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Survey on the indexes of health equity in the physical environment and infrastructures of Kermanshah province, Iran

Survey on the indexes of health equity in the physical environment and infrastructures of... Background: Health equity is directly associated with the proper distribution of resources, the existence of infrastructures, and the balanced physical environment. The present study aimed to survey the indexes of health equity in the physical environment and infrastructures of Kermanshah province based on the national indexes. Results: The results revealed that access to transportation, health centers, solid waste management, and green and sports per capita had the least distance from the negative ideal whereas the noise pollution index had the greatest distance. However, house hygiene and air pollution indexes were within the negative and positive ideal ranges. Conclusions: The health equity indexes were not distributed equitably across counties and geographical regions of Kermanshah province. Keywords: Health equity, Environment, Index, Geographic Information Systems 1 Introduction this regard to face the complex and major challenges. In Nowadays, governments by providing health services response to these concerns, the Commission for Social De- and adequate and timely care as well as equitable distri- terminants of Health was established in the World Health bution of services can affect the community’s well-being Organization (WHO), through which some recommenda- and health. It should be noted that providing the best tions were presented to develop and monitor rights to good healthcare alone is not sufficient [1]. Some experts health at local, national, and international levels [3]. define health equity as “lack of systematic differences in Recently, to assess gap in the health status of urban health means creating equal opportunities for health and population and its determinants, a tool called “respon- reducing health differences to the lowest possible level” siveness and justice measurement in urban health” has [2]. Health equity implies that all segments of the society been developed by the Health Development Center of should ideally have a fair chance of benefiting from the WHO which is used in Kobe, Japan [4, 5]. After design- services and financing to achieve their potential full ing this tool, the Tehran municipality announced to the health. Establishing health equity relates with health WHO Regional Office for the Eastern Mediterranean determinants and has special complexity due to numerous (EMRO) its readness to investigate and measure health dimensions and effects, causing officials and managers in equity as a pilot study in Tehran in 2007. The outcome of the efforts of this working group incorporated the proposal * Correspondence: SaediShahram@yahoo.com of six areas instead of four areas within Iran, including infra- Social Development & Health Promotion Research Center, Health Institute, structure and physical environment, human and social Kermanshah University of Medical Sciences, Kermanshah, Iran Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 2 of 10 development, economic development, governance, nutrition, province, western Iran, and its statistical population was and health [6]. all of 14 counties including Kermanshah, Eslamabad-e One of the levels for national and regional planning is Gharb, Paveh, Harsin, Kangavar, Sonqor, Javanrud, awareness of the capabilities of different provinces and Ravansar, Gilan-e Gharb, Sahneh, Qasr-e Shirin, and their counties. Moreover, evidence has shown that Sarpol-e Zahab, Dalahu, and Salas-e Babajani. Geographic Information System (GIS) has always been Data was collected about eight indexes related to the one of the most useful tools in this respect [7]. assessment of equity in the area of physical environment The destruction of the infrastructures of Kermanshah and infrastructures, codified by the Ministry of Health province because of the 8-year war between Iran and and Medical Sciences [6] and based on the study Iraq caused this province to fall behind development conducted in Kobe, Japan [5]. These indexes were as compared to other provinces. This issue led to the back- follows: wardness of this province and many other detrimental consequences including the settlement of a large part of 1) The data on house hygiene (the percentage of war veterans of the province in the capital city of households with waste disposal systems, sanitary Kermanshah and its excessive population growth. The toilets, and access to public drinking water main impact of this trend was the interruption and failure network) were collected through the statistics in the system of service distribution, and subsequently led provided by health center of Kermanshah. to the failure of citizens’ adequate access to such services 2) The data on air pollution (dust) including the [8]. On the other hand, Kermanshah is also faced with percentage of clean days in the year were collected other problems such as poverty, high general fertility in from the meteorological organization of some regions, AIDS, cancer [9], and economic loss in the Kermanshah. areas of animal husbandry, agriculture, farming, and gar- 3) The data on noise pollution by industries were dening due to air pollution (dust phenomenon). collected from the Industry, Mine and Trade Air pollution occurs in Kermanshah like other big Organization of Kermanshah province. cities, which ends to 500 as hazardous air quality that 4) The data on access to public transportation was necessitates avoidance of outdoor activities. The Air collected from the municipalities of counties. Quality Index (AQI) is an important tool to assess air 5) The data on access to health centers (including quality and evaluate its effects on health. AQI is deter- primary health care). mined by six major pollutants as important criteria: 6) The data on solid waste management (the status of ozone (O ), sulfur dioxides (SO ), inhalable particles waste management in urban areas, hospitals, and 3 2 (PM ), fine particulate matter (PM ), nitrogen dioxides villages) was collected from the Health Network in 10 2.5 (NO ), and carbon monoxide (CO) [10]. The AQI scale each county. is in the range of 0 to 500 to qualify the overall quality 7) The data on green space per capita in the province of the air into six levels in different colors (good in were collected from the municipalities of counties. green, moderate in yellow, lightly polluted in orange, 8) The data on sports per capita were collected from moderately polluted in red, heavily polluted in purple, the Sport Department of Kermanshah province. and severely polluted in maroon). These levels indicate air pollution overall effects on human health and decent 2.2 Data collection reference for people’s outdoor activities in a numerical The required information was collected through docu- pattern. A low number means good air quality, while an mentary methods from the related departments in increasing number means worsening air quality, for ex- Kermanshah province. Additionally, the demographic ample values over 300 represent hazardous air quality data of each county were collected through the statistical which is the health warning of emergency condition and blocks of the Official Statistics Center of Iran. Moreover, everyone is more likely to be affected [11]. The present the latest population statistics (the demographic data of study aimed to survey the indexes of health equity in the 2016) published by the Statistical Centre of Iran were physical environment and infrastructures of Kermanshah used as the basis of the study. province based on the national indexes. 