Translating policy into health outcomes: a mixed-methods health impact assessment of the family physician program in Bonab County, Iran

Abstract

Background

The Family Physician Program (FPP) represents a crucial reform in the primary healthcare system. Assessing its impact is essential to inform evidence-based policy decisions and to enhance its effectiveness in improving population health. This study employed a Health Impact Assessment (HIA) framework to evaluate the influence of the FPP on key health outcomes in Iran and to generate actionable recommendations for optimizing its implementation.

Method

A retrospective HIA using the Merseyside guidelines was conducted with a concurrent mixed-methods design across three phases. Phase I involved a quantitative analysis employing Interrupted Time Series Analysis (ITSA) over a 14-year period (2008–2021) to assess changes in health indicators following FPP implementation. Phase II used qualitative content analysis with interviews of 12 healthcare recipients and 7 providers from Bonab, Iran’s urban health centers, exploring program strengths, limitations, and health impacts. Phase III entailed a comparative integration of quantitative and qualitative findings to derive comprehensive policy and practice recommendations.

Results

According the quantitatve analysis, the Total Fertility Rate (TFR) initially exhibited a significant increase post-implementation (p = 0.007), followed by a gradual decline (p = 0.016). Modern contraceptive use declined (MCU) post-intervention, though likely influenced by unrelated national policy changes. The Infant Mortality Rate (IMR) experienced a marked immediate decline (p = 0.009), though the downward trend moderated over time (p = 0.045). Other maternal and child health indicators did not demonstrate statistically significant changes attributable to the intervention. Qualitative content analysis led to the identification of five main categories “Changes in Health-Oriented Beliefs and Behaviors of Service Recipients”, “Quantitative and Qualitative Enhancement of Service Delivery”, “socio-cultural and economic challenges”, “interpersonal communication” and “inefficient management”. The integration phase combined the quantitative and qualitative findings for a comprehensive interpretation.

Conclusion

While the FPP improved some health indicators, its overall effectiveness was constrained by socio-economic inequities, cultural barriers, and managerial inefficiencies. Strengthening the program requires systemic reforms, capacity-building, and addressing social determinants of health. Beyond Iran, this study offers a valuable framework for other low- and middle-income countries facing similar challenges in implementing large-scale primary care reforms, providing insights for optimizing program design and ensuring long-term sustainability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-24788-5.

Background

Global perspective

The Family Physician Program (FPP) represents a cornerstone initiative in the advancement of primary healthcare systems globally. Recognizing the need for equitable and effective healthcare delivery, the World Health Organization (WHO) has identified three fundamental objectives for the development of exemplary health systems: the delivery of care based on reliable standards, the establishment of robust accountability mechanisms, and the equitable distribution of health services across populations [1]. Despite various international efforts to achieve these goals, many health systems continue to face challenges in operationalizing family-centered health strategies, particularly in resource-constrained settings [1].

Within this framework, the FPP is acknowledged as a critical vehicle for promoting integrated, accessible, and contextually relevant primary care. It is designed to deliver person-centered, continuous, coordinated, and community-based services, aligning closely with the WHO’s vision of “health for all” [2]. As such, family physicians are not only the primary point of contact for individuals and families but also play a pivotal role in strengthening health system responsiveness, cost-effectiveness, and equity.

The FPP, first launched in the United Kingdom in the 1950 s, has since been adopted and adapted across various countries, including those in Northern Europe, Canada, and the Global South. These adaptations have demonstrated its capacity to improve health system efficiency and foster social justice by ensuring access to essential healthcare services, particularly for underserved populations [3]. More than 80 countries are currently affiliated with the World Organization of Family Doctors (WONCA), reflecting the global endorsement of this policy initiative [4].

Iranian implementation

In Iran, the FPP, launched in 2005, targeted rural and underserved communities to improve primary healthcare access [5]. In 2012, the Urban Family Physician Program (UFPP) extended these efforts to urban settings in provinces like Fars and Mazandaran, aiming to reduce disparities in health outcomes and enhance care affordability [6, 7]. Although the national pilot implementation was limited to Fars and Mazandaran, a number of other provinces, including East Azerbaijan, initiated localized implementations of the UFPP under the framework of the national Health Transformation Plan (HTP). Bonab County, with its diverse urban demographic and structured health infrastructure, serves as a representative microcosm for evaluating the UFPP’s impact on urban primary care reforms in Iran.

The UFPP, as a multi-phase intervention, incorporates a comprehensive care package designed to address diverse health needs, as outlined in Table 1. Specifically, in Bonab County, the program began in 2015 as part of an effort to expand and strengthen urban primary healthcare through a network of both governmental and non-governmental health complexes. These complexes were equipped with family physicians, nutritionists, psychologists, and health providers, representing a structured urban health model aligned with the national direction.

Table 1.

Key components of the urban family physician program care package

Component	Description
Healthcare service provision	Delivery of essential medical services, including general consultations, vaccinations, and maternal and child healthcare.
Health education initiatives	Programs to educate the community on health-related topics, such as nutrition, disease prevention, and lifestyle modifications.
Primary prevention strategies	Efforts to prevent diseases through initiatives like immunization campaigns and health promotion activities.
Active care delivery	Proactive engagement by healthcare providers to manage patients’ health needs via home visits and community outreach.
Systematic screening protocols	Regular assessments for early detection of diseases, including screening for hypertension, diabetes, and cancers.
Timely diagnostic procedures	Efficient and prompt testing methods to ensure accurate diagnoses without unnecessary delays.
First-level outpatient treatment	Initial treatment at health centers for common illnesses and minor injuries, reducing the need for specialist referrals.
Structured referral systems	Organized pathways to refer patients to higher levels of care, ensuring continuity and coordination of treatment.
Feedback mechanisms	Processes to collect patient and provider input to enhance program effectiveness.
Follow-up assessments	Regular evaluations of patient health outcomes and program impact to support ongoing service adjustments.

