian health settings are monitored by the MOHME in various ways, periodic evaluation of their continuous commitment to the national licensure standards in health domain is rare. The aim of the present study was to highlight the important of such evaluations by auditing the general health clinics of Tabriz (a metropolitan city in Northwestern Iran) based on national licensure standards. Methods: This across-sectional study surveyed all general health settings in Tabriz city. The data were collected using a validated researcher-made checklist. The collected data were summarized using descriptive statistical methods. The mean values were compared by t-test and ANOVA. Findings: The score of compliance to national licensure standards averaged at 70.5%. The highest level of compliance was observed for medical and non-medical devices dimension (78.2%) whereas the loest compliance was recorded for hygiene dimension (58.4%). Public clinics showed a significantly higher compliance to standards compared to the private settings (P and Conclusions: The level of current compliance of the surveyed clinical settings shows room for considerable improvement. Private health settings and the hygiene domain are the primary targets of focus for monitoring and intervention. Our results encourage further national-wide studies to gain a comprehensive view of the compliance of Iranian clinics to the licensure standards.

Background: Healthy City and Safe Community programs are the most common initiatives gaining increasing appeal in various communities to improve safety and health, independently. The aim of this study is to develop a joint application model of safe community and healthy city. Here, we have tried an applied model development effort. Methods: A comprehensive literature review was conducted on healthy city and safe community programs in 2018. The preliminary list of joint model dimensions and topics were extracted and then assessed by the experts. Eventually, the visual model was developed and approved by the experts. Results: Totally, 35 safety and health promotion topics were extracted. After investigating the topics accordance, they were assessed by experts via two-rounds of Delphi study and panel sessions. Eventually a joint model comprising 14 dimensions, 3 core principles and 4 values called Safe and Health Promoting Community, SHPC_ model was developed. Conclusions: SHPC model provides a parallel and comprehensive view on safety and health topics in a community. The implementation of an integrated model could be one possible way to enhance the commitments on behalf of state and local government, and health system leaders to prioritize injuries and non-communicable disease prevention to address promotion, prevention, treatment and social consequences of mutual community-based interventions. Keywords: Safe Community, Healthy City, Joint application Model

ObjectiveThe aim of this study was to describe health services utilisation and responsiveness in East Azerbaijan province, Iran.DesignA cross-sectional household study as part of a larger research on primary healthcare system.SettingWe carried out the study in East Azerbaijan Province, northwest Iran from July to September 2015.ParticipantsA total of 1318 households were included.ResultsMost of the participating households had social security health insurance. Heart failure or hypertension care, general outpatient care and arthritis care were the most used services. High services cost and inadequate medicine and medical equipment were introduced to be the main barriers to health services utilisation in Tabriz and province representative sample (PRS), respectively. Health system responsiveness mean score (the maximum is 100) was 33.71±16.15 (95% CI 32.45 to 34.97) in Tabriz and 32.02±14.3 (95% CI 30.9 to 33.13) in PRS, which showed significant difference (p≤0.02).ConclusionsDifferences in the utilisation and responsiveness of health services and distribution of health resources were observed between Tabriz and PRS. Evidently, health system responsiveness in both Tabriz and PRS was at low level. The results demonstrate the need for changing resource distribution policies and employing reactive health policies to response the public health.

Objectives In this study, the effects of food supplementation during pregnancy on maternal weight gain, hemoglobin (Hb) levels, and pregnancy outcomes were evaluated. Methods In this randomized controlled trial, we recruited 1360 pregnant women with a gestational age of 10 weeks who had BMI

Background: In 2015, it was estimated that the burden of disease in Iran comprised of 19 million disability-adjusted life years (DALYs), 74% of which were due to non-communicable diseases (NCDs). The observed leading causes of death were cardiovascular diseases (41.9%), neoplasms (14.9%), and road traffic injuries (7.4%). Even so, the health research investment in Iran continues to remain limited. This study aims to identify national health research priorities in Iran for the next five years to assist the efficient use of resources towards achieving the long-term health targets.Methods: Adapting the Child Health and Nutrition Research Initiative (CHNRI) method, this study engaged 48 prominent Iranian academic leaders in the areas related to Iran's long-term health targets, a group of research funders and policy makers, and 68 stakeholders from the wider society. 128 proposed research questions were scored independently using a set of five criteria: feasibility, impact on health, impact on economy, capacity building, and equity.Findings: The top-10 priorities were focused on the research questions relating to: health insurance system reforms to improve equity; integration of NCDs prevention strategy into primary health care; cost-effective population-level interventions for NCDs and road traffic injury prevention; tailoring medical qualifications; epidemiological assessment of NCDs by geographic areas; equality in the distribution of health resources and services; current and future common health problems in Iran's elderly and strategies to reduce their economic burden; the status of antibiotic resistance in Iran and strategies to promote rational use of antibiotics; the health impacts of water crisis; and research to replace the physician-centered health system with a team-based one.Conclusions: These findings highlight consensus amongst various prominent Iranian researchers and stakeholders over the research priorities that require investment to generate information and knowledge relevant to the national health targets and policies. The exercise should assist in addressing the knowledge gaps to support both the National General Health Policies by 2025 and the health targets of the United Nations' Sustainable Development Goals by 2030.

Background Flat capitations are not necessarily able to compensate health providers equitably due to the variability of resource consumption among different age and sex groups. The aim of this study is to develop a risk adjusted capitation formula as a base for primary health care payment in Health Complexes of Tabriz, in Iran. Method This cross-sectional study was conducted in four stages: (1) determining health service package, (2) calculating unit cost of services, (3) estimating service utilization, and (4) calculating age/sex weighted capitation. We calculated unit cost of services with and without building and equipment expenses. Data collection was carried out through a data extraction checklist. Data management and analysis was carried out via Microsoft Excel 2007. Result A list of 99 services and their processes were identified and then assigned each to one of 10 categories according to their resource consumption. The lowest and highest unit cost, respectively, belonged to prenatal care and group training by family physicians. The risk adjusted capitation was calculated with and without renting cost of building and equipment, respectively, 347 000 and 332 000 Rials (1 US$ worth 35 000 Iranian Rials). Conclusion The development of health risk adjusted capitation could improve equity in payment system and the efficiency of delivering primary health care services. Estimated weights proposed with our study can be adapted then applied in contexts with similar characteristics.

