Evaluation Strategies of Iran’s Medical Education Policies

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Introduction
Education, as the university's paramount mission is the basis for sustainable human development. 1The educational endeavors of any nation can be viewed as an investment made by one generation for the benefit of the next. 2 Medical universities play a pivotal role in advancing public health. 3The evaluation of medical education policies is of great importance.Researchers in political, economic, and social transformation must pay more attention to higher education in the policy sector. 4 In our ever-evolving society, the demands for constant change and progression necessitate a continuous restructuring of higher education across all dimensions.This includes a radical rethinking of educational approaches. 5olicy forms are affected by various stakeholders at the global, national, and local levels. 6Kante and Ndayizigamiye, 7 demonstrate that several issues, including a workforce shortage in the healthcare sector, climate change, demographic shifts, and changing lifestyles, pose significant challenges for policymakers in developing countries.To address these concerns effectively, it is crucial to establish policies that not only propose practical solutions but also provide clear guidelines for their implementation and utilization.
For decades, the definition of evidence, its roles in policy and practice, and the ways to enhance and support these roles have been the subject of discussions among research funders, users, and producers. 8The evaluation of the policymaking process and its outcomes is conducted through a limited-scope experimental implementation or primary performance.This involves data collection, which can be either quantitative, qualitative or a combination of both methods.The main criteria for evaluating educational policies are the educational objectives.These objectives serve as the key indicators for policy evaluation. 9Broadfoot stated that politicians worldwide are turning to changes in assessment practices to influence policy decisions related to the conduct and desired outcomes of education.They have recognized that if the stakes are high enough, with individual life chances hinging on the results of these assessments, any alterations in the form or content of what is being measured will lead to corresponding shifts in curriculum emphasis. 10Studies in Europe showed that the reform of higher education policies had increased the importance of prestige and reputation for European higher education institutions (HEIs). 11,12Policies are expertly interpreted and changed in the field of action, and rhetoric, literature, and the meanings of policymakers are not always executed directly and explicitly in institutional ways.There is resistance against policies, and sometimes they are implemented incorrectly or simply not applicable. 13n addition to providing health care services, medical universities have an important role in training expert and skilled manpower needed by different sections of society. 8edical education has gained astonishing developments simultaneously with the change in the entire higher education system of the world.The efforts of Abraham Flexner from the 1910s to 1940s sparked the first wave of medical education reform in Western countries, the result of which was an emphasis on curriculum standards and the provision of a planned learning experience.The second wave of reform took place from the 1960s until the 1980s in medical education of the world, which was influenced by the tremendous progress made in the andragogy learning theories.Scientists have noticed fundamental differences between the learning approaches of pedagogy and andragogy.The results of the second wave of reforms were the changes in educational methods and positions. 14he concern about evaluating public policies or programs is something that has recently been incorporated into the political agenda, since administrators' priority was channeled into the policy formulation process, with little emphasis on the other stages of the cycle. 8,15he history of formal university education in Iran has a rich heritage, dating back to 1700 years ago.However, the journey of science and technology policymaking in Iran embarked on a new path approximately 100 years ago. 16he Ministry of Health and Medical Education in Iran formulates legislation in collaboration with the Islamic Parliament of Iran, aligning with overarching documents such as general policies and the 20-Year Perspective Document for Iran.Policies in the realm of medical education have been delineated since the inception of the Ministry of Health and Medical Education, keeping pace with global advancements.These policies have been adapted at various times to meet the specific needs of the country's medical sciences, which the most important ones are as follows 17 : • General policies of the health system • Comprehensive scientific health plan • University strategic plan in medical education • Transformation and renovation document of Iranian medical education The transformation and renovation document of Iranian medical education was another policymaking experience in medical science education, compiled in 2011 by the Deputy of Education, Ministry of Health and Medical Education.This document, which emphasized the scientific and ethical foundations of the evolution and improvement of medical education, was not approved by any of the legal authorities inside or outside the Ministry of Health and remained within the limits of theoretical definitions. 18ver the past 25 years, medical education in the country has experienced substantial quantitative growth.This progress has effectively addressed the shortage of health care providers in the nation.The expansion of medical universities, the introduction of educational programs leading to certification, and the maximization of educational capacity have all contributed to this achievement. 19Evidence shows that there are concerns about learning in medical education today, 20 which needs further investigation for its evaluation.Medical education has not been fundamentally revised in the last 30 years, and administrative reports or news interviews of some university presidents in recent years have emphasized the need to improve policymaking processes and adopt clear policies in this regard.Furthermore, the integration of medical education with the health system is still one of the points of disagreement among the policymakers and implementers of this education, and it seems that one of the solutions to sufficiently convince the implementers is to use appropriate policy approaches and strategies in policy evaluation.The current study looks for the identification of strategies for evaluating medical education policies qualitatively and quantitatively.It is hoped that it would pave the way toward real solutions in this field at the community level by showing the hidden and apparent aspects of medical education policy evaluation strategies.The results of this study can lead to improved policies and provide superior strategies in the field of medical education by presenting strategies for evaluating medical education policies.

