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.

Identifying, Measuring, and Ranking Social Determinants of Health for Health Promotion Interventions Targeting Informal Settlement Residents.

OBJECTIVES: Considering the importance of social determinants of health (SDHs) in promoting the health of residents of informal settlements and their diversity, abundance, and breadth, this study aimed to identify, measure, and rank SDHs for health promotion interventions targeting informal settlement residents in a metropolitan area in Iran. METHODS: Using a hybrid method, this study was conducted in 3 phases from 2019 to 2020. SDHs were identified by reviewing studies and using the Delphi method. To examine the SDHs among informal settlement residents, a cross-sectional analysis was conducted using researcher-made questionnaires. Multilayer perceptron analysis using an artificial neural network was used to rank the SDHs by priority. RESULTS: Of the 96 determinants identified in the first phase of the study, 43 were examined, and 15 were identified as high-priority SDHs for use in health-promotion interventions for informal settlement residents in the study area. They included individual health literacy, nutrition, occupational factors, housing-related factors, and access to public resources. CONCLUSIONS: Since identifying and addressing SDHs could improve health justice and mitigate the poor health status of settlement residents, ranking these determinants by priority using artificial intelligence will enable policymakers to improve the health of settlement residents through interventions targeting the most important SDHs.

Decomposed Trends of Iranian Private Health Expenditures: Should Inequality be Appreciated?

Background: Inequalities in health and health care have drawn considerable attention in social determinants of health literature. This study aims to calculate the inequality of out-of-pocket health payments (OPHP) for Iranian households during the period 1984 to 2019 and provide decomposed inequality for households with different socioeconomic status. Methods: This longitudinal study utilized the Iranian Statistics Centre data on Iranian household income and expenditures survey. The analysis includes a total of 995,300 households during a 36-year period from 1984 to 2019. The Theil index and the mean logarithmic deviation were used to decompose inequality into within-group and between-group for OPHP among Iranian households. Results: The findings indicate that the mean of the Theil index for the households covered by insurance is 1.44 (SD ± 0.34), while the index was 1.35 (SD ± 0.31) for households without insurance coverage. The mean of the Theil index for rural and urban households was 1.29 (SD ± 0.29) and 1.43 (SD ± 0.33), respectively. Regardless of the fluctuations, the trends of between- group and within group inequalities in OPHP were almost similar until 2011, but they followed a different path since then. Conclusion: Households living in cities, households with insurance coverage, and households in high income levels have experienced more inequality in OPHP than other households. This study provides a novel interpretation of inequality in health care expenditures and provides a long-term time series data to assess the effectiveness of implemented policies in health care system.

Inequality in Private Health Care Expenditures: A 36-Year Trend Study of Iranian Households.

OBJECTIVES: Throughout history, societies have been impacted by inequality. Many studies have been conducted on the topic more broadly, but only a few have investigated inequalities in out-of-pocket health payments (OHP). This study measures OHP inequality trends among the Iranian households. METHODS: This study used data from the Iranian Statistics Center on Iranian household income and expenditures. The analysis included a total of 995 300 households during the 36 years from 1984 to 2019. The Gini coefficient, Atkinson index, and Theil index were calculated for Iranian OHP. RESULTS: Average Iranian household OHP increased from 33 US dollar (USD) in 1984 to 47 USD in 2019. During this 36-year span, the average±standard deviation Gini coefficient for OHP was 0.73±0.04, and the Atkinson and Theil indexes were 0.68±0.05 and 1.14±0.29, respectively. The Gini coefficients for the subcategories of OHP of outpatient diagnostic services, medical assistant accessories, hospital inpatient services, and addiction cessation were 0.70, 0.61, 0.84, and 0.64, respectively. CONCLUSIONS: In this study, we scrutinized trends of inequality in the OHP of Iranian households. Inequality in OHP decreased slightly over the past four decades. An analysis of trends among different subgroups revealed that affluent households, such as households with insurance coverage and households in higher income deciles, experienced higher inequality. Therefore, lower inequality in health care expenditures may be related to restricted access to health care services in Iran.

