Monitoring Social Well-Being in Iran

Fariba Mirbaha Hashemi1 • Farshad Pourmalek2 •

Arash Tehrani3 • Kambiz Abachizadeh4 • Nadereh Memaryan3 •

Narjes Hazar5 • Soheila Omidnia6 • Abbas Ziari7 •

Maziar Moradi Lakeh3

Accepted: 31 August 2015� Springer Science+Business Media Dordrecht 2015

Abstract The main aim of this study was to design a system for measuring and moni-

toring social well-being in Iran, utilizing a conceptual model and choosing contextually

specific domains and indicators. A number of different approaches in defining and mea-

suring social well-being exist. Some of these measuring systems use a descriptive approach

and employ sets of indicators, which cover topics of concern but lack any explicit theo-

retical basis. To better capture the specific societal context of social well-being within Iran,

we constructed a compound model from multiple pre-existing conceptual models, allowing

us to group indicators and show relationships among contextually relevant areas and

domains. Our framework proposes that there are societal and individual-level determinants

that affect social health in a society and that social health has outcomes and impacts. To

measure social health, variables of social integration, social contribution, social coherence,

social actualization, social acceptance, social support, and social functioning are consid-

ered. The outcomes and impacts are to be measured and monitored by 37 variables. In

many countries, social well-being measurements have been conducted on a regular basis

for decades. Some of these systems of social health focus on individual (micro) measures,

some on societal (macro) measures, and many on both. In this research, both individual

level and societal level well-being measures were selected after being deemed contextually

important for Iran. This system of social well-being measurement is to be used as a

& Fariba Mirbaha Hashemifaribamirbaha@yahoo.com

1 Knowledge Utilization Research Center, University of Tehran, Tehran, Iran

2 University of British Columbia, Vancouver, Canada

3 Iran University of Medical Sciences, Tehran, Iran

4 Department of Community Medicine, Shahid Beheshti University of Medical Sciences, Tehran,Iran

5 Department of Community Medicine, Tehran University of Medical Sciences, Tehran, Iran

6 Department of Social Health, Mental Health and Addiction, Ministry of Health, Tehran, Iran

7 Department of Community Medicine, Semnan University of Medical Sciences, Tehran, Iran

123

Soc Indic ResDOI 10.1007/s11205-015-1087-2

descriptive and monitoring tool but could potentially be utilized in goal setting, outcome-

based accountability, and evaluations in order to promote social well-being and social

policy research in Iran.

Keywords Social health � Social well-being � Indicators � Monitoring

1 Introduction

At the beginning of the twenty-first century, social well-being research and monitoring is

well established in many countries. In this article, we provide an overview of the steps that

have been taken to design such a system for measuring social well-being, also known as

social health, in Iran. Firstly, some of the systems and approaches for measuring social

well-being worldwide are briefly considered. Then, we discuss the compound conceptual

model created specifically for measuring social well-being in this research. And lastly, we

present the selected domains and indicators for individual and societal level measures of

social well-being.

Policy makers, academics, organizations and investigators have used several different

definitions and developed various measures to monitor social well-being and its changes. A

number of different approaches and definitions of social health exist but we will consider

the most contextually appropriate ones for Iran.

2 Social Well-Being

The World Health Organization (WHO) has long identified social well-being as a key

component of an individual’s overall health: ‘‘Health is a state of complete physical,

mental and social well-being and not merely the absence of disease or infirmity’’. While

there have been more advancement and agreement in defining and measuring physical and

mental health of individuals and populations, there is less consensus about the definition

and measurement methods for social health. A variety of conceptual and measurement

approaches and also reporting schemes have been utilized. There is not a standard, cross-

disciplinary definition and measurement system for social health (Andrews and Withey

1976; McDowell and Newell 1987; Keyes 1998; Opdycke and Miringoff 2008; Allin 2007;

De Leon and Boris 2010; Estes 1997, 2010). Definitions tend to vary according to research

interests and objectives.

