Explanatory Sequential Mixed Methods Design Research Articles

Reputational risks associated with nurses' presence on social media: proposed actions following the Vall d'Hebron case

A Spanish nurse posted a video on TikTok criticizing the requirement of a certain level of Catalan to work in the public health system of Catalonia (Spain). The video went viral, eliciting reactions from social media users, politicians, and professional nursing organizations. This study aims to evaluate the reputational damage suffered by the nurse, her hospital, and the nursing profession, with the goal of proposing actions to prevent, avoid, or manage similar situations. A sequential exploratory mixed-methods design was used to analyse the content of the video, its impact on the press and social media, and the management of the communication crisis by the hospital and nursing organizations involved. The nurse exercised her right to freedom of expression. However, her choice to convey the message, wearing the uniform that identified her as a staff member of a specific hospital, and her criticism of the language level requirement, led to reputational damage after the video spread via the press and Twitter/X. The hospital's reputation was affected due to the nurse being identified as one of its employees. In contrast, the reputation of the nursing profession was not significantly harmed, as multiple information sources suggested the incident was isolated. The creation of a safe, self-regulatory framework and training in social media and communication management are proposed as measures for healthcare centres, nursing organizations, and academic institutions to implement. The reputations of both the nurse and her hospital were impacted. A methodological model for analysing similar situations is proposed.

Enhancing the tenth graders’ self-efficacy in learning Social Studies through technology-based pedagogies

This research aimed to improve students' self-efficacy in Social Studies using technology-based pedagogies. The study utilized mixed methods sequential explanatory design which involves quantitative and qualitative data. Pre- and post-assessments were used to measure the development of students’ test scores and supported by pre- and post-self-efficacy surveys to identify the changes in students’ levels of self-efficacy. The Wilcoxon signed-rank test was used to determine the significant difference in pre- and post-self-efficacy survey scores. At the same time a paired sample t-test was used to analyze the pre- and post-assessment scores. On the other hand, the data obtained from the interview on the students’ experiences was analyzed thematically using Colaizzi's descriptive phenomenological data analysis technique. Results showed that students’ self-efficacy in learning Social Studies has improved with increased student engagement, active participation, and a more vibrant learning environment while implementing the interventions. Furthermore, the study recommends that teachers integrate different technological tools in their classes to enhance students' self-efficacy.

Exploring the supportive care needs of families affected by pancreatic cancer: a mixed-methods study protocol

BackgroundPancreatic cancer is an aggressive disease with most cases diagnosed at an advanced stage resulting in low survival rates. Family members often take on a role of supporting patients’ needs. Families tend to be unprepared for this and experience high levels of unmet needs and substantial impacts to their own wellbeing, heightened by the rapid deterioration and short life expectancy associated with pancreatic cancer.AimThe proposed study aims to explore the supportive care needs and associated psychosocial impact of pancreatic cancer on family members, and the role of support services in supporting these families.MethodsA sequential explanatory mixed methods design will be utilised. Data collection will consist of three phases: (1) Survey of affected family members to explore their supportive care needs and psychological wellbeing; (2) Semi-structured interviews to explore the lived experiences of family members across the disease trajectory, their psychosocial adjustment, and their perceptions of support services; (3) Focus groups with support services providers to explore their experiences in providing support to affected families.DiscussionBy combining quantitative and qualitative approaches, this research aims to provide a comprehensive understanding of the challenges and opportunities in providing psychosocial support to families affected by pancreatic cancer, ultimately enhancing their quality of life during and after the cancer journey. The findings may help to inform the development and enhancement of support programs, tailored to meet the specific needs of affected families.

Health and Well-Being in the Context of Health-Promoting University Initiatives: Protocol for a Mixed Methods Needs Assessment Study at Qatar University.

