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.

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.

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.

Inequality in Cosmetic Services and Surgery among Iranian Households in 2019: A Decomposition Analysis.

Background: The demand for cosmetic surgery is on the rise worldwide, making it the common form of surgery globally while the use of cosmetic surgery being exponentially high in Iran. The aim of this study was to investigate inequality in the use of cosmetic services and surgery (CSS) among Iranian households concerning demographic and socio-economic characteristics. Methods: This study used data of 38960 Iranian household from the income-expenditure survey of the statistical center of Iran (SCI) in 2019. Concentration index (C) was used to measure inequalities in the use of CSS. Microsoft Excel sheet 2019 was used to extract the data, and the analysis was performed using Stata statistical package version 14.2. Results: Households with female head, with single head, households with 3 - 4 people, headed with undergraduate education person, households with insurance coverage, with higher socio-economic quintiles, rural households and residents of northwestern Iran were accounted for the highest use of CSS. Also, according to the decomposition analysis, wealth and education level are the two main factors in creating inequality, with wealth, having the highest positive share (88.11%) and education level having the most negative share (-5.26%) in creating measured inequality. Conclusion: The use of CSS is more concentrated in well-off households in Iran. As the resources of health system are limited, the government and the policy makers should have defined plans with regards to CSS use especially taking factors like socioeconomic status and education status of target groups in to account.

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.

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.

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).

Explaining Socioeconomic Inequality Differences in Catastrophic Health Expenditure Between Urban and Rural Areas of Iran After Health Transformation Plan Implementation.

OBJECTIVE: Ensuring fair financial contribution is one of the main goals of the Health Transformation Plan (HTP) of Iran. This study aims to estimate socioeconomic inequality differences in catastrophic health expenditure (CHE) between urban and rural areas of Iran after the implementation of the HTP during 2017. MATERIALS AND METHODS: Data from a representative survey of households' income and xpenditure from the Iran Statistical Center (ISC) were used for the analysis. We applied the World Health Organization (WHO) cut-off of 40% payment for CHE, and Wagstaff's normalized concentration index (C) to measure and decompose the inequality. Also, Blinder-Oaxaca decomposition analysis was used to decompose contributors of inequality differences between rural and urban areas. RESULTS: The overall incidence of CHE among Iranian households during the year 2017 was 3.32% with a standard deviation (SD) of 17.91%, and the mean (SD) levels of CHE in rural and urban areas of Iran were 4.37% (20.45%) and 2.97% (16.99%), respectively. The aggregate socioeconomic status (SES)-related inequality in CHE was significantly (p<0.001) different from zero (C=-0.238) and there was a significant (p<0.05) difference between rural (C=-0.150) and urban (C=0.218) areas. SES was the highest contributor to inequality in both rural (130.09) and urban (144.17) areas. The Blinder-Oaxaca decomposition revealed that SES (175.01%) followed by outpatient services (120.29%) were the main contributors to differences in inequality in rural and urban areas. Sex (-101.42%) and health insurance coverage were among negative contributors to this inequality difference. CONCLUSION: Our findings revealed a significant pro-rich inequality in CHE. Also, some variables, such as sex and region, made different contributions in rural and urban areas. However, SES, itself, made the highest contribution in both areas and explained the greatest share of difference in inequality between the two areas. This issue calls for revision of the HTP to further address the risk of CHE and socioeconomic disparity among Iranian households, especially those with lowSES.

Socioeconomic inequality in dental caries experience expressed by the significant caries index: cross-sectional results from the RaNCD Cohort Study.