Need for evaluation

Effective policymaking requires systematic evaluation mechanisms to assess the impact of such initiatives on population health. One such method is Health Impact Assessment (HIA), a structured approach to evaluating the potential health effects of policies, programs, and projects before they are implemented [8, 9]. WHO has underscored the significance of HIA as a tool to recognize health-related impacts across all sectors, enabling the implementation of interventions to mitigate adverse effects and enhance beneficial outcomes. By providing a framework for collaboration among diverse departments, HIA facilitates the integration of research, policy, and action, making it an essential tool for public health policy evaluation [10].

Despite the expanding global literature on the FPP, limited empirical evidence exists on its health impacts within specific local contexts, particularly using a mixed-methods HIA approach. Several studies in Iran have explored the UFPP, primarily focusing on operational and managerial dimensions such as referral mechanisms, organizational performance, and physician satisfaction.

For example, Nikjoo et al. (2025) developed an evaluation tool for UFPP implementation, emphasizing system-level indicators rather than health outcomes [11]. Shams and Mohammadi (2024) investigated the challenges of UFPP from the perspective of insurance organizations, identifying barriers in service coordination and financing [12].

However, most existing research lacks Impact-based evaluation using longitudinal or mixed-method frameworks, especially at the local level. Furthermore, few studies have systematically analyzed the health impacts of UFPP using HIA methodology.

This gap limits our understanding of the program’s true effectiveness in improving population health and service equity. This study seeks to address this gap by assessing the health outcomes of the UFPP implementation in Bonab County, Iran.

Employing both quantitative and qualitative methods, this research aims to generate a comprehensive understanding of the program’s effectiveness, inform future health policies, and offer evidence-based recommendations for optimizing its impact on public health in Iran.

It not only reflects on the Iranian experience but also provides insights relevant for other low- and middle-income countries exploring similar reforms.

Method

Study design & framework

In this retrospective HIA study, we assessed the health impacts and health-related outcomes of the FPP on urban households in Bonab County, Iran, using the Merseyside guidelines as the methodological framework [13]. In accordance with established HIA frameworks, the retrospective HIA approach was chosen to evaluate the program’s impact after its implementation, using available quantitative and qualitative data spanning from 2008 to 2021. This framework, which is widely recognized in HIA practice, outlines a systematic approach consisting of five core phases: screening, scoping, appraisal, reporting, and monitoring. This study rigorously adhered to these steps, ensuring a structured and comprehensive assessment. We detail below how each phase was operationalized, with extensive stakeholder engagement integrated throughout the process, reflecting the participatory nature of the Merseyside HIA.

Screening

The need for an HIA of the UFPP was identified through initial reviews of urban health disparities and nd early program performance reports. Initial consultations with stakeholders including, district health authorities, primary care staff, and local community representatives, highlighted emerging concerns around service accessibility, referral efficiency, and health outcomes. This process was consistent with the “apply screening criteria to select project or policy” stage of the Merseyside guidelines for HIA. Given that the UFPP is a major policy intervention aimed at improving urban health equity and strengthening the primary care network in non-pilot provinces, it was determined to be a high-priority candidate for formal HIA. The program’s scale, structure, and potential for system-wide health impact warranted a systematic evaluation of its outcomes.

Scoping

Key health indicators were selected to reflect the program’s intended impacts, including maternal and child health, reproductive indicators, non-communicable disease detection, and screening coverage. The affected population was defined as urban residents in Bonab County, with comparisons drawn between the pre-intervention (2008–2014) and post-intervention (2015–2021) periods. Geographic focus was limited to Bonab county, East Azarbayjan. Data sources included routine health system records, statistical reports, and qualitative interviews with both healthcare providers and service recipients. These scoping decisions informed both the methodological design and outcome evaluation framework used in the subsequent assessment phases.

Appraisal

This phase involved a mixed-methods approach with a concurrent triangulation design integrating quantitative and qualitative data [14]. The mixed paradigm draws on the potential strengths of both methodologies, allowing the researchers to explore the diverse perspectives and uncover the relationships between the intricate layers of our multifaceted research questions, whereas neither method could exclusively answer them [15]. This study consisted of three phases: (1) A quantitative phase that was a fourteen-year-year (2008–2021) trend analysis to assess the trend of health-related indicators, before and after of the implementing FPP. (2) A qualitative phase to explore FPP stakeholders’ perspectives about the weaknesses and strengths of the plan. (3) An integration and termination phase with a comparative analysis approach to integrate quantitative and qualitative results in disscussion section, providing a set of recommendations to guide decisions and actions.

Setting & population

The study was conducted in urban Bonab County, East Azerbaijan, Iran, which has a population of approximately 143,752, with 63% residing in urban areas. Before the UFPP (2015), the county had two urban-rural health centers staffed by 26 personnel, including physicians and midwives. Post-implementation, non-governmental health complexes were established, each employing psychologists and nutritionists alongside family physicians and health providers. The governmental complexes also included mental health and nutrition specialists within their structures.The impact of these healthcare changes was assessed in this study.

Phase 1: quantitative ITS analysis

In the first phase, a fourteen-year-year trend analysis (2008–2021), was conducted to assess the health-related indicators. Interrupted Time Series Analysis (ITSA) is recommended to evaluate population-level interventions based on demographic variables, and not individual indicators. ITSA is a desired method to evaluate health policies, especially for indicators that measure repeatedly in a defined population over a period of time [16]. For our analyses, we developed ITSA regression models applying the following steps using R (R Core Team, 2021) [17].

Step 1: study design and its appropriateness

Population and data

This study evaluated the impact of the UFPP, using 14 years of health-related indicator data that were extracted from the official annual reports of the Bonab County Health Center through the Integrated Health System (SIB).

Intervention and comparison

The UFPP, as a multi-phase intervention, was applied for current study. Although the national pilot of the UFPP began in 2012 in Fars and Mazandaran provinces, the program was locally implemented in Bonab County (East Azerbaijan Province) in February 2015. In this study, the intervention time was from 2015 to 2021. In contrast, the comparison time was related to the time prior to the implementation of the UFPP (i.e., 2008–2014).