Health-promoting universities are dedicated to fostering learning environments and organizational cultures that support the physical and mental well-being of students, faculty, and staff. As students constitute the largest group within the university community, any policy intervention targeting them is likely to have a significant impact on the university as a whole. This study aims to assess the health status and needs of Qatar University (QU) students using a comprehensive and holistic definition of health, informed by the perspectives of students, faculty members, and key informants. The ultimate goal is to inform evidence-based policies and services designed to improve students' physical and mental well-being. An explanatory sequential mixed-methods research design will be used to conduct a comprehensive assessment of students' health status and needs. This assessment will consist of a quantitative component (a web-based health survey) administered to a convenience sample of students, and a qualitative component, including focus groups with students and faculty members, as well as interviews with key informants. Priority health issues and their determinants, identified through the quantitative assessment, will inform and guide the qualitative assessment to provide a deeper understanding of the various contexts and factors shaping them. Descriptive analyses (eg, proportions or means with SDs), comparative analyses (eg, t tests or chi-square tests), and association analyses (eg, linear, logistic, or Poisson regression models) will be used to analyze the quantitative data. Thematic analysis will be used in the qualitative assessments. Additionally, an environmental scan will be conducted to assess relevant facilities, services, and programs at the QU campus and the QU Primary Healthcare Corporation Center, as well as to review university policies and regulations that may affect students' health and well-being. Together, the needs assessment and environmental scan will inform the design of multilevel interventions, including health education and promotion programs, health services orientation, and proposed policy changes. Between March and December 2022, 812 students completed the web-based health survey. Data have been extracted, cleaned, and harmonized. Analyses to assess the extent of selection bias and the calculation of weights to account for this in all subsequent analyses have been completed (by December 2023). Following the completion of all quantitative data analyses (expected by the end of 2024), focus groups, interviews, and the environmental scan will begin in January-December 2025. This project will help identify and prioritize the health needs of QU students and their determinants, and inform relevant services and policies targeting these needs. By using comprehensive and context-appropriate methods, this project will contribute to QU's strategic efforts to become a Health-Promoting University. DERR1-10.2196/58860.

From need to action: decoding the role of motivation in adherence to home-based cardiac rehabilitation exercise in chronic heart failure patients

BackgroundAdherence to home-based cardiac rehabilitation exercise remains suboptimal, and motivation may be the intrinsic driving force. This study aimed to explore the role of exercise regulatory motivation in mediating the relationship between psychological needs and exercise adherence among chronic heart failure patients, and to develop a mechanism model.MethodsThis study adopted an explanatory sequential mixed-methods design. A hypothesized model of adherence behavior was developed. A survey was used to test the theory-driven model. A semi-structured interview delved deeper into chronic heart failure patients’ experiences with HBCR exercise, identifying reasons behind significant mediation effects and refining the mechanism model.ResultsA total of 248 eligible chronic heart failure patients participated in the quantitative study. Exercise regulatory motivation partially mediated the relationship between psychological needs and exercise adherence. In the qualitative study, 18 chronic heart failure patients from the quantitative sample were purposefully selected. Five sub-themes emerged from the textual data, which were distilled into two overarching themes: “Specific Functions of Pathway Variables” and “Reasons for Mediation Path Significance.” Integrating the qualitative and quantitative results, it was found that satisfying patients’ psychological needs for exercise activates regulatory motivation, which in turn triggers sustained exercise behavior. As motivation becomes increasingly internalized, patients are able to set clear goals and maintain or adjust their home-based cardiac rehabilitation exercise over the long term.ConclusionFrom a health psychology perspective, this study is the first to reveal the role of exercise regulatory motivation in linking psychological needs and exercise adherence among chronic heart failure patients, ultimately developing a mechanism model.Clinical Trial NumberNot applicable.

