The time measurement and workload of primary health care services in Qom's comprehensive health centers: Based on the Health Reform Plan

 Background and Aim: Promoting health and responding to the health needs of people and communities is the most important mission of any country's health system.In recent years،the concept of health and its determinants and on the other hand the health needs and demographic structure of societies have undergone many changes. Fair access to High quality health care seems impossible without formulating appropriate strategies and planning and utilizing human resources management principles. In other words, establishing a balance between workforce and the workload of health workers working in different areas, including suburban areas that have different demographic structure and needs compared to the urban population, is one of the health management requirements. To date, numerous studies have been done in Iran and other countries, but it can be said that the studies are mainly focused on specific areas such as treatment and have included one of the urban or rural contexts of research. Considering the variety of forms of health care systems in different countries as well as the type and variety of services and methods of study, the above studies have had a different approach than the present study. Also، timing of service delivery as the most important factor in improving productivity and optimizing the use of all available health resources and facilities، is necessary for rational and realistic human resource estimation as well as standard time setting. This study was designed to compare the timing of primary health care and the workload of staff working in Qom city comprehensive health bases in urban and marginal areas. Methods: This cross-sectional study was conducted in the second half of the year 1396 (Solar -Hijri) through random sampling from two bases located in two marginal bases of the city and two urban texture bases of Qom. Over a 3-month period, 1000 people-care at comprehensive health bases and age groups for infants, children, adolescents, youth, middle aged, elderly, mothers (prenatal, pregnancy and postnatal cares) were timed. The number of bases and sample size required for the study were determined by Systematic Random Sampling and according to the population of each geographical area in Qom. The four sites studied in this study were selected from four different urban areas. The present study was conducted in 4 stages. In the first phase, in order to coordinate the supervisors and health care providers, an 18 hour workshop was held for uniformizing the method of work, the variety of services, the type of care and the content of the training provided to the target group. During this period, 10 health educators were trained. In the second phase, out of 10 trained caregivers, 4 caregivers with the highest agreement rate in terms of service time, work experience, degree and field of study were selected. Each caregiver was referred to one of the health bases studied each day. In the third step, the timing was done by the Stop Watch method. In this process, the timing of services was recorded by a stopwatch in a complete care consisting of new or periodic care and from verbal communication with the caregiver to the end of full care. Also timing of each service and its components was measured by another stopwatch. Other references to follow-up or examination of tests or referral for purely special care were not subject to timing. In addition, in the event of a power failure or the Internet, the timing process was stopped and the time was recorded, and the duration of the power outage or the Internet was calculated separately and the necessary explanations were noted at the end of the checklist. In the fourth step, after recording the service times and their components in the standard timing checklists, data analysis was performed in SPSS software version 22 using descriptive and analytical statistics including mean and standard deviation and independent t-test. Results:  In this study, 96.1% of clients were Iranian and 3.9% were non-Iranian. Also, 497 people (49.7%) of all target groups were living in the marginal areas of the city and 503 people (50.3% of the samples) were living in urban areas of Qom. Out of 92 referrals for healthy reproductive care, 46 subjects were timed in the marginal areas and the same number in the urban context. The mean age of the subjects was 28.5 and 31.5 years in urban and suburban areas, respectively. Also out of 88 referrals that were timed for pregnancy care (including 44 subjects in urban tissue and 44 subjects in marginal areas) the mean age of mothers in urban and suburban contexts was 28.8±5 and 27±6 years, respectively. The mean age of women was 28.8±5 and 27±6 years for prenatal care so 25±5 and 28.6±5 years for postpartum care (respectively at the comprehensive health base in urban and marginal areas). in the case of neonatal and child care the mean age was considered in terms of day (for neonatal care) and month(for child care)  and it was 18±11 as well 20±11 days(for neonatal care) and 19±15 as well17±16  month (for child care)  in urban and suburban areas. The mean age (in terms of year) for adolescent and youth care in this study was 11±4 as well 11±5 (for adolescent care) and 25±3 as well 23.5±4 (for youth care) in urban and marginal texture, respectively. Based on the findings of this study, the mean age of female middle-aged women cares in urban and suburban areas was 42± 8 years. Similarly, the mean age for middle-aged men in both areas was 40±7years. Finally, the mean age for the elderly cares was 64±4 in urban context and 66±6 in marginal context. In all service packages, except for prenatal care, there was no significant difference between the mean age of the subjects in urban and marginal areas (p <0.05). In this study, the mean of total time for prenatal and postpartum care was 23 ± 6 and 20±5 minutes. The mean time of postpartum care was 21.5 ±4.5 and 18 ±3 minutes (in marginal and urban context, respectively) and the difference was not statistically significant (p = 0.08). But, unlike postnatal care, the timing of prenatal care showed a significant difference in the marginal (27.4 ± 4min) and urban (18 ± 3min) tissue (p = 0.001). Also, pregnancy care with a total mean of 35 ± 9.5 minutes was the most time consuming care and there was a significant difference in the mean time allocated to this care in the urban (28±7min) and suburb (39±8min) context(p =0.005).  Mean timing of healthy reproductive care was 7.7±3 and 6.8±2.7 minutes in marginal and urban areas respectively (the total time devoted to these cares was 7.4 ± 2.8 minutes. According to statistical tests, the difference between the time of healthy reproductive care in the marginal and urban context was not significant (p = 0.139). While the results obtained from the timing of other cares provided in the Health Reform Plan package, the average overall time for infant and children cares were 24.7 ± 5 and 22 ± 6, respectively, The mean time of neonatal care was 27±7 and 22± 4 minutes (respectively at the comprehensive health base in marginal and urban areas) and the observed difference was statistically significant (p =0.004). Also, there was a significant difference between the timing of child care in the urban and marginal areas (19± 3.5 and 25± 6 minutes respectively).In the case of middle-age women care the average overall time was 26.5 ± 4.5 min and the difference observed in timing of care (33±6 and 23±5 in marginal and urban areas) was significant (p =0.001). In contrast, the results of the study showed no significant difference between the timing of middle-aged men care in urban (26±6 min) and suburban (34±8 min) area (p =0.29) and the total time of care in this case was 31±9 minutes. The total time of the elderly care was 33± 9 min (37±8 and 27±8 in marginal and urban areas), which showed significant difference between urban basin health and urban areas (p =0.001). In addition, the mean of total time for adolescent and youth cares were, 32.5 ± 5.8 and 24 ± 6.4 min which did not show any significant difference between urban basin health and suburban areas (p = 0. 1). The mean of time taken to care for adolescents and youths was 40±6 and26±6 min in suburban texture 38±8 as well 23±7 min in urban area. Conclusion: Differences in the timing of health services and work load in suburban and urban texture health contexts can be used in planning the number of appropriate manpower by the type of care, service location, and needs of the target group in order to provide high quality care in accordance with the principles of human resources. In other words, fairer access to primary health care requires more attention from planners and policymakers to demographic differences and the needs of urban and marginal regions. Further studies are recommended to compare the timing of services in different age and sex groups. A comparative study with other developing and developed countries can also highlight the strengths and weaknesses of the program.