|Year : 2016 | Volume
| Issue : 1 | Page : 5-9
Impact of Family Physician Program Implementation on Maternal and Child Health Indicators in Rural Population of Isfahan Province
Elham Forouzandeh1, Hedayatalah Asgari2, Mohsen Rohani1, Mehdi Khosravi1, Rasol Hemamy1, Maryam Kheirmand3
1 Department of Health, Isfahan University of Medical Sciences, Isfahan, Iran
2 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Community Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||4-May-2016|
Dr. Hedayatalah Asgari
Faculty of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Hezar Jerib Avenue, Isfahan
Source of Support: None, Conflict of Interest: None
Introduction: Family physician program as the greatest reforms of Iran's health system was initiated since 2008. The most important goals of this program were improvement in primary health services delivery. In this study, the Impact of family physician program implementation on the trend of changes in some of the maternal and newborn health indicators in a rural population of Isfahan province from 2001 to 2010 were investigated. Subject and Methods: This research was a retrospective study. The data were extracted from statistical and official documents. Indicators mean after and before family physician program implementation were compared using descriptive analysis and paired samples t-test. Results: The results of this study indicated that there were a significant difference between neonatal mortality rate, infant mortality rate and under-five mortality rate before and after of family physician program implementation. And performing this program has been the effective impact on improving mentioned indicators. The indicators of mothers mortality rate and low births weight rate were not indicated significant difference before and after of family physician program implementation. Conclusion: Considering trend of changes in studied indicators it can be said that family physician program implementation has been the effective impact on improving all of mother and child indicators except low births weight rate.
Keywords: Family physician, health indicators, mother and child health, rural population
|How to cite this article:|
Forouzandeh E, Asgari H, Rohani M, Khosravi M, Hemamy R, Kheirmand M. Impact of Family Physician Program Implementation on Maternal and Child Health Indicators in Rural Population of Isfahan Province. J Earth Environ Health Sci 2016;2:5-9
|How to cite this URL:|
Forouzandeh E, Asgari H, Rohani M, Khosravi M, Hemamy R, Kheirmand M. Impact of Family Physician Program Implementation on Maternal and Child Health Indicators in Rural Population of Isfahan Province. J Earth Environ Health Sci [serial online] 2016 [cited 2020 Oct 21];2:5-9. Available from: https://www.ijeehs.org/text.asp?2016/2/1/5/181799
| Introduction|| |
Health status of society is assessed based on its health indicators, and health pathway is estimated based on changes trend of indicators overtime. After implementation of primary health care (PHC) program which lead to constituting health houses, urban health centers, rural health centers, and other health structures, many health indicators throughout the country were progressed considerably. 
Successful implementation of PHC program in the format of the national health services network convinced us that performing each program or plan would be successful if it follows PHC principles. Hence, the same four fundamental principles of national PHC network, social equality, intersectional cooperation, public involvement, and adequate technology, were considered. Based on this viewpoint, the urban insurance plan in the referral system and family physician program were distinguished as the most effective strategy.
Family physician program in the referring system with the participation of health insurance organization was initiated in Iran since 2004. In this program, physician and the health team have the responsibility of providing health services for all rural population and their families. Furthermore, this team is responsible to follow the patients after referring them to a higher level of the health system. One of the most important of family physicians duties is to provide PHC to target population actively. 
Many studies have been conducted on the rural population, one of the valid studies is the comprehensive analysis which was carried out by Naghavi, on the 10 years data of vital horoscope (1993-2003), which was published as a book. 
In another study entitled "Demographic and Health Survey of 1379 in Iran", in which comprehensive information and insight into the health status of mothers and children were collected. 
Raeissi et al. in their study showed that the family physician program has a positive impact on all the indicators of maternal and child health, maternal mortality rate has more than the expectation. 
In the another study titled "impact of family physician program on health indicators" which conducted by Barati et al., four mortality indicator includes of infant mortality rate (IMR) and under-five mortality rate (U5MR), neonatal mortality rate (NMR) and mothers mortality rate (MMR).
Have significant difference in the studied years and, therefore, family physician program implementation (at the beginning of 1995), have effective impact on improving mentioned indicators. 
In the Abramimipour et al. study, mean of 13 indicators of health houses covered by Mashhad Health Center during the years 2001-2010 were extracted and using statistical test of variances analysis were studied. The trend of four indicators; crude birth rate, births attended by nonskilled health staff, percent of hospital delivery, and aging population percent, had a significant difference. Meanwhile, infants mortality rate, crude death rate, birth control coverage and under-five deaths-related to diarrhea, vomiting, and respiratory infections, have considerable changes, but these changes were not statistically significant. 
The results of Margan et al. study titled "investigating family physician program implementation impact on the trend of under-five mortality rate on the rural population of Sarakhs district from 2003 to 2007" shows decreasing trend of death in mentioned years, but she has considered the death pattern different. In this study, deaths related to respiratory infections, trauma, poisoning, burn, low birth weight (LBW) complications, immaturity, and congenital anomalies have had decreasing trend and deaths related to diarrhea, vomiting, vaccination-preventable diseases, had a steady trend meanwhile other causes of deaths have had an increasing trend. 