Health indicators assessed

The study employed a comprehensive set of health system performance indicators, categorized as follows, to evaluate the impact of the intervention. These indicators represent a mix of health-related outcomes, intermediate impacts, and key determinants of health that are directly influenced by primary healthcare interventions:

Reproductive health

Rates of childbearing counseling, Modern contraceptive use (MCU), Total fertility rate (TFR), and Crude birth rate (CBR). 

Maternal health

Prenatal care visits, Postpartum care visits, First-time prenatal care, ≥ 6 pregnancy care visits, Out of hospital delivery rates, Cesarean section (CS) rates, High-risk deliveries, and Maternal mortality ratio (MMR). 

Neonatal and child health

Stillbirth rate (SBR), Neonatal mortality rate (NMR), Completion rates of Ages and Stages Questionnaires (ASQ), Positive ASQ screenings, Low birth weight (LBW), Formula feeding rates, Overweight/obesity prevalence in children, Infant mortality rate (IMR), and 1–59-month-old mortality rate.

Non-Communicable diseases (NCDs)

Chronic Vascular Disease (CVD) screening coverage (≥ 30 years, high-risk groups), Diabetes management, Hypertension management, Incidence of brucellosis, and Incidence of tuberculosis.

Middle-Aged adult health

Visit rates for men, Visit rates for women, and Clinical breast examination (CBE) rates.

Geriatric care

Elderly care visit rates.

Mental Health

Mental disorder screening rate, and Mental disorder assessment rates.

Nutritional Improvement

Percentage of people overweight and obesity (5–19, 20–29, 30–49, and ≥ 60 years old).

Health promotion

Coverage of self-care programs, and Student health ambassadors program coverage.

Step 2: the impact model

In order to assess the causal associations between the program (as an intervention) and the health-related indicators of interest, we used ITSA regression models.

The segmented regression model is specified as:

Yt​=β0​+β1​Timet​+β2​Interventiont​+β3​(Timet​×Interventiont​) + et​.

Where:

• Yt: The outcome variable at time point t.

• Timet: A continuous variable indicating time since the start of the study period (2008–2021).

• Interventiont: A binary variable coded 0 for all observations before the UFPP implementation (2008–2014) and 1 for time points after its implementation (2015–2021).

• Timet×Interventiont: An interaction term capturing the change in trend following the intervention.

• et: The error term, accounting for random variability and potential autocorrelation.

• Interpretation of Coefficients:

• β0 (Intercept): The estimated level of the outcome at the start of the study period (2008).

• β1 (Time trend): Represents the underlying trend in the outcome prior to the intervention (i.e., annual change from 2008 to 2014).

• β2 (Level change): Captures the immediate effect of the UFPP, indicating any abrupt shift in the outcome level post-implementation in 2015.

• β3 (Trend change): Reflects the long-term impact, showing whether the trajectory of the outcome changed following the intervention.

• This model allows differentiation between:

• Pre-intervention trend (β1).

• Immediate level change post-intervention (β2).

• Post-intervention trend modification (β3).

This framework enables a robust examination of policy effectiveness by separating short-term shocks from gradual behavioral or system-level changes. In line with Bernal et al. (2017), we included all three core parameters—time, intervention, and interaction—to capture both level and slope changes attributable to the UFPP.

Step 3: descriptive analysis

Descriptive analyses were reported as means and standard deviations (SD) for numeric variables. The descriptive time trend line charts were used to present the process and outcome indicators over the time. Additionally, the scatter plots were generated to show the changes of process and outcome indicators over the study time points (years).

Step 4: regression analysis

Segmented regression models, as proposed by Bernal et al., [16] were applied to analyze the data, enabling the assessment of changes in trends and levels associated with the intervention.

Phase 2: qualitative content analysis

A qualitative study with a conventional content analysis approach was conducted to explore the perspective of stakeholders and key informants regarding the health impacts of the FPP. The primary research question guiding this qualitative inquiry is: “How do stakeholders (health service recipients and providers) describe the UFPP?”

A purposeful sampling method with maximum variation in terms of age, gender, work experience, residential area, and level of education was used to recruit the participants. The participants were selected from the care recipients and the experts of the program. After collaborating with the head of the center, the researcher selected the eligible participants from the five health centers in Bonab City. For care recipients, the inclusion criteria encompassed familiarity with the implementation of the UFPP, utilization of healthcare services, an age of 18 years or older, a minimum residency of 10 years in the city, and expressed willingness to participate. The inclusion criteria for key health stakeholders in the city of Bonab included experts from various units associated with the FPP, as well as directors and specialists from urban primary healthcare centers. These stakeholders were selected based on their direct involvement with the program, a minimum of one year of work experience, and willingness to participate.

The exclusion criteria for both groups were a lack of willingness to participate in the study and an inability to communicate effectively with the research team.

Data were collected through semi-structured individual interviews using a pre-designed interview guide tailored for each participant group (Supplementary file- Sect. 1). The interview guides were developed based on the study objectives, a review of relevant literature, and discussions among the research team to ensure content validity. Questions were open-ended to elicit detailed experiences, perceptions, and views regarding the health impacts of the FPP. Nineteen individuals (key informants = 7, service receivers = 12) participated in the qualitative phase of study. The details of participants characteristics are provided in Supplementary file (Sect. 4).

For care recipients, the interview typically began with a general question: " How would you describe the UFPP?“, followed by specific questions about service quality, changes in lifestyle and health status, as well as expectations and perceived challenges. For key, initial question addressed the quality of services under the FPP, followed by queries about the advantages, disadvantages, challenges, impact on population health and behavior, and evaluation of novel services introduced by the program. Additionally, questions were included to explore whether factors other than the UFPP may have influenced population health from the perspectives of both experts and community members. Throughout all interviews, complementary probing questions such as “Can you explain more?” and “What do you mean?” were used to encourage further exploration and gather detailed insights. Interview guides were pilot-tested with a small sample to refine clarity and relevance. All interviews were conducted face-to-face, allowing participants to freely express their opinions and experiences.

The time and place of the interview sessions were determined by mutual agreement between interviewee and the interviewer. Hence, the place of interview was either the health center or the interviewer work place. Each interview lasted between 30 and 60 min. The interview continued until the data was saturated [18].