Aim To improve the medical waste management (MWM) standards in Tabriz community health centers (CHCs) through clinical audit process. Background Management of medical waste is not only a legally necessity but also a social responsibility in health systems. Owing to the potential risks for human health and environmental impacts, MWM is a global concern. Methods This was an interventional research designed using clinical audit cycle that was implemented in Tabriz CHCs in 2016. MWM was assessed through observation, as well as reviewing relevant documents and interviews with waste workers in CHCs and completion of a researcher-made checklist. Intervention plans were developed and implemented based on the assessment results. To analyze the data, Excel 2016 software was used and information was reported as descriptive statistics through comparison of standards adherence before and after the interventions. Results Generally, 30% improvements in MWM standards adherence were experienced (45.8–75.1%) in the CHCs, after the interventions. The greatest improvement was observed in the dimensions of management and education, and separation and collection of medical waste, up to 30 and 28.5%, respectively. Conclusions As the results demonstrated, standards of MWM processes were improved in Tabriz CHCs, due to the intervention. Moreover, it was experienced that using systematic method, stakeholders’ participation and evidence-based planning would lead to process improvement. MWM was an ignored issue in primary care that must be more in attention.

Utilization is one of the dimensions of equity in health systems. Identifying the factors affecting utilization of health services can be helpful for interventional purposes. This study systematically reviewed the factors affecting the utilization of inpatient, outpatient, diagnostic, and pharmaceutical services. This systematic review was conducted between 2016 and 2017. The search was performed using keywords based on MeSH in valid databases such as Scopus, Embase, ProQuest, ScienceDirect, PubMed, and Web of Science in the fields of title, abstract, and keyword. Related papers published from 2000 to 2017 were searched. First, the retrieved studies were screened and checked for quality; then, the useful data were extracted and analyzed. Out of the 1178 retrieved publications, 20 studies were included in the final analysis. The identified factors were categorized into 5 areas, including demographic (4 items), socioeconomic (13 items), health services–related (13 items), health status–related (7 items), and health insurance–related factors (2 items), and reported. The findings of this study can be a useful source and a comprehensive body of evidence on the utilization of health services. The results can be used by the policy makers and managers in designing interventions for changing the utilization patterns of health services. [GMJ.2019;8:e1236]

Background and Purpose: The emergency severity index (ESI) triage system has been recommended by the Ministry of Health to classify patients at emergency departments. This study aimed to assess the validity of ESI system (version 4) in the emergency department of a teaching hospital. Outcome measures were hospitalization, emergency department (ED) length of stay, resource consumption, in-hospital mortality, and patient service costs. Methods: In this retrospective cross-sectional study, medical records of 562 ED patients were reviewed to determine the ESI level and outcome measures in April 2013. Possible correlations were assessed using Phi and Cramer's V and Spearman's Rho. Data analysis was performed in SPSS V.16, and P value of 0.05 was considered significant. Results: In this study, frequency of five ESI levels (1-5) was 24, 14, 365, 158 and 0, respectively. In addition, Phi and Cramer's V for hospitalization and mortality were 0.350 (P

Purpose – Clinical governance (CG) was used as a driver to improve safety and quality of healthcare. CG implementing is a change in health system and all the stakeholders must be participating. The purpose of this paper is to study nurses’ experience about CG movement in Tabriz hospitals. Design/methodology/approach – A qualitative study using Focus Group Discussions (FGD) was done. Purposeful Sampling was used to select the objectives including 65 participants. Actually seven FGD’s were held. Content analysis was used to extract the meaningful themes. Findings – It is revealed that nurses are the focal point in CG implementation in hospitals. Low commitment of managers and lack of physicians’ contribution was experienced by nurses. However, personnel education and development and patient safety have got more attention. Blame culture and increased work stress was reported as challenges. Originality/value – CG as a change in healthcare system, especially in low- and middle-income countries, is faced by several challenges and its implementation would have different experiences. Nursing staff, the major group in hospitals, would be having interesting experiences through CG. Their practical opinions could guide the policy makers to employ proper plans to effectively implement CG. Considering the result of this study in practice would lead to improve CG implementation.

​Background and objectives : Quality in health care has three main dimensions: Technical Quality, Service Quality and Customer Quality. This study aimed to assess the quality of delivered maternity care based on Comprehensive Quality Measurement in Health care (CQMH) model. Material and Methods : This cross-sectional study was conducted with the participation of 185 pregnant women in their ninth month of pregnancy who were receiving maternity care from urban health centers and health posts in Tabriz in 2011. All participants were selected randomly from 40 health centers and health posts. Data were collected using researcher-made questionnaire which its validity was reviewed and confirmed by 10 experts and its reliability was confirmed according to Cronbach's alpha index (Service Quality (SQ); α = 0.85, Technical Quality (TQ); α = 0.77, Customer Quality (CQ); α = 0. 71). Final scores for each dimension were referred on a 0-100 scale with high values indicating better quality. Independent Samples Test and ANOVA followed by Tukey HSD Post Hoc Test were conducted to compare CQ, SQ, TQ and QI score between categorical variables. Data were analyzed using SPSS-17 statistical package. Results : The average Quality Index was 58.59 of a 0-100 scale and average SQ, TQ, CQ scores were 75.3, 40.54, and 67.79 respectively.The results regarding customer quality indicated that the majority of the mothers remained in active participation and taking action phase. There was a significant gap between received maternity care and recommended standards. The quality of inter-personal and non-technical aspects of prenatal care was poor. Conclusion : Quality Index indicates that the current situation was worrying about quality of care from the patients’ perspective. Empowering pregnant women by engaging them in the service delivery process and decision-making can promote customer quality and pregnant women’s ability to take good decisions and good action and improve other aspects of quality.

Introduction: Higher education institutions are expected to clarify their educational quality, and there should be an educational quality assurance system that measures the aspects of quality institutions. Educational evaluation is a formal process that uses data collection and program assessment to evaluate the effectiveness and/or value of an educational organization, program, process and curriculum. There are many different models and approaches used to evaluate higher education all over the world, and countries often adopt or develop these models to evaluate educational performance. The purpose of this study is to examine types of evaluation and audit models in educational settings all over the world. Method: A systematic review was conducted from March to May 2014 using two search engines, Google Scholar and PubMed, and three databases, Scopus, ScienceDirect and Emerald Insight, to search for articles with no study design limitation. We also searched the Scientific Information Database and Magiran databases for Iranian articles. We used a list of key words: evaluation, audit, educational audit, educational evaluation, academic evaluation, academic audit, model, method, education, college, school, department, university, higher education institution and mixed them with "AND" and "OR" as a search strategy. Result: Thirty-two papers completely related to the research questions were finally studied. Results showed that educational evaluation is done at these levels: university, school/college or institution, department or group, educational program or curriculum, course evaluation and practice placement or training evaluation. For each level there are some researcher-developed models or pre-determined models that the authors applied. The majority of studies focused on the college and school level, but in Iran the departmental level was the most important. Conclusion: The quality evaluation criteria, procedures and indicators should be student centered, and reflect the institutional mission and values. Institutions can adopt models of evaluation that exist and use benefits of these or develop a model.

