This study aimed to survey the indexes of equity in the physical environment and infrastructures of Kermanshah province based on the national indexes.
The results showed that the indexes of access to transportation, access to health centers, solid waste management, and green and sports per capita had the least distance from the negative ideal whereas the noise pollution index had the greatest distance. However, house hygiene and air pollution indexes were within the negative and positive ideal ranges. Hence, it can be concluded that the status of equity in the physical environment and infrastructures in Kermanshah province was unbalanced.
Additionally, the findings of the present study on better conditions of eight indexes in some counties indicated the lack of sustainable development in Kermanshah province, even if the standard per capita was similar between counties. It is well known that any development that is not comprehensive and not following a systematic and integrated model cannot be sustainable . The results of a study performed by Maleki et al. in Khuzestan province showed the lack of spatial equity in distribution of facilities and health services across its counties .
The results of the present study showed that the majority of households had proper house hygiene, the highest level was in Harsin and the lowest in Ghasr-e-Shirin, which was consistent with the results of a study conducted by Ghadermarzy et al. . Given that Ghasr-e-Shirin is located in the border area of Iran with Iraq and was the first point attacked by Iraqi army in the 8-year Iran-Iraq war, it is likely that damages on its infrastructures, late reconstruction of destroyed houses, in addition the long distance from the province center have led to the lower level of house hygiene; however, this explanation requires further studies. House hygiene indicators such as toilets and sewage are important because they have a direct impact on the prevalence of infectious diseases and the physical health of family members [15, 16]. However, the general situation of the house hygiene index in the province was favorable.
The findings of the present study indicated that Kermanshah province had good category of Air Quality Index (AQI) around 95% of the days of the year. Kermanshah province is exposed to air pollution only 5% of the days of the year, showing a downward trend compared with the statistics of 2009–2010, similar to the results of a study performed by Shamshiri et al. . In the last two decades, dust storms in the south and west of Iran have been a reemerging phenomenon whose number of days in previous years has been variable and affected by rainfall and air temperature [18, 19]. Due to the increase in rainfall over the past few years in Kermanshah province , this increase in rainfall has probably been effective in reducing dust storm and air pollution.
Our findings on solid waste management showed that all hospitals in the province had recycling and disposal waste facilities. Moreover, urban and rural areas had access to solid waste management. However, there is no integrated and codified program for waste management in urban and rural areas of Kermanshah province. Also rural areas of Ravansar and Harsin counties had the poorest solid waste management, requiring the attention and effort of health authorities of Kermanshah province. This finding was consistent with the results of a study conducted by Bakhtyari et al. . Studies show that access to sound waste management services is still limited in developing countries, especially in rural areas . Disposal of waste in the natural environment and the lack of dumpsites are the main reasons for the low quality of waste management in rural areas .
Other results showed that Kermanshah and Javanrood had the highest access to health centers while Salas-e Babajani, Ravansar, and Dalahu had the lowest access (less than 10%). This finding was consistent with the results of studies done by Sulaimany et al.  and Mousavi et al. . This difference was very significant between the counties, which indicated a lack of geographical heterogeneity and inequality in access to health centers throughout Kermanshah province. This needs a rapid shifting in policies towards people’s access to health services. Similarly, health inequity between different regions of Iran  and within Kermanshah province in terms of access to health services have been shown . Despite the primary health care system (PHC) at the level of health houses, rural and urban health centers, and hospitals in each county, it seems that the geographical condition, relative deprivation, and lack of road development in each county has affected the existence of health service centers and people’s access to the available health centers.
The results of our study showed the poor condition of sports per capita in Kermanshah province compared to the national  and the international standards . This index was much lower in Kermanshah than provincial level. Similarly, the results of other studies have also pointed to the inappropriate distribution of sports spaces in other provinces of Iran [27, 29].
Another finding of present study indicated a significant shortage in the green space per capita in Kermanshah province compared to the global standards , and the value obtained is also lower than the national standards . The lack of equal access to green space in the province was consistent with the results of a study conducted by Tajdar et al. . The importance of access to green space has been emphasized in some other studies [6, 33].
Based on the results of the present study, more than 15% of the households in the province suffered from noise pollution. This statistic was calculated based on industrial-towns along with other structures . The results of comparing counties demonstrated that Ravansar and Sarpol-e-Zahab had the highest and Sahneh and Harsin had the lowest percentage of noise pollution. This difference is probably due to the lack of suitability of land applications in Kermanshah province and other reasons such as the urban structure, as mentioned in other studies . However, the results of this study showed that noise pollution is not limited to large and industrial cities and also exists in small cities of the province, which may be due to the activity of small technical business in the cites, development of urban housing complexes, and lack of proper land use. The problem of noise pollution is a public health challenge in all developed and developing countries, mainly due to roads, airports, industrial towns, and technical occupations [35, 36]. The negative effects of noise pollution in the counties can be mitigated through applying land use plans and creating audio maps and comprehensive analysis of various policies at the county level.
Our findings showed that more than half of the province’s population had appropriate access to public transportation. The results also indicated that Dalahu and Kermanshah counties had the highest and lowest percentages of access to public transportation, respectively, consistent with the results of study by Tajdar et al. which confirmed the differences in various regions of the province . It is likely that the sudden increase in the population of Kermanshah city during the last two decades and the incompatibility of public transportation with the population is the main reason for this difference. That is why the urban Kermanshah monorail project was put on the agenda, but its slow progress contributed to the continued problem of public transportation in Kermanshah.
In the present study, consistent with the similar studies , we used the GIS to assess the environmental and physical infrastructural indexes. This indicates that geography and GIS can be applicable scientific tools in health and inequalities assessments. We also used Shannon’s Entropy Method and TOPSIS for weighting and ranking. Moreover, the Arc/GIS software was used for displaying the conditions of counties similar to some other studies .
The results of our study demonstrated that the counties of Islamabad, Kangavar, Sarpol-e-Zahab, and Ravansar were far from the positive ideal and had the lowest ranks in terms of health equity in physical environment and infrastructure. In addition to the necessity to investigate the causes of this inequity, there is a need for scientific planning and practical measures to reduce the inequalities. This issue has become more important due to the 7.3 magnitude earthquake in 2017 in the west of Kermanshah province, especially Sarpolzahab, Islamabad, and Ravansar, which had destructive effects on physical infrastructure and health.
The imbalance in the physical environment and infrastructures in Kermanshah province means that the implemented policies have not led to health equity in the province. In studies conducted outside Iran, policy-making and planning have also been mentioned as important issues on health equity [38, 39]. Concentration of services in urban places created bipolar areas and also led to migration from the rural to urban areas, and subsequently creating the inequity and misdistribution of services and facilities in the province. Imbalance and inequality in infrastructure is evident when we compare the counties. Javanrood and Ravansar, as two neighboring counties, have the highest and lowest rank in terms of equity in the physical environment and infrastructures, respectively. Similarly, Rezaei et al. concluded that Javanrood and Ravansar were developed and underdeveloped in terms of access to health services, respectively . This finding indicates the need to precise regional planning in Kermanshah province towards balanced development in all areas.
The present study only examined the indices of physical environment and infrastructures, and the reasons for this inequity were not assessed. Hence, it is recommended that the causes of this inequity be investigated for each of the eight indexes in future studies.