A composite index; socioeconomic deprivation and coverage of reproductive and maternal health interventions.

Objective: To examine inequalities in the coverage of reproductive and maternal health interventions in low- and middle-income countries and territories using a composite index of socioeconomic deprivation status. Methods: We obtained data on education and living standards from national household surveys conducted between 2015 and 2019 to calculate socioeconomic deprivation status. We assessed the coverage of reproductive and maternal health interventions, using three indicators: (i) demand for family planning satisfied with modern methods; (ii) women who received antenatal care in at least four visits; and (iii) the presence of a skilled attendant at delivery. Absolute and relative inequalities were evaluated both directly and using the slope index of inequality and the concentration index. Findings: In the 73 countries and territories with available data, the median proportions of deprivation were 41% in the low-income category, 11% in the lower-middle-income category and less than 1% in the upper-middle-income category. The coverage analysis, conducted for 48 countries with sufficient data, showed consistently lower median coverage among deprived households across all health indicators. The coverage of skilled attendant at delivery showed the largest inequalities, where coverage among the socioeconomically deprived was substantially lower in almost all countries. Antenatal care visits and demand for family planning satisfied with modern methods also showed significant disparities, favouring the less deprived population. Conclusion: The findings highlight persistent disparities in the coverage of reproductive and maternal health interventions, requiring efforts to reduce those disparities and improve coverage, particularly for skilled attendant at delivery.

Making health inequality analysis accessible: WHO tools and resources using Microsoft Excel.

Addressing health inequity is a central component of the Sustainable Development Goals and a priority of the World Health Organization (WHO). WHO supports countries in strengthening their health information systems in order to better collect, analyze and report health inequality data. Improving information and research about health inequality is crucial to identify and address the inequalities that lead to poorer health outcomes. Building analytical capacities of individuals, particularly in low-resource areas, empowers them to build a stronger evidence-base, leading to more informed policy and programme decision-making. However, health inequality analysis requires a unique set of skills and knowledge. This paper describes three resources developed by WHO to support the analysis of inequality data by non-statistical users using Microsoft Excel, a widely used and accessible software programme. The resources include a practical eLearning course, which trains learners in the preparation and reporting of disaggregated data using Excel, an Excel workbook that takes users step-by-step through the calculation of 21 summary measures of health inequality, and a workbook that automatically calculates these measures with the user's disaggregated dataset. The utility of the resources is demonstrated through an empirical example.

Strengthening and expanding health inequality monitoring for the advancement of health equity: a review of WHO resources and contributions.

As part of its commitment to advance health equity, the World Health Organization (WHO) has a developed area of work to promote and strengthen health inequality monitoring. This includes an emphasis on the collection, analysis and use of disaggregated health data, which are central to evidence-informed decision making. The aim of this paper is to review WHO's work on health inequality monitoring, namely the 2022-27 Inequality monitoring and analysis strategy and corresponding activities, resources and tools. The strategy has three goals pertaining to: strengthening capacity for health inequality monitoring; generating and disseminating the latest evidence on health inequality and supporting data disaggregation; and developing and refining health inequality monitoring methods, resources and best practices. In alignment with these goals, WHO has published reference materials focused on conceptual approaches to health inequality monitoring, which are applied in the global State of Inequality report series. The Health Inequality Monitoring eLearning channel on OpenWHO and capacity building workshops and webinars facilitate the uptake and application of inequality monitoring practices across diverse settings and stakeholders. A key tool available to support the analysis and reporting aspects of health inequality monitoring is the Health Equity Assessment Toolkit (HEAT) application, which allows users to explore data interactively. The Health Inequality Data Repository, a collection of the largest publicly available database of disaggregated data from around the globe, further enables inequality monitoring and analyses. This collection of resources is an important contribution to promote health inequality monitoring across diverse settings. The uptake of evidence from health inequality monitoring remains crucial to the advancement of equity as part of global health and development initiatives.

Health Equity Assessment Toolkit (HEAT and HEAT Plus): exploring inequalities in the COVID-19 pandemic era.

BACKGROUND: The Sustainable Development Goals have helped to focus attention on the importance of reducing inequality and 'leaving no one behind'. Monitoring health inequalities is essential for providing evidence to inform policies, programmes and practices that can close existing gaps and achieve health equity. The Health Equity Assessment Toolkit (HEAT and HEAT Plus) software was developed by the World Health Organization to facilitate the assessment of within-country health inequalities. RESULTS: HEAT contains a built-in database of disaggregated health data, while HEAT Plus allows users to upload and analyze inequalities using their own datasets. Version 4.0 of the software incorporated enhancements to the toolkit's capacity for equity assessments. This includes a multilingual interface, interactive and downloadable visualizations, flexibility to analyze inequalities using any dataset of disaggregated data, and the built-in calculation of 19 summary measures of inequality. This paper outlines the improved features and functionalities of the HEAT and HEAT Plus software since their original release, highlighted through an example of how the toolkit can be used to assess inequalities in the COVID-19 pandemic era. CONCLUSIONS: The features of the HEAT and HEAT Plus software make it a valuable tool for analyzing and reporting inequalities related to the COVID-19 pandemic, as well as its indirect impacts on inequalities in other health and non-health areas, providing evidence to inform equity-oriented interventions and strategies.

Education-related inequalities in beliefs and behaviors pertaining to COVID-19 non-pharmaceutical interventions.

