{'fraction_non_alphanumeric': 0.021224984839296544, 'fraction_numerical': 0.005154639175257732, 'mean_word_length': 5.258444022770399, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Situation Analysis for Promotion of Hot‑Lines: An Experience from Iran

Background: The hot line services were developed in response to the perceived need for 24‑hour help services in crises ranging from suicide to unwanted pregnancy. This study is aimed at analyzing the strengths, weaknesses, challenges, and suggestions of improving the performance of the help centers from the perspective of key stakeholders. Methods: We conducted a qualitative study to elicit the key informants’ opinion regarding the performance of Iranian hot‑lines. All the conversations were audio‑recorded with the permission of the participants. To reach the saturation limit, the number of interviews was completed in the saturation of data. Data was gathered from 15 individual in‑depth interviews. Collecting and analyses of data was based on content analysis through which simultaneously during texts open coding, main concepts were extracted and then in axial coding similar concepts were categorized. Results: According to the study results, there is no specific and independent system for assessing the hot‑ lines. One of the major weaknesses was the lack of standard protocols. Most participants believed that most of these guidelines came from the general principles of counseling and are not standard. As another point, the existence of referral services is one of the main problems of counseling lines. The most important suggestion from the majority of experts were the development of services and modification of their investments. Conclusions: The findings, in addition to providing the applied data for policy‑making in the health system, will significantly contribute to the creation of scientific, technical, and skillful personnel in the community of researchers.


Introduction
As the identity of the person is hidden, telephone counseling is usually welcomed by many families. On the other hand, there are fewer problems, especially the psychological security of telephone users. [10,11] The content and the way information is transmitted, the quality of the counseling, and many other related issues are factors that obviously affect the consequence of processes. [12] Despite of the importance and priority of the problem, the studies in this area are very limited and almost there is no comprehensive review of these centers and mechanisms of promotion of services. [1,13] Therefore, we planned to reveal the challenges and possible suggestions for improving the counseling lines.

Methods
This vast comprehensive study is aimed at studying the qualitative performance of the Iranian hot lines from the perspective of key informants.
The key informants' opinions were assessed through qualitative methods by trained research experts and then positive suggestions and appropriate interventions were provided. The stages of the study were as follows:

Executive processes
Establishment of scientific and executive committees with experts, mental and the medical related specialists, and community representatives to design the research process. The main responsibilities of the executive committee were: advocacy, assessing potential facilities and opportunities, and selection of informants for interviews.

Participation of key informants
Through a comprehensive quality plan, 15 deep-seated individual interviews (in-depth interviews) were conducted with targeted individuals identified through the snowball technique. To attract the stakeholders and key person's participation, several participatory meetings were held and different related aspects of the project were discussed.

The guide questionnaire
Based on the objectives of study, the guide questionnaire was developed and approved. The main axes were as follow: 1. The success of centers in implementing standard protocols 2. The success of centers in the provision of specialized services 3. The success of centers in providing health services in the form of referral and follow-up 4. The success of the centers in crisis prevention/ management 5. The strengths, weaknesses, challenges and suggestions.

Interviews and data gathering
Data were collected by deep, semi-structured, face-to-face interviews. At the beginning of the interviews, the research goals and methods were explained to the participants. Each session lasted for 45-100 minutes (with a mean duration of 65 minute). All interviews were conducted in a peaceful environment and with prior agreement of the participants. The interview began with general questions and open-ended ones based on the study objectives. The interview then continued with exploratory questions to clarify the concept and get more in-depth information. All the conversations were audio-recorded with the permission of the participants. To reach the saturation limit, the number of interviews was completed in the saturation of data. [14]