The conventional content analysis based on the Graneheim and Lundman method was used [19]. The interviews were transcribed verbatim and read several times to achieve a sense of the whole. Then, the data were broken down into units of meaning that were extracted from the statements and labeled with conceptual names (codes). After this open coding, the codes were compared based on similarities and differences and grouped into categories. Each subcategory with similar mean was grouped together as categories, and the categories are then grouped as main categories [20]. The extracted codes were also managed using MAXQDA 2018 text data organization software.

Trustworthiness

The trustworthiness of the research was established using Guba and Lincoln’s evaluation criteria for data credibility [21]. prolonged engagement with participants during interviews built rapport and improved insight. Peer debriefing sessions helped clarify the research team’s stance on data interpretation and analysis. The team consistently verified interview data and findings throughout the study. Member checking was employed to test analytical categories, interpretations, and conclusions. Detailed documentation of all research steps ensured auditability and reliability. COREQ guidelines were followed for transparent reporting [22].

Phase 3: data integration

Integration of quantitative and qualitative data occurred primarily at the interpretation phase in disscussion, following separate analyses of each data type. The quantitative findings from the ITS analysis (regarding changes in health indicators) were compared and contrasted with the qualitative findings (regarding stakeholder experiences and perceptions). This process aimed to:

• Triangulate findings: Identify areas where both quantitative and qualitative data converged to provide stronger evidence for the program’s impact.

• Explain quantitative findings: Use qualitative data to provide context and explanations for the observed trends or lack of change in the quantitative outcomes.

• Explore divergent findings: Investigate discrepancies between the quantitative and qualitative results to gain a deeper understanding of the complexities of the program’s implementation and impact.

• Generate richer insights: Combine the strengths of both approaches to provide a more nuanced and comprehensive understanding of the FPP’s impact than would have been possible with either method alone.

A visual overview of the study process is shown in Fig. 1.

Fig. 1.

Phases of the study implementation

Reporting

Quantitative and qualitative findings were synthesized in a triangulated format to ensure a balanced interpretation of the UFPP’s health effects. Reports were reviewed by local stakeholders to validate the practical relevance and accuracy of interpretations.

Monitoring and Follow-up

While formal prospective monitoring was outside the scope of this retrospective HIA, our analysis included trend comparisons and stakeholder-reported outcomes to offer actionable recommendations. These findings are intended to inform policy adjustments and guide future monitoring strategies by local health authorities.

Ethics

Ethical approval was provided by the Ethics Committee of the Tabriz University of Medical Sciences. All participants provided informed consent, and confidentiality was maintained throughout the study.

Limitations & sensitivity analyses

The study faced several limitations: (1) Due to the annual reporting of outcome and process indicators, seasonal analyses could not be conducted. (2) numerous process indicators were not measured before implementation of the program, so, it was virtually impossible to compare their data before and after the intervention (3) maternal education level had to be considered as a confounder for maternal, infant and child mortality outcome indicators, but we did not have information on this factor. (4) Since the control group was not available for comparison and some indicators overlap conceptually (e.g., various maternal health metrics), and may be influenced by broader health system reforms or national-level policies unrelated to UFPP. To address this, we conducted sensitivity analyses by: (a) grouping highly correlated indicators to prevent overestimation of effects, (b) comparing indicator changes with national trends reported in Ministry of Health reports to contextualize observed patterns, and (c) discussing plausible alternative explanations in the interpretation of results. Additionally, Qualitative data from stakeholder interviews and policy reviews were integrated to identify and contextualize external influences. These adjustments aimed to isolate UFPP effects, though limitations persisted, as noted in the Limitations section.

Results

Quantitative phase

This study evaluated multiple health indicators to assess the impact of the UFPP. ITSA were conducted where sufficient pre- and post-intervention data were available. For certain indicators where data limitations prevented meaningful time series analysis, descriptive statistics are reported and corresponding trends are illustrated in time-series (Fig. 2) and scatter plots figures (Figs. 3 and 4, and Supplementary file - Sects. 2& 3).

Fig. 2.

Trends of changes in primary health indicators, a, Reproductive health and delivery indicators, b, maternal health indicators, c, neonatal and child health indicators, d, communicable and non-communicable disease indicators, over the study period (2008–2021) in urban areas of County Bonab, East Azerbaijan province, Iran

Fig. 3.

Scotter plot of changes in Reproductive and maternal health indicators, a total fertility rate, b cesarian section delivery rate, c delivery in high-risk group rate, d maternal mortality rate, and e out of hospital delivery, over the study period (2008–2021) in urban areas of County Bonab, East Azerbaijan province, Iran

Fig. 4.

Scotter plot of changes in Neonatal and child health indicators, a still birth rate, b infant mortality rate, c neonatal mortality rate, d 1–59-month mortality rate, e low birth weight rate, and f infant formula rate, over the study period (2008–2021) in urban areas of County Bonab, East Azerbaijan province, Iran

Reproductive health

The analysis of reproductive health outcomes demonstrated multifaceted impacts of the UFPP. For the TFR, the intervention was associated with a statistically significant immediate increase, followed by a significant negative interaction effect, suggesting a declining trend over time. The mean TFR rose from 1.94 pre-intervention to 2.08 post-intervention, aligning with the model’s findings.

The mean MCU rate declined markedly from 61.46% before the intervention to 26.31% afterward. However, this decline coincided with national policy changes—specifically, the discontinuation of free contraceptive provision—which likely contributed to the observed reduction. Due to this confounding factor, and the inability to conduct ITS analysis on this indicator, we refrain from attributing this change directly to the UFPP. Instead, descriptive statistics are presented in Supplementary File (Sect. 2) to reflect the trend.

The CBR exhibited a marginally significant interaction. Descriptive analysis showed a decline from a mean of 19.40 to 16.09, suggesting a potential reduction in birth rates following UFPP implementation.

Maternal health

Regarding maternal health indicators, the CS rate remained relatively stable pre- and post-intervention (57.60% vs. 57.33%). Although regression analysis suggested a slight, non-significant annual increase and a non-significant immediate decrease following the intervention, these effects did not reach statistical significance. Similarly, despite a notable reduction in the MMR from 23.97 to 12.13, ITS analysis indicated no statistically significant intervention effect, and the model explained only a modest portion of the variance.

