Decomposition of Healthcare Utilization Inequality in Iran: The Prominent Role of Health Literacy and Neighborhood Characteristics.

Unequal utilization in healthcare can potentially affect the right to health. Access to healthcare services and achieving positive health outcomes and health equity are essential principles in promoting human rights. This study aims to assess and analyze socioeconomic-related inequalities in outpatient health services utilization (OHSU) among various socio-demographic subgroups to inform policies that foster health equity. Data were collected through a cross-sectional survey of 1200 households in Tehran, Iran. Inequality in OHSU among the socio-demographic subgroups was calculated by concentration, Wagstaff, and Erigers indices. Decomposition was used to identify the factors contributing to inequality in OHSU. Marginal effect and elasticity were used to calculate the relative absolute shares of socio-demographic variables in the inequality. The rate of OHSU was 63.61% (CI: 60-66.80) which concentrated among households with better socioeconomic status. Based on the results, living in an affluent neighborhood (Relative share (RS): 85.48) and having a disabled member in the household (RS: 6.58) were the most important factors in the concentration of OHSU in favor of the privileged groups. In contrast, very low levels of health knowledge (RS: -83.79) and having basic insurance coverage (RS: -3.92) concentrated OHSU in favor of the lower socioeconomic households. The study was conducted based on survey data, and this may lead to some limitations. Given that this study was a cross-sectional study, we were unable to establish causal relationships between explanatory variables and outpatient health service utilization and its relevant predictors. Households with disabled member(s), as well as a member(s) with chronic diseases, may experience severe inequalities in access to healthcare services. Policies that facilitate access to health services for these households can play a significant role in improving health equity.

Factors Associated with Medication Adherence in Elderly Individuals with Tuberculosis: A Qualitative Study.

Methods: This qualitative study was conducted in two phases, using an integrative literature review and individual interviews. Studies were gathered without time restriction from MEDLINE databases, Institute for Scientific Information (ISI), Google Scholar, Scopus, and EMBASE, as well as national databases, including Scientific Information Database and Magiran. The findings of 38 studies that met the inclusion criteria were analyzed through the conventional content analysis method based on the ecological approach. After reviewing and forming the data matrix, purposive sampling was performed among healthcare professionals, elderly tuberculosis patients aged 60 and over, and family caregivers of elderly patients to conduct individual interviews. Data obtained from 20 interviews were analyzed using the directed content analysis method. After coding, the data from individual interviews were entered based on similarity and difference in the categories of data matrix obtained from the literature review. Results: In general, the aforementioned codes were placed in four main categories, including individual factors (i.e., biological factors, affective-emotional factors, behavioral factors, cognitive factors, tuberculosis-related factors, and economic factors), interpersonal factors (i.e., patient's relationship with treatment team and family-related factors), factors related to healthcare service provider centers (i.e., medical centers' facilities and capacity building in healthcare service provider), and extraorganizational factors (i.e., social factors and health policymaking). Conclusion: The results of this study showed that medication adherence in elderly patients with tuberculosis was a complex and multidimensional phenomenon. Therefore, society, policymakers, and healthcare providers should scrutinize the factors affecting medication adherence in this group of patients to plan and implement more effective interventions.

Inequality in the Experience of Stressful Psychological Events: Evidence from a Regional Survey in Tehran.

Background: Socioeconomic status is one of the most important social determinants of the formation of stressful events. The purpose of this study was to estimate the amount of inequality in experiencing stressful events among higher and lower socio-economic groups and zones of Tehran citizens. Methods: The study was descriptive-analytical and cross-sectional. Through a multistage sampling method, 5895 adult residents in Tehran were selected. The research tool was a researcher-made questionnaire designed to measure stressful events in Tehran, which includes 11 dimensions of stressful factors. Concentration index and concentration curves were used to analyze the data. Results: Among the 11 stressful life events, 6 of them were significant. Stress by the neighborhood problems (CI = -0.47, 95% CI: -0.66, -0.28) and living problems (CI = -0.50, 95% CI: -0.68, -0.32) was pro-rich, and these two dimensions formed the greatest inequality between the poor and the rich. The other 3 dimensions of stress caused by housing problems, political problems and fear of the future were also pro-rich. Only educational problem stressors were pro-poor. Stressful life event experience was concentrated on residents of low-development areas (zones 1 and 2). Conclusion: Residents of Tehran experience stressful events unequally, and this inequality exists both within and between social groups. Most stressful events were observed among the poor and less developed zones.

