Understanding determinants of socioeconomic inequality in mental health in Iran's capital, Tehran: a concentration index decomposition approach

Morasae Esmaeil, Forouzan Ameneh, Majdzadeh Reza, Asadi-Lari Mohsen, Noorbala Ahmad, Hosseinpoor, Hosseinpoor Ahmad

Description

Mental health is of special importance regarding socioeconomic inequalities in health. On the one hand, mental health status mediates the relationship between economic inequality and health; on the other hand, mental health as an "end state" is affected by social factors and socioeconomic inequality. In spite of this, in examining socioeconomic inequalities in health, mental health has attracted less attention than physical health. As a first attempt in Iran, the objectives of this paper were to measure socioeconomic inequality in mental health, and then to untangle and quantify the contributions of potential determinants of mental health to the measured socioeconomic inequality. Methods In a cross-sectional observational study, mental health data were taken from an Urban Health Equity Assessment and Response Tool (Urban HEART) survey, conducted on 22 300 Tehran households in 2007 and covering people aged 15 and above. Principal component analysis was used to measure the economic status of households. As a measure of socioeconomic inequality, a concentration index of mental health was applied and decomposed into its determinants. Results The overall concentration index of mental health in Tehran was -0.0673 (95% CI = -0.070 - -0.057). Decomposition of the concentration index revealed that economic status made the largest contribution (44.7%) to socioeconomic inequality in mental health. Educational status (13.4%), age group (13.1%), district of residence (12.5%) and employment status (6.5%) also proved further important contributors to the inequality. Conclusions Socioeconomic inequalities exist in mental health status in Iran's capital, Tehran. Since the root of this avoidable inequality is in sectors outside the health system, a holistic mental health policy approach which includes social and economic determinants should be adopted to redress the inequitable distribution of mental health.

Sujets

• Mental health
• Décomposition
• Tehran

Informations

• Publié par: biomed
• Publié le: 01 janvier 2012
• Nombre de lectures: 9
• Langue: EnglishEnglish