Factors Associated with Adherence to the 2022 Pre-Employment Algorithm for Asymptomatic Patients with Suspected Pulmonary Tuberculosis Among Pulmonologists in the Lung Center of The Philippines

BackgroundPulmonary tuberculosis is a global health concern and a leading cause of death from infectious diseases. Screening is crucial in high prevalence TB-areas such as the Philippines, particularly among asymptomatic patients. This study explores factors influencing pulmonologists' adherence to the 2022 Pre-Employment Algorithm at the Health and Fitness Assessment Office (HFAO) of the Lung Center of the Philippines. MethodologyUsing a sequential explanatory mixed-methods design, the study conducted a quantitative survey of 16 HFAO pulmonologists, followed by a qualitative focused group discussion (FGD) with 12 participants. Thematic analysis of FGD transcripts provided insights into factors influencing adherence to the algorithm. ResultsThe quantitative phase revealed varying awareness and compliance levels among pulmonologists that directly affected adherence to the algorithm. The FGD identified these specific factors influencing adherence: limited awareness resulting in inconsistent application of the guidelines; personal beliefs and patient-related factors influencing individualized decision-making; institutional challenges (i.e., resource constraints) hindering the implementation process; and perceived algorithm inefficacy, coupled with communication barriers among healthcare professionals, further reducing adherence rates. ConclusionsKnowledge gaps, resource limitations, and personal decision-making significantly affected adherence to the 2022 Pre-Employment Algorithm. Addressing these issues through targeted training, clearer guidelines, and improved resource management can improve adherence and enhance TB screening outcomes. ----- This article has supplementary materials which can be accessed here.

Structure and process evaluation of complex interventions in pain therapy : Description of amethodological approach using the example of POET-Pain

To evaluate the quality of care, particularly in the case of new forms of healthcare interventions, the healthcare services to be provided are defined and documented in advance. The presented explanatory sequential mixed methods design combines quantitative and qualitative data collection and the analysis enables adeeper understanding of anew healthcare intervention. Using the example of the POET-Pain project, which investigates the effect of aperioperative transitional pain service (TPS), the methodological application of the explanatory sequential mixed methods design is demonstrated in order to present the structural and process evaluation of the new healthcare intervention (in this case TPS) and to understand its influence on the quality of care. The mixed methods design presented enables the results of the quantitative phase to be interpreted and expanded in depth using qualitative data, which leads to acomprehensive understanding of the subject matter (second pillar of health services research).

Eyes on communication: strategies to facilitate uptake of clinical practice guidelines for implementation of eye-gaze control technology by people with cerebral palsy. A mixed methods study

Guidelines for implementation of eye-gaze control technology by people with cerebral palsy were published in 2021. The purpose of this study was to identify barriers and facilitators clinicians perceive exist relating to use of these guidelines for eye-gaze control technology, and to explore potential resources that may be developed to support their implementation. A two-phased mixed methods explanatory sequential design was adopted. In phase 1, an online survey containing quantitative and open-ended questions was completed by 97 health professionals and in phase 2 two online focus groups of five clinicians were conducted. The guidelines for eye-gaze control technology were considered helpful for clinicians new to eye-gaze control technology, useful to provide insight into processes for implementing eye-gaze control technology, were flexible, supported clinical reasoning and professional credibility, and were easy to use. However, time to read the guidelines for eye-gaze control technology, and insufficient funding for time to implement the technology were prominent barriers identified in this study. Through the qualitative findings four themes emerged: (1) Complexity of learning to use and implement the guidelines for eye-gaze control technology; (2) Time and resources in short supply; (3) Takes a dedicated team working together; and (4) guidelines for eye-gaze control technology informing practice. Participants in both study phases identified: case studies and video examples; education and training; and practice in implementing eye-gaze control technology, as facilitators to aligning their practice with the guidelines for eye-gaze control technology recommendations and to optimise outcomes.