2.3 Data analysis 2 Methods In the first step, data about the studied eight indexes 2.1 Design and setting were collected. Then, the Technique for Order of Prefer- This cross-sectional study was performed using quanti- ence by Similarity to Ideal Solution (TOPSIS) that is a tative models, based on the national indexes codified by multi-criteria decision analysis method was used. This the Ministry of Health and Medical Education of Iran in technique, as one of the best multi-criteria decision- 2016. The geographic area of this study was Kermanshah making models which are used extensively, was first Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 3 of 10 proposed by Hawang and Yoon in 1981 [12]. In this The results of solid waste management in urban areas method, m alternatives are evaluated by n criteria. This showed that seven cities had provided more than 90% of technique is based on the notion that the selected alterna- the proper waste management. Table 1 and Fig. 1b tive should have the furthest distance from the negative showed that Salas-e Babajani and Kermanshah counties ideal solution. It is assumed that the utility of each index had the lowest and highest levels of urban proper waste is uniformly increasing or decreasing. Problem-solving management (85% and 95%, respectively). In the rural using TOPSIS includes the following steps: waste management index, only in Paveh County, more than 80% of proper waste management was provided, 1) Formation of data matrixes based on an alternative and in other cities, it was less than 70% (86% and 51% in (counties) and m indexes (the applied indexes in Paveh and Ravansar, respectively). All counties had the research), proper waste management in hospitals and inpatient 2) Creating the normalized decision matrix. treatment centers. 3) Establishing the weighted normalized matrix (V): According to Table 2 and Fig. 1c, Paveh and Sarpol-e the normalized matrix (N) is multiplied by the Zahab had the most and the fewest percentage of clean diagonal matrix of weights (Wn). days, an indicator of lacking air pollution (97.53% vs. 4) Determining the ideal positive solutions 91.2%, respectively). (determination of the maximum value for each of The results showed that access to health centers was the weighted standardized indicators) and negative more than 80% in only one county and less than 60% in solutions (determination of the minimum value for other cities. Figure 1d shows that Kermanshah (80.93%) each of the weighted standardized indicators). and Ravansar (5.36%) counties had the highest and least 5) Calculating the distance of each alternative from access to health centers, respectively. Moreover, Ravan- the positive ideals and negative ideals. sar and Harsin according to Fig. 1e had the highest and 6) Determining the relative proximity of alternatives to lowest levels of noise pollution (51% and 0.4%, respect- ively). Furthermore, Dalahu (87%) and Kermanshah the ideal solution.Cl ¼ − þ d þd (25%) counties had the highest and least access to public 7) Ranking the alternatives in ascending order by the transportation, respectively (Fig. 1f). According to Fig. value of Consistency Index (CI): the alternatives 1g, Sarpol-e Zahab and Ghasr-e-Shirin had the highest selected must have the shortest distance from the and lowest green space per capita (14.66 and 2.66 m , positive ideal solution and the farthest from the respectively), and Fig. 1h showed that Ghasr-e-Shirin negative ideal solution. If the CI value is closer to 2 2 (4.56 m ) and Kermanshah (0.61 m ) had the highest one, the situation is better. and lowest values of sports per capita. The results demonstrated that Javanrood, Ghasr-e- Then, the priority map of counties was drawn in terms shirin, Harsin, Sahneh, and Dalahoo were ranked one to of the indexes of health equity using the Arc/GIS 10.6 five according to the TOPSIS. Regarding the counties of Software. Kermanshah, Salas-e Babajani, Paveh, Gilan-e Gharb, It is worth noting that the Shannon’s Entropy Method and Songhor were ranked sixth to tenth, respectively. was used to weighting in TOPSIS because knowing the Moreover, the counties of Islamabad, Kangavar, Sarpol-e relative weights of indexes is an effective step in the Zahab, and Ravansar held the 11th to 14th positions, problem-solving process when it comes to multi-criteria respectively (Tables 2, 3, 4, 5, 6 and 7). decision making. Moreover, K is a positive constant, and As shown in Table 5, comparison of 8 indicators the P-value (normalized matrix) was calculated for each i showed that access to transportation (0.0029), access to (alternative) and j (index). TOPSIS method was used in health centers (0.0057), solid waste management the TOPSIS-SOLVER Software. Finally, the results of eight (0.0001), green space per capita (0.0098), and sports per indices were presented in proper maps to display the capita (0.0139) had the shortest distance with a negative condition of counties using the Arc/GIS 10.6 Software. ideal. On the other hand, the noise pollution index had the longest distance from the negative ideal (0.2925), 3 Results and the house hygiene and air pollution indices were As shown in Table 1 and Fig. 1a, all counties obtained between the two negative and positive ideals. further than 95% of scores in house hygiene index. All households residing in Kermanshah province had access 4 Discussion to safe drinking water and standard sanitary toilets. Also, This study aimed to survey the indexes of equity in the household sanitary sewage disposal was lower than 90% physical environment and infrastructures of Kermanshah in only three cities, including Dalahu (88.8%), Paveh province based on the national indexes. (87.5%), and Qasr-e Shirin (85.3%). Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 4 of 10 Table 1 The status of physical environment indexes, Kermanshah, Iran Number of The status of house hygiene (%) The status of households’ Percentage of Status of Status of Status of Green Sports households solid waste management (%) clean days in access to noise access to space per the year in health pollution public per capita Families with Families Families Families Urban Rural Hospitals Total terms of dust services per transportation capita (in m ) appropriate with waste with safe with areas areas (%) (%) phenomenon per household per household (in m ) per house hygiene disposal drinking sanitary (%) (%) per household household in in percentage per person (%) systems (%) water (%) toilets (%) (%) in percentage percentage (%) person (%) (%) Islamabad- 40,052 100 100 93 97.66 90 78 100 89.33 96 33.6 19 69 7.51 1.23 Gharb Paveh 15,899 100 100 87.5 95.83 89 86 100 91.66 97.53 39.29 12 71 4.84 1.4 Salas-e 8811 100 100 91.9 97.33 85 77 100 87.33 97 3.85 0 50 3.47 1.07 Babajani Javanrood 17,830 100 100 94.2 98.06 88 73 100 87 96.71 54.42 0 69 4.08 0.9 Dalahoo 10,362 100 100 88.8 96.26 89 71 100 86.66 91.5 6.26 0 87 5.02 1.01 Ravansar 12,125 100 100 92 97.33 89 51 100 80 97.2 5.36 51 58 10.46 1.92 Sarpol-e 21,670 100 100 92 97.33 90 79 100 89.66 91.2 31 48 63 14.66 1.47 Zahab Songhor 26,189 100 100 95.1 98.36 91 67 100 86 97.5 28.72 17 62 7.54 1.74 Sahneh 22,046 100 100 93 97.66 92 66 100 86 96.16 22.67 8 65 20.31 0.91 Ghasr-e- 6050 100 100 85.3 95.1 87 80 100 89 91.78 46.2 11 70 2.66 4.56 Shirin Kermanshah 287,931 100 100 93.9 97.96 95 61 100 85.33 96.7 80.93 14 25 10.77 0.61 Kangavar 22,652 100 100 92 97.33 91 73 100 88 95.89 32.65 24 66 11.03 2 Gilan-e 15,617 100 100 93.2 97.33 86 77 100 87.66 91.78 27.6 14 86 9.25 1.24 Gharb Harsin 23,173 100 100 95.9 98.63 93 54 100 82.33 96.98 27.61 4 59 11.46 0.87 Whole 530,407 100 100 92 97.32 89.64 70.92 100 86.85 95.28 31.44 15.85 64.28 8.79 1.49 province Source: Water and Sewage Department of Kermanshah province; the Vice-chancellery for Health of Kermanshah province; Kermanshah Meteorological Department; Vice-chancellery for Health of Kermanshah province; Industry, Mine and Trade Organization of Kermanshah province; Statistics Center of Kermanshah City Hall; Municipality Organization and Kermanshah Sports and Youth Department, 2016 Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 5 of 10 Fig. 1 The map of the status of health equity in physical and infrastructure indexes and counties ranking in Kermanshah province in 2016 using GIS Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 6 of 10 Table 2 The indexes of equity in physical environment and infrastructures across Kermanshah province, Iran Counties House Air pollution Noise pollution Access to public Access to Solid waste Green Sports per 2 2 hygiene (%) (%) from industries transportation (%) health management space (m ) capita (m ) (%) centers (%) (%) Kermanshah 97.96 96.7 14 25 80.93 85.33 10.77 0.61 Islamabad- Gharb 97.66 96 19 69 33.6 89.33 7.51 1.23 Harsin 98.63 96.98 4 59 27.61 82.33 11.46 0.87 Kangavar 97.33 95.89 24 66 32.65 88 11.03 2 Songhor 98.36 97.5 17 62 28.72 86 7.54 1.74 Sahneh 97.66 96.16 8 65 22.67 86 20.31 0.91 Javanrood 98.06 96.71 0 69 54.42 87 4.08 0.9 Sarpol-e Zahab 97.33 91.2 48 63 31 89.66 14.66 1.47 Paveh 95.83 97.53 12 71 39.29 91.66 4.84 1.4 Gilan-e Gharb 97.33 91.78 14 86 27.6 