The Most Important Social Determinants of Slum Dwellers' Health: A Scoping Review.

OBJECTIVES: Given the importance of social determinants of health in promoting the health of slum residents, this study was conducted with the aim of identifying the main dimensions and components of these determinants. METHODS: This scoping review study was conducted according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A comprehensive search was performed of PubMed, ProQuest, Scopus, and Web of Science for articles conducted from 2010 to the end of 2019. Studies were selected based on inclusion criteria, with a special focus on studies dealing with the social determinants of physical and mental health or illness. RESULTS: Thirty-three articles were selected to extract information on the social determinants of health. After reviewing the articles, 7 main dimensions (housing, socioeconomic status of the family, nutrition, neighborhood characteristics, social support and social capital, occupational factors, and health behaviors) and 87 components were extracted as social determinants of health among slum dwellers. CONCLUSIONS: This framework could be used by planners, managers, and policy-makers when making decisions affecting the health of these settlements' residents due to the common characteristics of slums around the world, especially in developing countries.

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.

Child labor in Tehran, Iran: Abuses experienced in work environments.

BACKGROUND: Child labor is exploitative and harmful and deprives children of opportunities for a healthy life. Nonetheless, child labor is prevalent worldwide. Abusive working conditions are common, especially in developing countries. OBJECTIVE: This study was designed both to measure the prevalence of abuse in work environments and to identify possible risk and protective factors for such abuse in child laborers in Tehran, Iran. METHOD: The researchers conducted this cross-sectional study from September 2018 to May 2019 in Tehran and recruited 250 children from seven child labor support centers. RESULTS: The results demonstrated a relatively high rate of abuses experienced in work environments among Iranian child laborers: 77.6 % of children experienced at least one type of abuse, with emotional abuse (70.4 %) as the most frequently experienced abuse followed by neglect (52 %), physical abuse (5.8 %), and sexual abuse (3.6 %). Furthermore, living alone or with a single parent (OR = 3.15, CI 95 %: 1.33-7.45) was a risk factor, while working in home jobs (OR = 2.08, CI 95 %: 1.19-3.63), being male (OR = 0.19, CI 95 %: 0.06-0.55), and being older (OR = 0.32, CI 95 %: 0.17-0.60) were the protective factors of abuses experienced at work among child laborers. CONCLUSION: The findings of this study have implications for designing and implementing early interventions to provide less harmful work environments for child laborers. Further, advocacy efforts to prevent and eliminate child labor should be pursued.

Determinants of Outpatient Health Service Utilization according to Andersen's Behavioral Model: A Systematic Scoping Review.

BACKGROUND: The present review focuses on identifying factors contributing to health service utilization (HSU) among the general adult population according to Anderson's behavioral model. METHODS: Published articles in English on factors related to HSU were identified by systematically probing the Web of Science, MEDLINE (via PubMed research engine), and Scopus databases between January 2008 and July 2018, in accordance with the PRISMA guidelines. The search terms related to HSU were combined with terms for determinants by Boolean operators AND and OR. The database search yielded 2530 papers. Furthermore, we could find 13 additional studies following a manual search we carried out on the relevant reference lists. RESULTS: Thirty-seven eligible studies were included in this review, and the determinants of HSU were categorized as predisposing, enabling, and need factors according to Andersen's model of HSU. The results demonstrated that all predisposing, enabling, and need factors influence HSU. In most studies, the female gender, being married, older age, and being unemployed were positively correlated with increased HSU. However, evidence was found regarding the associations between education levels, regions of residence, and HSU. Several studies reported that a higher education level was related to HSU. Higher incomes and being insured, also, significantly increased the likelihood of HSU. CONCLUSION: This review has identified the importance of predisposing, enabling, and need factors, which influence outpatient HSU. The prediction of prospective demands is a major component of planning in health services since, through this measure, we make sure that the existing resources are provided in the most efficient and effective way.