Outpatient health service utilization and associated factors: A cross-sectional population-based study in Tehran in 2019.

Background: Health service utilization (HSU) is a significant health and political issue. Awareness of factors that affect HSU and the status of health service utilization can help health professionals improve their services. The aim of this study was to investigate the status of HSU and identify the factors affecting health service utilization among households residing in Tehran. Methods: The present cross-sectional study included 1200 residing households from different regions of Tehran, the capital of Iran. They were selected by a multi-stage cluster sampling method in accordance with the zoning of Tehran concerning socio-economic development. Interviews were conducted by trained individuals using a health service utilization questionnaire introduced by the World Health Organization, Zimet's social support questionnaire, and demographic checklist during winter 2018 and spring 2019. Simple and multiple logistic regression models were applied to analyze the data. In order to include the factors related to the status of outpatient health service utilization, a set of bivariate analyses was conducted, and then the factors with a p-value of ≤0.20 were included in the multiple models. Data were analyzed using Stata 12 software. Results: The results of the study indicated that the rate of outpatient HSU among households residing in Tehran was 63.61% (CI:60, 66.80). In addition, regarding the results of the study, asset index of family (OR=0.51, 95% CI: 0.28, 0.91), the level of awareness and knowledge of family members regarding health issues (OR=0.55, 95% CI: 0.34, 0.88) as well as the mother knowledge on health issues (OR=0.64, 95% CI: 0.45, 0.93), the level of social support (OR = 0.50, 95% CI: 0.37,0.68), family health expenditure (OR=1.20, 95% CI: 1.18, 4.06), having a member with a sort of disability in family (OR=1.66, 95% CI: 1.01, 2.77), and having an alcoholic member in family (OR=2.44, 95% CI: 1.27, 4.68) were factors associated with outpatient HSU among households. Considering the adjusted values of odds ratios, the prevalence of the HSU varied according to the area of residence. It should be noted that the variables included in the model explained 15% of the changes in the prevalence of HSU. Conclusion: According to the results of the study and in order to increase HSU in different classes, the level of social support, especially among women in the family due to their role in the general health of family members, should be enhanced. Also, policies should be adopted to increase the awareness, knowledge, and information of family members about health issues, lifestyle changes, nutrition, and health behaviors through social media.

Spatial pattern of well-being in Tehran: The north-south gap.

Background: Human well-being is a core global issue. Thus, achieving and sustaining higher levels of well-being is a challenge for citizens, governments, and international organizations worldwide. The present study aimed at describing the well-being status of residents of Tehran municipal districts. To achieve this, a composite well-being index was constructed for 22 municipal districts of Tehran (Tehran Well-being Index; TWI). Methods: This cross sectional study was conducted from May to October 2017 in Tehran using the data collected in the second round of Urban Health Equity Assessment and Response Tool (Urban HEART) Project of Tehran (2012-2013). The statistical population of this study was 22 municipal districts of Tehran and a sample of 34 700 households (118 000 individuals) selected using multistage cluster sampling. TWI was developed through the Organization for Economic Cooperation and Development (OECD) methodology of constructing composite indicators. Then, 22 municipal districts were categorized based on TWI scores. All data were analyzed using SPSS v.18. In addition, a cartogram was applied using GIS software to classify well-being status among Tehran municipal districts. Results: Factor analysis results showed that the Kaiser-Meyer-Olkin (KMO) value was 0.691 and 2 factors (material well-being and psychological well-being) explained 74.13% of the total variances. Furthermore, the best and worst performances were found in districts 6 and 17, respectively. District 6 had the best and district 17 the worst material well-being status. Also, districts 6 and 19 had the best and worst psychological well-being status, respectively. Conclusion: In general, the well-being status of the municipal districts of Tehran can be divided into 5 main categories: (a) prosperous (districts 1, 2, 3, 5, and 6); (b) fairly prosperous (districts 4, 21, and 22); (C) moderately prosperous (districts 7, 8, and 13); (d) less prosperous (9, 10, 11, 14, and 12); and (e) deprived zone (districts 12, 15, 16, 17, 18 and 19).