Peritoneal dialysis vs. hemodialysis among patients with end-stage renal disease in Iran: which is more cost-effective?

BACKGROUND

There is little economic evidence on different modalities among patients with end-stage renal disease (ESRD) in Iran. This study aimed to assess the cost-utility of peritoneal dialysis (PD) and hemodialysis (HD) among ESRD patients in Iran.

METHODS

From the health system perspective and with a 10-year time horizon, we conducted a cost-utility analysis based on a Markov model to compare three strategies of PD and HD [the second scenario (30% PD, 70% HD), the third scenario (50% PD, 50% HD) and the fourth scenario (70% PD, 30% HD)] among ESRD patients with the current situation (PD, 3% vs. HD, 97%) as the basic scenario (the first scenario) in Iran. Cost data for PD, HD and kidney transplantation were extracted from the medical records of 720 patients in the Health Insurance Organization (HIO) database. The Iranian version of the EQ-5D-5 L questionnaire was filled out through direct interview with 518 patients with ESRD to obtain health utility values. Other variables such as transition probabilities and survival rates were extracted from the literature. To examine the uncertainty in all variables included in the study, a probabilistic sensitivity analysis (PSA) was performed. TreeAge Pro 2020 software was used for data analysis.

FINDINGS

Our analysis indicated that the average 10-year costs associated with the first scenario (S1), the second scenario (S2), the third scenario (S3) and the fourth scenario (S4) were 4750.5, 4846.8, 4918.2, and 4989.6 million Iranian Rial (IRR), respectively. The corresponding average quality-adjusted life years (QALYs) per patient were 2.68, 2.72, 2.75 and 2.78, respectively. The ICER for S2, S3 and S4 scenarios was estimated at 2268.2, 2266.7 and 2266.7 per a QALY gained, respectively. The analysis showed that at a willingness-to-pay (WTP) threshold of 3,000,000,000 IRR (2.5 times the GDP per capita), the fourth scenario had a 63% probability of being cost-effective compared to the other scenarios.

CONCLUSION

Our study demonstrated that the fourth scenario (70% PD vs. 30% HD) compared to the current situation (3% PD vs. 97% HD) among patients with ESKD is cost-effective at a threshold of 2.5 times the GDP per capita (US$4100 in 2022). Despite the high cost of PD, due to its greater effectiveness, it is recommended that policymakers pursue a strategy to increase the use of PD among ESRD patients.

Inpatient healthcare utilization among people with disabilities in Iran: determinants and inequality patterns

BACKGROUND

People with disabilities (PWD) have different health service needs and different factors affect the utilization of these services. Therefore, the aim of this present study was to identify determinants of inpatient healthcare utilization among PWDs in Iran.

METHODS

This research was a secondary data analysis of a cross-sectional study. The present study used data gathered for 766 PWDs (aged 18 years and older) within the Iranian Society with Disabilities (ISD) between September and December 2020. Multiple logistic regression models calculated adjusted odds ratios (aOR) and 95% confidence intervals in order to identify determinants of inpatient healthcare utilization among PWDs.

RESULTS

Data for 766 people with disabilities were analyzed. A large number of participants were over 28 years of age (70.94%), male (64.36%), and single (54.02%). In the present study, more than 71% of participants had no history of hospitalization during the last year. In this study, males [aOR 2.11(1.14-3.91), participants with Civil Servants health insurance coverage [aOR 3.44 (1.16 - 10.17)] and individuals in the 3th quartile of disability severity [aOR 2.13 (1.01 - 4.51)] had greater odds of inpatient healthcare utilization compared to the other groups. The value of the concentration index (C) for inpatient healthcare utilization was - 0.084 (P.value = 0.046). The decomposition analysis indicated that gender was the greatest contributor (21.92%) to the observed inequality in inpatient healthcare utilization among participants.

CONCLUSION

Our findings suggested that the likelihood of hospitalization among the study participants could be significantly influenced by factors such as gender, the health insurance scheme, and the degree of disability severity. These results underscore the imperative for enhanced access to outpatient services, affordable insurance coverage, and reduced healthcare expenditures for this vulnerable population. Addressing these issues has the potential to mitigate the burden of hospitalization and promote better health outcomes for disadvantaged individuals.

Cost-effectiveness analysis of different screening strategies for helicobacter pylori infection in Iran: A model-based evaluation

BACKGROUND

The World Health Organization recommends assessing screening for helicobacter pylori infection to lower gastric cancer (GC) rates. Therefore, we carried out a study to evaluate the cost-effectiveness of different H. pylori screening approaches in Iran.

MATERIALS AND METHODS

We used a Markov model with a 50-year time horizon and health system perspective to compare four H. pylori screening strategies (endoscopy, serology, urea breath test [UBT], stool antigen test [SAT]) to no screening in the population aged 20 years and older in Iran. Model parameters were extracted from primary data and published studies. Cost data also came from medical records of 120 patients at different stages of GC. We calculated costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) for each strategy. Probabilistic sensitivity analysis (PSA) using Monte Carlo simulation tested the model's robustness. All analyses were done in TreeAge Pro 2020.

RESULTS

All screening strategies provided more QALYs compared to no screening. Base-case analysis found the UBT strategy was the most cost-effective, with an ICER of 101,106,261.5 Iranian rial (IRR) per QALY gained, despite being more costly. No screening and endoscopy were dominated strategies, meaning they had higher costs but provided fewer effectiveness compared to other options. PSA showed at a willingness-to-pay (WTP) threshold of 316,112,349 IRR (Iran's GDP per capita) per QALY, UBT was the optimal strategy in 57.1% of iterations.

CONCLUSION

This cost-effectiveness analysis found that screening for H. pylori may be cost-effective in Iran. Among the 4 screening strategies examined, UBT was the most cost-effective approach. Further studies should do cost-effectiveness analyses for specific age groups to optimize the benefits achieved with limited resources.

The Effect of COVID-19 Pandemic on Households' Utilization of Rehabilitation Services: National Evidence from Iran Health System

Background

The coronavirus disease-2019 (COVID-19) pandemic has affected the pattern of utilization of healthcare services. This study aimed to investigate the utilization of rehabilitation services before and after the COVID-19 pandemic in the health system of Iran.

Methods

This descriptive-analytical study used data from the Household Income and Expenditure Surveys of the Iran Statistics Center in 2018-2019 (before COVID-19) and 2020 (after COVID-19). The patterns of utilization and expenditures of rehabilitation services before and after this pandemic were investigated in different household sub-groups. The multilevel logistic regression model was used to investigate the effect of COVID-19 on the utilization of health services by households.

Results

Although 258 (0.66%) households used rehabilitation services before the COVID-19 pandemic, only 175 (0.47%) households utilized them after the pandemic. Additionally, the average total rehabilitation costs per utilized household were 3,438,185 Iranian Rials (IRR) in 2018-2019 and 2,996,511 IRR in 2020-2021. Sex, age, education, size of household, place of residence, health insurance coverage, and income significantly affected the utilization of rehabilitation services by households during the study period (p < 0.001). Furthermore, the average use of rehabilitation services decreased by 22% (odds ratio = 0.78, p < 0.01) after the pandemic.

Conclusion

In Iranian households, the utilization and average expenditure of rehabilitation services significantly decreased after the COVID-19 pandemic. These findings strongly recommend health system policymakers to develop comprehensive plans to address future shocks arising from pandemics and other emergencies.

