Depiction of Health. 2023;14(4): 477-491.
doi: 10.34172/doh.2023.37
  Abstract View: 499
  PDF Download: 157

Community Involvement and Intersectoral Collaboration in Health Care System

Policy Brief

Designing a Model for Participatory Health Policy at the Local Level

Maryam Ebrahimnezhad 1, Shabnam Ghasemyani 2 ORCID logo, Leila Doshmangir 1 ORCID logo, Javad Babaei 1 ORCID logo, Alireza Hajizadeh 3 ORCID logo, Rahim Khodayari-Zarnaq 1* ORCID logo

1 Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Health Services Management, School of Management and Medical Informatics, Iran University of Medical Sciences, Tehran, Iran
3 Department of Health Economics and Management, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
*Corresponding Author: Email: Rahimzarnagh@gmail.com


Background. Today, the participation of local levels in the health policy process is emphasized, which can be used as a means to more appropriately solve the problems of local communities and support the health system in achieving its goals. This study aimed to design a health policy model based on participation at the local level.
Methods. This multi-method study was conducted to design a model for participation in health policymaking at the local level during three phases of systematic review, semi-structured in-depth interview, and Delphi technique. The purpose of the systematic review was to identify the factors affecting this participation, which was done by searching for suitable keywords in English and Persian databases. The objective of the qualitative phase was to identify the barriers and facilitators of participation. To this end, 16 people were selected by purposive sampling method and semi-structured interviews were conducted. The elements and components of the initial model were provided to experts in this field through the Delphi technique to confirm the items and validate them, so that the final model could be designed.
Results. The influential factors for participation included individual, environmental, and contextual factors, which were identified from a systematic review of 21 articles. Facilitators obstacles, challenges, advantages, and disadvantages of local level participation in the policymaking process were identified through the results of a qualitative study, which were categorized into three main themes, including the participation process, the beneficiaries of the process, and the strategies to facilitate participation. Finally, the health policy model based on participation at the city level was validated and finalized using the opinion of experts.
Conclusion. Participation in the health policy process requires the use of facilitators and the removal of obstacles. Local levels in terms of health issues in Iran involve complex and diverse challenges that can be solved through real participation.

Extended Abstract
Public participation policies are prioritized as a tool to increase the responsiveness of health systems. In fact, community participation in health sector policies is an essential element of a fair and rights-based approach to health. In recent years, community participation has emerged as a priority for global health following the launch of sustainable development goals (SDG). Beyond the use of community participatory approaches to improve the effectiveness of implemented health programs, public participation in healthcare decision-making is increasingly seen as strengthening more responsive policies, better healthcare, healthier populations, improving the quality of health research, increasing community empowerment, and reducing health inequalities. The status of health indicators in different areas and the diversity of socio-cultural status have emphasized the importance of local assessment of health needs, as well as using the opinions of beneficiaries and recipients of health services.
In this study, a sequential exploratory multi-method research method was used. In the first step, articles were searched with the appropriate combination of English and Persian keywords in databases, including PubMed, Web of Science, Cochrane, Scopus, SID, and Magiran. All the articles related to the factors affecting the participation of local institutions in health policy were included in the review without time limit. Data analysis was done by qualitative content analysis method. The second stage was a qualitative study of an exploratory type, which was carried out in the form of an analysis of policy stakeholders. The research population was all policy documents related to policymaking at the local level and all key informants and stakeholders in the policymaking process at the local level. The sample was identified by snowball method and semi-structured interviews were used. The inclusion criteria were all people involved in policymaking and management at the local level, who volunteered to participate in the research. Data collection continued until saturation was reached. The collected data was analyzed by qualitative content analysis using the MAXQDA10 software. We designed the initial policy model by examining and combining the data obtained from the previous two steps. In the final stage, to validate the model, the dimensions of the model were provided to the experts using the Delphi technique and their opinions were applied. We investigated the following 12 options through using a questionnaire: ability to implement, compliance with upstream documents, ability to accept the proposed model by stakeholders, efficiency, flexibility, effectiveness, simplicity, coherence and integration between model components, sequence of model components, proportionality, balance between model components, and appropriateness of the items of the proposed model for the participation of local institutions in the health policy process. In the Delphi method, a purpose-based sampling method was used, and the data was analyzed using the SPSS-16 software.
In the first stage, the results of a systematic review of local institutions’ participation in the health policy process, including challenges, obstacles, facilitators, and other factors affecting participation, were reported. According to the results of the final 21 studies, meta-synthesis was performed for these studies. It should be noted that the qualitative phase of the multi-method studies was used for meta-synthesis. The three main components of these studies included environmental, contextual, and individual factors. At this stage, 16 semi-structured interviews were conducted. Next, the codes were categorized and integrated to extract sub- themes and main themes. The three main topics included the process of participation, beneficiaries, and solutions to facilitate participation. The compiled model had various components as follows: participation of local institutions of the city, policy cycle at the city level, contextual, factors, and individual factors influencing participation extracted from the systematic review, challenges of the health policy process, facilitators of the health policy process, and obstacles and benefits of participation from the point of view of the health stakeholders. To validate the model, there were 12 options, including model execution capability, compatibility with upstream documents, acceptance of the proposed model by stakeholders, efficiency, flexibility, effectiveness, simplicity, coherence and integration between model components, sequence of model components, proportionality, and balance between model components, as well as the appropriateness of the proposed model for the participation of health stakeholders in the health policy process. In this checklist, the options were “strongly disagree”, “disagree”, “agree”, and “strongly agree”, and the average of each item was determined. Then, the number of answers for each item was multiplied by the score of each item, and after summing it up, it was divided by the number of participants and the final number was rounded, which represented the final opinion of the Delphi participants. The implementation capability, compliance of the model with the upstream documents of the country, ability of the model to be accepted by the stakeholders, efficiency, flexibility, simplicity, sequence of components, appropriateness, balance between the components of the proposed model and the proposed model for Iran's health system from the point of view of experts with an average score of 3 had high performance capability. The items of effectiveness of the proposed model, coherence and integration between the components of the proposed model, and comprehensiveness of the proposed model with an average score of 4 also obtained a very high implementation capability from the experts' point of view.
It is necessary to increase community knowledge and awareness about health policy and plan at the local level through various ways such as communication with experts and the media. The results of the study showed that there are major influencing factors and obstacles in the participation of the local levels. The existing obstacles should be removed, and the influencing factors should be used in the best way. Also, identifying the facilitators of participation of local levels in the policymaking process should be considered to provide the context for active participation of the community and local levels in health policymaking activities. The participation of non-governmental organizations in the health policy process can have benefits for the general society, which ultimately improves community health.
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Submitted: 11 Feb 2023
Revision: 28 Jun 2023
Accepted: 15 Aug 2023
ePublished: 30 Aug 2023
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