Socioeconomic inequality in informal payments for health services among Iranian households: a national pooled study.

BACKGROUND: There is limited evidence on the prevalence and socioeconomic inequality in informal payments (IP) of households in the Iranian health system. This study was conducted to investigate the prevalence of IP and related socioeconomic inequalities among Iranian households in all provinces. METHOD: Data on Household Income and Expenditure Surveys (HIES) for 91,360 households were used to examine the prevalence and inequality in informal health sector payments in the years 2016 to 2018. The Normalized Concentration Index (NC) was used to examine inequality in these payments and the decomposition analysis by the Wagstaff approach was used to determine the share of variables affecting the measured inequality. RESULTS: Of the total households, 7,339 (7.9%) reported IP for using health services. Urban households had higher IP (10%) compared to rural ones (5.42%). Also, the proportion of households with IP in 2016 (11.69%) was higher than in 2017 (9.9%), and 2018 (4.60%). NC for the study population was 0.129, which shows that the prevalence of IP is significantly higher in well-off households. Also, NC was 0.213 (p < 0.0001) and -0.019 for urban and rural areas, respectively (p > 0.05). Decomposition analysis indicated that income, sex of head of household, and the province of residence have the highest positive contribution to measured inequality (with contributions of 156.2, 45.8, and 25.6%, respectively). CONCLUSION: There are a significant prevalence and inequality in IP in Iran's health system and important variables have shaped it. On the whole, inequality was pro-rich. This may lead to increasing inequality in access to quality services in the country. Our findings showed that previous health policies such as regulatory tools, and the health transformation plan (HTP) have not been able to control IP in the health sector in the desired way. It seems that consumer-side policies focusing on affluent households, and high-risk provinces can play an important role in controlling this phenomenon.

The impact of COVID-19 pandemic on hospital admissions for nine diseases in Iran: insight from an interrupted time series analysis.

BACKGROUND: Associations between the COVID-19 pandemic and hospitalizations have not been studied Iran. This study aimed to examine the impact of the COVID-19 pandemic on hospital admissions for nine categories of disease in seven public hospitals in Kermsnahah city, the capital of Kermsnahah province, in the west of Iran. METHODS: Data on monthly hospitalization rates (number of hospitalizations per 100,000 population) were collected for nine categories of disease for a period of 40 months (23 months before and 17 months after the COVID-19 outbreak in Iran) from the health information systems of all seven public hospitals in Kermanshah city. Categories of disease included those related to pregnancy, childbirth and the puerperium period, neoplasms, diseases of the digestive, respiratory, circulatory, genitourinary and nervous systems, mental and behavioural disorders, and infectious and parasitic diseases. Population data were extracted from the Statistics Centre of Iran. An interrupted time series analysis with segmented regression was used to examine the impact of COVID-19 on hospital admissions. FINDINGS: Average monthly hospitalization rates fell for all nine categories of disease included in the study after the onset of the pandemic, with overall rates of 85.5 per 100,000 population in the period before the COVID-19 outbreak and 50.4 per 100,000 population after the outbreak began. The relative reduction in hospitalizations for the nine diseases was 56.4%. Regression analysis of monthly data indicated a sharp decrease in hospitalisations during the first month after the COVID-19 outbreak, which was statistically significant for all diseases (p < 0.001). After the initial reduction following onset of the pandemic, significant increases were observed for some diseases, including neoplasms (increase of 3.17 per 100,000 population; p < 0.001), diseases of the digestive system (increase of 1.17 per 100,000 population; p < 0.001) and diseases related to pregnancy, childbirth and the puerperium period (increase of 1.73 per 100,000 population). For other categories of disease, rates significantly declined, including infectious and parasitic diseases (decrease of 2.46 per 100,000 population; p < 0.001). Hospitalization rates did not increase to pre-pandemic levels for any disease, with the exception of those related to pregnancy, childbirth and the puerperium period. CONCLUSIONS: Our study indicated that the COVID-19 pandemic had a significantly negative effect on hospitalizations in Iran. Although use of hospital care has gradually increased post-outbreak, it has yet to return to normal levels.

Contributing factors to healthcare costs in individuals with autism spectrum disorder: a systematic review.