A pilot evaluation of school-based LEGO® robotics therapy for autistic students

There is emerging evidence that LEGO® therapy is an effective way of supporting younger autistic children develop their communication and social skills. LEGO® robotics therapy – which uses the principles of LEGO® therapy applied to LEGO® robotics – may be an age-appropriate intervention to reduce anxiety and increase social skills in autistic adolescents. The aims of this study, involving 24 autistic students aged 13–16 years, were to examine (a) the effect of an 8-week LEGO® robotics therapy on students’ anxiety, social skills, academic motivation, and engagement, and (b) the views and perceptions of all stakeholders (students, parents, school staff and facilitators) regarding the program. An adapted explanatory sequential basic mixed-methods design was used. Groups of three students supported by two facilitators participated in the LEGO® robotics therapy for eight sessions at school. Quantitative data was collected before and after therapy using the Anxiety Scale for children-Autism Spectrum Disorder, Social Skills Improvement System and the Motivation and Engagement scale. Qualitative data was collected using open-ended online questionnaires, interviews, and focus groups from all stakeholders. No statistically significant within group differences were found in relation to students’ anxiety, social skills, motivation and engagement before and after the program. Qualitative findings indicated predominantly positive student experiences and outcomes such as better school attendance, increased confidence, and social skills. The findings suggest that LEGO® robotics therapy may be associated with a range of nuanced positive experiences and outcomes for individuals and groups of students, suggesting potential value in further efforts to refine the program.

Development and Validation of a Novel Tool to Measure Medication Adherence for Noncommunicable Diseases in India: Protocol for an Exploratory Sequential Mixed Methods Multicentric Study.

In high-income countries, only 50% of patients treated for chronic diseases adhere to the prescribed treatment. This issue is even more pronounced in resource-limited countries. Medication adherence scales are simple, low-cost approaches to identify nonadherence in clinical practice. In India, nonadherence to medication varies from 18.7% to 74%, assessed using scales validated in the Western population, as there is no validated medication adherence tool contextualized to the Indian setting. The phrasing of questions in scales validated elsewhere and its interpretations may vary when applied in Indian patients unless accounting for the unique cultural, social, and economic factors influencing medication adherence in India. This could result in inaccurate reports of adherence behavior. This study aims to develop and validate a novel medication adherence tool for select noncommunicable diseases (diabetes mellitus, hypertension, chronic obstructive pulmonary disease, bronchial asthma, and coronary artery disease) in the Indian population. An exploratory sequential mixed methods design will be used, beginning with a qualitative phase where the construct of the scale is defined and preliminary items are generated through a scoping review, focus group discussions, and in-depth interviews. This will be followed by the tool's development phase, including an expert panel review and item revision. Finally, a quantitative phase in 4 zones in India (North, South, East, and West) will be conducted to confirm and validate the newly developed scale. In the first phase, we will frame the construct definition and develop an inventory of potential items for the proposed medication adherence tool. In the second phase, item-level and scale-level content validity indices, along with content validity ratio, will be estimated. In the third phase, we will conduct an item reduction analysis and determine the scoring matrix and item weightage after expert review. We will assess the tool's psychometric properties, plot the receiver operating characteristic (ROC) curve to set an adherence cut-off score, and compute the construct validity and test-retest reliability from the quantitative survey. A medication adherence tool for noncommunicable diseases, developed after ensuring it is ethnically, culturally, and linguistically appropriate incorporating stakeholder perspectives and validated in community settings, would offer a real-world perspective of adherence. The tool will have 2 versions for clinical practice and research, aiding policy makers in adopting tailored adherence policies. PRR1-10.2196/60805.

Navigating The Duality: Privacy And Security Concerns In Knowledge Management Systems (KMS)

This study delves into the intricate relationship between privacy and security within Knowledge Management Systems (KMS). It identifies and analyzes distinct employee perceptions of these intertwined issues within a company's KMS environment. By exploring these perspectives, the authors aim to dispel the confusion surrounding privacy and security in KMS settings. The research employed an explanatory sequential mixed method design. First, a questionnaire survey was distributed directly to KM staff across three companies. This was followed by semi-structured interviews with four KM staff members. The findings reveal a high level of employee awareness regarding the importance of KMS and, consequently, the significance of personal information privacy and security. The study further distinguishes between privacy and security concerns within KMS. Privacy concerns, differentiated across three dimensions: confidentiality, trust, and behavior, are primarily viewed from the organizational layer. Security aspects, on the other hand, are seen as aligned with the ICT layer, governed by legal frameworks and KMS architecture.

