Mohammad-Sadegh Massarrat MD^•, Susan Tahaghoghi-Mehrizi MD

The health status of a country depends mainly on its socioeconomic and educational level as well as on the budget determined for its health services. Knowledge about the standards of health of a community enables the government to take the necessary measures for overcoming its health problems, defining health priorities and providing the budget needed to improve health through a well-organized plan.

The aims of these surveys were to increase the level of knowledge of health authorities about the health problems of Iran and to identify the quality and quantity of health problems in various parts of this country with respect to population, geographi-cal region and socioeconomic status. Similar studies have been conducted in other countries, but not on such a large scale.

Here, we briefly report some parts of the 1999 health survey and compare them with the survey of 1991.

The population sample of both surveys consisted of one thousandth of the total Iranian population; non-Iranians were excluded. They were randomly chosen by cluster sampling. Each cluster consisted of eight families which were visited on a single day by a team of four persons (two physicians, one interviewer, and one laboratory technician). Data derived from medical history, physical examination and laboratory findings were recorded.

The second survey was performed during a period of 2 years (1997-1999). The urban and rural population sample comprised of 1097 clusters (8776 families) and 509 clusters (4719 families), respectively. A total of 61,137 subjects (38279 from urban and 22,858 from rural areas) were interviewed. Paraclinical tests were performed in the laboratories of each province and included hemoglobin and hematocrit levels, MCV, cholesterol, HBsAg, HIV infection and stool examination. Six different questionnaires were completed as follows:

Questionnaire no. 1 contained general infor-mation about the cluster including the number of family members, their age and sex, and the nutritional status of children less than 3 years.

Table 1. Age distribution of the urban and rural populations of Iran.

Questionnaire no. 2 contained information about the standard of hygiene in the household. Questionnaire no. 3 contained information about the foodstuff ingested by the family within the last 48 hours. Questionnaire no. 4 was comprised of three parts: Part 1 contained questions about hygienic conditions, medical history and general physical state. Level of education and occupation of subjects older than 7 years, and martial status and smoking habit of subjects more than 15 years as well as the age of menopause of elderly females were also sought. Part 2 assessed the level of psychologic health and included seven questions about somatization, seven about anxiety state, seven about social dysfunction, and seven about depression. Part 3 contained questions about fertility in married 15 to 45-year-old female subjects. Questionnaire no. 5 contained information about the clinical findings detected by the examining physicians. Questionnaire no. 6 contained information about the results of blood and stool examinations.

The age distribution of the Iranian population is shown in Table 1. The populations under 10 years and older than 70 years were higher in rural areas, indicating a higher birth and survival rate in rural than urban areas. Of the 50285 subjects, 18.2% were illiterate; 77.3% of which were older than 70 years and 20.6% of males and 7% of females had received only 1 to 4 years of education.

The average weight of 40-49-year-old subjects was 71.9±12.5 kg. A total of 74.9% of subjects regularly washed their hands with soap and water before eating and after using the toilet and on the average they took a bath 2.1 times a week. Among the total subjects studied, 55676 were examined for dental health. Of these, 14.3% brushed their teeth at least once a day and 29.9% did not brush their teeth at all. Among the 36498 subjects older than 15 years, 88.1% were nonsmokers and 4.4% smoked more than 20 cigarettes per day. Pipes or water pipes were used by 3.6% of all smokers. Also, 1.8% of the population wore hearing aids and 12.3% wore glasses.

Table 2 shows the social characteristics of the urban and rural population of Iran. The marriage age of 15-49-year-old females was 18.1 years in urban and 17.3 years in rural areas. In the same age group, 5.9% of females in urban and 8.1 % of females in rural areas were pregnant.

Table 2. Social characteristics of the urban and rural population of Iran.

Contraception (oral pills, intrauterine devices, condoms or ligation procedures) was practiced by 57.4 % and 59.3 % of females in urban and rural areas, respectively. On the average, each family had 4.4 members and the mothers in urban and rural areas had 3 children and 3.7 children who were alive at that time, respectively. The mode of delivery was by cesarean section in 29.8% of cases. Of all deliveries, 93.4% of the children had been born alive and healthy, 5.6% had been aborted and 1% had been delivered dead.

Eye, ear, extremity and other organ defects were present in 2.7% of the population older than 2 years; 25% were congenital and 25% were caused by accidents.

Chronic cough (of more than 3 weeks duration) was present in 3.6% of the 40 to 69-year-old population and in 7.8% of those aged more than 70 years.