BACKGROUND: Individuals with autism spectrum disorder (ASD) are more likely to use healthcare than their counterparts without disabilities, which imposes high medical costs to families and health systems. This study aimed to investigate healthcare costs and its determinants among individuals with ASD. METHODS: In this systematic review, we searched online databases (Web of Science, Medline through PubMed and Scopus) for observational and experimental studies that included data on service use and costs associated with ASD and published between January 2000 and May 2021. Exclusion criteria included non-English language articles, duplicates, abstracts, qualitative studies, gray literature, and non-original papers (e.g., letters to editors, editorials, reviews, etc.). RESULTS: Our searches yielded 4015 articles screened according to PRISMA guidelines. Of 4015 studies identified, 37 articles from 10 countries were eligible for final inclusion. Therapeutic interventions, outpatient visits and medications constituted the largest proportion of direct medical expenditure on individuals with ASD. Included studies suggest lack of health insurance, having associated morbidities, more severe symptoms, younger age groups and lower socioeconomic status (SES) are associated with higher medical expenditure in individuals with ASD. CONCLUSIONS: This systematic review identified a range of factors, including lower SES and lack of health insurance, which are associated with higher healthcare costs in people with ASD. Our study supports the formulation of policy options to reduce financial risks in families of individuals with ASD in countries which do not have a tax-based or universal health coverage system.

Socio-economic inequality in reported dental self-care behaviour among Iranian households: A national pooled study.

BACKGROUND: Setting out effective prevention strategies in dental diseases needs recognition related factors of the prevention behaviours and targeting the most disadvantaged groups in the term of dental hygiene. This study aimed to investigate socio-economic inequality in the dental self-care status (DSS) of Iranian households and decompose the measured inequality into its contributors. METHOD: In this cross-sectional study, pooled data were extracted from Households Income and Expenditure Surveys (HIESs) conducted in Iran from 2012 to 2017. The index of socio-economic status (SES) for each household was constructed using principal components analysis (PCA). We used Wagstaff normalized concentration index as a measure of socio-economic inequality in dental self-care. Decomposition analysis was applied to determine the main factors contributed to the measured inequality. RESULTS: The prevalence of dental self-care in the whole population was 40.56%. The total concentration index was 0.271 (CI: 0.266, 0.275). The results of decomposition analysis for the measured inequality showed that SES, was the highest positive contributors (90.19%) followed by sex of household's head (12.15%), place of residence (11.79%) and education level of household's head (11.71%). Furthermore, the province of residence had the highest negative contribution (-11.37) to the inequality. CONCLUSION: The findings of this study showed that a huge portion of the observed inequality was explained by SES that might give us a policy recommendation: There is room for improving dental health and reducing inequality in dental self-care by paying more attention to SES-disadvantaged households.

Application of discrete choice experiments to estimate value of life: a national study protocol in Iran.

BACKGROUND: Global concerns regarding the significant burden of non-communicable diseases and injuries (NCDIs) exist from both public health and economic perspectives. Our research focuses on the reduction of fatal risks due to NCDIs and the citizens' preferences about health programs and intervention to reduce premature death due to NCDIs. Governments and health authorities need reliable evidence and information to prioritize the interests of their citizens. One crucial piece of evidence to justify the resources spent on NCDIs is the value derived from the interventions on prevention and NCDIs control. This concept is usually called "Value of Statistical Life" (VSL), meaning the monetary value that individuals place on changes in the risk levels of life- threatening events. To the best of our knowledge, for the first time, our study will estimate the statistical value of life for selected interventions for the prevention and control of NCDIs at both national and sub-national levels in the context of Iran. This paper reports the development of a national protocol through Discrete Choice Experiments (DCEs) method. METHODS AND DESIGNS: Our study comprises several stages: (a) a literature review to identify the attributes and levels of the prevention programs and Willingness to Pay (WTP) for reducing the NCDI's fatal risks; (b) experimental design to assessing, prioritizing, and finalizing the identified attributes and levels; (c) instrumental design to conduct face-to-face structured survey interviews of 3180 respondents aged 18-69 across the entire country; (d) statistical analysis to estimate the results through the Mixed Multinomial logit (MMNL) model. DISCUSSION: We anticipate that our findings will help build a stronger empirical basis for monetizing the value of small changes in selected fatality risks. It paves the way for other national or vast VSL estimates for NCDIs, as well as other major causes of morbidity and mortality in the context of Iran, and perhaps other low and middle-income countries (LMICs).

