Reza Majdzadeh

Background: In acute stroke, prehospital decisions determine whether symptom recognition leads to timely prioritisation, specialist assessment, and transfer to definitive care. East Suffolk and North Essex include coastal and rural communities where deprivation, distance, workforce configuration, and hospital-interface pressures may combine to produce unequal access to time-sensitive stroke care. This study examined how emergency-system arrangements shape inequities in the recognition, prioritisation, assessment, conveyance, pre-alerting, and transfer of suspected stroke before definitive hospital care. Methods: We undertook a qualitative study between May 2024 and July 2025 using semi-structured interviews with 11 purposively selected stakeholders in East Suffolk and North Essex, including paramedics, stroke nurses, general practitioners, managers, a neurologist, and an academic stroke researcher. The work was classified as a service evaluation. Data were analysed thematically in NVivo 14 and mapped to the World Health Organization Health System Performance Assessment (WHO-HSPA) framework and Tanahashi’s coverage model. Intersectionality was used to examine how organisational processes interacted with social and geographical circumstances to shape exposure to delay, misrecognition, and reduced access to stroke-capable care. Patients and carers were not interviewed; findings therefore reflect provider and system-stakeholder accounts. Results: Participants identified inequity where recognition had to be converted rapidly into dispatch priority, on-scene capability, pre-alerting, and transfer. Rural and coastal distance became more consequential when combined with limited mobility, complex extrication, Category 2 ambulance queueing, or secondary transfer. Limited English, communication difficulty, and atypical symptoms became more consequential when crews lacked consistent access to translation, digital tools, or specialist support. Effective coverage was further constrained where Face, Arm, Speech, Time (FAST)-oriented recognition intersected with living alone, multimorbidity, or subtle presentations. Across these domains, participants described compounded disadvantage when social and geographical circumstances interacted with uneven organisational capability and pathway design. Conclusions: Inequities in prehospital stroke care were described as arising from interactions between patients’ circumstances and emergency-system design. Organisational arrangements governing recognition, prioritisation, workforce capability, digital support, and transfer could make particular social, clinical, and geographical circumstances more consequential. The findings identify potential areas for local service review, including workforce development, digital and specialist support, transfer processes, and equity-sensitive feedback; their feasibility and effectiveness require further evaluation.

The systematic destruction of academic infrastructure, termed scholasticide, has been normalised across the Eastern Mediterranean Region (EMR) over more than two decades. The doctrine has operated through two coexisting modalities: the targeted assassination of individual scholars and the physical destruction of institutions, escalating in scale from selective killings and partial looting to the dismantling of entire academic systems. Drawing on evidence from several EMR countries, we describe a causal cascade through which acute military strikes and chronic structural exclusion, including sanctions, platform over-compliance, and visa barriers, produce generational health workforce depletion, disrupt core public health functions, and cause population-level health harms. We argue that academic institutions constitute a distinct, upstream structural determinant of population health whose destruction is an attack on health systems, not merely on education. We propose five categories of action, implemented through standing regional and international mechanisms, to protect academic infrastructure across the EMR whenever and wherever it is attacked.

Background and Aims: Rehabilitation is essential in supporting individuals with disabilities to improve their functional abilities and independence, and it is considered a key element of universal health coverage (UHC). This study examines the current considerations within Iran's rehabilitation system and offers policy suggestions aimed at strengthening and improving its performance. Methods: This qualitative study utilized a systematic review of relevant documents, 22 in‐depth interviews, and two focus group discussions (FGDs) with 24 participants from different levels of the health system. Participants included policymakers from the Ministry of Health and the Social Security Organization, rehabilitation center managers, and academic faculty. Data were thematically analyzed using MAXQDA version 22. Results: Rehabilitation services in Iran have not yet been fully incorporated into health policy and planning, which has resulted in opportunities for further development in areas such as accessibility, service availability, governance structures, stakeholder coordination, and workforce training. The current governance arrangements and intersectoral collaboration mechanisms may benefit from greater coherence to enhance overall system performance. Moving toward a more unified stewardship framework under the Ministry of Health could contribute to aligning policies and strengthening cross‐sectoral coordination. Furthermore, integrating rehabilitation services into primary healthcare represents an important step toward providing comprehensive and continuous care. Designing an evidence‐based integration model will require a systematic assessment of existing capacities and resources. Conclusion: Enhancing Iran's rehabilitation system can benefit from context‐sensitive and evidence‐informed policy initiatives. Recognizing rehabilitation as an integral component of universal health coverage may support more equitable access, continuity of services, and improved health outcomes for individuals who require such care.