Data analysis
After each session, the notes taken and the recorded tapes and comments were observed in initial analysis. Collection and analysis of data were based on content analysis through which simultaneously during texts open coding, main concepts were extracted and then in axial coding similar concepts were categorized. Comparison and integration of similar codes lead to novel comments, suggestion, and ideas. The reliability was established throughout the study by the amount of similarity between the research findings with separate results extracted independently by another expert by coding and analyses.
The rigor of the data was determined using Lincoln and Guba's evaluative criteria, including credibility, dependability, transferability, and conformability. [14][15][16] To provide rigor and reliable data concerning credibility, the researcher had a long and close acquaintance with the participants and spent a long time in the field searching for data and enough time to gather and analyze the data. Furthermore, triangulation in data collection, peer check, and constant comparison were used. Dependability was established by using the experts' comments, and revision was done by the participants and co-workers. Transferability was obtained by description of data-rich. [14,16]

Ethical considerations
The study was approved by the ethics committee of the Iran University of Medical Sciences. Participation in the study was voluntary and participants were ensured that they could withdraw from the study whenever they wanted. A written informed consent was obtained from all of participants. All information was collected anonymously and the outcomes were used for research purposes.

Results
In this study, to achieve data saturation, fifteen individual in-depth interviews were conducted with informants. The demographic characteristics of the participants are provided in Table 1.

Expert job position
The results of the qualitative analysis indicate seven themes or major categories with 11 subthemes or subcategories.

Expert/canceller position
The participants of this group were mostly experts of counseling and were less active in social emergency; so, their experiences were mostly related to the counseling lines and not the crisis lines. According to their opinions, there is no specific and independent system for assessing crisis management. More often, informally and case-by-case, monitoring of counseling is carried out. Most of the participants revealed that; "Considering the supervision is essential need for promotion of the crisis and social emergencies"; "Our performance can be verified by customer satisfaction, but we still do not think anyone will check it." "There is no precise scientific evaluation to evaluate. We only say our assessment based on the patient's call." As another point, they said that "Patient feedback at the end of the call reflects the effectiveness of counseling." The most important suggestion from the majority of experts were development of services and modification of their investments. One of specialist advice is also available: "As much as possible, services are provided, but there is a need for outsourcing."

Academic position
These participants were mostly managers of the department of clinical psychology at different universities or scientifically familiar with mental health. The common feature of many of the people in this group was the lack of awareness of the status of crisis counseling lines. The results of the analysis of the interviews show that there are seven main categories and 14 subcategories in this group. All of these participants emphasized on the need for a standard protocol in the crisis lines; either they did not know about the protocols in the consultation lines or they believed that standardized protocols were not used in the consultation lines, and eventually the forms and instructions which are not standard.
The majority of contributors believed that there is an evident gap in supervising systems. "For better possibility of supervision, the supervisor should be placed in the process of the process." The participants also said that the welfare organization had a supervisory system but did not design a particular style sheet for this. The use of customer feedback has also been mentioned by other contributors.
From the perspective of all participants, the existence of referral services is one of the main problems of counseling lines. Through the systemic relationship between counseling lines and relevant organizations, the referral systems should be defined precisely in lines.
"These lines are the only window that opens the door to problems solving."

Management position
Participants in this group included five managers with more than 10 years of experience in managing systems. This group has six main categories and 15 subclasses.
Most participants believed that most of these guidelines came from the general principles of counseling and are not standard. Only for addiction, a participant who has had a history of managing the line for several years pointed that the advisory line on addiction has a standard protocol. One of the participants in the emergency department also believed that there was no protocol for events if the patient had a mental illness (such as suicide).
All of contributors emphasized on the need to review and update all guidelines for consultation lines. "A process-based protocol is a step-by-step process." Many contributors believed that the presence of in-person counseling on the lines would save money and time for the clients. Some also stated that the existence of crisis counseling lines has been effective in controlling social crises. Facilitating factors in this regard are the existence of knowledgeable consultants on crisis management and the existence of specific protocols and guidelines.
"In the area of mental health, the application and importance of telephone counseling and counseling is a wider application crisis than other areas of medicine." "Telephone counseling can be very effective in controlling the crisis." "The service is available and effective" Contributors made very different views on the existence of standard protocols in the crisis lines, and there was generally no consensus in the standard definition.

