People with Disabilities and Financial Challenges in Access to Rehabilitation Services: Evidence of Socioeconomic Inequality in Iran.

Background: People with disabilities (PWD) typically face a range of obstacles when accessing healthcare, particularly when compared with the general population. This challenge becomes more pronounced for PWDs in lower socioeconomic groups. This study aimed to assess the socioeconomic-related disparity in financial access to rehabilitation services among Iranian PWDS. Methods: A total of 766 Iranian PWDs aged ≥18 years participated in this cross-sectional study. We employed the concentration index (C) to estimate socioeconomic inequality in accessing rehabilitation services. Results: In this study, 766 Iranian adults aged 18 to 70 took part, with a mean age of 36.50 (SD, ±10.02) years. The findings revealed that 72.15% (n = 469) of participants had to borrow money to cover the costs of rehabilitation services. The concentration index (C = -0.228, P = 0.004) demonstrated a notable concentration of inadequate financial access to rehabilitation services among individuals with lower socioeconomic status (SES). Decomposition analysis identified the wealth index as the primary contributor to the observed socioeconomic disparities, accounting for 309.48%. Conclusion: Our findings show that socioeconomic inequalities disproportionately impact PWDs in lower socioeconomic groups. It is recommended that efforts be made to enhance the national capacity for monitoring the financial protection of PWDs and to develop equitable mechanisms that promote prepayment and risk pooling, thus reducing reliance on out-of-pocket payments at the time of service utilization.

Decomposing socioeconomic disparity in the utilization of screening mammography: A cross-sectional analysis from the RaNCD cohort study.

We aimed to examine the degree of socioeconomic inequality in screening mammography among Kurdish women of Iran. Data from the Ravansar Non-Communicable Diseases (RaNCD) Cohort Study were used. A total of 3,219 women aged 35-65 years were studied. The concentration index (CIn) was used to measure the magnitude of socioeconomic-related inequalities in screening mammography. Decomposition analysis was employed to calculate the contribution of each explanatory variable to the observed inequality. The participation rate for screening mammography was 19.7%. The CIn of screening mammography was 0.142 (95% CI: 0.0197, 0.0656), indicating that screening mammography is more concentrated among high-SES women. Socioeconomic status, education level and area of residence were the main contributors to the observed inequality, respectively. We found a pro-rich inequality in screening mammography among Iranian Kurdish women. For mitigating socioeconomic inequality in screening mammography policymakers should focus more on the poor and rural communities.

Decomposing socioeconomic inequality in poor mental health among Iranian adult population: results from the PERSIAN cohort study.

BACKGROUND: Socioeconomic inequality in mental health in Iran is poorly understood. This study aimed to assess socioeconomic inequality in poor mental health among Iranian adults. METHODS: The study used the baseline data of PERSIAN cohort study including 131,813 participants from 17 geographically distinct areas of Iran. The Erreygers Concentration index (E) was used to quantify the socioeconomic inequalities in poor mental health. Moreover, we decomposed the E to identify factors contributing to the observed socioeconomic inequality in poor mental health in Iran. RESULTS: The estimated E for poor mental health was - 0.012 (95% CI: - 0.0144, - 0.0089), indicating slightly higher concentration of mental health problem among socioeconomically disadvantaged adults in Iran. Socioeconomic inequality in poor mental health was mainly explained by gender (19.93%) and age (12.70%). Region, SES itself, and physical activity were other important factors that contributed to the concentration of poor mental health among adults with low socioeconomic status. CONCLUSION: There exists nearly equitable distribution in poor mental health among Iranian adults, but with important variations by gender, SES, and geography. These results suggested that interventional programs in Iran should focus on should focus more on socioeconomically disadvantaged people as a whole, with particular attention to the needs of women and those living in more socially disadvantaged regions.

Socioeconomic - related inequalities in overweight and obesity: findings from the PERSIAN cohort study.