Objective To study the effects of customer self-audit on the service quality (SQ) and customer quality (CQ) of maternity care. Design A community-based cluster-randomized controlled trial. Setting Twenty-one health centres and health posts in Tabriz, Iran. Participants Of 21 health centres/health posts, 10 were randomly assigned to the intervention group and 11 randomly assigned to the control group. Participants were 185 pregnant women selected from health centre/post registration lists (intervention group: n = 92; control group: n = 93). Interventions The intervention was a customer self-audit based on the CenteringPregnancy® model of prenatal group care. The intervention group attended group support sessions focused on participants’ opinions, questions, and self-management concerns. They also received sessions on experiential learning, coping, problem-solving, and goal-setting by a family health expert, a midwife, and a doctor. Control group participants continued to receive individual care. Primary outcome measures SQ and CQ were assessed using questionnaires. Patients rated the importance and performance of non-health quality dimensions. SQ was calculated as: SQ = 10 − (Importance × Performance). Results Total mean SQ scores were 7.63 (0.91) and 8.91 (0.76) for the control and intervention groups, respectively, a statistically significant difference (p

Despite the growing trend of the safe community movement in the world, very limited evidences have addressed its challenges and sustainability factors. This study aimed to qualitatively investigate the safe community movement in Iran based on the experts’ opinion. Using qualitative approach, an open-ended goal-driven questionnaire was used for data collection filled by countrywide safe community experts (n=8) in 2016. Moreover, 2 in-depth interviews were done. Study participants were selected using cherry picking method, firstly, and then we used snowball method to identify the SC experts in the country. Content analysis method was used for themes extraction. It was discussed that beside the increasing tendency to join the safe communities’ network, communities must pay more on the main goal of safety promotion. Lack of national attitude, unclear inter-sectoral collaborations, high turnover of city managers and weak community participation were raised as safe community challenges in Iran. Moreover, longterm planning, country-wide policymaking and improving public participation were discussed as the main sustainability factors of a safe community. Despite the growing trend of SC movement in Iran, like other developing countries, it was faced with a chain of challenges including weak inter-sectoral collaboration, funding problems, political support and other factor. The results provide useful information for other countries, especially Low and Middle income countries, to adapt their local policies to effective safe community movement leading. Keywords

Objective This study has been designed and conducted to develop domestic indicators for evaluating the performance of clinical governance in dimensions of risk management and clinical effectiveness. Design This study implemented a 5-stage process including conducting a comprehensive literature review, expert panel (∼1000 h per person per session, 11 experts), semi-structured interviews, a 2-round Delphi study (33 experts were in attendance) and a final expert panel (8 experts were in attendance). Setting East Azerbaijan-Iran Province. Participants Fifty-six specialists and experts in different fields of medical sciences. Main Outcome Measures Importance and applicability of indicators. Results Using a thorough literature review, 361 indicators (129 risk management indicators in 4 dimensions and 232 clinical effectiveness indicators in 18 dimensions) were found. After conducting expert panels and interviews, the number of indicators decreased to 168 cases (65 risk management indicators in 4 dimensions and 103 clinical effectiveness indicators in 12 dimensions). Two rounds of Delphi identified four indicators that were omitted. The members of the final expert panel agreed on 113 indicators (43 risk management indicators in 4 dimensions and 70 clinical effectiveness indicators in 11 dimensions). Conclusion In this study, indicators for assessing clinical governance in domains of risk management and clinical effectiveness were designed that can be used by policy-makers and other authorities for improving the quality of services and evaluating the performance of clinical governance. Those indicators can be used with slight modifications in other countries having healthcare systems similar to that of Iran.

Background: The safe community initiative was developed by the World Health Organization following the increasing trend in the frequency of injuries. Similar to most countries, it was implemented in Iran to improve community safety. The aim of this study was to quantitatively analyze the Iranian designated safe communities. Methods: Using a descriptive design, this study analyzed the reports by Iranian designated safe communities (n, 33) in 2016. Data were extracted from the website of WHO collaborating centre on community safety promotion in Sweden, using an objective-based questionnaire. Microsoft Access 2010 was used for data management, and SPSS version 21 was utilized for data analysis. Results: The Iranian designated safe communities were all located in 3 out of 31 provinces of Iran, namely Tehran, Fars, and Khorasan Razavi. All the safe communities had covered traffic safety. In total, 69.7% of the safe communities reported the incorporation of occupational and sport safety activities, as well as violence and suicide prevention interventions. No significant difference was found among provinces in the frequency distribution of improved safety issues (P > 0.05). Moreover, 26 (78.8%) communities reported having an injury surveillance system. Conclusions: Iranian safe communities used a set of strategies to improve community safety. Accordingly, the neglected areas must be acknowledged by other interested communities. Moreover, rigorous scientific studies are required to assess the effectiveness of interventions.

To investigate managerial barriers and challenges facing East Azerbaijan Province health system.This qualitative study was conducted in Tabriz, Iran, from August 2014 to August 2015, and comprised professionals, experts and informants working at the East Azerbaijan Health Centre. Data was collected through focus group discussions and semi-structured, face-to-face, individual and group interviews were conducted. Interviews and focus group discussions were taped, transcribed and analysed using content analysis method..Of the 46 participants, 29(63%) were male and 17(37%) were female. Moreover, 15(33%) participants were head of their respective units and 8(17%) were district health managers. Managerial barriers witnessed during the study period differed between the three managerial levels of interest, i.e., district health centres, provincial health centre departments and top levels of provincial health centre and macro-management systems outside the health centre. Lack of management training, inadequate resources, unclear duties and responsibilities were considered to be the most common barriers facing district health centres. Unclear budgeting mechanisms, instability of management positions and shortage of trained staff on provincial and district levels were reported to be managerial barriers in provincial health centre departments. Political interference in technical decisions, treatment-based approaches, lack of clear career paths on all levels of health system management, unnecessary bureaucracy lying within inter-organisational relationships and ineffective employment legislation were identified as managerial barriers on top levels of the provincial health system and in macro-management systems independent of the health system.Diverse challenges influenced the performance of health managers.

