Understanding determinants of unequal distribution of stillbirth in Tehran, Iran: a concentration index decomposition approach

Contrasting socioeconomic inequality with noncommunicable diseases: Insights from a population-based survey using the concentration index in Kong cohort study

Background

Noncommunicable diseases (NCDs) are the major causes of mortality across the globe, which impose a substantial burden on health care systems, particularly in low- and middle-income countries. The present study aimed to determine socioeconomic inequality in the prevalence of NCDs using the concentration index (CI).

Methods

This cross-sectional study was conducted on the baseline data of the Bandar Kong cohort. The principal component analysis was used to determine people's socioeconomic status (SES). The CI and Lorenz Curve were used for the assessment of socioeconomic inequality. Multivariate logistic regression was used to assess the relationship between SES and the prevalence of NCDs. A p Value less than 0.05 is considered significant.

Results

Frequency and prevalence of diabetes was 653 (16.22%), hypertension 848 (21.06%), chronic lung diseases 161 (4%), epilepsy 70 (1.74%), mental disorders 191 (4.74%), stillbirth 299 (13.94%), thyroid disorders 391 (9.71%) and depression 146 (3.63%). CI for the prevalence of diabetes was [-0.107, %95 CI: -0.146 to -0.068], hypertension [-0.122, %95 CI: -0.155 to -0.088], chronic lung disease [-0.116, %95 CI: -0.202 to -0.03], psychiatric disorders [-0.230, %95 CI: -0.304 to -0.155], depression [-0.132, %95 CI: -0.220 to-0.043] and stillbirth [-0.162, %95 CI: -0.220 to -0.105]. The Gini index was negative for all these diseases, indicating that these are significantly concentrated in people of poor SES.

Conclusions

The findings suggest that selected NCDs were concentrated among the poor and the low-income. Particular attention may be necessary to address the problem of NCDs among these groups.

Research on equity of medical resource allocation in Yangtze River Economic Belt under healthy China strategy

Objective

This study aimed to assess the fairness of medical resource allocation in the Yangtze River Economic Belt, based on the Healthy China strategy. It aimed to identify the issues with resource allocation fairness and provide optimization suggestions.

Methods

To assess the allocation fairness from a geographical population perspective, the study used the Health Resource Concentration and Entropy Weight TOPSIS methods. Additionally, the study analyzed the allocation fairness from an economic level angle, using the Concentration Curve and Concentration Index.

Results

The study found that the downstream area had higher resource allocation fairness than the midstream and upstream areas. The middle reaches had more resources than the upper and lower reaches, based on population concentration. The Entropy Weight TOPSIS method found that Shanghai, Zhejiang, Chongqing, and Jiangsu had the highest comprehensive score index of agglomeration. Furthermore, from 2013 to 2019, the fairness of medical resource distribution gradually improved for different economic levels. Government health expenditure and medical beds were distributed more equitably, while general practitioners had the highest level of unfairness. However, except for medical and health institutions, traditional Chinese medicine institutions, and primary health institutions, other medical resources were mostly distributed to areas with better economic conditions.

Conclusion

The study found that the fairness of medical resource allocation in the Yangtze River Economic Belt varied greatly based on geographical population distribution, with inadequate spatial accessibility and service accessibility. Although the fairness of distribution based on economic levels improved over time, medical resources were still concentrated in better economic areas. The study recommends improving regional coordinated development to enhance the fairness of medical resource allocation in the Yangtze River Economic Belt.

Exposure-lag response of fine particulate matter on intrauterine fetal death: an analysis using a distributed lag non-linear model in Linxia Hui Autonomous Prefecture, China

The results of studies on intrauterine fetal death (IUFD) caused by exposure to fine particulate matter (PM_2.5) during pregnancy are inconsistent. Further exploration of the dose-response relationship and exposure window is required. We aimed to provide a reference for policy formulation by estimating the exposure-lag relationship of PM_2.5 on IUFD and looking for sensitive exposure windows. IUFD data was obtained from China Children Under 5 Death Surveillance Network in Linxia Hui Autonomous Prefecture from 2016 to 2020. Air pollution data and temperature data were obtained from ambient air monitoring stations and China Meteorological Data Network, respectively. The moving average is used to describe the trend and seasonality of PM_2.5 exposure; the distributed lag non-linear model (DLNM) is used to estimate the exposure-lag effect; the sandwich estimators are used to correct the variance-covariance matrix; and the model selected by Akaike's Information Criterion (AIC) finally adjusts gender, temperature, and district. About 180,622 infants were enrolled in the study, including 952 IUFDs (5.27‰). The median of PM_2.5 exposure is 34.08 μg/m³. There is an exposure-lag effect of PM_2.5 on IUFD approximate to a wavy shape; the concentration with effect is 40-90 μg/m³; and the sensitive lag time is 1, 2, 3, 8, 9, and 10 months. The maximum RR value of the exposure-lag effect of PM_2.5 on IUFD is 1.61 [95% CI 1.19, 2.19], in which the concentration of PM_2.5 is 62 μg/m³, and the lag month is 9 months. In the case of less than 6 months lag, the maximum RR value of the exposure-lag effect of PM_2.5 on IUFD is 1.43 [95% CI 1.24, 1.67], in which the concentration of PM_2.5 is 73 μg/m³, and the lag month is 3 months. Exposure to PM_2.5 concentrations above 40 μg/m³ may increase the risk of IUFD, especially in the first and third trimesters.