87.66 9.25 1.24 Ravansar 97.33 97.2 51 58 5.36 80 10.46 1.92 Dalahoo 96.26 91.5 0 87 6.26 86.66 5.02 1.01 Ghasr-e-Shirin 95.1 91.78 11 70 46.2 89 2.66 4.56 Salas-e Babajani 97.3 97 0 50 3.85 87.33 3.47 1.07 The results showed that the indexes of access to trans- indicated the lack of sustainable development in portation, access to health centers, solid waste manage- Kermanshah province, even if the standard per capita ment, and green and sports per capita had the least was similar between counties. It is well known that any distance from the negative ideal whereas the noise development that is not comprehensive and not pollution index had the greatest distance. However, house following a systematic and integrated model cannot be hygiene and air pollution indexes were within the negative sustainable [13]. The results of a study performed by and positive ideal ranges. Hence, it can be concluded that Maleki et al. in Khuzestan province showed the lack of the status of equity in the physical environment and infra- spatial equity in distribution of facilities and health ser- structures in Kermanshah province was unbalanced. vices across its counties [13]. Additionally, the findings of the present study on The results of the present study showed that the major- better conditions of eight indexes in some counties ity of households had proper house hygiene, the highest Table 3 Standardized matrix of indexes Counties House Air pollution Noise pollution Access to public Access to Solid waste Green Sports hygiene from industries transportation health centers management space per capita Kermanshah 0.2691 96.7 14 25 80.93 85.33 10.77 0.61 Islamabad-Gharb 0.2682 96 19 69 33.6 89.33 7.51 1.23 Harsin 0.2709 96.98 4 59 27.61 82.33 11.46 0.87 Kangavar 0.2673 95.89 24 66 32.65 88 11.03 2 Songhor 0.2702 97.5 17 62 28.72 86 7.54 1.74 Sahneh 0.2682 96.16 8 65 22.67 86 20.31 0.91 Javanrood 0.2693 96.71 0 69 54.42 87 4.08 0.9 Sarpol-e Zahab 0.2673 91.2 48 63 31 89.66 14.66 1.47 Paveh 0.2632 97.53 12 71 39.29 91.66 4.84 1.4 Gilan-e Gharb 0.2673 91.78 14 86 27.6 87.66 9.25 1.24 Ravansar 0.2673 97.2 51 58 5.36 80 10.46 1.92 Dalahoo 0.2644 91.5 0 87 6.26 86.66 5.02 1.01 Ghasr-e-Shirin 0.2612 91.78 11 70 46.2 89 2.66 4.56 Salas-e Babajani 0.2673 97 0 50 3.85 87.33 3.47 1.07 Shannon’s Entropy 0.0001 0.0003 0.4753 0.0287 0.207 0.0006 0.1378 0.1502 of weighting Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 7 of 10 Table 4 Standardized weight matrix of indexes Counties House Air pollution Noise pollution Access to public Access to Solid waste Green Sports hygiene from industries transportation health centers management space per capita Kermanshah 0 0.0001 0.0803 0.0029 0.1206 0.0002 0.0398 0.0139 Islamabad-Gharb 0 0.0001 0.109 0.008 0.0501 0.0002 0.0278 0.028 Harsin 0 0.0001 0.0229 0.0069 0.0411 0.0002 0.0424 0.0198 Kangavar 0 0.0001 0.1376 0.0077 0.0487 0.0002 0.0408 0.0455 Songhor 0 0.0001 0.0975 0.0072 0.0428 0.0002 0.0279 0.0396 Sahneh 0 0.0001 0.0459 0.0076 0.0338 0.0002 0.0751 0.0207 Javanrood 0 0.0001 0 0.008 0.0811 0.0002 0.0151 0.0205 Sarpol-e Zahab 0 0.0001 0.2753 0.0073 0.0462 0.0002 0.0542 0.0334 Paveh 0 0.0001 0.0688 0.0083 0.0586 0.0002 0.0179 0.0318 Gilan-e Gharb 0 0.0001 0.0803 0.01 0.0411 0.0002 0.0342 0.0282 Ravansar 0 0.0001 0.2925 0.0068 0.008 0.0001 0.0387 0.0437 Dalahoo 0 0.0001 0 0.0101 0.0093 0.0002 0.0186 0.023 Ghasr-e-Shirin 0 0.0001 0.0631 0.0081 0.0689 0.0002 0.0098 0.1037 Salas-e Babajani 0 0.0001 0 0.0058 0.0057 0.0002 0.0128 0.0243 level was in Harsin and the lowest in Ghasr-e-Shirin, 5% of the days of the year, showing a downward trend which was consistent with the results of a study con- compared with the statistics of 2009–2010, similar to ducted by Ghadermarzy et al. [14]. Given that Ghasr-e- the results of a study performed by Shamshiri et al. [17]. Shirin is located in the border area of Iran with Iraq and In the last two decades, dust storms in the south and was the first point attacked by Iraqi army in the 8-year west of Iran have been a reemerging phenomenon whose Iran-Iraq war, it is likely that damages on its infrastruc- number of days in previous years has been variable and tures, late reconstruction of destroyed houses, in affected by rainfall and air temperature [18, 19]. Due to addition the long distance from the province center have the increase in rainfall over the past few years in led to the lower level of house hygiene; however, this ex- Kermanshah province [20], this increase in rainfall has planation requires further studies. House hygiene indica- probably been effective in reducing dust storm and air tors such as toilets and sewage are important because pollution. they have a direct impact on the prevalence of infectious diseases and the physical health of family members [15, 16]. However, the general situation of the house hygiene Table 6 Distance from the positive and negative ideals index in the province was favorable. Indexes of equity in the physical Positive ideals Negative ideals The findings of the present study indicated that environment and infrastructures (A+) (A−) Kermanshah province had good category of Air Quality Kermanshah 0.1258 0.2432 Index (AQI) around 95% of the days of the year. Islamabad-Gharb 0.1576 0.1903 Kermanshah province is exposed to air pollution only Harsin 0.1223 0.2739 Kangavar 0.1694 0.1667 Table 5 Positive and negative ideals Songhor 0.148 0.201 Indexes of equity in the physical Positive ideals Negative ideals Sahneh 0.1286 0.2568 environment and infrastructures (A+) (A−) House hygiene 0 0 Javanrood 0.11 0.3022 Air pollution 0.0001 0.0001 Sarpol-e Zahab 0.2945 0.0656 Noise pollution from industries 0 0.2925 Paveh 0.1305 0.2307 Access to public transportation 0.0101 0.0029 Gilan-e Gharb 0.1419 0.2171 Access to health centers 0.1206 0.0057 Ravansar 0.3212 0.0417 Solid waste management 0.0002 0.0001 Dalahoo 0.1487 0.2929 Green space 0.0751 0.0098 Ghasr-e-Shirin 0.1045 0.2544 Sports per capita 0.1037 0.0139 Salas-e Babajani 0.1529 0.2927 Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 8 of 10 Table 7 Township rankings using TOPSIS lack of road development in each county has affected the existence of health service centers and people’s Counties name Relative proximity Ranking of alternatives (Cli) access to the available health centers. Javanrood 0.7332 1 The results of our study showed the poor condition of sports per capita in Kermanshah province compared to Ghasr-e-Shirin 0.7088 2 the national [27] and the international standards [28]. Harsin 0.6913 3 This index was much lower in Kermanshah than provin- Sahneh 0.6663 4 cial level. Similarly, the results of other studies have also Dalahoo 0.6633 5 pointed to the inappropriate distribution of sports spaces Kermanshah 0.6591 6 in other provinces of Iran [27, 29]. Salas-e Babajani 0.6568 7 Another finding of present study indicated a signifi- cant shortage in the green space per capita in Kerman- Paveh 0.6387 8 shah province compared to the global standards [30], Gilan-e Gharb 0.6047 9 and the value obtained is also lower than the national Songhor 0.5759 10 standards [31]. The lack of equal access to green space Islamabad- Gharb 0.547 11 in the province was consistent with the results of a study Kangavar 0.496 12 conducted by Tajdar et al. [32]. The importance of Sarpol-e Zahab 0.1822 13 access to green space has been emphasized in some other studies [6, 33]. Ravansar 0.1149 14 Based on the results of the present study, more than 15% of the households in the province suffered from Our findings on solid waste management showed that noise pollution. This statistic was calculated based on all hospitals in the province had recycling and disposal industrial-towns along with other structures [34]. The waste facilities. Moreover, urban and rural areas had results of comparing counties demonstrated that Ravan- access to solid waste management. However, there is no sar and Sarpol-e-Zahab had the highest and Sahneh and integrated and codified program for waste management Harsin had the lowest percentage of noise pollution. in urban and rural areas of Kermanshah province. Also This difference is probably due to the lack of suitability rural areas of Ravansar and Harsin counties had of land applications in Kermanshah province and other the poorest solid waste management, requiring the at- reasons such as the urban structure, as mentioned in tention and effort of health authorities of Kermanshah other studies [34]. However, the results of this study province. This finding was consistent with the results of showed that noise pollution is not limited to large and a study conducted by Bakhtyari et al. [21]. Studies show industrial cities and also exists in small cities of the that access to sound waste management services is still province, which may be due to the activity of small tech- limited in developing countries, especially in rural areas nical business in the cites, development of urban hous- [22]. Disposal of waste in the natural environment and ing complexes, and lack of proper land use. The the lack of dumpsites are the main reasons for the low problem of noise pollution is a public health challenge quality of waste management in rural areas [23]. in all developed and developing countries, mainly due to Other results showed that Kermanshah and Javanrood roads, airports, industrial towns, and technical occupa- had the highest access to health centers while Salas-e tions [35, 36]. The negative effects of noise pollution Babajani, Ravansar, and Dalahu had the lowest access in the counties can be mitigated through applying (less than 10%). This finding was consistent with the land use plans and creating audio maps and compre- results of studies done by Sulaimany et al. [24] and hensive analysis of various policies at the county Mousavi et al. [25]. This difference was very significant level. between the counties, which indicated a lack of Our findings showed that more than half of the prov- geographical heterogeneity and inequality in access to ince’s population had appropriate access to public trans- health centers throughout Kermanshah province. This portation. The results also indicated that Dalahu and needs a rapid shifting in policies towards people’s access Kermanshah counties had the highest and lowest per- to health services. Similarly, health inequity between centages of access to public transportation, respectively, different regions of Iran [9] and within Kermanshah consistent with the results of study by Tajdar et al. province in terms of access to health services have been which confirmed the differences in various regions of shown [26]. Despite the primary health care system the province [32]. It is likely that the sudden increase in (PHC) at the level of health houses, rural and urban the population of Kermanshah city during the last two health centers, and hospitals in each county, it seems decades and the incompatibility of public transportation that the geographical condition, relative deprivation, and with the population is the main reason for this Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 9 of 10 difference. That is why the urban Kermanshah monorail were not distributed equitably between the counties of project was put on the agenda, but its slow progress Kermanshah province. Accordingly, the asymmetric contributed to the continued problem of public trans- distribution of indexes in counties was the key factor in portation in Kermanshah. creating health inequity and should be considered as a In the present study, consistent with the similar studies challenge by planners, health managers, and policy- [32], we used the GIS to assess the environmental and phys- makers. The model proposed in the present study can ical infrastructural indexes. This indicates that geography be used in all provinces of Iran and other developing and GIS can be applicable scientific tools in health and countries. inequalities assessments. We also used Shannon’sEntropy Acknowledgements Method and TOPSIS for weighting and ranking. Moreover, We would like to thank Meteorology Center of Kermanshah, Kermanshah the Arc/GIS software was used for displaying the conditions Water and Wastewater Company; Kermanshah Sports Department; of counties similar to some other studies [37]. Kermanshah Municipality; Industry, Mining, and Trade Organization of Kermanshah province; Kermanshah Governorate; and Kermanshah University The results of our study demonstrated that the counties of Medical Sciences. of Islamabad, Kangavar, Sarpol-e-Zahab, and Ravansar were far from the positive ideal and had the lowest ranks Authors’ contributions SR and ShS conceptualized the main idea. ShS designed and analyzed. SR, in terms of health equity in physical environment and ShS, ARZ, RazT, and RT interpreted the results and drafted the manuscript. All infrastructure. In addition to the necessity to investigate the authors take responsibility for the integrity of the work as a whole from the causes of this inequity, there is a need for scientific inception to the published article. SR is the guarantor. ShS, AA, MKh, SRN, and KGK conducted the corrections, further analysis, and language editing. planning and practical measures to reduce the inequalities. All the authors read and approved the final manuscript. This issue has become more important due to the 7.3 magnitude earthquake in 2017 in the west of Kermanshah Funding province, especially Sarpolzahab, Islamabad, and Ravansar, This study was funded by the Vice Chancellor for Research and Technology of Kermanshah University of Medical Sciences (grant number: 980463). which had destructive effects on physical infrastructure and health. Availability of data and materials The imbalance in the physical environment and infra- Data will be available upon request. structures in Kermanshah province means that the imple- mented policies have not led to health equity in the Ethics approval and consent to participate Approval of Research Ethics Committee (REC) of Kermanshah University of province. In studies conducted outside Iran, policy-making Medical Sciences was granted (code 980463). Consent to participate is not and planning have also been mentioned as important issues applicable. The permission and access to the data were obtained from the on health equity [38, 39]. Concentration of services in data holders. urban places created bipolar areas and also led to migration Consent for publication from the rural to urban areas, and subsequently creating Not applicable. theinequityand misdistribution of services and facilities in the province. Imbalance and inequality in infrastructure is Competing interests evident when we compare the counties. Javanrood and The authors declare no competing interests. Ravansar, as two neighboring counties, have the highest Author details and lowest rank in terms of equity in the physical environ- 1 Social Development & Health Promotion Research Center, Health Institute, ment and infrastructures, respectively. Similarly, Rezaei Kermanshah University of Medical Sciences, Kermanshah, Iran. Department of Nursing, School of Nursing and Midwifery, Hamadan University of Medical et al. concluded that Javanrood and Ravansar were devel- Sciences, Hamadan, Iran. Clinical Laboratory Science, Tabriz University, oped and underdeveloped in terms of access to health 4 Tabriz, Iran. Department of Art, Architecture and Design, University of South services, respectively [40]. This finding indicates the need to Australia, Adelaide, Australia. Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of precise regional planning in Kermanshah province towards Medical Sciences, Bandar Abbas, Iran. balanced development in all areas. Received: 9 October 2019 Accepted: 9 February 2021 4.1 Study limitations The present study only examined the indices of physical References environment and infrastructures, and the reasons for this 1. Health WCoSDo, Organization WH. Closing the gap in a generation: health inequity were not assessed. Hence, it is recommended that equity through action on the social determinants of health: Commission on Social Determinants of Health, final report. Geneva: World Health the causes of this inequity be investigated for each of the Organization; 2008. eight indexes in future studies. 2. McGovern T, Ahmed A. Equity in health. In: Foundations of global health & human rights. Gostin L, Meier B, editors. Ch 14. Oxford: Oxford University Press; 2020. 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Kobe: WHO Centre for Health of urban park provision. Landsc Urban Plan. 2017;158(8):139–54. Development; 2010. 29. Zarei B, Khodamoradpoor M, Rezaei S. Designing the students sports development strategy in Kermanshah University. Eur J Phys Educ Sport Sci. 6. Beheshtian M, Manesh AO, Bonakdar S, Afzali HM, Larijani B, Hosseini L, 2017;3(6):72–84. et al. Intersectoral collaboration to develop health equity indicators in Iran. 30. Oh K, Jeong S. Assessing the spatial distribution of urban parks using GIS. Iran J Public Health. 