Two broad approaches to measuring social health are the individual (micro) and societal

(macro) views. The individual view of social well-being focuses on the interactions of the

individual within a society. Keyes (1998), for example, argues for benefits of social life as

a foundation for the definition of social well-being. He names social integration, sense of

belonging, interdependence, collective consciousness and collective fate as some of the

potential benefits of social life. In considering the best way to measure social well-being,

he argues for the individual approach, defining social well-being as ‘‘the appraisal of one’s

circumstance and functioning in society’’ (p. 122). The societal approach, on the other

hand, aims for data that paint a broad picture of a society and provide information about

social conditions and progress for a community as a whole (Miringoff and Miringoff 2003,

Feb.). According to this view, the strength of key aspects of a society (such as education,

F. M. Hashemi et al.

123

health, work and safety) and their interrelations provide a sense of the society’s overall

condition and well-being of its people. Measurements of social well-being at the societal

level can provide an understanding of the current status and future prospects for a com-

munity (Miringoff 1995).

The societal well-being view (McKee and Figueras 2012; Index of Social Health 2013;

Porter et al. 2014) seems to be more tuned into socio-economic development, social

determinants of health, inequities within and among societies, and government account-

ability. In Iran, research with both individual (Abachizadeh et al. 2013, 2014) and societal

(Amini Rarani et al. 2013; Feizzadeh and Madani 2002) approaches to definition and

measurement of social health has been performed.

In many countries, regular social well-being measurements are conducted (Table 1).

Some of these efforts use summary indexes. These indexes are made up of a number of

social well-being indicators, which are measured and reported across subnational territories

for comparison purposes in a country or region. Key examples include the Fordham Index

of Social Health (Miringoff 2003), and the French composite Index of Social Health (Jany-

Catrice 2009). Some countries or international organizations report on social health with a

set of social well-being indicators (without use of a summary index), like the Organization

for Economic Co-operation and Development (OECD) Social Indicators (Compendium of

OECD well-being indicators—OECD 2011), New Zealand’s indicators of social well-

being (Social Report 2010 n.d.), the Social Health Atlas of Australia (Glover et al. 1999),

and the OECD’s Society at a Glance (OECD 2011). Table 1 shows the typology of systems

of social health measurements (for a more comprehensive list, see Pega et al. 2010).

Table 1 Characteristics of social health (well-being) measures

Conceptualapproach

Indicators level Geographical scope CompositeIndex

Micro Macro Individual Societal National International

1. Keyes’ social well-being

* * * *

2. Fordham Index ofSocial Health

* * * *

3. Community Well-Being Index

* * * *

4. Individual Level SocialHealth in Iran

* * *

5. OECD SocialIndicators

* * * * *

6. Social Health of theFrench Regions

* * * *

7. Social Well-Being inNew Zealand

* * * * *

8. Social Health Atlas ofAustralia

* * * * *

9. Society at a glance * * *

1. Keyes (1998), 2. Index of social health (2013), 3. Cooke (2005), 4. Abachizadeh et al. (2013), 5.Compendium of OECD well-being indicators—OECD (2011), 6. Jany-Catrice (2009), 7. Social Report 2010(n.d.), 8. Glover et al. (1999), 9. OECD (2011)

Monitoring Social Well-Being in Iran

123

In New Zealand, the Ministry of Social Development has been issuing the Social

Report regularly since 2001, following a nationwide public consultation to identify

what constitutes well-being in the country. The ministry arrived at a definition of social

well-being as ‘‘…those aspects of life that society collectively agrees are important for

a person’s happiness, quality of life and welfare’’ (Social Report 2010 n.d.). A set of

social well-being domains subsequently was identified as key for a person’s overall

well-being in New Zealand. These are: knowledge and skills; paid work; economic

standard of living; health; civil and political rights; cultural identity; leisure and

recreation; physical environment; safety; and social connectedness. These areas are

obviously related. For example, someone’s poor health may impact the person’s ability

to work or participate in recreation or leisure activities. This in turn limits their

opportunities to connect with other people. As a result of the Social Report, mea-

surements to evaluate these connections and relationships and programs to improve

social well-being have been proposed.

