Geographic distribution of need and access to health care in rural population: an ecological study in Iran

Impact of social and clinical factors on the diagnostic delay of chronic kidney disease: an evaluation study

AIM

This study aimed to investigate the impact of social and clinical factors on the diagnostic delay of chronic kidney disease (CKD) among Iranian patients.

MATERIALS AND METHODS

Our study was conducted on 350 CKD patients who were referred to Faghihi and Motahari clinics (the two largest kidney diseases referral centers in Shiraz the capital of Fars province). Data were collected via an interviewer-administered questionnaire. A multiple linear regression model was used to measure the effect of factors affecting the delay of CKD diagnosis.

RESULTS

The medians and Interquartile ranges (IQR) of all delays, patient delay, and doctor delay were 6.5 (0-12.2), 5.1 (0-11.2), and 0.9 (0-3.1) months, respectively. The results showed that women were diagnosed 1.61 months earlier than men (p < 0.05). The duration of all delays in patients residing in the rural areas was 1.28 months longer than patients residing in the urban areas (p < 0.05). Also, patients with perceived good economic status were diagnosed 1.30 months earlier than patients who reported having very poor economic status (p < 0.05).

CONCLUSIONS

The delay is in part due to the neglect and misinterpretation of symptoms by both patients and physicians. It is necessary to improve the awareness of CKD among general public and medical professionals.

The contribution of service density and proximity to geographical inequalities in health care utilisation in Indonesia: A nation-wide multilevel analysis

Background

Geographical inequalities in access to health care have only recently become a global health issue. Little evidence is available about their determinants. This study investigates the associations of service density and service proximity with health care utilisation in Indonesia and the parts they may play in geographic inequalities in health care use.

Methods

Using data from a nationally representative survey (N = 649 625), we conducted a cross-sectional study and employed multilevel logistic regression to assess whether supply-side factors relating to service density and service proximity affect the variability of outpatient and inpatient care utilisation across 497 Indonesian districts. We used median odds ratios (MORs) to estimate the extent of geographical inequalities. Changes in the MOR values indicated the role played by the supply-side factors in the inequalities.

Results

Wide variations in the density and proximity of health care services were observed between districts. Outpatient care utilisation was associated with travel costs (odds ratio (OR) = 0.82, 95% confidence interval (CI) = 0.70-0.97). Inpatient care utilisation was associated with ratios of hospital beds to district population (OR = 1.23, 95% CI = 1.05-1.43) and with travel times (OR = 0.72 95% CI = 0.61-0.86). All in all, service density and proximity provided little explanation for district-level geographic inequalities in either outpatient (MOR = 1.65, 95% CrI = 1.59-1.70 decreasing to 1.61, 95% CrI = 1.56-1.67) or inpatient care utilisation (MOR = 1.63, 95% CrI = 1.55-1.69 decreasing to 1.60 95% CrI = 1.54-1.66).

Conclusions

Supply-side factors play important roles in individual health care utilisation but do not explain geographical inequalities. Variations in other factors, such as the price and responsiveness of services, may also contribute to the inequalities. Further efforts to address geographical inequalities in health care should go beyond the physical presence of health care infrastructures to target issues such as regional variations in the prices and responsiveness of services.

A review of appropriate indicators for need-based financial resource allocation in health systems

BACKGROUND

Optimal, need-based, and equitable allocation of financial resources is one of the most important concerns of health systems worldwide. Fulfilling this goal requires considering various criteria when allocating resources. The present study was conducted to identify the need indicators used to allocate health resources in different countries worldwide.

METHODS

A systematic review conducted on all published articles and reports on the need-based allocation of health financial resources in the English language from 1990 to 2020 in databases, including PubMed, Cochrane, and Scopus as well as those in Persian language databases, including magiran, SID, and Google and Google scholar search engines. After performing different stages of screening, appropriate studies were identified and their information were extracted independently by two people, which were then controlled by a third person. The extracted data were finally analyzed by content analysis method using MAXQDA 10 software.

RESULT

This search yielded 823 studies, of which 29 were included for the final review. The findings indicated that many need-based resource allocation formulas attempt to deal with health care needs using some weighting methods for individuals. In this regard, the most commonly used indicators were found as follows: age, gender, socio-economic status or deprivation, ethnicity, standardized mortality ratio (SMR), the modified health indicators (disease consequences, self-assessed health, and disability), geographical area / place of residence (geographical) (rural versus urban), cross-boundary flows, cost of services, and donations.

CONCLUSION

The indicators used in allocating the health systems' financial resources in each country should be designed in order to be simple and transparent and in accordance with the moral norms of that society. Moreover, these should be a good representative of the health needs of people in different geographical areas of that country. In addition, their related data should be available to an acceptable extent.

Effect and significance of incorporating access in estimating the number of required physicians: focus on differences in population density in the target area

BACKGROUND

Geographical imbalances in the health workforce, particularly the shortage of health care workers in rural areas, is an issue of social and political concern in most countries. Estimating the number of required doctors is essential for evidence-based health policy planning. In this study, we propose two methods for estimating the number of required doctors using a simple method. One is counting by unit and the other is incorporating access to medical institutions. The purpose of this study is to verify the need to incorporate access to medical institutions when estimating the number of required physicians in a region by comparing both estimation methods from the viewpoint of regional population density.