Materials and Methods
This study aimed to identify strategies for evaluating medical education policies in Iran.In this regard, this research has been conducted in two qualitative (grounded theory) and quantitative (cross-sectional survey) phases.
The grounded theory method was used to identify, and determine medical education policy evaluation strategies.The statistical population at this stage includes policymaking managers and professors of East Azarbaijan province, who were selected purposefully and nonrandomly with two approaches, intensity and snowball.
Eligibility criteria include work experience in policy groups and decision-making councils, specialized education of at least a doctorate, teaching experience in specialized higher education courses in the field of educational sciences, higher education, health management and general medical treatment, fields of study, dentistry and there have been similar areas.A semi-structured interview is used to collect data in the qualitative phase.It is tried to focus on the subject of the interview and maintain the flow of the interview continuously, with prior coordination and preliminary agreement in terms of choosing the time and place of the interview.The average duration of the interview was 35 minutes, a minimum of 16 minutes, and a maximum of 52 minutes.Examples of interview questions are: In your opinion, what strategies should be used to evaluate medical education policies?What are the ways to implement these strategies?The semi-structured interview with the experts continued until the saturation of the information, and three interviews were conducted after feeling the saturation of the data and not receiving new information to ensure the saturation of the data and new codes.A total of 17 interviews were conducted individually with 17 experts.The demographic characteristics of the participants are reported in Table 1.
Interviewees were 17 physicians and medical professors.They were 40-55 years old.The method of Strauss and Corbin was used to code the texts of the interviews.Among the reasons for using this method, we can mention the transparency of the steps of this method and the tendency of most of the grounded theory researchers in health sciences to use this method.This method consists of three basic steps: (1) open coding; (2) axial coding; (3) Selective coding (Table 2).
To validate the results of this stage of the research, both the validation by the participants and the four criteria of Lincoln and Guba's qualitative research evaluation have been taken into consideration.
In the second stage of the research, the results of coding the texts of the interviews based on themes and subthemes in the form of a 5-degree questionnaire with 61 items were designed and provided to the research sample.The statistical population at this stage included professors and educational managers of medical education in East Azarbaijan province.The more basic ratio for determining the sample size in factor analysis is the ratio of 20/1, that is, at least 20 samples for each variable.Since we had 9 variables, 180 samples were confirmed in the first stage, and considering that the minimum sample size in factor analysis using the maximum likelihood method is 200 people.therefore, a total of 200 professors and educational managers of medical education in East Azarbaijan province, were chosen.To validate the strategies at this stage, first and second-order confirmatory factor analysis tests have been used.
This research was conducted following ethical principles and the ethical requirements included obtaining the informed consent of the participants in the research and -Precise definition of information resources.
Unfortunately, it has not been defined in the information resource system.Managerial information systems are not active, or if they are active, their information is not complete and correct.Information systems must be able to be a means of decision-making.
maintaining the confidentiality of the relevant information.Moreover, the ethical identifier of the research is IR.SSRC.1399.079.