Introduction Evidence-based medicine (EBM) has emerged as an effective strategy to improve health care quality. The aim of this study was to systematically review and carry out an analysis on the barriers to EBM. Methods Different database searching methods and also manual search were employed in this study using the search words (‘evidence-based’ or ‘evidence-based medicine’ or ‘evidence-based practice’ or ‘evidence-based guidelines’ or ‘research utilization’) and (barrier* or challenge or hinder) in the following databases: PubMed, Scopus, Web of Knowledge, Cochrane library, Pro Quest, Magiran, SID. Results Out of 2592 articles, 106 articles were finally identified for study. Research barriers, lack of resources, lack of time, inadequate skills, and inadequate access, lack of knowledge and financial barriers were found to be the most common barriers to EBM. Examples of these barriers were found in primary care, hospital/specialist care, rehabilitation care, medical education, management and decision making. The most common barriers to research utilization were research barriers, cooperation barriers and changing barriers. Lack of resources was the most common barrier to implementation of guidelines. Conclusion The result of this study shows that there are many barriers to the implementation and use of EBM. Identifying barriers is just the first step to removing barriers to the use of EBM. Extra resources will be needed if these barriers are to be tackled.

Purpose – Clinical governance should be based on cultural elements that value lifelong learning, skill development and research. The purpose of this paper is to introduce a set of indicators to improve educational governance in hospitals. Design/methodology/approach – Key indicators were identified from the international and national literatures. Later, the indicators were rated and prioritized by a multidisciplinary panel of medical professionals using two rounds of Delphi technique. Subsequently at two consensus meetings, the panel evaluated the indicators. Findings – A set of 51 draft indicators were identified. The expert panel members rated 28 indicators as high priority indicators for measuring educational performance of the hospitals. Practical implications – This set of indicators can be used to measure the educational performance of the hospitals in identifying the gaps and take steps to resolve them. Originality/value – Education and training is the basic component of clinical governance. Hospital staff education and training is a fundamental step towards organizational and individual development. To improve the educational performance at hospital level it is necessary to reliably measure such performance. This can be done through developing and using relevant indicators. There are limited systematic studies, especially in middle and low income countries, to introduce appropriate indicators. This study has investigated developing a set of indicators to measure and improve the educational performance in hospitals.

Background and Objectives : Customer Quality (CQ) refers to customer’s characteristics and is concerned with the knowledge, skills and confidence of health services customers who actively participate with health team in proper decision-making, appropriate activities and changing environment and health related behaviors. The purpose of this study was measuring customer quality of pregnant women during prenatal care. Materials and Methods : This is a cross- sectional study which was conducted with the participation of 185 pregnant women who received prenatal care from urban health centers in Tabriz city. All participants were selected randomly from 40 health centers. Customer quality was measured based on CQMH-CQ questionnaire. Questionnaire content validity was reviewed and confirmed by 10 experts and its reliability was confirmed based on Cronbach's alpha index (α = 0.714). Spss v.17 was used for data analysis. Results : According to the results, the mean score of customer quality among pregnant women was (11.29±) 67.79 and only %14 of the participants reported the highest customer quality score and ability of continuity of care under stressful situations. There was a positive relationship between customer quality score and visiting midwife and a better evaluation of overall quality of care, but there was inverse relationship with early registration at health centers. Conclusion : The participation of pregnant women in service delivery process and decision-making can promote costumer quality. Furthermore, training health care providers in empowering patients and using their abilities to improve quality of care and paying attention to patient-centered care will be helpful. ​

To assess districts health managers educational needs and develop management training programmes.This mixed-method study was carried out between August 2014 and August 2015 in Tabriz, Iran. Four focus group discussion sessions and three semi-structured face-to-face interviews were conducted among district health managers and experts of a health centre. Besides, 52 questionnaires were completed to weigh and finalise management education module and courses. Interviews and focus group discussions were tape-recorded, transcribed and analysed using content analysis method. Data was analysed using SPSS17.There were 52 participants, of whom 40(78.8%) were men and 12(21.2%) were women. All of the subjects (100%) took part in the quantitative phase, while 25(48.08%) participated in the qualitative phase. In the qualitative section, 11(44%) participants were heads of unit/departments in provincial health centre and 14(56%) were district health managers. In the quantitative phase, 30(57.7%) participants were district health managers and 8(28.8%) were heads of units/departments. Moreover, 33(63.4%) participants had medical education. The job experience of 3(5.8%) participants in the current position was below five years. Districts health management training programme consisted of 10modules with 53 educational topics. The normalised score out of a total of 100 for rules and ethics was 75.51, health information management 71.19, management and leadership 69.27, district management 68.08, human resources and organisational creativity 67.58,quality improvement 66.6, health resources management 62.37, planning and evaluation 61.87, research in health system 59.15, and community participation was 53.15.Considering district health managers' qualification in health and medicine, they had not been trained in basic management. Almost all the management and leadership courses were prioritised as most necessary.

Introduction: Presence of family and patients’ relatives throughout resuscitation procedure is one of the most challenging concerns. Methods: In an interventional (quasi-experimental) study that was conducted during a 6 months period, the patients’ relatives were randomly divided into two groups of intervention (the relatives who were eager to be present throughout the resuscitation procedure- under the family protection protocol, all of the procedure steps were explained to the relatives by an expert nurse who was not involved in the resuscitation procedure and control group (those who were not invited routinely to be present throughout the resuscitation procedure. However, if the control group were eager to be present, they were allowed to observe the procedure (these people were not supported by the protocol). After 90 days, subjects were contacted through telephone and filled standard questionnaires (Hospital Anxiety and Depression Scale [HADS]) and Impact of Event Scale (IES) were completed for all subjects. These questionnaires focus on anxiety, depression and post-traumatic stress disorder (PTSD). The obtained data were analyzed. Results: One hundred thirty three relatives were divided into two groups of control (59 subjects) and intervention (74 people). No significant difference was observed between two groups regarding demographic features. The evaluation after 90 days revealed depression, anxiety disorders and PTSD to be significantly more prevalent in control group than the intervention group (P < 0.0001 ). Conclusion: Emotional and psychological support and intervention on the patients’ relatives are efficient and can prevent the emergence of psychological disorders.

