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Volume 12, Issue 4 (2024)
Health Educ Health Promot 2024, 12(4): 571-579 |
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History
Received: 2024/09/2 | Accepted: 2024/11/7 | Published: 2024/11/10
Received: 2024/09/2 | Accepted: 2024/11/7 | Published: 2024/11/10
How to cite this article
Namdar Ahmadabad H, Rajabzadeh R, Hosseini S, Jafarimoghadam A. Evaluating Health Promotion Standards in Educational Hospitals Affiliated with North Khorasan University of Medical Sciences. Health Educ Health Promot 2024; 12 (4) :571-579
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1- Vector-borne Diseases Research, Center, North Khorasan University of Medical Sciences, Bojnurd, Iran
2- Department of Midwifery, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
3- Department of Health Education and Health Promotion, School of Health, North Khorasan University of Medical Sciences, Bojnurd, Iran
4- Vice-Chancellor of Treatment Affairs, North Khorasan University of Medical Sciences, Bojnurd, Iran
2- Department of Midwifery, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
3- Department of Health Education and Health Promotion, School of Health, North Khorasan University of Medical Sciences, Bojnurd, Iran
4- Vice-Chancellor of Treatment Affairs, North Khorasan University of Medical Sciences, Bojnurd, Iran
Keywords:
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Introduction
In accordance with the World Health Organization’s (WHO) definition, health is delineated as “not merely the absence of disease or infirmity, but a state of comprehensive physical, social, and mental well-being.” Consequently, endeavors aimed at enhancing these facets of health, including education, disease prevention, and rehabilitation, are considered health promotion initiatives. Multiple environments, such as schools, workplaces, residential areas, and hospitals, have the potential to contribute significantly to the promotion of health [1].
Hospitals account for over 40% of healthcare costs and are often criticized for focusing solely on diagnostic and therapeutic activities [2]. The WHO proposes health-promoting hospitals (HPHs) as an effective strategy for reforming health services [3]. The WHO launched the HPHs project in 1988 with the goal of reducing costs, improving patient and staff satisfaction, and implementing effective preventive programs [4]. The WHO delineates HPHs as institutions that offer superior medical and nursing services while cultivating an organizational identity that aligns with health promotion objectives. These establishments actively develop a health-promoting organizational structure and culture, which incorporates proactive and cooperative roles for patients and all employees. In addition, HPHs transform themselves into environments that foster well-being and health, ultimately encouraging collaborative relationships with the surrounding community [5]. HPHs aim to address the physical, mental, and social needs of patients, staff, organizations, and society, focusing on management policy, patient assessment and intervention, promoting a healthier work environment, and ensuring continuity and cooperation [6].
HPHs focus on the needs of patients and their companions, serving as the foundation for fostering a healthy lifestyle for both patients and society. These institutions encourage staff to adopt and maintain a healthy lifestyle and strive to enhance overall health by mitigating environmental risks. Furthermore, they promote staff well-being [5, 7].
The international network of HPHs has experienced consistent growth, with over 900 hospitals and health service centers in more than 40 countries participating [8]. Most of these are located in developed countries, but health promotion programs in developing countries are gaining attention, albeit at a slower pace [2].
The first studies examining the condition of Iranian hospitals in terms of health promotion standards (HPSs), as set by the WHO, were conducted in 2013 [9]. Since then, studies have been carried out in various city hospitals in this field. Hamidi et al. reviewed studies pertaining to the state of Iranian hospitals with respect to the WHO’s HPS, announcing that there are several limitations. Firstly, the number of studies related to HPHs is limited, and more research is needed. Secondly, the findings of these studies demonstrate that Iranian hospitals need to achieve optimal conditions regarding HPS [10].
In previous studies, HPSs in Iranian hospitals have been evaluated either internally by hospital staff or externally by a group of researchers. Additionally, all these studies have utilized the WHO’s self-assessment tool to evaluate the state of HPS in hospitals [10].
Yaghoubi and Javadi emphasize that the effective implementation of hospital health promotion programs across different societies is influenced by the culture, values, and beliefs of those societies [9]. Therefore, it is crucial to consider adapting the evaluation tool for health promotion hospitals to local contexts. Believing that the self-assessment tool for improving hospital health should be appropriate to the cultural, social, political, economic, and health contexts of Iran, previous studies have localized the WHO’s self-assessment tool for health promotion to make it more practical and collaborative [11-13].