INTRODUCTION: Socioeconomic inequality in dental caries among Iranian middle-aged adults remains largely unstudied. This study aimed to measure socioeconomic inequality in dental caries experience and to identify determinants of this inequality. MATERIALS AND METHODS: Data were obtained from the Ravansar Non-Communicable Diseases (RaNCD) Cohort Study. This cross-sectional analysis included 10,002 adults aged 35-65 years. Caries experience was dichotomised based on the decayed, missing and filled teeth (DMFT) of one-third of the population with the highest caries scores (i.e. significant caries index). Socioeconomic status (SES) was calculated using the principal component analysis. The concentration index (CI) was used to quantify the extent of socioeconomic inequality in dental caries experience. Decomposition analysis was conducted to quantify the contribution of each determinant to the observed inequality. RESULTS: The mean DMFT for all individuals was 16.1(SD 9.1). The CI of having significant dental caries was -0.236 (95% CI: -0.0259, -0.213), indicating that having significant dental caries was more concentrated among low-SES individuals. SES (65.6%), age group (24.7%) and female gender (3.7%) were found to have the largest percentage of contributions to the observed inequality in dental caries. CONCLUSION: This study indicates pro-rich inequalities in dental caries experience among middle-aged adults in Iran. The findings highlight the importance of early prevention of dental caries experience before it happens. To mitigate inequalities in dental caries experience, policy interventions should focus on females, older age groups, and low-SES individuals.

Decomposing socioeconomic inequality in dental caries in Iran: cross-sectional results from the PERSIAN cohort study.

BACKGROUND: The current study aimed to measure and decompose socioeconomic-related inequalities in DMFT (decayed, missing, and filled teeth) index among adults in Iran. METHODS: The study data were extracted from the adult component of Prospective Epidemiological Research Studies in IrAN (PERSIAN) from 17 centers in 14 different provinces of Iran. DMFT score was used as a measure of dental caries among adults in Iran. The concentration curve and relative concentration index (RC) was used to quantify and decompose socioeconomic-related inequalities in DMFT. RESULTS: A total of 128,813 adults aged 35 and older were included in the study. The mean (Standard Deviation [SD]) score of D, M, F and DMFT of the adults was 3.3 (4.6), 12.6 (10.5), 2.1 (3.4) and 18.0 (9.5), respectively. The findings suggested that DMFT was mainly concentrated among the socioeconomically disadvantaged adults (RC = - 0.064; 95% confidence interval [CI), - 0.066 to - 0.063). Socioeconomic status, being male, older age and being a widow or divorced were identified as the main factors contributing to the concentration of DMFT among the worse-off adults. CONCLUSIONS: It is recommended to focus on the dental caries status of socioeconomically disadvantaged groups in order to reduce socioeconomic-related inequality in oral health among Iranian adults. Reducing socioeconomic-related inequalities in dental caries should be accompanied by appropriate health promotion policies that focus actions on the fundamental socioeconomic causes of dental disease.

A healthy behavior and socioeconomic inequality in school-age children in the West of Iran.

BACKGROUND: Sufficient physical activity (SPA) in children and adolescents has an important role in health, growth, and development of persons. This study aimed to investigate the prevalence of and inequality in physical activity (PA) in 12-15-year-old students in the West of Iran, 2018. MATERIALS AND METHODS: In this cross-sectional study, 1404 students from 14 schools of Kermanshah city were included. Data on demographic and socioeconomic status (SES) of students and their family, body mass index, moderate-to-vigorous PA of students were collected. Normalized concentration index (NC) and decomposition analysis applied to measure inequality in SPA and the contribution of affecting factors, respectively. RESULTS: About 19% of the students had SPA. The proportion of SPA in boys was higher than girls (38.98% vs. 9.84%). There was a significant deviation from equality line (NC = 0.31; 95% confidence interval [CI]: 0.23, 0.38) and NC for boys and girls were 0.15 (95% CI: 0.04, 0.25) and 0.05 (95% CI: -0.07, 0.17). Sex of students and SES of households with 59.09% and 39.77% contribution to the measured inequality in SPA were the highest positive contributors. Household size (-2.60) had a negative contribution to inequality in SPA. CONCLUSION: There was a significant pro-rich socioeconomic inequality in SPA and sex, and SES were the main contributors to the inequality in PA. Some interventions are needed to improve PA among children and adolescents with a focus on girls and low-SES groups to narrow the existing gaps.

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 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 - 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.

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.

Eliciting Preferences for Health Insurance in Iran Using Discrete Choice Experiment Analysis.

