Abstract: The aim of this study was to identify and analyze the advantages of developing home health care system in Iran. In this qualitative study in total, 19 professionals participated in the Interview and FGDs. Three of informants were interviewed and 16 professionals participated in 3 focus group discussions. Discussions and Interviews were well planned, the FGD environments were suitable and after interviews completion the notes were checked with participants for completeness. Each interview took 40-60 min and each FGDS about 90-120 min. In the semi-structured interview guideline was designed based on literature review and FGD results. Thematic analysis method was used for the analysis of qualitative data. Five themes and 47 sub-themes regarding home health care advantages were identified as follows: Economic and social advantages and advantages for patient, family and health system. Finding indicates that home care insures solidarity in Iranian families and society and will flourish and promote the quality of life and health of community together with reduced costs. Home care increases satisfaction of patient and family and improves quality of services since it is being provided in familiar and friendly context. It also reduces the medical errors and adverse affects caused by clinical and hospital procedures. Home care plays an important role in having to provide socioeconomic advantages, unique care in accordance to individual patient needs, empowering and using the capacity of the families, communities and NGO in service provision. Implementing home care in Iran will help to develop better community participation, a principle of Primary Health Care (PHC) which has not yet been obtained in Iran.

INTRODUCTION

The next 20 years will see dramatic changes in the health needs of the world’s populations. Non-communicable diseases will become the leading causes of disability, although HIV/AIDS, tuberculosis and malaria will continue to be major causes of morbidity (and death). With increase of up to 300% in the population of many developing countries and the continuing less dramatic-increases and universal growth in the need for home based long-term care (Aguliar, 2000).

According to the World Health Organization (WHO) estimates, chronic diseases will account for approximately three-quarter of all the death in the developing world by the year 2020 (Boutayeb, 2006). In the Islamic Republic of Iran, chronic diseases are the major cause of death and disability worldwide. Chronic diseases accounted for 70% of all deaths in 2002 (Delavari et al., 2005). The care for chronically ill and geriatric patients has become the key issue of current health policy and will remain one of the top priorities in the following century, as well. More and more people are reaching good old age and they will experience a shift from an acute disease to chronic ones and different causes of death (Brodsky et al., 2003).

During the last two decades, health care systems around the world have undergone profound change, driven by a complexity of economic and political factors. One of the outcomes of these changes has been the shift of consumers from traditional inpatient facilities to a range of community based treatment options (Kisa, 2008). Home Based Care (HBC) as one of the community base care intervention is recognized as a key form of care and support especially in resource limited setting

(Musau et al., 2005). Home care is an important health service which deals with patients in their home environment and the sharing in their management. It has many advantages for both the patients and health services (Pitsillides et al., 2007). Home care for people with chronic illnesses and disabilities presents an urgent challenge around the world (WHO, 2002). In developed countries, current home care focuses on all age groups in need of assistance and support from others due to the limitation caused by their state of health (Lezoric et al., 2007).

Positive outcomes of using home care including delivering comprehensive health care, control of chronic disease follow up of hospital services, cost reduction, reduction of need to hospital care, increased community participation and customer or patient satisfaction indicates that philosophy of home care is one of priorities and on the other hand medical technology has brought about the opportunity which makes the context suitable to develop and use the home care (Grunden, 2001). Thereby, due to the importance of home care, this study was designed to assess the Iranians professional’s point of view about home care system. It is assumed that its finding will be helpful in future decision making and policy development to further improve the health care indicators.

MATERIALS AND METHODS

This research was a qualitative study using thematic analyses which identifies and analyzes the themes. Statistical population of it includes, policy makers, informants academic members, community medicine specialists, public health, management and nursing practitioners. Sampling method was purposeful sampling. Using selection sampling method and semi structured interview, 3 of informants were interviewed and 16 professionals participated in 3 focus group discussions. In total, 19 professionals interviews and participated FGDs. Discussions and interviews were well planned, the FGD environments were suitable and after interviews completion the notes were checked with participants for completeness. Each interview took 40-60 min and each FGDS about 90-120 min.

Data analysis: All interviews and FGDS were recorded by MP3 Player and then typed word by word. Before analysis all recorders were checked with the notes to assess respondent validity. All of the notes were read several times and themes were given codes in order to make them as meaningful as possible. All notes were checked for correctness with participants too.

In order to assess expert validation, interview contents already were checked with two academic members specialists in qualitative research and then combined. Ethical considerations such as keeping findings confidential and giving the choice to participants to withdraw from study any time were conveyed to participants.

RESULTS

From 3 FGDS and 3 semi structure interviews which included in total 19 professionals (1 professor 6 associate professor, 6 assistant professor and 6 lecturers) were categorized accordance to themes. The findings were classified in 5 major and 47 sub-themes (Table 1).