METHODS

We calculated the ratio of outpatients who can access medical institutions and the number of required physicians using the travel time by car and the number of patients who can be treated per doctor per day (estimation method for the number of physicians based on the access simulation, hereinafter referred to as EAS). We compared the results of this estimation with those of a conventional method, such as the number of doctors per population (estimation method for the number of physicians based on the number of patients, hereinafter referred to as ENP) to show how important it is to incorporate the element of accessibility in such a simulation analysis. Based on the results, we discussed the applicability of the proposed method.

RESULTS

ENP estimated that 38,685 outpatient primary care (PC) physicians were required and EAS estimated that 46,378 were required. There was a difference of about 8000. A comparison of the EAS-estimated number of physicians and the ENP-estimated number of physicians showed that the ENP-estimated number was small, particularly in areas with low population density.

CONCLUSIONS

The results showed that it is effective to use the proposed EAS method for the estimation of PC physicians, particularly in areas with low population density. We showed that the method of allocating the number of physicians in proportion to the number of patients in a certain unit requires paying attention to the setting of the unit.

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.

Prevalence of amblyopia and its determinants in a rural population: a population-based cross-sectional study

To determine the prevalence of amblyopia and its determinants in underserved rural villages of Iran. This population-based cross-sectional study was conducted in 3850 subjects selected from two underserved districts in the north (Kojur District, Nowshahr County, Mazandaran Province) and southwest (Shahyun District, Dezful County, Khuzestan Province) of Iran using multi-stage cluster sampling. The subjects underwent complete ophthalmic examinations including the measurement of uncorrected (UCVA) and best-corrected (BCVA) visual acuity, objective and subjective refraction, unilateral and alternate cover tests and ocular health examination. Amblyopia was defined as a reduction of BCVA to 20/30 or less in one eye or a 2-line interocular optotype acuity difference in the absence of any pathological factors. Of 3850 selected subjects, 3314 participated in the study (response rate = 86.08%). The mean age of the participants was 36.90 ± 20.21 years (range: 3-93 years). The prevalence and 95% confidence interval of total, bilateral, and unilateral amblyopia were 2.73% (2.17 to 3.38), 0.50% (0.28 to 0.83), and 2.23% (1.73 to 2.83), respectively. The most common type of amblyopia was anisometropic followed by strabismic and mixed. The lowest and highest prevalence was seen in the age group 6-20 years (1.36%; 0.65 to 2.49) and above 70 years (5.97%; 3.02 to 10.44), respectively. According to the results of multiple logistic regression analysis, compared to illiterate subjects, the odds ratio of amblyopia was 0.321 (P = .033) in subjects with High school education, 0.181 (P = .030) in subjects with secondary School education, and 0.486 (P = .041) in subjects with primary school education. The odds ratio of amblyopia for north villages residence vs southwest villages residence was 2.105 (P = .012). The odds ratio of amblyopia was 2.765 for age group>70 years vs. 6-20 years (P = .033). The prevalence of amblyopia was higher in north region, in participants with lower education level and older individuals. The high prevalence of amblyopia in older people may be due to the lack of screening programs in previous generations and consequently the lack of timely diagnosis and treatment.

Factors affecting the technical efficiency of rural primary health care centers in Hamadan, Iran: data envelopment analysis and Tobit regression

Background

Studying and monitoring the efficiency of primary health care centers has a special place in the health system. Although studies have been conducted in the field of efficiency in Iran, few have focused on rural primary health care centers. In addition, previous studies have not used the child mortality rate and Behvarzes as input and output.

Objective

The present study was conducted aimed to estimate the technical efficiency of rural primary health care centers and determinant factors in Hamadan using data envelopment analysis and Tobit regression.

Methods

This is a Longitudinal study of rural primary health care centers in Hamadan province (2002–2016). Data Envelopment Analysis was employed to estimate technical efficiency of sampled health facilities while Panel Tobit Analysis was applied to predict factors associated with efficiency levels. The outputs were child mortality rate under 1 year of age and child mortality rate 1 year to 5 years of age. The input was Behvarzes (rural health workers).

Results

The results of efficiency analysis showed that the average efficiency scores of the centers had a fluctuating trend during the period of the study, but the average performance scores generally decreased in 2016, as compared with 2002. The highest and lowest average performance scores were observed in 2003 (0.78) and 2013 (0.56), respectively. Number of physicians and rural primary healthcare centers per population had a positive statistically significant and the number of midwives and the total fertility per population had a negative statistically significant effect on efficiency.

Conclusions

The findings suggest some level of wastage of health resources in primary health centers. Findings indicate a level of waste of health resources in primary health centers. Behvarz functions in providing primary care services can be considered in the reallocation and optimal use of available resources at the level of rural health centers.

Ranking of Iranian provinces based on healthcare infrastructures: before and after implementation of Health Transformation Plan

Background

Health Transformation Plan (HTP) was occurred in 2014 to improve access and equity and reduce out of pocket payments in Iranian Health Care System. In this regard the aim of this study is evaluating and ranking the service provider’s infrastructures among the country provinces as an indicator of equity before and after implementation of the HTP.

