Journal of Preventive Medicine and Public Health

Original Articles

From Rich to Poor: A Decomposition Analysis of Socioeconomic Inequality in Health-related Quality of Life in Iran: Satar Rezaei; J Prev Med Public Health. 2025;58(5):538-547. Published online August 20, 2025; DOI: https://doi.org/10.3961/jpmph.25.383

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Abstract Summary PDF Supplementary Material: Objectives
Socioeconomic status (SES) is a well-established predictor of health outcomes across an individual’s lifespan. People from lower socioeconomic backgrounds generally have shorter life expectancies and lower levels of health-related quality of life (HRQoL) compared with those from higher-income groups. This study aimed to quantify income-related inequalities in HRQoL among adults in Iran.
Methods
A total of 3518 adults aged 18 years and older were selected using a convenience sampling method across 9 provinces in Iran. HRQoL was assessed with the EuroQoL 5-Dimension 5-Level (EQ-5D-5L) instrument, which evaluates 5 dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. The concentration index (CI) approach was used to measure income-related inequality in worse HRQoL (disutility=1–utility value) and to identify the socioeconomic factors contributing to the observed inequality.
Results
The CI for worse HRQoL was -0.116, while the CI for the EuroQol visual analogue scale (EQ-VAS) score was 0.027. The CIs for reporting any problems in the EQ-5D-5L dimensions were: mobility (-0.122), self-care (-0.070), usual activities (-0.074), pain/discomfort (-0.139), and anxiety/depression (-0.139). Decomposition analysis showed that income (38.00%), educational level (31.53%), age (8.05%), and physical activity (7.30%) were the main factors contributing to socioeconomic inequality in poorer HRQoL in Iran.
Conclusions
This study identified a pro-poor distribution of poorer HRQoL and reported problems across all dimensions of the EQ-5D-5L in Iran. Targeted interventions should focus on reducing disparities in income, education, and physical activity levels.; Summary

Key Message
The study of 3518 adults across 9 Iranian provinces revealed significant pro-poor socioeconomic inequality in health-related quality of life (HRQoL), with worse HRQoL concentrated among lower-income groups (concentration index: -0.116). Income (38%) and education level (31.53%) were the largest contributors to this inequality, followed by age (8.05%) and physical activity (7.30%) based on decomposition analysis. All five EQ-5D-5L health dimensions showed more reported problems in lower socioeconomic groups, emphasizing the need for targeted interventions addressing income, education, and lifestyle factors to reduce HRQoL disparities in Iran.

Household Overcrowding in Iran, a Low-middle-income Country: How Major of a Public Health Concern Is It?: Leila Jansar Hosseini, Ali Hussein Samadi, Abraha Woldemichael, Masoumeh Najaf Gharebelagh, Satar Rezaei, Enayatollah Homaie Rad; J Prev Med Public Health. 2021;54(1):73-80. Published online January 11, 2021; DOI: https://doi.org/10.3961/jpmph.20.568

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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.

Summary

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Measuring and decomposing socioeconomic inequality in catastrophic healthcare expenditures in Iran: Satar Rezaei, Mohammad Hajizadeh; J Prev Med Public Health. 2019;52(4):214-223. Published online June 14, 2019; DOI: https://doi.org/10.3961/jpmph.19.046

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Abstract PDF

Objectives
Equity in financial protection against healthcare expenditures is one the primary functions of health systems worldwide. This study aimed to quantify socioeconomic inequality in facing catastrophic healthcare expenditures (CHE) and to identify the main factors contributing to socioeconomic inequality in CHE in Iran.
Methods
A total of 37 860 households were drawn from the Households Income and Expenditure Survey, conducted by the Statistical Center of Iran in 2017. The prevalence of CHE was measured using a cut-off of spending at least 40% of the capacity to pay on healthcare services. The concentration curve and concentration index (C) were used to illustrate and measure the extent of socioeconomic inequality in CHE among Iranian households. The C was decomposed to identify the main factors explaining the observed socioeconomic inequality in CHE in Iran.
Results
The prevalence of CHE among Iranian households in 2017 was 5.26% (95% confidence interval [CI], 5.04 to 5.49). The value of C was -0.17 (95% CI, -0.19 to -0.13), suggesting that CHE was mainly concentrated among socioeconomically disadvantaged households in Iran. The decomposition analysis highlighted the household wealth index as explaining 71.7% of the concentration of CHE among the poor in Iran.
Conclusions
This study revealed that CHE is disproportionately concentrated among poor households in Iran. Health policies to reduce socioeconomic inequality in facing CHE in Iran should focus on socioeconomically disadvantaged households.