The rate of DHRG increased slightly post-intervention (mean: 24.24 vs. 20.98), but ITS analysis showed no significant intervention effect. Nevertheless, the model accounted for approximately 48.5% of the variance, suggesting moderate explanatory power.

Neonatal and child health

For neonatal and child health outcomes, ITSA detected a significant immediate reduction in the IMR post-intervention, alongside a positive interaction effect, indicating a moderation of the initial decline over time. Mean IMR decreased slightly from 9.97 to 9.52, corroborating model predictions.

Other indicators, including SBR; (0.806 to 0.638), NMR; (6.83 to 6.80), and 1-59MR; (5.08 to 4.16), showed minor declines post-intervention; however, these changes were not statistically significant.

The mean proportion of LBW infants increased from 4.55% pre-intervention to 7.28% post-intervention. Despite the model’s strong explanatory power (adjusted R² = 0.78), ITS analysis found no significant effect of the intervention or time interaction.

The IFR decreased from 2.87 to 2.42% following the intervention. ITS analysis suggested a borderline immediate effect and a marginally significant interaction with time, warranting further longitudinal investigation. 

Non-Communicable diseases (NCDs)

The mean tuberculosis incidence decreased notably from 10.83 to 5.88 cases. ITS analysis revealed a statistically significant decreasing trend over time, without a significant immediate intervention effect or time interaction, indicating that the observed decline was likely attributable to broader epidemiological trends rather than the intervention.

Similarly, brucellosis incidence declined from 21.84 to 6.93 cases. A significant downward trend over time was observed, but no significant immediate effect or time interaction was detected.

Middle-Aged adult health

The mean of the CBE rate improved from 21.08% pre-intervention to 29.54% post-intervention. However, ITS analysis showed that neither the time trend, the immediate intervention effect, nor the interaction effect were statistically significant. The model exhibited moderate explanatory power, yet the overall model was not significant, limiting the strength of causal inferences.

Qualitative phase

Nineteen individuals (key informants = 7, service receivers = 12) participated in the qualitative phase of study. The details of participants characteristics are provided in Supplementary file (Sect. 4). The experiences of participants in this field were organized into Qualitative content analysis led to the identification of five main categories “Changes in Health-Oriented Beliefs and Behaviors of Service Recipients”, “Quantitative and Qualitative Enhancement of Service Delivery”, “socio-cultural and economic challenges”, “interpersonal communication” and “inefficient management” (Supplementary file- Sect. 5). While the latter three themes have been previously reported [23], this section primarily presents findings from the first two categories, with a brief contextual reference to the published themes to ensure a holistic evaluation of health outcomes.

First main category: changes in health-oriented beliefs and behaviors of service recipients

This category expresses shifts in service recipients’ health perceptions and practices following the UFPP implementation, encompassing “heightened health sensitivity “and “lifestyle adjustments”. Participants attributed these changes to the program’s multidisciplinary approach, which integrated family physicians with allied health professionals, such as nutritionists and psychologists, and emphasized personalized counseling. systematic follow-up, and stronger patient–provider relationships, distinguishing it from prior health center services that offered general lifestyle counseling and screening.

For instance, Healthcare Recipients (HR) noted increased vigilance toward their health, spurred by new screening and education initiatives: “I got a Pap smear and mammogram… the staff’s advice made me think about my health” (P14, HR). This reflects a broader pattern of enhanced health literacy, especially among women for breast and cervical cancer screening.

This mindset change also extended to lifestyle, with participants reporting healthier dietary choices like cutting out fizzy drinks, and increased physical activity. Tobacco reduction was also noted, though partial “He smokes outside now” (P1, HR).

Second main category: quantitative and qualitative enhancement of service delivery

This category highlights UFPP-driven improvements in service provision, focusing on expanded diversity and accessibility. It includes six sub-themes:

Increased diversity of services

The program has significantly expanded the range of services, transforming healthcare delivery. One of the Healthcare providers (HP) stated: “Referring pregnant women to psychologists ensures their mental health is monitored” (P8, HP).

Enhanced community participation

The program’s comprehensive services have boosted participation across age and gender groups, engaging men, youth, and the elderly alongside women and children: “Entire families now participate—elderly referrals have surged, unlike their rare visits before” (P4, HP).

Improved access to health services

The program has enhanced both geographic and financial access to care. The addition of physicians to health centers has increased service availability, particularly in underserved areas. A participant explained “I can now afford tests that would’ve been prohibitive outside” (P1, HR).

Early detection of non-communicable diseases

Screening initiatives have proven critical in identifying and managing chronic conditions likes, hypertension, diabetes, and breast cancer. One of the participant shared: “My mother-in-law’s diabetes and hypertension were caught through screening in health centers” (P6, HR).

Reduced unnecessary specialist referrals

The program’s robust primary care services have decreased reliance on specialists. A participant stated: “I check with the health center first—if they can’t help, then I seek a specialist” (P15, HR).

Lower out-of-pocket costs

By providing free or subsidized services, the program has alleviated financial burdens. Participants reported significant savings on medications and consultations. One participant noted: “Free physician visits and tests make care affordable for those who can’t pay” (P 12, HR).

Contextual reference to previously reported challenges

To contextualize these positive outcomes, it is pertinent to acknowledge barriers identified in prior work [23]. Socio-cultural and economic challenges, Interpersonal communication difficulties, and Inefficient management, undermined service effectiveness. These challenges, detailed elsewhere, interacted with the reported benefits, shaping the UFPP’s overall health impact.

Integration phase

In the last phase, the finding of the quantitative and qualitative phases of the study were compared using a interpretive approach and formed policy implications and strategic recommendations, as recommended by Creswell and Plano Clark [24]. A matrix approach [25] was used to align quantitative results from the trend analysis (2008–2021) with qualitative themes derived from stakeholder interviews. The triangulation process identified areas of convergence, divergence, and complementarity to provide a comprehensive evaluation of the FPP’s impact on urban peoples health in Bonab County and to formulate evidence-based policy recommendations. The sensitivity analysis checks were performed to address potential confounding factors and improve the robustness of the findings. Integrated interpretations are presented in the Discussion section and summarized in Table 2, which juxtaposes key quantitative trends with corresponding qualitative themes.

