To what extent has the Iranian Health Transformation Plan addressed inequality in healthcare financing in Iran?

BACKGROUND: One of the major goals of health systems is providing a financing strategy without inequality; this has a significant impact on people's access to healthcare. The present study aimed to investigate the inequality in households' financial contribution (HFC) to health expenditure both before and after the implementation of the Iranian Health Transformation Plan (HTP) in 2014. METHODS: This study is a secondary analysis of two waves of a national survey conducted in Iran. The data were collected from the Households Income and Expenditure Survey in 2013 and 2015. The research sample included 76,195 Iranian households. The inequality in households' financial contributions to the health system was assessed using the Gini coefficient, and the concentration index (CI). In addition, by using econometric modeling, the relationship between the implementation of the HTP and inequality in HFC was studied. The households' financial contribution included healthcare and health insurance prepayments. RESULTS: The Gini coefficient values were 0.67 and 0.65 in 2013 and 2015, respectively, indicating a medium degree of inequality in HFC in both years. The CI values were 0.54 and 0.56 in 2013 and 2015, respectively, suggesting that inequalities in HFC were in favor of higher income quintiles in the years before and after the implementation of the HTP. Regression analysis showed that households with a female head, with an unemployed head, or with a head having income without a job were contributing more to financing health expenditure. The presence of a household member over the age of 65 was associated with a higher level of HFC. The implementation of the HTP had a negative relationship with the HFC. CONCLUSION: The HTP, aiming to address inequality in the financing system, did not achieve the intended goal as expected. The implementation of the HTP neglected certain factors at the household level, such as the presence of family members older than the age of 65, a female household head, and unemployment. This resulted in a failure to reduce the inequality of the HFC. We suggest that, in the future, policymakers take into account factors at the household level to reduce inequality in the HFC.

Measuring Safety Culture Using an Integrative Approach: The Development of a Comprehensive Conceptual Framework and an Applied Safety Culture Assessment Instrument.

An exponential amount of academic research has been dedicated to the safety culture concept, but still, no consensus has been reached on its definition and content. In general, safety culture research lacks an interdisciplinary approach. Furthermore, although the concept of safety culture is characterised by complexity and multifacetedness, the safety culture concept has been characterised by reductionism, where models and theories simplify the concept in order to better grasp it, leading to confined approaches. In this article, the multifacetedness of safety culture is acknowledged, and the topic is addressed from a safety science perspective, combining insights from multiple academic disciplines. An integrative and comprehensive conceptual framework to assess safety culture in organisations is developed, taking into account the limitations of existing models, as well as the needs of the work field. This conceptual framework is called the 'Integrated Safety Culture Assessment' (ISCA), where the 'assessment' refers to its practical usability. The practical rendition of ISCA can be used to map the safety culture of an organisation and to formulate recommendations in this regard, with the ultimate goal of bringing about a change towards a positive safety culture. The comprehensiveness of ISCA lies in the inclusion of technological factors, organisational or contextual factors and human factors interacting and interrelating with each other, and in considering both observable or objective safety-related aspects in an organisation, and non-observable or subjective safety-related aspects. When using ISCA, organisational safety culture is assessed in an integrative way by using a variety of research methods involving the entire organisation, and by taking into account the specific context of the organisation.

The Claiming Costs Scale: A new instrument for measuring the costs potential beneficiaries face when claiming social benefits.

It is a well-known feature of social protection systems that not all persons who are entitled to social benefits also claim these benefits. The costs people face when claiming benefits is considered an important cause of this phenomenon of non-take-up. In this paper, we developed and examined the psychometric properties of a new scale, the Claiming Cost Scale (CCS), which measures three dimensions of costs associated with claiming benefits. A multi-phase instrument development method was performed to develop the instrument. The item pool was generated based on a literature review, and presented to academic experts (n = 9) and experts by experience (n = 5) to assess content and face validity. In a second stage, centrality and dispersion, construct validity, convergent and divergent validity, and internal reliability of the instrument were tested. These analyses were based on two samples (n = 141 and n = 1265) of individuals living in low-income households in Belgium. Nine items were retained, which represent three factors (Information costs, Process costs and Stigma). The confirmatory factor analysis proved adequate model fitness. Both convergent and divergent validity were good, and internal consistency was adequate, with Cronbach's alpha ranging between .73 and .87. The findings showed that the CCS is a valid and reliable instrument for assessing the costs potential beneficiaries face when claiming benefits. Consisting of only nine items, the scale can be easily implemented in large-scale survey research or used in day-to-day work of service providers who are interested in understanding non-take-up of their service.

