Health promoting Hospitals in Iran: How it is.

BACKGROUND: The World Health Organization (WHO) produced the Ottawa Charter for Health Promotion (HPH) back in 1986. Then expressed the Budapest Declaration of Health Promoting Hospitals and after determined standards for reorienting hospitals towards health promotion So, this study evaluated Iranian hospitals based on WHO-HPH standard.
MATERIALS AND METHODS: This study was a descriptive - analytical survey in selected hospitals of Iran (38 hospitals from 5 provinces). Method of data collecting was through review of documentation related to each of the standards. WHOs self-assessment tool for health promotion was used. RESULT: Overall the mean score of health promotion standard in the state hospital was 54.1 ± 15.1 that means the private hospitals have higher score. In general, patient information and intervention standard had the highest score (70. 8 ± 8. 1) both in private and government hospitals and the patient assessment standard had the lowest score (44. 2 ± 20.1).
CONCLUSION: [corrected] Hospitals must design a specific system for improving and evaluating health promotion in order to encourage policy-makers and health service administrators to invest resources.

INTRODUCTION

The World Health Organization's (WHO) Ottawa Charter for Health Promotion made a path to the development of a series of ‘settings-based’ health promotion strategies during mid-1980s.[1] One of them was the health-promoting hospital (HPH) in 1988. Peculiarly, the progress of HPH has come about a series of influential reports that include The Ljubljana Charter on Reforming Health Care, The Budapest Declaration on Health Promoting Hospitals and The Vienna Recommendations on Health Promoting Hospitals.[234567]

Health-promoting hospitals (HPH) were initiated with the WHO model project ‘Health and Hospital involving 20 hospitals from 11 European countries by the European Pilot Hospital Project in 1993–1997, at the end of 1980s’.[5]

Standards for health promotion in Hospitals

Application of existing standard and criteria in hospitals has not led to noticeable results.

Also, the integration and productivity of existing standard does not facilitate health development and promotion. Therefore, designing the standards for health promotion activities in hospitals is required.[89] Putting stronger emphasis on working conditions in hospitals is needed so as to improve the health of staff, and efficiency and quality of care. Setting standards is the main strategy to improve quality in health care. However, a review of the main standards in use by accreditation agencies yielded few standards related to health promotion actions.[10]

Recognizing the need for standards for health promotion in hospitals, WHO established a working group at the ninth International Conference on health promoting hospitals, Copenhagen, May 2001. Thereafter, several working groups and country networks have been working on the development of standards.[8] After these three workshops, the standards for health promotion in hospitals are considered to be in their final format (subject to future revision once new evidence emerges). It can be said that due to the nature of these standards that today's role and responsibility of hospitals is health promotion of patient, staff, organization and community.[11]

Finally, five standards were developed addressing the following issues:

Standard 1: Management policy: Demand that a hospital has a written policy for health promotion. This policy must be implemented as part of the overall organization quality system and is aiming to improve health outcome. It is stated that the policy is aimed at patient, relatives and staff.

Standard 2: Patient assessment: Describes the organizations’ obligation to ensure the assessment of the patients’ needs for health promotion, disease prevention and rehabilitation.

Standard 3: Patient information and intervention: States that the organization must provide the patient with information on significant factors concerning their disease or health condition and health promotion interventions should be established in all patients’ pathways.

Standard 4: Promoting a healthy workplace: It gives the management the responsibility to establish conditions for the development of the hospital as a healthy workplace.

Standard 5: Continuity and cooperation: Demanding a planned approach to collaboration with other health service sectors and institutions.[12]

MATERIALS AND METHODS

This study was a descriptive - analytical survey in selected hospitals of Iran (38 hospitals from 4 provinces: Tehran, Esfahan, shiraz, Gilan). Method of data collecting was through reviewing documentation related to each of the standards. WHOs self-assessment tool for health promotion was used for data collection.

Each standard has substandards. Substandards operationalize the standard and break it down into its principle components. There are overall 24 substandards; the number of substandards per standards varies from 4 to 6. Content validity was considered for instrument validity. Reliability was calculated via Cronbach's alpha (r = 0.78).

Evidence for evaluation

To collect data documentation related to each of the standard some documents were reviewed.

A sample of reviewed documents for each of standards is explained below:

Standard 1: Management policy: Strategic planning for mentioned health promotion concepts in the mission and vision statement, agreement with other organizations such as the Ministry of Health to participate in the HPH project, The hospital's quality and business plans including HPH concept, existing guidelines for action related to patients, specific plan for staff and community, staff member nominated for the coordination of HPH pans, reviewing annual performance evaluation or staff's participation in the HP program, reviewing newsletters, posters or brochures related HP, training program on HP.

Standard 2: Patient assessment: Availability of patient health promotion needs assessment guidelines, review of patient records. The date of patient assessment which is written down in the patient record, and availability of Information from referring physician or other relevant sources in the patients record.

Standard 3: Patient information and intervention: Random review of patient records for all patients, availability of general health and high-risk disease information, doing various assessment methods: survey, focused group with managers, interview with staff, questionnaire.

Standard 4: Healthy workplace: Interviews with new staff for HP training, Availability of smoking cessation programs, Availability of policy for healthy food, checking food offered in canteen, checking questionnaire used for staff's knowledge on health promotion, checking minutes of working groups for participation of staff representatives. Availability of staffs annual assessment program about HP, checking with staff for participating in the seminar.

Standard 5: Continuity and cooperation: Interviewing with management board making sure of their awareness toward the health plan, availability of review documents related to health programs and documenting their references, patients’ evaluation assessed in patient surveys, existence of specific rehabilitation programs for patients, list of health organizations colleague in the hospital, existence of programs and activities after patient discharge. Availability of procedures for the exchange of information with other health care organizations that take account of patient confidentiality, reviewing patient's medical records for rehabilitation programs.