The term “HPHs” is relatively new in Iran, and there have been limited studies on this topic. Previous research has been conducted in a single center or specific clinical departments, using non-native evaluation tools and without simultaneous internal and external evaluations. These limitations have been identified in earlier studies. Thus, the present study aimed to determine the state of HPSs in educational hospitals affiliated with North Khorasan University of Medical Sciences (NKUMS) using both internal and external evaluation methods.
Instrument and Methods
Subjects
This cross-sectional descriptive-analytical study was conducted at educational hospitals affiliated with NKUMS in 2023. A census sampling method was utilized to select the educational hospitals. The criteria for participation in the study included the satisfaction of hospital officials and the willingness of the hospital accreditation team. All educational hospitals affiliated with NKUMS were included in this study. The educational hospitals of NKUMS, which include Imam Reza, Imam Hassan, Imam Ali, and Bent Al-Huda hospitals in Bojnourd city, as well as Khatam and Imam Khomeini hospitals in Shirvan city, were considered the research community.
Data collection tool
In this study, the WHO self-assessment tool for health promotion in hospitals was employed. This tool had previously been translated, localized, and validated in the Persian language in Iran [11, 13]. The tool included four standards and 67 substandards, with an average content validity index of 0.867 for the entire tool. The internal reliability of the tool was evaluated using Cronbach’s alpha index, with results ranging from 78.1% to 95.5% for the four standards and a Cronbach’s alpha of 90.02% for the entire tool. The intragroup correlation coefficient value was 0.87, indicating acceptable stability of the tool (Table 1).
We utilized a five-point grading system to assess the degree of fulfillment for each substandard associated with HPSs. The grading system includes grade A (fully achieved substandard with a score of 9-10), grade B (substandard with high progress with a score of 7-8), grade C (substandard with moderate progress with a score of 5-6), grade D (substandard with low progress with a score of 3-4), and grade E (substandard with intention to start with a score of 1-2). In this tool, the evaluators scored the status of each substandard through observations, documents, and interviews.
Table 1. Standards for evaluating health promotion hospitals
![src=./files/hehp/images/HTML_Publish/76826/1.png]()
The process of evaluating health promotion standards
An internal evaluation team was established in each hospital to assess the HPSs in educational hospitals. Hospital staff members who participated in the hospital’s accreditation and quality improvement programs and possessed adequate knowledge about the hospital’s activities related to HPSs, as well as documentation of these activities, were selected for the internal evaluation team of each hospital. The team consisted of the hospital manager, accreditation officer, quality improvement officer, educational supervisor, environmental health officer, social worker, patient education officer, and health promotion unit officer.
During a meeting with each hospital’s internal evaluation team, the evaluation objectives, HPS, evaluation tool, and methodology for scoring each substandard related to the hospitals’ HPS were explained. The members of the internal evaluation team completed the evaluation forms based on observations, documents, and interviews.
For the external evaluation of HPS, the research team, which included health education and health promotion specialists, as well as the manager of the accreditation unit of the Vice-Chancellor of Treatment Affairs of NKUMS, visited the hospital. In collaboration with the hospital’s head manager, they interviewed hospital staff, patients, and family members, performed observations, and reviewed existing documents to complete the evaluation forms.
Statistical analysis
GraphPad Prism version 9 software was utilized to conduct the statistical analysis in this study. A significance level of less than 0.05 was considered for all tests performed. Descriptive statistics, including absolute and relative frequency, mean, and standard deviation, were employed to address the research objectives. The total score of each hospital and the score of each standard were presented as mean±standard deviation. To compare the results across different groups, descriptive statistical methods were used to extract and analyze the data. Mean and standard deviation were used for analyzing quantitative data, while frequency and percentage were employed for qualitative data. The normality of the distribution was evaluated using the Kolmogorov-Smirnov test. Additionally, the independent sample t-test was performed to compare the average scores of each standard among different types of hospitals, locations, and numbers of hospital beds.