BACKGROUND: The preferences of Iranians concerning the attributes of health insurance benefit packages are not well studied. This study aimed to elicit health insurance preferences among insured people in Iran during 2016. METHODS: A mixed methods study using a discrete choice experiment (DCE) approach was conducted to elicit health insurance preferences on a total sample of 600 insured Iranians residing in Tehran. The final design of the DCE included 8 health insurance attributes. Data were analyzed using conditional logistic regression models. RESULTS: The final model of this DCE study included 8 attributes, and the findings indicated statistically significant (P<.001) increase in the odds ratio (OR) of choosing health insurance at all levels of cost coverage except for the rehabilitation and para-clinical benefits, where at 70% cost coverage there was insignificant (P=.485) disutility (OR=0.95). With the increase in cost coverage level, the probability of choosing health insurance was significantly (P<.001) the highest for the private hospitals' benefits (OR=2.82) followed by public hospitals' benefits (OR=2.02) and outpatient benefits (OR=1.75), and the premium revealed statistically significant (P<.001) disutility (OR=0.96). CONCLUSION: Our findings revealed that participants would be willing to choose health insurance plans with higher cost coverage of healthcare services and with lower premiums. However, the demographic characteristics, income, and health status of the insured individuals affected their health insurance preferences. The findings can contribute to the design of better health insurance policies, improve the participation of individuals in health insurance, and increase the insured individuals' utility from the insurance benefits packages.

Measuring and Explaining Socioeconomic Inequalities in Public Healthcare Utilization in Western Iran: Evidence from a Cross-sectional Survey.

BACKGROUND: Equity in healthcare utilization is a major health policy goal in all healthcare systems. This study aimed to examine socioeconomic inequalities in public healthcare utilization in Kermanshah City, western Iran. STUDY DESIGN: A cross-sectional study. METHODS: Using convenience sampling method, 2040 adult aged 18-65 yr were enrolled from Kermanshah City in 2017. A self-administrated questionnaire was used to collect data on socio-demographic characteristics, socioeconomic status, behavioral factors, and utilization of public healthcare services (inpatient and outpatient care) over the period between from May to Aug 2017. The concentration index (C) was used to measure and decompose socioeconomic inequalities in the utilization inpatient and outpatient care in public sector. The indirect standardization method was used to estimate the horizontal inequity (HI) indices in inpatient and outpatient care use. RESULTS: The utilization outpatient (C=-0.121, 95% CI: -0.171, -0.071) and inpatient care in public sector (C=-0.165, 95% CI: -0.229, -0.101) were concentrated among the poor in Kermanshah, Iran. Socioeconomic status, health-related quality of life, marital status and having a chronic health condition were the main determinants of socioeconomic-related inequalities in the utilization of inpatient and outpatient care in public sector among adults. The distributions of outpatient (HI=-0.045, CI: -0.093 to 0.003) and inpatient care (HI= -0.044 95% CI: -0.102, 0.014) in Kermanshah were pro-poor. These results were not statistically significant (P<0.05). CONCLUSIONS: The utilization of public healthcare services in Iran are pro-poor. The pro-poor distribution of inpatient and outpatient care in public facilities calls for initiatives to increase the allocation of resources to public facilities in Iran that may greatly benefit the health outcomes of the poor.

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 Economic Burden of Liver Cirrhosis in Iran: a Cost of Illness Study.

BACKGROUND: According to importance of cirrhosis of the liver and the lack of information about the economic burden of the disease, we performed this study to estimate the economic burden of liver Cirrhosis in Iran in 2011. METHODS: The cost-of-illness method, based on the human capital theory, has been used. Both direct and indirect costs have been estimated using a prevalence approach and bottom-up method. The inpatient and outpatient records were investigated for obtaining the medical costs. Also, a questionnaire was used for collection the other data such as transportation costs, out of pocket payment and times of inpatients, etc. Costs consisted of expenditures which happened during March 2011 to February 2012 and the perspective of the study was Iranian society. RESULTS: The total cost of the disease was 2014.5 billion Rials (USD164.32 million). Direct and indirect costs were 1384.16 and 630.4 billion Rials (86.7% and 11.3% of the total cost), respectively. Cost due to premature death was USD 38.66 million, included 23.52% of the total cost and 75% of indirect cost. CONCLUSION: Liver Cirrhosis impose enormous economic burden on Iranian society. Policymakers should therefore take this into consideration and according to available health resources provide services and facilities for the prevention and treatment of the disease.