Methods

This cross sectional study is conducted in 2017. The study population included 31 provinces of the country. Data related to 4 years from 2012 to 2016 were included from the data bases of Ministry of Health and Medical Education as well as the statistics yearbook of the country. The obtained results of multi-criteria decision-making methods were analyzed as well. SPSS₁₈ and Excel₂₀₁₃ software were used for data analysis.

Results

Based on the VIKOR method, in 2012, Mazandaran, Tehran and Fars provinces and in 2013, the provinces of Tehran, Fars and Isfahan ranked from first to third respectively. Similarly after HTP, in 2015, the provinces of Tehran, Khorasan Razavi and Fars and in 2016 the provinces of Tehran, Fars and Khorasan Razavi have ranked from first to third respectively. Paramedic, dentist, pharmacist, medical institutions and hospital bed had a significant difference before and after the implementation of Health Transformation Plan, so that the number of these indicators increased after implementation of the HTP (P value < 0.05).

Conclusions

According to the results, there are many differences between the provinces and these disparities have not decreased significantly after HTP. Consequently, it is suggested to the health sector policy makers to make regional plans and allocate the budget of HTP, based on the status of the provinces. In addition, responding to these inequalities requires a transparent and systematic approach to provide the budget for allocating to the population, health needs, and the lack of development and geographical isolation of regions.

Malaria Prevention Measures among Pregnant Women: A Population-Based Survey in Nnewi, Nigeria

We examined factors related to the uptake of two malaria prevention measures, insecticide-treated bed-nets and prophylactic sulphadoxine-pyrimethamine (SP), among pregnant women in Nnewi, Nigeria. The survey had a quantitative and qualitative part. For each part, the subjects meeting our inclusion criteria were systematically identified in a population-based manner. For the qualitative part, focused group discussions, in-depth interviews with a wide variety of stakeholders (e.g., health workers, males whose wives are pregnant, and drug and net sellers), and key informants including doctors and nurses were held. All data covered various aspects related to the topics. A total of 384 subjects participated. The mean age was 28.9 years (95% CI 23.4-34.5). The primigravidae (odds 1.8-2.3) and illiterates (odds 4.1-13.5) were less likely to sleep under the net. Primigravidae were 2.0x less likely to uptake adequate SP. The uptake was also associated with having adequate knowledge on SP (2.4x), completing usual (≥4 visits) antenatal visits (3.9x), and being in the best (≥9 visits) antenatal visit scenario (10.5x). Other barriers identified were thermal discomfort, lack of availability, cost, and unsupervised uptake of SP. Based on a representative sample, systematic procedures, and within current evaluation limits, we conclude that primigravidae and those with no formal education and inadequate antenatal visits should be the foremost group for encouraging uptake of malaria prevention measures. The policymakers should resolve issues of thermal discomfort, availability, cost, unsupervised uptake, and inadequate awareness and confidence on SP prophylaxis. The solutions are available and should be actively sought.

How can the spatial equity of health services be defined and measured? A systematic review of spatial equity definitions and methods

Background

Spatial equity analysis has been carried out in a variety of contexts and on a range of health services. However, there is no clear consensus on spatial equity definitions or measures. This review seeks to summarize spatial equity definitions and methods of analysis.

Methods

We systematically searched two electronic databases and six journals for papers providing a definition of spatial equity or performing a spatial equity analysis on health services. Studies were classified according to four definition themes: (1) distributional fairness; (2) needs-based distribution; (3) focus on outcomes or causes and (4) none provided.

Results

Seventy-five studies met our inclusion criteria. Sixty-one papers provided a definition of spatial equity, while a further 14 papers analysed the spatial equity of health services without providing a definition. Most authors used a needs-based definition of spatial equity, while the Gini coefficient was the most commonly used equity measure. However, analysis approaches varied according to the definition provided by each paper. Among the needs-based definitions, spatial autocorrelation was the most common spatial equity measure.

Conclusions

To our knowledge, this is the first systematic review summarizing spatial equity definitions and analysis methods. A lack of consensus on definitions and measures persists. The classification of measures according to definition themes makes this review a useful tool for planning and interpreting spatial equity investigations. Future research should examine the impact different measures of accessibility and need have on the results of spatial equity research.

Characteristics and Workload of Pediatricians in China

OBJECTIVES

Although it is widely believed that China is facing a major shortage of pediatricians, the real situation of the current national status of pediatric human resources and their working conditions has not been evaluated to date.

METHODS

We administered a survey to 54 214 hospitals from all 31 provinces in mainland China from 2015 to 2016. Hospital directors of all secondary and tertiary hospitals with pediatric services and a random sample (10%) of primary hospitals provided information on number of pediatricians and their educational levels, specialties, workloads, dropout rates, and other hospital characteristics. A data set of medical resources and socioeconomic information regarding each region (1997-2016) was constructed from the Chinese National Statistics Bureau. The Gini coefficient was used to describe the geographical distributions of pediatricians and hospitals.

RESULTS

There were 135 524 pediatricians in China or ∼4 pediatricians per 10 000 children. Pediatricians' average educational level was low, with ∼32% having only 3 years of junior college training after high school. The distribution of pediatricians was extremely skewed (Gini coefficient 0.61), and the imbalance of highly educated pediatricians was even more skewed (Gini coefficient 0.68). The dropout rate of pediatricians was 12.6%. Despite an increase in the Chinese government's financial investment in health over the last decade, physicians have been burdened with a greater workload.