2013;42(Suppl 1):31–5. Landsc Urban Plan. 2007;82(1):25–32. 7. AbouZahr C, Boerma T, Hogan D. Global estimates of country health 31. Khakpor B, Kazemibiniaz M, Asadi A, Razavi M. Analysis of urban green indicators: useful, unnecessary, inevitable? Glob Health Action. 2017; space and the optimal location using raster calculator (case study: 3RD 10(Supppl 1):4–17. Mashhad Municipality Zone). J Environ Sci Technol. 2015;17(2):117–29. 8. 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Sulaimany A, Masum MG, Riahi V. The development level of health indicators in Kermanshah province from the perspective of social justice in 2010. J Kerman Univ Med Sci. 2014;17(10):647–56. 25. Mousavi S, Seyedin S, Aryankhesal A, Sadeghifar J, Armoun B, Safari Y, et al. Stratification of Kermanshah province districts in terms of health structural indicators using scalogram model. J Health Promot Manage. 2013;2(2):7–15. 26. Shojaei P, Ghanbarzadegan A, Najibi M, Bastani P. Ranking of Iranian provinces based on healthcare infrastructures: before and after implementation of health transformation plan. Cost Effect Resour Allocation. 2020;18(1):4. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Egyptian Public Health Association Springer Journals

Survey on the indexes of health equity in the physical environment and infrastructures of Kermanshah province, Iran

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Abstract

Background: Health equity is directly associated with the proper distribution of resources, the existence of infrastructures, and the balanced physical environment. The present study aimed to survey the indexes of health equity in the physical environment and infrastructures of Kermanshah province based on the national indexes. Results: The results revealed that access to transportation, health centers, solid waste management, and green and sports per capita had the least distance from the negative ideal whereas the noise pollution index had the greatest distance. However, house hygiene and air pollution indexes were within the negative and positive ideal ranges. Conclusions: The health equity indexes were not distributed equitably across counties and geographical regions of Kermanshah province. Keywords: Health equity, Environment, Index, Geographic Information Systems 1 Introduction this regard to face the complex and major challenges. In Nowadays, governments by providing health services response to these concerns, the Commission for Social De- and adequate and timely care as well as equitable distri- terminants of Health was established in the World Health bution of services can affect the community’s well-being Organization (WHO), through which some recommenda- and health. It should be noted that providing the best tions were presented to develop and monitor rights to good healthcare alone is not sufficient [1]. Some experts health at local, national, and international levels [3]. define health equity as “lack of systematic differences in Recently, to assess gap in the health status of urban health means creating equal opportunities for health and population and its determinants, a tool called “respon- reducing health differences to the lowest possible level” siveness and justice measurement in urban health” has [2]. Health equity implies that all segments of the society been developed by the Health Development Center of should ideally have a fair chance of benefiting from the WHO which is used in Kobe, Japan [4, 5]. After design- services and financing to achieve their potential full ing this tool, the Tehran municipality announced to the health. Establishing health equity relates with health WHO Regional Office for the Eastern Mediterranean determinants and has special complexity due to numerous (EMRO) its readness to investigate and measure health dimensions and effects, causing officials and managers in equity as a pilot study in Tehran in 2007. The outcome of the efforts of this working group incorporated the proposal * Correspondence: SaediShahram@yahoo.com of six areas instead of four areas within Iran, including infra- Social Development & Health Promotion Research Center, Health Institute, structure and physical environment, human and social Kermanshah University of Medical Sciences, Kermanshah, Iran Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 2 of 10 development, economic development, governance, nutrition, province, western Iran, and its statistical population was and health [6]. all of 14 counties including Kermanshah, Eslamabad-e One of the levels for national and regional planning is Gharb, Paveh, Harsin, Kangavar, Sonqor, Javanrud, awareness of the capabilities of different provinces and Ravansar, Gilan-e Gharb, Sahneh, Qasr-e Shirin, and their counties. Moreover, evidence has shown that Sarpol-e Zahab, Dalahu, and Salas-e Babajani. Geographic Information System (GIS) has always been Data was collected about eight indexes related to the one of the most useful tools in this respect [7]. assessment of equity in the area of physical environment The destruction of the infrastructures of Kermanshah and infrastructures, codified by the Ministry of Health province because of the 8-year war between Iran and and Medical Sciences [6] and based on the study Iraq caused this province to fall behind development conducted in Kobe, Japan [5]. These indexes were as compared to other provinces. This issue led to the back- follows: wardness of this province and many other detrimental consequences including the settlement of a large part of 1) The data on house hygiene (the percentage of war veterans of the province in the capital city of households with waste disposal systems, sanitary Kermanshah and its excessive population growth. The toilets, and access to public drinking water main impact of this trend was the interruption and failure network) were collected through the statistics in the system of service distribution, and subsequently led provided by health center of Kermanshah. to the failure of citizens’ adequate access to such services 2) The data on air pollution (dust) including the [8]. On the other hand, Kermanshah is also faced with percentage of clean days in the year were collected other problems such as poverty, high general fertility in from the meteorological organization of some regions, AIDS, cancer [9], and economic loss in the Kermanshah. areas of animal husbandry, agriculture, farming, and gar- 3) The data on noise pollution by industries were dening due to air pollution (dust phenomenon). collected from the Industry, Mine and Trade Air pollution occurs in Kermanshah like other big Organization of Kermanshah province. cities, which ends to 500 as hazardous air quality that 4) The data on access to public transportation was necessitates avoidance of outdoor activities. The Air collected from the municipalities of counties. Quality Index (AQI) is an important tool to assess air 5) The data on access to health centers (including quality and evaluate its effects on health. AQI is deter- primary health care). mined by six major pollutants as important criteria: 6) The data on solid waste management (the status of ozone (O ), sulfur dioxides (SO ), inhalable particles waste management in urban areas, hospitals, and 3 2 (PM ), fine particulate matter (PM ), nitrogen dioxides villages) was collected from the Health Network in 10 2.5 (NO ), and carbon monoxide (CO) [10]. The AQI scale each county. is in the range of 0 to 500 to qualify the overall quality 7) The data on green space per capita in the province of the air into six levels in different colors (good in were collected from the municipalities of counties. green, moderate in yellow, lightly polluted in orange, 8) The data on sports per capita were collected from moderately polluted in red, heavily polluted in purple, the Sport Department of Kermanshah province. and severely polluted in maroon). These levels indicate air pollution overall effects on human health and decent 2.2 Data collection reference for people’s outdoor activities in a numerical The required information was collected through docu- pattern. A low number means good air quality, while an mentary methods from the related departments in increasing number means worsening air quality, for ex- Kermanshah province. Additionally, the demographic ample values over 300 represent hazardous air quality data of each county were collected through the statistical which is the health warning of emergency condition and blocks of the Official Statistics Center of Iran. Moreover, everyone is more likely to be affected [11]. The present the latest population statistics (the demographic data of study aimed to survey the indexes of health equity in the 2016) published by the Statistical Centre of Iran were physical environment and infrastructures of Kermanshah used as the basis of the study. province based on the national indexes. 