BACKGROUND: Overweight and obesity are major health concerns worldwide, with adverse health consequences during the life span. This study measured socioeconomic inequality in overweight and obesity among Iranian adults. METHODS: Data were extracted from 129,257 Iranian adults (aged 35 years and older) participated in the Prospective Epidemiologic Research Studies in IrAN (PERSIAN) in 14 provinces of Iran in 2014. Socioeconomic-related inequality in overweight and obesity was estimated using the Concentration Index (Cn). The Cn further decomposed to find factors explaining the variability within the Socioeconomic related inequality in overweight and obesity. RESULTS: Of the total number of participants, 1.98, 26.82, 40.76 and 30.43% had underweight, normal weight, overweight and obesity respectively. The age-and sex standardized prevalence of obesity was higher in females than males (39.85% vs 18.79%). People with high socioeconomic status (SES) had a 39 and 15% higher chance of being overweight and obese than low SES people, respectively. The positive value of Cn suggested a higher concentration of overweight (0.081, 95% confidence interval [CI]; 0.074-0.087) and obesity (0.027, 95% CI; 0.021-0.034) among groups with high SES. There was a wide variation in socioeconomic-related inequality in overweight and obesity rate across 14 provinces. The decomposition results suggested that SES factor itself explained 66.77 and 89.07% of the observed socioeconomic inequalities in overweight and obesity among Iranian adults respectively. Following SES, province of residence, physical activity, using hookah and smoking were the major contributors to the concentration of overweight and obesity among the rich. CONCLUSIONS: Overall, we found that overweight and obesity is concentrated among high SES people in the study population. . Accordingly, it seems that intersectional actions should be taken to control and prevent overweight and obesity among higher socioeconomic groups.

Mothers' willingness to accept and pay for vaccines to their children in western Iran: a contingent valuation study.

BACKGROUND: The clients' willingness to accept (WTA) and willingness to pay (WTP) for a given good or service can help elicit the monetary value of that good or service. This study aims to assess the WTA and WTP of mothers attending primary health centers for vaccines to their children during 2019 in Kermanshah city, western Iran. METHODS: We conducted a cross-sectional study on a total of 667 mothers attending primary health centers for vaccines to their children aged two to 18 months. A multistage sampling technique was employed to involve the mothers in the study, and data were collected using a self-administrated open-ended questionnaire. The multivariate linear regression model was used to identify the factors associated with the mothers' WTP and WTA for vaccines to their children. RESULTS: The study indicated that 94.2 and 93.1% of the mothers respectively had WTA and WTP values greater than zero, with their corresponding mean values of US$ 6.8 and US$ 4.4. The mothers in the higher monthly household income category, mothers born in the urban areas, and being a female child showed statistically significant positive associations with the mothers' WTA for the vaccines. While there was a statistically significant positive relationship between monthly household income and the mothers' WTP; a statistically significant negative relationship exists between the mothers' age and their WTP for the vaccine to their children. CONCLUSIONS: The findings indicated the mothers' WTA to WTP ratio of greater than one for the vaccines to their children. The most important factor associated with the mothers' WTA and WTP was the monthly household income. Thus, improving the socio-economic standards of women in the study area might contribute to reinforcing their immunization services seeking behavior to their children.

Socioeconomic-related inequalities in oral hygiene behaviors: a cross-sectional analysis of the PERSIAN cohort study.