CONCLUSIONS

Uneven development of the pediatric care system, inadequately trained pediatricians, low job satisfaction, and unmet demand for pediatric care are the major challenges facing China's pediatric health care system.

Women's right to health in Iran: Domestic implementation of international human rights law

In Iran, discrimination based on gender in enjoyment of the right to health is prohibited. Making health services physically and financially accessible to the entire population and removing social and cultural barriers of women's access to health services are main considerations of the health laws and policies of Iran. The health of Iranian women has improved considerably in recent years. But there are disparities in health status and access of women to health services around the country. Some groups of women, including the poor, the elderly, the disabled, the illegal immigrant, and those without an appropriate male guardian, and rural women have limited access to health services in Iran. To realize women's right to health, this country should immediately remove the disparities and use all the necessary means including legislative, administrative, budgetary, promotional, and judicial measures. National plans on women's empowerment and support should be interpreted in provincial programs and action plans. Moreover, a monitoring system and certain benchmarks for tracing the progress of the plans should be established. Realizing other economic, social, and cultural rights including the rights to food, shelter, education, work, social security, and participation in society will improve the Iranian women's enjoyment of their right.

The relationship between important reproductive health indices and human development index in Iran

Background: Reviewing the reproductive health indicators (RHIs) provides the possibility of periodic health system performance evaluation to achieve balanced development. This study aimed to determine the trend of ten reproductive health indicators changes during 2002-2011, and examining their relationship with the Human Development Index (HDI).

Methods: In this ecological study the trend of ten reproductive health indicators from five selected provinces of Iran were mapped. Then the relationship of these ten indicators with HDI was investigated using non parametric Spearman's rank correlation coefficient in SPSS v. 20.

Results: There was a statistically significant direct and strong correlation between the percentage of childbirth by a trained person and HDI (r= 0.9, p=0.037).

Conclusion: In our study, it can be expected that the provinces with similar reproductive health indicators, likely have similar HDI.

Perceived barriers on mental health services by the family of patients with mental illness

BACKGROUND

Various efforts have been made by the Indonesian government to improve mental health services. In 2014, the government established Law no 18, which is about mental health and the treatment of people with mental illness covered by the universal health coverage. However, many people still experience difficulty in accessing mental health services. In Indonesia, family plays the role of a caregiver to people with mental illness.

OBJECTIVE

This study aims to identify the perceived barriers on mental health services by families whose members suffers from mental illness.

METHODS

This study is a qualitative research study with a phenomenological approach. Sampling was conducted by purposive sampling with a sample size of 12 participants. Data were collected using semistructured in-depth interviews. Thematic analysis was performed using Colaizzi steps.

RESULTS

The obtained results presented three themes. Theme 1, mental health service affordability; theme 2, mental health service availability; and theme 3, negative attitudes (stigma).

CONCLUSION

Families whose members suffered from mental illness still experienced barriers in relation to mental health services even with universal health coverage. Improved mental health services are related to the health insurance coverage, affordability, availability of mental health services and stigma reduction in the health professionals and wide community.

Status of Iran's Primary Health Care System in Terms of Health Systems Control Knobs: A Review Article

BACKGROUND

After the establishment of Primary Health Care (PHC) program in Iran, health indicators have improved every year. This progress was so rapid that a number of shortcomings and weaknesses of the PHC program remained silent behind its successes. This study aimed to assess the status of Iran's PHC system (strengths, weaknesses, opportunities and threats) in terms of health system's control knobs.

METHODS

The search was conducted through two English 'databases of Web of Knowledge and PubMed, two English publications of Science Direct and Springer and two Persian databases of Magiran and SID. Keywords were selected from MeSH and included primary health care, PHC and Iran in both Persian and English. No time limit was considered.

RESULTS

Iran's PHC system has numerous successes in dealing with health system's control knobs; which largely part of that related to the health network implementation, the role of Behvarz, improvement of health indicators in rural areas and the elimination of urban-rural inequality, but there are some weaknesses, opportunities and threats in the Iranian PHC system as well.

CONCLUSION

By considering socio-economic changes the current structure of PHC system needs to be reformed to coordinate with phenomenon of chronic diseases, accidents and aging. The current information system in PHC does not provide the required information for decision makers and policy makers so it needs to be transformed to the electronic system with unique electronic health file for individuals.

Geographic distribution indices of general practitioners, midwives, pediatricians, and gynecologists in the public sector of Iran

BACKGROUND

Health workforce distribution is so important in access posture, coverage and equity. Following millennium development goals (MDGs), special attention to health workforces in relation with maternal and child health is required.

OBJECTIVE

The aim of the current study was to determine distribution of maternal and child health related workforces in Iran during 2010-2012, using inequality measures.

METHODS

In this cross-sectional study, data about the number of physicians and midwives obtained from Ministry of Health reports and demographic statistics were obtained from the Statistical Center of Iran. Gini coefficient and Robin Hood index were calculated in terms of population ratio, need adjusted index for birth (NAIB) and need adjusted index for mortality (NAIM). For calculations, DAD software version 4.6 was used.