2.3 Data analysis 2 Methods In the first step, data about the studied eight indexes 2.1 Design and setting were collected. Then, the Technique for Order of Prefer- This cross-sectional study was performed using quanti- ence by Similarity to Ideal Solution (TOPSIS) that is a tative models, based on the national indexes codified by multi-criteria decision analysis method was used. This the Ministry of Health and Medical Education of Iran in technique, as one of the best multi-criteria decision- 2016. The geographic area of this study was Kermanshah making models which are used extensively, was first Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 3 of 10 proposed by Hawang and Yoon in 1981 [12]. In this The results of solid waste management in urban areas method, m alternatives are evaluated by n criteria. This showed that seven cities had provided more than 90% of technique is based on the notion that the selected alterna- the proper waste management. Table 1 and Fig. 1b tive should have the furthest distance from the negative showed that Salas-e Babajani and Kermanshah counties ideal solution. It is assumed that the utility of each index had the lowest and highest levels of urban proper waste is uniformly increasing or decreasing. Problem-solving management (85% and 95%, respectively). In the rural using TOPSIS includes the following steps: waste management index, only in Paveh County, more than 80% of proper waste management was provided, 1) Formation of data matrixes based on an alternative and in other cities, it was less than 70% (86% and 51% in (counties) and m indexes (the applied indexes in Paveh and Ravansar, respectively). All counties had the research), proper waste management in hospitals and inpatient 2) Creating the normalized decision matrix. treatment centers. 3) Establishing the weighted normalized matrix (V): According to Table 2 and Fig. 1c, Paveh and Sarpol-e the normalized matrix (N) is multiplied by the Zahab had the most and the fewest percentage of clean diagonal matrix of weights (Wn). days, an indicator of lacking air pollution (97.53% vs. 4) Determining the ideal positive solutions 91.2%, respectively). (determination of the maximum value for each of The results showed that access to health centers was the weighted standardized indicators) and negative more than 80% in only one county and less than 60% in solutions (determination of the minimum value for other cities. Figure 1d shows that Kermanshah (80.93%) each of the weighted standardized indicators). and Ravansar (5.36%) counties had the highest and least 5) Calculating the distance of each alternative from access to health centers, respectively. Moreover, Ravan- the positive ideals and negative ideals. sar and Harsin according to Fig. 1e had the highest and 6) Determining the relative proximity of alternatives to lowest levels of noise pollution (51% and 0.4%, respect- ively). Furthermore, Dalahu (87%) and Kermanshah the ideal solution.Cl ¼ − þ d þd (25%) counties had the highest and least access to public 7) Ranking the alternatives in ascending order by the transportation, respectively (Fig. 1f). According to Fig. value of Consistency Index (CI): the alternatives 1g, Sarpol-e Zahab and Ghasr-e-Shirin had the highest selected must have the shortest distance from the and lowest green space per capita (14.66 and 2.66 m , positive ideal solution and the farthest from the respectively), and Fig. 1h showed that Ghasr-e-Shirin negative ideal solution. If the CI value is closer to 2 2 (4.56 m ) and Kermanshah (0.61 m ) had the highest one, the situation is better. and lowest values of sports per capita. The results demonstrated that Javanrood, Ghasr-e- Then, the priority map of counties was drawn in terms shirin, Harsin, Sahneh, and Dalahoo were ranked one to of the indexes of health equity using the Arc/GIS 10.6 five according to the TOPSIS. Regarding the counties of Software. Kermanshah, Salas-e Babajani, Paveh, Gilan-e Gharb, It is worth noting that the Shannon’s Entropy Method and Songhor were ranked sixth to tenth, respectively. was used to weighting in TOPSIS because knowing the Moreover, the counties of Islamabad, Kangavar, Sarpol-e relative weights of indexes is an effective step in the Zahab, and Ravansar held the 11th to 14th positions, problem-solving process when it comes to multi-criteria respectively (Tables 2, 3, 4, 5, 6 and 7). decision making. Moreover, K is a positive constant, and As shown in Table 5, comparison of 8 indicators the P-value (normalized matrix) was calculated for each i showed that access to transportation (0.0029), access to (alternative) and j (index). TOPSIS method was used in health centers (0.0057), solid waste management the TOPSIS-SOLVER Software. Finally, the results of eight (0.0001), green space per capita (0.0098), and sports per indices were presented in proper maps to display the capita (0.0139) had the shortest distance with a negative condition of counties using the Arc/GIS 10.6 Software. ideal. On the other hand, the noise pollution index had the longest distance from the negative ideal (0.2925), 3 Results and the house hygiene and air pollution indices were As shown in Table 1 and Fig. 1a, all counties obtained between the two negative and positive ideals. further than 95% of scores in house hygiene index. All households residing in Kermanshah province had access 4 Discussion to safe drinking water and standard sanitary toilets. Also, This study aimed to survey the indexes of equity in the household sanitary sewage disposal was lower than 90% physical environment and infrastructures of Kermanshah in only three cities, including Dalahu (88.8%), Paveh province based on the national indexes. (87.5%), and Qasr-e Shirin (85.3%). Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 4 of 10 Table 1 The status of physical environment indexes, Kermanshah, Iran Number of The status of house hygiene (%) The status of households’ Percentage of Status of Status of Status of Green Sports households solid waste management (%) clean days in access to noise access to space per the year in health pollution public per capita Families with Families Families Families Urban Rural Hospitals Total terms of dust services per transportation capita (in m ) appropriate with waste with safe with areas areas (%) (%) phenomenon per household per household (in m ) per house hygiene disposal drinking sanitary (%) (%) per household household in in percentage per person (%) systems (%) water (%) toilets (%) (%) in percentage percentage (%) person (%) (%) Islamabad- 40,052 100 100 93 97.66 90 78 100 89.33 96 33.6 19 69 7.51 1.23 Gharb Paveh 15,899 100 100 87.5 95.83 89 86 100 91.66 97.53 39.29 12 71 4.84 1.4 Salas-e 8811 100 100 91.9 97.33 85 77 100 87.33 97 3.85 0 50 3.47 1.07 Babajani Javanrood 17,830 100 100 94.2 98.06 88 73 100 87 96.71 54.42 0 69 4.08 0.9 Dalahoo 10,362 100 100 88.8 96.26 89 71 100 86.66 91.5 6.26 0 87 5.02 1.01 Ravansar 12,125 100 100 92 97.33 89 51 100 80 97.2 5.36 51 58 10.46 1.92 Sarpol-e 21,670 100 100 92 97.33 90 79 100 89.66 91.2 31 48 63 14.66 1.47 Zahab Songhor 26,189 100 100 95.1 98.36 91 67 100 86 97.5 28.72 17 62 7.54 1.74 Sahneh 22,046 100 100 93 97.66 92 66 100 86 96.16 22.67 8 65 20.31 0.91 Ghasr-e- 6050 100 100 85.3 95.1 87 80 100 89 91.78 46.2 11 70 2.66 4.56 Shirin Kermanshah 287,931 100 100 93.9 97.96 95 61 100 85.33 96.7 80.93 14 25 10.77 0.61 Kangavar 22,652 100 100 92 97.33 91 73 100 88 95.89 32.65 24 66 11.03 2 Gilan-e 15,617 100 100 93.2 97.33 86 77 100 87.66 91.78 27.6 14 86 9.25 1.24 Gharb Harsin 23,173 100 100 95.9 98.63 93 54 100 82.33 96.98 27.61 4 59 11.46 0.87 Whole 530,407 100 100 92 97.32 89.64 70.92 100 86.85 95.28 31.44 15.85 64.28 8.79 1.49 province Source: Water and Sewage Department of Kermanshah province; the Vice-chancellery for Health of Kermanshah province; Kermanshah Meteorological