Table 2.

Summary of qualitative findings

Main Category	Subcategory	Illustrative Quote/Code
1. Changes in Health-Oriented Beliefs and Behaviors of Service Recipients	1.1 Heightened health sensitivity	“I underwent a Pap smear and mammogram after health workers’ recommendations.” (P14, HR) “Since the health worker referred my son to a nutritionist, he eats more mindfully.” (P15, HR)
	1.2 Lifestyle adjustments	“We’ve reduced soda intake and now consume milk, yogurt, and cheese.” (P7, HR) “My mother-in-law’s diabetes and hypertension were diagnosed through screening.” (P6, HR)
2. Quantitative and Qualitative Enhancement of Service Delivery	2.1 Increased diversity of services	“This scheme provides lifelong care, reshaping community perceptions.” (P4, HP)
	2.2 Enhanced community participation	“Entire families now participate—elderly referrals have surged.” (P4, HR)
	2.3 Improved access to health services	“New clinics in remote areas ensure broader service reach.” (P3, HP)
	2.4 Early detection of Non-Communicable Diseases	“My mother-in-law’s diabetes and hypertension were caught through screening.” (P6, HR)
	2.5 Reduced unnecessary specialist referrals	“Clients are satisfied with our thorough care, reducing specialist visits.” (P5, HP)
	2.6 Lower out-of-pocket costs	“Free physician visits and tests make care affordable for those who can’t pay.” (P12, HR)
3. Socio-cultural and Economic Challenges	3.1 Adherence to indigenous norms	“Despite training, people believe solid oil is beneficial.” (P4, HP)
	3.2 Financial difficulties	“We advise people to increase protein intake, but they say it’s not affordable.” (P4, HP)
4. Interpersonal Communication difficulties	4.1 Disrespectful behaviors	“Healthcare providers are careless, impatient, and do not communicate positively.” (P3, HP)
	4.2 Lack of trust in healthcare providers’ competencies	“I do not trust doctors here because I did not receive good services.” (P12, HR)
5. Inefficient Management	5.1 Temporary hiring and inefficient workforce	“Most physicians in these centers are inefficient and unsatisfactory.” (P12, HR).
	5.2 Lack of resources	“In Iran, one doctor serves 10–12 thousand people, unlike 1,000 in Canada or UK.” (P3, HP).
	5.3 Poor announcement and notification	“People don’t know enough about FPP services. Awareness is low” (P4,HP).
	5.4 Quantity orientation and poor quality of service delivery	“…Sometimes the healthcare providers become so preoccupied with registering the number of health services in electronic system that they forget to teach the important subjects, such as teaching mothers how to make baby food, while one of our main tasks is health education” (P3, HP).

HR Healthcare Recipient; HP Healthcare Provider

Discussion

In a concurrent mixed-methods design, the discussion section plays a crucial role in integrating quantitative and qualitative findings to provide a comprehensive interpretation of the results [15]. In this study, we have adopted an interpretive approach by first presenting a statistical outcome and then aligning these findings with qualitative data. This process facilitates a deeper understanding of the phenomena under investigation, ensuring that numerical trends are contextualized through participants’ experiences and perspectives.

To further illustrate this integration, Table 3 presents a matrix aligning the quantitative trends (2008–2021) with key qualitative themes. This triangulation highlights areas of convergence, divergence, and complementarity between statistical outcomes and stakeholders’ perspectives, offering a more holistic understanding of the FPP’s health impacts and informing actionable policy recommendations.

Table 3.

Triangulation matrix: integrated comparison of quantitative and qualitative findings with sensitivity analyses

Health Domain	Quantitative Results	Qualitative Findings	Integration Insight	Interpretive Summary	Grouping of Correlated Indicators	Comparison with National Trends	Alternative Explanations
Reproductive Health (TFR, MCU, CBR)	TFR increased initially then declined over time; MCU dropped sharply; CBR declined slightly	Participants reported restricted access to contraception and dissatisfaction with policy changes	Convergent: Decline in MCU aligns with reported dissatisfaction and barriers to access	Decline in contraceptive use and TFR changes were shaped by both UFPP and concurrent population policies. Stakeholders expressed concern over reduced contraceptive availability and increased unplanned pregnancies.	TFR, MCU, and CBR were grouped, due to high correlation in reproductive metrics to avoid overestimation of UFPP effects.	TFR& MCU declined; The sharper decline in MCU in Bonab suggests UFPP-specific access issues in the county.	National family planning policy changes (end of free contraception)
Maternal Health (CS rate, MMR, DHRG)	No significant trends; MMR declined but not significantly; CS rate stable	Perceptions of overburdened staff and insufficient care continuity were noted	Divergent: Stakeholders reported poor service quality while quantitative improvements were minimal	Lack of significant improvement in outcomes reflects underlying service delivery issues and managerial inefficiencies. CS outcomes are confounded by the Health Transformation Plan.	CS rate, MMR, and DHRG were grouped to account for overlapping maternal health indicators and prevent overestimation of effect.	Nationally, CS rates were stable; MMR declined; DHRG was stable. Bonab’s trends align with national patterns.	Overlap with Health Transformation Plan reform.
Child Health (IMR, NMR, 1–59MR, LBW)	Significant immediate reduction in IMR; other indicators showed non-significant decline	Participants acknowledged improved child checkups, but emphasized that socioeconomic barriers remained	Complementary: Some perceived improvements were not strongly supported by data	Gains in IMR may reflect the UFPP’s enhanced screening, but child health is still shaped by broader structural determinants beyond healthcare access.	IMR, NMR, 1–59MR, and LBW were grouped to correlated child health outcomes to mitigate overestimation.	IMR, NMR, 1–59MR declined. LBW was stable. The steeper decline in IMR in Bonab suggests UFPP impact.	Socioeconomic constraints
Non-Communicable Diseases (TB, Brucellosis)	Declining trends but not due to UFPP (no intervention effect)	Participants reported better detection and management due to more regular checkups and structured screening	Divergent: Perceived improvements not statistically attributed to UFPP	The decline likely reflects national epidemiological trends; however, UFPP improved access to early detection, which stakeholders valued.	Grouped TB + Brucellosis shows same trend	The trends of Bonab are align with national declines.	National TB control programs and veterinary surveillance improvements likely drove declines, independent of UFPP.
Preventive Behavior & Health Awareness (CBE)	CBE rate increased slightly but not significantly	Participants noted increased awareness and engagement with screening, driven by personalized counseling	Convergent (partial): Awareness increased, but behavior change limited	The UFPP fostered a culture of health sensitivity, but measurable behavior changes (e.g., screening uptake) were constrained by trust issues and socioeconomic barriers.	Single indicator	Limited national trend data	Trust issues, socioeconomic barriers