International organizations such as the United Nations (1989) and the OECD have

actively contributed to the social well-being field with the publication of international

social reports. The OECD (Compendium of OECD well-being indicators—OECD 2011)

considers both objective and subjective aspects of people’s well-being because both living

conditions and individuals’ appreciation of them are deemed crucial in understanding well-

being. The OECD created a framework to measure well-being that included two main

domains of material living conditions and the appreciation of one’s living conditions. To

measure these domains, 11 dimensions were proposed. These include, under material

living conditions: (1) income and wealth, (2) jobs and earnings, and (3) housing. For living

conditions, the following are offered: (1) health status, (2) work and life balance, (3)

education and skills, (4) civic engagement and governance, (5) social connections, (6)

environmental quality, (7) personal security, and (8) subjective well-being. There are

substantial overlaps between these 11 dimensions and the 10 areas that are measured in

New Zealand. In addition, conditions to ensure sustainability of well-being over time are

reported to be important for OECD. Sustainability depends on the way human conditions

affect different kinds of capital (natural, economic, human and social). Suitable indicators

to monitor sustainability, however, are said to be still lacking (Compendium of OECD

well-being indicators—OECD 2011).

It seems that the two individual and societal approaches discussed above are com-

plementary not contradictory. The individual approach uses population surveys for the

measurement of social health (Keyes 1998). The societal approach may use (a) only

population-level macro indicators (like the Fordham Index of Social Health or indi-

cators such as the infant mortality rate) (Miringoff 2003) or (b) both population level

and survey based variables [like suicide rates as a population level measurement and

perceived discrimination as a survey based variable in New Zealand (The Social Report

2010 n.d.)]. Some individual or micro-level social health indicators are more akin to

quality-of-life (subjective) measures. Some national and international measures (such as

social well-being in New Zealand and OECD Social Indicators) seem to encompass all

aspects of individuals’ well-being, both subjective and objective. Most measures,

regardless of their conceptual scope, seem to emphasize the importance of individuals’

active social contribution, participation, connectedness and accomplishments in their

overall well-being.

F. M. Hashemi et al.

123

3 Why and How to Measure Social Health

Raymond Bauer, in 1966, defined social indicators which may be used to measure social

health as ‘‘statistics, statistical series, and all other forms of evidence that enable us to

assess where we stand and are going with respect to our values and goals’’ (Bauer 1966,

p. 1). Social indicators could provide a broad and comprehensive description of the health

of a society. But the question lies in which social indicators need to be utilized? There is

more to a society, its well-being, how it is doing and where it is going than can be

measured by conventional economic measures such as gross domestic product (GDP).

Clearly, GDP does not take into account the non-economic factors that impact well-being.

Nor does GDP provide the broad-based information needed for monitoring social change,

evaluating social programs, guiding policy making, and providing comprehensive picture

of the quality of life or well-being in a society. Social well-being, then, needs to be

measured by indicators beyond economic growth and GDP.

There are two broad segments to the measurement of social well-being: the health of the

society (i.e. the condition in which individuals live) and individuals’ satisfaction with

living in that society, as captured in the OECD well-being indicators.

Frameworks for the selection of indicators include three components: domains, vari-

ables, and the scope of population coverage (whether to include whole population or

subgroups) (Sharp 1999, 2004). The selection of domains typically follows an explicit or

implicit conceptual framework of social health and the selection of variables follows an

array of defined selection criteria. The selection of population coverage depends on the

intended purpose of the social health indicators. The purpose may range from high-level

observation to low-level monitoring and includes planning, policy-making, research, and

general monitoring of social conditions (Miringoff and Miringoff 2003, Feb.; United

Nations 1989). There are other challenges involved in monitoring and ultimately

improving social health of a society. Considerable time and care need to be invested in this

regard. Social health is inherently multilevel and multivariate. Moreover, monitoring

emerging trends in social health could be challenging because data from the past for

comparison and time-series purposes often are scant or absent. Once the domains, vari-

ables, and population coverage are established, periodic measurements are necessary to

monitor change, acknowledging that interventions in social health may yield results many

years later as population level characteristics often change at a slow rate (Andrews 1983).