In the Sayadah-Lyla et al. study titled as "mothers mortality rate due to pregnancy and delivery complications and the impact of family physician program implementation on it's in the rural population of Quchan district from 2005 to 2011" indicated that family physician program implementation has had a considerable effect on decreasing pregnant mothers deaths. The study data were extracted from population information of 21 covered health centers. 
The study of Eshrati et al. and others titled as "Assessment of Inequity for Childhood Health Care Package Provision in Family Medicine Program According to the distance to the Center of the District and Province" All indices calculated for variables, <0.1, the difference was not statistically significant from 0 (P > 0.05). Regarding results of this study, there was no significant difference in providing services for healthy and sick children in health houses of Markazi province considering health house distance to the district and province center. 
In the Nouri et al. study, conducted in Kalaleh district, the results showed that family physician program have been a positive impact on mothers and children indicators and also birth control so that the indicators of NMR, IMR and U5MR were decreased during 2004-2009. 
Benjamin and Hendel in a research titled as "Couba A healthy revolution?" indicated that family physicians implementation has been effective for decreasing NMR. 
In a systematic review which conducted by Sans-Corrales et al. in 2005 with the title of "correlation of family physician program, satisfaction health and costs" the results of 19 articles among 356 ones from different countries were investigated. The results showed that there is a correlation between family physician program and indictors which evaluate services outputs, between patient satisfaction and access to services, and also between care and consultation time were proved. 
This study is aimed to investigate impact trend of family physician program on the five important indicators of mother and child health (the view point of WHO), in the rural population, covered by the medical university of Isfahan during years 2002-2011.
| Subject and Methods|| |
This study was carried out through a descriptive-cross-sectional analysis in the rural population of Isfahan province covered by health houses and 21 district health centers.
Data collection was done through official documents such as annual statistical reports, vital horoscope, and information system software. Studied indicators include of five indicators of NMR, IMR, U5MR, MMR and LBW rate which are the most important mother and child health indicators based on the WHO viewpoint. Mentioned data were gathered in the forms provided by consultants and experts. Data analysis was performed using SPSS software SPSS version 16.0 for windows (IBM SPSS, 2007 Microsoft Corp., Bristol, UK).
To conduct a precise investigation, at first, the data were drawn as descriptive tables and linear diagrams of provincial means changes of indicators in 10 years period (2001-2011).
Then mean of five indicators in years before (2001-2004) and after (2004-2011) of family physician program implementation were compared. The correlation coefficient was used to reveal the relationship between year and indicators.
To estimate data accordance and also accurate findings interpretation, the correlation coefficient of some indicators such as NMR, IMR, and U5MR, were calculated and paired-sample t-test at the significance level of 0.05 were used.
| Results|| |
The correlation of indicators and year is shown in [Table 1]. The strongest inverse correlation was seen between year and indicators in the following order; NMR, U5MR, IMR, and MMR, at the significance level of 0.05.
|Table 1: correlation coefficient between year and mother and child health indicators in the rural areas of Isfahan province during years 2001-2011 |
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It seems that trend of changes in these indicators during study years has revealed the strongest linear relationship, also a positive but not strong correlation between year and LBW rate.
To ensure the consistency of data, the correlation coefficient was used. There was a very strong relationship between NMR, the IMR, and U5MR. These findings indicated that the data were consonantal.
Comparison of the trend of provincial changes of indicators; NMR, IMR, U5MR, MMR, and LBW rate during years 2001-2011 is briefed in [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
|Figure 1: Comparison of trends in indicators of infant mortality rate in rural areas before and after the implementation of family physicians|
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|Figure 2: Comparison of trends in indicators of children infant mortality rate in rural areas before and after the implementation of family physicians|
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|Figure 3: Comparison of trends in indicators of children under-five mortality rate in rural areas before and after the implementation of family physicians|
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|Figure 4: Comparison of trends in indicators mothers mortality rate in rural areas before and after the implementation of family physicians|
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|Figure 5: Comparison of trends in indicators low birth weight in rural areas before and after the implementation of family physicians|
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[Figure 1] shows that NMR has been passed a decreasing trend except for the years of 2008 and 2010.
[Figure 2] shows that IMR during the years of 2001-2004 has had steady trend and between the years 2004-2011 has had an alternate decreasing and increasing trend.
Regarding [Figure 3], U5MR has had decreasing trend during 2001-2005, an alternate decreasing and increasing trend during 2006-2009 and after 2009 having a steady trend.
As it is obvious in three above figures, decreasing in NMR and IMR, have less inclination than decreasing in U5MR.
[Figure 4] shows that MMR has had an increasing trend during the years 2001-2004 and a decreasing trend since 2004-2011 except for 2008 and 2010.