RESULTS

Gini coefficient was reduced for general physicians (GPs) and pediatricians, and had increasing and decreasing trends for gynecologists. For achieving equality within provinces, the number of transferable health workforces was more than 1 person per 10 health workforces.

CONCLUSION

Health workforce distribution had various trends in Iran. Special attention to deprived provinces is required. Most of the reduction in Gini coefficient is due to the increase in health workforce in developing provinces, and deprived provinces still have serious problems. The health system could achieve better equality by considering deprived provinces and using Gini coefficient and Robin Hood index together.

Assessment of HTLV-1 proviral load, LAT, BIM, c-FOS and RAD51 gene expression in adult T cell leukemia/lymphoma

Adult T cell leukemia/lymphoma (ATLL) is a life-threatening malignancy of HTLV-1 infected Th lymphocytes. In the present study host-virus interactions were investigated by assessment of HTLV-1 proviral load (PVL) and host gene expression. A cross-sectional study was carried out on 18 ATLL, 10 HAM/TSP patients and 18 HTLV-1 asymptomatic carriers (ACs). DNA and mRNA of the peripheral blood mononuclear cells were extracted for PVL and LAT, BIM, c-FOS and RAD51 gene expression measurement using qRT-PCR. The mean PVL in ATLL patients was 11,430 ± 3770 copies/10⁴ which was statistically higher than ACs, 530 ± 119 copies/10⁴, (p < 0.001). The expression of BIM, and c-FOS in ATLL patients were higher than HTLV-1 ACs; however, there were no statistically significant differences. The expression of RAD51 as an essential player on DNA repair showed around 160 times increase in ATLL group (166 ± 95) compared to ACs (1.04 ± 0.34) which is statistically significant (p < 0.001). Interestingly, there was a positive correlation between RAD51 expression and HTLV-PVL. The expression of LAT as a central adaptor in TCR signaling interestingly was around 36 times higher in ATLL group than ACs (ATLL; 41.33 ± 19.91 vs. ACs; 1.15 ± 0.22, p < 0.001). This finding showed that TCR signaling pathway mainly provides the growth factors for transformed cells. Furthermore, the overexpression of RAD51 which has been induced in HTLV-1 infected cells as a consequence of virus replication is not able to overcome the DNA damage toward cell transformation.

Geographical Disparities in the Health of Iranian Women: Health Outcomes, Behaviors, and Health-care Access Indicators

BACKGROUND

Women's health is a key factor affecting the health of the whole population. Tackling inequality in determinants of health is recognized as the main path toward reducing the inequality in health outcomes. This study aimed to analyze the provincial inequality in determinants of women's health and health care in Iran.

METHODS

Using the Moss's model (2002) as a comprehensive framework of determinants of women's health, including "geopolitical environment," "culture, norms, sanctions," "women's roles in reproduction and production," "health-related mediators," and "health outcome" categories, we chose 13 indicators. Afterward, using data sources including the Iranian Multiple Indicators of Demographics and Health Survey, the National Organization for Civil Registration, and Statistics Centre of Iran, we analyzed provincial inequality in these indicators in Iran (2011). Gini coefficient and Lorenz curve were used for measuring inequality.

RESULTS

Gini coefficients calculated as follows; life satisfaction level (0.027), literate women (0.398), women with proper knowledge about HIV/AIDS prevention (0.483), unemployed women (0.380), women without an income (0.384), women who use at least one type of mass media (0.389), women who used computer or internet (0.467), women who had received pregnancy care from a skill birth attendant (SBA) (0.420), women who had delivered with the help of an SBA (0.426), women who currently smoke cigarettes (0.603), women who currently consume hookah (0.561), women with at least one chronic disease (0.438), and women's deaths in 2010 and 2011 (0.393 and 0.359, respectively).

CONCLUSIONS

We found large provincial disparities in determinants of women's health in Iran. Determinants such as lifestyle, health behavior, health knowledge, and health-care services availability should be considered by health policymakers in addressing the inequality in women's health at a provincial level.

Assessment inequality in access to public cardiovascular health services in Iran

Background: Timely access to cardiovascular health services is necessary to prevent heart damages. The present study examined inequality in geographical distribution of cardiovascular health services in Iran. Methods: Present study is a cross-sectional study conducted using demographic data from all Iranian provinces (31 provinces) from 2012 census by the Statistics Center of Iran (SCI). The Gini coefficients of CCU beds and cardiologists were used to assess equality in access to cardiovascular health services in Iran. MS Excel software was used to calculate Gini coefficients. Results: The proportions of CCU bed and cardiologist per 100,000 population were 4.88 and 1.27, respectively; also the Gini coefficients were 0.129 and 0.045, respectively. Conclusion: Descriptive statistics showed a skewness in distribution of pubic cardiovascular health services in Iran, though Gini coefficient revealed no significant inequality. However, equal distribution of CCU beds and cardiovascular specialists does not mean they are sufficiently available in Iran.