Discussion
The purpose of this study was to explain the strengths, weaknesses, challenges, and suggestions of improving the performance of Iranian hot lines from the perspective of key stakeholders. Our findings confirm that one of the major weaknesses spotted by most contributors was the lack of standard protocols in the lines. We need to a comprehensive protocol that covers all aspects of providing counseling and evaluation of the performances.
Based on relevant scientific evidence, evaluation of health services gives policy makers a documentary evidence of performance. On the other hand, it is possible to monitor the results of improvement and over time monitoring. [2,11] Suicidal emergency phones are one of the first hot lines designed and exploited in England as one of the earliest experiences. [3,11] These settings in most of countries work as telephone counseling services and are available to manage and control the crisis. One of these communication lines is dial-up phones. These services are available daily and 24 hours a day. According to the needs and policies, these systems generally provide their specialized services and sometimes provide services to specific groups. [3,11,17] In a related study to assess the prospects and implications of suicide prevention guidance lines, focusing on California, the quality of providing services for suicide risk callers has been evaluated. These suicide prevention guidelines generally help through two ways. First, they support the immediate safety of suicide victims, and on the other hand, they try to identify those who may be at risk of suicide. The results of this study indicated that support and management of suicide guidance is associated with financial pressures, changes in the use of technology and other potentially hazardous risk factors. The results of this assessment also indicate uncertainty about whether the suicide prevention guidance lines are currently meeting the needs of the at-risk population of California or not. [18] The effectiveness of telephone counseling was evaluated in groups of young people seeking help showed that utilizing these services has a significant role in controlling the conditions of the crisis and preventing suicide. [19] Many developing countries, in view of the growing importance and prevalence of suicide in different demographic groups, follow plotting and pursuing suicide prevention strategies. One of the most important points in this regard is the attention paid to the quality of the services and the level of knowledge and skills of the individuals who serve as consultants. Studies emphasize that these individuals should be applied in a prestigious and quality scientific and qualification. It is also sufficient evidence to assess the potential benefits of suicide prevention in primary care, general education, and media guidelines. [20,21] In a study focusing on the investigation of crisis-induced violence, rapid information procedures for legal and security helps, as well as the provision of concurrent assistance to manage the conditions were emphasized. [22] The findings of the comprehensive review of the 113 crisis line show that, despite of the current success of most of these collections, there is an increasing need for the standardization of service delivery protocols and the upgrading of the appropriate infrastructure. In this context, the use of new techniques such as chats, will be helpful. [23] The other study was conducted in official mental health centers and volunteer centers. Volunteer centers often performed risk assessments, had more empathy, had more respect than callers, and had significantly more callers. However, there was also no significant difference between the performance of volunteers and official employees. [24] Based on the results of the content analysis on the local telephone line over a 5-year period, all the callers identified as the main victims use significantly more referral settings. Men who access the telephone line were advised of a crisis mainly due to rape by their peers. [25] Based on the findings of study, we propose the participatory strategies for the development and operation of the comprehensive protocol for crisis hot-lines which is based on the specific needs assessment of different target groups with respect to the designing, development, and implementation of required programs for more effective interventions. [25,26] Lack of generalizability is one of the most important limitations in qualitative research studies such as this study.

Conclusions
In addition to providing the applied data for policy-making in the health system, conducting such studies will significantly contribute to the creation of scientific, technical and skillful capacities in the community of researchers in the country, and it is hoped that with cooperation of senior policy makers and country's leading researchers at the universities, we plan for promotion of valuable national studies.
thanks go out to the key informants who have helped in gathering the data and in the implementation processes. This project was run under the supervision of the Deputy of Research and Technology, Ministry of Health and Medical Education, Tehran, Iran.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.