Findings
Analysis and comparison of internal and external evaluation scores for health promotion standards
The internal evaluations revealed that educational hospitals have made significant progress in promoting health standards, with a total average score of 7.05±2.25. This score indicates a strong emphasis on health promotion and demonstrates high progress. Three hospitals—Imam Ali, Imam Hassan, and Bent Al-Huda—achieved the highest scores in the internal evaluation (Figure 1). When comparing the different standards, the highest score was related to the standard for health promotion of patients and families (8.05±1.69), while the lowest score was associated with the standard for health promotion of staff (6.37±2.31).
The total average score of the external evaluation was 5.44±2.04, indicating a 50% improvement in hospital HPSs. Notably, all hospitals evaluated for HPS were in the moderate stage of progress, except for Imam Khomeini Hospital, which was in the low stage of progress (Figure 1). In alignment with the internal evaluation results, the highest average score in the external evaluation was related to the standard for health promotion of patients and families (6.86±1.41), while the lowest total average score was associated with the standard for health promotion of staff (7.00±1.83).
![src=./files/hehp/images/HTML_Publish/76826/f1.png]()
Figure 1. Comparison of average internal and external evaluation scores for health promotion standards in different educational hospitals
Our results showed that the average scores of internal evaluations were significantly higher than those of external evaluations in each of the educational hospitals (p<0.05). Furthermore, the comparison of each HPS indicated that the average score of the external evaluation for each standard was significantly higher than the average score of the internal evaluation (p<0.05; Table 2).
Table 2. Comparison of the average scores of internal and external evaluation of health promotion standards in hospitals
![src=./files/hehp/images/HTML_Publish/76826/2.png]()
We compared HPS scores across different hospital characteristics. Our research revealed a significant difference in scores related to the hospitals’ locations (p<0.05). However, we did not find any significant variation in the number of active beds, the number of staff members, or the hospital’s age (p>0.05; Table 3).
Table 3. Comparison of average health promotion standards scores among hospitals with different characteristics. The results are presented as Mean ± SD; a p-value less than 0.05 is considered significant
![src=./files/hehp/images/HTML_Publish/76826/3.png]()
Evaluation of the first standard: Management policy and program
In the internal evaluation of various hospitals, the highest number of substandards for the first standard was observed in the state of high progress, while the lowest number of substandards was in the state of intention to start (Figure 2A). According to the results of this internal evaluation, all the hospitals in Bojnourd City obtained a total average score higher than six for this standard. In contrast, two hospitals in Shirvan City obtained a total average score of less than six.
The external evaluation results showed that most of the substandards related to the first standard were in a state of moderate progress, while the lowest number of substandards was in a fully achieved state (Figure 2B). In this evaluation, the three hospitals—Imam Hassan, Imam Reza, and Bent Al-Huda—achieved an average score of more than five (moderate progress). In comparison, the three hospitals—Imam Ali, Khatam, and Imam Khomeini—achieved an average score of less than five (low progress).
Among the various substandards of the first standard, “a clear statement to promote the health of neighbors around the hospital in the management policy of the hospital,” “determining a sufficient budget for health promotion services,” and “cooperation of the hospital with other partners (organizations and institutions) to ensure and improve the health of patients, staff, and neighbors” received the lowest scores and were in the state of intention to start. In other words, no action was taken regarding these substandards in the evaluated educational hospitals, but evidence of their intention to act in this regard has been observed.
Evaluation of the second standard: Health promotion of patients and families
In the internal evaluation of health promotion for patients and families, most substandards were reported as fully achieved (Figure 2C). In all hospitals except Imam Reza, the total average score surpassed seven, indicating high progress in the second standard.
In the external evaluation, the majority of the substandards for the second standard were in a state of high progress (Figure 2D). The average total score for the second standard was over six in all hospitals.
Out of 19 substandards of the second standard, most hospitals showed low progress in four substandards. These substandards with low progress included “recording information about the factors influencing the health promotion of patients along with social and cultural factors in their files,” “recording a summary of the conditions and needs for health promotion of patients and the interventions performed in their files,” “recording health promotion activities and expected outcomes in patients’ files,” and “access of families and visitors to updated knowledge about health promotion.”