Impact of social and clinical factors on diagnostic delay of breast cancer: A Cross-sectional Study

One of the reasons for high mortality of breast cancer is long delay in seeking medical care. This study was designed to measure the association of a wide range of socio-demographic and clinical factors with the diagnostic delay in breast cancer among Iranian patients.This study was conducted on 505 newly diagnosed patients with breast cancer from southern part of Iran. Medical files of the patients who were admitted to the hospital from November 2013 to May 2015 were examined and clinical and demographic information were extracted.According to the results, illiterate patients were diagnosed on average 87.42 days later compared with those with a college degree (95%CI: 29.68-145.16, P = 0.003) and those from rural area were diagnosed on average 72.48 days later (95%CI: 35.94-109.03, P = 0.001) compared with urban residences. Single women were diagnosed 65.99 days later (95%CI: 7.37-124.61, P = 0.02) compared with those married. Lobular or medullary types of cancer were diagnosed 65.19 days later (95%CI: 2.67-127.70, P = 0.04) compared with ductal type. On the other hand, those who were able to perform breast self-exam were diagnosed 49.07 days earlier compared with others (95%CI: 18.69-79.45, P = 0.002). Those felt lump as the initiating symptom were diagnosed 62.01 days earlier, (95%CI: 8.17-115.85, P = 0.02) compared with those with other initial symptoms. The only factor associated with doctors diagnosis delay was the place of residence as rural residences were diagnosed on average 87.42 days later compared with urban residences, (95%CI: 53.82-121.92, P = 0.001).Higher education, living in cities, ductal type of tumor, and noticing lump in breast were the most important demographic and clinical factors associated with shorter breast cancer diagnosis delay. Informing women and doctors, especially general physicians who are practicing in rural areas, of the common symptoms of breast cancer as well as training women to perform breast self-examination are effective measures in reducing breast cancer diagnosis delay. Providing accessible and effective diagnosis services to rural women reduces diagnosis delay in rural patients.

Trends of geographic inequalities in the distribution of human resources in healthcare system: the case of Iran

Introduction

Considering the scarcity of skilled workers in the health sector, the appropriate distribution of human resources in this sector is very important for improving people’s health. Having information about the degree of equality in the distribution of health human resources and their time trends is necessary for better planning and efficient use of these resources. The aim of this study was to determine the trend of inequality in the allocation of human resources in the health sector in Tehran between 2007 and 2013.

Methods

This cross-sectional study was conducted in Tehran Province in Iran. The inequality in the distribution of human resources (specialists, general practitioners, pharmacists, paramedics, dentists, nurses and community health workers (Behvarz)) in 10 cities in Tehran Province was investigated using the Gini coefficient and the dissimilarity index. The time trend of inequality was examined by regression analysis. The required data were collected from the statistical yearbook of the Iran Statistics Center (ISC).

Results

The highest value of the Gini coefficient (GC) was related to nurses (GC = 0.291) in 2007. The highest value of the Gini coefficient was related to nurses and Behvarzs in 2008 and 2009, respectively. The distribution of specialists had the highest inequality in 2010 (GC = 0.298), 2011 (GC = 0.300) and 2013 (GC = 0.316). General practitioners had the lowest Gini coefficient for 2007, 2008 and 2012. Nurses for 2009 and Behvarzs for 2010, 2011 and 2013 had the lowest value of Gini coefficient. The dissimilarity indexes for specialists and general practitioners were 26.64 and 8.72 in 2013, respectively. The means of this index for included resources were 31.35, 18.27, 16.91, 22.32, 15.82, 26.74, and 24.33, respectively. The time trend analysis showed that the coefficient of time was positive for all of the human resources, except Behvarzes, and only the coefficient of general practitioners was statistically significant ( p<0.01).

Conclusion

Over time, inequalities in the distribution of resources in the health sector have been increasing. By developing the private sector and considering the trend of this sector to operate in the more developed regions, health policy makers should continually evaluate the distribution of human resources, and they should arrange a specific plan for the allocation of human resources in the health sector.

Inequality of Paediatric Workforce Distribution in China

Child health has been addressed as a priority at both global and national levels for many decades. In China, difficulty of accessing paediatricians has been of debate for a long time, however, there is limited evidence to assess the population- and geography-related inequality of paediatric workforce distribution. This study aimed to analyse the inequality of the distributions of the paediatric workforce (including paediatricians and paediatric nurses) in China by using Lorenz curve, Gini coefficient, and Theil L index, data were obtained from the national maternal and child health human resource sampling survey conducted in 2010. In this study, we found that the paediatric workforce was the most inequitable regarding the distribution of children <7 years, the geographic distribution of the paediatric workforce highlighted very severe inequality across the nation, except the Central region. For different professional types, we found that, except the Central region, the level of inequality of paediatric nurses was higher than that of the paediatricians regarding both the demographic and geographic distributions. The inner-regional inequalities were the main sources of the paediatric workforce distribution inequality. To conclude, this study revealed the inadequate distribution of the paediatric workforce in China for the first time, substantial inequality of paediatric workforce distribution still existed across the nation in 2010, more research is still needed to explore the in-depth sources of inequality, especially the urban-rural variance and the inner- and inter-provincial differences, and to guide national and local health policy-making and resource allocation.

Experience of Behvarzes (Iranian primary healthcare providers) from giving primary health services in health houses

BACKGROUND

Primary healthcare (PHC) providers play a major role in provision of public health in rural areas in Iran. They are considered as the key elements of health development in rural population. There is limited research on clarification of their experiences from provision of health services in their working conditions. This study aimed to clarify the experience of PHC providers from working conditions in giving primary health services in health houses (district branches of rural health care centers).

