Socio-Economic Inequalities in Health-Related Quality of Life Among Iranian Adolescents: Application of Health Equity Assessment Toolkit Running title: Socio-Economic Inequalities & Health-Related Quality of Life

Socio-Economic Inequalities in Health-Related Quality of Life Among Iranian Adolescents: Application of Health Equity Assessment Toolkit Running title: Socio-Economic Inequalities & Health-Related Quality of Life | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Socio-Economic Inequalities in Health-Related Quality of Life Among Iranian Adolescents: Application of Health Equity Assessment Toolkit Running title: Socio-Economic Inequalities & Health-Related Quality of Life Azam Maleki, Elham Faghihzadeh, Samaneh Youseflu, Shahnaz Zamani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1774898/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Jan, 2023 Read the published version in BMC Pediatrics → Version 1 posted 8 You are reading this latest preprint version Abstract Background: One of the main concerns of public health is increasing inequality of health status, which has an adverse effect on people's life. Purpose : The current study aims to analyze the role of socioeconomic inequalities in health-related quality of life (QoL) among Iranian adolescents. Methods: A cross-sectional descriptive study was conducted on 576 adolescents aged 15 to 18 years. The samples were selected using the Multi-stage sampling method. Data were collected by a demographic checklist, and KIDSCREEN-52 questionnaire and analyzed by SPSS ver.16. The Health Equity Assessment Toolkit (HEAT) Version 4.0 (beta) was used to assess adolescents' QoL inequalities in terms of socio-economic subgroups. Results: The results show that 27.2 adolescents had low quality of life. The score of physical and autonomy components of QoL was significantly more in male versus school environment in female students. Also, the asset index, father's, and mother's education, and family income in female students, and the assets and family income in male students were significantly related to the quality of life (p<0.05). The risk of lower QOL in the poorest quintile was 1.12 times more than in the richest quintile. The consideration index of Asset in terms of sex was 4.5 and the modified Gini index was more than 0.5 in females and males. Conclusion: Our findings highlight the significant effects of socioeconomic inequality on HRQL of Iranian adolescents. Requires a targeted policy approach to reach the poorest quintile for improving the quality of life of adolescents. Health-related quality of life socio-economic inequality adolescence 1. Introduction Adolescence is a major transition period and is one of the most critical, and sensitive stages of life for adolescents and their families. Upon entering this course of life, adolescents experience profound physical, psychological, social, and cognitive changes, so it is very important to pay attention to their health and well-being of them from different aspects. ( 1 , 2 ) Furthermore, their health and well-being are essential for their growth and development, including the acquisition of emotional and cognitive abilities for independence, completion of education, transition to employment, civic participation and the establishment of lifelong relationships. ( 1 – 3 ) As a result, childhood-living conditions are considered the basis, and foundations of lifelong health. ( 4 ) In some counties, little investment has been made in adolescent health needs and their concerns in the primary health care system are neglected ( 5 ). In Iran, like in other countries, due to quarantine conditions and social distance, some families have experienced changes in terms of social, cultural, economic and lifestyle( 6 ). Providing a clear and complete overview of the situation and the health inequality could help to prioritize the target audience's needs and technical knowledge( 7 ). Assessing youth and adolescents' quality of life is of great importance due to the rapid emotional and cognitive changes that are characteristic of this age group. ( 5 , 8 ) Health-Related Quality of Life (HRQL) is a measure used to assess physical and social functioning, mental health, and well-being as health outcomes among children and adolescents, as well as to evaluate population-based intervention programs. ( 8 ) The components of adolescents 'quality of life are different from those of adults because, in addition to the physical and psychological components, their relationship with family and peers and the school environment should also be considered, which is less important in adulthood. ( 9 ) Therefore, the quality of life of adolescents should be considered in different dimensions. Measuring quality of life can improve clinical decision making, evaluate the quality of medical care, estimate health care needs in a particular population, understand the different causes and consequences in health, and ultimately health policy. ( 10 , 11 ) Some experts consider the quality of life of children and adolescents as a mental and changeable feeling about their health and believe that this feeling is a reflection of their desires, hopes, and expectations about their current and future life situation, which is influenced by factors such as gender, age, personal and family characteristics, as well as economic and social status. ( 12 , 13 ) The socioeconomic status indicated an overall measure of the economic and social status of people or their families relative to others, which were measured by income, occupation, and education. ( 14 ) The socio-economic status, and family environment are related to an adolescent health condition, so unhealthy habits, unavailability of healthcare services, and face higher socio-economic pressure are more seen in people who have low socioeconomic status. ( 5 , 15 ) Furthermore, the availability of material and social resources and reactions to stress-inducing conditions by peers, and their family can impress adolescent health ( 15 , 16 ). Also, socioeconomic status is related to health inequality. ( 17 ) There is an enormous body of evidence showing the effect of socioeconomic status on children and adolescents' quality of life. ( 5 , 12 , 16 , 18 ) The adolescence QoL could be influenced by many factors, such as socioeconomic status, parental educational level, better work status, household income, age, gender, higher family wealth, high level of social capital, migration, positive family climate, personal factor (i.e., self-efficacy, optimism, sense of coherence), and social support. ( 5 , 12 , 16 , 18 ) One of the main concerns of public health is increasing inequality of health status, which has an adverse effect on people's life. Considering the importance of assessing the HRQL of adolescents as an indicator of justice in health and its impact on social and individual factors, the current study aims to analyze the role of socioeconomic inequalities in health-related quality of life (QoL) among Iranian adolescence 2. Material & Method 2.1. Type of study & Study setting The cross-sectional study was conducted in Zanjan city, a province northwest of Iran from December 2020 to February 2021. The study setting included all health centers that were located in the capital of the province. The study population included all adolescents who were referred to the centers. 2.2. Participants & Sampling procedure Considering the acceptable percentage of quality of life 50% ( 19 ), statistical error of 5%, acceptable accuracy of 4% the total sample size was estimated at 600 people. Inclusion criteria were healthy adolescents, aged 15–18 years, and willingness to participate in the study. In Iran, all people living in urban and rural areas, including adolescents, are covered by health centers and can be identified by a national electronic identification code. Reproductive health care services, cancer screening and vaccinations are provided at health centers. But there is no specific care for teenagers. In this study, eligible adolescents were selected using the multi-stage sampling method in this way. Level 1: to access the diversity of socio-economic samples, the residential areas of Zanjan city were clustered into four-level based on municipal zoning. The city has 4 municipal zoning and 35 health centers. Level 2: three health centers were selected randomly in each selected area. Level 3: the eligible cases be randomly selected using their identification number through a national electronic identification system (CIB), and then data be collected through interviews by trained providers. In this way, they called the person and after explaining the objectives of the study and obtaining verbal consent to participate in the study, the questionnaires were completed according to the statements of the participants. If there are no eligible people in the household, who did not want to participate in the study, or did not answer the phone number after two calls the selected number is removed and the next number replaced. The response rate in this study was about 75%. 2.3. Measures 2.3.1. Demographic questionnaire : A self-designed questionnaire was used to assess socioeconomic and demographic characteristics including Age, Sex, Birth rank, Father's job, Mother's job, Father's education, Mother's education, Family income, Family home ownership status, Insurance, and assets. To collect the household asset data, we used a questionnaire in which we asked if their family-owned any of the 16 household assets. Then household assets are categorized into quintiles. We also collect family’ income status on a qualitative scale at three levels" lower than adequacy", "Adequate", and" More than adequacy". 