Jafar Sadegh Tabrizi,1 Mostafa Farahbakhsh,2 Homayoun Sadeghi-Bazargani,3,4 Roya Hassanzadeh,5 Akram Zakeri,6 Leili Abedi7 1Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; 2Research Center of Psychiatry & Behavioral Sciences, Tabriz University of Medical Sciences, Tabriz, Iran; 3Road Traffic Injury Research Center, Department of Statistics & Epidemiology, Tabriz University of Medical Sciences, Tabriz, Iran; 4WHO Collaborating Center on Community Safety Promotion, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden; 5Department of Health Services Management, Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, 6National Public Health Management Center, Tabriz University of Medical Sciences, Tabriz, 7Department of Statistics and Epidemiology, Faculty of Health, Kerman University of Medical Sciences, Kerman, Iran Background: Iranian traditional primary health care (PHC) system, although proven to be successful in some areas in rural populations, suffers major pitfalls in providing PHC services in urban areas especially the slum urban areas. The new government of Iran announced a health reform movement including the health reform in PHC system of Iran. The Health Complex Model (HCM) was chosen as the preferred health reform model for this purpose.Methods: This paper aims to report a detailed research protocol for the assessment of the effectiveness of the HCM in Iran. An adaptive controlled design is being used in this research. The study is planned to measure multiple endpoints at the baseline and 2 years after the intervention. The assessments will be done both in a population covered by the HCM, as intervention area, and in control populations covered by the traditional health care system as the control area.Discussion: Assessing the effectiveness of the HCM, as the Iranian PHC reform initiative, could help health system policy makers for future decisions on its continuation or modification.Trial registration: The study protocol is registered in Iranian Registry of Clinical Trials under the unique code IRCT201402112150N3. Keywords: health reform, health complex model, public private partnership, primary health care, health network, capitation, Iran

Background The licensure is an evaluation mechanism, which allows health centers or individuals to assess health services delivery based on minimum requirements. Objectives The present study aimed to audit the general practitioner (GP) offices in Tabriz city to assess their compliance with national licensure standards in 2015. Methods This was across-sectional study, which audited 228 general practitioner offices randomly. The data from offices was collected based on researcher-made checklist, the validity of which was approved. Firstly, descriptively analysis of data was done and then, the relationship between clinics characteristics and compliance with standards was assessed using Analysis of Variance (ANOVA) and Tukey’s test. To perform the analysis, the SPSS19 software was used, and P < 0.05 was considered significant. Results Based on the study results, the mean standards compliance in GP offices was 78.9%, with highest compliance dedicated to medical documents and informatics dimension with 99.1% compliance level and lowest compliance related to hygiene dimension with 56.2% compliance level. In the analysis of the statistical relationship between the offices characteristics and licensure standards, there was significant relationships, between daily admittance of patients in offices and standards compliance in human resources dimension; GPs’ job experience and standards compliance in medical and non-medical devices dimension; and urban district of office and standards compliance in physical environment dimension and medical and non-medical devices dimension. In addition, there was a significant difference between total score of standards compliance and offices of urban districts (P < 0.05). Conclusions Generally, the status of Tabriz general health clinics was relatively acceptable. Thus, evaluation authorities should pay attention especially to the hygiene dimension.

Background This population-based study aimed at investigating the prevalence and associated factors of prehypertension/hypertension in Iran. Methods and Findings The data (n = 2818) for this study were collected in 2015 as a part of the major Lifestyle Promotion Project (LPP) conducted in East Azerbaijan (urban and regional parts). The data for socio-demographic status, dietary information, and physical activity and anxiety levels were collected through validated questionnaires. Then, physical examination including systolic and diastolic blood pressure (SBP, DBP), body mass index (BMI) and conicity index was performed. First-morning spot urine (SU) sample was collected to assume salt intake. The One-way ANOVA, logistic regression, chi-square test and independent t-test were used for statistical analysis. The prevalence of prehypertension, stage I and stage II hypertension, and overall hypertension was 47.3%, 13.6%, 5.45% and 22.6% respectively. The mean systolic (p = 0.004) and diastolic (p

Background : Performance of hospital managers need to be evaluated based on suitable criteria to get better performance. Unfortunately no formal and systematical performance assessment system has been used to evaluate managers. The aim of this study is to determine the concrete and suitable hospital managers, performance assessment using experts, views. Materials and Methods: This study was a qualitative research with thematic analysis method. By using semi structured questionnaire with 2 health system experts interview was conducted and 20 experts participated in focus group discussion. After each interview and group discussion withdrawals were checked with participants. The initial interviews were analyzed by two faculty members and then were combined. Results: 7 main themes about necessary criteria for hospital managers, performance assessment were obtained from experts, views. These themes are: skills related to planning, organization and staff performance management, leadership, information management, clinical governance and performance indicators. Conclusion: All participants in the study had a history of hospital management therefore their comments will be an effective step in identifying the criteria for making hospital managers, performance assessment tool. In addition to Professionals, perspectives and studies done in other countries, in order to design this kind of tools, it is necessary to adjust the obtained findings according to the local hospital conditions.

Background: Health cooperatives in similar structure of health network in Iran, give primary health cares to defined population with supervisory of public sector. Materials and method: This study compares health system performance between public (PHC) and cooperative (CHC) health centers. Results: Client's satisfaction was 4.14 in CHC and 3.9 in PHC in 5 point Likert scale. The mean for daily health services of CHC and PHC were 110.8 and 85 respectively. Conclusion: Health cooperatives are appropriate strategy for downsizing of government in health sector

A high uric acid (UA) level is demonstrated as a major risk factor of nephropathy and cardiovascular events in people with type 2 diabetes (T2D). This study aimed to evaluate the lovastatin effect on serum UA levels in people with type 2 diabetic nephropathy (T2DN).Thirty patients completed the study course, out of 38 adult male patients with T2DN who were initially enrolled. Lovastatin, 20 mg/d, was administered for 90 days. Afterwards, lovastatin was withdrawn for the next 30 days. Blood samples were obtained at baseline, after 45 and 90 days of intervention, and 30 days after the withdrawal of lovastatin. The serum level of UA was assessed by the uricase/PAP method. The lipid profile and high-sensitivity C-reactive protein (hs-CRP) were determined using commercial reagents and the ELISA method.After 90 days of lovastatin intervention, cholesterol (Chol) and low-density lipoprotein cholesterol (LDL-C) levels significantly decreased and the high-density lipoprotein cholesterol (HDL-C) level increased significantly, despite the unchanged level of triglyceride (TG). After withdrawal, Chol, TG, and LDL-C levels were significantly increased, without any change in the HDL-C level. The baseline serum UA level was 5.94 ± 2.02 mg/dL and not changed after the intervention (5.95 ± 2.21 mg/dL; p = 0.969) and withdrawal period (5.80 ± 1.51 mg/dL; p = 0.647). The changes of serum UA levels were not correlated with the changes of serum hs-CRP levels, both after intervention and withdrawal (p = 0.963p = 0.835).Lovastatin does not have any effect on the serum UA level in people with T2DN. There is no correlation between the anti-lipidemic and anti-inflammatory effects of lovastatin and its effect on serum UA.