The effect of Iran's health sector evolution plan on hospitals performance indicators: an interrupted time series analysis

Background

The Health Sector Evolution Plan (HSEP) was set up in Iran's health system to respond to some of the main problems in hospitals and other health sectors. We aimed to compare the effect of the HSEP on teaching hospital performance before and after the implementation of the HSEP through the interrupted time series (ITS) analysis.

Methods

With a cross-sectional design, data collection was performed in 17 teaching hospitals affiliated with the Kermanshah University of Medical Sciences (KUMS). We used the existing data on three indicators of hospitalization rate (per 10,000 population), Emergency Department Visits (EDVs) (per 10,000 population), and in-hospital mortality (per 10,000 population). The monthly data from 2009 to 2019 was analyzed by the ITS method 60 months before and 61 months after the HSEP.

Results

We found a non-statistically significant decrease in the monthly trend of hospitalization rate relative to the period before the HSEP implementation (-0.084 per 10,000 population [95%CI: -0.269, 0.101](. There was a statistically significant increase in the monthly trend of EDVs rate compared to before the HSEP implementation (1.07 per 10,000 population [95%CI: 0.14, 2.01]). Also, a significant decrease in the monthly trend of in-hospital mortality compared to before the HSEP implementation [-0.003 per 10,000 population (95%CI: -0.006, -0.001)] was observed.

Conclusion

Our study demonstrated a significant increasing and decreasing trend for EDVs and in-hospital mortality following the HSEP implementation, respectively. Regarding the increase in hospitalization rate and EDVs after the implementation of HESP, it seems that there is a need to increase investment in healthcare and improve healthcare infrastructure, human resources-related indicators, and the quality of healthcare.

Gastric troubles in Iran: The role of social and economic factors in Helicobacter pylori infection

Background

Helicobacter pylori infection is a major risk factor for gastric cancer in Iran, but the impact of socioeconomic factors on its prevalence is poorly understood. This study aimed to assess the socioeconomic inequalities and risk factors associated with H. pylori infection in Iran.

Methods

This cross-sectional study was conducted based on the PERSIAN cohort study. A total of 20460 individuals aged 35 to 70 years in Ardabil, Iran were included in the study. H. pylori infection was determined based on stool tests and clinical records. Multilevel logistic regression models with random intercepts at household and community levels were used to identify risk factors associated with H. pylori prevalence. The concentration index (CIn) and concentration curve (CC) were employed to assess socioeconomic-related inequality.

Results

In this study, 70.4% (CI 69.6-71.0) of the participants were infected with H. pylori, with a higher prevalence in women (71.2%) than men (69.6%). Age (OR: 1.37, CI: 1.17-1.61), sex (OR: 1.20, CI: 1.12-1.28), level of education (OR: 1.33, CI: 1.17-1.49), cardiac disease (OR: 1.32, CI:1.18-1.46), and BMI groups (OR: 2.49, CI: 1.11-5.58) were significantly associated with H. pylori infection based on the multivariable logistic regression. The results of the CIn and CC indicated that H. pylori were more prevalent among economically disadvantaged groups (CIn: -0.1065; [-0.1374 to -0.0755]).

Conclusion

The prevalence of H. pylori in Iran is higher than in other developing countries, and significant socioeconomic inequality exists between the poor and the rich. To reduce the rate of gastric cancer, socio-economic and demographic factors, especially the poor and people with low levels of education, should be considered.

The COVID-19 pandemic and healthcare utilization in Iran: evidence from an interrupted time series analysis

BACKGROUND

This study aimed to examine the effect of the coronavirus disease 2019 (COVID-19) outbreak on the hospitalization rate, emergency department (ED) visits, and outpatient clinic visits in western Iran.

METHODS

We collected data on the monthly hospitalization rate, rate of patients referred to the ED, and rate of patients referred to outpatient clinics for a period of 40 months (23 months before and 17 months after the COVID-19 outbreak in Iran) from all 7 public hospitals in the city of Kermanshah. An interrupted time series analysis was conducted to examine the impact of COVID-19 on the outcome variables in this study.

RESULTS

A statistically significant decrease of 38.11 hospitalizations per 10,000 population (95% confidence interval [CI], 24.93-51.29) was observed in the first month of the COVID-19 outbreak. The corresponding reductions in ED visits and outpatient visits per 10,000 population were 191.65 (95% CI, 166.63-216.66) and 168.57 (95% CI, 126.41-210.73), respectively. After the initial reduction, significant monthly increases in the hospitalization rate (an increase of 1.81 per 10,000 population), ED visits (an increase of 2.16 per 10,000 population), and outpatient clinic visits (an increase of 5.77 per 10,000 population) were observed during the COVID-19 pandemic.

CONCLUSION

Our study showed that the utilization of outpatient and inpatient services in hospitals and clinics significantly declined after the COVID-19 outbreak, and use of these services did not return to pre-outbreak levels as of June 2021.

Has Iran achieved the goal of reducing the prevalence of households faced with catastrophic health expenditure to 1%?: A national survey

Background and Aims

One of the goals of the Islamic Republic of Iran is to reduce the prevalence of catastrophic health expenditures among Iranian households to 1% by the end of the sixth 5-year development plan (2016-2021). This study was conducted to evaluate the level of access to this goal in the final year of this program.

Methods

A national cross-sectional study was conducted on 2000 Iranian households in five provinces of Iran in 2021. Data were collected through interviews using the World Health Survey questionnaire. Data from households whose health care costs were more than 40% of their capacity to pay were included in the group of households with catastrophic health expanditure (CHE). Determinants of CHE were identified using univariate and multivariate regression analysis.

Results

8.3% of households had experienced CHE. The variables of being a female head of household (odd ratio [OR] = 2.7), use of inpatient (OR = 1.82), dental (OR = 3.09), and rehabilitation services (OR = 6.12), families with disabled members (OR = 2.03) and low economic status of the households (OR = 10.73) were significantly associated with increased odds of facing CHE (p < 0.05).

Conclusion

In the final year of the sixth 5-year development plan, Iran has not yet achieved its goal of "reducing the percentage of households exposed to CHE to 1%." Policymakers should pay attention to factors increasing the odds of facing CHE in designing interventions.

Burden of COVID‐19 disease in Kurdistan province in west of Iran using disability‐adjusted life years

Background and Aims

During the coronavirus disease 2019 (COVID‐19) pandemic, about seven million people were infected with the disease, of which more than 133,000 died. Health policymakers need to know the extent and magnitude of the disease burden to decide on how much to allocate resources for disease control. The results of this investigation could be helpful in this field.

Methods

We used the secondary data released by the Kurdistan University of Medical Sciences between February 2020 to October 2021 to estimate the age‐sex standardized disability‐adjusted life years (DALY) by the sum of the years of life lived with disability (YLD) and the years of life lost (YLL). We also applied the local and specific values of the disease utility in the calculations.

Results

The total DALY was estimated at 23316.5 and 1385.5 per 100,000 populations The YLD and YLL constituted 1% and 99% of the total DALY, respectively. The DALY per 100,000 populations was highest in the men and people aged more than 65 years, but the prevalence was the highest in people under the age of 40.

Conclusions

Compared to the findings of the “burden of disease study 2019,” the burden of COVID‐19 in Iran is ranked first and eighth among communicable and noncommunicable diseases, respectively. Although the disease affects all groups, the elderly suffer the most from it. Given the very high YLL of COVID‐19, the best strategy to reduce the burden of COVID‐19 in subsequent waves should be to focus on preventing infection in the elderly population and reducing mortality.