Results
The research findings are presented separately for the qualitative stage of the research, including answering the research questions, the quantitative stage of the study including the demographic characteristics of the studied sample, and the validation of the results of the quantitative analysis.In the qualitative phase of the study, the strategies for evaluating medical education policies and their components after coding the interview texts are as Table 3. Demographic characteristics of the studied sample in quantitative research: Ninety-six persons (48%) out of 200 statistical samples in this study were females, and 104 persons (52%) were males, of which seven persons (3.5%) had less than five years of experience, 68 persons (34%) had work experience of 5 to 10 years, 68 persons (34%) had a work experience of 15 to 20 years, and 16 persons (8%) had a work experience of more than 20 years.The strategies obtained from the qualitative research were provided to the respondents through a questionnaire, and the results of the first and second-order confirmatory factor analysis are as follows: Nine strategies and 61 items were used in the research factor analysis to examine the strategies related to the evaluation of medical education policies.Strategies for simultaneous attention to institutional and non-institutional agenda were examined with questions (1-6); Prioritizing social interests were examined with questions (7-10); Economic strategies were examined with questions (11-16); Updating resources and information were examined with questions (17-21); Precise definition and design of policies were examined with questions (22-28); Executive strategies were examined with questions (29-37); Systematic policy was examined with questions (38-44); Monitoring and evaluation strategies were examined with questions (45-52); Policy research was examined with questions (53-61).The criterion for validating factors and items related to each factor in the confirmatory factor analysis is that the amount of factor load is above 0.3.Accordingly, the observed factor burden of systematic policymaking and monitoring and evaluation was less than 0.3, which was not acceptable.The t-value also confirmed this result.Then, valid strategies in the validation phase were examined by eliminating systematic policy strategies and monitoring and evaluation as follows: Factor analysis of strategies related to the evaluation of higher education policies in the medical field after the elimination of invalid strategies: In factor analysis, after eliminating systematic policy strategies, Monitoring, and Evaluation, seven strategies with 46 items were entered into the analysis as the related strategies.Each item is displayed with q1 to q2 indices.The factor load observed in all cases is a value greater than 0.3, which indicates that the correlation between hidden variables and visible variables is acceptable.A significant test was performed after the correlation of variables was identified (Figure 1).
The T-value statistic was used to evaluate the significance of the relationship between variables.Based on the findings of Figure 2, the t-value of the measurement indices of each of the scales used at the 95% confidence interval is more significant than 1.96 (except question 40), which means that the observed correlations are meaningful (Figure 2).
Normal chi-square fitting indices are desirable if the value is between 1 and 5. 21 In this study, the normal chi-square is equal to 1.99, and therefore the result is desirable.The root mean square error of approximation (RMSEA) index is also used as the main fit index in most confirmatory factor analyses and structural equation models.If the value of this index is less than 0.1, the fit of the model is excellent. 22In the present model, this index is equal to 0.074, which shows that the fit of the model is also desirable.
Determining the priority and factor load of the model components: Table 4 shows the factor load of all the studied items in the item number order.According to this item, entering the field of postgraduate education in priority fields of medical sciences needs to be facilitated, which is part of the executive strategy and has the highest factor load among all items.As a result, it can be found that this variable was the most important from the respondents' point of view.

Discussion
The results of the research revealed that the strategies related to medical education policy evaluation strategies include components of simultaneous attention to institutional and non-institutional agenda; Prioritizing social interests; Economic strategies; Updating resources and information; Precise definition and design of policies; Executive strategies; Policy research is one of the related strategies for evaluating higher education policies in medical fields.Systematic thinking provides the health system with important theories, models, and approaches to understanding and assessing complexity.However, the utility and application of systems thinking for solution generation and decision-making is uncertain at best, particularly amongst health policy-makers. 23In the current study, systematic thinking in the evaluation model of medical science policies was eliminated.
Decentralization has become the buzzword of health policy over the last decades.Decentralization is thus seen as a response to poor efficiency, slow innovation, and lack of responsiveness. 24ommon interests in the study of Kheiry et al, 25 also should be considered in the implementation of the policy and executive criteria for the organization of higher health education in the Islamic Republic of Iran, which is consistent with the results obtained, including prioritizing social interests in evaluating medical higher