MATERIALS AND METHODS

This is a content analysis qualitative study, conducted through personal and group interviews with 12 health workers working in health care centers in rural areas in Isfahan province, 2010. Sampling continued until data saturation. Data were analyzed through conventional content analysis and constant comparative method.

RESULTS

Data analysis led to extraction of 11 categories, and finally, four themes of "ignoring the rights," "causing tension in working climate," "pressure or overload of expectations beyond the power," and "occupational worn out" were yielded from the categories. These themes reveal the concepts and nature of PHC providers' experiences from giving health care at health houses as the first level of PHC centers.

CONCLUSION

The results of the present study showed that the PHC providers work in a tense condition in health houses. Although they devote themselves to the health of society members, their own health is neglected. Policy makers and authorities should amend working conditions of PHC providers through modification of resources and making supportive and collaborative strategies to improve the quality of services and promote the health level of the service receivers.

Regional Disparity in Physical Resources in the Health Sector in Iran: A Comparison of Two Time Periods

BACKGROUND

One of the major health policy issues, in the both developed and developing countries, is the equality in the distribution of health resources. The aim of this study was to investigate the disparity in the distribution of health physical resources across the provinces of Iran in 2001 and 2011.

METHODS

This was a cross-sectional retrospective study which investigated inequality in the distribution of health physical resources by three indexes of Gini Coefficient, Gaswirth index and Index of Dissimilarity. The data on provinces were obtained from the yearbook statistics and Ministry of Health, and Medical Education. The Excel software was used to calculated indexes.

RESULTS

The finding showed the mean Gini Coefficient for all variables was 0.178 in 2001 and 0.158 in 2011. Besides, the mean Gaswirth index and index of dissimilarity were 11.5 and 1.5% in 2001 and 11 and 1.4% in 2011, respectively.

CONCLUSION

There was slightly inequality in distribution of physical health resources in Iran. According to the results of three indexes, this study showed when Tehran province excluding from total sample, the inequality was decreased.

Trend in distribution of primary health care professionals in Jiangsu province of eastern China

Introduction

Since the late 1990s, the Chinese government has carried out several reforms on the primary health care, which is greatly improved but still left much to be desired, especially for the health workforces. The aim of this study was to analyze the number of health workforces and the trends in distribution of health workforces in Jiangsu province of eastern China from 2008 to 2012.

Methods

The time trends in number and distribution of health professionals were compared in study period. Lorenz curves were plotted and Gini coefficient, Atkinson index and Theil index were calculated for inequalities in the distribution of health workforces to population and area.

Results

The number of health workforces increased every year and the inequality in the distribution of health workforces showed a decline trend from 2008 to 2012. After 2009, these trends changed more rapidly. There was the disproportionality between physicians and nurses. The values of three inequality indicators based on area were larger than those based on population.

Conclusion

The health reform in 2009 might play an important role in increasing the number of health workforces and improving the distribution of health workforces in primary health care facilities. The disproportionality between physicians and nurses was related to the shortage of number of nurses.

A cross-sectional ecological study of spatial scale and geographic inequality in access to drinking-water and sanitation

Introduction

Measuring inequality in access to safe drinking-water and sanitation is proposed as a component of international monitoring following the expiry of the Millennium Development Goals. This study aims to evaluate the utility of census data in measuring geographic inequality in access to drinking-water and sanitation.

Methods

Spatially referenced census data were acquired for Colombia, South Africa, Egypt, and Uganda, whilst non-spatially referenced census data were acquired for Kenya. Four variants of the dissimilarity index were used to estimate geographic inequality in access to both services using large and small area units in each country through a cross-sectional, ecological study.

Results

Inequality was greatest for piped water in South Africa in 2001 (based on 53 areas (N) with a median population (MP) of 657,015; D = 0.5599) and lowest for access to an improved water source in Uganda in2008 (N = 56; MP = 419,399; D = 0.2801). For sanitation, inequality was greatest for those lacking any facility in Kenya in 2009 (N = 158; MP = 216,992; D = 0.6981), and lowest for access to an improved facility in Uganda in 2002 (N = 56; MP = 341,954; D = 0.3403). Although dissimilarity index values were greater for smaller areal units, when study countries were ranked in terms of inequality, these ranks remained unaffected by the choice of large or small areal units. International comparability was limited due to definitional and temporal differences between censuses.

Conclusions

This five-country study suggests that patterns of inequality for broad regional units do often reflect inequality in service access at a more local scale. This implies household surveys designed to estimate province-level service coverage can provide valuable insights into geographic inequality at lower levels. In comparison with household surveys, censuses facilitate inequality assessment at different spatial scales, but pose challenges in harmonising water and sanitation typologies across countries.

Overall, gender and social inequalities in suicide mortality in Iran, 2006-2010: a time trend province-level study

OBJECTIVES

Suicide is a major global health problem imposing a considerable burden on populations in terms of disability-adjusted life years. There has been an increasing trend in fatal and attempted suicide in Iran over the past few decades. The aim of the current study was to assess overall, gender and social inequalities across Iran's provinces during 2006-2010.