When a social monitoring system is designed, special attention needs to be paid to the

specific concerns in that society. In Iran, some of these concerns include the smuggling

illicit drugs and addiction, low social participation, illiteracy and low literacy, violence and

crime, suicide, run-away adolescents, child abuse and neglect, prostitution, panhandling,

identity crises, lack of trust, dishonesty, high rates of divorce, social deviance and law

evasion, adultery, poverty, unemployment, brain drain, theft and robbery, embezzlement,

vandalism, destroying and disrespecting the environment (Social Deviances and their trend

in Iran 2004; Motamedi 2007; Noorbala 2011). We will next consider a few of these social

concerns and the available information about them.

Addiction is a major social problem in Iran. There are no official statistics for drug use

in the country, but according to a recent study, 1,325,000 individuals in the 15–64 year old

age group were estimated to have addition to drugs. The total population of this age group,

according to a national survey, was 50 million. While the annual population growth is less

than 2 % for the country, drug addiction increases 8 % annually, which is more than three

Monitoring Social Well-Being in Iran

123

times the rate of population growth (Sarami et al. 2013). At this growth rate, in approx-

imately 12 years, there will be twice as many drug addicts (Noorbala 2011).

Divorce also has been on the rise in Iran. According to the country’s civil registration

services, in a decade from 2001 to 2011, the number of divorces more than doubled (from

60,500 to 142,841) whereas number of registered marriages went from 641,940 to 874,792 in

the country. Traffic accident fatalities are also very high in Iran. In fact, Iran has one of highest

rates of fatalities due to automobile accidents in the world. From 2001 to 2012, the total

number of traffic accident deaths in a year ranged from 19,727 to 27,755 with the highest

number in 2005 (Lankarani et al. 2014). This represents not only a significant amount of health

and economic loss for the country, also creates a significant societal disruption, not tomention

the various consequences it has for the involved individuals and families.

The substantial outmigration of highly educated individuals—estimated to be more than

15 % of college graduates in 1990 only to the U.S.—is also very costly for Iran (Detra-

giache and Carrington 1999). Brain drain decreases human capital and as a result, is a

major blow to the economic growth of the country (Tayebi et al. 2012). There are no

official figures, but it is estimated that between 150,000 and 180,000 specialists leave Iran

every year (Noorbala 2011).

Although data on many of the social concerns outlined above are available from various

organizations in the country, it would benefit efforts to improve social well-being in Iran if

one organization were to take the responsibility of gathering all available data and pub-

lishing official statistics for the use of monitoring and research.

To assist in this effort, we embarked on the development of a conceptual framework and

a set of contextually relevant variables. The process of creating the framework and

choosing the relevant variables is explained next.

4 Conceptual Model and Variables

An extensive review of the available social well-being literature for Iran and other

countries revealed two basic approaches to measuring social well-being. The first was a

descriptive approach that employs sets of indicators covering specific topic areas of con-

cern but lacking any discernible theoretical basis. The second approach provided a theo-

retical underpinning for a conceptual model to guide the analysis.

For our purposes, we chose to have a conceptual model in order to group the indicators

appropriately and to attempt to show the relationships among them. After an extensive

search in the literature for a suitable conceptual model, we decided that no single model

would adequately allow for the clear and consistent measurement of social well-being in

Iran. As a result, we picked segments of different models to construct a novel compound

model with contextually appropriate areas and domains. The two main models informing

the construction of the model in this research are shown in Figs. 1 and 2. First is the health

Inputs Processes Outputs Outcomes Impact

Fig. 1 Results chain framework employed for construction of research conceptual model (source used withpermission from Ardalan A. Guidelines of results-based management for public health planning. Tehran:Tehran University of Medical Sciences, 2008. p. 25)

F. M. Hashemi et al.

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results chain framework shown in Fig. 1, which demonstrates how inputs through pro-

cesses end in results (including outputs, outcomes, and impacts) (Ardalan 2008). These

inputs, processes and results are obviously specific for each situation. The second

framework that was deemed useful was the proximal and distal causes of disease model

shown in Fig. 2 (Murray and Lopez 2002). This model informed the categories of deter-

minants of social health in our research model.