BACKGROUND: Socioeconomic-related inequality in oral hygiene behaviors in Iran is poorly understood. This study aims to measure and decompose socioeconomic-related inequalities in oral hygiene behaviors among middle-aged and elderly adults in Iran. METHODS: A cross-sectional analysis was performed using data from the Prospective Epidemiological Research Studies in IrAN (PERSIAN), a large national cohort study. A total of 130,016 individuals aged 35 years and above from 17 cohort centers in Iran were included in the study. The normalized concentration index (Cn) was used to measure the magnitude of inequality in oral hygiene behaviors, i.e. brushing at least twice and flossing once daily, among middle-aged and elderly Iranian adults included in the cohort centers. Decomposition analysis was performed to quantify the contribution of each determinant to the observed inequality in oral hygiene behaviors. RESULTS: Totally, 65.5% of middle-aged and elderly adults brushed their teeth twice a day or more, 7.6% flossed at least once a day and 3.48% had both habits. The estimated Cn of the two habits combined, i.e. tooth brushing and dental flossing, for all provinces taken part in the PERSIAN cohort study was 0.399 (95% confidence interval [CI]: 0.383 to 0.417), indicating that the prevalence of the two habits combined is more concentrated among individuals with higher socioeconomic status. Inequality in oral hygiene behaviors was pro-rich in all cohort centers. The decomposition results suggested socioeconomic status as the main factor contributing to the overall inequality, followed by the level of education, and the province of residence. CONCLUSION: A low prevalence of oral hygiene behaviors among middle-aged and elderly Iranian adults was observed. There was also a pro-rich inequality in oral hygiene behaviors among middle-aged and elderly adults in all cohort centers. These results suggest an urgent need for targeted policy interventions to increase the prevalence of preventive oral hygiene behaviors among the poor and less-educated middle-aged and elderly adults in Iran.

Socio-cognitive determinants of colorectal cancer screening uptake: An application of intervention mapping approach.

Background: Fecal occult blood test (FOBT) is one of the common screening tests for colorectal cancer. This study was designed to determine the socio-cognitive determinants related to FOBT uptake for colorectal cancer screening based on intervention mapping (IM). Methods: A total of 500 individuals aged over 50 years were randomly selected to participate in this study in Kermanshah, Iran, in 2016. Data were collected by interviews based on a questionnaire and analyzed by SPSS16 using bivariate correlation, linear, and logistic regression models. Results: Of the 500 respondents, 468 (93.6%) signed the consent form and voluntarily participated in the study. Almost 11.1% of the participants had a history of FOBT uptake. Socio-cognitive variables accounted for 38% of the variation in the outcome measure of the intention to uptake FOBT. Perceived self-efficacy (OR = 3.345 & 95% CI: 1.342, 8.339), perceived susceptibility (OR = 2.204& 95% CI: 1.320, 3.680), attitude (OR = 1.674& 95% CI: 1.270, 2.137), and perceived severity (OR = 1.457& 95% CI: 0.954, 2.224) were the strongest predictors of fecal occult blood test uptake. Conclusion: IM-based analysis of behavior may provide insights to design interventions for modifying individuals' beliefs about the usefulness of FOBT uptake to prevent colorectal cancer.

The predictors of access to health services for people with disabilities: A cross sectional study in Iranian context.

Background: In developing countries, people with disabilities (PWD) are more likely to have unequitable access to health care services than their counterparts without disabilities. Access to health care is a multidimensional concept and PWD experience various barriers to use health care. This quantitative study explored the predictors and determents of access to health care for PWD in an Iranian context. Methods: Data were collected from a cross sectional study conducted in Tehran in 2017. A total of 403 adults with physical and/or intellectual disabilities were selected using census method. The data on PWD were collected from 14 rehabilitation centers affiliated to Welfare Organization and Red Crescent Organization. The self-report World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) was used to collect data on disability status. T test, ANOVA, and multiple linear regressions were used to determine factors influencing access to health care for PWD. Significance level was set at 5%. Also, SPSS software version 20.0 was used for data analysis. Results: The mean of access to health care among people with intellectual disabilities (mean: 61.77, 95% confidence interval (CI):59.20, 64.35) was significantly lower than their counterparts with physical disabilities (Mean: 67.97, 95% CI: 65.26, 70.69). The results of multiple linear regression analysis showed that in the affordability dimension, type of disability, marital status, and supplemental health insurance could predict access to health services for PWD. In availability dimension, only location predicted the outcome variable significantly. Also, location and type of disability were considered to be potential predictors of access to health services in acceptability dimension. Conclusion: The results indicate that various factors can limit access to health services for PWD. To achieve universal health coverage, vulnerable groups and their needs should be identified to increase equitable access to health care services. Also, the health care system should pay more attention to demographic differences when planning and providing affordable and acceptable health care for PWD. Finally, the role of the government as the heath stewardship is vital to promote health care access for PWD in Iran.

The impact of health sector evolution plan on hospitalization and cesarean section rates in Iran: an interrupted time series analysis.