![src=./files/hehp/images/HTML_Publish/76826/f2-1.png]()
![src=./files/hehp/images/HTML_Publish/76826/f2-2.png]()
Figure 2. Status of the first and second standards based on the results of internal evaluation (A and C) and external evaluation (B and D) in educational hospitals
The third standard: Staff health promotion
In the internal evaluation of staff health promotion, most substandards showed moderate progress (Figure 3A). The average total score for Imam Hassan, Imam Reza, and Bent Al-Huda hospitals was above 7 (indicating a high progress state). In contrast, Imam Ali Hospital had an average total score of 6.69 (indicating a moderate progress state), while Khatam and Imam Khomeini hospitals had average total scores below five (indicating a low progress state).
The external evaluation results were consistent with the internal evaluation results, as most substandards of the third standard were also in the moderate progress state (Figure 3B). The average total score for Imam Hassan, Imam Reza, and Bent Al-Huda hospitals was above five, while the scores for Imam Ali, Khatam, and Imam Khomeini hospitals were below five.
Among the various substandards of the third standard, the evidence and documentation related to the substandards of “staff knowledge and awareness of health and safety promotion” and “planning of support and welfare services for hospital staff” were insufficient and in the state of intention to start.
The fourth standard: Promoting the health of the environment inside and around the hospital
The internal evaluation results for the fourth standard showed that the majority of substandards were fully achieved (Figure 3C). Imam Hassan, Imam Khomeini, and Imam Ali hospitals achieved an average total score above seven, while Khatam and Bent Al-Huda hospitals scored between five and seven.
The external evaluation results indicated that the majority of the fourth standard’s substandards were in a high progress stage (Figure 3D). Imam Ali, Imam Hassan, and Bent Al-Huda hospitals achieved an average total score of over six, whereas Imam Reza, Khatam, and Imam Khomeini hospitals scored an average of less than five.
Our results showed that in most hospitals, the indicator “interventions related to the prevention and control of risk factors for neighbors of the hospital” was in the state of intention to start.
![src=./files/hehp/images/HTML_Publish/76826/f3-1.png]()
![src=./files/hehp/images/HTML_Publish/76826/f3-2.png]()
Figure 3. Status of the third and fourth standards based on the results of internal evaluation (A and C) and external evaluation (B and D) in educational hospitals.
Discussion
In the present study, the state of HPS in educational hospitals affiliated with NKUMS was investigated using both external and internal evaluation methods. Various studies have evaluated the state of HPSs in hospitals across different cities in Iran. The majority of these evaluations have been internal assessments conducted by the hospital staff themselves. Limitations of internal evaluation methods, such as bias, limited perspective, and potential conflict of interest, have undoubtedly impacted the results of these studies [14].
The results of the internal evaluation indicated that hospitals could be classified into two groups based on the implementation and fulfillment of HPSs, including the high-progress group and the moderate-progress group. Hospitals in the high-progress group showed clear evidence of their commitment to these standards, with 50% of the evaluated hospitals falling into this category. Meanwhile, the moderate-progress group represented hospitals that have made around 50% progress in implementing the standards, comprising the remaining 50% of the evaluated hospitals. The results of the external evaluation revealed that all hospitals exhibited moderate progress in the implementation of HPS, with only one hospital demonstrating low progress. The evidence suggests that the implementation of HPS in this hospital could be more cohesive.
In accordance with the World Health Organization’s (WHO) definition, health is delineated as “not merely the absence of disease or infirmity, but a state of comprehensive physical, social, and mental well-being.” Consequently, endeavors aimed at enhancing these facets of health, including education, disease prevention, and rehabilitation, are considered health promotion initiatives. Multiple environments, such as schools, workplaces, residential areas, and hospitals, have the potential to contribute significantly to the promotion of health [1].
Hospitals account for over 40% of healthcare costs and are often criticized for focusing solely on diagnostic and therapeutic activities [2]. The WHO proposes health-promoting hospitals (HPHs) as an effective strategy for reforming health services [3]. The WHO launched the HPHs project in 1988 with the goal of reducing costs, improving patient and staff satisfaction, and implementing effective preventive programs [4]. The WHO delineates HPHs as institutions that offer superior medical and nursing services while cultivating an organizational identity that aligns with health promotion objectives. These establishments actively develop a health-promoting organizational structure and culture, which incorporates proactive and cooperative roles for patients and all employees. In addition, HPHs transform themselves into environments that foster well-being and health, ultimately encouraging collaborative relationships with the surrounding community [5]. HPHs aim to address the physical, mental, and social needs of patients, staff, organizations, and society, focusing on management policy, patient assessment and intervention, promoting a healthier work environment, and ensuring continuity and cooperation [6].