Trends in Socio-economic Inequality in Smoking Among Middle-aged and Older Adults in China: Evidence From the 2011 and 2018 China Health and Retirement Longitudinal Study

INTRODUCTION

Socio-economic inequalities in smoking and related health problems are a public health concern worldwide. To support the development of effective tobacco control policies, this study examines trends in smoking rates according to socio-economic status (SES) in China.

AIMS AND METHODS

We analyzed data from repeated cross-sectional China Health and Retirement Longitudinal Study (CHARLS) on adults aged ≥45 years for the years 2011 and 2018, which involved 16 471 participants in 2011 and 19 367 in 2018. We then estimated the SES of individuals based on four types of wealth-related variables, namely, education, occupation, household characteristics, and durable consumer goods. Principal-component analysis was conducted to measure SES, and the Erreygers normalised concentration index (ECI) was used to calculate socio-economic inequality in current smoking by gender, age, and region.

RESULTS

The overall ECI (95% confidence interval) for women was -0.042 (-0.054 to -0.031) and -0.038 (-0.047 to -0.029) for 2011 and 2018, respectively. The ECI (95% confidence interval) for men was -0.077 (-0.101 to -0.050) and -0.019 (-0.042 to 0.005) for 2011 and 2018, respectively. The inequality in smoking by SES for adults aged < 60 years in the Northeast region increased during 2011-2018, from -0.069 (-0.144 to 0.006) to -0.119 (-0.199 to -0.038) for women and from 0.009 (-0.115 to 0.132) to -0.164 (-0.296 to -0.032) for men.

CONCLUSIONS

smoking inequality by socio-economic among adults aged ≥45 years declined in recent years in China. However, smoking inequality by SES increased in other population groups.

IMPLICATIONS

Our research indicated that socio-economic inequality of current smoking among residents aged 45 years and older declined in 2018 when compared with 2011 numbers, particularly for men aged ≥ 60 years. Women in the Northeast region displayed more significant smoking inequality by SES than women in other regions did. During the study period, there was an increase in inequality in smoking by SES for adults aged < 60 years in the Northeast region. Thus, tobacco control policies and interventions should be targeted at high-risk subpopulations with lower SES, particularly in Northeast China.

Socioeconomic inequality in congenital heart diseases in Iran

INTRODUCTION

Social-economic factors have an important role in shaping inequality in congenital heart diseases. The current study aimed to assess and decompose the socio-economic inequality in Congenital Heart Diseases (CHDs) in Iran.

METHODS

This is a cross-sectional research conducted at Shahid Rajaie Cardiovascular Medical and Research Center in Tehran, Iran, as one of the largest referral heart hospitals in Asia. Data were collected primarily from 600 mothers who attended in pediatric cardiology department in 2020. The polychoric principal component analysis (PCA) and Errygers corrected CI (ECI) were used to construct household socioeconomic status and to assess inequality in CHDs, respectively. A regression-based decomposition analysis was also applied to explain socioeconomic-related inequalities. To select the explanatory social, medical/biological, and lifestyle variables, the chi-square test was first used.

RESULTS

There was a significant pro-rich inequality in CHDs (ECI = -0.65, 95% CI, - 0.72 to - 0.58). The social, medical/biological, and lifestyle variables accounted for 51.47, 43.25, and 3.92% of inequality in CHDs, respectively. Among the social variables, family SES (about 50%) and mother's occupation (21.05%) contributed the most to CHDs' inequality. Besides, in the medical/biological group, receiving pregnancy care (22.06%) and using acid folic (15.70%) had the highest contribution.

CONCLUSION

We concluded that Iran suffers from substantial socioeconomic inequality in CHDs that can be predominantly explained by social and medical/biological variables. It seems that distributional policies aim to reduce income inequality while increasing access of prenatal care and folic acid for disadvantaged mothers could address this inequality much more strongly in Iran.

Promotion of posttraumatic stress disorder following traumatic birth experiences and the influence of maternity religious Attitude: A correlational study

BACKGROUND

Women who experience stillbirth and preterm delivery are likely to be associated with an increased risk of posttraumatic stress disorder (PTSD) compared to women with live births and dose religious attitude related to posttraumatic stress? The aim of the study was promotion PTSD following traumatic birth experiences and the influence of maternity religious Attitude.