OBJECTIVE: To investigate the effect of the health sector evolution plan (HSEP) on hospitalization and cesarean section (C-section) rates in Kermanshah province in the western region of Iran. DESIGN: Interrupted time series analysis. SETTING: Hospital care system in Kermanshah province. STUDY PARTICIPANTS: Fifteen hospitals affiliated to Ministry of Health and Medical Education (MoHME) in Kermanshah province. INTERVENTION(S): Health sector evolution plan. MAIN OUTCOME MEASURES: Hospitalization rate and C-section rate. RESULTS: We observed a statistically significant increase in the hospitalization rate (12.9 hospitalizations per 10 000 population, P < 0.001) in the first month after the implementation of the HSEP. Compared with the monthly trend in hospitalization rate before the intervention, we found a significant increase of 0.70 hospitalizations per 10 000 population (P < 0.001) in monthly trend in hospitalization rate after the HSEP. Although the proportion of C-section from total deliveries decreased by 11% (P = 0.044) in the first month after the implementation of the HSEP, the proportion of C-section from total deliveries increased at the rate of 0.0017% (P = 0.001) per month during post-intervention period. CONCLUSION: We found an increase in the hospitalization rate after the intervention of HSEP. Although the C-section rate in the first month after the HSEP decreased, we observed an increasing trend in C-section rate over the study period; this implies that the HSEP did not promote vaginal delivery in Iran, which is outlined as one of the objectives of the intervention.

Does smoking status affect cost of hospitalization? Evidence from three main diseases associated with smoking in Iran.

Background: Smoking is recognized as one of the main public health problems worldwide and is accounted for a high financial burden to healthcare systems and the society as a whole. This study was aimed at examining the effect of smoking status on cost of hospitalization among patients with lung cancer (LC), chronic obstructive pulmonary disease (COPD) and ischemic heart diseases (IHD) in Iran in 2014. Methods: A total of 1,271 patients (consisting of 415 LC, 427 COPD and 429 IHD patients) were included in the study. Data on age, sex, and insurance status, length of hospital stay and cost of hospitalization were extracted from the medical records of the patients. The smoking status of the patients was obtained through a telephone survey. A generalized linear model (GLM) was used to compare the costs of hospitalization of current, former and never smokers. The analysis was done using Stata v.12. Results: The mean±SD cost of hospitalization per patient was 45.6 ± 41.8 million IR for current smokers, 34.8±23 million IR for former smokers and 27.6±24.6 million IR for never smokers, respectively. The findings indicated that the cost of hospitalization for current and former smokers was 65% and 26% in the unadjusted model and 35% and 24% in the adjusted model higher than for never smokers. Conclusion: The findings revealed that smoking drains a large hospital resource and imposes a high financial burden on the health system and the society. Therefore, efforts should focus on reducing the prevalence of smoking and the negative economic consequences of smoking.

Health system responsiveness after health sector evolution plan (HSEP): An inpatient survey in Kermanshah in 2015.

BACKGROUND: Responsiveness is one of the three main goals of the health system introduced by World Health Organization. This study aimed at examining health system responsiveness after Health Sector Evolution Plan in Kermanshah, Western Iran. METHODS: A sample of 335 hospitalized patients was selected using proportionate allocation to population size method in the city of Kermanshah (Iran) in 2015. World Health Survey (WHS) questionnaire was used to collect data. Data were analyzed using descriptive statistics and principal component analysis by STATA 12. RESULTS: The overall health system responsiveness score was 72.6. The best and worst performance for domains of dignity and autonomy were 82.2 and 62.5, respectively. Socio-demographic variables of the patients had no significant effect on the total health system responsiveness score. The principal component analysis findings indicated that 68% of the variance of the overall responsiveness score was explained by four components. CONCLUSION: The overall responsiveness score of each of the domains was higher than that of other similar previous studies in Iran. Although it is difficult to reach a conclusion, our findings may show better responsiveness of the health system compared to the previous reports.

Productivity costs and years of potential life lost associated with five leading causes of death: Evidence from Iran (2006-2010).