The construction of our social-well being framework can be seen in Figs. 3 and 4.

Figure 3 shows the high-level representation of this compound conceptual model. As

presented in Fig. 3, societal and individual-level determinants are proposed to be affecting

social health, and these in turn result in outcomes and impacts. Components of this model

are postulated to be influencing each other and to have bidirectional effects. When the main

domains were placed in each component of this scheme, the model became what is rep-

resented in Fig. 4.

As shown in Fig. 4, the specific social health variables include social integration, social

contribution, social coherence, social actualization, social acceptance, social support, and

social functioning.

For the outcome and impact domains, through a literature review, we compiled a list of

variables that have been used in social well-being studies around the world. The literature

Fig. 2 Distal and proximal causal model employed for construction of research conceptual model (sourceused with permission from Murray CJL, Salomon JA, Mathers CD, Lopez AD (eds.) Summary Measures ofPopulation Health: Concepts, Ethics, Measurement and Applications. Geneva: World Health Organization,2002. p. 276)

Determinants

Societal-levelIndividual-level

Results

OutcomesImpacts

Social Health

Fig. 3 Social well-being conceptual model

Monitoring Social Well-Being in Iran

123

review was performed with predefined search methodology and specific relevant phrases.

Specifically, we searched the PubMed, Social Sciences Citation Index, SCOPUS, Iranian

journals, databases, and books, as well as all governmental health policies, laws, and plans

related to social well-being in Iran. We also performed a free Internet search and reviewed

relevant books on the subject matter.

From the resulting list of variables, we selected subdomains and variables that are

contextually relevant for the country. We then presented the model, domains, subdomains,

and variables to a technical expert panel of social health stakeholders in Iran. We incor-

porated their suggestions and verified with them the final configuration of variables,

domains, and the conceptual model. Table 2 shows the ‘‘individual’’ level sub-domains and

Determinants ResultsSocial Health

Social Level Determinants

Social

Economic

Political

Cultural

Environmental

Health System

Individual Level

Determinants

Life Style & Behavior

Genes & Biology

Age & Gender

Social Integration

Social Contribution

Social Coherence

Social Actualization

Social Acceptance

Social Support

Social Functioning

Ultimate Impacts

Positive Impacts

Negative Impacts

Outcomes

Physical and Mental Health

Positive Outcomes

Negative Outcomes

Fig. 4 Conceptual model of social well-being including the main domains

Table 2 Individual level domains, subdomains and variables in social well-being system of Iran

Domains Sub-domains Variables

Impacts of social health Quality of life Average score of quality of life among adults surveyedin the population

Positive impacts Vitality Average score of vitality among adults surveyed

Negative impacts Social alienation % of adults reporting social alienation score of mediumto high

Social anomie % of adults reporting a social anomie score of medium tohigh

Positive outcomes ofsocial health

Subjective well-being

% of adults reporting subjective well-being as good orvery well

Life satisfaction % of adults reporting life satisfaction as high or veryhigh

Working-lifesatisfaction

% of working adults with satisfaction of high and veryhigh

Sense of security % of adults reporting feeling secured at good or verygood levels

Social adjustment Average score of social adjustment among adults

F. M. Hashemi et al.

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Table 3 Social level domains, subdomains and variables in social well-being system of Iran

Domains Sub-Domains Variables

Negative impacts ofsocial health

Suicide Suicide rate in all age groups

Positive outcomes ofsocial health

Social capital Average score of social capital amongadults

Social justice Gini indexEmployment rate among 18–60-year-olds

Social welfare Amartya Sen’s social welfare functionscore

Social commitment % of population sensitive to social issues atthe medium level or higher