A Study on the Knowledge, Attitudes, and Behaviors of Pregnant Women Regarding HIV and Routine Rapid Testing: An Assessment in a High-Risk Marginal Area.

Acquired immunodeficiency syndrome (AIDS) is one of the main obstacles to communities' development. The disease mostly involves active and productive population groups. This study aimed to determine the knowledge, attitudes, and behaviors of pregnant women regarding HIV prevention and rapid HIV tests. Pregnant women who were referred to the local health centers and who were willing to participate in the study were interviewed. To collect data, a standard questionnaire was used among 200 pregnant women in eight local health centers of Kermanshah, Iran. The survey contained 50 questions on demographic characteristics and the knowledge, attitudes, and behaviors regarding HIV/AIDS prevention and rapid tests for pregnant women. Although the majority (82.5%) of the pregnant women knew that mother-to-child HIV transmission during pregnancy was possible, fewer than half (48.2%) of them knew that HIV can be transmitted from mother to child through breastfeeding. Only 22.5% of pregnant women knew that a Cesarean section for HIV-positive mothers is recommended. The mean attitudes of pregnant women toward HIV prevention and HIV rapid testing were 4.5 (SD = 0.4) and 4 (SD = 0.3), respectively. Of the women, 11.5% had participated in an HIV rapid test counseling class, and 25.5% had participated in HIV education and counseling classes. The low knowledge of mothers regarding HIV transmission highlights the need for education and counseling classes and campaigns to improve knowledge and behaviors related to HIV prevention, especially during pregnancy for women in marginal regions.

Determinants of hookah smoking among men in the coffee houses: an application of socio-ecological approach.

BACKGROUND: Tobacco smoking is the second leading cause of death and is closely linked to fatal diseases. Hookah Smoking (HS) is a traditional way to smoke tobacco, especially in the Eastern Mediterranean region that is constantly rising around the world. This study aimed to evaluate the different levels of personal, interpersonal and social HS in Iranian urban men and determine the most important predictors of the levels through applying the socio-ecological approach (SEA). METHODS: This study was conducted in the coffee houses of Hashtrud and Qarah Aghaj counties in East Azerbaijan, Iran. Data collection was conducted from the entire coffee house (n = 18) from April to June 2017. Systematic sampling was employed to recruit 266 men in the coffee house. A valid and reliable instrument was used to investigate the frequency of HS and its determinants based on SEA. The SEA consists of three levels: personal (age, education, employment, income, and perceived severity and sensitivity), interpersonal (perceived reward), and social level (social support) intended to assess HS determinants. Hierarchical regression was used to determine the predictive value of SEA levels and frequency of HS. RESULTS: The mean age of daily hookah smokers (once per day and more than once per day) were (26.8) significantly lower than those (30.4) smokes weekly (once a week or more than once a week). The hierarchical logistic regression model showed that in the first step individual variables significantly predict 25.1% HS. In the second and third level interpersonal and social levels of SEA explained HS 30.1 and 30.8%, respectively. CONCLUSION: This study found that age, income, education, and perceived reward were all important factors influencing HS among men youth. Application of SEA to determine the factors associated with HS could contribute in the development of a holistic prevention program.

Perceived barriers to methadone maintenance treatment among Iranian opioid users.

BACKGROUND: Opioid use is a severe problem in Iran. Despite methadone maintenance treatment (MMT) programs being one of the most important treatment strategies for reducing individual and public harms associated with opioid use, a large proportion of Iranian patients refuse to participate in such treatment programs. METHODS: The present study aims to explore the beliefs and attitudes toward MMT programs of opioid-dependent patients who were participating or had participated in methadone therapy. In-depth interviews were conducted with 23 opioid users between 27 and 58 years of age from Kurdistan provinces. RESULTS: Overall, six themes were discovered to be key barriers relating to methadone treatment, including financial barriers related to methadone treatment, lack of awareness about methadone treatment, negative attitudes regarding using methadone, worries about methadone's side effects, social stigma ascribed to methadone therapy, and systemic barriers to methadone treatment. CONCLUSION: Our study revealed that the cost of treatment is a major obstacle to attending and continuing at MMT programs and that addicts and their families are not always accurately informed about the duration of MMT programs and the side effects of methadone treatment.

Sociodemographic Characteristics of Trans Persons in Belgium: A Secondary Data Analysis of Medical, State, and Social Data.