HPHs focus on the needs of patients and their companions, serving as the foundation for fostering a healthy lifestyle for both patients and society. These institutions encourage staff to adopt and maintain a healthy lifestyle and strive to enhance overall health by mitigating environmental risks. Furthermore, they promote staff well-being [5, 7].
The international network of HPHs has experienced consistent growth, with over 900 hospitals and health service centers in more than 40 countries participating [8]. Most of these are located in developed countries, but health promotion programs in developing countries are gaining attention, albeit at a slower pace [2].
The first studies examining the condition of Iranian hospitals in terms of health promotion standards (HPSs), as set by the WHO, were conducted in 2013 [9]. Since then, studies have been carried out in various city hospitals in this field. Hamidi et al. reviewed studies pertaining to the state of Iranian hospitals with respect to the WHO’s HPS, announcing that there are several limitations. Firstly, the number of studies related to HPHs is limited, and more research is needed. Secondly, the findings of these studies demonstrate that Iranian hospitals need to achieve optimal conditions regarding HPS [10].
In previous studies, HPSs in Iranian hospitals have been evaluated either internally by hospital staff or externally by a group of researchers. Additionally, all these studies have utilized the WHO’s self-assessment tool to evaluate the state of HPS in hospitals [10].
Yaghoubi and Javadi emphasize that the effective implementation of hospital health promotion programs across different societies is influenced by the culture, values, and beliefs of those societies [9]. Therefore, it is crucial to consider adapting the evaluation tool for health promotion hospitals to local contexts. Believing that the self-assessment tool for improving hospital health should be appropriate to the cultural, social, political, economic, and health contexts of Iran, previous studies have localized the WHO’s self-assessment tool for health promotion to make it more practical and collaborative [11-13].
The term “HPHs” is relatively new in Iran, and there have been limited studies on this topic. Previous research has been conducted in a single center or specific clinical departments, using non-native evaluation tools and without simultaneous internal and external evaluations. These limitations have been identified in earlier studies. Thus, the present study aimed to determine the state of HPSs in educational hospitals affiliated with North Khorasan University of Medical Sciences (NKUMS) using both internal and external evaluation methods.
Instrument and Methods
Subjects
This cross-sectional descriptive-analytical study was conducted at educational hospitals affiliated with NKUMS in 2023. A census sampling method was utilized to select the educational hospitals. The criteria for participation in the study included the satisfaction of hospital officials and the willingness of the hospital accreditation team. All educational hospitals affiliated with NKUMS were included in this study. The educational hospitals of NKUMS, which include Imam Reza, Imam Hassan, Imam Ali, and Bent Al-Huda hospitals in Bojnourd city, as well as Khatam and Imam Khomeini hospitals in Shirvan city, were considered the research community.
Data collection tool
In this study, the WHO self-assessment tool for health promotion in hospitals was employed. This tool had previously been translated, localized, and validated in the Persian language in Iran [11, 13]. The tool included four standards and 67 substandards, with an average content validity index of 0.867 for the entire tool. The internal reliability of the tool was evaluated using Cronbach’s alpha index, with results ranging from 78.1% to 95.5% for the four standards and a Cronbach’s alpha of 90.02% for the entire tool. The intragroup correlation coefficient value was 0.87, indicating acceptable stability of the tool (Table 1).
We utilized a five-point grading system to assess the degree of fulfillment for each substandard associated with HPSs. The grading system includes grade A (fully achieved substandard with a score of 9-10), grade B (substandard with high progress with a score of 7-8), grade C (substandard with moderate progress with a score of 5-6), grade D (substandard with low progress with a score of 3-4), and grade E (substandard with intention to start with a score of 1-2). In this tool, the evaluators scored the status of each substandard through observations, documents, and interviews.
Table 1. Standards for evaluating health promotion hospitals
The process of evaluating health promotion standards
An internal evaluation team was established in each hospital to assess the HPSs in educational hospitals. Hospital staff members who participated in the hospital’s accreditation and quality improvement programs and possessed adequate knowledge about the hospital’s activities related to HPSs, as well as documentation of these activities, were selected for the internal evaluation team of each hospital. The team consisted of the hospital manager, accreditation officer, quality improvement officer, educational supervisor, environmental health officer, social worker, patient education officer, and health promotion unit officer.