Contextual and Individual Determinants of Mental Health: A Cross-sectional Multilevel Study in Tehran, Iran.

OBJECTIVES: Our aim was to answer the following questions: (1) Can mental health variance be partitioned to individual and higher levels (e.g., neighborhood and district); (2) How much (as a percentage) do individual-level determinants explain the variability of mental health at the individual-level; and (3) How much do determinants at the neighborhood- or district-level explain the variability of mental health at the neighborhood- or district-level? METHODS: We used raw data from the second round of the Urban Health Equity Assessment and Response Tool in Tehran (in 2012-2013, n=34 700 samples nested in 368 neighborhoods nested in 22 districts) and the results of the official report of Tehran's Center of Studies and Planning (in 2012-2013, n=22 districts). Multilevel linear regression models were used to answer the study questions. RESULTS: Approximately 40% of Tehran residents provided responses suggestive of having mental health disorders (30-52%). According to estimates of residual variance, 7% of mental health variance was determined to be at the neighborhood-level and 93% at the individual-level. Approximately 21% of mental health variance at the individual-level and 49% of the remaining mental health variance at the neighborhood-level were determined by determinants at the individual-level and neighborhood-level, respectively. CONCLUSIONS: If we want to make the most effective decisions about the determinants of mental health, in addition to considering the therapeutic perspective, we should have a systemic or contextual view of the determinants of mental health.

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).

Current status of health index in Tehran: A multidimensional approach.

Background: Health is an essential component of human rights and the rights are interdependent, indivisible, and correlated. The present study aimed at codifying a multidimensional health index according to multistage index development and describing the status of this index in 22 municipal districts of Tehran. Methods: This study was conducted using the data collected in the second round of Urban HEART Project of Tehran (2012-2013). The sample size was 34 700. To develop a multidimensional health index (MDHI), the nine steps of the Organization for Economic Cooperation and Development (OECD) were followed, from codifying theoretical framework to introducing the index. Results: According to the constructed MDHI, the districts no. 13, 10, 17, 1, 3, 4, and 22 had the best status and the district no. 8 the worst status. With respect to physical health, the districts no. 13, 17, 1, 3, 10, and 18 had the best status and the district no. 8 the worst. Concerning mental health, the districts no. 3, 6, 1, and 10 had the best status and the districts no. 8 and 12 the worst status. With respect to social health, the districts no. 10, 22, and 21 had the best status and the districts no. 6, 7, 12, and 14 the worst status. The analysis of sensitivity indicated that the MDHI was more sensitive towards physical health. Based on the mean, minimum, and maximum scores on each indicator of the questionnaires, the physical, mental, social, and MDHI status of Tehran residents (2012-2013) was high-medium, medium, low-medium, and high-medium, respectively. Conclusion: The right to health should be widely investigated, as it is a primary principle needed for sustainable development, which can be accomplished when the attitudes of different organizations towards the health construct are multidimensional rather than unidimensional.

A systematic review of the prevalence and risk factors of depression among iranian adolescents.

Depression is the most common mood and psychiatric disorder. The aim of this comprehensive study was to provide a complete picture of the prevalence and risk factors of depression. The study employed a systematic review methodology, searching Iranian and international databases. After screening and evaluating the articles, a synthesis of 53 articles was accumulated. A meta-analysis of the studies showed that the prevalence of children and adolescent depression was 43.55% using the BDI, 15.87 % using SCL-90, and 13.05% using CDI. Also, the prevalence of depression was higher among girls than boys based on the BDI and CDI results. The most important factors contributing to depression were: the female sex, poor inter-parental relationship, poor adolescent-parent relationship, low socio-economic status (SES), state of parenting styles, low level of parental education, and poor academic performance. The comparatively high prevalence of depression among Iranian adolescents call for further investigation and measures.