Implementing Best Practices for Nurses in Detecting and Reporting Adverse Drug Reactions in a Tertiary Hospital in Tabriz, Iran: A Mixed-Method Study.

According to the World Health Organization (WHO), an Adverse Drug Reaction (ADR) is defined as "a response to a drug which is noxious and unintended, and which occurs at doses normally used in humans for the prophylaxis, diagnosis, or therapy of disease, or for the modification of physiological function." The aim of this research was to evaluate the current practice and implement the best practices for detecting and reporting ADR in a tertiary hospital in Tabriz, Iran. We used a mixed-methods sequential explanatory design in the current study. The research was conceptually informed by the Joanna Briggs Institute model of Evidence-Based Healthcare (JBI EBHC). A three-phase implementation process, outlined by this model, was used in this study. The first and third phases comprised the quantitaive phase of the study, in which we evaluated the current practice and conducted a final evaluation to measure changes in compliance with the best practice. The qualitative phase, the second phase of the JBI EBHC model,was conducted to identify barriers and develop implementation strategies. There were seven evidence-based audit criteria for evaluating the practice, with a sample size of 23 nurses for the quantitative phase and 10 participants for the qualitative phase. The quantitative findings revealed an improvement in compliance rates for all criteria following the follow-up audit. From the qualitative analysis, four themes of barriers were identified: time and workload, lack of a proper reporting system for ADR, lack of belief and readiness for change among nurses, and lack of awareness about the importance of documenting ADR. The results of this implementation study demonstrated enhanced ADR reporting. It can be inferred that implementing educational strategies, such as holding conferences, informal meetings, workshops, and educational pamphlets, can facilitate the implementation of evidence into practice. Findings will help nurses across sectors of primary, secondary, and tertiary care use the implemented strategies to improve the quality of care and reduce ADR.

Bee The CURE: Increasing Student Science Self-Efficacy, Science Identity, and Predictors of Scientific Civic Engagement in a Community College CURE.

"Bee the CURE" is a Power-of-Place course-based undergraduate research experience (PoP-CUREs; Jaeger et al., 2024) that combines place-based education (Demarest, 2014; Gruenewald, 2014) with CUREs, emphasizing student scientific civic engagement where research is relevant to the community where the research is taking place. PoP-CUREs have potential to build students' knowledge, skills, value, and self-efficacy when engaging with the public using science skills (i.e., scientific civic engagement). A mixed-methods sequential explanatory design utilizing surveys and semistructured interviews was used for this study (Warfa, 2016). Students made gains in science self-efficacy over the course of the semester and showed a trend of increasing science identity in both Fall 2021 and Spring 2022 semesters. Students' scientific civic knowledge, or a student's sense of how to use or apply knowledge and skills to help a community, increased significantly, while other predictors of scientific civic engagement started high and remained high throughout the course. Bee the CURE demonstrates psychosocial outcomes that are similar to previously studied CUREs and expands our understanding of how PoP-CUREs might influence outcomes with evidence that an important predictor of future scientific civic engagement increases. Implications for PoP-CURE instruction at Hispanic serving community colleges are discussed.

A national perspective of ambulance clinicians’ perceptions, experiences and decision-making processes when assessing older adults with a head injury: a mixed-methods study