MATERIALSAND METHODS

A cross-sectional analytical study was conducted at selected hospitals of Shiraz University of Medical Sciences on 82 subjects in 2018. The instruments were demographic questionnaire, Religious Attitude questionnaire, and Mississippi PTSD Scale which were completed after delivery. Data were analyzed using SPSS software, version 22, using the Pearson correlation test.

RESULTS

About 75% stillbirth group and 65% of the preterm delivery group had a high level of religious attitude. In the stillbirth group, 90% had high levels of PTSD and in the preterm delivery group, 90% had moderate stress, and 10% had high PTSD levels. The correlation between religious attitude and PTSD after stillbirth was 0.373 with a significance level of 0.018. Therefore, there was a significant positive relationship between religious attitude and PTSD. However, the relationship between religious attitude and PTSD after preterm delivery was not statistically significant (P = 0.158).

CONCLUSION

PTSD was significantly higher in mothers with stillbirth and had a significant relationship with religious attitude. However, in mothers of preterm infants, the level of stress was moderate and did not have a significant relationship with religious attitude. The findings indicate the need of mothers for interventions to cope better with the physical and psychological problems of stillbirth and preterm delivery.

Health equity in Iran: A systematic review

Background: Health inequities are among debatable and challenging aspects of health systems. Achieving equity through social determinants of health approach has been mentioned in most upstream national plans and acts in Iran. This paper reports the findings of a systematic review of the current synthesized evidence on health equity in Iran.

Methods: This is a narrative systematic review. The relevant concepts and terminology in health equity was found through MeSH. We retrieved the relevant studies from PubMed/MedLine, Social Sciences Database, and Google Scholar in English, plus the Jihad University Database (SID), and Google Scholar in Farsi databases from 1979 until the end of January 2018. The retrieved evidence has been assessed primarily based on PICOS criteria and then Ottawa-Newcastle Scale, and CASP for qualitative studies. We used PRISMA flow diagram and a narrative approach for synthesizing the evidence.

Results: We retrieved 172 455 studies. Following the primary and quality appraisal process, 114 studies were entered in the final phase of the analysis. The main part (approximately 95%) of the final phase included cross-sectional studies that had been analyzed through current descriptive inequality analysis indicators, analytical regression, or decomposition-based approaches. The studies were categorized within 3 main groups: health outcomes (40.3%), health utilization (32%), and health expenditures (27%).

Conclusion: As a part of understanding the current situation of health equity in the policymakers’ need to refer the retrieved evidence in this study, they need more inputs specially regarding the social determinants of health approach. It seems that health equity research plan in Iran needs to be redirected in new paths that give appropriate weights to biological, gene-based, environmental and contextbased, economic, social, and political aspects of health as well. We advocate addressing the aspects of Social Determinant of Health (SDH) in analyzing health inequalities.

Measurement components of socioeconomic status in health-related studies in Iran

OBJECTIVE

The socioeconomic status (SES) is as a symbol of social determinants of health which has a dominant influence on population health. The purpose of this study was collecting, weighing, and determining the most relevant SES measurement items in Iran.

RESULTS

The SES health studies conducted in Iran was searched from 2007 to 2017. First, the SES items were categorized. Then, each item was weighed based on its reliability and generalizability. Finally, the necessity of items was determined, weighed, and ranked. This is the two-round Delphi technique. After weighing 57 SES items, 37 items were selected with ≥ 1 weight and classified in 7 categories. According to the Delphi evaluation, 15 items were identified ≥ 3.5 for measuring SES of Iranian households: household size, head of household education, head of household job, household monthly income, type of school that children attend, house ownership, local value of residence, number of rooms in the house, house area, personal computer/laptop, smart cell phone, 3D TV, dishwasher, microwave, and car ownership. The SES items for the present society are categorized in 7 domains. The items collected in this study have the most comprehension of all studies related to income, life facilities, and assets.

The effect of prepregnancy body mass index on birth weight, preterm birth, cesarean section, and preeclampsia in pregnant women

Objective: The objective of this study is to determine the impact of maternal prepregnancy BMI on birth weight, preterm birth, cesarean section, and preeclampsia among pregnant women delivering singleton life birth. Methods: A cross-sectional study of 4397 women who gave singleton birth in Tehran, Iran from 6 to 21 July 2015, was conducted. Women were categorized into four groups: underweight (BMI < 18.5 kg/m²), normal (BMI 18.5-25 kg/m²), overweight (BMI 25-30 kg/m²) and obese (BMI >30 kg/m²), and their obstetric and infant outcomes were analyzed using both univariate and multivariate logistic regression. Results: Prepregnancy BMI of women classified 198 women as underweight (4.5%), 2293 normal (52.1%), 1434 overweight (32.6%), and 472 as obese (10.7%). In comparison with women of normal weight, women who were overweight or obese were at increased risk of preeclampsia (odds ratio (OR) = 1.47, 95% CI = 1.06-2.02; OR = 3.67, 95% CI = 2.57-5.24, respectively) and cesarean section (OR = 1.21, 95% CI = 1.04-1.41; OR = 1.35, 95% CI = 1.06-1.72, respectively). Infants of obese women were more likely to be macrosomic (OR = 2.43, 95% CI = 1.55-3.82). Conclusion: Prepregnancy obesity is a risk factor for macrosomia, preeclampsia, and cesarean section and need for resuscitation.