ObjectiveTo evaluate the district health management fellowship training programme in the north-west of Iran.Data sources/study settingThe programme was introduced to build the managerial capacity of district health managers in Iran. Eighty-nine heads of units in the province’s health centre, district health managers and the health deputies of the district health centres in the north-west provinces of Iran had registered for the district health management fellowship training programme in Tabriz in 2015–2016.Study designThis was an educational evaluation study to evaluate training courses to measure participants' reactions and learning and, to a lesser extent, application of training to their job and the organisational impact.Data collection/extraction methodsValid and reliable questionnaires were used to assess learning techniques and views towards the fellowship, and self-assessment of health managers’ knowledge and skills. Also, pretest and post-test examinations were conducted in each course and a portfolio was provided to the trainees to be completed in their work settings.Principal findingsAbout 63% of the participants were medical doctors and 42.3% of them had over 20 years of experience. Learning by practice (scored 18.37 out of 20) and access to publications (17.27) were the most useful methods of training in health planning and management from the participants’ perspective. Moreover, meeting peers from other districts and the academic credibility of teachers were the most important features of the current programme. Based on the managers’ self-assessment, they were most skilful in quality improvement, managing, planning and evaluation of the district. The results of the post-test analysis on data collected from district health managers showed the highest scores in managing the district (77 out of 100) and planning and evaluation (69) of the courses.ConclusionThe results of this study indicated that training courses, methods and improvement in managers' knowledge about the health system and the skills necessary to manage their organisation were acceptable.

Aims: To assess the service quality of care as perceived by people with Type 2 diabetes mellitus. Methods: A cross-sectional survey using a self-administered questionnaire was carried out among members of Diabetes Australia-Queensland with Type 2 diabetes. For 12 aspects of service quality derived from a literature review and focus group research, patients scored the relative importance of the aspects and their perception of quality of received care. A measure of service quality was derived by combining the relative importance and actual performance. Results: A total of 603people with Type 2 diabetes participated. Of the 12 aspects of care, communication, availability of support group, safety and prevention had the highest scores for importance; support group and basic amenities had the highest average performance values; but the highest service quality values were for support group, basic amenities, dignity and confidentiality. Younger participants had lower service quality scores (P = 0.001) and participants with good control of their diabetes had higher scores (P < 0.001). Compared with the reference population, our sample had 8.7% fewer people under 65 years old. Conclusions: From the perspective of people with Type 2 diabetes, there is a notable gap between their expectations and what they have actually received in most aspects of provided care. In addition, overall service quality and six aspects of service quality (choice of care provider, accessibility, prevention, continuity, timeliness and safety) were identified to be of inadequate quality. Hence, this study demonstrates a significant opportunity to improve quality of healthcare services.

Objective: T o determine the service quality of delivered care for people who have undergone endoscopic procedures. Methods: A cross-sectional study was conducted on 172 patients admitted to the endoscopy ward of Imam Reza Hospital at Tabriz University of Medical Sciences in Iran between January to December 2013. Service quality was obtained through the "Service Quality = 10– ( Importance × Performance )" formula, based on the importance, performance and SQ with respect to the patients’ perspective. Independent t-test and ANOVA were applied to investigate the differences in service quality score between categorical variables. Regression analysis was applied to examine the correlation between demographics and SQ scores. Data were analyzed using the SPSS-17 statistical software package. Results: The average scores of importance, performance and SQ of delivered care were 6.45, 0.41 and 7.53 respectively, from zero to 10 scale ((where 10 indicated the top score). The quality of basic amenities and the choice of care provider reached the highest SQ scores. Communication, Safety, Dignity and Autonomy gained poor SQ scores. Females, in comparison to males, had 0.47 lower SQ scores with respect to variances in variables of age and health insurance. Conclusion: Relatively low SQ, perceived by patients admitted to the endoscopy ward, indicates significant room for improvement of the quality of care. As an effective quality improvement strategy, it is recommended to promote the patients’ awareness about the delivered care, care facilities and providers and prepare them to actively participate in the process of care.

Purpose: The aim of this study was to curtail the full version of instrument by 50% (short version) and 25% (ultra-short version) of its original size (22 items) and evaluate the reliability and validity of both versions. Methods: The experts’ comments were used to make short and ultra-short versions. The two versions were evaluated by use of indicators related to reliability (internal consistency and test-retest) and diagnostic validity, diagnosis of marginal areas from central areas using ROC curve analysis, among 1600 households. Also, intraclass correlation coefficient (ICC), Pearson correlation coefficient and Bland-Altman plot were used in order to assess agreement between full and shortened versions. Results: The short and ultra-short versions were included 10 items and 6 items, respectively. Cronbach’s Alpha was 0.83 and 0.65 for short version and ultra-short version respectively. The Pearson correlation coefficient and the coefficient of agreement were desirable and acceptable for both versions (p

Purpose: To investigate the activities and performance of designated and active safe communities till 2005. Methods: In this study, the entire 65 designated safe communities being active till 2005, were investigated based on the available virtual data. Data were extracted from the webpages of designated safe communities (saved in 2005) presented at the time in the WHO collaborating center for community safety promotion website. Frequency tables, graphs, Pearson correlation coefficient and chi-square tests were used to analyze the data. Results: The majority of safe communities belonged to Sweden, Norway and Australia respectively. 26.2% of safe communities had started their activities before 1990. Nearly all of the communities had specific injury prevention programs for different age groups and 49 (75.4%) of safe communities had programs for high risk groups. Activities in the field of occupational safety promotion were more frequent in Sweden compared to other countries (P