During a meeting with each hospital’s internal evaluation team, the evaluation objectives, HPS, evaluation tool, and methodology for scoring each substandard related to the hospitals’ HPS were explained. The members of the internal evaluation team completed the evaluation forms based on observations, documents, and interviews.
For the external evaluation of HPS, the research team, which included health education and health promotion specialists, as well as the manager of the accreditation unit of the Vice-Chancellor of Treatment Affairs of NKUMS, visited the hospital. In collaboration with the hospital’s head manager, they interviewed hospital staff, patients, and family members, performed observations, and reviewed existing documents to complete the evaluation forms.
Statistical analysis
GraphPad Prism version 9 software was utilized to conduct the statistical analysis in this study. A significance level of less than 0.05 was considered for all tests performed. Descriptive statistics, including absolute and relative frequency, mean, and standard deviation, were employed to address the research objectives. The total score of each hospital and the score of each standard were presented as mean±standard deviation. To compare the results across different groups, descriptive statistical methods were used to extract and analyze the data. Mean and standard deviation were used for analyzing quantitative data, while frequency and percentage were employed for qualitative data. The normality of the distribution was evaluated using the Kolmogorov-Smirnov test. Additionally, the independent sample t-test was performed to compare the average scores of each standard among different types of hospitals, locations, and numbers of hospital beds.
Findings
Analysis and comparison of internal and external evaluation scores for health promotion standards
The internal evaluations revealed that educational hospitals have made significant progress in promoting health standards, with a total average score of 7.05±2.25. This score indicates a strong emphasis on health promotion and demonstrates high progress. Three hospitals—Imam Ali, Imam Hassan, and Bent Al-Huda—achieved the highest scores in the internal evaluation (Figure 1). When comparing the different standards, the highest score was related to the standard for health promotion of patients and families (8.05±1.69), while the lowest score was associated with the standard for health promotion of staff (6.37±2.31).
The total average score of the external evaluation was 5.44±2.04, indicating a 50% improvement in hospital HPSs. Notably, all hospitals evaluated for HPS were in the moderate stage of progress, except for Imam Khomeini Hospital, which was in the low stage of progress (Figure 1). In alignment with the internal evaluation results, the highest average score in the external evaluation was related to the standard for health promotion of patients and families (6.86±1.41), while the lowest total average score was associated with the standard for health promotion of staff (7.00±1.83).
Figure 1. Comparison of average internal and external evaluation scores for health promotion standards in different educational hospitals
Our results showed that the average scores of internal evaluations were significantly higher than those of external evaluations in each of the educational hospitals (p<0.05). Furthermore, the comparison of each HPS indicated that the average score of the external evaluation for each standard was significantly higher than the average score of the internal evaluation (p<0.05; Table 2).
Table 2. Comparison of the average scores of internal and external evaluation of health promotion standards in hospitals
We compared HPS scores across different hospital characteristics. Our research revealed a significant difference in scores related to the hospitals’ locations (p<0.05). However, we did not find any significant variation in the number of active beds, the number of staff members, or the hospital’s age (p>0.05; Table 3).
Table 3. Comparison of average health promotion standards scores among hospitals with different characteristics. The results are presented as Mean ± SD; a p-value less than 0.05 is considered significant
Evaluation of the first standard: Management policy and program
In the internal evaluation of various hospitals, the highest number of substandards for the first standard was observed in the state of high progress, while the lowest number of substandards was in the state of intention to start (Figure 2A). According to the results of this internal evaluation, all the hospitals in Bojnourd City obtained a total average score higher than six for this standard. In contrast, two hospitals in Shirvan City obtained a total average score of less than six.
The external evaluation results showed that most of the substandards related to the first standard were in a state of moderate progress, while the lowest number of substandards was in a fully achieved state (Figure 2B). In this evaluation, the three hospitals—Imam Hassan, Imam Reza, and Bent Al-Huda—achieved an average score of more than five (moderate progress). In comparison, the three hospitals—Imam Ali, Khatam, and Imam Khomeini—achieved an average score of less than five (low progress).