DESIGN

Ecological study.

SETTING

The data on distribution of population at the provinces were obtained from the Statistical Centre of Iran. The data on the annual number of deaths caused by suicide in each province were gathered from the Iranian Forensic Medicine Organization.

METHODS

Suicide mortality rate per 100,000 population was calculated. Human Development Index was used as the provinces' social rank. Gini coefficient, rate ratio and Kunst and Mackenbach relative index of inequality were used to assess overall, gender and social inequalities, respectively. Annual percentage change was calculated using Joinpoint regression.

RESULTS

Suicide mortality has slightly increased in Iran during 2006-2010. There was a substantial and constant overall inequality across the country over the study period. Male-to-female rate ratio was 2.34 (95% CI 1.45 to 3.79) over the same period. There were social inequalities in suicide mortality in favour of people in better-off provinces. In addition, there was an increasing trend in these social disparities over time, although it was not statistically significant.

CONCLUSIONS

We found substantial overall, gender and social disparities in the distribution of suicide mortality across the provinces in Iran. The findings showed that men in the provinces with low socioeconomic status are at higher risk of suicide mortality. Further analyses are needed to explain these disparities.

Assessment the trend of inequality in the distribution of intensive care beds in Iran: using GINI index

Background and Aim:

While most of the published researches have reported the amount of inequity in geographical distribution of important health resources, only a small number of studies have focused on the trend of inequality in the distribution of these resources.

The purpose of this study was to determine the trend of inequality in the distribution of intensive care beds in Iran during 2010 to 2012 by using the Gini coefficient.

Methods:

This is a cross-sectional research conducted in 2013. The changes over three years (2010 to 2012) were calculated by Gini coefficient to investigate the trend of inequality in geographical distribution of intensive care beds (CCU, ICU and NICU).

Results:

The Gini coefficient for CCU beds was calculated as 0.02, 0.04 and 0.06 in 2010, 2011 and 2012, respectively. The Gini coefficient for ICU beds was calculated as 0.03, 0.05 and 0.05 in 2010, 2011 and 2012, respectively. Also, the Gini coefficient for NICU bed was calculated as 0.02, 0.03 and 0.04 in 2010, 2011 and 2012, respectively.

Conclusion:

Regarding to Gini coefficient, the trend of inequality was increased in the distribution of intensive care beds in Iran. Particularly, the inequalities in distribution of CCU beds were significantly increased during past years. In fact, if this trend of inequality continues, the distribution of intensive care beds will be extremely unequal in the next five years in Iran.

Factors associated with health service utilization in Ulaanbaatar, Mongolia: a population-based survey

BACKGROUND

Understanding patterns of health service utilization can improve health care and increase use of health services. We examined patterns of health service utilization among residents of Ulaanbaatar, Mongolia.

METHODS

A total of 500 adults were surveyed using paper-based questionnaires. The χ(2) test and multiple logistic regression were used to identify associations between factors.

RESULTS

44.1% of respondents had visited a physician during the previous 12 months. After controlling for determinants, the significant predictors of utilization of health service were attention to health examinations (OR = 3.6, CI: 1.93-6.76), being married (OR = 2.7, CI: 1.50-4.72), being satisfied with the overall cleanliness of the hospital (OR = 2.4, CI: 1.12-5.19), being a nonsmoker (OR = 2.2, CI: 1.21-3.98), having periodic physical examinations (OR = 2.2, CI: 1.25-3.71), not being a hospital patient during the previous 3 years (OR = 2.1, CI: 1.22-3.73), having proper documentation (OR = 1.9, CI: 1.10-3.43), having medical insurance (OR = 1.9, CI: 1.96-3.28), not wanting to receive information on food and nutrition (OR = 0.6, CI: 0.36-0.96), having more than 5 household members (OR = 0.5, CI: 0.50-0.85), low income (OR = 0.5, CI: 0.30-0.85), lack of concern for food and nutrition (OR = 0.5, CI: 0.28-0.84), self-medication during the past 12 months (OR = 0.4, CI: 0.24-0.69), and desire for treatment abroad (OR = 0.4, CI: 0.20-0.60).

CONCLUSIONS

A number of health-related behaviors and sociodemographic factors were important predictors of health service utilization.

Pure and social disparities in distribution of dentists: a cross-sectional province-based study in Iran

During past decades, the number of dentists has continuously increased in Iran. Beside the quantity, the distribution of dentists affects the oral health status of population. The current study aimed to assess the pure and social disparities in distribution of dentists across the provinces in Iran in 2009. Data on provinces’ characteristics, including population and social situation, were obtained from multiple sources. The disparity measures (including Gini coefficient, index of dissimilarity, Gaswirth index of disparity and relative index of inequality (RII)) and pairwise correlations were used to evaluate the pure and social disparities in the number of dentists in Iran. On average, there were 28 dentists per 100,000 population in the country. There were substantial pure disparities in the distribution of dentists across the provinces in Iran. The unadjusted and adjusted RII values were 3.82 and 2.13, respectively; indicating area social disparity in favor of people in better-off provinces. There were strong positive correlations between density of dentists and better social rank. It is suggested that the results of this study should be considered in conducting plans for redistribution of dentists in the country. In addition, further analyses are needed to explain these disparities.