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.

The impact of COVID-19 pandemic on hospital admissions for nine diseases in Iran: insight from an interrupted time series analysis

BACKGROUND

Associations between the COVID-19 pandemic and hospitalizations have not been studied Iran. This study aimed to examine the impact of the COVID-19 pandemic on hospital admissions for nine categories of disease in seven public hospitals in Kermsnahah city, the capital of Kermsnahah province, in the west of Iran.

METHODS

Data on monthly hospitalization rates (number of hospitalizations per 100,000 population) were collected for nine categories of disease for a period of 40 months (23 months before and 17 months after the COVID-19 outbreak in Iran) from the health information systems of all seven public hospitals in Kermanshah city. Categories of disease included those related to pregnancy, childbirth and the puerperium period, neoplasms, diseases of the digestive, respiratory, circulatory, genitourinary and nervous systems, mental and behavioural disorders, and infectious and parasitic diseases. Population data were extracted from the Statistics Centre of Iran. An interrupted time series analysis with segmented regression was used to examine the impact of COVID-19 on hospital admissions.

FINDINGS

Average monthly hospitalization rates fell for all nine categories of disease included in the study after the onset of the pandemic, with overall rates of 85.5 per 100,000 population in the period before the COVID-19 outbreak and 50.4 per 100,000 population after the outbreak began. The relative reduction in hospitalizations for the nine diseases was 56.4%. Regression analysis of monthly data indicated a sharp decrease in hospitalisations during the first month after the COVID-19 outbreak, which was statistically significant for all diseases (p < 0.001). After the initial reduction following onset of the pandemic, significant increases were observed for some diseases, including neoplasms (increase of 3.17 per 100,000 population; p < 0.001), diseases of the digestive system (increase of 1.17 per 100,000 population; p < 0.001) and diseases related to pregnancy, childbirth and the puerperium period (increase of 1.73 per 100,000 population). For other categories of disease, rates significantly declined, including infectious and parasitic diseases (decrease of 2.46 per 100,000 population; p < 0.001). Hospitalization rates did not increase to pre-pandemic levels for any disease, with the exception of those related to pregnancy, childbirth and the puerperium period.

CONCLUSIONS

Our study indicated that the COVID-19 pandemic had a significantly negative effect on hospitalizations in Iran. Although use of hospital care has gradually increased post-outbreak, it has yet to return to normal levels.

COVID-19 Pandemic and Hospital Efficiency in Iran: Insight from an Interrupted Time Series Analysis and Pabon Lasso Model

Background

Limited evidence exists on the impact of the Coronavirus Disease 2019 (COVID-19) pandemic on hospital efficiency worldwide. This study aimed to investigate the impact of the COVID-19 pandemic on public hospitals in Iran.

Methods

In this quasi-experimental study, monthly data on the average length of stay (ALoS), bed occupancy rate (BOR), bed turnover rate (BTR) and bed turnover interval (BTI) were collected for 58 months (36 months before and 22 months after the COVID-19 outbreak in Iran) from the health information systems of all 18 public hospitals affiliated with Kermanshah University of Medical Sciences in Kermanshah province, Iran. We used interrupted time series analysis and the Pabon Lasso model to investigate the impact of the COVID-19 pandemic on hospital efficiency.

Results

The monthly average ALoS, BOR, BTR and BTI before (after) the COVID-19 pandemic was 3.30 (3.48) days, 70.14% (49.37), 6.78 (4.81) patients per bed and 1.15 (2.88) days, respectively. The study indicated that a statistically significant decrease in ALoS of 0.29 and BOR of 25.09 in the first month following the COVID-19 pandemic. Compared with the before pandemic period, we observed a significant increase in the monthly trend of ALoS (coefficient = 0.021; p = 0.015), BOR (coefficient = 1.30; p = 0.002), and BTR (coefficient = 0.08, p = 0.012). We found a significant decrease in the monthly trend in BTI (coefficient = -0.11, p = 0.009) after the COVID-19 pandemic when compared with before the pandemic. Based on the Pabon Lasso model, before (after) the pandemic, 29.4% (29.4%) of the hospitals were located in zone 1 as an inefficient area, and 17.6% (35.3%) of hospitals were located in zone 3 as an efficient area.

Conclusion

The study demonstrated that the BOR and BTR decreased substantially after the outbreak of COVID-19. In contrast, the ALoS and BTI have significantly increased following the COVID-19 pandemic. We also found that hospitals' performance in both periods was poor, and only 30% of hospitals were located in the efficient zone (zone three) based on the Pabon Lasso model. Further studies aimed at identifying the main factors affecting lower efficiency among hospitals in Iran are recommended.

The socio-economic inequality in body mass index: a PERSIAN cohort-based cross-sectional study on 20,000 Iranian adults

INTRODUCTION

The aim of the present study was to explore and determine the association between BMI and socio-economic factors in Iran.

METHODS

Adults aged 35 to 70 (n = 20,460) were included from Ardabil Non-Communicable Disease (ArNCD) cohort study. BMI was calculated as kg/m². Principal Component Analysis (PCA) was used to determine the socio-economic quintiles. Multivariate linear regression was performed to analyze the association of BMI as dependent variable with explanatory variables, Additionally, decomposition analyzing conducted to identify factors that explained wealth-related inequality in obesity.

RESULTS

The prevalence of overweight and obese people was 83.7% (41.4% overweight and 42.5% obese) wherein the highest frequency of obese people belonged to the age group of 45 to 49 years old (19.9%) and to the illiterate people (33.1%). The results of multivariate linear regression model showed that age, being female, marriage, lower education level, having chronic disease, alcohol use, and higher socioeconomic level positively associated with obesity. The results of the decomposition model showed that the most important variables affecting socioeconomic inequality in higher BMI level were socioeconomic status (75.8%), being women (5.6%), education level (- 4.1%), and having chronic disease (2.4%).

CONCLUSION

BMI showed significant association with socio-economic status, where richest people had significantly higher BMI than poorest group. Considering the direct role of high BMI in non-communicable diseases, new policies are needed to be developed and implemented by means of diet intervention and increased physical activity to control the BMI in the population of Iran.

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.

The Evalutation of the Effect of 12 Weeks of Water Aerobic Exercise and Atrovastatin Drug on Apolipoproteins A1 Changes, ANP, BNP and CRP in Older Men with Cardiovascular Disesaes

Background

The aim of this study is to investigate the effect of of 12 weeks of water aerobic exercise and atrovastain drug on apolipoproteins changes A1, ANP, BNP and CRP in older men with cardiovascular disesaes.

Methods

In this study, we chose 40 patients with cardiovascular disease that were divideded in to four groups. Experimental groups selected exercise 3 times per weeks during 3 months with the method ofwalking on the water and carnal swimming.

Results

The results were expressed as the mean ± sd, and all statistical comparisons were made by means of a one-way ANOVA test, followed by Tukey'sPost-Hoc analysis.

Conclusion

The effect of exercise and intervention taking Atorvastatin increased Apolipoproteins A1changes, but reducedANP, BNP, and CRP, followed by the reduction of disease cardiovascular and improve cardiovascular function.