Among the various substandards of the first standard, “a clear statement to promote the health of neighbors around the hospital in the management policy of the hospital,” “determining a sufficient budget for health promotion services,” and “cooperation of the hospital with other partners (organizations and institutions) to ensure and improve the health of patients, staff, and neighbors” received the lowest scores and were in the state of intention to start. In other words, no action was taken regarding these substandards in the evaluated educational hospitals, but evidence of their intention to act in this regard has been observed.
Evaluation of the second standard: Health promotion of patients and families
In the internal evaluation of health promotion for patients and families, most substandards were reported as fully achieved (Figure 2C). In all hospitals except Imam Reza, the total average score surpassed seven, indicating high progress in the second standard.
In the external evaluation, the majority of the substandards for the second standard were in a state of high progress (Figure 2D). The average total score for the second standard was over six in all hospitals.
Out of 19 substandards of the second standard, most hospitals showed low progress in four substandards. These substandards with low progress included “recording information about the factors influencing the health promotion of patients along with social and cultural factors in their files,” “recording a summary of the conditions and needs for health promotion of patients and the interventions performed in their files,” “recording health promotion activities and expected outcomes in patients’ files,” and “access of families and visitors to updated knowledge about health promotion.”
Figure 2. Status of the first and second standards based on the results of internal evaluation (A and C) and external evaluation (B and D) in educational hospitals
The third standard: Staff health promotion
In the internal evaluation of staff health promotion, most substandards showed moderate progress (Figure 3A). The average total score for Imam Hassan, Imam Reza, and Bent Al-Huda hospitals was above 7 (indicating a high progress state). In contrast, Imam Ali Hospital had an average total score of 6.69 (indicating a moderate progress state), while Khatam and Imam Khomeini hospitals had average total scores below five (indicating a low progress state).
The external evaluation results were consistent with the internal evaluation results, as most substandards of the third standard were also in the moderate progress state (Figure 3B). The average total score for Imam Hassan, Imam Reza, and Bent Al-Huda hospitals was above five, while the scores for Imam Ali, Khatam, and Imam Khomeini hospitals were below five.
Among the various substandards of the third standard, the evidence and documentation related to the substandards of “staff knowledge and awareness of health and safety promotion” and “planning of support and welfare services for hospital staff” were insufficient and in the state of intention to start.
The fourth standard: Promoting the health of the environment inside and around the hospital
The internal evaluation results for the fourth standard showed that the majority of substandards were fully achieved (Figure 3C). Imam Hassan, Imam Khomeini, and Imam Ali hospitals achieved an average total score above seven, while Khatam and Bent Al-Huda hospitals scored between five and seven.
The external evaluation results indicated that the majority of the fourth standard’s substandards were in a high progress stage (Figure 3D). Imam Ali, Imam Hassan, and Bent Al-Huda hospitals achieved an average total score of over six, whereas Imam Reza, Khatam, and Imam Khomeini hospitals scored an average of less than five.
Our results showed that in most hospitals, the indicator “interventions related to the prevention and control of risk factors for neighbors of the hospital” was in the state of intention to start.
Figure 3. Status of the third and fourth standards based on the results of internal evaluation (A and C) and external evaluation (B and D) in educational hospitals.
Discussion
In the present study, the state of HPS in educational hospitals affiliated with NKUMS was investigated using both external and internal evaluation methods. Various studies have evaluated the state of HPSs in hospitals across different cities in Iran. The majority of these evaluations have been internal assessments conducted by the hospital staff themselves. Limitations of internal evaluation methods, such as bias, limited perspective, and potential conflict of interest, have undoubtedly impacted the results of these studies [14].
The results of the internal evaluation indicated that hospitals could be classified into two groups based on the implementation and fulfillment of HPSs, including the high-progress group and the moderate-progress group. Hospitals in the high-progress group showed clear evidence of their commitment to these standards, with 50% of the evaluated hospitals falling into this category. Meanwhile, the moderate-progress group represented hospitals that have made around 50% progress in implementing the standards, comprising the remaining 50% of the evaluated hospitals. The results of the external evaluation revealed that all hospitals exhibited moderate progress in the implementation of HPS, with only one hospital demonstrating low progress. The evidence suggests that the implementation of HPS in this hospital could be more cohesive.