Eliciting preferences of patients about the quality of hospital services in the west of Iran using discrete choice experiment analysis.

OBJECTIVES: Knowing about accurate customer expectations is the most important step in defining and delivering high-quality services. This study aimed to evaluate the preferences of patients referring to two hospitals in Kermanshah, Iran. METHOD: Discrete choice experiment (DCE) method used to elicit preferences of 328 patients who were admitted in two hospitals of Kermanshah city in the west of Iran. Literature review and experts opinion were used to identify a candidate list of attributes related to the quality of cares in hospitals. The final study attributes were quality of physician care, quality of nursing care, waiting time for admission, cleaning of wards and toilets, and behavior of staff. Experimental design applied to extract choice sets of hospitals. The data was analyzed by a conditional logit regression. RESULTS: The regression results showed the most important predictors of hospital selection by respondents was the good quality of physician care (aOR: 3.18, 95% CI 2.61, 3.87), followed by friendly behavior of staffs (aOR: 2.03, 95% CI 1.81, 2.27), cleanness of wards and toilet (aOR: 1.61, 95% CI 1.40, 1.85), and finally quality of nursing cares (aOR: 1.13, 95% CI 0.89, 1.44). However, increasing waiting time made disutility in the study participants (aOR: 0.69, 95% CI 0.60, 0.80). CONCLUSIONS: Our study finding emphasized some potential opportunity of quality augmentation in hospital sector by paying attention to different quality attributes including quality of physician, friendly behavior of staffs, cleanness of hospital environment and finally quality of nursing cares. Considering patients preferences in decision making process could lead to substantial satisfaction improvement.

The impact of out-of pocket payments of households for dental healthcare services on catastrophic healthcare expenditure in Iran.

BACKGROUND: Dental healthcare is the costliest and single most source of the financial barrier to seeking and use of needed healthcare. Hence, this study aims to analyses impact of out-of-pocket (OOP) payments for dental services on prevalence catastrophic healthcare expenditure (CHE) among Iranian households during 2018. METHODS: We performed a cross-sectional analysis to determine the prevalence rate of CHE due to use of dental healthcare services among 38,858 Iranian households using the 2018 Household Income and Expenditure Survey (HIES) survey data of Iran. The WHO approach was used to determine the CHE due to use of dental care services at the 40% of household capacity to pay (CTP). Multiple logistic regression models were used to obtain the odds of facing with CHE among households that paid for any dental healthcare services over the last month while adjusting for covariates included in the model. These findings were reported for urban, rural areas and also for low, middle and high human development index HDI across provinces. RESULTS: The study indicated that the prevalence of CHE among households that used and did not used dental services over the last month was 16.5% (95% CI: 14.9 to 18.3) and 4.3% (95% CI: 4.1 to 4.6), respectively. The adjusted odds ratio (AOR) for the covariates revealed that the prevalence of CHE for the overall households that used dental healthcare service was 6.2 times (95% CI: 5.4 to 7.1) than those that did not use dental healthcare services. The urban households that used dental healthcare had 7.8 times (95%CI: 6.4-9.4) while the rural ones had 4.7 times (95% CI: 3.7-5.7) higher odds of facing CHE than the corresponding households that did not use dental healthcare services. CONCLUSIONS: The study indicates that out-of-pocket costs for dental care services impose a substantial financial burden on household's budgets at the national and subnational levels. Alternative health care financing strategies and policies targeted to the reduction in CHE in general and CHE due to dental services in particular are urgently required in low and middle income countries such as Iran.

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.