Introduction: UK ambulance services employ diverse models of care, resulting in 40‐60% emergency department (ED) conveyance rates. Head injury conveyance rates for older adults (60 years and over) remain high (60‐70%), despite most being mild. This research aimed to explore ambulance clinicians’ perceptions, experiences and decision-making processes when assessing older adults with head injuries, considering the various factors influencing their clinical decisions.Methods: This study used a mixed-methods sequential explanatory design comprising an online survey and one-to-one interviews with patient-facing ambulance clinicians in the UK. The survey, distributed through nine ambulance services and via social media, gathered data about clinicians’ experiences, confidence levels and perceptions when assessing older adults with head injuries. It focused on exposure frequency, confidence in assessing asymptomatic patients, perceived risks of medications and confidence in available decision tools. The subsequent interviews delved deeper into the survey responses.Results: A total of 385 participants were recruited, predominantly male paramedics (61%), with a median age of 35 years and a median of eight years of ambulance service experience. Participants reported frequent encounters with older adults with head injuries, and expressed high confidence in assessing visible injuries but lower confidence in conducting neurological examinations. Participants found NICE and JRCALC guidelines satisfactory, and reported confidence in conveying patients to the ED but less confidence in alternative referrals or discharges. The interviews revealed two overarching themes: guideline-based care and patient-centred care, with sub-themes emphasising the importance of shared decision making, collaboration with other healthcare professionals and safety-netting strategies.Conclusion: Although clinicians express confidence in using clinical guidelines for ED conveyances, they often find such guidance overly prescriptive and struggle to translate them for individual cases. There is a need for more patient-centred, holistic decision making, especially considering the unique aspects of head injuries in older adults. Challenges include fear of poor outcomes, limited feedback on patient outcomes and low confidence in making referral or discharge decisions. Specific guidelines tailored to this demographic, as well as improved support services, may aid in reducing unnecessary ED conveyances.

포스트 코로나 시대 학교상담자의 효과적인 비대면 상담 기술과 제한점 탐색

Purpose: This study investigated non-face-to-face counseling skills that could be effectively utilized by school counselors in the post-COVID-19 era, aiming to enhance their counseling competence. Methods: To achieve this objective, a sequential exploratory mixed methods design incorporating both quantitative and qualitative research approaches was employed. A total of 13 school counselors with extensive experience in non-face-to-face counseling participated in the study, and they were categorized into three groups based on educational stages: elementary, middle, and high schools. Focus Group Interviews (FGI) were selected as the qualitative research method to collect data on the usability, effectiveness, and limitations of non-face-to-face counseling skills that have been employed over the past three years. Data collected from FGIs was analyzed according to the roles based on the National Model by the American School Counselor Association. Additionally, a questionnaire was developed to assess the usability and effectiveness of these skills, ensuring objectivity of effective non-face-to-face counseling skills and distribution later in the field. Results: Subsequently, a survey targeting proficient school counselors in non-face-to-face counseling was conducted to perform descriptive statistical analysis. Six effective non-face-to-face counseling skills related to instructional aspects were found along with five limitations. Additionally, five effective counseling skills related to appraisal and three limitations were identified, as well as six effective counseling skills and five limitations pertaining to counseling-relevant skills. Conclusion: Based on the research findings, effective counseling skills and limitations for school counselors in the post-COVID-19 era were discussed and recommendations for theirapplication were suggested.

Investigating EFL instructors’ approaches to classroom-based assessment culture: an explanatory sequential mixed-method approach

Based on sociocultural theory and pragmatism philosophical underpinnings, this study explores the classroom assessment practices of tertiary EFL practitioners, focusing on their alignment with contemporary constructivist assessment trends, methods, and approaches, rather than psychometrical assessments. The study extends knowledge on language teachers’ preparedness for implementing classroom assessment literacy. Participants were tertiary EFL instructors from four higher educational institutions in Saudi Arabia. Adopting an explanatory sequential mixed-methods research design, data were collected through self-reported questionnaires, classroom observations, and a review of assessment documents and artifacts. Descriptive statistics were used to analyze quantitative data and thematic analysis qualitative data. The dominance of traditional over alternative assessment methods was demonstrated, indicating gaps in teachers’ classroom assessment literacy. The findings highlight the contradiction, discrepancy, and complexity of the relationship between teachers’ articulated and exercised assessment practices. They provide baseline data for L2 classroom assessment policy, a classroom-based assessment framework, and a guide for teachers’ professional development in language assessment literacy.

Key factors for inappropriate supplement intake in risk-taking users: An exploratory sequential mixed-methods pilot study in Japan.