2.3.2. The KIDSCREEN-52 questionnaire The KIDSCREEN is a self-report measure to assess children’s and adolescents’ health-related quality of life (HRQOL) aged from 8 to 18 years. The time frame refers to the past week. The questionnaire was developed and tested within a European public health project. The questionnaire included ten dimensions: Physical- (5 items), Psychological Well-being (6 items), Moods and Emotions (7 items), Self-Perception (5 items), Autonomy (5 items), Parent Relations and Home Life (6 items), Social Support and Peers (6 items), School Environment (6 items), Social Acceptance (Bullying) (3 items), Financial Resources (3 items). The scoring of each question is in a five-point of a Likert scale, with the frequency of a particular behavior or feeling (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always) or the severity of attitude (1 = not at all, 2 = partially, Shows 3 = average, 4 = very much, 5 = infinite). The following questions are scored in reverse (12-13-14-15-16-17-18-21-22-23-50-51-52). The overall scores ranged from 52 to 260. A higher score means a better quality of life. In this study, the overall score of QOL was categorized in tertile levels. The score lower than 25%, 25 to 75%, and more than 75% of total scores were considered poor, moderate, and good levels, respectively. The internal consistency reliability of the instrument was reported by Cronbach's alpha method in all dimensions between 0.77 to 0.89. ( 9 ) The Persian version of the KIDSCREEN-52 has adequate reliability and validity in Iranian adolescents. ( 20 ) 2.4. Statistical analysis Data weighted by the population covered for each municipal zoning. The data were analyzed using the Statistical Package for Social Science (SPSS) 16. Descriptive statistics including the mean ± SD, frequencies, and percentage used to describe the demographic status of participants. The independent t-test and chi-square test were also used to compare the continuous and dichotomous variables between the groups, respectively. The principal component analysis (PCA) was used to reduce the large data sets of asset ownership variables into a smaller number of dimensions. Because smaller data sets are easier and faster to analyze without extraneous variables to process. A total of 6 items were retained with higher eigenvalues (> 1) accounting for 51.164% of the variance. They were considered one of the socio-economic indices in this study. The Health Equity Assessment Toolkit (HEAT) Version 4.0 (beta) was used to assess adolescents' QOL inequalities in terms of socio-economic subgroups. A summary measure of health inequality, including Concentration Index, Ratio (R), and Modified Gini was used to report numerical results. The Gini index < 0.2 represents perfect income equality, 0.2–0.3 relative equality, 0.3–0.4 adequate equality, 0.4–0.5 big income gap, and above 0.5 represents a severe income gap. 3. Results A total of 600 questionnaires were completed. Twenty-one questionnaires were not analyzed due to incomplete data; therefore, the reported results included 579 samples. The results of demographic characteristics of students have been shown in table1 according to the results, the highest percentage of participants in the study was male (50.3%) and aged 16 years (35.1%). Most of them have more than 1 in birth rank (51.7%), have insurance (81.4%) and have lower than adequate family income (51.7%). Most of her/his fathers (34.6%) and mothers (30.3%) had a diploma education level. Furthermore, the job status of her/his father (40.1%) and mother (80.1%) was self-employed and unemployed respectively (Table1). 3.1 QOL status of participants The mean (SD) and median QOL were 196.51(17.22) and 196.00 respectively. Furthermore, the percentage of a poor, moderate, and good level of QOL was 27.2%, 49.8%, and 23% respectively. 3.2 Socio-Economic Inequality Considering the median cutoff point of the quality-of-life score, the socio-economic inequality, and the quality of life compared between male and female students. The result showed that the asset, father's education, mother's education, and family income in female students, the assets and family income in male students were significantly related factors to the quality of life (p<0.05) (Table2). The comparison of quality-of-life component scores between male and female students showed that the physical and autonomy components were significantly more in male versus school environment components scores was in female students (Table 3). There were economic-related inequalities in the QOL of adolescents in Zanjan. The score of QOL increases with increasing economic status. QoL was lowest in the poorest quintile (40.3) and the highest in the richest quintile (65.7). The risk of lower QOL in the poorest quintile was 1.12 times more than in the richest quintile (Table 4). The consideration index of Asset in terms of sex was 4.5 and the modified Gini index was more than 0.5 in females and males. The result showed that the quality of life of both sexes was affected by economic status (Table 5). 4. Discussion This study describes the HRQL of a sample of Iranian adolescents and also assesses the influential factors of HRQL in 15–18-year-old adolescents. Our results show that the majority of participants had moderate, and good levels of HRQL. The component of HRQL was different between female and male adolescence. In males, physical and autonomy components were more than in females, and school environment components had more effect on HRQL of female adolescence. Moreover, there are positive correlations between socio-economic backgrounds and HRQL. Many studies highlight the importance of socioeconomic inequality on the adolescent quality of life. ( 5 , 15 , 17 , 18 ) In this regard, Hovsepian et al. study reported a positive association between socioeconomic status, school functioning, psychosocial function, and total score of HRQOL in both males, and female students. Moreover, in their study all components of HRQL except its social subscale were low in female adolescence, ( 21 ) while in our study, boy adolescents only have better scores in the physical and autonomy components of HRQL than girls. The field of autonomy examines the adolescent's freedom of choice, self-sufficiency, and independence, and considers the individual's opportunities to create leisure and social activity. ( 22 ) Upon entering this period of life, very profound biological, psychological and social changes occur in adolescents. ( 1 , 23 ) The need for connection can create a conflict between the desires of the adolescent and their family, thereby putting his or her independence at risk. ( 23 ) We observed a lower score of autonomy component in girls, which indicated more communication problems with parents. It seems that socio-cultural issues related to gender role, preference and more attention for the male sex, brain development, and different physiological changes following puberty play an important role in this difference. The school environment was one of the main components of HRQL and has a greater impact on girls vs. boys. Similar to our results, Gaspar et al. show that female students compared with males had a lower level of quality of life in all domains except school environments ( 24 ). In the same sense, another study revealed that adolescents with positive perceptions about their school climate had good self-rated health, school satisfaction, and quality of life. ( 24 ) Explaining the role of gender differences in health-related quality of life, Hyde states in his gender similarity hypothesis that males and females are similar in most psychological variables. Only in variables such as motor behavior, aggression, and some aspects of sexual activity, there are differences between the two sexes. ( 25 ) Furthermore, physical changes during puberty in girls, such as the onset of menstruation and hormonal imbalances, decrease their psychological well-being compared to boys. ( 26 ) We also observe those female adolescents compared with males had lower scores in the physical component. In this regard, Michel state that physical changes during puberty and conflict with exaggerated cultural norms of beauty make girls feel more unbalanced in their physical and mental well-being. ( 27 ) In this study, the relationship between income inequality and HRQL was evaluated using the Concentration Index, Ratio (R), and Modified Gini Index. The Gini index as one of the measures of health inequality examines the distribution of income, or in other words, the distribution of wealth among a population. The Gini coefficient is a number between zero and 1(0 denoting complete equality and 1 complete inequality). We observed a modified Gini index of more than 0.5 in females and males, which indicated a severe income gap. Assessing the relationship between these variables, and HRQL reveal that the quality of life in both sexes was affected by economic status. Our finding also reveals that socio-economic variables that affect HRQL are different between male and female adolescence. Parental education was one of the main factors of female adolescence, and variables such as assets, and family income were effective on HRQL of both groups. These results are consistent with the findings of other studies in this field. ( 5 , 15 , 17 , 18 ) In line with our study, Spurrier et al. reported a high level of HRQL among children in families of higher income, educated, as well as employed. Moreover, they reported living in an original family with both parents has a positive impact on HRQL. ( 28 ) Also, in Barriuso-Lapresa, et al. study, there was a high quality of life, and mental health for children of mothers who had a university degree, and high social classes. ( 29 ) The results of one path analysis show the major effects of socioeconomic status (eg, occupational prestige, household income, and parental education), social support on HRQL, and health behavior such as smoking, and toothbrush in adolescents. ( 30 ) Another study demonstrated that gender, ethnicity, maternal education level, socio-economic status and weight status are the main predictors of HRQL. ( 31 ) Our study was conducted during the second peak of the COVID-19 pandemic. Previous literature has documented the negative effects of this pandemic on both HRQL and family income. ( 32 – 35 ) Studies have shown that the COVID-19 outbreaks have caused the biggest shock to the world economy, so the implementation of government disease control policies, such as social exclusion and quarantine, has led to the temporary closure of businesses. ( 32 , 33 ) Shrinking the global economy, increasing unemployment, poverty, income inequality, gender inequality, and widening the gap between different countries are just some effects of this pandemic. ( 33 , 34 ) All of these factors can have adverse effects on a person's quality of life. Tran et al. study shows a negative effect of COVID-19 on household income and psychological health. And they state that having a chronic disease, female gender, and living in a family with 3–5 members were related to low-quality life. ( 36 ) In another study, during the outbreak, socio-economic inequality was one of the main predictors of death in Brazilian children. ( 37 ) Ravens-Sieberer et al. reported that children and adolescents experienced a high level of anxiety, mental health problems, and low HRQL after the COVID-19 pandemic, and socioeconomic status, migration background and limited living space had the greatest impact. ( 38 ) In Adıbelli et al. study, the score of the quality of life of children was good, but their parents reported that in their children gained weight, tendency to sleep and internet use increased during the pandemic. ( 39 ) 4.1. Limitation One of the limitations of this study is that we didn't assess the influence of other variables such as psychological wellbeing, parental relationship, and COVID-19-related issues, which can affect the HRQL of adolescence. It has been suggested that future studies consider them in the study design. However, this study was conducted during the QOVID-19 pandemic, but their information (such as disease status, the impact of COVID-19 on their socioeconomic status, quarantine, etc.) is not available. Also, the design of this study is cross-sectional, so the causal relationship between the variables is not predictable. However, according to the definition of the WHO, adolescence is in the age range of 11 to 21 years, and we only included 15 to 18 years of age (middle adolescence age) in the study. 