Department; Vice-chancellery for Health of Kermanshah province; Industry, Mine and Trade Organization of Kermanshah province; Statistics Center of Kermanshah City Hall; Municipality Organization and Kermanshah Sports and Youth Department, 2016 Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 5 of 10 Fig. 1 The map of the status of health equity in physical and infrastructure indexes and counties ranking in Kermanshah province in 2016 using GIS Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 6 of 10 Table 2 The indexes of equity in physical environment and infrastructures across Kermanshah province, Iran Counties House Air pollution Noise pollution Access to public Access to Solid waste Green Sports per 2 2 hygiene (%) (%) from industries transportation (%) health management space (m ) capita (m ) (%) centers (%) (%) Kermanshah 97.96 96.7 14 25 80.93 85.33 10.77 0.61 Islamabad- Gharb 97.66 96 19 69 33.6 89.33 7.51 1.23 Harsin 98.63 96.98 4 59 27.61 82.33 11.46 0.87 Kangavar 97.33 95.89 24 66 32.65 88 11.03 2 Songhor 98.36 97.5 17 62 28.72 86 7.54 1.74 Sahneh 97.66 96.16 8 65 22.67 86 20.31 0.91 Javanrood 98.06 96.71 0 69 54.42 87 4.08 0.9 Sarpol-e Zahab 97.33 91.2 48 63 31 89.66 14.66 1.47 Paveh 95.83 97.53 12 71 39.29 91.66 4.84 1.4 Gilan-e Gharb 97.33 91.78 14 86 27.6 87.66 9.25 1.24 Ravansar 97.33 97.2 51 58 5.36 80 10.46 1.92 Dalahoo 96.26 91.5 0 87 6.26 86.66 5.02 1.01 Ghasr-e-Shirin 95.1 91.78 11 70 46.2 89 2.66 4.56 Salas-e Babajani 97.3 97 0 50 3.85 87.33 3.47 1.07 The results showed that the indexes of access to trans- indicated the lack of sustainable development in portation, access to health centers, solid waste manage- Kermanshah province, even if the standard per capita ment, and green and sports per capita had the least was similar between counties. It is well known that any distance from the negative ideal whereas the noise development that is not comprehensive and not pollution index had the greatest distance. However, house following a systematic and integrated model cannot be hygiene and air pollution indexes were within the negative sustainable [13]. The results of a study performed by and positive ideal ranges. Hence, it can be concluded that Maleki et al. in Khuzestan province showed the lack of the status of equity in the physical environment and infra- spatial equity in distribution of facilities and health ser- structures in Kermanshah province was unbalanced. vices across its counties [13]. Additionally, the findings of the present study on The results of the present study showed that the major- better conditions of eight indexes in some counties ity of households had proper house hygiene, the highest Table 3 Standardized matrix of indexes Counties House Air pollution Noise pollution Access to public Access to Solid waste Green Sports hygiene from industries transportation health centers management space per capita Kermanshah 0.2691 96.7 14 25 80.93 85.33 10.77 0.61 Islamabad-Gharb 0.2682 96 19 69 33.6 89.33 7.51 1.23 Harsin 0.2709 96.98 4 59 27.61 82.33 11.46 0.87 Kangavar 0.2673 95.89 24 66 32.65 88 11.03 2 Songhor 0.2702 97.5 17 62 28.72 86 7.54 1.74 Sahneh 0.2682 96.16 8 65 22.67 86 20.31 0.91 Javanrood 0.2693 96.71 0 69 54.42 87 4.08 0.9 Sarpol-e Zahab 0.2673 91.2 48 63 31 89.66 14.66 1.47 Paveh 0.2632 97.53 12 71 39.29 91.66 4.84 1.4 Gilan-e Gharb 0.2673 91.78 14 86 27.6 87.66 9.25 1.24 Ravansar 0.2673 97.2 51 58 5.36 80 10.46 1.92 Dalahoo 0.2644 91.5 0 87 6.26 86.66 5.02 1.01 Ghasr-e-Shirin 0.2612 91.78 11 70 46.2 89 2.66 4.56 Salas-e Babajani 0.2673 97 0 50 3.85 87.33 3.47 1.07 Shannon’s Entropy 0.0001 0.0003 0.4753 0.0287 0.207 0.0006 0.1378 0.1502 of weighting Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 7 of 10 Table 4 Standardized weight matrix of indexes Counties House Air pollution Noise pollution Access to public Access to Solid waste Green Sports hygiene from industries transportation health centers management space per capita Kermanshah 0 0.0001 0.0803 0.0029 0.1206 0.0002 0.0398 0.0139 Islamabad-Gharb 0 0.0001 0.109 0.008 0.0501 0.0002 0.0278 0.028 Harsin 0 0.0001 0.0229 0.0069 0.0411 0.0002 0.0424 0.0198 Kangavar 0 0.0001 0.1376 0.0077 0.0487 0.0002 0.0408 0.0455 Songhor 0 0.0001 0.0975 0.0072 0.0428 0.0002 0.0279 0.0396 Sahneh 0 0.0001 0.0459 0.0076 0.0338 0.0002 0.0751 0.0207 Javanrood 0 0.0001 0 0.008 0.0811 0.0002 0.0151 0.0205 Sarpol-e Zahab 0 0.0001 0.2753 0.0073 0.0462 0.0002 0.0542 0.0334 Paveh 0 0.0001 0.0688 0.0083 0.0586 0.0002 0.0179 0.0318 Gilan-e Gharb 0 0.0001 0.0803 0.01 0.0411 0.0002 0.0342 0.0282 Ravansar 0 0.0001 0.2925 0.0068 0.008 0.0001 0.0387 0.0437 Dalahoo 0 0.0001 0 0.0101 0.0093 0.0002 0.0186 0.023 Ghasr-e-Shirin 0 0.0001 0.0631 0.0081 0.0689 0.0002 0.0098 0.1037 Salas-e Babajani 0 0.0001 0 0.0058 0.0057 0.0002 0.0128 0.0243 level was in Harsin and the lowest in Ghasr-e-Shirin, 5% of the days of the year, showing a downward trend which was consistent with the results of a study con- compared with the statistics of 2009–2010, similar to ducted by Ghadermarzy et al. [14]. Given that Ghasr-e- the results of a study performed by Shamshiri et al. [17]. Shirin is located in the border area of Iran with Iraq and In the last two decades, dust storms in the south and was the first point attacked by Iraqi army in the 8-year west of Iran have been a reemerging phenomenon whose Iran-Iraq war, it is likely that damages on its infrastruc- number of days in previous years has been variable and tures, late reconstruction of destroyed houses, in affected by rainfall and air temperature [18, 19]. Due to addition the long distance from the province center have the increase in rainfall over the past few years in led to the lower level of house hygiene; however, this ex- Kermanshah province [20], this increase in rainfall has planation requires further studies. House hygiene indica- probably been effective in reducing dust storm and air tors such as toilets and sewage are important because pollution. they have a direct impact on the prevalence of infectious diseases and the physical health of family members [15, 16]. However, the general situation of the house hygiene Table 6 Distance from the positive and negative ideals index in the province was favorable. Indexes of equity in the physical Positive ideals Negative ideals The findings of the present study indicated that environment and infrastructures (A+) (A−) Kermanshah province had good category of Air Quality Kermanshah 0.1258 0.2432 Index (AQI) around 95% of the days of the year. Islamabad-Gharb 0.1576 0.1903 Kermanshah province is exposed to air pollution only Harsin 0.1223 0.2739 Kangavar 0.1694 0.1667 Table 5 Positive and negative ideals Songhor 0.148 0.201 Indexes of equity in the physical Positive ideals Negative ideals Sahneh 0.1286 0.2568 environment and infrastructures (A+) (A−) House hygiene 0 0 Javanrood 0.11 0.3022 Air pollution 0.0001 0.0001 Sarpol-e Zahab 0.2945 0.0656 Noise pollution from industries 0 0.2925 Paveh 0.1305 0.2307 Access to public transportation 0.0101 0.0029 Gilan-e Gharb 0.1419 0.2171 Access to health centers 0.1206 0.0057 Ravansar 0.3212 0.0417 Solid waste management 0.0002 0.0001 Dalahoo 0.1487 0.2929 Green space 0.0751 0.0098 Ghasr-e-Shirin 0.1045 0.2544 Sports per capita 0.1037 0.0139 Salas-e Babajani 0.1529 0.2927 Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 8 of 10 Table 7 Township rankings using TOPSIS lack of road development in each county has affected the existence of health service centers and people’s Counties name Relative proximity Ranking of alternatives (Cli) access to the available health centers. Javanrood 0.7332 1 The results of our study showed the poor condition of sports per capita in Kermanshah province compared to Ghasr-e-Shirin 0.7088 2 the national [27] and the international standards [28]. Harsin 0.6913 3 This index was much lower in Kermanshah than provin- Sahneh 0.6663 4 cial level. Similarly, the results of other studies have also Dalahoo 0.6633 5 pointed to the inappropriate distribution of sports spaces Kermanshah 0.6591 6 in other provinces of Iran [27, 29]. Salas-e Babajani 0.6568 7 Another finding of present study indicated a signifi- cant shortage in the green space per capita in Kerman- Paveh 0.6387 8 shah province compared to the global standards [30], Gilan-e Gharb 0.6047 9 and the value obtained is also lower than the national Songhor 0.5759 10 standards [31]. The lack of equal access to green space Islamabad- Gharb 