Social attachment % of those who have a sense of attachmentto their society

Social support % of those 60 and above who receive apension

% of unemployed who receiveunemployment benefits

Negative outcomes ofsocial health

Family issues % of those leaving home without tellinganyone (for at least one night)

Ratio of divorces to marriages in a year

Exploitation of children Detected cases of child and adolescentabuse in a year

Number of homeless children (with orwithout parents)

Children and adolescentsdelinquency

Number of children in correction andrehabilitation centers

Prostitution The average starting age of prostitution

Social exclusion/marginalization Rate of perceived discrimination

Homelessness Average number of homeless who useshelters in a month

Migration Rate of brain drain

Domestic violence Prevalence of physical abuse in women

Anti-social behavior/vandalism Rate of driving offensesNumber of embezzlement or bribery courtcases in a year

Human trafficking (stratified bynon-Iranians entering thecountry/Iranians in the countryand also adult/children)

Number of human trafficking cases forunpaid labor in a year

Social violence Rate of homicidesNumber of armed robbery cases in a year

Physical and mentalhealth outcomes ofsocial health

Fatal traffic accidents Number of fatal accidents due to drivingunder the influence of drugs or alcohol ina year

Addiction Prevalence of addiction to drugs

Child mortality Infant mortality rate

Mental health Prevalence of mental health disorders inthe adult population

Monitoring Social Well-Being in Iran

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variables. These variables have to be measured with representative surveys in the country.

‘‘Social’’ level subdomains and variables of social well-being monitoring system for Iran

are also listed in Table 3. Most of the social level variables and subdomains are already

being measured at the national or international level. There are five exceptions where

measurement is currently weak or nonexistent, including: social commitment, social

attachment, prostitution, social exclusion, and human trafficking. For the purposes of

ongoing measurement and policy making in Iran, this means that data are available for 23

out of a total of 37 individual and social level variables but they need to be evaluated for

their quality. The remaining 14 of the variables (9 individual and 5 social level variables)

would require a new periodical measurement effort. We recognize that determinants of

social health, such as poverty and education, are also very important and will be addressed

in future studies. Other elements for future considerations include: operational definitions

of the variables and a timeframe for their periodic measurement.

5 Conclusion

The variables chosen for the system of monitoring social well-being in Iran are similar

to, and extracted from a number of other monitoring systems of well-being around the

world (examples of these systems are listed in Table 1). The selected variables were

deemed particularly important in Iran’s country context. As explained above, the specific

social health variables (Fig. 4) include variables of social integration, social contribu-

tion, social coherence, social actualization, social acceptance, social support, and social

functioning. For the outcome and impact section of the system, there were 31 sub-

domains and 37 variables chosen. These indicators were designed to measure the

underlying concepts and are sensitive to changes over time. According to Brown and

Corbett (1997), five basic policy relevant uses of social indicators can be: description,

monitoring, setting goals, outcome-based accountability and evaluation. Our intention is

for this social well-being framework to provide a useful descriptive and monitoring tool

of social well-being for Iranians that, if proven effective, can be utilized in other

countries. This compound conceptual model has the potential to make a positive con-

tribution to goal-setting, accountability, and health resource allocation in order to pro-

mote social well-being and social policy research in Iran. The purpose of this study was

to begin the process of establishing a system of adequate indicators to monitor social

well-being in Iran on a regular basis. Data would be compiled from monitoring these

indicators for analysis and broadcasting and would be utilized to amend the social health

system even more contextually relevant in the future (Canadian Council on Social

Development 1997).

Acknowledgments We would like to thank William Heisel, Director of Communications of the Institutefor Health Metrics and Evaluation at the University of Washington, for kindly editing our manuscript.

Funding This research was supported by a Grant from Social Health Department at Ministry of Health andMedical Education organized through Iran University of Medical Sciences.

Compliance with Ethical Standards

Conflict of interest None.

F. M. Hashemi et al.

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