5. Conclusion Our findings highlight the significant effects of socioeconomic inequality on HRQL of Iranian adolescents. Since having a healthy society requires improving the quality of life, it is suggested that health policymakers consider comprehensive planning in the field of economic equality, and improving the quality of life of adolescents. Socio-economic inequalities should also be considered when designing interventions to improve adolescents' quality of life. Declarations Ethics approval and consent to participate The protocol of the current study was approved by the Ethics Committee of Zanjan University of medical science (IR. ZUMS. REC. 1399.064). The consent was obtained from all participants and their parents. Also, they all made sure that their information will be kept private and confidential. All procedures were in accordance with the ethical standards of the Regional research committee and with the Declaration of Helsinki 1964 and its later amendments. Due to the coid-19 restriction data was collected by telephone and informed verbal consent was obtained from all participants and their parents included in the current study. Consent for publication: Not applicable Availability of data and materials: The data sets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare no conflict of interest. Funding: The current study was funded by social determinent research center of Zanjan University of medical sciences (The code “A-11-344-15-6”). Authors' contributions: A.M & S.Y. wrote the main manuscript text and E.F. analyzed the data. Sh. Z prepared the tables and figures. All authors reviewed the manuscript. Acknowledgements The article is a part of a research project that has been approved by the Social determinant of health research center of Zanjan University of Medical Sciences with the code A-11-344-18. The researchers would like to thank the staff of health center for your collaboration and all mothers for participating in this study. References Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. The Lancet Child & Adolescent Health. 2018;2(3):223-8. Susman EJ, Koch PB, Maney DW, Finkelstein JW. Health promotion in adolescence: Developmental and theoretical considerations. Early Adolescence: Routledge; 2020. p. 247-60. 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Tables Table 1 Baseline socio-demographic characteristics of participants(n=579) * Variables Frequency (%) Asset Component Steam Cleaner Wash Floor 14.2 Stove with Oven 36 Handmade carpets 26.9 Microwave oven 27.6 Home Dish Washing Machine 18.7 Laptop 38.3 Sex Female 288(49.7) Male 291(50.3) Age(year) 15 135(23.3) 16 203(35.1) 17 161(27.8) 18 80(13.8) Family home ownership status Leased 95(16.4) Personal 470(81.2) Other 14(2.4) Father's job Unemployed 51(8.9) Worker 65(11.4) Self-employer 229(40.1) Government employee 133(23.3) Other 93(16.3) Mother's job Unemployed 464(81.1) Employed 108(18.9) Mother's education Illiterate 30(5.2) Primary 132(22.9) Guidance 108(18.7) High school& diploma 175(30.3) College 132(22.9) Insurance Yes 468(81.4) No 107(18.6) Birth rank 1 279(48.3) >1 299(51.7) Family income Lower than adequacy 390(67.5) Adequate 155(26.8) More than adequacy 33(5.7) Father's education Illiterate 24(4.2) Primary 94(16.3) Guidance 93(16.2) High school& diploma 199(34.6) College 165(28.7) Table 2 Socio-economic inequality of QoL in term of gender Variables Lower Than Median Upper Than Median P Value Female N(%) Male N(%) Female N(%) Male N(%) Asset Quantile Poorest 40(26.5) 28(20.9) 20(16.0) 27(18.8) Female=0.045 Male=0.021 Poorer 28(18.5) 37(27.6) 19(15.2) 31(21.5) Middle 39(25.8) 27(20.1) 29(23.2) 20(13.9) Richer 25(16.6) 26(19.4) 28(22.4) 26(18.1) Richest 19(12.6) 16(11.9) 29(23.2) 40(27.8) Father's Job Government Employee 30(19.4) 25(18.0) 38(27.9) 41(28.1) Female=0.08 Male=0.062 Self-Employer 62(40.0) 50(36.0) 58(45.0) 59(40.4) Worker 22(14.2) 22(15.8) 8(6.2) 13(8.9) Other 23(14.8) 27(19.4) 17(13.2) 25(17.1) Unemployed 18(11.6) 15(10.8) 10(7.8) 8(5.5) Mother's Job Unemployed 132(84.1) 111(81.0) 104(80.6) 117(79.6) Female=0.444 Male=0.762 Employed 25(15.9) 26(19.0) 25(19.4) 30(20.4) Father's Education Illiterate 10(6.3) 4(2.9) 4(3.1) 6(4.1) Female=0.041 Male=0.128 Primary 35(22.2) 21(15.0) 19(14.7) 19(13.0) Guidance 27(17.1) 31(22.1) 16(12.4) 19(13.0) High School, Diploma 57(36.1) 47(33.6) 49(38.0) 46(31.5) College 29(18.4) 37(26.4) 41(31.8) 56(38.4) Mother's Education Illiterate 9(5.7) 9(6.4) 2(1.5) 10(6.8) Female=0.006 Male=0.118 Primary 41(25.9) 36(25.7) 30(23.1) 25(17.0) Guidance 39(24.7) 29(20.7) 17(13.1) 23(15.6) High School, Diploma 39(24.7) 39(27.9) 53(40.8) 44(29.9) College 30(19.0) 27(19.3) 28(21.5) 45(30.6) Family income Lower than adequacy 120(75.9) 117(83.0) 71(55.0) 82(55.4) Female=0.001 Male=0.001 Adequate 34(21.5) 20(14.2) 48(37.2) 52(35.1) More than adequacy 4(2.5) 4(2.8) 10(7.8) 14(9.5) Family home ownership status Personal 117(74.1) 117(83.0) 108(83.1) 126(85.1) Female=0.117 Male=0.211 leased 36(22.8) 22(15.6) 21(16.2) 16(10.8) other 5(3.2) 2(1.4) 1(0.8) 6(4.1) Table 3 the comparison of quality-of-life components between male and female QOL components Sex Mean (SD) P value Physical Female 18.62(3.00) 0.001 Male 19.44(3.02) Psychological Well-being Female 22.50(3.02) 0.984 Male 22.51(3.26) Moods and Emotions Female 29.47(3.61) 0.450 Male 29.23(4.27) Self-Perception Female 19.42(2.97) 0.786 Male 19.35(2.90) Autonomy Female 17.66(2.94) 0.036 Male 18.17(2.96) Parent Relations and Home Life Female 23.64(2.94) 0.120 Male 23.26(3.00) Financial Resources Female 10.54(2.08) 0.521 Male 10.64(1.94) Social Support and Peers Female 18.94(4.36) 0.979 Male 18.93(4.38) School Environment Female 21.99(2.91) 0.044 Male 21.47(3.29) Social Acceptance (Bullying) Female 13.71(1.38) 0.514 Male 13.79(1.51) Total score Female 179.20(14.40) 0.03 Male 179.16(16.04) Table 4 Economic- related inequality in QOL Asset affected population Estimate CI 95% Setting average Poorest 24.0 % 40.3 32.0 48.5 47.9 Poorer 19.8 43.5 33.4 51.8 Middle 19.8 43.5 34 52.7 Richer 18.3 50.9 41.3 60.6 Richest 18.1 65.7 56.5 74.9 Risk Q1/Q5= 24/19.8= 1.12 Table 5 consideration index of Asset in term of sex Index N of obs. Index value Std. error P value Modified Gini Female 276 .61403232 .00097112 0.001 Male 280 .61981277 0.00132458 0.001 Absolute concentration index 4.5 - Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Jan, 2023 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Major revision 29 Aug, 2022 Reviews received at journal 18 Aug, 2022 Reviewers agreed at journal 08 Aug, 2022 Reviewers invited by journal 05 Aug, 2022 Editor assigned by journal 05 Aug, 2022 Editor invited by journal 22 Jun, 2022 Submission checks completed at journal 22 Jun, 2022 First submitted to journal 19 Jun, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1774898","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":115531011,"identity":"7f39bfef-dec4-4d49-93ac-a6e1534df2cb","order_by":0,"name":"Azam Maleki","email":"","orcid":"","institution":"Zanjan University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Azam","middleName":"","lastName":"Maleki","suffix":""},{"id":115531013,"identity":"2e911439-78f7-4855-9c94-40598b62d3a4","order_by":1,"name":"Elham Faghihzadeh","email":"","orcid":"","institution":"Zanjan University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Elham","middleName":"","lastName":"Faghihzadeh","suffix":""},{"id":115531014,"identity":"cb3e94e0-675f-4ecb-8768-0423f1289b77","order_by":2,"name":"Samaneh Youseflu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYPACORkG9gYGZlK0GPMw8BwgWYtEApFa5Bt4DB/+qDDgMbj5xvBzQYUNA397dwJeLQYHeIyNec4AtdzOMZaecSaNQeLM2Q34tTDwmEkztv0BaTGQ5m07zGAgkYtfC9BhZpI//4Ecdsb4N1FaGA7wmEnwNgC13ABaR5QWg8NsxcY8xwx4JM+klVnznEnjIegX+fbmjQ9/1BjI8R0/vPk2T4WNHH97LwGHMXMYQFkQBg9+5WDA/gCdMQpGwSgYBaMAFQAAPOw+lv4Gd6kAAAAASUVORK5CYII=","orcid":"","institution":"Isfahan University of medical sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Samaneh","middleName":"","lastName":"Youseflu","suffix":""},{"id":115531018,"identity":"87884f4e-e890-4e1a-aec2-95632419a9cb","order_by":3,"name":"Shahnaz Zamani","email":"","orcid":"","institution":"Zanjan University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shahnaz","middleName":"","lastName":"Zamani","suffix":""}],"badges":[],"createdAt":"2022-06-20 03:59:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1774898/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1774898/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-022-03815-z","type":"published","date":"2023-01-11T18:16:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44716546,"identity":"0b7c0d9d-badc-4f54-ac40-01729f27fc33","added_by":"auto","created_at":"2023-10-16 18:26:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":405571,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1774898/v1/5aabb740-44e4-491d-8f65-8a53fa3ea2f2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Socio-Economic Inequalities in Health-Related Quality of Life Among Iranian Adolescents: Application of Health Equity Assessment Toolkit Running title: Socio-Economic Inequalities \u0026 Health-Related Quality of Life","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAdolescence is a major transition period and is one of the most critical, and sensitive stages of life for adolescents and their families. Upon entering this course of life, adolescents experience profound physical, psychological, social, and cognitive changes, so it is very important to pay attention to their health and well-being of them from different aspects. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Furthermore, their health and well-being are essential for their growth and development, including the acquisition of emotional and cognitive abilities for independence, completion of education, transition to employment, civic participation and the establishment of lifelong relationships. (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) As a result, childhood-living conditions are considered the basis, and foundations of lifelong health. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) In some counties, little investment has been made in adolescent health needs and their concerns in the primary health care system are neglected (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In Iran, like in other countries, due to quarantine conditions and social distance, some families have experienced changes in terms of social, cultural, economic and lifestyle(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Providing a clear and complete overview of the situation and the health inequality could help to prioritize the target audience's needs and technical knowledge(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAssessing youth and adolescents' quality of life is of great importance due to the rapid emotional and cognitive changes that are characteristic of this age group. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Health-Related Quality of Life (HRQL) is a measure used to assess physical and social functioning, mental health, and well-being as health outcomes among children and adolescents, as well as to evaluate population-based intervention programs. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) The components of adolescents 'quality of life are different from those of adults because, in addition to the physical and psychological components, their relationship with family and peers and the school environment should also be considered, which is less important in adulthood. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Therefore, the quality of life of adolescents should be considered in different dimensions. Measuring quality of life can improve clinical decision making, evaluate the quality of medical care, estimate health care needs in a particular population, understand the different causes and consequences in health, and ultimately health policy. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Some experts consider the quality of life of children and adolescents as a mental and changeable feeling about their health and believe that this feeling is a reflection of their desires, hopes, and expectations about their current and future life situation, which is influenced by factors such as gender, age, personal and family characteristics, as well as economic and social status. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe socioeconomic status indicated an overall measure of the economic and social status of people or their families relative to others, which were measured by income, occupation, and education. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) The socio-economic status, and family environment are related to an adolescent health condition, so unhealthy habits, unavailability of healthcare services, and face higher socio-economic pressure are more seen in people who have low socioeconomic status. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) Furthermore, the availability of material and social resources and reactions to stress-inducing conditions by peers, and their family can impress adolescent health (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Also, socioeconomic status is related to health inequality. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) There is an enormous body of evidence showing the effect of socioeconomic status on children and adolescents' quality of life. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe adolescence QoL could be influenced by many factors, such as socioeconomic status, parental educational level, better work status, household income, age, gender, higher family wealth, high level of social capital, migration, positive family climate, personal factor (i.e., self-efficacy, optimism, sense of coherence), and social support. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOne of the main concerns of public health is increasing inequality of health status, which has an adverse effect on people's life. Considering the importance of assessing the HRQL of adolescents as an indicator of justice in health and its impact on social and individual factors, the current study aims to analyze the role of socioeconomic inequalities in health-related quality of life (QoL) among Iranian adolescence\u003c/p\u003e"},{"header":"2. Material \u0026 Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Type of study \u0026amp; Study setting\u003c/h2\u003e \u003cp\u003eThe cross-sectional study was conducted in Zanjan city, a province northwest of Iran from December 2020 to February 2021. The study setting included all health centers that were located in the capital of the province. The study population included all adolescents who were referred to the centers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Participants \u0026amp; Sampling procedure\u003c/h2\u003e \u003cp\u003eConsidering the acceptable percentage of quality of life 50% (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), statistical error of 5%, acceptable accuracy of 4% the total sample size was estimated at 600 people. Inclusion criteria were healthy adolescents, aged 15\u0026ndash;18 years, and willingness to participate in the study. In Iran, all people living in urban and rural areas, including adolescents, are covered by health centers and can be identified by a national electronic identification code. Reproductive health care services, cancer screening and vaccinations are provided at health centers. But there is no specific care for teenagers. In this study, eligible adolescents were selected using the multi-stage sampling method in this way. Level 1: to access the diversity of socio-economic samples, the residential areas of Zanjan city were clustered into four-level based on municipal zoning. The city has 4 municipal zoning and 35 health centers. Level 2: three health centers were selected randomly in each selected area. Level 3: the eligible cases be randomly selected using their identification number through a national electronic identification system (CIB), and then data be collected through interviews by trained providers. In this way, they called the person and after explaining the objectives of the study and obtaining verbal consent to participate in the study, the questionnaires were completed according to the statements of the participants. If there are no eligible people in the household, who did not want to participate in the study, or did not answer the phone number after two calls the selected number is removed and the next number replaced. The response rate in this study was about 75%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Measures\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1. \u003cb\u003eDemographic questionnaire\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eA self-designed questionnaire was used to assess socioeconomic and demographic characteristics including Age, Sex, Birth rank, Father's job, Mother's job, Father's education, Mother's education, Family income, Family home ownership status, Insurance, and assets. To collect the household asset data, we used a questionnaire in which we asked if their family-owned any of the 16 household assets. Then household assets are categorized into quintiles. We also collect family\u0026rsquo; income status on a qualitative scale at three levels\" lower than adequacy\", \"Adequate\", and\" More than adequacy\".\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2. The KIDSCREEN-52 questionnaire\u003c/h2\u003e \u003cp\u003eThe KIDSCREEN is a self-report measure to assess children\u0026rsquo;s and adolescents\u0026rsquo; health-related quality of life (HRQOL) aged from 8 to 18 years. The time frame refers to the past week. The questionnaire was developed and tested within a European public health project. The questionnaire included ten dimensions: Physical- (5 items), Psychological Well-being (6 items), Moods and Emotions (7 items), Self-Perception (5 items), Autonomy (5 items), Parent Relations and Home Life (6 items), Social Support and Peers (6 items), School Environment (6 items), Social Acceptance (Bullying) (3 items), Financial Resources (3 items). The scoring of each question is in a five-point of a Likert scale, with the frequency of a particular behavior or feeling (1\u0026thinsp;=\u0026thinsp;never, 2\u0026thinsp;=\u0026thinsp;rarely, 3\u0026thinsp;=\u0026thinsp;sometimes, 4\u0026thinsp;=\u0026thinsp;often, 5\u0026thinsp;=\u0026thinsp;always) or the severity of attitude (1\u0026thinsp;=\u0026thinsp;not at all, 2\u0026thinsp;=\u0026thinsp;partially, Shows 3\u0026thinsp;=\u0026thinsp;average, 4\u0026thinsp;=\u0026thinsp;very much, 5\u0026thinsp;=\u0026thinsp;infinite). The following questions are scored in reverse (12-13-14-15-16-17-18-21-22-23-50-51-52). The overall scores ranged from 52 to 260. A higher score means a better quality of life. In this study, the overall score of QOL was categorized in tertile levels. The score lower than 25%, 25 to 75%, and more than 75% of total scores were considered poor, moderate, and good levels, respectively.\u003c/p\u003e \u003cp\u003eThe internal consistency reliability of the instrument was reported by Cronbach's alpha method in all dimensions between 0.77 to 0.89. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) The Persian version of the KIDSCREEN-52 has adequate reliability and validity in Iranian adolescents. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Statistical analysis\u003c/h2\u003e \u003cp\u003eData weighted by the population covered for each municipal zoning. The data were analyzed using the Statistical Package for Social Science (SPSS) 16. Descriptive statistics including the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, frequencies, and percentage used to describe the demographic status of participants. The independent t-test and chi-square test were also used to compare the continuous and dichotomous variables between the groups, respectively.\u003c/p\u003e \u003cp\u003eThe principal component analysis (PCA) was used to reduce the large data sets of asset ownership variables into a smaller number of dimensions. Because smaller data sets are easier and faster to analyze without extraneous variables to process.\u003c/p\u003e \u003cp\u003eA total of 6 items were retained with higher eigenvalues (\u0026gt;\u0026thinsp;1) accounting for 51.164% of the variance. They were considered one of the socio-economic indices in this study.\u003c/p\u003e \u003cp\u003eThe Health Equity Assessment Toolkit (HEAT) Version 4.0 (beta) was used to assess adolescents' QOL inequalities in terms of socio-economic subgroups. A summary measure of health inequality, including Concentration Index, Ratio (R), and Modified Gini was used to report numerical results. The Gini index\u0026thinsp;\u0026lt;\u0026thinsp;0.2 represents perfect income equality, 0.2\u0026ndash;0.3 relative equality, 0.3\u0026ndash;0.4 adequate equality, 0.4\u0026ndash;0.5 big income gap, and above 0.5 represents a severe income gap.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 600 questionnaires were completed. Twenty-one questionnaires were not analyzed due to incomplete data; therefore, the reported results included 579 samples. The results of demographic characteristics of students have been shown in table1 according to the results, the highest percentage of participants in the study was male (50.3%) and aged 16 years (35.1%). Most of them have more than 1 in birth rank (51.7%), have insurance (81.4%) and have lower than adequate family income (51.7%). Most of her/his fathers (34.6%) and mothers (30.3%) had a diploma education level. Furthermore, the job status of her/his father (40.1%) and mother (80.1%) was self-employed and unemployed respectively (Table1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1 QOL status of participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean (SD) and median QOL were 196.51(17.22) and 196.00 respectively. Furthermore, the percentage of a poor, moderate, and good level of QOL was 27.2%, 49.8%, and 23% respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Socio-Economic Inequality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsidering the median cutoff point of the quality-of-life score, the socio-economic inequality, and the quality of life compared between male and female students. The result showed that the asset, father\u0026apos;s education, mother\u0026apos;s education, and family income in female students, the assets and family income in male students were significantly related factors to the quality of life (p\u0026lt;0.05) (Table2).\u003c/p\u003e\n\u003cp\u003eThe comparison of quality-of-life component scores between male and female students showed that the physical and autonomy components were significantly more in male versus school environment components scores was in female students (Table 3).\u003c/p\u003e\n\u003cp\u003eThere were economic-related inequalities in the QOL of adolescents in Zanjan. The score of QOL increases with increasing economic status. QoL was lowest in the poorest quintile (40.3) and the highest in the richest quintile (65.7). The risk of lower QOL in the poorest quintile was 1.12 times more than in the richest quintile (Table 4). The consideration index of Asset in terms of sex was 4.5 and the modified Gini index was more than 0.5 in females and males. The result showed that the quality of life of both sexes was affected by economic status (Table 5).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study describes the HRQL of a sample of Iranian adolescents and also assesses the influential factors of HRQL in 15\u0026ndash;18-year-old adolescents. Our results show that the majority of participants had moderate, and good levels of HRQL. The component of HRQL was different between female and male adolescence. In males, physical and autonomy components were more than in females, and school environment components had more effect on HRQL of female adolescence. Moreover, there are positive correlations between socio-economic backgrounds and HRQL.\u003c/p\u003e \u003cp\u003eMany studies highlight the importance of socioeconomic inequality on the adolescent quality of life. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) In this regard, Hovsepian et al. study reported a positive association between socioeconomic status, school functioning, psychosocial function, and total score of HRQOL in both males, and female students. Moreover, in their study all components of HRQL except its social subscale were low in female adolescence, (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) while in our study, boy adolescents only have better scores in the physical and autonomy components of HRQL than girls.\u003c/p\u003e \u003cp\u003eThe field of autonomy examines the adolescent's freedom of choice, self-sufficiency, and independence, and considers the individual's opportunities to create leisure and social activity. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) Upon entering this period of life, very profound biological, psychological and social changes occur in adolescents. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) The need for connection can create a conflict between the desires of the adolescent and their family, thereby putting his or her independence at risk. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) We observed a lower score of autonomy component in girls, which indicated more communication problems with parents. It seems that socio-cultural issues related to gender role, preference and more attention for the male sex, brain development, and different physiological changes following puberty play an important role in this difference.\u003c/p\u003e \u003cp\u003eThe school environment was one of the main components of HRQL and has a greater impact on girls vs. boys. Similar to our results, Gaspar et al. show that female students compared with males had a lower level of quality of life in all domains except school environments (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In the same sense, another study revealed that adolescents with positive perceptions about their school climate had good self-rated health, school satisfaction, and quality of life. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eExplaining the role of gender differences in health-related quality of life, Hyde states in his gender similarity hypothesis that males and females are similar in most psychological variables. Only in variables such as motor behavior, aggression, and some aspects of sexual activity, there are differences between the two sexes. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) Furthermore, physical changes during puberty in girls, such as the onset of menstruation and hormonal imbalances, decrease their psychological well-being compared to boys. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) We also observe those female adolescents compared with males had lower scores in the physical component. In this regard, Michel state that physical changes during puberty and conflict with exaggerated cultural norms of beauty make girls feel more unbalanced in their physical and mental well-being. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn this study, the relationship between income inequality and HRQL was evaluated using the Concentration Index, Ratio (R), and Modified Gini Index. The Gini index as one of the measures of health inequality examines the distribution of income, or in other words, the distribution of wealth among a population. The Gini coefficient is a number between zero and 1(0 denoting complete equality and 1 complete inequality). We observed a modified Gini index of more than 0.5 in females and males, which indicated a severe income gap. Assessing the relationship between these variables, and HRQL reveal that the quality of life in both sexes was affected by economic status. Our finding also reveals that socio-economic variables that affect HRQL are different between male and female adolescence. Parental education was one of the main factors of female adolescence, and variables such as assets, and family income were effective on HRQL of both groups. These results are consistent with the findings of other studies in this field. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) In line with our study, Spurrier et al. reported a high level of HRQL among children in families of higher income, educated, as well as employed. Moreover, they reported living in an original family with both parents has a positive impact on HRQL. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) Also, in Barriuso-Lapresa, et al. study, there was a high quality of life, and mental health for children of mothers who had a university degree, and high social classes. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) The results of one path analysis show the major effects of socioeconomic status (eg, occupational prestige, household income, and parental education), social support on HRQL, and health behavior such as smoking, and toothbrush in adolescents. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) Another study demonstrated that gender, ethnicity, maternal education level, socio-economic status and weight status are the main predictors of HRQL. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOur study was conducted during the second peak of the COVID-19 pandemic. Previous literature has documented the negative effects of this pandemic on both HRQL and family income. (\u003cspan additionalcitationids=\"CR33 CR34\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Studies have shown that the COVID-19 outbreaks have caused the biggest shock to the world economy, so the implementation of government disease control policies, such as social exclusion and quarantine, has led to the temporary closure of businesses. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) Shrinking the global economy, increasing unemployment, poverty, income inequality, gender inequality, and widening the gap between different countries are just some effects of this pandemic. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) All of these factors can have adverse effects on a person's quality of life. Tran et al. study shows a negative effect of COVID-19 on household income and psychological health. And they state that having a chronic disease, female gender, and living in a family with 3\u0026ndash;5 members were related to low-quality life. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) In another study, during the outbreak, socio-economic inequality was one of the main predictors of death in Brazilian children. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Ravens-Sieberer et al. reported that children and adolescents experienced a high level of anxiety, mental health problems, and low HRQL after the COVID-19 pandemic, and socioeconomic status, migration background and limited living space had the greatest impact. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) In Adıbelli et al. study, the score of the quality of life of children was good, but their parents reported that in their children gained weight, tendency to sleep and internet use increased during the pandemic. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Limitation\u003c/h2\u003e \u003cp\u003eOne of the limitations of this study is that we didn't assess the influence of other variables such as psychological wellbeing, parental relationship, and COVID-19-related issues, which can affect the HRQL of adolescence. It has been suggested that future studies consider them in the study design. However, this study was conducted during the QOVID-19 pandemic, but their information (such as disease status, the impact of COVID-19 on their socioeconomic status, quarantine, etc.) is not available. Also, the design of this study is cross-sectional, so the causal relationship between the variables is not predictable. However, according to the definition of the WHO, adolescence is in the age range of 11 to 21 years, and we only included 15 to 18 years of age (middle adolescence age) in the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eOur findings highlight the significant effects of socioeconomic inequality on HRQL of Iranian adolescents. Since having a healthy society requires improving the quality of life, it is suggested that health policymakers consider comprehensive planning in the field of economic equality, and improving the quality of life of adolescents. Socio-economic inequalities should also be considered when designing interventions to improve adolescents' quality of life.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol of the current study was approved by the Ethics Committee of Zanjan University of medical science (IR. ZUMS. REC. 1399.064). The consent was obtained from all participants\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eand their parents. Also, they all made sure that their information will be kept private and confidential. All procedures were in accordance with the ethical standards of the Regional research committee and with the Declaration of Helsinki 1964 and its later amendments. Due to the coid-19 restriction data was collected by telephone and informed verbal consent was obtained from all participants and their parents included in the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe data sets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe current study was funded by social determinent research center of Zanjan University of medical sciences (The code \u0026ldquo;A-11-344-15-6\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eA.M \u0026amp; S.Y. wrote the main manuscript text and E.F. analyzed the data. Sh. Z prepared the tables and figures. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe article is a part of a research project that has been approved by the Social determinant of health research center of Zanjan University of Medical Sciences with the code A-11-344-18. The researchers would like to thank the staff of health center for your collaboration and all mothers for participating in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. The Lancet Child \u0026amp; Adolescent Health. 2018;2(3):223-8.\u003c/li\u003e\n\u003cli\u003eSusman EJ, Koch PB, Maney DW, Finkelstein JW. Health promotion in adolescence: Developmental and theoretical considerations. 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Journal of racial and ethnic health disparities. 2021;8(3):732-42.\u003c/li\u003e\n\u003cli\u003eNobari H, Fashi M, Eskandari A, Villafaina S, Murillo-Garcia \u0026Aacute;, P\u0026eacute;rez-G\u0026oacute;mez J. Effect of COVID-19 on Health-Related Quality of Life in Adolescents and Children: A Systematic Review. International Journal of Environmental Research and Public Health. 2021;18(9):4563.\u003c/li\u003e\n\u003cli\u003eTran BX, Nguyen HT, Le HT, Latkin CA, Pham HQ, Vu LG, et al. Impact of COVID-19 on Economic Well-Being and Quality of Life of the Vietnamese During the National Social Distancing. Front Psychol. 2020;11:565153-.\u003c/li\u003e\n\u003cli\u003eMartins-Filho P, Quintans-J\u0026uacute;nior L, de Souza Ara\u0026uacute;jo A, Sposato K, Tavares CS, Gurgel R, et al. Socio-economic inequalities and COVID-19 incidence and mortality in Brazilian children: a nationwide register-based study. Public Health. 2021;190:4-6.\u003c/li\u003e\n\u003cli\u003eRavens-Sieberer U, Kaman A, Erhart M, Devine J, Schlack R, Otto C. Impact of the COVID-19 pandemic on quality of life and mental health in children and adolescents in Germany. European Child \u0026amp; Adolescent Psychiatry. 2021.\u003c/li\u003e\n\u003cli\u003eAdıbelli D, S\u0026uuml;men A. The effect of the coronavirus (COVID-19) pandemic on health-related quality of life in children. Children and Youth Services Review. 2020;119:105595.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eBaseline socio-demographic characteristics of participants(n=579)\u003cspan dir=\"RTL\"\u003e\u0026nbsp;*\u003c/span\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable align=\"\" border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse: collapse; margin: 0px auto;\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"63.8235294117647%\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003eFrequency (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003e\u0026nbsp;Asset Component\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eSteam Cleaner Wash Floor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eStove with Oven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eHandmade carpets\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eMicrowave oven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e27.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eHome Dish Washing Machine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eLaptop\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e38.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e288(49.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e291(50.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eAge(year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e135(23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003e16\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e203(35.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e161(27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e80(13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFamily home ownership status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eLeased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e95(16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003ePersonal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e470(81.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e14(2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFather\u0026apos;s job\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e51(8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eWorker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e65(11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eSelf-employer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e229(40.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eGovernment employee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e133(23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e93(16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003e\u0026nbsp; Mother\u0026apos;s job\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e464(81.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e108(18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMother\u0026apos;s education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eIlliterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e30(5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e132(22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eGuidance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e108(18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eHigh school\u0026amp; diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e175(30.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e132(22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eInsurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e468(81.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e107(18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eBirth rank\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e279(48.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003e\u0026gt;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e299(51.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFamily income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eLower than adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e390(67.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eAdequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e155(26.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eMore than adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e33(5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFather\u0026apos;s education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.91176470588235%\"\u003e\n \u003cp\u003eIlliterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"36.1764705882353%\"\u003e\n \u003cp\u003e24(4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e94(16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eGuidance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e93(16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eHigh school\u0026amp; diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e199(34.