By performing secondary data analyses of existing medical, social, and state data, this study examined the sociodemographic profile of trans persons in Belgium and gains knowledge on those who are functionally invisible in traditional epidemiological studies or clinical samples. Based on medical interventions, post-operative transsexual persons were selected from a social survey data set, to compare their sociodemographic profile with available data on legal sex changes from the Belgian National Register and with published data on clinical samples of post-operative transsexual persons. Furthermore, based on self-chosen gender identity categories in the social survey data, transsexual participants were compared with the transgender participants (those people feeling neither female nor male, or both female and male, or otherwise). The sociodemographic data on the post-operative transsexual persons from the three datasets appeared to be very similar. Based on identity categories, the data on transsexual and transgender persons from the social survey showed differences in marital status and employment. Transsexual persons were significantly more often divorced than transgender persons. Both groups differed significantly in employment status. Information about transgender people (or the "in-between" group) is too often lacking from studies but can be obtained when identity instead of medical criteria are used in research.

Financial stress, parent functioning and adolescent problem behavior: an actor-partner interdependence approach to family stress processes in low-, middle-, and high-income families.

The family stress model proposes that financial stress experienced by parents is associated with problem behavior in adolescents. The present study applied an actor-partner interdependence approach to the family stress model and focused on low-, middle-, and high-income families to broaden our understanding of the pathways by which the financial stress of mothers and fathers are related to adolescent outcomes. The study uses dyadic data (N = 798 heterosexual couples) from the Relationship between Mothers, Fathers and Children study in which two-parent families with an adolescent between 11 and 17 years of age participated. Path-analytic results indicated that in each of the families the association between parents' financial stress and problem behavior in adolescents is mediated through parents' depressive symptoms, interparental conflict, and positive parenting. Family stress processes also appear to operate in different ways for low-, middle-, and high-income families. In addition to a higher absolute level of financial stress in low-income families, financial stress experienced by mothers and fathers in these families had significant direct and indirect effects on problem behavior in adolescents, while in middle- and high-income families only significant indirect effects were found. The financial stress of a low-income mother also had a more detrimental impact on her level of depressive feelings than it had on mothers in middle-income families. Furthermore, the study revealed gender differences in the pathways of mothers and fathers. Implications for research, clinical practice, and policy are also discussed.

Predicting adolescents' disclosure of personal information in exchange for commercial incentives: an application of an extended theory of planned behavior.

This study adopts a global theoretical framework to predict adolescents' disclosure of personal information in exchange for incentives offered by commercial Websites. The study postulates and tests the validity of a model based on the theory of planned behavior (TPB), including antecedent factors of attitude and perceived behavioral control (PBC). A survey was conducted among 1,042 respondents. Results from SEM analyses show that the hypothesized model fits the empirical data well. The model accounts for 61.9 percent of the variance in adolescents' intention to disclose and 43.7 percent of the variance in self-reported disclosure. Perceived social pressure exerted by significant others (subjective norm) is the most important TPB factor in predicting intention to disclose personal information in exchange for incentives. This finding suggests that in discussions of adolescents' information privacy, the importance of social factors outweighs the individually oriented TPB factors of attitude and PBC. Moreover, privacy concern and trust propensity are significant predictors of respondents' attitudes toward online disclosure in exchange for commercial incentives, whereas the frequency of Internet use significantly affects their level of PBC.

Female and male transgender quality of life: socioeconomic and medical differences.

INTRODUCTION: Studies show a positive impact of gender reassignment treatment on the quality of life (QOL) of transgender persons, but little is known about the influence of their socioeconomic status. AIM: First, to assess health-related QOL of transgender men and women and compare it with a general population sample, second, to investigate the differences between transgender men and transgender women, and third, to analyze how their levels of QOL differ according to socioeconomic and transition data. METHODS: One hundred forty-eight current and former transgender patients of a gender identity clinic participated in a large QOL study. MAIN OUTCOMES MEASURES: Health-related QOL was measured using the Short Form 36-Item Questionnaire. RESULTS: The QOL of transgender women did not differ significantly from the general Dutch female population, although transgender men showed reduced mental health-related QOL compared with the general Dutch male sample. Transgender women had a lower QOL than transgender men for the subscales physical functioning and general health, but better QOL for bodily pain. Time since start of hormone use was positively associated for transgender women with subscales bodily pain and general health, and negatively associated for transgender men with the subscale role limitations due to physical health problems. There was no significant difference in QOL between the group who had undergone genital surgery or surgical breast augmentation and the group who did not have these surgeries. Transgender men with an erection prosthesis scored significantly better on the subscales vitality and (at trend level) on role limitations due to emotional problems. A series of univariate analyses revealed significantly lower QOL scores for transgender persons that were older, low educated, unemployed, had a low household income, and were single. CONCLUSIONS: Specific social indicators are important in relation to health-related QOL of transgenders in a context of qualitative and adequate medical care.