Data analysis

Data analysis was performed through statistical indicators (mean, SD) and t-test, paired t-test. Sample of research was government and private hospitals in 5 provinces in Iran.

RESULTS

Overall the mean score of health promotion standard in the state hospital was 54.1 ± 15.1 showing that the private hospitals have higher score.

In general, patient Information and intervention standard had the highest score (70.8 ± 8.1), both in private and government hospitals. Score of this standard in private hospitals was (75 ± 8.6) and in government hospitals was (69 ± 9.4). Based on these results the private hospitals have been better.

In this standard, substandards 3-1 and 3-4 had the highest standard and the patient assessment standard had the lowest score (44.2 ± 20.1). Score of this standard in private hospitals was (43.5 ± 5.1) and in government hospitals was (44.4 ± 24. 6). Clearly also in this standard, private hospitals have been better in this standard, substandards 2-3 and 2-4 had the lowest standard. Continuity and cooperation standard had the lowest score among the government hospitals, which in this standard, substandards 5-2 and 5-4 had the lowest standard.

Patient assessment standard had the lowest score among the private hospitals, which in this standard, and the need assessment for health promotion for diagnosis-related patient-groups substandard had the lowest standard [Table 1].

Table 1

Means and SD of health promotion standard and substandards in selected hospitals

T-test showed that there is no significant difference of mean score of S1 until S4 among government and private hospitals. However, significantly the S5 mean score in private hospitals were higher than government hospitals [Table 2].

Table 2

Comparison of mean score of health promotion in private and government Hospitals

Repeated measure of ANOVA showed that the mean scores of different standards of health promoting were not equal in hospitals (F = 16.4, P = 0.00).

As seen in Table 3 highest scores are related to the S3, S1 and S4 are located in the second grade and S2 and S5 have been in the third grade. Also, T-paired test showed that S1 and S4 standards are not significantly different together also no significant difference between S2 and S5, but significantly S3 mean score is more than the rest standard. And also significantly S1 and S4 have higher score than S2 and S5 [Table 3].

Table 3

Health promotion standard mean score in total Hospitals

DISCUSSION

Overall the mean score of health promotion standard in the hospitals was 54.1 ± 15.1, showing that the private hospitals had higher score. And in general the patient information and intervention standard had the highest score (70.8 ± 8.1). This suggests that the hospitals have a strong information system of patients and their family and patients are given clear, understandable and appropriate information about their condition, treatment, care and factors influencing their health. This standard both in private and government hospitals had the highest score, and the patient assessment standard had lower score (44.2 ± 20.1). This suggests a lack of clear systems and procedures regarding the determination and evaluation of patient's health promotion needed in hospitals. may be a hospital has a program for patient assessment but in this assessment does not pay attention to social and cultural issues governmental hospitals had a lower score in continuity and cooperation standard. This shows that governmental hospitals do not identify and cooperate with existing health and social care providers, related organizations and groups in the community and do not implement activities and procedures after patient discharge as t-test showed that significantly the mean score of S5 in private hospitals were higher than government hospitals. In fact, private hospitals had a clear plan in providing services after discharge, time, procedures of cooperation with other organizations and information exchange procedures. Also, they documented the interventions. One important element in creating a health promoting hospital is training to staff and patients in improving and implementing health promotion. This issue is one of the elements of S1 (Management Policy) in health promotion standards and is emphasized in many studies.[131415161718] Researchers have expressed four domains for health promotion in the hospital (patient - oriented, staff-oriented, organization and community- oriented).[19] In this study a WHO health promoting hospital tool was used which is also emphasized on above domain. So it is similar to another research.[122021] Johnson offers four different types of organizational approaches to HPH. In the best type, the hospital is improving health promotion of patient, staff, organization and community.[22] Also WHO concerned that a HPH is improving health promotion of patient, staff, organization and community. The issue has observed in the questionnaire that was used. Research shows that hospitals that get accreditation certificate, have a planning for improving health promotion for patient, staff, organization and community.[23] In fact, these hospitals have comprehensive services, also the check list used in this research considers health promotion for patient, staff, organization and community. To use WHO -HPH tools in the other countries of Africa or Asia this research is needed to be redesigned. This tool was edited considering the culture of patients and the health system in Iran.

Richardson expressed that the hospital environments would not seem as centers of excellence’.[24] Also this research in a s4 (promoting a healthy workplace) has emphasized this issue. One of the main obstacles against the development of HPH is shortage of supplies, personnel, training, time, managers understanding of the concept and principles of health promotion in hospital and professional skills.[6] This paper has considered above cases in evaluation hospitals as a HPH. Peter Olden has stated management as one of the stages of health promotion implementation.[25] This issue is expressed in a S1 (management policy) that was used in this paper. Two strategies for improving health promotion are education and experimental classes[26] Education as one important element in this study is standard 1 (management policy).

CONCLUSION

In fact in the last 20 years, there have been many developments in health promoting hospitals and health services (HPH),[27] so far no research has been done in HPH in Iran. But this research showed that hospitals in Iran do appropriate activities in order to move towards health promotion.

Particularly, in giving appropriate information to patients and their relatives.

And having responsibility for responding to patient demands for health information.[28]

Hospitals must design a specific system for improving and evaluating health promotion. And also encourage policy-makers and health service administrators to invest resources in HPH.[27] After more than a decade of promotion from WHO, HPH is now proved not to be only a vision, but also a concrete development strategy for hospitals[18]