Background: Economic burden due to premature mortalities is significant both on health system and on the society as a whole. This study aimed to determine the productivity costs and years of potential life lost associated with five leading causes of death in Iran from 2006 to 2010. Methods: Data on mortality by sex and age-groups due to five main leading causes of death (myocardial infarction (MI), cerebral vascular diseases (CVD), transport accidents (TA), hypertensive heart disease (HHD) and gastric cancer (GC)) were obtained from the Ministry of Health and Medical Education from 2006 to 2010 for 29 providences of Iran (data on Tehran province was not available). Three measures including years of potential life lost (YPLL), years of potential productive life lost (YPPLL) and the cost of productivity loss (CPL) due to premature mortality were used. To estimate the CPL and YPLL, the human capital approach and life expectancy method were used, respectively. Results: There were 518,815 deaths due to the five main leading causes of death; of which, 58% occurred in males. The estimated YPPLL resulted in 209,552,135 YPPLL from 2006 to 2011; of which, 141,966,592 (67%) were in males and 67,585,543 (33%) in females. The total cost of productivity loss caused by premature deaths due to the five leading causes of death was 7.86 billion dollars (US$) from 2006 to 2010, ranging from 1.63 billion dollars in 2006 to 1.31 billion dollars in 2010. Conclusion: This study revealed that the economic burden of premature mortalities due to the five main causes of death is substantial, and that these five leading causes should be considered in policy/decision making and prevention programms. The allocation of financial resources to control these causes may decrease their economic burden, resulting in higher level of health and well-being.

Epidemiology and Economic Burden of an Outbreak of Cyclopeptide-Containing Mushroom Poisoning in the West of Iran.

Little evidence is available on the epidemiological and economical dimensions of certain foodborne diseases such as wild mushroom poisoning. This study aimed to investigate the epidemiology and estimate the costs of poisoning with cyclopeptide-containing mushrooms in Kermanshah province in 2018. In this study, poisoning was investigated in different subgroups. The cost of illness method with a bottom-up approach was used to estimate the poisoning costs. Both direct and indirect costs of the poisoning were included in the analysis. The perspective of the study was society. Required data were obtained from the medical records of Imam Khomeini hospital and completed through a line survey with the patients. Two hundred eighty-three patients were poisoned in Kermanshah due to poisoning with cyclopeptide-containing mushrooms. Of 283 patients, 143 (50.53%) were men and 59.01% of patients were rural residents. About 43% of admissions were out-patient cases and ~40% of patients were hospitalized within 1-3 days. Also, eight patients were pronounced dead in the area. The total cost of poisoning with cyclopeptide-containing mushrooms in Kermanshah province was $ 1,259,349.26. Of that, $ 69,281.65 was related to direct medical costs and $ 10,727.23 was direct non-medical costs. The indirect costs of death were estimated to be $ 1,125,829.7. The current study revealed that there is a significant financial burden due to cyclopeptide-containing mushrooms on patients, the health system, and society as a whole. Further studies are recommended to clarify the epidemiological and economic burden of foodborne illnesses related to wild mushroom poisonings. Sharing the outputs with health authorities, and informing the general public are warranted to reduce the burden of such diseases.

The prevalence of people who inject drugs among those with HIV late presentation: a meta-analysis.

BACKGROUND: One of the most important routes of HIV transmission is through injections of drugs, and this group, due to unawareness of their infection, causes the spread of HIV. The coexistence of other opportunistic infections and diseases with HIV among people who inject drugs (PWID) imposes healthcare costs and is associated with high morbidity/mortality rates. Early detection of HIV among PWID is essential to prevent and control the spread of the disease. OBJECTIVES: This study aimed to determine the prevalence of PWID among those with late presentation (LP). METHODS: Three electronic databases of PubMed, Scopus, and Web of science were searched using appropriate keywords. Besides the prevalence data reported for PWID among LP, the other outcomes of interest were LP defined as having CD4 count < 350 cells/µL or HIV or advanced disease defined with CD4 count < 200 cells/µL or HIV at the time of diagnosis. RESULTS: Of the 160 studies found, only eight met the inclusion criteria. Among those presented late, 36.5% were PWID (95% CI = 24.88-48.17). Compared with men who have sex with men (MSM), HIV-infected PWID had a higher risk of LP [OR = 1.51; 95% CI = 0.96-2.06]. CONCLUSION: The results of this study show that HIV is diagnosed late in the majority of PWID when CD4 is less than 350 cells/µL. Targeted interventions/strategies are highly required to reduce LP among HIV-infected PWID.

