Assessments of Gaps in Health Status of Urban Populations, and the Creation of an Improved Model for Urban Health Equity Assessment and Response Tool (Urban-Heart) in Tehran

Background Information

Due to the growing population of Tehran, the issue of health in the capital became an important issue and a major concern for urban managers. Due to the difference in the income level of different social groups, the Tehran Municipality realized that a gap in the health status of different social groups in Tehran has gradually formed. In order to find suitable solutions to this challenge, it was necessary to have a scientific, original and authentic evaluation and assessment of the current health status in Tehran. 

To this end, an improved model of the Urban Health Equity Assessment and Response Tool (Urban-Heart) in Tehran was defined as a modified version of the Urban-Heart project of the World Health Organization (WHO).                                             

Goals of the Initiative

The Urban-Heart project in Tehran seeks to help policy and decision makers at the national and local level to make better decisions regarding sustainable social development.

The main objectives are:

•To identify the differences between the health, health determinants and well-being of people living in disadvantaged urban areas and the general population.

•To determine appropriate, feasible, acceptable and cost-effective strategies, interventions and actions that can reduce inequity gaps between the residents of the city.

Employing Urban-Heart may create several bi-products for different parties, such as a unique index to measure inequities for policy makers, identification of current gaps and relationships to other indices for public health practitioners and empowering interested parties to care about health conditions at all social levels. 

Parties and Partners to the Initiative and Resources Used for Implementation

The Tehran Municipality is the main authorizer, mentor and partner for the implementation of this project. The Deputyship of Social and Cultural Affairs of the Tehran Municipality and the Department of Health of the Tehran Municipality were also partners of the initiative.       As a research project, members of universities and research institutions also played an important role for the project. Mohsen Asadi-Lari, MD PHD (Assistant Professor of Epidiomology), and Mohammad R Vaez-Mahdavi, MD (Professor of Physiology), led the research efforts of the initiative.

The resources used for implementing the initiative include:

Financial resources from the Tehran Municipality, the public and volunteers were the main financial support of this project.

Innovation for the Initiative

The "Health Equity Assessment and Response Tool" helps countries, cities, and districts to systemically assess and respond to the inequity of health conditions and in urban settings. It will also stimulate city-to-city learning and the sharing of experiences among countries and across regions.

An improved model of Urban-Heart is used in Tehran. It incorporates the six domains of infrastructure, social development, economy, governance, health and nutrition. 

The indicators are summarized as:

•Physical infrastructure: Indicators include safe drinking water: microbial, nitrate and nitrite; traffic accidents, burning, falling and other domestic accidents; electric shock suffocation, air pollution, noise pollution, access to public transport and health center utilization.

•Social development: Indicators include education (net enrollment rate and gross enrollment rate, attaining final year of primary school, illiteracy rate for the age of 15-24, adult illiteracy, higher education); domestic violence, street violence, death due to suicide and homicide, disabilities due to violence, adult smoking, addiction, smoke-free places, mental health and social capital

•Economic: Indicators include employment, residency in adequate homes, person per room per capita, fair financial contribution index, catastrophic costs, household costs, absolute and relative poverty, social welfare index and human development index (HDI).

•Governance (within Tehran): Indicators include annual reports by municipality (within districts), satisfaction of citizens with municipality services, lawfulness, responsiveness to citizens’ complaints (hot lines), contracts transparency (quantity, monetary) and community participation (local elections financial).

•Health: Indicators include vaccination, early pregnancy, exclusive breast feeding, 24 month breast feeding, infant mortality rate, under-five-year old mortality rate, maternal mortality rate, health-related quality of Life, safe delivery and disability

•Nutrition: Indicators include calorie poverty, waste, stunting, low birth weight, food diary, food costs, cereal costs and BMI.

Obstacles and Solutions for Innovation

Since the health of citizens is a personal issue for them involving information about their private lives, sometimes there were challenges in collecting appropriate data. Especially regarding women, due to the sensitivity of their health issues, this challenge proved to be more serious. 

With a proper introduction of the program, and by clarifying the importance of this issue for the citizens, they actively participated in the process and the problem was widely resolved.

Outcomes and Assessments

Outcomes achieved are as follows:

•The improvement of health and social status of people living in poor and disadvantaged urban areas.

•The mobilization of communities to promote health alongside equity determinants.

•The consideration of the importance of social determinants of health (SDH) in health equity.

•The promotion of activities reducing inequity in health and development at the city level.

•Value comparable equity data and analysis

•The planning of and implementation of interventions, actions and responses according to priorities.

Methods Applied

A Technical Survey Committee (TAC) was set up to determine which data collection approach would be appropriate. A comprehensive questionnaire was developed by TAC in order to collect data for all the indicators. To finalize the questionnaire, each single indicator was extensively discussed in different meetings with relevant experts from different disciplines. 

This questionnaire consisted of the following sections:

•House identification

•General information of all family members

•Home facilities and assets

•Health, vaccinations and health status within families

•Accidents and injuries

•Domestic violence

•Disabilities

•Responsiveness and satisfaction

•Household costs

•Smoking and addiction status

•Mental health status

•Health related quality of life (SF-12)

A specific questionnaire to assess ‘Social Capital’ was also added to the main questionnaire. This specific questionnaire had been employed in a number of surveys at national and local levels prior to the Urban-Heart survey. 

Benefits to Other Cities

The following achievements and goals are crucial to the Urban-Heart project, which enables urban managers to enhance the quality of life regarding the health of citizens. The following goals could be used as a model for other cities and regions in order to enhance the health equity of their cities.

•Promoting health indicators of the city

•Encouraging active participation of the society and empowering the people in securing and sustaining their own health and that of their communities

•Securing a healthy urban living environment

•Expanding applied research in the field of urban health

•Enhancement of the quality of life of the disabled, war-injured, war veterans and elderly people by making appropriate policies based on scientific surveys

•Prevention of hazardous activities and the rehabilitation of social harms

•Establishment of “comprehensive health system” for the city

•Securing food safety and ensuring food security

•Expanding the health-oriented approach to urban management