عنوان

تحلیل نابرابری و چندسطحی بهره‌مندی از خدمات سرپایی سلامت در خانوارهای ساکن در شهر تهران در سال 1398-1397

Text of Note

Background:Health service utilization is a significant health and political issue and one of the indispensable indicators in evaluation of the efficacy of the health care system, especially in developing countries (1, 2). Factors helping people have health service utilization are numerous and complex. Awareness of these factors and the status of out-patient health service utilization can help health professionals improve their status. The aim of this study was to investigate the status of out-patient health service utilization and associated factors, inequality and multi-level analysis of out-patient health service utilization in households residing in Tehran. Methods:The present descriptive-analytical study was cross-sectional including 1200 households from different regions of Tehran, which were selected by multi-stage cluster sampling method in accordance with the zoning of Tehran concerning development. Interviews were asked by trained individuals using health service utilization questionnaire introduced by World Health Organization, Zimet’s social support questionnaire, and demographic checklist in winter and spring 2019. Feeling the need in the last 30 days in one of the family members to refer to the service provider and receive health service was considered as a consequence of variable of outpatient health service utilization. Simple and multiple logistic regressions were applied to analyze the data. In order to include the factors related to the status of outpatient health service utilization, first two-variable analyzes were conducted and then the factors with a significant value of 0.2 and less were included in the multiple model. The inequality distribution in the regions of Tehran was calculated with three relative inequality indices: 1) Standard Concentration Index (SCI), 2) Wagstaff Index (WI), and 3) Erreygers Index (EI). The status of each index was tested with zero number. A p-value less than or equal to 0.05 was considered as a significant level. Multilevel analysis was used to assess the variables of neighborhood and region level on the use of outpatient services for household health. Data were analyzed using STATA software. Results: The present study was conducted in four phases. In the systematic review phase, 37 final studies were identified: Predisposing factors (gender, age, marital status, ethnicity), Enabling factors (education, employment status, income level, insurance status, urban or rural, Household size, health literacy, social support), need-related factors (perceived need, disability, illness) and contextual factors (distance to service center, time required to receive health services, density of health service centers) were the factors related to the outpatient health service utilization. The findings of the study in the second phase indicated that the rate of outpatient health service utilization among households in Tehran was 63.61%. In addition, regarding the results of the study, asset index of family (OR = 0.51, 95% CI: 0.28-0.91), the level of awareness and knowledge of family members (OR = 0.55, 95% CI: 0.34-0.88) and the mother (OR = 0.64 , 95% CI: 0.45-0.93) on health issues, the level of social support (OR = 0.50, 95% CI: 0.37-0.68), family health expenditure (OR = 1.2, 95% CI: 1.18-4.06), having a member with disability in family (OR = 1.66, 95% CI: 1.01-2.77) and alcoholic family member (OR = 2.44, 95% CI: 1.27-4.68) were factors associated with outpatient HSU among households. Considering the adjusted values of the chance ratios, the rate of health service utilization varied according to the area of residence. It should be noted that the variables included in the model explained 15% of the changes in the rate of health service utilization.The results of the study in the third phase, by analyzing inequality indicators by development zones, indicated that there was a significant inequality (p <0.05) in two high and very high zones and there wasn't any significant inequality in the other three zones (p <0.05). Given the positive indicators of inequality, it was found that the out-patient health services utilization was more concentrated in rich households (inequality pro- rich). The results of Multilevel analysis in the fourth phase of the study indicate that due to the adjusted values of odds ratios, the rate of out-patient health services utilization varied according to the region of residence. It should be noted that the variables included in the model explained 15% of the changes of out-patient health services utilization. In addition, the results of two-level analysis at the household-region level showed that the 11.7% of the explained variance was at the region level and the rest at the household level. Also, the results of two-level analysis at the household-neighborhood level showed that 8.12% of the explained variance was at the neighborhood level and the rest was at the household level.Conclusion: According to the results of the study and in order to increase outpatient health service utilization in different classes, interventions related to increase the awareness and information of family members about health issues, increasing the level of social support at low income levels. Also, policies and strategies should be adopted to improve health service utilization in families with a disabled person, as well as interventions to change lifestyle and nutrition and health behaviors and reduction of alcohol consumption are recommended. Given that the increasing in the number of pharmacies and health centers that providing care services is associated with more outpatient health service utilization, at the policy level, the responsible organizations are advised to be careful in the distribution of these centers.Keywords: Outpatient Health Service Utilization, Inequality in Outpatient Health Service Utilization, Multi-level Analysis, Households, Tehran