Socio-Economic Status and Clinical Breast Examination Screening Uptake: Findings from the First Cohort Study among Iranian Kurdish Women.

Clinical Breast Examination (CBE) is utilized as a screening modality in many low income countries without widespread mammography capability. The aim of the current study was to evaluate the impact of socio-economic status (SES) on CBE screening rates in Iranian Kurdish women. A cross-sectional study was conducted in the western region of Iran. A sample of 5,289 Iranian Kurdish women aged 35-65 years old was analyzed. Data were collected from July 2014 to September 2018. The Concentration Index-CI and Concentration Curve were used to estimate the socioeconomic inequalities in CBE rate. The analysis of data was done by STATA software (Version 14). 12.3% of the women had received CBE at least once. CBE rates in the 46-50 age group were higher than in other age groups (OR = 2.06; 95% CI = 1.56-2.71). Women with 6-9 years of education had higher odds ratio of receiving CBE (OR = 1.41; 95% CI = 1.02-1.94). Women living in rural areas were less likely to have received CBE compared to those living in urban areas (OR=0.54; 95% CI = 0.42-0.61). The overall concentration index for receipt of CBE was 0.188. In countries without widespread mammography programs, strategies for the promotion of CBE should focus on the lower SES population.
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Efficiency of Iranian Hospitals Before and After Health Sector Evolution Plan: A Systematic Review and Meta-Analysis Study.

Purpose: Aging, chronic diseases, and development of expensive and advanced technologies has increased hospitals costs which have necessitated their efficiency in utilization of resources. This systematic review and meta-analysis study has assessed the efficiency of Iranian hospitals before and after the 2011 Health Sector Evolution Plan (HSEP). Methods: Internal and external databases were searched using specified keywords without considering time limitations. The retrieved articles were entered into EndNote considering inclusion and exclusion criteria, and the final analysis was performed after removing duplicates. Heterogeneity between the studies was assessed using Q and I2 tests. A forest plot with 95% confidence intervals (CI) was used to calculate different types of efficiency. The data were analyzed using STATA 14. Results: Random pooled estimation of hospitals technical, managerial, and scale efficiencies were 0.84 (95%CI = 0.78, 0.52), 0.9 (95%CI = 0.85, 0.94), and 0.88 (95%CI = 0.84, 0.91), respectively. Sub-group analysis on the basis of study year (before and after HSEP in 2011) indicated that random pool estimation of technical (0.86), managerial (0.91), and scale (0.90) efficiencies of Iranian hospitals for 2011 and before were better than technical (0.78), managerial (0.86), and scale (0.74) efficiencies after 2011. Conclusion: Type of hospital ownership was effective on hospital efficiency. However, HSEP has not improved hospital efficiency, so it is necessary for future national plans to consider all aspects.

Using Insights from Behavioral Economics to Mitigate the Spread of COVID-19.

The outbreak of 2019 coronavirus disease (COVID-19) has become a public health emergency of international concern. The number of COVID-infected individuals and related deaths continues to rise rapidly. Encouraging people to adopt and sustain preventive behaviors is a central focus of public health policies that seek to mitigate the spread of COVID-19. Public health policy needs improved methods to encourage people to adhere to COVID-19-preventive behaviors. In this paper, we introduce a number of insights from behavioral economics that help explain why people may behave irrationally during the COVID-19 pandemic. In particular, present bias, status quo bias, framing effect, optimism bias, affect heuristic, and herding behavior are discussed. We hope this paper will shed light on how insights from behavioral economics can enrich public health policies and interventions in the fight against COVID-19.