Advantages of home care: Findings indicate that most of the participations in FGDs and interviews confirm that home care is a necessity in Iran and believe, it has advantages for community, household, patient and health systems. Advantages of home care are classified in five major themes as follows:

Economical advantages of home care: Majority of the participants believe that home care in Iran will have a considerable affect in reducing financial burden on household, government, health system and community. Home care can reduces the financial pressure of government and reduces the social and household costs which will lead to total cost reduction of health system. It is logical to provide services with cost reduction with focusing on community and using home care system (FGD3. P7). The cost will be reduced substantially one day hospitalization cost is too much and much more than the cost of providing services at home with a team (FGD3. P1); Health costs and expenditures in total will be reduced and gives the household the choice to spend their income on other priorities (Interwiver 2).

Escalating hospital costs have made the policy makers to look for alternative and cheap ways of service delivery. The reason is having the patient to spend one week or 10 days in hospital after surgical procedures performed which in itself, it increases the cost and burden at households (FGD2. P6); escalating cost of hospital can be limited by home care system and the only cost will be transportation of physicians, nurses and cost of medicines. Thereby, the increased cost of hospital will be saved for patients (Interwiver 3).

Social advantages of home care: Participants strongly believe that implementing home care will improve community participation, social solidarity, health literacy,and psychological well being.

Table 1:	Advantages of home health care system developing in Iran

It highlights the feeling pride and social values in regards to the fact that a team of care providers care for community and it results in improvement, community participation, neighborhood caring and so on (FGD2. P5). One said: It will reduce the stress of community members I, myself feel secure and it will end up in communities solidarity (Interwiver 2).

Having home care in community is the indicator of health literacy development of its members and caring for their own health (FGD2. P5). Home care will flourish the community collaboration through institutional developments such as NGOs, private sector and lay people participation (Interwiver 1). In regards to communicable diseases, it will not spread widely and community becomes safe and it will benefit financially and its culture becomes even richer (Interviwer 2). So cultural context will improve (FGD.2. P5); Security and social support will substantially get better (FGD.1 P.1). In total, the work load becomes less and it can help to reduce the work load of traffic, physician and costs etc. (FGD2. P1). It can be said that community wills becomes satisfied and feel psychologically secure (FGD2. P2).

Advantages home care for patients and clients of health care: Participants think home care has many advantages, for patients and clients. It will reduce the transportation volume, waiting time and other factors such as those related to climate changes. It sure will improve the quality of life of patient too. One of its important advantages is continuity and sustainability of care. In case of maternal and child care, elderly and chronically ill patients, once home care is delivered it can guarantee the continuity, otherwise waiting for long time to get services at hospital, physicians office can have adverse affect on continuity (FGD2. P2).

I believe primary advantage of it is that patient is being cared in an environment which is familiar to him/her and it has family support. I mean patient or client thinks that they are being cured in a supportive atmosphere and his/her emotional needs are being met by family (FGD1. P1). Patient is cared well and its emotional needs are met when in family and patient does not have to spend long hours in hospital saloons and finally, it will capacitate family and patient (Interviwer 1).

Home care reduces the unwanted transportations, waiting times and climate related things like hot weather (FGD3. P3). Patient feels being treated as a human being and important (Interviwer 2). Family members, once become familiar with patients illness and its care can do even much better than. Medical team, since they feel pity all the time and think of their patient loved one all the time. It sure will affect the care process in providing good services (Interviwer 3).

Advantages of home care for families: Home care has many advantages for families including building capacity in them and increasing their participation in care for their patient. Their participation improves the quality of care. Once family members observe the medical team work at caring for the patient, understands what they are doing then they can use their skills of care for patient. So family members by obtaining necessary training can capacitate themselves in working with the sick (FGD1. P1). It helps the family financially and they feel relaxed when they see that every necessary care is being provided at home for their loved one. Who is at the end stage or has a chronic illness (FGD2. P2).

For family feeling that specialists are trying to help them in caring for patient (FGD1.P1). Family members participate and follow up the care and feeling of togetherness among family members will increase and having to respect patient after hearing the explanation of a specialist about the cure will increase (FGD2. P2). Again, it will reduce the cost burden to family; it insures to get oriented and support it. From ethical point, it is for the benefit of patient and family since they have the chance to care for their elderly at home and will never feel emotionally broke down having their loved one at nursing home (Interviewer 2).

Advantages of home care for health system: Home care will reduce the volume of treatment, hospital services and hospice cares. It will shift the care form institutions to home care. Community itself will take the responsibly of care otherwise health system should build up systems and establish hospitals which is not known what capacity of it is being beneficial and used (Interviwer 2). Some of participants think that home care is a kind of entrepreneurship in health system. For health systems, it creates new jobs which is important and valuable job (FGD2. P5). The researchers train too many physicians, nurses, midwives but the researchers were not able to define new duties or jobs for them, it means the researchers did not do good entrepreneurship for them, this plan or home care can do a lot for having new jobs for medical professionals (Interwiver 3).

Home care will improve quality and effectiveness of the patient care. Now patients have to bear the exhausted physicians and nurses but at home things will differ, it is much letter (Interweaver 3). Home care reduces the burden of care and shifts it to home (FG2. P5). Home care has all the features of a good care, continuity, quality, accessibility and affordability is better and has less adverse affects. It is comprehensive and a lot of other good things and if it is implemented in an appropriate manner it is much better than care of physicians office or hospital (FGD2. P3).

