This review aims to explore factors affecting the implementation of initiatives to substitute doctors with nurses in primary care. The review has following specific objectives: • To identify, quality appraise and synthesise qualitative evidence on barriers and facilitators to the implementation of interventions to substitute doctors with nurses in primary care. • To integrate the findings of this review of qualitative evidence with those of the relevant Cochrane review of effects, so as to enhance and extend understanding of how these complex interventions work and how context impacts on implementation. • To identify hypotheses for subgroup analyses of future updates of the Cochrane systematic review of the effectiveness of substituting doctors with nurses. 1 Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: qualitative evidence synthesis (Protocol)

Background Cesarean section (CS) rates have been increasing globally. Iran has one of the highest CS rates in the world (47.9%). This review was conducted to assess the prevalence of and reasons for women’s, family members’, and health professionals’ preferences for CS in Iran. Methods and findings In this mixed-methods systematic review, we searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, Google scholar; as well as Iranian scientific databases including SID, and Magiran from 1 January 1990 to 8th October 2019. Primary quantitative, qualitative, and mixed-methods studies that had been conducted in Iran with Persian or English languages were included. Meta-analysis of quantitative studies was conducted by extracting data from 65 cross-sectional, longitudinal, and baseline measurements of interventional studies. For meta-synthesis, we used 26 qualitative studies with designs such as ethnography, phenomenology, case studies, and grounded theory. The Review Manager Version 5.3 and the Comprehensive Meta-Analysis (CMA) software were used for meta-analysis and meta-regression analysis. Results showed that 5.46% of nulliparous women (95% CI 5.38–5.50%; χ2 = 1117.39; df = 28 [p < 0.00001]; I2 = 97%) preferred a CS mode of delivery. Results of subgroup analysis based on the time of pregnancy showed that proportions of preference for CS reported by women were 5.94% (95% CI 5.86–5.99%) in early and middle pregnancy, and 3.81% (95% CI 3.74–3.83%), in late pregnancy. The heterogeneity was high in this review. Most women were pregnant, regardless of their parity; the risk level of participants were unknown, and some Persian publications were appraised as low in quality. A combined inductive and deductive approach was used to synthesis the qualitative data, and CERQual was used to assess confidence in the findings. Meta-synthesis generated 10 emerging themes and three final themes: ‘Women’s factors’, ‘Health professional factors’, andex ‘Health organization, facility, or system factors’. Conclusion Despite low preference for CS among women, CS rates are still so high. This implies the role of factors beyond the individual will. We identified a multiple individual, health facility, and health system factors which affected the preference for CS in Iran. Numerous attempts were made in recent years to design, test and implement interventions to decrease unnecessary CS in Iran, such as mother-friendly hospitals, standard protocols for labor and birth, preparation classes for women, midwives, and gynaecologists, and workshops for specialists and midwives through the “health sector evolution policy”. Although these programs were effective, high rates of CS persist and more efforts are needed to optimize the use of CS.

In the Coronavirus Disease 2019 (COVID-19) pandemic, medical staff Are in direct contact with the patients and experience high work pressure. Direct contact with the patients could create some psychological problems in this group. Thus, the prevalence of such problems must be investigated in them. The present study aimed to determine the level of stress, anxiety, and depression among the healthcare staff in Zanjan City, Iran, during the COVID-19 epidemic. Methods: This descriptive study has a cross-sectional design. The Sample of the study population consisted of 535 Staff healthcare members of Vali-e-Asr Hospital in Zanjan City, Iran. A sample of 200 of medical staff was randomly selected to participate in the present study. The required data were collected using the electronic version of Depression, Anxiety, Stress Scale (DASS) tool. Descriptive statistics, as well as the inferential statistics (the Pearson correlation coefficient, Spearman correlation coefficient, Phi, and Cramer's correlation tests), were used to analyze the obtained data in SPSS. Results: The mean age of the study participants was 40.60 years. The mean values of depression, anxiety, and stress in study samples were 6.27, 5.38, and 8.41, respectively. There was a significant relation between gender and variables of depression, anxiety, and stress. There was also an inverse relationship between stress and variables of educational level and age (P<0/05). Conclusion: We found that our sample reported a normal degree of Depression, anxiety, and stress. The extent of stress induced by direct contact with patients was higher in female employees. Furthermore, with the increase in the education and age of the employees, their stress level decreased.

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Background and aimPostpartum is a critical period for mothers which often leads to neglect of their own health. Mothers’ new responsibilities may affect their health promoting lifestyle (HPL). The aim of this study was to determine the impact of both general health and social support on health-promoting lifestyle.MethodsA cross-sectional survey was conducted on 310 women who gave birth over a one-year period in Zanjan (Iran), 2016. A proportionate stratified random sampling technique was used to select respondents from each stratum. Health-promoting lifestyle was assessed using the health-promoting lifestyle profile II (HPLP II) scale. A structure equation model (SEM) was used to determine the relationship between observed and latent variables. Data were analysed using SPSS version 22 and LISREL 8.5 software.ResultsThe age of 42.6% of the participants was more than 30 years and 40.3% of them had an academic education. The mean score of the health-promoting lifestyle was 131.28 (15.37). The structural equation model fitted well with RMSEA =0.07, CFI=0.92, and GFI=0.94. Among the latent factors, general health, with a factor load of −0.68, had greater impact on health-promoting lifestyle than social support. Moreover, there was a significant correlation (−0.63) between general health and perceived social support in the postpartum period.Conclusionhealth-promoting lifestyle was not at appropriate levels among women in the first year after delivery. These findings suggest that strengthening general health and social support would improve a health-promoting lifestyle in Iranian postpartum women.