Extrait

Morasae et al. International Journal for Equity in Health 2012, 11:18
http://www.equityhealthj.com/content/11/1/18
RESEARCH Open Access
Understanding determinants of socioeconomic
inequality in mental health in Iran’s capital, Tehran:
a concentration index decomposition approach
1 2* 3 4Esmaeil Khedmati Morasae , Ameneh Setareh Forouzan , Reza Majdzadeh , Mohsen Asadi-Lari ,
5 6Ahmad Ali Noorbala and Ahmad Reza Hosseinpoor
Abstract
Background: Mental health is of special importance regarding socioeconomic inequalities in health. On the one
hand, mental health status mediates the relationship between economic inequality and health; on the other hand,
mental health as an “end state” is affected by social factors and socioeconomic inequality. In spite of this, in
examining socioeconomic inequalities in health, mental health has attracted less attention than physical health. As
a first attempt in Iran, the objectives of this paper were to measure socioeconomic inequality in mental health, and
then to untangle and quantify the contributions of potential determinants of mental health to the measured
socioeconomic inequality.
Methods: In a cross-sectional observational study, mental health data were taken from an Urban Health Equity
Assessment and Response Tool (Urban HEART) survey, conducted on 22 300 Tehran households in 2007 and
covering people aged 15 and above. Principal component analysis was used to measure the economic status of
households. As a measure of socioeconomic inequality, a concentration index of mental health was applied and
decomposed into its determinants.
Results: The overall concentration index of mental health in Tehran was -0.0673 (95% CI = -0.070 - -0.057).
Decomposition of the concentration index revealed that economic status made the largest contribution (44.7%) to
socioeconomic inequality in mental health. Educational status (13.4%), age group (13.1%), district of residence
(12.5%) and employment status (6.5%) also proved further important contributors to the inequality.
Conclusions: Socioeconomic inequalities exist in mental health status in Iran’s capital, Tehran. Since the root of
this avoidable inequality is in sectors outside the health system, a holistic mental health policy approach which
includes social and economic determinants should be adopted to redress the inequitable distribution of mental
health.
Keywords: Mental health, Socioeconomic inequality, Concentration index, Decomposition, Tehran
Background health is unequally distributed in our societies, meaning
Mental health is an integral and essential component of that people who live in a socially and economically
dishealth; undeniably, there can be no health without men- advantaged situation suffer from a disproportionate
burden of mental disorders and subsequent adversetal health [1,2]. Mental health influences a large range
of qualities for individuals and communities, including consequences [2,3].
higher quality of life, better physical health, productivity, The etiology of mental disorders is multifactorial; risk
social cohesion, and wellbeing [1]. However, mental is determined by a combination and interaction of
biological, psychological, and social determinants [2]. Social
determinants have been shown to account for a
remark* Correspondence: [e-mail]
2 ably large part of the prevalence and unequal distributionCenter for Research on Social Determinants of Health, University of Social
Welfare and Rehabilitation Sciences, Tehran, Iran of mental disorders within and among countries [2].
Full list of author information is available at the end of the article
© 2012 Morasae et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.Morasae et al. International Journal for Equity in Health 2012, 11:18 Page 2 of 13
http://www.equityhealthj.com/content/11/1/18
In fact, a number of studies have found convincing evi- However, in order to provide the necessary evidence,
dence implicating socioeconomic position, gender Iran has recently taken a great leap to assess the social
inequality, education, income inequality, racial and ethni- determinants of health in its megacities by applying the
cal discrimination, and other social factors as determi- Urban Health Equity Assessment and Response Tool
nants of mental disorders [2-4]. However, evidence from (Urban HEART), a survey piloted and conducted in
low- and middle-income countries has been scarce in Iran’s capital, Tehran [11]. Fortunately, mental health
has been a significant part of Tehran’sUrbanHEART,this respect and there is a need for more contextual
in which mental health social determinants-related dataresearch to enrich the current knowledge and policy
peris collected. From this, an unprecedented opportunity istaining to socioeconomic inequalities in mental health
[2]. being provided to assess mental health inequalities in
The Islamic republic of Iran is a developing, middle- Iran.
income country in the Middle East, where mental health There are different measures for assessing health
has always had a specific place in the health agenda inequalities, and one common measure is the
Concen[4,5]. Since the late 1980s, Iran has sought full integra- tration Index (CI) [12-14]. This measure can be
decomtion of mental health into its Primary Health Care posed into its determinants so that the contribution of
(PHC) [5,6]. This integration has helped bring about these determinants to the inequality could be untangled
great improvements in the accessibility of affordable and and quantified [14-18].
acceptable mental health care on a national scale and is Thus, using Tehran’s Urban HEART data on mental
currently one of the most successful models in the health and the CI method, the present study, for the
world [6]. However, owing to lack of strong PHC in first time, aimed to measure socioeconomic mental
urban areas, the integration has been much more lim- health inequality in Iran and then decompose the
meaited in urban areas compared with rural areas [6,7]. Pro- sured inequality into its determinants. Through such
gram coverage was reported to be 21.7% in urban areas analysis and revealing the contribution of each
determiand 82.8% in rural areas in 2004 [6]. nant to mental health inequality, we hope to more
speMoreover, mental disorders have been among the top cifically identify interventional policies and also
disabling disorders in Iran; next to unintentional acci- vulnerable target groups in order to reduce this
dents, they rank second in the list of burden of diseases inequality.
in the country [8]. Recent studies have shown that
increasingly more Iranian people are suffering from Methods
mental disorders; according to a national survey in Data
2001, the prevalence of mental disorders was estimated ThedataforthisstudyweretakenfromtheUrban
to be around 22% and was worse among women [9]. Health Equity Assessment and Response Tool (Urban
In terms of inequalities in mental health, limited infor- HEART) survey, conducted in Tehran in 2007, covering
mative and beneficial data is available in Iran, as with people aged 15 and above. The sampling design was
stramost other developing countries. To be specific, some tified multistage cluster sampling and, to avoid internal
descriptive studies have revealed that some groups like cluster correlations, stratified two-dimensional systematic
women, the elderly, unemployed, divorced, widowed, sampling was used [11]. First, Tehran’s22districtswere
and people of lower education status had higher rates of defined as strata. Then, applying cluster sampling, 120
mental disorders in Iran [9]; however, the magnitude of blocks were chosen from each stratum. In each block,
these inequalities in mental health have not been inves- eight households were selected by systematic sampling,
tigated in detail thus far. Therefore, Iran’s mental health meaning that 960 households were chosen from each
system lacks such useful evidence. However, this matter stratum. The original sample comprised 25,485 people.
has had its implications for Iranian mental health care The response rate in Urban HEART was approximately
and mental health equity has been mostly absent from 87%. Therefore, data from 22,135 people from the
origiany proposed health agendas. nal sample were entered into the analyses. Interviewers
Appropriate evidence on health distribution and level gathered information on two persons from each
houseis vital for understanding the scale of the problem, hold: the head of the household for economic status and
assessing the effects of action and monitoring progress a chosen member for mental health data. A
self-adminis[10]. Consequently, it is essential to have a clear picture tered 28-item General Health Questionnaire (GHQ-28)
of the mental health inequalities and their determinants was used as a screening tool for detection of possible
in place and introduce mechanisms to ensure that the cases of mental disorders [19]. The validity and reliability
data is understood and applied to develop more effective of this questionnaire has been confirmed for Iranians
policies, systems, and programs. [20]. The best cut-off point, determined by the Likert