Objectives: To explore the needs, expectations, feelings and experiences of people with type 2 diabetes for developing quantitative instruments for a questionnaire study of service quality. Methods: Using two focus group discussions (n=33), potential service quality dimensions for type 2 diabetes were assessed for Australian relevance. These included 11 indicators identified from a systematic literature review: communication, autonomy, choice of care provider, continuity of care, quality of basic amenities, dignity, timeliness, prevention and early detection, safety, confidentiality and availability. Results: The focus group discussions supported the importance of the 11 service quality indicators but gave more importance to education, diet, communication, autonomy, choice of care provider and support group and less to confidentiality and availability. Three new themes were generated from the discussions: education, diet and support group. Conclusion: Measuring service quality for type 2 diabetes requires considering health system, culture and disease-specific factors. © 2007 The Authors. Journal Compilation

Objective: To determine the relationship between personal, hormonal and lifestyle risk factors and surgically treated benign prostatic hyperplasia (BPH). Materials and methods: A population-based case-control study was conducted in Western Australia (WA) on men aged 40-75 years who were surgically treated at public and private hospitals for BPH during 2001-2002. Controls were recruited from the WA electoral roll Cases and controls were compared with regard to demographic and Lifestyle factors and proxy measures of hormonal status using logistic regression. Data were available for 398 cases and 471 controls. Results: No associations with BPH were found for family history of prostate cancer in father or brother, serving in the military in a combat area, pattern of baldness, smoking status, obesity, alcohol intake and occupational physical activity. The only inverse relationship was observed with heavy alcohol drinking (>30g/day), however, this was not statistically significant. An increased risk of BPH, not statistically significant, was observed for British-born men compared to Australian born and for history of vasectomy. The analysis was repeated after excluding 28% of controls with moderate and severe symptoms of BPH and 7% of cases with mild symptoms prior to surgery, and our results remained essentially unchanged. Conclusions: The results suggest that there are few risk factors for BPH although perhaps country of birth, vasectomy and heavy alcohol consumption may be considered further. (c) 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.

Background: Excellence and quality models are comprehensive methods for improving the quality of healthcare. The aim of this study was to design excellence and quality model for training centers of primary health care using Delphi method. Methods: In this study, Delphi method was used. First, comprehensive information were collected using literature review. In extracted references, 39 models were identified from 34 countries and related sub-criteria and standards were extracted from 34 models (from primary 39 models). Then primary pattern including 8 criteria, 55 sub-criteria, and 236 standards was developed as a Delphi questionnaire and evaluated in four stages by 9 specialists of health care system in Tabriz and 50 specialists from all around the country. Results: Designed primary model (8 criteria, 55 sub-criteria, and 236 standards) were concluded with 8 criteria, 45 sub-criteria, and 192 standards after 4 stages of evaluations by specialists. Major criteria of the model are leadership, strategic and operational planning, resource management, information analysis, human resources management, process management, costumer results, and functional results, where the top score was assigned as 1000 by specialists. Functional results had the maximum score of 195 whereas planning had the minimum score of 60. Furthermore the most and the least sub-criteria was for leadership with 10 sub-criteria and strategic planning with 3 sub-criteria, respectively. Conclusion: The model that introduced in this research has been designed following 34 reference models of the world. This model could provide a proper frame for managers of health system in improving quality.

Background: Preoperative anxiety is associated with adverse clinical, behavioral, and psychological outcomes. Various effective interventions targeting preoperative anxiety in children exist. Objectives: The aim of this study was to evaluate the educational intervention by residents on children and maternal anxiety and their satisfaction from anxiety management. Patients and Methods: After obtaining the institutional ethics committee approval and written informed parental consent, 36 ASA-I, II children (age range, 8 - 10 years) underwent small operations were included in this prospective randomized study. The participants were allocated into the intervention (n =18) and control (n =18) groups. Children in the first group were prepared routinely. In the second group children and their mothers received data about anesthesia and operation by the booklet. Children-maternal anxiety was assessed using the anxiety level form, at the night and in the morning before surgery. Few days after surgery mothers, residents, and children experiences and satisfaction from anxiety management were assessed in the focus group discussion. Results: Mean scores and standard deviations of state anxiety in the intervention group before and after training were 33.1 ± 5.5 and 30.8 ± 6, respectively (P = 0.06). In the control group it was 32 ± 6.5 on the night and 34.1 ± 6.7 in the morning before surgery (P = 0.00). Comparison between groups was not significant (P = 0.6) and (P = 0.1). The mean levels of anxiety in the control group mothers on the night before and in the morning of surgery were 39.2 ± 13. 1 and 42.8 ± 14 (P = 0.00), respectively. In the intervention group, mothers’ anxiety before education was 41 ± 12.7 and after education it was 35.6 ± 9.5 (P = 0.04). Comparison between groups was not significant (P = 0.7) and (P = 0.1). According to the focus group discussions, booklet study, provided education, sympathy of medical team, spiritual issues and beliefs reduced anxiety and fear of surgery. Anesthesia and lack of knowledge of what will happen, crying and restlessness of children increased preoperative anxiety. Conclusions: In this study, the preoperative anxiety was reduced by explaining anesthesia and surgery to the mothers and children (in mothers it was significant P < 0.05). Since there is a direct relation between mothers’ and their children’s anxiety, using an effective method to reduce anxiety in children and their mothers together at the same time would be very useful for children and their mothers.

Objective: Nowadays, successful health systems in the world have focused their attention on performance indicators, particularly on quality indicators. Given that accreditation is one of the main aspects of health system management and has a profound effect on these indicators, this study aimed to investigate challenges of Iranian accreditation system based on the requirements of the International Society for Quality in Healthcare (ISQua). Methods : This was a qualitative study and its instrument was a checklist earlier published by ISQua. The researchers initially translated checklist and assessed its validity based on the opinions of 20 experts finally developing a checklist with 39 items to assess four main dimensions. Furthermore, the experts’ perspective was obtained and analyzed related to procurement of requirements in Iranian accreditation system and the results were reported in descriptive statistics. Results: The Iranian accreditation system had a variety of weaknesses in all dimensions such as the involuntary participation of health centers in accreditation process; the weak participation of clinicians in accreditation activities and performance improvement; management of the accreditation process by a governmental organization; the accreditation program is not conducted by a committee composed of main stakeholders; healthcare organizations do not provide suitable data of clinical practice, and hospital administrators do not have formal training in health management (with 100% agreement of Experts). But this system has strengths including; the government has approved the creation of the accreditation program (95% agreement); there is a professional organization for controlling the registration of medical practitioners and nurses nationally, and accreditation program has access to data collected routinely by health providers to the Ministry of Health (80% agreement). Conclusions: This study showed that the challenges facing the new accreditation system of the country are abundant and the successful implementation of this program requires serious monitoring to eliminate detected obstacles. Undoubtedly, the barriers identified and the recommendations presented in this study can be used as a guide to achieve this important.