Effects of Interval Training Intensity and Curcumin on expression of Endothelial Progenitor Cells mRNA and C Reactive Protein in Elderly Rats Heart

INTRODUCTION

Endothelial progenitor cells (EPCs) play a role in preventing endothelial dysfunction and increasing the angiogenesis process. Regular training increases these cells. Turmeric Curcumin has anti-inflammatory and anti-atherosclerotic properties.

ANIMAL, MATERIALS AND METHODS

49 Wistar rats were randomly assigned to control (C), Saline (S), curcumin (cur), moderate interval training (MIT), high interval training (HIT), MIT+curAndHIT+cur. The training groups trained 8 weeks,3 sessions per week and 40 minutes each session at 28 and 34 m / min. 48 hours after the last training, The gene expression of the CD34 and KDR was measured by Real-time PCR and CRP usesthe ELISA method.

FINDINGS

CD34 and KDR mRNA in cur, MIT and HIT groups showed a significant increase compared to C and Sgroups.The highest levels of CD34 and KDR mRNA were observed in HIT+curgroup. While the increase of CD3 mRNA in HIT group was greater than the cur and MIT groups(P = 0.0001). KDR showed a significant increase in MIT and HIT groups compared to C, S, cur and MIT+cur groups. Serum CRP means significantly decreased in all experimental groups compared to C and S groups.

DISCUSSION AND CONCLUSION

The rate of increase in EPCs mRNA in response to aerobic training is dependent on training intensity. HIT training is likely to be more effective in the repair and development of coronary arteries. These findings can be useful for cell therapy and improve cardiovascular regeneration after injury and myocardial disor-der, especially in elderly conditions.

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.

What explains gender inequality in HIV infection among high-risk people? A Blinder-Oaxaca decomposition

Background

Despite clear evidence on role of gender in vulnerability and exposure to HIV infection, information on gender-related inequalities in HIV and related factors are rarely documented. The aim of this study was to measure gender inequality in HIV infection and its determinates in Tehran city, the capital of Iran.

Methods

The study used the data of 20,156 medical records of high-risk people who were admitted to Imam Khomeini Voluntary Counseling and Testing site in Tehran from 2004 to 2018. The Blinder-Oaxaca decomposition was used to quantify the contribution of explanatory variables to the gap in the prevalence of HIV infection between female and male.

Results

The age-adjusted proportion of HIV infection was 9.45% (95%Cl: 9.02, 9.87). The absolute gap in the prevalence of HIV infection between male and female was 4.50% (95% CI: − 5.33, − 3.70%). The Blinder-Oaxaca decomposition indicated that most explanatory factors affecting the differences in HIV infection were job exposure, drug abuse, history of imprisonment, injection drug, heterosexual unsafe sex, and having an HIV-positive spouse.

Conclusion

The results can provide evidence for health policymakers to better planning and conducting gender-based preventive and screening programs. Policies aiming at promoting HIV preventive behaviors among male may reduce the gap in HIV infection between female and male in Iran.

Unmet dental care need in West of Iran: determinants and inequality

Purpose

The purpose of this study was to assess the self-perceived need, seeking and use of dental care and its main determinants in Kurdistan province, Iran.

Design/methodology/approach

A total of 1,056 adults in Kurdistan province were included in this cross-sectional study. Multistage sampling approach was used to select the samples. Data on sociodemographic characteristics, economic status, self-perceived need, seeking and use of dental care were collected using a self-administrated questionnaire. Multivariate logistic regression model was used to assess factors affecting the use of dental care. In addition, socioeconomic inequality relating to dental care needs and use of dental care were examined using concentration curve and concentration index.

Findings

In this study, unmet dental care need was 62.7%. There was a perceived need for dental care among 13.7% (n = 145) of the participants in the past month, with only 39.3% (n = 57) seeking the care. The most important reasons for unmet dental care need were “Could not afford the cost” and “Insurance did not cover the costs.” Multivariate logistic regression showed that supplementary insurance status and household economic status were identified as main determinants affecting dental care-seeking behavior. The result of concentration index revealed that seeking dental care was more concentrated among the rich, whereas the perceived dental care need is more prevalent among the poor.

Originality/value

This study demonstrated that the prevalence of unmet dental care needs is high in the study setting. Also, financial barrier was identified as the main determinant of unmet dental care needs.

Health-care determinants of mortality and recovered cases from COVID-19: Do heath systems respond COVID-19 similarly?

BACKGROUND

The COVID-19 pandemic has spread rapidly across the world and has currently impacted most countries and territories globally. This study aimed to identify health-care determinants of mortality and recovery rates of COVID-19 and compare the efficiency of health systems in response to this pandemic.

MATERIALS AND METHODS

A cross-sectional study was conducted using data obtained from the World Bank database, that provides free and open access to a comprehensive set of health- and socioeconomic-related data, by September 12, 2020. An adjusted linear regression model was applied to determine predictors of mortality (per 1 million population [MP]) and recovery rates (per 1 MP) in the included countries. One-way analysis of variance was applied to assess health systems' efficiency in response to COVID-19 pandemic using mortality and recovery rate (output variables) and current health expenditure (CHE) per capita (input variable).

RESULTS

Globally, San Marino and Qatar had the highest mortality rate (1237/1 MP) and confirmed case rate (43,280/1 MP) until September 12, 2020, respectively. Iran had a higher mortality rate (273/1 MP vs. 214.5/1 MP) and lower recovery rate (4091.5/1 MP vs. 6477.2/1 MP) compared to countries with high CHE per capita. CHE per capita (standardized coefficient [SC] = 0.605, P < 0.001) and population aged 65 years and over as a percentage of total population (SC = -0.79, P < 0.001) significantly predicted recovered cases from COVID-19 in the included countries.

CONCLUSION

This study revealed that countries with higher CHE per capita and higher proportion of older adults were more likely to have a higher recovery rate than those with lower ones. Furthermore, our study indicated that health systems with higher CHE per capita statistically had a greater efficiency in response to COVID-19 compared to those with lower CHE per capita. More attention to preventive strategies, early detection, and early intervention is suggested to improve the health system efficiency in controlling COVID-19 and its related mortalities worldwide.

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.

Catastrophic health expenditures for children with disabilities in Iran: A national survey

OBJECTIVE

The aim of this study was to investigate the percentage of households with disabled children aged 0-8 years who had faced catastrophic health expenditures (CHEs) due to the health costs of these children in Iran.

METHODS

This cross-sectional study was carried out on 2000 households with disabled children aged 0-8 years in five provinces of Iran in 2020. Data were collected using the World Health Survey questionnaire and face-to-face interview. Determinants of CHE were identified using logistic regression.

RESULTS

32.7% of households with disabled children had faced CHE. Head of household being female (Adjusted OR = 18.89, 95%CI: 10.88-29.42), poor economic status of the household (Q1: Adjusted OR = 20.26, 95% CI, 11.42-35.94; Q2: Adjusted OR = 8.27, 95%CI, 4.45-15.36; Q3: Adjusted OR = 13.88, 95%CI, 7.89-24.41), lack of supplementary insurance by a child with disabilities (Adjusted OR = 6.13, 95%CI, 3.39-11.26), having a child with mental disability (Adjusted OR = 2.71, 95%CI, 1.60-4.69), and type of basic health insurance (having Iranian Health Insurance: Adjusted OR = 2.20, 95%CI, 1.38-3.49; having Social security insurance: Adjusted OR = 1.66, 95%CI, 1.06-2.61) significantly increased the chances of facing CHE.

