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

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.