Background: Smoking is the cause for many preventable deaths worldwide. The rate of smoking has not increased in Iran in the past two decades, but its increase among adolescents and young adults is a concern. This study investigates the risk factors of initiation and continuation of smoking in Iran using a qualitative approach. Methods: This is a qualitative content analysis study conducted on 12 smokers and 6 non-smokers in 4 selected cities in Iran. Data were collected with deep and semi-structured interviews, verbatim transcription and simultaneously coding. Then, they were analyzed through content analysis. Results: Three themes and 16 subcategories emerged. The themes were personal inefficacy with 6 subgroups included inadequate information, low age, curiosity, consideration of smoking not as a major problem, wrong beliefs, and making reasons. Family inefficacy with 4 subgroups included poor authority, lack of reaction, existence of stressors, and history of smoking. Vulnerable social environment with 6 subgroups included poverty, social stressors, magnification of smoking, network of cigarette smoking, smoking as a norm and convenience of access. Conclusion: Recognition of smoking among children, modification of wrong beliefs about smoking, empowerment of the individuals against smoking from the very childhood, consideration of familial stress and crisis, and ultimately, paying attention to the role of social variables will play a major role in prevention of smoking and encouraging individuals to quit smoking.

Purpose: The aim of this review was to compare the reliability of existing triage scales. The research question was that, using kappa value as reliability measure, in adult ED patients to what extent did clinicians’ triage ratings agree with eachother or with a gold standard? Methods: The search was limited to studies on adult patients (≥15 years) visiting EDs for somatic reasons and to English and Persian studies that have reported kappa. Studies solely on geriatric patients, computerized triage, telephone triage, and specialty triages were excluded. PubMed, Scopus, ISI web of knowledge, Mosby's Nursing Index, Magiran and SID, were systematically searched through August 2013. 13 articles for kappa (n=38829), 11 articles for linear weighted kappa (LWK) (n= 22697) and 12 articles for quadratic weighted kappa (QWK) (n=10915) met our inclusion criteria. Heterogeneity among studies and publication bias were checked. All pooled analyses of kappa scores for each triage scale were calculated based on random-effects model and then the scales were compared. Results: Findings suggest that five-level scales are more reliable in triaging patients in the emergency department than others (pooled kappa: 0.53, 95% CI (0.48, 0.57), LWK= 0.76, 95% CI (0.72, 0.81) and QWK = 0.74, 95% CI (0.69, 0.79)). The Canadian Triage and Acuity Scale (CTAS) and the Emergency Severity Index (ESI) have been studied more than the other scales. Conclusion: It seems necessary to set a consensus method to assess and compare the reliability of triage scales. This review suggests more specific studies on reliability of triage scales, especially on intra-rater agreement.

Purpose: Considering the importance of information in hospitals, this study assessed the common pattern of data collection in Tabriz hospitals and the reasons explaing them. Methods: The study had a descriptive cross-sectional design and all the hospitals in Tabriz city were studied (census). The questionnaire was developed by the researchers consisting of two parts (information about the HIS and indicators for hospital data collection). The content validity of the questionnaire was verified by a panel of experts. Results: Out of the 20 participating hospitals, 19 hospitals were equipped with HIS. In eligible hospitals, the data used to be recorded as 48% manually, 28% by computer, 15% through both methods, and in 9% the indicators were not recorded. Indicators of demographic information entry and their modification; list of prepared medicines for inpatients in hospital pharmacy; and entry of the number of free beds in the wards had the highest rates of computerized data entry upto a proportion of 80%. Indicators of patients' clinical information as well as the safety and data regarding complaints had the highest manual recording rate among the studied hospitals with a proportion of upto 90%. The reasons that the staff didn’t use the HIS included; unnecessary complexity; unfriendliness of the software; poor quality of the used hardware and shortage of options on the software; laws and regulations; fearand personnel’s viewpoints, and finally the hospital approach or policy. Conclusion: Despite spending much cost and time to implement and maintain the HIS, still almost half of the data entry was being done manually. It requires the policies of using the HIS systems to be revised.

Purpose: To assess the service quality of care as perceived by people with Type 2 Diabetes (T2D). Methods: A cross-sectional study was carried out among 180 people with Type 2 diabetes in diabetes clinic using simple random sampling method in Tabriz, Iran in 2012. Service quality was calculated using: SQ=10 – (Importance ×Performance) based on importance and performance of non-health aspects from the patients' perspective. Validity of questionnaire was confirmed by 10 experts. Data analyzed by SPSS13 software. Results: From the participants' perspective, of12 aspects of service quality, communication and prevention had the highest score for importance. Dignity had the highest score for performance. But the highest service quality values were for continuity of care, dignity and confidentiality. There was no statistically significant relationship between service quality score, age and diabetes status. Conclusion: The findings revealed that there is a notable gap between patients' expectations and perceptions. Also overall service quality and all aspects of service quality with the exception of continuity of care, dignity and confidentiality achieved inadequate quality.

Ab s t r a c t The Tabriz Clinical Governance Research Project (TCGRP) was conducted in Tabriz, East Azerbaijan Province of Iran. The project was done based on the National Clinical Governance Movement of the Iranian health system since 2009. The TCGRP aimed to monitor the progress of clinical governance in Tabriz hospitals. The TCGRP had three components: 1- A comprehensive literature review was conducted to identify draft indicators. 2- Draft indicators were evaluated by experts through Delphi technique and expert panels, 3- The indicators were assessed through data collection at three sampling levels of hospitals, patients and community. All Tabriz hospitals (n=21) with various ownerships were included in the study. Moreover, 3000 patients (inpatients and outpatients) as well as 1050 Tabriz households were investigated. The TCGRP protocol is designed to provide basic performance information for policymakers as well as the researchers in field of clinical governance. Results from TCGRP are assumed to identify the weaknesses and facilitate the development of effective interventions to improve the clinical governance practice.