CONCLUSION

A significant percentage of households with disabled children had faced CHE because of their disabled child's health costs. The key determinants of CHE should be considered by health policy-makers in order to more financial protection of these households.

Assessing unmet health-care needs of the elderly in west of Iran: A case study

Purpose

The purpose of this study is to investigate the status of perceived need, seeking behavior and utilization of health services in the elderly population of Sanandaj (west of Iran).

Design/methodology/approach

This is a cross-sectional study conducted on 800 elderly people in Sanandaj. Subjects were selected using multistage sampling and data were collected using self-report questionnaires. A multivariate logistic model with odds ratios (ORs) was used to determine the relationship of independent variables with seeking perceived need. Also, the concentration index was used to measure the inequality in using health services.

Findings

The perceived need for outpatient (during the last 30 days) and inpatient health-care services (during the past 12 months) was 69.7% and 29.7%, respectively. Among them, the unmet need for outpatient and inpatient health-care services was 46.6% and 17%, respectively. Having health insurance (adjusted OR 12.08; 95% confidence interval [CI] 1.04–140.11), middle economic status (adjusted OR 5.18; 95% CI 1.30–20.51) and being in an age group of 65–70 years (adjusted OR 7.60; CI 1.42–40.61) increased the chance of seeking inpatient care. Also, being in an age group of 60–65 years (adjusted OR 0.41; 95% CI 0.18–0.95) reduced the chance of seeking outpatient care. There was also a pro-rich inequality in using outpatient health services.

Originality/value

The elderly population suffers from unmet health-care needs, especially in outpatient services. The most important reason for not seeking outpatient and inpatient services was financial barriers and self-medication, respectively. So, designing targeted policies and interventions to address barriers in the conversion of need to demand in the elderly population is essential.

Comparing the properties of the EQ-5D-5L and EQ-5D-3L in general population in Iran

BACKGROUND

Little information exists on properties of EQ-5D-5L (the 5L hereafter) compared to the EQ-5D-3L (the 3L hereafter) measures in the context of Iran. This study aims to compare the measurement properties of the two versions of the EQ-5D (the 3L vs. the 5L) using data obtained from general population in Iran.

METHODS

A total of 886 adults aged 18 years and above from September to November 2020 participated in this cross-sectional analysis. The required data collected using self-administered and-standard questionnaire and multistage sampling method was used to select the samples. The 3L and 5L measures compared in terms of celling effect, distribution and redistribution pattern, feasibility, convergent validity, know-groups validity and informativity.

RESULTS

From September to November 2020, 886 adults (mean aged = 44.6 years; 55% male and 87.1% married) included in the study. The study indicated that the 5L had lower celling effects compared to the 3L (45% vs. 46%). A better convergent validity and known-groups validity was found for the 5L version compared to the 3L and significantly stronger association found between the 5L measure with both the Visual Analogue Scale and the 5-point health status scale. The 5L index score showed higher relative efficiency (RE) in 9 of 11 condition (mean RE = 1.36). Compared to the 3L, the 5L classification system had higher Shannon index (H') in all dimensions: mobility (0.52 vs. 0.40), self-care (0.23 vs. 0.20), usual activities (0.61 vs. 0.47), pain/discomfort (1.19 vs. 0.89) and anxiety/depression (1.22 vs. 0.47).

CONCLUSION

The study demonstrated that the measurement properties of 5L version in terms of celling effects, convergent validity, known-groups validity, RE and informativity similar or better than the 3L among general population; suggesting the use of 5L in the context of Iran. Hence, we suggested the use of the 5L in economic evaluation, clinical and public health studies in Iran.

Eliciting preferences of professors and medical group students for evaluation methods of theoretical courses: An application of discrete choice experiment analysis

BACKGROUND

Evaluation has become an inseparable part of education process which gives feedback to students and professors to improve education quality. This study aimed to elicit preferences of professors and students about attributes of evaluation methods in theoretical courses in Kermanshah University of Medical Sciences, Iran, in 2018.

MATERIALS AND METHODS

Discrete choice experiment (DCE) method used for eliciting preferences of participants of the study. A narrative literature review and interview with eight professors and ten students conducted to determine attributes and levels of evaluation methods in the university. Furthermore, experimental design used for making final choice sets of the evaluation methods. We included 213 students and 30 professors in the study. Conditional logistic regression model performed to data analysis.

RESULTS

Most of the professors (36.67%) preferred to allocate up to 30% of evolution scores to midterm examination. However, the most percentage of students (30.45%) were agree to include midterm examination up to 15% of total scores. The majority of students prefer to examination questions compromise just presented materials, while 70% of professors prefer to include additional texts for evaluation examinations. In case of quiz examination, professors in comparison with students prefer that quiz should have higher proportion of total scores. DCE analysis indicated that professors and students preferred a mix of questions in examinations. In addition, additional resources beyond what is taught in class made utility for professors and disutility for students. Quiz, also, increased the utility of an evaluation package in professors.

CONCLUSION

The findings showed that there is a gap between preferences of professors and students regarding some attributes of evaluation methods such as student's discipline, examination materials, and quiz. Further studies are needed to examining other attributes of evaluation methods in theatrical and practical courses in Iran and other contexts.

Barriers in access to healthcare for women with disabilities: a systematic review in qualitative studies

Background

Studies show that different socio-economic and structural factors can limit access to healthcare for women with disabilities. The aim of the current study was to review barriers in access to healthcare services for women with disabilities (WWD) internationally.

Methods

We conducted a systematic review of relevant qualitative articles in PubMed, Web of Science and Scopus databases from January 2009 to December 2017. The search strategy was based on two main topics: (1) access to healthcare; and (2) disability. In this review, women (older than 18) with different kinds of disabilities (physical, sensory and intellectual disabilities) were included. Studies were excluded if they were not peer-reviewed, and had a focus on men with disabilities.

Results

Twenty four articles met the inclusion criteria for the final review. In each study, participants noted various barriers to accessing healthcare. Findings revealed that WWD faced different sociocultural (erroneous assumptions, negative attitudes, being ignored, being judged, violence, abuse, insult, impoliteness, and low health literacy), financial (poverty, unemployment, high transportation costs) and structural (lack of insurance coverage, inaccessible equipment and transportation facilities, lack of knowledge, lack of information, lack of transparency, and communicative problems) factors which impacted their access healthcare.

Conclusions

Healthcare systems need to train the healthcare workforce to respect WWD, pay attention to their preferences and choices, provide non-discriminatory and respectful treatment, and address stigmatizing attitudinal towards WWD. In addition, families and communities need to participate in advocacy efforts to promote WWD’s access to health care.

Household Overcrowding in Iran, a Low-middle-income Country: How Major of a Public Health Concern Is It?

Objectives

Household overcrowding (HC) can contribute to both physical and mental disorders among the members of overcrowded households. This study aimed to measure the status of HC and its main determinants across the provinces of Iran.

Methods

Data from 39 864 households from the 2016 Iranian Household Income and Expenditures Survey were used in this study. The Equivalized Crowding Index (ECI) and HC index were applied to measure the overcrowding of households. Regression models were estimated to show the relationships between different variables and the ECI.