Prolonged economic sanctions—often framed as non-military tools—have increasingly harmed health systems, especially where institutional and policy capacities are fragmented. Despite the growing debate on sanctions, documented analyses of health system responses remain scarce. This study examines Iran to assess how prolonged sanctions shaped its health policy architecture and resilience capacity, with attention to compounded crises such as COVID-19. Phase one synthesized seven empirical studies conducted by the authors—including document reviews, interviews, Delphi, and policy analyses—to assess how resilience principles were embedded across the four stages of the health policy cycle: agenda-setting, policy formulation, implementation, and evaluation. These findings formed the foundation for Phase two, which applied an expanded Theory of Change (ToC) framework to reconstruct policy logics, surface implicit assumptions, and identify institutional breakpoints. After modelling the ToC, a panel of experts reviewed and validated the findings, ensuring methodological rigour and contextual accuracy in mapping resilience under sanctions. The findings indicate that while Iranian health authorities implemented adaptive measures, responses were shaped by fragmented coordination, untested assumptions, and limited structured learning systems. Resilience limitations emerged during implementation and were embedded in early design phases, not fully anticipated or addressed, given the complex and uncertain policy environment. This study offers an analytical framework for mapping resilience in policy systems under long-term constraints. Building on identified governance and design weaknesses, we recommend strengthening international legal safeguards; establishing protected humanitarian corridors; institutionalizing risk-informed planning; routine scenario-based resilience testing; and feedback-driven learning mechanisms within national policy systems. These capacities are essential to absorb shocks and enable adaptive, inclusive, sustainable responses. By clarifying structural domains where resilience can be embedded in advance, the analysis offers guidance for countries under comparable pressures to target strategies in governance, planning, and resource protection. This provides a transferable blueprint for strengthening justice-oriented health systems under long-term constraints.

Introduction: Given the critical perspective of intersectionality and its potential to identify the causes of inequalities, it has been employed increasingly in studies related to health. Despite the rich theoretical evidence about intersectionality, there is a need to consider this approach empirically. This study aimed to apply the intersectionality in practice for health policy makers and researchers seeking to reduce health inequalities. In this regard, we described the development of an intersectionality-based and context-specific intervention focusing on HIV testing uptake among Afghan immigrants in Iran. Methods: This is an intervention development study. The intersectionality was used to design a peer-led intervention guided by the 2008 MRC framework. We undertook the following activities related to the three stages of the MRC framework: 1. Identifying the existing evidence (conducting a scoping review to investigate the application of intersectionality in designing and implementing health interventions; designing the checklist of applying the intersectionality in health interventions and programs); 2. Identifying and developing a program theory (conducting a realist review to identify why, how, and under what conditions peer interventions can improve HIV testing uptake among immigrants); and 3. Modeling process and outcomes (adapting the contextual factors identified by conducting a qualitative study and the realist review; extracting considerations regarding intersectionality principles using the checklist of applying the intersectionality in health interventions and programs; determining context specific, intersectionality-based and evidence-based intervention components for each of the intervention pathways). Results: According to considerations regarding checklist of application of intersectionality principles, the intervention at the different individual, organizational, and policy levels with multiple strategies should be designed to respond to needs/conditions affecting HIV testing uptake among immigrants. We determined the peer-led intervention features to improve the use of HIV testing services in Afghan immigrants following the intersectionality principles, target group needs, and contextual conditions aiming to modify power structures. Intervention strategies included HIV information provision, support, community-based services, and structural interventions. Conclusion: This study provides a practical framework for health planners and researchers seeking to reduce inequalities by presenting how intersectionality can influence the design of a health intervention. Accordingly, it is necessary to revisit the social relationships and power structures, determine the intervention components based on evidence tailored to the target group’s needs, and apply changes at different levels.