Iran Journal of Nursing

Introduction
Preterm birth is a major health challenge worldwide, accounting for approximately 1 in 10 live births, with the highest rates in South Asia and sub-Saharan Africa [1]. In Iran, the rate of preterm births varies across regions, reported at 2.5% in Guilan, 5.5% in Shiraz, 3.7% in Ahvaz, and 21.8% in Arak [2]. Advancements in healthcare have improved survival rates; however, preterm infants remain vulnerable to biological instability and health complications after discharge, including ineffective breastfeeding, respiratory instability, hypoglycemia, temperature drops, sepsis, and developmental issues [3]. These issues can persist into childhood and adulthood, making the post-discharge period crucial for ongoing health monitoring. Effective post-discharge follow-up can reduce readmission rates, improve breastfeeding and neurodevelopment growth, and enhance parent-infant interactions. The post-discharge care establishes an ongoing connection between healthcare teams and parents of infants. This connection provides a space for regular monitoring, training, counseling, and troubleshooting of care issues [4-6]. 
Studies in the U.S. and Australia have highlighted the importance of post-discharge care and follow-up of high-risk children for addressing developmental delays and long-term mental health, as well as enhancing parental confidence and anxiety [7, 8]. However, in Iran, systematic post-discharge follow-up of premature infants faces challenges. Current post-discharge follow-ups in Iran often rely on parental visits, but financial constraints limit accessibility to these services, resulting in high readmission rates and economic burdens [9, 10, 14-15]. Post-discharge follow-ups can reduce costs and improve outcomes [11-13]. This study aimed to develop a comprehensive post-discharge follow-up program for preterm infants in Iran.

Methods
This study utilizes a triangulation approach comprising four phases: Qualitative interviews, Delphi technique, SWOT analysis, and root cause analysis (RCA) tree diagram.
In the first phase, to assess follow-up requirements after discharge, semi-structured interviews were conducted with 42 neonatal care experts, including neonatologists, nurses, and developmental care specialists, from three hospitals affiliated with Isfahan University of Medical Sciences in 2021. Each interview focused on themes such as follow-up needs and discharge challenges. Data analysis was done using Graneheim and Lundman’s approach to identify core themes [14-16].
The second phase utilized a two-round Delphi technique to validate and prioritize the follow-up care concepts identified in the previous phase. In this regard, a questionnaire was designed with five questions about the necessity and priority of the identified concepts using a five-point Likert scale. Fifteen experts, including neonatal experts and nurses, participated in this phase. In the first round, responses were collected on-site. In the second round, results were emailed for further input to assess priorities [17].
The SWOT analysis in the third phase evaluated the strengths (e.g., available resources), weaknesses (e.g., accessibility issues), opportunities (e.g., social support networks), and threats (e.g., limited funding and policy shifts) related to existing post-discharge follow-up care, providing a comprehensive view of current challenges and potential improvements [18].
An RCA tree diagram was employed in the final phase to clarify the program’s goals by examining causal relationships among identified issues. Key outcomes were categorized based on their impact, allowing for the prioritization of relevant objectives. Insights can facilitate the development of targeted strategies [19].
The initial draft of the post-discharge follow-up program was developed based on experts’ opinions. The final draft prioritized actionable objectives, outlining two main goals and six specific objectives for the follow-up program [20].

Results
The qualitative interviews revealed four main themes: Mothers’ poor caregiving empowerment, ineffective post-discharge follow-up planning, lack of psychological support for mothers, and insufficient maternal education. The first two themes were prioritized during the Delphi process. The SWOT analysis identified significant weaknesses, particularly in mothers’ caregiving and the follow-up care providing system. 
In the RCA tree diagram, weaknesses in mothers’ caregiving had four main categories: Weakness in learning about breastfeeding, post-discharge complications, factors disrupting maternal education, and mothers’ physical and mental stress. Regarding the weakness in the follow-up care providing system, there were two categories of “insufficient access to post-discharge services for infants” and “frequent visits to medical centers”. The program aimed to improve follow-up care and increase access to post-discharge services while reducing referrals to medical centers. 
The final program focused on two general goals: “improving mothers’ caregiving capabilities” and “improving post-discharge follow-up”. The first goal included the following categories: Increasing mothers’ knowledge of breastfeeding, reducing common post-discharge complications (e.g., respiratory distress syndrome, infections, and developmental delays), reducing factors hindering maternal learning, and reducing mothers’ physical and mental stress. The second goal included two categories: Expanding infants’ access to services after discharge and reducing frequent visits to healthcare centers.
Experts emphasized the development of remote care methods, such as telephone follow-up methods, to maintain remote communication with families. Additionally, integrating this program with other approved follow-up plans, such as home care, was recommended for increased effectiveness.

Conclusion 
This study developed a post-discharge follow-up program for premature infants to improve post-discharge care, enhance access to services after discharge, and minimize frequent medical visits. 

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Isfahan University of Medical Sciences (Code: IR.MUI.NUREMA.REC.1400.055).

Funding
This article was extracted from the PhD thesis of the first author, funded by Isfahan University of Medical Sciences.

Authors' contributions
Design, investigation, data collection, and data analysis: Atefeh Shamsi; conceptualization, methodology, and supervision: Mahboobeh Namnabati; data collection, data analysis, review & editing: Asghar Ehteshami and Hamed Zandi Esfahani

Conflict of interest
The authors declare no conflicts of interest.

Acknowledgments
The authors would like to thank the professors from Isfahan University of Medical Sciences who participated in this study as part of the panel of experts. 


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