Results

The overall, urban, and rural prevalence of HC was 8.2%, 6.3%, and 10.1%, respectively. The highest prevalence of HC was found in Sistan and Baluchestan Province (28.7%), while the lowest was found in Guilan Province (1.8%). The number of men in the household, rural residency, the average age of household members, yearly income, and the household wealth index were identified as the main determinants of the ECI and HC.

Conclusions

The study demonstrated that the ECI and HC were higher in regions near the borders of Iran than in other regions. Therefore, health promotion and empowerment strategies are required to avoid the negative consequences of HC, and screening programs are needed to identify at-risk families.

Exploring socioeconomic inequalities in the use of medicinal herbs among Iranian households: evidence from a national cross-sectional survey

Background

Association between socioeconomic status and medicinal herbs (MH) are rarely documented in Iran. Our goal was to measure and decompose socioeconomic inequalities in MH use among Iranian households.

Methods

The data used in this cross-sectional study were extracted from the 2018 Household Income and Expenditure Survey (HIES) (N = 38,859). Data on MH use, age, gender, and education status of the head of household; a constructed wealth index of household (as a proxy for household’s socioeconomic status); and place of residence (urban or rural) were obtained from the survey. Publicly available province-level data on Human Development Index (HDI) were obtained from the Institute for Management Research at Radbound University. We used the concentration curve and the normalized concentration index (C_n) to measure the magnitude of socioeconomic inequalities in MH among Iranian households. The C_n was decomposed to identify the main determinants of socioeconomic inequalities in MH in Iran.

Results

The overall prevalence of MH use among Iranian households was 4.7% (95% confidence interval [CI]: 4.5 to 4.9%) in the last month before data collection. The C_n for MH use for the whole of samples was 0.1519; 95% CI = 0.1254 to 0.1784; suggesting a higher concentration of MH use among the households with high socioeconomic level. The decomposition analysis indicated that the main contributing factors to the concentration of MH use were the economic status of households, development status of the province, and education level of the household head.

Conclusions

This study demonstrated that MH use is more concentrated among socioeconomically advantaged households in Iran and its provinces. This finding might contrast with the widespread belief that wealthy and socioeconomically advantaged populations, compared to low SES groups, tend to seek disproportionately more modern medical treatments and medications than MH. Understanding the factors affecting MH use, socioeconomic inequality in use of MH and its determinants provide an opportunity for health policymakers to design effective evidence-based interventions among providers and consumers of MH.

Trend and status of out-of-pocket payments for healthcare in Iran: equity and catastrophic effect

Background

Equity in the distribution of health care resources and mitigating the risk of out-of-pocket (OOP) catastrophic healthcare expenditures (CHE) are the major objectives of the health system of a country. This study aims to measure equity in OOP payments for healthcare and the incidence of CHE among Iranian households over time.

Methods

This retrospective cross-sectional study utilized data extracted from the household income and expenditure survey (HIES) of Iran, collected by the Statistical Center of Iran. The analysis included a total of 174,341 households’ five yearly data of 6 years starting from 1991 to 2017. Kakwani progressivity index (KPI) was used to measure the equity in OOP payment for each year and examine the households’ incidence of CHE at 20%, 30%, and 40% of their capacities to pay (CTP). The trend series regression analysis was used to examine the trend in the KPI and the incidence of the CHE over time.

Results

The findings indicated that the households’ expenditure on health out of their monthly budgets for the years 1991 and 2017 were 2.1% and 10.1%, respectively. The KPI for the OOP payment was negative for all 6-year observations (1991 = − 0.680; 1996 = − 0.608; 2001 = − 0.554; 2006 = − 0.265; 2011 = − 0.225, and 2017 = − 0.207), indicating that the OOP payments for healthcare are regressive and more concentrated among the socioeconomically disadvantaged households. There was a statistically significant (p = 0.003) increase in the KPI (i.e., decline in the regressivity) over time. The incidence of the CHE (1.12, 1.93, and 3.71%) in 1991 at the CTP levels of 20%, 30%, and 40% was lower than the incidence at the corresponding levels of CTP (5.26, 10.88, and 22.16) in 2017. The findings of the time-series regression indicated a statistically significant (p < 0.05) increase in the incidence of the CHE at the 20%, 30%, and 40% levels of the households’ CTP.

Conclusions

The current study demonstrated that OOP payment as a source of healthcare funding in Iran is inequitable. While the use of interventions such as the prepaid and publicly funded programs may contribute to the reduction of CHE and improvement of equity in healthcare financing, further inequality analyses in the incidence of the CHE among households and its main determinants can contribute to evidence-informed planning to reduce the CHE in the context.

An exploratory study to estimate cost-effectiveness threshold value for life saving treatments in western Iran

Background

Cost-effectiveness analysis provides a crucial means for evidence-informed decision-making on resource allocation. This study aims to elicit individuals' willingness to pay (WTP) for one additional quality-adjusted life-year (QALY) gained from life-saving treatment and associated factors in Kermanshah city, western Iran.

Methods

We conducted a cross-sectional study on a total of 847 adults aged 18 years and above to elicit their WTP for one additional QALY gained by oneself and a family member using a hypothetical life-saving treatment. We used a multistage sampling technique to select the samples, and the Iranian version of EQ-5D-3L, and visual analogue scale (VAS) measures to obtain the participants’ health utility value. The Tobit regression model was used to identify the factors affecting WTP per QALY values.

Results

The mean WTP value and standard deviation (SD) was US$ 862 (3,224) for the respondents. The mean utility values using EQ-5D-3L and VAS methods for respondents were 0.779 and 0.800, respectively. Besides, the WTP for the additional QALY gained by the individual participants using the EQ-5D-3L and VAS methods were respectively US$ 1,202 and US$ 1,101, while the estimated value of the family members was US$ 1,355 (SD = 3,993). The Tobit regression models indicated that monthly income, education level, sex, and birthplace were statistically significantly associated (p < 0.05) with both the WTP for the extra QALY values using the EQ-5D-3L and the VAS methods. Educational level and monthly income also showed statistically significant relationships with the WTP for the additional QALY gained by the family members (p < 0.05).

Conclusion

Our findings indicated that the participants' WTP value of the additional QALY gained from the hypothetical life-saving treatment was in the range of 0.20–0.24 of the gross domestic product (GDP) per capita of Iran. This value is far lower than the World Health Organization (WHO) recommended CE threshold value of one. This wide gap reflects the challenges the health system is facing and requires further research for defining the most appropriate CE threshold at the local level.

Hand hygiene adherence among Iranian nurses: A systematic review and meta-analysis

Background & Aim: Adherence of nurses to hand hygiene is important for the prevention of healthcare-associated infections. This study aims to systematically review the existing studies that assess Iranian nurses' adherence to hand hygiene and estimate their amount with meta-analysis. Methods & Materials: We performed a systematic search for peer-reviewed journals published from 2005 to 2018. The systematic search was conducted using both international (Google Scholar, PubMed, SCOPUS, and Web of Sciences) and Iranian databases (Scientific Information Database, IranMedex, Magiran, and MedLib). The search was carried out using a combination of the following terms: “adherence”, “compliance”, “hand hygiene”, “nurse”, “Iran”, “nursing practice”, “nursing”, and “guidelines”. The combinations of these words with Boolean operators like ‘AND’, ‘OR’ and ‘NOT’ were used. Results:  A total of 22 articles were used in the final analyses. The pooled proportion of hand hygiene adherence was 40.5 percent [95% confidence interval [CI]: 31.1–49.8]. Sensitivity analysis confirmed that the overall estimated pooled proportion of hand hygiene adherence did not vary significantly with the elimination of any of the 22 studies, observer or self-reported hand hygiene, instrument of measurement, unit of measurements, sample size, and time. Conclusion: The level of adherence of Iranian nurses to hand hygiene can potentially increase the chance of healthcare-associated infections and put patients and nurses at risk. Hospital and nursing managers should take practical steps to investigate factors contributing to the failure of hand hygiene adherence among nursing staff. They should ensure the continuous implementation of hand hygiene improvement strategy.