Strategies
Open codes (concepts)

Simultaneous attention to institutional and noninstitutional agenda
-Community-oriented policies -Family support for higher education policies -Government support for higher education policies -Normative selection from existing policies -Decentralization in the higher health education system -Offloading educational processes in various fields of admission, supervision, evaluation, etc, to academic medical universities.
-Facilitate the presence of the private sector in higher medical education at all levels Prioritizing social interests -Conformity of public issues with the proposed policies -Focus on social interests -Paying attention to the dimensions of justice -Paying attention to the general needs of people and the country -Institutionalizing a responsive higher education approach in the health system -Dynamic policymaking -Regional planning of disciplines -Effective presence in the fields of regional and global education in higher health education -Utilization of hospital information management systems in the field of higher medical education -Identify existing national, regional, and global capacities in the medical education system to create knowledge-based wealth -Signing a letter of intent with industries related to medical science education to strengthen knowledge-based education   Family and government support for medical higher education policies are beneficial to the community.0.61 Approved 3.
To obtain valuable policies, a normative choice must be made from the existing policies in higher education in medical disciplines.0.42 Approved 4. Decentralization in the higher health education system needs to be further explored.0.71 Approved

5.
The policies of entrusting educational processes in various fields of admission, supervision, evaluation, etc., should be assigned to medical universities.0.67 Approved

6.
Policies to facilitate private sector participation in higher medical education at all levels can be effective.0.64 Approved Prioritizing social interests 7.
Focusing on the public interest in medical higher education policies is a priority.0.69 Approved

8.
In medical higher education policies, more attention should be paid to the dimensions of justice.0.72 Approved

9.
Paying attention to the public needs of the people and the country in medical higher education policies can solve related problems.0.79 Approved 10.Institutionalization policies of a responsive higher education approach to the health System can be even more beneficial.education policies.In the research of Pourabbasi et al, 26 critical issues in higher health education policy in Iran include implementing programs in the context of land management, attention to international standards, and planning for actions at the international level, which is consistent with the results obtained.In the study of Barimani et al, 27 reviewing policy in higher education based on knowledge market requirements, adapting curricula to the needs of society and industry and paying more attention to the social responsibility of the university, and providing educational and motivational programs for professors, students and staff and university administrators concerning the requirements of globalization and the components of the knowledge market and their empowerment are necessary, which is consistent with the results obtained in terms of updating resources and information.The results of this study are in line with the model of Ellahi and Zaka, 28 in terms of prioritizing social interests in strategies for evaluating medical education policies, which refers to public opportunities (stakeholder participation) in the evaluation model of the higher education policy framework."Variety of educational programs", "Inclusive", and "Creating equal and continuous learning opportunities" in Kamyabi et al 29 were identified as some of the basic policies of medical education that need to be reviewed, and this finding is consistent with the results of the current study with a precise definition and design of policies that executive policies are part of the strategies related to the evaluation of medical education policies.

Conclusion
Based on the strategies identified in this research as well as related research, in a general conclusion it can be said that improving medical education based on policies and evaluating policies requires contexts such as: appropriate use of expert human resources, decentralization, community-oriented, use of private sector facilities, respect for justice, attention to ecological features, compliance with information validation standards and information sources, new technologies, organization of existing policies, improvement of institutional infrastructure, dynamics in policy making, communication with industry, continuous evaluation, organization of evaluation mechanisms, supportive policies and future research.By having such requirements, it is possible to ensure the correct evaluation of educational policies and hope for the improvement of educational policies through their revision based on the results of the evaluation, and provide effective and efficient implementation results in the medical education system.To solve the problems related to policymakers, it is suggested to adopt policies that can make more use of the bachelor's degree and higher health education in medical universities.Medical education policymakers can take advantage of the hospital information system in medical education to make the necessary arrangements to solve the problems in this area.By creating a solid health-oriented policymaking body, steps can be taken to eliminate functional weaknesses in medical education policymaking and remove political constraints.It is also possible to strengthen the medical education infrastructure by building a specialized network in policymaking of the medical education system.It can be more effective in providing economic strategies by identifying and estimating more cost-benefit in medical education policies.Strengthening the equipment infrastructure of universities and teaching hospitals connected with medical education using new and uptodate technologies can be one of the executive strategies of medical education policy.The strategy of updating information and resources by developing new medical knowledge, while emphasizing interdisciplinary areas and focusing on new science and technologies in the country and the world, can be proposed in medical sciences.