Socioeconomic inequality of unintended pregnancy in the Iranian population: a decomposition approach

BACKGROUND

There are several studies regarding the predictors or risk factors of unintended pregnancy, but only a small number of studies have been carried out concerning the socio-economic factors influencing the unintended pregnancy rate. This study aimed to determine the socioeconomic inequality of unintended pregnancy in Tehran, Iran, as a developing country.

METHODS

In this hospital based cross-sectional study, 5152 deliveries from 103 hospitals in Tehran (the capital of Iran) were included in the analysis in July 2015. Socioeconomic status (SES) was measured through an asset-based method and principal component analysis was carried out to calculate the household SES. The concentration index and curve was used to measure SES inequality in unintended pregnancy, and then decomposed into its determinants. The data was analyzed by statistical Stata software.

RESULTS

The Wagstaff normalized concentration index of unintended pregnancy (- 0.108 (95% Confidence Interval (CI) = - 0.119 ~ - 0.054)) endorses that unintended pregnancy is more concentrated among poorer mothers. The results showed that SES accounted for 27% of unintended pregnancy inequality, followed by the mother's nationality (19%), father's age (16%), mother's age (10%), father's education level (7%) and Body Mass Index (BMI) groups (5%).

CONCLUSION

Unintended pregnancy is unequally distributed among Iranian women and is more concentrated among poor women. Economic status had the most positive contribution, explaining 27% of inequality in unintended pregnancy.

Decomposition of socioeconomic inequalities in preterm deliveries in Tehran, Iran

OBJECTIVE

To investigate associations between economic inequality in preterm delivery.

METHODS

The present secondary analysis included cross-sectional data collected in interviews with patients following delivery at 103 hospitals in Tehran, Iran, between July 6 and 21, 2015. Principal component analysis was used to measure the socioeconomic status of participants and the concentration index was used to measure inequalities in preterm delivery among patients of different socioeconomic status.

RESULTS

Data were included from 5170 patients. The concentration index for preterm delivery was 0.087 (95% confidence interval 0.036-0.134), indicating that preterm deliveries were concentrated among patients with higher socioeconomic status. Higher socioeconomic status (94%), younger maternal age (29%), younger paternal age (21%), and being a homemaker (17%) had the highest positive contributions to the measured inequalities in preterm deliveries; vaginal delivery (-58%) had the highest negative contribution.

CONCLUSION

Preterm deliveries were distributed unequally among the study patients in Iran, and were concentrated among patients of higher socioeconomic status. Alongside future etiological studies, reproductive programs in Iran should focus on this population to redress the observed inequality.

Impact of Gestational Weight Gain on Cesarean Delivery Risk, Perinatal Birth Weight and Gestational Age in Women with Normal Pre-pregnancy BMI

Background

Gestational weight gain (GWG) proportional to body mass index before pregnancy is one of the factors on maternal and neonatal outcomes. The aim of the current study was to assess association between GWG, and cesarean section, birth weight and gestational age at birth in women with normal BMI prior to pregnancy.

Methods

This was a cross-sectional study carried out in 103 hospitals in Tehran, the capital of Iran, from July 6 to 21, 2015. The data were extracted by 103 trained midwives. Finally, 2394 pregnant women with normal BMI before pregnancy and singleton birth were examined. GWG was categorized based on Institute of Medicine (IOM) recommendations.

Results

Prevalence of low birth weight (LBW) was 5.41% and prevalence of macrosomia was 2.18%. The prevalence of LBW in women with GWG less than the weight gain recommended by IOM was 2.13 times [95% confidence interval (CI) 1.13-4.02, P = 0.019] more than in women with GWG equal to the weight gain recommended by IOM. There was no statistically significant difference in the prevalence of LBW between women with GWG more than recommended weight gain by IOM and women with GWG equal to the weight gain recommended by IOM (OR = 1.21, 95% CI 0.61-2.38, P = 0.580).

Conclusion

After controlling for confounding variables, the prevalence of cesarean section and preterm birth had no significant difference at various levels of GWG. Accordingly, the prevalence of LBW among women with GWG less than the recommended weight gain by IOM was significantly 2.13 more than that among women with GWG equal to the recommended weight gain by IOM.