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Measuring and Decomposing Socioeconomic Inequalities in Adult Obesity in Western Iran: Farid Najafi, Yahya Pasdar, Behrooz Hamzeh, Satar Rezaei, Mehdi Moradi Nazar, Moslem Soofi; J Prev Med Public Health. 2018;51(6):289-297. Published online October 29, 2018; DOI: https://doi.org/10.3961/jpmph.18.062

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Abstract PDF

Objectives
Obesity is a considerable and growing public health concern worldwide. The present study aimed to quantify socioeconomic inequalities in adult obesity in western Iran.
Methods
A total of 10 086 participants, aged 35-65 years, from the Ravansar Non-communicable Disease Cohort Study (2014-2016) were included in the study to examine socioeconomic inequalities in obesity. We defined obesity as a body mass index ≥30 kg/m2 . The concentration index and concentration curve were used to illustrate and measure wealth-related inequality in obesity. Additionally, we decomposed the concentration index to identify factors that explained wealth-related inequality in obesity.
Results
Overall, the prevalence of obesity in the total sample was 26.7%. The concentration index of obesity was 0.04; indicating that obesity was more concentrated among the rich (p<0.001). Decomposition analysis indicated that wealth, place of residence, and marital status were the main contributors to the observed inequality in obesity.
Conclusions
Socioeconomic-related inequalities in obesity among adults warrant more attention. Policies should be designed to reduce both the prevalence of obesity and inequalities in obesity by focusing on those with higher socioeconomic status, urban residents, and married individuals.

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What Explains Socioeconomic Inequality in Health-related Quality of Life in Iran? A Blinder-Oaxaca Decomposition: Satar Rezaei, Mohammad Hajizadeh, Yahya Salimi, Ghobad Moradi, Bijan Nouri; J Prev Med Public Health. 2018;51(5):219-226. Published online August 7, 2018; DOI: https://doi.org/10.3961/jpmph.18.012

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Abstract PDF

Objectives
This study aimed to explain the health-related quality of life (HRQoL) gap between the poorest and the wealthiest quintiles in the capitals of Kermanshah and Kurdistan Provinces (Kermanshah and Sanandaj), in western Iran.
Methods
This was a cross-sectional study conducted among 1772 adults. Data on socio-demographic characteristics, socioeconomic status (SES), lifestyle factors, body mass index, and HRQoL of participants were collected using a self-administered questionnaire. The slope and relative indices of inequality (SII and RII, respectively) were employed to examine socioeconomic inequality in poor HRQoL. Blinder-Oaxaca (BO) decomposition was used to quantify the contribution of explanatory variables to the gap in the prevalence of poor HRQoL between the wealthiest and the poorest groups.
Results
The overall crude and age-adjusted prevalence of poor HRQoL among adults was 32.0 and 41.8%, respectively. The SII and RII indicated that poor HRQoL was mainly concentrated among individuals with lower SES. The absolute difference (%) in the prevalence of poor HRQoL between the highest and lowest SES groups was 28.4. The BO results indicated that 49.9% of the difference was explained by different distributions of age, smoking behavior, physical inactivity, chronic health conditions, and obesity between the highest and lowest SES groups, while the remaining half of the gap was explained by the response effect.
Conclusions
We observed a pro-rich distribution of poor HRQoL among adults in the capitals of Kermanshah and Kurdistan Provinces. Policies and strategies aimed at preventing and reducing smoking, physical inactivity, chronic health conditions, and obesity among the poor may reduce the gap in poor HRQoL between the highest and lowest SES groups in Iran.

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From Rich to Poor: A Decomposition Analysis of Socioeconomic Inequality in Health-related Quality of Life in Iran
Satar Rezaei
Journal of Preventive Medicine and Public Health.2025; 58(5): 538. CrossRef
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Chris Mweemba, Wilbroad Mutale, Felix Masiye, Peter Hangoma
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Effects of Iranian Economic Reforms on Equity in Social and Healthcare Financing: A Segmented Regression Analysis: Hamed Zandian, Amirhossein Takian, Arash Rashidian, Mohsen Bayati, Telma Zahirian Moghadam, Satar Rezaei, Alireza Olyaeemanesh; J Prev Med Public Health. 2018;51(2):83-91. Published online February 6, 2018; DOI: https://doi.org/10.3961/jpmph.17.050

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Objectives
One of the main objectives of the Targeted Subsidies Law (TSL) in Iran was to improve equity in healthcare financing. This study aimed at measuring the effects of the TSL, which was implemented in Iran in 2010, on equity in healthcare financing. Methods: Segmented regression analysis was applied to assess the effects of TSL implementation on the Gini and Kakwani indices of outcome variables in Iranian households. Data for the years 1977-2014 were retrieved from formal databases. Changes in the levels and trends of the outcome variables before and after TSL implementation were assessed using Stata version 13. Results: In the 33 years before the implementation of the TSL, the Gini index decreased from 0.401 to 0.381. The Gini index and its intercept significantly decreased to 0.362 (p<0.001) 5 years after the implementation of the TSL. There was no statistically significant change in the gross domestic product or inflation rate after TSL implementation. The Kakwani index significantly increased from -0.020 to 0.007 (p<0.001) before the implementation of the TSL, while we observed no statistically significant change (p=0.81) in the Kakwani index after TSL implementation. Conclusions: The TSL reform, which was introduced as part of an economic development plan in Iran in 2010, led to a significant reduction in households’ income inequality. However, the TSL did not significantly affect equity in healthcare financing. Hence, while measuring the long-term impact of TSL is paramount, healthcare decision-makers need to consider the efficacy of the TSL in order to develop plans for achieving the desired equity in healthcare financing.

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Equity in healthcare financing: a case of Iran
Faride Sadat Jalali, Abdosaleh Jafari, Mohsen Bayati, Peivand Bastani, Ramin Ravangard
International Journal for Equity in Health.2019;[Epub] CrossRef

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