Following the implementation of the UFPP, a clear downward shift in modern contraceptive coverage was observed, accompanied by an upward trend in fertility patterns (TFR). This likely reflects the combined influence of the UFPP and concurrent national pronatalist policies, which shaped both service availability and public behavior [26]. The qualitative findings support this interpretation, revealing widespread dissatisfaction with reduced access to contraceptive methods. Participants noted that changes in service provision, coupled with sociocultural sensitivities, limited their ability to obtain reproductive health services. Together, these patterns suggest that the observed reproductive health outcomes are influenced not solely by the UFPP, but also by broader policy shifts and social norms. This underscores the importance of aligning program implementation with community needs and ensuring continuity in essential health services [27].

This mixed pattern reflects the intersection of service delivery and broader policy mandates, as explained by the WHO Social Determinants of Health Framework, which emphasizes how macro-policies influence health behaviors and outcomes beyond clinical settings.

Furthermore, the rise in fertility among high-risk age groups (under 18 and over 35) was consistent with findings from Alizadeh et al. (2022) in rural Azerbaijan [28]. Participants attributed this trend to socioeconomic pressures and shifting cultural norms, such as delayed childbearing among educated urban women and early marriage in underserved populations [27, 29]. This contrast reflects contextual diversity, where rural and urban subpopulations may experience the same policy differently due to varying baseline conditions and support systems.

Quantitative data indicated a slowdown in the rise of CS rates post-UFPP, though the trend remained upward overall. This short-term stabilization aligns with other studies examining CS within FPP [28, 30, 31]. However, the simultaneous implementation of the HTP—which included specific strategies to reduce CS rates—likely confounded the effect of the UFPP [32]. This reinforces the importance of controlling for policy-level confounders in health impact evaluations. Without accounting for such simultaneous interventions, the findings risk over- or underestimating the true effect of the family physician program.

To explain this interaction, we draw upon Donabedian’s model, which separates health system performance into structure, process, and outcome [33]. While the UFPP improved the structure (e.g., provider teams), challenges in process (e.g., referral inefficiencies) limited outcome improvements like CS reduction.

Qualitative findings confirmed this complexity. Stakeholders noted structural and systemic issues influencing delivery choices, such as workload pressure on physicians, unclear care responsibilities, and lack of follow-up, suggesting that structural reforms must be matched with operational changes.

Access to healthcare is fundumental for improving maternal health outcomes and reducing MMR. Previous studies have shown that enhanced access to healthcare services can lead to better quality of care and a significant decrease in maternal mortality [34, 35]. However, the implementation of FPP has produced heterogeneous outcomes. While some studies report improvements in maternal health indicators, others indicate persistent challenges, such as increased MMR post-intervention, potentially due to factors like poor service quality or social determinants of health [36, 37]. In alignment with these findings, our study observed that, the UFPP faced difficulties in sustaining maternal health gains, likely due to systemic issues in care delivery. Stakeholders emphasized that high workloads and staffing shortages compromised service quality. Such observations are consistent with the conclusions of Koblinsky et al. (2021), who similarly emphasized that gains in healthcare access do not invariably translate into improved outcomes in the presence of service inadequacies [38]. These challenges underscore the need for further research to identify and mitigate discrepancies in UFPP implementation to enhance maternal healthcare delivery.

The UFPP’s implementation increased healthcare providers, including physicians and midwives, aiming to enhance child health outcomes, but significant improvements were limited to infant mortality, with minimal impact on neonatal, stillbirth, and 1–59-month mortality rates. Previous studies on the FPP show mixed results, with some reporting reductions in infant mortality and stillbirth rates but not in under-five mortality, aligning with our findings [36, 37, 39, 40]. Stakeholders emphasized that systemic barriers, such as inadequate resource allocation and socio-cultural challenges, constrained the program’s effectiveness, suggesting that child mortality is influenced by social, economic, and cultural determinants beyond healthcare access [41, 42]. Consequently, future FPPs should integrate socio-economic interventions, such as improving nutrition access and addressing cultural barriers, to enhance child health outcomes [43]. This is best understood through the WHO SDH framework, which advocates for multi-sectoral interventions to tackle underlying inequalities in child health [44].

The UFPP sought to enhance health awareness and screening uptake, but quantitative findings revealed only a modest, non-significant increase in CBE rates, indicating limited impact on preventive health behaviors. Qualitative findings suggest stakeholders perceived heightened health sensitivity and increased engagement with preventive measures, driven by the UFPP’s multidisciplinary team-based approach and personalized counseling. However, cultural resistance, economic constraints, and relational barriers, such as limited trust and inadequate provider–patient communication, hindered sustained behavioral adoption. This disconnect can be explained using the Health Belief Model, which shows that awareness alone does not predict action. Barriers such as trust deficits, low health literacy, and weak provider–patient communication (as also shown in Jerome-D’Emilia, 2021) [45] can prevent behavior change.

To improve program effectiveness, policymakers should prioritize strategies that focus on strengthening provider–patient relationships, improving care continuity, and addressing socio-economic barriers to translate awareness into actionable health outcomes.