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"46.868250539956804%\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"53.131749460043196%\"\u003e\n \u003cp\u003e165(28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Socio-economic inequality of QoL in term of gender \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eLower Than Median\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eUpper Than Median\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAsset Quantile\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePoorest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40(26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28(20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20(16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27(18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale=0.045\u003c/p\u003e\n \u003cp\u003eMale=0.021\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePoorer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28(18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37(27.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19(15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31(21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39(25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27(20.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29(23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20(13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRicher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25(16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26(19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28(22.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26(18.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRichest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19(12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16(11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29(23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40(27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFather\u0026apos;s Job\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGovernment Employee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30(19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25(18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38(27.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41(28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale=0.08\u003c/p\u003e\n \u003cp\u003eMale=0.062\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSelf-Employer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62(40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50(36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58(45.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59(40.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWorker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22(14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22(15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8(6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13(8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23(14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27(19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17(13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25(17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18(11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15(10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10(7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8(5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eMother\u0026apos;s Job\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e132(84.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e111(81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e104(80.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e117(79.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eFemale=0.444\u003c/p\u003e\n \u003cp\u003eMale=0.762\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25(15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26(19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25(19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30(20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFather\u0026apos;s Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIlliterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10(6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4(2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4(3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6(4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale=0.041\u003c/p\u003e\n \u003cp\u003eMale=0.128\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21(15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19(14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19(13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGuidance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27(17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31(22.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16(12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19(13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh School, Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57(36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47(33.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49(38.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46(31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29(18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37(26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41(31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56(38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003eMother\u0026apos;s Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIlliterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9(5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9(6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10(6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale=0.006\u003c/p\u003e\n \u003cp\u003eMale=0.118\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41(25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36(25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30(23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25(17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGuidance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39(24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29(20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17(13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23(15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh School, Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39(24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39(27.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53(40.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44(29.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30(19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27(19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28(21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45(30.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eFamily income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLower than adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e120(75.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e117(83.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71(55.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82(55.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eFemale=0.001\u003c/p\u003e\n \u003cp\u003eMale=0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAdequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34(21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20(14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48(37.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52(35.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMore than adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4(2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4(2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10(7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14(9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eFamily home ownership status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePersonal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e117(74.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e117(83.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e108(83.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e126(85.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eFemale=0.117\u003c/p\u003e\n \u003cp\u003eMale=0.211\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eleased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36(22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22(15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21(16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16(10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5(3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2(1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1(0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6(4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;the comparison of quality-of-life components between male and female\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003eQOL components\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003ePhysical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e18.62(3.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e19.44(3.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003ePsychological Well-being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e22.50(3.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e0.984\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e22.51(3.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003eMoods and Emotions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e29.47(3.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e0.450\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e29.23(4.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003eSelf-Perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e19.42(2.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e0.786\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e19.35(2.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003eAutonomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e17.66(2.