This study identified the control factors of inappropriate supplement intake to support public agencies in preventing health problems. We used an exploratory sequential mixed-method design with the integrated behavioral model (IBM). Control factors in the IBM were identified with 95 participants. The highest impact behavioral change was established for the following two out of 19 control factors: "I trust others' blogs as a source of information when they post the bad as well as the good" (r = -0.324, p < 0.001) and "I can control any health problems by adjusting the amount and frequency of my supplement intake" (r = -0.308, p < 0.001). The findings suggest that when providing safety information on supplement use, it is important to: (1) disseminate information to online communities of supplement users who share knowledge based on real experiences and (2) effectively demonstrate the risks associated with continued supplementation.

Does access to and use of primary healthcare services influence health insurance uptake? A mixed-methods study in the Wa Municipality, Ghana

ABSTRACT Purpose This study explored access to quality primary healthcare services under Ghana's National Health Insurance Scheme (NHIS), its impact on NHIS enrolment, and the implications for attaining Universal Health Coverage (UHC). Methods A sequential explanatory mixed-method research design was employed using a multistage sampling technique. We collected data from 413 insured individuals and 47 healthcare facilities for quantitative community-level analysis using questionnaires. Purposive sampling was used to select 17 healthcare providers and 20 insured key informants for qualitative investigation using interview guides. Quantitative data were analyzed using descriptive statistics, independent t-tests, and binary logistic regression. Qualitative data were thematically analyzed to explain the quantitative findings. Results The results indicated a positive association between outpatient and inpatient services, maternal healthcare, and laboratory testing. Maternal healthcare and laboratory diagnostics positively influenced the renewal of NHIS membership. Binary logistic regression revealed that access to, and utilization of PHC services significantly increased the likelihood of NHIS membership renewal, influenced by healthcare system factors such as service availability, acceptability, and affordability. Conclusion Our findings suggest that policymakers must enhance the NHIS with improved service delivery to attain UHC in Ghana.

Insights into Health Program Implementation and Evaluation in Iran: A Brief Review of National Healthcare Programs in Iran.

Healthcare program monitoring can play a key role in evaluating their implementation and identifying their strengths and weaknesses. This study was performed with the exploratory sequential mixed methods design in 2023 at Tehran, Iran. The information was categorized into indicators, refining, analysis, interpretation, reporting, and proposed challenges and recommendations. Medical Sciences Department of Public Health (TUMSDoPH) evaluation of its public health programs revealed a comprehensive approach covering a wide spectrum from disease management to health promotion, emphasizing electronic health records, targeted disease interventions, and strategies for non-communicable diseases, alongside efforts to enhance community health. There is a need for initiating "the monitoring committee" under the supervision of the deputy chancellor for public health to monitor key performance indicators and policies to discover the problems of each part of the health system and provide recommendations.

Experiences of gender-affirming healthcare among transgender and gender diverse (TGD) people during the COVID-19 pandemic: an explanatory sequential mixed methods study

Background: Access to timely, gender affirming healthcare (GAH) for transgender and gender diverse (TGD) people is lifesaving. Yet, little is known about the GAH experiences of TGD people during the height of the COVID-19 pandemic. Methods: Utilizing an explanatory sequential mixed methods design, and applying critical transgender and intersectional theories, we examined baseline survey data (n = 44) and follow-up semi-structured interview data (n = 18 qualitative sub-sample from quantitative participants) with a cohort of TGD persons from a COVID-19 eHealth intervention (#SafeHandsSafeHearts) in Toronto, Canada. Results: One-sixth (n = 6/39, 15.4%) of the survey sample reported reduced access to GAH because of COVID-19. Qualitative participants described widespread barriers to access and negative mental health impacts given de-prioritization of TGD health during the pandemic. The cessation of gender affirming surgeries, deemed nonessential, was of greatest concern, along with fear that substantial progress made in improving access to GAH was being unraveled. Nevertheless, community resilience was highlighted through discussion of community support, particularly the development of TGD communities of care to compensate for the lack of institutional support. Despite these struggles, participants embodied trans joy, an act of resistance, refusing to be erased by a system that devalues their healthcare needs. Conclusions: Results inform recommendations for TGD healthcare and improvements that reprioritize TGD community health.