While interpreting the findings of the present study, it is essential to acknowledge the undeniable impact of economic sanctions against Iran on the implementation, funding, and performance of health indicators. Sanctions, as a social determinant of health, have indirectly affected Iran’s healthcare system [46] and directly contributed to the rising trend in child mortality rates [47]. These repercussions may result in significant challenges in delivering healthcare services, promoting public welfare, and ensuring equitable access to the necessities of a standard life—such as nutritious food, healthcare, and essential medicines—particularly affecting the lives of patients, women, and children [48, 49].

Policy implications and strategic recommendations

Based on the findings of the HIA and stakeholder feedback, several policy interventions are recommended to enhance the effectiveness of the UFPP. To close existing implementation gaps, the Ministry of Health and Medical Education should prioritize the recruitment of skilled, permanent personnel and invest in infrastructure development, particularly digital connectivity and facility adequacy.

Integrating social determinants of health through mechanisms such as social prescribing and health literacy promotion is essential to improve long-term health outcomes.

Enhancing service specialization—such as assigning specific staff to areas like school health education or dental care—could reduce inefficiencies and increase accessibility.

Additionally, targeted public awareness initiatives and a robust referral system are critical to improving service uptake, especially among underserved populations such as men.

These reforms, in conjunction with socioeconomic improvements, have the potential to substantially amplify the UFPP’s public health impact.

Limitations

This study’s novelty, particularly its mixed-methods HIA approach to the UFPP in a specific Iranian context, precludes direct comparison with prior HIAs, though indirect parallels exist.

A primary limitation was the inherent challenge in isolating the precise impact of the UFPP from other concurrent health sector reforms. Specifically, the UFPP’s implementation in Bonab County (2015) occurred within the broader context of Iran’s HTP, which commenced in 2014. While the UFPP itself represents a key strategic component of the HTP aimed at strengthening primary healthcare, disentangling its isolated effects from other simultaneous HTP initiatives or other unmeasured socio-economic factors is complex in a real-world setting.

Furthermore, the COVID-19 pandemic, which significantly impacted Iran from early 2020 and falls within our post-intervention study period (2015–2021), introduced an unprecedented external shock. This global health crisis fundamentally altered healthcare service utilization patterns and health behaviors, potentially confounding the observed trends in the later years of our quantitative analysis. While ITSA inherently controls for pre-existing secular trends and autocorrelation, our model did not explicitly account for the distinct interruption caused by the pandemic or other specific concurrent interventions.

Another notable limitation concerns the data availability for certain indicators. The recent integration of services such as NCDs, nutrition, and mental health into the primary care network limited the availability of consistent historical data for these specific areas, thereby constraining comprehensive longitudinal analysis via ITSA. Despite observed short-term gains in some areas, the full long-term impact on these newly integrated services could not be thoroughly assessed, necessitating future research with more extended data.

Notably, the absence of a directly comparable control group represents a significant limitation in terms of definitive causal inference. While the robust nature of ITSA allows for controlling pre-existing trends and provides strong evidence of association, without a control group, we cannot confidently rule out the influence of other concurrent health system changes, secular trends, or unmeasured confounders or other contextual changes that might have occurred uniquely in Bonab County during the study period. This restricts our ability to make definitive causal claims solely attributable to the UFPP. We recommend that future evaluations incorporate matched control regions or synthetic control methodologies to improve causal attribution. These constraints highlight the need for extended evaluation periods to fully gauge the UFPP’s health impact.

Conclusion

This mixed-methods HIA highlights the UFPP’s complex influence on public health in Bonab County, revealing both achievements and challenges. The program positively influenced reproductive and child health outcomes, alongside fostering greater health awareness and service accessibility among stakeholders, driven by its multidisciplinary, team-based approach. However, persistent socio-cultural, economic, and management barriers limited its overall effectiveness, particularly in sustaining improvements in maternal health and screening uptake. Stakeholders emphasized that socio-economic determinants, such as employment and economic stability, are critical to enhancing health outcomes, underscoring the need for health system reforms to integrate with broader social welfare policies. Based on the integration of quantitative and qualitative findings, strengthening the UFPP requires comprehensive reforms: strengthening human resources and infrastructure, reducing service fragmentation, increasing public engagement through targeted health communication, and establishing robust referral systems. Beyond Iran, these findings provide a framework for evaluating and strengthening primary care initiatives in similar socio-economic contexts, contributing to global health equity efforts. The mixed-methods HIA approach proved valuable for evaluating complex interventions, offering a template for future research and policy evaluation. By prioritizing equity, addressing social determinants, and fostering system-level improvements, programs like the UFPP can advance sustainable health impacts and support the Sustainable Development Goals.

Abbreviations

FPP

Family Physician Program

HIA

Health Impact Assessment

WHO

World Health Organization

WONCA

World Organization of Family Doctors

UFPP

Urban Family Physician Program

ITSA

Interrupted Time Series Analysis

MCU

Modern contraceptive use

TFR

Total fertility rate

CBR

Crude birth rate

CS

Cesarean section

MMR

Maternal mortality ratio

SBR

Stillbirth rate

NMR

Neonatal mortality rate

ASQ

Ages and Stages Questionnaires

LBW

Low birth weight

NCDs

Non-Communicable Diseases

CVD

Chronic Vascular Disease

CBE

Clinical breast examination

SD

standard deviations

SIB

Integrated Health System

AMT

Abbreviated Mental Test

HTP

Health System Transformation Plan

Authors’ contributions

Conceptualization: HN and PH. Data collection: PH and MH. Data analysis: PH, MH, and AJ. Manuscript drafting: PH, HN, and MH. Manuscript review and editing: HN, PH, and AJ.

Funding

Tabriz University of Medical Sciences provided financial resources.

Data availability

The datasets generated and analyzed during the current study are not publicly available due to the sensitive and confidential nature of qualitative data but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki, ensuring the protection of participants’ rights, dignity, and well-being. Ethical considerations were addressed, with the study protocol approved by the ethics committee of Tabriz University of Medical Sciences. The aim and process of the study were explained to the participants, and each interview was conducted individually in a private space. The interviews were recorded anonymously using code numbers. Clinical trial number: not applicable.’

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.