It improves the access of those who are in need to care, reduces adverse affects, especially infections, medical errors and so on. It will finally improve the quality of care and leads to sustainability (FGD2. P3). Home care will eliminate the spread of infections and communicable disease. The physicians offices and hospitals are full of patients or fear of being infected or already infected. Thereby, it will have a tremendous effect on reduction of it by caring at home (Interwiver 3). Home care is a complementary care for hospital care. Patient even receives the best care or surgery, once discharged from hospital; the researchers do not know what happens to him/her. Thereby, hospital care without home care is incomplete (FGD2. P6).

DISCUSSION

This study being a qualitative research, evaluates the perception of health specialists about the development of home care in Iran. However, 3 FGD and 3 Interviewers with 19 academic members and specialists, managers and policy maker were conducted. Results were analyzed and categorized in major and sub themes. Results were classified in five themes including economic and social advantages and advantages for patient, family and health systems.

Home care is an excellence program due to the fact of providing quality services improved health services for those of end stage in comparison to other medical services, comprehensive feature of home care in looking after patients and collaborating with family members and other disciplines of medicine in regards to unique needs of individual patients (Timothy, 2005). Uys (2001) in evaluation Aids patients, care has shown that integrated home care and community participation has many positives effects for patients, hospitals and the clinical team members. Vetter et al. (2004) also has indicated that using home health volunteers together with nurses and physicians can improve the management of diabetic patients and can also help to have better follow up and progressive improvements. In addition to it, many studies have suggested much of competencies and abilities for home care (Brien and Nelson, 2002).

According to the result of this study, home care holds all of the good features of a care such as continuity, quality, accessibility, feasibility and comprehensiveness; these features are not part of hospital or office care yet. In other hand, implementation of home care enhances the solidarity in society. Increase health literacy, empowers patient, family and also improves the psychological status of the community. It is therefore, reasonable to say that home care is part of comprehensive and continuous health services (Socol, 2006). Ensuring the access of elderly to heath services with increased quality and cheap in comparison to hospitalized care which is almost possible with home care (Brodsky et al., 2000). Further analysis of findings show that having less adverse affects and comprehensiveness of home care is a unique feature of it and may be a strength in providing quality services to patients.

Many studies put emphasis on its economical feasibility. Study at cost effectiveness in Hong Kong has shown that serving elderly at home reduces economic burden of the family by eliminating acute hospital cure and length of stay (Leung et al., 2004). Findings at two studies of Lee (2004) and Koutkias et al. (2002) suggests that home care costs less especially in providing services to elderly with chronic diseases. The findings on the other hand indicate that majorities of participants believes in home cares, economic feasibility in comparison to clinical or hospital care is obvious.

Some studies conclude that progressive quality improvement, satisfaction, confidence and effectiveness of home care is obvious. Study of Glasco University, showed that rehabilitation services of patient at home reduces the intervention of care in routine and daily function such as walking, and putting clothes up to 28%. In addition, it has capacitated 14% of the patient in performing daily activities (McMackin and Lcsw, 2006).

Results at Falahi Khoshkonab in Tehran study showed that psycho nursing at home improved client’s psychological status who received this care at home better than those who did not receive such a care (Fallahi-Khoshknab, 2008).

Shamsaie et al. (2008)’s study, at Hamadan Hospitals indicated that psychological nursing care towards home is much effective for those with Schizophrenia, since it reduces the hospital stay and risk of getting the case more worse.

Research showed that patients quality of life of with Myocardial infarction can get much better with educating the patient in self care (Najafi-Mehri et al., 2009). Which is consistent with the findings: majority of participants believe, home care increases satisfaction of patient and family and improves quality of services since it is being provided in familiar and friendly context, it also reduces the medical errors, adverse affects caused by clinical hospital procedures.

Studies show that patient education being part of home care, plays an important role in controlling chronic diseases (Ohtsu and Shinobu, 2003). Fields et al. (1999) study indicates that outcomes of home care for children and parent’s satisfaction is much more than caring for children at hospital.

Majority of those who took part in the study think that home care can bring about patient and family satisfaction Improved quality care due to the fact that environment of care is familiar and friendly. It also will reduce the medical errors, adverse affects of clinical procedures, hospital injuries and will improve patient care.

CONCLUSION

According to findings of the study, researchers conclude that developing community oriented care, especially home care is a necessity of today’s health care system for improving health status in Iran. Home care plays an important role in having to provide socioeconomic advantages, unique care in accordance to individual patient needs, empowering and using the capacity of the families, communities and NGO in service provision. Implementing home care in Iran will help to develop better community participation, a principle of Primary Health Care (PHC) which has not yet been obtained in Iran. It is believed that home care insures solidarity in Iranian families and society and will flourish the promotion of quality of life and health of community with reduced costs.

ACKNOWLEDGMENT

The researcher thanks to the great assistance of health services administration Department, Iran Medical University in conducting this study which was done in partial fulfillment of my PhD thesis.