Estimating utility value for female genital mutilation.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is a clear violation of women's rights and can have adverse and irreversible health effects as well. Worldwide, more than 200 million women and girls have undergone FGM/C. Utility value of FGM/C has not been estimated yet, so we designed this study to extract the health utility value of FGM/C for the first time in the world. METHODS: In a cross-sectional study in Iran, 125 girls and women who underwent FGM/C procedure were examined by the trained midwives in order to determine its type. In addition, a questionnaire was completed for identifying the socio-demographic factors and extracting the health utility of these individuals. Health utility was measured using Time Trade-off method and also to determine the effects of the socio-demographic factors on the health utility a two-limit censored regression model was applied. RESULTS: The mean and median of the health utility of women with FGM/C were 0.971 (SE: 0.003) and 0.968 (IQR: 1-0.95), respectively. Number of non-traders was 58 (46.4%) who reported perfect health utility. However, the mean of health utility among traders was 0.946 (SE: 0.002). Only type 1 (Clitoridectomy) and type 2 (Excision) FGM/C were seen in this study. Women with Type 1 FGM/C had significantly lower health utility value (Mean: 0.968, Median: 0.957) than their type 2 counterparts (Mean: 0.987, Median: 1.00). Moreover, women in the age group of 31-45 years (Mean: 0.962, Median: 0.956), single (Mean: 0.950, Median: 0.954), divorced (Mean: 0.951, Median: 0.950), employed (Mean: 0.959, Median: 0.956), and with supplementary insurance (Mean: 0.962, Median: 0.950) had significantly lower health utility than their counterparts. CONCLUSION: FGM/C affects physical and psychological well-being of these individuals, resulting in a lack of personal and marital satisfaction, which ultimately leads to a 3% reduction in their health related quality of life. Therefore, preventing from this practice is very important and should be considered by health system policy makers more than before.

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.

Effect of female genital mutilation on mental health: a case-control study.

Objectives: The study aimed to investigate the mental health status of women with female genital mutilation/cutting (FGM/C) and compare it with that of a similar group of women without FGM/C.Methods: A case-control study was carried out in 2018 among 122 women with FGM/C and 125 women without FGM/C who had been referred to one of the general health service centres in Kermanshah Province, western Iran. The 28 item General Health Questionnaire (GHQ-28) was used to collect data on participants' mental health. A multivariate logistic model with odds ratios (ORs) was used to determine the relationship of independent variables with the outcome variable, mental health status.Results: The mean age of the FGM/C and control groups was 35.7 (standard deviation [SD] 8.6) and 31.3 (SD 7.2) years, respectively. According to the GHQ-28 questionnaire, 65.6% (n = 80) of the FGM/C group and 52% (n = 65) of the control group had symptoms of a mental health disorder; the difference between the groups was statistically significant (p = .03). The prevalence of severe depression in the FGM/C group was significantly higher than in the control group (p = .021). Multivariate logistic regression showed that having a history of FGM/C (adjusted OR 1.79; 95% confidence interval [CI] 1.05, 3.05) and being in employment (adjusted OR 3.46; 95% CI 1.23, 9.74) had a significant effect on presentation with symptoms of a mental health disorder (p < .05).Conclusion: Women who suffer from FGM/C are more vulnerable to mental health disorders such as depression.

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.

Socioeconomic gradient in physical activity: findings from the PERSIAN cohort study.

BACKGROUND: The level of socioeconomic-related inequality in physical activity in Iran is largely unknown. This study investigates socioeconomic-related inequality in poor-physical activity (PPA) among Iranian adults. METHODS: A total of 129,257 adult participants enrolled in the PERSIAN (Prospective Epidemiological Research Studies in IrAN) Cohort were included in this study. Physical activity of adults was measured using metabolic equivalent rates (METs). Physical activity less than 41 METs/hour/day was considered PPA. The Concentration index (C) was used to quantify socioeconomic-related inequality in PPA. Moreover, the C was decomposed to identify the relative contribution of explanatory variables to inequality in PPA. RESULTS: There were significant regional variations in physical activity level among Iranian adults (29.8-76.5%). The positive value of C (0.098, 95% CI = 0.092 to 0.104) suggested that the higher concentration of PPA among higher socioeconomic status (SES) adults in Iran which was consistently observed in all cohort sites. CONCLUSIONS: The higher prevalence of PPA among Iranian adults, especially, women and older adults, warrant further public health attention. Since PPA is concentrated more among the high-SES population in Iran, strategies for the promotion of physical activity should focus more on economically well-off population.

Developing attributes and levels for a discrete choice experiment on basic health insurance in Iran.