Regarding [Figure 5], the LBW with the minimum rate of 6.99 in the 2002 and the maximum rate of 8.08 in 2011, has had an alternate decreasing and increasing trend.
To more accurate investigation of decreasing death rate difference in these age groups, regression coefficient was used. This coefficient was at −0.81 for NMR, at 0.91 for IMR and at −1.12 for U5MR at the significance level of lower than 0.001 (P < 0.001). In the other word in each year, NMR −0.81 and U5MR more than 1 in 1000 cases, have decreased.
In [Table 2], mean of studied health indicators by years before and after of family physician program implementation were presented and also results of calculating paired-sample t-test were shown. This table indicates that 3 death rate of NMR, IMR, and U5MR through studied years have significant differences, and it seems family physician program implementation from beginning the year of 2005 have been effective for improving mentioned indicators.
The indicators of MMR and LBW have not indicated significant difference during studied years.
|Table 2: Mean maternal and child health indicators studied in rural areas of 2001 to 2011 years and paired t-test results on them |
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| Discussion|| |
Considering exist challenges in providing health services and increasing out of packet.
Costs, and also nonconformity in health resources which lead to reducing access and satisfaction of caregivers; Family physician program and referring system with the comprehensive and public health services approach were established in all levels of health system delivery throughout the country. Consequently, all rural population was covered by basic health insurance, and health system was obliged to health teams deployment in all parts of the country even remote regions. It caused to increase clients load in health centers to, so that, there have been 175,183 clients in the second 6 months of 2004 (before of family physician program implementation), meanwhile the number of clients in the first 6 months of 2005 have increased to 409,769 persons and also in 2006 have increased to 486,157 persons.
This trend in the last years also continued. The increase in clients load, health providing team attendance, training and health literacy improvement, diseases recognition, screening, and treatment have caused to improving health indicators.
This study results also indicated that there was a significant difference between NMR, IMR and U5MR before and after of family physician program implementation. Study of NMR trend showed that in the initiating years of study, mentioned indicator has had 28% decrease. It can imply to the effective impact of the program.
In spite of increasing, rate of 12% this indicator in the year 2008. The increase in NMR in the year 2008 can be due to more attention to gathering data because the data registry system was established in 2008 and caused to more accurate gathering data.
In the Barati et al., Nouri et al., Margan et al. and Benjamin and Hendel studies also have been reported that there was seen a significant difference between NME, IMR, and U5MR before and after of family physician program implementation. ,,,,,
However in the Raeissi et al. and Abramimipour et al. study, there was not a significant correlation between mentioned variables, although investigating the trend of this rate suggests that family physician program implementation has been a positive impact on improving its (P = 0.002). ,,,,,
Studying the trend of U5MR showed that At the end of the 1 st year of the program, a decrease of 15% was occurred in that indicator, whereas it has a little increase in 2006 and a 17% increase in 2008 which are due to data registry system establishment and more accuracy of data gathering in that year. In the Barati et al. study also there was seen a significant difference between U5MR before and after of family physician program implementation. 
Findings of this study also showed that there was no significant difference between MMR before and after of family physician program implementation. However, the trend of MMR in the years before of program was ascending, while in the initiating years of program, until 2007, there were occurred a dramatic decrease in this indicator, So that this indicator has been reached to 10 deaths in 100,000 live birth in 2007, but this rate was increased and to 32 deaths in 100,000 live birth in 2008. Studies of are consistent with this findings, but in the Raeissi et al. study, there was not seen a significant difference between MMR, before and after of family physician program implementation. ,,,,
There was not seen a significant difference between LBW before and after of family physician program implementation (P = 0.69). Data showed a slow trend of decrease-increase in indicators. In the study of Raeissi et al. also there was not seen significant difference between LBW, before and after of family physician program implementation. 
Khadivi et al. in a similar research came to the conclusion that: Following family physician program measurements, the main reproductive health indices such as NMR, IMR, and U5MR have been decreased markedly in rural areas of the Isfahan province. 
Comparing other countries, Cuba is the only country which has implemented a program similar to Iran's family physician program. A systematic review study results which was carried out by Sans-Corrales et al. showed that there was a positive relation among health status and family physician program implementation. This finding is in accordance with the results of this study. 
Briefly results of this study showed that in the recent decade studied indicators.
In rural population covered by medical university of Isfahan in the most areas have been improved significantly and this improvement after of family physician program implementation is more considerable. This is important to know, Apart from the implementation of family physician program; many other affecting factors such as public health education improvement, lifestyle, increasing in access to information systems and public economical strengthening in the rural areas could be effective in changing mentioned indicators.
I appreciate all of health system staff efforts, specifically all colleagues which helped us for data collection. I would like to express my sincere gratitude to Dr. Kamal Heidari for valuable guidance, Dr. Mohammad Hossein Yarmohamadian et al. of health economic research center for cooperation to approving research proposal and Dr. Payman Adibi for the financial support of research.
Financial support and sponsorship
Deputy of Isfahan University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]