0.547 11 in the province was consistent with the results of a study Kangavar 0.496 12 conducted by Tajdar et al. [32]. The importance of Sarpol-e Zahab 0.1822 13 access to green space has been emphasized in some other studies [6, 33]. Ravansar 0.1149 14 Based on the results of the present study, more than 15% of the households in the province suffered from Our findings on solid waste management showed that noise pollution. This statistic was calculated based on all hospitals in the province had recycling and disposal industrial-towns along with other structures [34]. The waste facilities. Moreover, urban and rural areas had results of comparing counties demonstrated that Ravan- access to solid waste management. However, there is no sar and Sarpol-e-Zahab had the highest and Sahneh and integrated and codified program for waste management Harsin had the lowest percentage of noise pollution. in urban and rural areas of Kermanshah province. Also This difference is probably due to the lack of suitability rural areas of Ravansar and Harsin counties had of land applications in Kermanshah province and other the poorest solid waste management, requiring the at- reasons such as the urban structure, as mentioned in tention and effort of health authorities of Kermanshah other studies [34]. However, the results of this study province. This finding was consistent with the results of showed that noise pollution is not limited to large and a study conducted by Bakhtyari et al. [21]. Studies show industrial cities and also exists in small cities of the that access to sound waste management services is still province, which may be due to the activity of small tech- limited in developing countries, especially in rural areas nical business in the cites, development of urban hous- [22]. Disposal of waste in the natural environment and ing complexes, and lack of proper land use. The the lack of dumpsites are the main reasons for the low problem of noise pollution is a public health challenge quality of waste management in rural areas [23]. in all developed and developing countries, mainly due to Other results showed that Kermanshah and Javanrood roads, airports, industrial towns, and technical occupa- had the highest access to health centers while Salas-e tions [35, 36]. The negative effects of noise pollution Babajani, Ravansar, and Dalahu had the lowest access in the counties can be mitigated through applying (less than 10%). This finding was consistent with the land use plans and creating audio maps and compre- results of studies done by Sulaimany et al. [24] and hensive analysis of various policies at the county Mousavi et al. [25]. This difference was very significant level. between the counties, which indicated a lack of Our findings showed that more than half of the prov- geographical heterogeneity and inequality in access to ince’s population had appropriate access to public trans- health centers throughout Kermanshah province. This portation. The results also indicated that Dalahu and needs a rapid shifting in policies towards people’s access Kermanshah counties had the highest and lowest per- to health services. Similarly, health inequity between centages of access to public transportation, respectively, different regions of Iran [9] and within Kermanshah consistent with the results of study by Tajdar et al. province in terms of access to health services have been which confirmed the differences in various regions of shown [26]. Despite the primary health care system the province [32]. It is likely that the sudden increase in (PHC) at the level of health houses, rural and urban the population of Kermanshah city during the last two health centers, and hospitals in each county, it seems decades and the incompatibility of public transportation that the geographical condition, relative deprivation, and with the population is the main reason for this Reshadat et al. Journal of the Egyptian Public Health Association (2021) 96:8 Page 9 of 10 difference. That is why the urban Kermanshah monorail were not distributed equitably between the counties of project was put on the agenda, but its slow progress Kermanshah province. Accordingly, the asymmetric contributed to the continued problem of public trans- distribution of indexes in counties was the key factor in portation in Kermanshah. creating health inequity and should be considered as a In the present study, consistent with the similar studies challenge by planners, health managers, and policy- [32], we used the GIS to assess the environmental and phys- makers. The model proposed in the present study can ical infrastructural indexes. This indicates that geography be used in all provinces of Iran and other developing and GIS can be applicable scientific tools in health and countries. inequalities assessments. We also used Shannon’sEntropy Acknowledgements Method and TOPSIS for weighting and ranking. Moreover, We would like to thank Meteorology Center of Kermanshah, Kermanshah the Arc/GIS software was used for displaying the conditions Water and Wastewater Company; Kermanshah Sports Department; of counties similar to some other studies [37]. Kermanshah Municipality; Industry, Mining, and Trade Organization of Kermanshah province; Kermanshah Governorate; and Kermanshah University The results of our study demonstrated that the counties of Medical Sciences. of Islamabad, Kangavar, Sarpol-e-Zahab, and Ravansar were far from the positive ideal and had the lowest ranks Authors’ contributions SR and ShS conceptualized the main idea. ShS designed and analyzed. SR, in terms of health equity in physical environment and ShS, ARZ, RazT, and RT interpreted the results and drafted the manuscript. All infrastructure. In addition to the necessity to investigate the authors take responsibility for the integrity of the work as a whole from the causes of this inequity, there is a need for scientific inception to the published article. SR is the guarantor. ShS, AA, MKh, SRN, and KGK conducted the corrections, further analysis, and language editing. planning and practical measures to reduce the inequalities. All the authors read and approved the final manuscript. This issue has become more important due to the 7.3 magnitude earthquake in 2017 in the west of Kermanshah Funding province, especially Sarpolzahab, Islamabad, and Ravansar, This study was funded by the Vice Chancellor for Research and Technology of Kermanshah University of Medical Sciences (grant number: 980463). which had destructive effects on physical infrastructure and health. Availability of data and materials The imbalance in the physical environment and infra- Data will be available upon request. structures in Kermanshah province means that the imple- mented policies have not led to health equity in the Ethics approval and consent to participate Approval of Research Ethics Committee (REC) of Kermanshah University of province. In studies conducted outside Iran, policy-making Medical Sciences was granted (code 980463). Consent to participate is not and planning have also been mentioned as important issues applicable. The permission and access to the data were obtained from the on health equity [38, 39]. Concentration of services in data holders. urban places created bipolar areas and also led to migration Consent for publication from the rural to urban areas, and subsequently creating Not applicable. theinequityand misdistribution of services and facilities in the province. Imbalance and inequality in infrastructure is Competing interests evident when we compare the counties. Javanrood and The authors declare no competing interests. Ravansar, as two neighboring counties, have the highest Author details and lowest rank in terms of equity in the physical environ- 1 Social Development & Health Promotion Research Center, Health Institute, ment and infrastructures, respectively. Similarly, Rezaei Kermanshah University of Medical Sciences, Kermanshah, Iran. Department of Nursing, School of Nursing and Midwifery, Hamadan University of Medical et al. concluded that Javanrood and Ravansar were devel- Sciences, Hamadan, Iran. Clinical Laboratory Science, Tabriz University, oped and underdeveloped in terms of access to health 4 Tabriz, Iran. Department of Art, Architecture and Design, University of South services, respectively [40]. This finding indicates the need to Australia, Adelaide, Australia. 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