Background: Nonmarket stated preferences valuation, especially discrete choice experiments (DCEs), is one of the commonly used techniques in the health sector. The primary purpose of this approach is to help select attributes and attributes-levels that are able to properly describe health care products or services. This study aimed at developing attributes and attributes-levels for basic health insurance system in Iran. Methods: This study was conducted in 3 phases. First, narrative review was performed to identify related attributes. Also, 9 experts were interviewed to identify relevant attributes of health insurance in context. Other 36 experts rated the attributes and levels. Then, the research team decided on the inclusion of attributes and levels in the final design. The design was constructed using generic and Defficient method with SAS 9.1. The design was divided into 3 blocks, each having 8 choice sets. Finally, the choice set was piloted with 45 participants. Results: Public hospitals, and private hospitals benefits, dental insurance coverage, inpatient benefits, rehabilitation therapy, and paraclinical benefits, long-term care, medical devices benefits (Ortez, Protez, etc.), and monthly premium were identified and included in the final attribute design (D-efficiency = 98.16). The pilot study revealed that participants could easily understand and answer all the choice sets. Conclusion: The results of our study indicated that health insurance service benefit packages and premium were among the most important attributes that need to be included in the final attribute design for Iranians. The policymakers and health insurance organizations should emphasize these attributes in the benefit packages to make improvements. The emphasis on these attributes can help elicit people's preferences and willingness to pay for attributes.

Determinants of healthcare expenditures in Iran: evidence from a time series analysis.

BACKGROUND: A dramatic increase in healthcare expenditures is a major health policy concern worldwide. Understanding factors that underlie the growth in healthcare expenditures is essential to assist decision-makers in finding best policies to manage healthcare costs. We aimed to examine the determinants of healthcare spending in Iran over the periods of 1978-2011. METHODS: A time series analysis was used to examine the effect of selected socio-economic, demographic and health service input on per capita healthcare expenditures (HCE) in Iran from 1978 to 2011. Data were retrieved from the Central Bank of Iran, Iranian Statistical Center and World Bank. Autoregressive distributed lag approach and error correction method were employed to examine long- and short-run effects of covariates. RESULTS: Our findings indicated that the GDP per capita, degree of urbanization and illiteracy rate increase healthcare expenditures, while physician per 10,000 populations and proportion of population aged≥ 65 years decrease healthcare expenditures. In addition, we found that healthcare spending is a "necessity good" with long- and short-run income (GDP per capita), elasticities of 0.46 (p<0.01) and 0.67 (p = 0.01), respectively. CONCLUSION: Our analysis identified GDP per capita, illiteracy rate, degree of urbanization and number of physicians as some of the driving forces behind the persistent increase in HCE in Iran. These findings provide important insights into the growth in HCE in Iran. In addition, since we found that health spending is a "necessity good" in Iran, healthcare services should thus be the object of public funding and government intervention.

The Effect of COVID-19 Pandemic on Households' Utilization of Rehabilitation Services: National Evidence from Iran Health System.

Background: The coronavirus disease-2019 (COVID-19) pandemic has affected the pattern of utilization of healthcare services. This study aimed to investigate the utilization of rehabilitation services before and after the COVID-19 pandemic in the health system of Iran. Methods: This descriptive-analytical study used data from the Household Income and Expenditure Surveys of the Iran Statistics Center in 2018-2019 (before COVID-19) and 2020 (after COVID-19). The patterns of utilization and expenditures of rehabilitation services before and after this pandemic were investigated in different household sub-groups. The multilevel logistic regression model was used to investigate the effect of COVID-19 on the utilization of health services by households. Results: Although 258 (0.66%) households used rehabilitation services before the COVID-19 pandemic, only 175 (0.47%) households utilized them after the pandemic. Additionally, the average total rehabilitation costs per utilized household were 3,438,185 Iranian Rials (IRR) in 2018-2019 and 2,996,511 IRR in 2020-2021. Sex, age, education, size of household, place of residence, health insurance coverage, and income significantly affected the utilization of rehabilitation services by households during the study period (p < 0.001). Furthermore, the average use of rehabilitation services decreased by 22% (odds ratio = 0.78, p < 0.01) after the pandemic. Conclusion: In Iranian households, the utilization and average expenditure of rehabilitation services significantly decreased after the COVID-19 pandemic. These findings strongly recommend health system policymakers to develop comprehensive plans to address future shocks arising from pandemics and other emergencies.

Willingness to pay for a COVID-19 vaccine and its associated determinants in Iran.