Socioeconomic inequalities in tobacco, alcohol and illicit drug use: evidence from Iranian Kurds

BACKGROUND

The associations between socioeconomic status (SES) and tobacco use, alcohol consumption and drug use are poorly understood in the Islamic Republic of Iran.

AIMS

To measure education- and wealth-related inequalities in cigarette smoking, hookah smoking, illicit drug use and alcohol consumption in Kermanshah Province, Islamic Republic of Iran.

METHODS

We used baseline data from the Ravansar Noncommunicable Disease (RaNCD) study. The study collected information on socioeconomic and demographic characteristics, cigarette and hookah smoking, alcohol consumption and illicit drug use of 10 015 adults aged ≥ 35 years between 2014 and 2016. The relative concentration index and absolute concentration index were used to measure education- and wealth-related inequalities in cigarette smoking, hookah smoking, illicit drug use and alcohol consumption.

RESULTS

Cigarette smoking was concentrated among less-educated and less-wealthy men and women. Similarly, illicit drug use was concentrated among lower-SES men. In contrast, hookah smoking and alcohol consumption were more prevalent among higher-SES men.

CONCLUSIONS

There were education- and wealth-related inequalities in tobacco, alcohol and illicit drug use in the west of the Republic of Iran. Future studies should aim to identify the main socioeconomic determinants of these inequalities in Kermanshah Province and generally in the Islamic Republic of Iran.

Cigarette Smoking and Its Financial Burden among Iranian Households: Evidence from Household Income and Expenditures Survey

Background: The financial burden of cigarette smoking on households’ budget is not well documented in Iran. We aimed to identify the determinants of cigarette consumption and its financial burden among households in Iran.

Study design: A cross-sectional study.

Methods: A total of 39,864 Iranian’s households from 31 provinces were included in the analysis. Data on sociodemographic and socioeconomic characteristics (age, sex, household size, education level, employment status, income and wealth index), living area, number of cigarettes smoked and cigarette expenditures for households were extracted from the 2016 Household Income and Expenditures Survey (HIES). Tobit model was used to identify the determinants of cigarette smoking frequency and expenditures among Iranian households.

Results: The average number of cigarettes smoked and cigarettes expenditures by all household members was 85.25 cigarettes and US$ 2.64 per month. Living in urban areas, wealth index of households, household income, household size and low educational attainment of household members were positively associated with frequency and expenditures of cigarette smoking. Results also indicated increasing patterns in the number of cigarettes smoked and cigarettes expenditures from east to west of the country. East Azerbaijan, Hamadan, Markazi and Chaharmahal va Bakhtiari provinces had higher cigarette smoking frequency and expenditures in Iran.

Conclusions: Tobacco control interventions in Iran should focus more on households living in urban areas and low-educated households. As the frequency of cigarette smoking was higher in the western region of Iran, comprehensive tobacco control policies should be adopted in western provinces.

Oral Health Behaviors among Schoolchildren in Western Iran: Determinants and Inequality

Introduction

Little information exists on the status of oral hygiene behavior (OHB) and socioeconomic inequalities in developing countries like Iran. The aim of this study was to assess OHB and its determinants and socioeconomic inequality among schoolchildren in western Iran during 2018.

Methods

A cross-sectional survey was conducted on 1,457 students aged 12–15 years living in Kermanshah city, western Iran. We used multistage sampling to select the samples. A self-administrated questionnaire was used to collect data on OHB, sociodemographic characteristics, and economic status of the households of students. Multivariate logistic regression was used to examine the association between OHB and its determinants. We used the relative concentration index, normalized (RCIn) and a concentration curve (CC) to examine socioeconomic-related inequality in OHB.

Results

The study indicated that crude and age-adjusted prevalence of good OHB was 14.61% (95% CI 12.89%–16.53%) and 15.17% (95% CI 13.22%–17.35%), respectively. Logistic regression analysis showed that sex, mother’s education, socioeconomic status, and oral health literacy had a statistically significant positive impact on OHB. RCIn (0.2582, 95% CI0.1770–0.3395) values and the CC indicated that good OHB was more concentrated among the richer children.

Conclusion

This study provides evidence that good OHB was less prevalent, signifying that oral health remains a public-health concern in Iran. Effective polices aimed at improving the socioeconomic status of households and mother’s education can contribute positively and to the prevention of oral disorders among schoolchildren.

Quality and quantity of price elasticity of cigarette in Iran

OBJECTIVE

Effectiveness of tax policies to control cigarette consumption largely depends on the sensitivity of cigarette demand due to price change. Price elasticity is the measurement of this responsiveness. The main objective of this study is to measure quantity, and quality price elasticity of demand (PED) and cross-price elasticity of demand (XED) for Iranian and non-Iranian cigarette brands in Iran.

METHODS

This study used data from the 2017 Iranian household income and expenditures survey conducted in all 31 provinces of Iran. A total of 39,864 households were included in the survey. PED of quantity and quality and XED were estimated using restricted, unrestricted and quintile regression models.

RESULTS

Our results s show that the Iranian and non-Iranians brands cigarettes were price inelastic and elastic, respectively. XED between Iranian and non-Iranian brands was positive suggesting households' preference for Iranian brands of cigarettes over non-Iranian brands. Quintile regression results suggest that PED varied between -1.20 and -0.91 across the distribution of quantity demanded.

CONCLUSION

Imposing tax could be a useful policy tool to control smoking initiation and intensity in Iran. However, the effectiveness of such policy would depend on the better governance of taxation imposed on different brands of cigarettes.

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.

Preferences of Medical Sciences Students for Work Contracts in Deprived Areas of Iran: A Discrete Choice Experiment Analysis

Background

An unequal distribution of human resources affects access to health-care services. This study aimed to elicit the preferences of medical, dentistry, and pharmacy students about attributes of work contracts in deprived areas of Iran; this is a primary important step to decrease inequity.

Methods

Two-hundred and one students were entered into the study through proportional sample size estimation from Kermanshah University of Medical Sciences in the west of Iran in 2018. The attributes of work contracts were determined using the discrete choice experiment (DCE) method, then possible dual scenarios of work contracts were designed through the D-efficiency method of SAS software and the data were collected using a questionnaire designed by the researchers. The conditional logistic model was used to analyze the data.

Results

Salary, workplace, side facilities, scholarship, and workload were considered as important factors for working in the deprived areas (p<0.001). There were differences between the students’ preferences regarding their residential areas, majors, and state or tuition-paying education (p<0.001). Higher payments, side facilities, and availability of quota after working in the deprived areas were considered as creators of higher utility, and working in deprived areas and high workload were considered as creators of lower utility (p<0.001).

Conclusion

This study provides new evidence about the preferences of medical sciences students for work contracts in deprived areas of Iran. According to the findings, money is not the only factor that affects the decisions of medical sciences students related to working contracts in deprived areas of Iran. Designing work contracts that are matched with preferences of the workforce can lead to an improvement in equity, access, and utilization of health-care services.