In females, constipation (passage of stools two times per week or less) showed a rise from 9.6% in the 40 to 69-year to 20.5% in the over 70-year age group. In the 40 to 69-year age group the prevalence was two-fold higher in females than in males but became equal thereafter.

Medication was regularly used by 22% and 29.9% of the 40 to 69-year and over 70-year age groups, respectively and was 1.5 times more common in females than males.

Laboratory studies were carried out for 84.6% of the total population studied. Mean hemoglobin concentration was 14.6 ± 1.6 g/dL (± 1 SD) and 13.2 ± 1.6 g/dL (± 1 SD) in males and females, respectively and the mean hematocrit concentration was 44.2% in males and 40.4% in females. The hemoglobin concentration was between 11g/dL and 11.9g/dL in 9.6% and 11g/dL or less in 5.4% of the population. Blood cholesterol level was high (≥ 240 mg/dL) in 14.3% of males and 20.7% of females aged between 40 and 69 years, and in 20.2% of males and 22.7% of females older than 69 years, with no significant differences between urban or rural areas.

Among the 46,631 subjects older than 1 year, 1.7% were hepatitis B virus (HBV) carriers. HBV infection rate increased from 0.8% in the 2 to 4-year age group to 2.9% in those aged more than 70 years, and was higher in males than females (1.9% vs. 1.5%). Only four of the 46,631 subjects examined for HIV were found to be positive. The prevalence of HIV infection was 8.6/100,000 in those aged 1 year or more.

Overall, the health and hygienic status of the Iranian population had improved. Table 3 compares the important characteristics of the first and second health surveys. The population less than 9 years and the number of family members per household had decreased showing that the family planning program had been successful. Also, the population older than 60 years had increased, indicating a higher life expectancy. The educated population had risen in both males and females as well as in the elderly population. More families had a higher per capita living surface area and access to a bath than that reported in the first survey. Regular hand washing with soap and water, before meals and after using the toilet, and the decrease in the frequency of parasitic infestations are signs of improved hygiene. Although the population of nonsmokers had not changed much in those aged 15 years or older, the proportion of young persons who had begun to smoke in the under-15-year age group had increased. The population who wore hearing aids had increased due to better economic conditions. In the first survey, body weight had been registered only for those less than 19 years. By comparison of the weight, there was a linear increase in the weight of both males and females aged between 2 and 18. However, the 18-year-olds weighed more in the first survey than in the second survey. Although increased body weight was evident in the second survey, due to a higher caloric intake, the cholesterol level had not increased in the corresponding age groups.

The prevalence of HBV infection had declined from 1.5% to 0.6% in children less than 14 years in rural areas and from 1.1% to 0.9% in those residing in urban areas, while in the older age groups there was no significant difference between the prevalence of HBV infection in urban and rural areas. It is assumed that the decline in HBV-carrier rate was due to the vaccination practice, which minimized longitudinal transmission of infection.

Table 3. Comparison of health indicators between 1991 and 1999.

Table 4. Population per physician and hospital beds per 10,000 population in Iran compared with other countries.⁴

Table 5. Comparison of cardiovascular disease risk factors in the 1999 Iranian National Health Survey with those of other countries.

Alcohol and infectious diseases, such as AIDS, do not play a major role in the development of disease in Iran. The important cardiovascular disease risk factors are compared with those of other developed countries (Europe and the USA) in Table 5, which provides insight into the cardiovascular risk status of the Iranian population and shows that these risk factors are rarer in Iran. Smoking, which is an important risk factor for cardiovascular diseases as well as for many types of cancer, is a less common habit in Iran as compared with Germany and the USA. In addition, it seems that conditions causing high mortality due to cardiovascular diseases are less frequent in the Iranian population. The fact that cardiovascular disease risk factors are less prevalent in Iran shows that better survival in Iranians depends mainly on the establishment of health services for the elderly.

The results of these surveys provided information, that was of value to the health authorities as well as to epidemiologists, and helped identify differences between the health services available in various parts of Iran. The major health problems were recognized and any weaknesses noted.

These surveys also helped determine the priorities for future research plans. Based on these findings, decisions were made about the methods used for promoting health, distributing the budget and assessing the effectiveness of health programs.

A shortcoming of these surveys, however, was that clinical examination was performed by many physicians and no standard or uniform staging system was used, thus interobserver variation affected the reliability of their clinical findings.