Introduction: Understanding the individuals' willingness to pay (WTP) for the COVID-19 vaccine could help design policy interventions to control the COVID-19 pandemic. This study aimed to estimate the individuals' willingness to pay (WTP) for a COVID-19 vaccine and to identify its associated determinants. Methods: A cross-sectional survey was conducted on 526 Iranian adults using a web-based questionnaire. A double-bounded contingent valuation approach was used to estimate WTP for the COVID-19 vaccine. The parameters of the model were estimated based on the maximum likelihood method. Results: A considerable proportion of participants (90.87%) were willing to pay for a COVID-19 vaccine. Based on our discrete choice model, the estimated mean WTP for a COVID-19 vaccine was US$ 60.13 (CI: 56.80-63.46; p < 0.01). Having a higher perceived risk of being contaminated with COVID-19, higher average monthly income, higher education level, pre-existence of chronic diseases, previous experience of vaccination, and belonging to higher age groups were significant determinants associated with WTP for COVID-19 vaccination. Conclusion: The present study indicates a relatively high WTP and acceptance of a COVID-19 vaccine among the Iranian population. Average monthly income, risk perception, education level, the preexistence of chronic disease, and previous vaccination experience increased the likelihood of WTP for a vaccine. Subsidizing the COVID-19 vaccine for the low-income population and raising risk perception among the population should be considered in formulating vaccine-related interventions.

The effect of Iran's health sector evolution plan on hospitals performance indicators: an interrupted time series analysis.

Background: The Health Sector Evolution Plan (HSEP) was set up in Iran's health system to respond to some of the main problems in hospitals and other health sectors. We aimed to compare the effect of the HSEP on teaching hospital performance before and after the implementation of the HSEP through the interrupted time series (ITS) analysis. Methods: With a cross-sectional design, data collection was performed in 17 teaching hospitals affiliated with the Kermanshah University of Medical Sciences (KUMS). We used the existing data on three indicators of hospitalization rate (per 10,000 population), Emergency Department Visits (EDVs) (per 10,000 population), and in-hospital mortality (per 10,000 population). The monthly data from 2009 to 2019 was analyzed by the ITS method 60 months before and 61 months after the HSEP. Results: We found a non-statistically significant decrease in the monthly trend of hospitalization rate relative to the period before the HSEP implementation (-0.084 per 10,000 population [95%CI: -0.269, 0.101](. There was a statistically significant increase in the monthly trend of EDVs rate compared to before the HSEP implementation (1.07 per 10,000 population [95%CI: 0.14, 2.01]). Also, a significant decrease in the monthly trend of in-hospital mortality compared to before the HSEP implementation [-0.003 per 10,000 population (95%CI: -0.006, -0.001)] was observed. Conclusion: Our study demonstrated a significant increasing and decreasing trend for EDVs and in-hospital mortality following the HSEP implementation, respectively. Regarding the increase in hospitalization rate and EDVs after the implementation of HESP, it seems that there is a need to increase investment in healthcare and improve healthcare infrastructure, human resources-related indicators, and the quality of healthcare.

The COVID-19 pandemic and healthcare utilization in Iran: evidence from an interrupted time series analysis.

BACKGROUND: This study aimed to examine the effect of the coronavirus disease 2019 (COVID-19) outbreak on the hospitalization rate, emergency department (ED) visits, and outpatient clinic visits in western Iran. METHODS: We collected data on the monthly hospitalization rate, rate of patients referred to the ED, and rate of patients referred to outpatient clinics for a period of 40 months (23 months before and 17 months after the COVID-19 outbreak in Iran) from all 7 public hospitals in the city of Kermanshah. An interrupted time series analysis was conducted to examine the impact of COVID-19 on the outcome variables in this study. RESULTS: A statistically significant decrease of 38.11 hospitalizations per 10,000 population (95% confidence interval [CI], 24.93-51.29) was observed in the first month of the COVID-19 outbreak. The corresponding reductions in ED visits and outpatient visits per 10,000 population were 191.65 (95% CI, 166.63-216.66) and 168.57 (95% CI, 126.41-210.73), respectively. After the initial reduction, significant monthly increases in the hospitalization rate (an increase of 1.81 per 10,000 population), ED visits (an increase of 2.16 per 10,000 population), and outpatient clinic visits (an increase of 5.77 per 10,000 population) were observed during the COVID-19 pandemic. CONCLUSION: Our study showed that the utilization of outpatient and inpatient services in hospitals and clinics significantly declined after the COVID-19 outbreak, and use of these services did not return to pre-outbreak levels as of June 2021.