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Paying attention to the type of universities and budget and facilities -Cost-benefit detection and estimation -Diagnosis and estimation of efficiency -effectiveness -Alignment of goals and interests -Simultaneous calculation of the capacity and productivity of different departments of medical education to make good use of available facilities -Using different and diverse fields of industries in the province to educate university medical students Updating resources and information -Paying attention to the completeness and updating of information and resources -Precise definition of information sources -Defining information communities -Decisions based on actual financial information -Identify different options for funding higher medical education -Developing new knowledge with an emphasis on interdisciplinary areas and focus on new science and technologies in both disciplines Precise definition and design of policies -Designing the right goals -Designing the comprehensive map -Paying attention to policy priorities -Typology of network policy type -Organizing policies -Paying simultaneous attention to the quantity and quality of higher education policies -Eliminating redundant regulations -Paying attention to institutional infrastructure -Taking advantage of the opinions of consultants and international policies -Improving educational processes in hospitals and academic centers Executive Strategies -Formation of executive working groups -Collecting executive information -Gathering relevant information to predict results -Using expert decisions -Having an executive commitment -Cleverly determine policy implementation -Expanding the context of clinical education in medical education -Diversification of student admission, recruitment, and evaluation methods -Development of distant and virtual education patterns in both medical and non-medical disciplines -Facilitate the process of entering the field of higher education in priority fields of medical sciences -Strengthening the equipment infrastructure of universities and educational hospitals in connection with education Systematic policymaking strategy -Determining the program of policies with execution ability -Analysis and option making -Predicting the desired and unwanted results

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Institutional and realistic evaluations -Pay attention to continuous evaluations -Accurate evaluation of higher education performance -Comprehensive feedback and correction -Following evaluations -Use of technical experts in the evaluation -Use of internal and external evaluations -Normative oversight of existing policies -Strengthen evaluation mechanisms in terms of technology and human resources -Determining the correct indicators for evaluations -Conclusion and follow-up of evaluations until actual results are achieved -Evaluate policy defaults -Evaluation of expected results -Attention to localization in higher health education to distribute human resources fairly -Establishment of a professional ethics monitoring system in higher medical education -Using monitoring, evaluation, and cross-assessment teams in the field of university pole policies based on the results of scientific studies and research -Politician participation -Futurism -Establishment of a medical education land management system -Diversification of admission systems for international students in medical education -Supporting top universities to enter international competitions in the field of medical sciences -Strengthen the delegation of authority to medical universities based on the land use planning model -Creating knowledge-based wealth in the field of the higher medical education system -Production and localization of valid scientific evidence for the promotion of higher medical education (education research) Table 3. Continued.

Figure 1 .
Figure 1.Standard coefficients test components of strategies related to the evaluation of medical education policies

Table 1 .
Demographic characteristics of participants in the qualitative stage of the research

Table 2 .
Coding sample by Strauss and Corbin method

Table 3 .
Medical education policy evaluation strategies

Table 4 .
Factor burden of strategies related to the evaluation of medical education policies

Table 4 .
Devolution policies for medical universities based on the land use planning model should be strengthened.0.73 Approved 45.The importance of creating knowledge-based wealth in the medical field of higher education policy should be more than ever.0.69 Approved 46.The production and localization of credible scientific evidence for the promotion of higher medical education (education research) should be at the forefront of policymaking.0.66 Approved Continued.
Figure 2. Statistics of the t-value test for components of strategies related to medical education policies