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e0.036 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e18.17(2.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003eParent Relations and Home Life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e23.64(2.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e0.120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e23.26(3.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003eFinancial Resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e10.54(2.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e0.521\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e10.64(1.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003eSocial Support and Peers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e18.94(4.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e0.979\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e18.93(4.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003eSchool Environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e21.99(2.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e21.47(3.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003eSocial Acceptance (Bullying)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e13.71(1.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e\u0026nbsp;0.514\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e13.79(1.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"39.40972222222222%\"\u003e\n \u003cp\u003eTotal score \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.618055555555557%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.21527777777778%\"\u003e\n \u003cp\u003e179.20(14.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.756944444444445%\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"42.803030303030305%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"57.196969696969695%\"\u003e\n \u003cp\u003e179.16(16.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u0026nbsp;\u003cstrong\u003eTable 4\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Economic- related inequality in QOL\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"109%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"10.1010101010101%\"\u003e\n \u003cp\u003eAsset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.282828282828284%\"\u003e\n \u003cp\u003eaffected population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.161616161616163%\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"27.272727272727273%\"\u003e\n \u003cp\u003eCI 95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.181818181818183%\"\u003e\n \u003cp\u003eSetting average\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.1010101010101%\"\u003e\n \u003cp\u003ePoorest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\"\u003e\n \u003cp\u003e24.0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.161616161616163%\"\u003e\n \u003cp\u003e40.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.121212121212121%\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.151515151515152%\"\u003e\n \u003cp\u003e48.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" width=\"18.181818181818183%\"\u003e\n \u003cp\u003e47.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.345679012345679%\"\u003e\n \u003cp\u003ePoorer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.5679012345679%\"\u003e\n \u003cp\u003e19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.753086419753085%\"\u003e\n \u003cp\u003e43.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.814814814814815%\"\u003e\n \u003cp\u003e33.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.51851851851852%\"\u003e\n \u003cp\u003e51.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.345679012345679%\"\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.5679012345679%\"\u003e\n \u003cp\u003e19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.753086419753085%\"\u003e\n \u003cp\u003e43.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.814814814814815%\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.51851851851852%\"\u003e\n \u003cp\u003e52.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.345679012345679%\"\u003e\n \u003cp\u003eRicher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.5679012345679%\"\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.753086419753085%\"\u003e\n \u003cp\u003e50.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.814814814814815%\"\u003e\n \u003cp\u003e41.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.51851851851852%\"\u003e\n \u003cp\u003e60.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.345679012345679%\"\u003e\n \u003cp\u003eRichest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.5679012345679%\"\u003e\n \u003cp\u003e18.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.753086419753085%\"\u003e\n \u003cp\u003e65.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.814814814814815%\"\u003e\n \u003cp\u003e56.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.51851851851852%\"\u003e\n \u003cp\u003e74.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" width=\"100%\"\u003e\n \u003cp\u003eRisk Q1/Q5= 24/19.8= 1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;consideration index of Asset in term of sex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.649484536082475%\"\u003e\n \u003cp\u003eIndex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eN of obs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eIndex value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eStd. error \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.371134020618557%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"21.649484536082475%\"\u003e\n \u003cp\u003eModified Gini\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003e.61403232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003e.00097112 \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.371134020618557%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.42105263157895%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.42105263157895%\"\u003e\n \u003cp\u003e280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.68421052631579%\"\u003e\n \u003cp\u003e.61981277\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.68421052631579%\"\u003e\n \u003cp\u003e0.00132458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.789473684210526%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"51.515151515151516%\"\u003e\n \u003cp\u003eAbsolute concentration index\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.181818181818183%\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"30.303030303030305%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health-related quality of life, socio-economic, inequality, adolescence","lastPublishedDoi":"10.21203/rs.3.rs-1774898/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1774898/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e One of the main concerns of public health is increasing inequality of health status, which has an adverse effect on people's life.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: The current study aims to analyze the role of socioeconomic inequalities in health-related quality of life (QoL) among Iranian adolescents.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A cross-sectional descriptive study was conducted on 576 adolescents aged 15 to 18 years. The samples were selected using the Multi-stage sampling method. Data were collected by a demographic checklist, and KIDSCREEN-52 questionnaire and analyzed by SPSS ver.16. The Health Equity Assessment Toolkit (HEAT) Version 4.0 (beta) was used to assess adolescents' QoL inequalities in terms of socio-economic subgroups.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The results show that 27.2 adolescents had low quality of life. The score of physical and autonomy components of QoL was significantly more in male versus school environment in female students. Also, the asset index, father's, and mother's education, and family income in female students, and the assets and family income in male students were significantly related to the quality of life (p\u0026lt;0.05). The risk of lower QOL in the poorest quintile was 1.12 times more than in the richest quintile. The consideration index of Asset in terms of sex was 4.5 and the modified Gini index was more than 0.5 in females and males. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Our findings highlight the significant effects of socioeconomic inequality on HRQL of Iranian adolescents. Requires a targeted policy approach to reach the poorest quintile for improving the quality of life of adolescents.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Socio-Economic Inequalities in Health-Related Quality of Life Among Iranian Adolescents: Application of Health Equity Assessment Toolkit Running title: Socio-Economic Inequalities \u0026amp; Health-Related Quality of Life","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-30 14:56:24","doi":"10.21203/rs.3.rs-1774898/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-08-29T04:38:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-08-19T00:53:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"fdf3ebc2-577c-4974-9816-8c818544f2ec","date":"2022-08-08T16:09:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-08-05T15:51:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-08-05T15:16:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-06-22T10:45:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-06-22T10:24:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2022-06-20T03:57:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2ec5be5f-499e-4b1a-8b3d-5fe2a041150a","owner":[],"postedDate":"June 30th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T18:23:32+00:00","versionOfRecord":{"articleIdentity":"rs-1774898","link":"https://doi.org/10.1186/s12887-022-03815-z","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2023-01-11 18:16:48","publishedOnDateReadable":"January 11th, 2023"},"versionCreatedAt":"2022-06-30 14:56:24","video":"","vorDoi":"10.1186/s12887-022-03815-z","vorDoiUrl":"https://doi.org/10.1186/s12887-022-03815-z","workflowStages":[]},"version":"v1","identity":"rs-1774898","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1774898","identity":"rs-1774898","version":["v1"]},"buildId":"ehx78VzkSd0WSzXnipQa-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}