Socioeconomic Inequality in Self-Medication in Iran: Cross-Sectional Analyses at the National and Subnational Levels

Background

Self-medication (SM) is a public health concern globally. This study aimed to measure socioeconomic inequality in SM and identify its main determinants among Iranian households.

Methods

A total of 38,859 households from the 2018 Household Income and Expenditure Survey (HIES) were included in the study. Data on SM, household size, age, gender and education status of the head of household, monthly household’s expenditures (as a proxy for socioeconomic status), health insurance coverage and living areas and provinces were obtained for the survey. The concentration curve and the normalized concentration index (C_n) were used to quantify the magnitude of socioeconomic inequality in SM among Iranian households. The C_n was decomposed to identify the main determinants of socioeconomic inequality in SM in Iran.

Results

The results indicated that 18.2% (95% confidence interval [CI]: 17.7% to 18.5%) of households in Iran had SM practice in the past month. The results suggested a higher concentration of SM among the rich households (C_n= 0.0466; 95% CI= 0.0321 to 0.0612) in Iran. The concentration of SM among high SES households was also found in urban (0.0311; 95% CI=0.0112 to 0.0510) and rural (= 0.0513; 95% CI=0.0301 to 0.0726) areas. SM was concentrated among the rich households in Tehran, Qom, Esfahan, Ardebil, Golestan, and Sistan and Baluchestan provinces. In contrast, a higher concentration of SM was found among the poor households in Semnan, North Khorasan, Kerman, Bushehr, and South Khorasan provinces. The decomposition revealed SES of household, itself, as the main contributing factor to the concentration of SM among the wealthy households.

Conclusion

This study demonstrated that SM is more concentrated among socioeconomically advantaged households in Iran. Thus, effective evidence-based interventions should be implemented to improve awareness about SM and its negative consequences. Further studies are required to investigate the consequences of SM practice among people.

Socioeconomic-related inequalities in self-rated health status in Kermanshah city, Islamic Republic of Iran: a decomposition analysis

Background

Socioeconomic-related inequalities in health are a major public health challenge in both developed and developing countries. Little evidence is available on socioeconomic-related inequalities in health in different regions of the Islamic Republic of Iran.

Aims

This study aimed to determine socioeconomic-related inequality in poor self-rated health in adults in Kermanshah city, western Islamic Republic of Iran.

Methods

This cross-sectional study with stratified sampling obtained data on socioeconomic status, demographic characteristics, behavioural risk factors and self-rated health of 2040 adults (≥ 18 years) in Kermanshah city. A self-administrated questionnaire was used to collect data from the participants. The concentration (C) index and C curve were used to determine the socioeconomic-related inequality in poor self-rated health. A decomposition analysis of the C index was done to identify the factors explaining socioeconomic-related inequality in poor self-rated health.

Results

The crude and age-adjusted prevalence of poor self-rated health was 13.8% and 18.1%, respectively. The estimated C for the whole sample was -0.295, indicating that poor SRH was concentrated in the poor. The decomposition results suggested that socioeconomic status (45.5%), having a chronic health condition (11.9%) and smoking (7.3%) were the main factors contributing to the concentration of poor self-rated health among those of lower socioeconomic status.

Conclusion

The concentration of poor self-rated health among the poor in Kermanshah city warrants policy attention. Policies aimed at reducing inequality in wealth distribution and risky health behaviour and preventing chronic health conditions among the poor may mitigate socioeconomic-related inequalities in poor self-rated health in Kermanshah.

Socioeconomic inequality in tobacco expenditure in Iran: a cross-sectional analysis at national and subnational levels

BACKGROUND

Tobacco expenditure has adverse impacts on expenditure on basic needs and resource allocation of the households. Using data from a nationally representative survey, we measured socioeconomic inequality in tobacco expenditure as the share of household budget (TEHB) and explained its main determinants among Iranian households at the national and sub-national levels.

METHODS

This cross-sectional study used data from the Iranian Household Income and Expenditure Survey (IHIES), 2018. We included a total of 7649 households with tobacco expenditure more than zero in the analysis. Province-level data on the Human Development Index (HDI) was obtained from the Institute for Management Research at Radbound University. The concentration curve (CC) and the concentration index (C) were used to measure socioeconomic inequality in TEHB at national and sub-national levels. The C was decomposed to identify the factors explaining the observed socioeconomic inequality in TEHB.

RESULTS

At the national level, households with at least one smoker spent more than 5% of their budget for tobacco consumption in the last month. Households from the urban areas allocated less of their budgets on tobacco products compared to rural households (4.6% vs. 5.8%). Overall, TEHB was more concentrated among the poorer households (C = 0.1423, 95% CI: - 0.1552 to - 0.1301). In other words, the distribution of TEHB was pro-poor in Iran. Pro-poor inequality in TEHB was also found in urban (C = - 0.1707, 95% CI: - 0.1998 to - 0.1516) and rural (C = - 0.1314, 95% CI: - 0.1474 to - 0.1152) areas. We also found that pro-poor inequalities were higher in Iranian provinces with low HDI. The decomposition results indicate that wealth and education were the main factors contributing to the concentration of TEHB among the poorer households.

CONCLUSION

This study found that TEHB was disproportionality concentrated among poorer households in Iran. The extent of inequality in TEHB was higher in urban areas and less developed provinces. Designing and implementing tobacco control interventions to decrease the smoking prevalence and increase smoking cessation could protect worse-off households against the financial burden of tobacco spending.

Mothers' willingness to accept and pay for vaccines to their children in western Iran: a contingent valuation study

Background

The clients’ willingness to accept (WTA) and willingness to pay (WTP) for a given good or service can help elicit the monetary value of that good or service. This study aims to assess the WTA and WTP of mothers attending primary health centers for vaccines to their children during 2019 in Kermanshah city, western Iran.

Methods

We conducted a cross-sectional study on a total of 667 mothers attending primary health centers for vaccines to their children aged two to 18 months. A multistage sampling technique was employed to involve the mothers in the study, and data were collected using a self-administrated open-ended questionnaire. The multivariate linear regression model was used to identify the factors associated with the mothers’ WTP and WTA for vaccines to their children.

Results

The study indicated that 94.2 and 93.1% of the mothers respectively had WTA and WTP values greater than zero, with their corresponding mean values of US$ 6.8 and US$ 4.4. The mothers in the higher monthly household income category, mothers born in the urban areas, and being a female child showed statistically significant positive associations with the mothers’ WTA for the vaccines. While there was a statistically significant positive relationship between monthly household income and the mothers’ WTP; a statistically significant negative relationship exists between the mothers’ age and their WTP for the vaccine to their children.

Conclusions

The findings indicated the mothers’ WTA to WTP ratio of greater than one for the vaccines to their children. The most important factor associated with the mothers’ WTA and WTP was the monthly household income. Thus, improving the socio-economic standards of women in the study area might contribute to reinforcing their immunization services seeking behavior to their children.

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000-17: analysis for the Global Burden of Disease Study 2017

BACKGROUND

Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea.

METHODS

We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates.

FINDINGS

The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1-65·8), 17·4% (7·7-28·4), and 59·5% (34·2-86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage.

INTERPRETATION

By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health.

FUNDING

Bill & Melinda Gates Foundation.

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.