BACKGROUND: The coronavirus pandemic has exposed existing social inequalities in relation to disease preventive behaviors, risk of exposure, testing and healthcare access, and consequences as a result of illness and containment measures across different population groups. However, due to a lack of data, to date there has been limited evidence of the extent of such within-country inequalities globally. METHODS: We examined education-related inequalities in four COVID-19 prevention and testing indicators within 90 countries, using data from the University of Maryland Social Data Science Center Global COVID-19 Trends and Impact Survey, in partnership with Facebook, over the period 1 June 2021 to 31 December 2021. The overall level of education-related inequalities, as well as how they differ across country income groups and how they have changed over time were analyzed using the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII). We also assessed whether these education-related inequalities were associated with government policies and responses. RESULTS: Education-related inequalities in beliefs, mask wearing, social distancing and testing varied across the study countries. Mask wearing and beliefs in the effectiveness of social distancing and mask wearing were overall more common among people with a higher level of education. Even after controlling for other sociodemographic and health-related factors, social distancing practice was higher among the most educated in low/lower middle income countries, but was higher overall among the least educated in high income countries. Overall there were low education-related inequalities in COVID-19 testing, though there was variation across countries. CONCLUSIONS: The study highlights important within-country education-related differences in COVID-19 beliefs, preventive behaviors and testing, as well as differing trends across country income groups. This has implications for considering and targeting specific population groups when designing public health interventions and messaging during the COVID-19 pandemic and future health emergencies.

Health Inequality Monitoring channel on OpenWHO: capacity strengthening through eLearning.

BACKGROUND: Health inequality monitoring can generate important evidence to inform and motivate changes to policy, programmes and practices. However, the potential of health inequality monitoring practices to quantify inequalities between population subgroups and track progress on the advancement of health equity is under-realized. Capacity strengthening on health inequality monitoring can play an important role in enhancing political will for the generation and use of disaggregated data and for wider adoption of this practice to inform health decision-making. There is a lack of widely available and accessible training materials related to health inequality monitoring that may be used by a range of stakeholders. OBJECTIVE: In this paper, we describe the design, development and implementation of the Health Inequality Monitoring channel on the OpenWHO eLearning platform. We discuss the anticipated impact and potential opportunities for these eLearning courses to contribute to strengthened health inequality monitoring practices. RESULTS: The Health Inequality Monitoring channel on the OpenWHO platform is a self-directed learning environment, designed to meet the immediate learning needs of users. The channel contains three series of courses: health inequality monitoring foundations courses; topic-specific health inequality monitoring courses; and health inequality monitoring skill building courses. Courses are primarily targeted to monitoring and evaluation officers, data analysts, academics and researchers, public health professionals, medical and public health students, and others with a general interest in health data and inequality monitoring. CONCLUSIONS: WHO eLearning courses on health inequality monitoring are addressing the need for capacity strengthening in the collection, analysis and reporting of inequality data. They introduce learners to the foundational concepts, best practices, tools and skills required to conduct health inequality monitoring. The courses on the Health Inequality Monitoring channel demonstrate how technical information can be simplified and presented to broad audiences in a manner that is highly accessible to learners. The Health Inequality Monitoring channel on OpenWHO is an innovative and necessary addition to existing tools and resources to support the advancement of health equity.

Exploring the potential for a new measure of socioeconomic deprivation status to monitor health inequality.

BACKGROUND: Monitoring health inequalities is an important task for health research and policy, to uncover who is being left behind - and where - and to inform effective and equitable policies and programmes to tackle existing inequities. The choice of which measure to use to monitor and analyse health inequalities is thereby not trivial. This article explores a new measure of socioeconomic deprivation status (SDS) to monitor health inequalities. METHODS: The SDS measure was constructed using the Alkire-Foster method. It includes eight indicators across two equally weighted dimensions (education and living standards) and specifies a four-level gradient of socioeconomic deprivation at the household-level. We conducted four exercises to examine the value-added of the proposed SDS measure, using Demographic and Health Surveys data. First, we examined the discriminatory power of the new measure when applied to outcomes in four select reproductive, maternal, neonatal, and child health (RMNCH) indicators across six countries: skilled birth attendance, stunting, U5MR, and DTP3 immunisation. Then, we analysed the behaviour and association of the new SDS measure vis-à-vis the DHS Wealth Index, including chi-squared test and Pearson correlation coefficient. Third, we analysed the robustness of the SDS measure results to changes in its structure, using pairwise comparisons and Kendal Tau-b rank correlation. Finally, we illustrated some of the advantageous properties of the new measure, disaggregation and decomposition, on Haitian data. RESULTS: 1) Higher levels of socioeconomic deprivation are generally consistently associated with lower levels of achievements in the RMNCH indicators across countries. 2) 87% of all pairwise rank comparisons across a range of SDS measure structures were robust. 3) SDS and DHS Wealth Index are associated, but with considerable cross-country variation, highlighting their complementarity. 4) Haitian households in rural areas experienced, on average, more severe socioeconomic deprivation as well as lower levels of RMNCH achievement than urban households. CONCLUSIONS: The proposed SDS measure adds analytical possibilities to the health inequality monitoring literature, in line with ethically and conceptually well-founded notions of absolute, multidimensional disadvantage. In addition, it allows for breakdown by its dimensions and components, which may facilitate nuanced analyses of health inequality, its correlates, and determinants.

Subnational inequalities in diphtheria-tetanus-pertussis immunization in 24 countries in the African Region.

OBJECTIVE: To analyse subnational inequality in diphtheria-tetanus-pertussis (DTP) immunization dropout in 24 African countries using administrative data on receipt of the first and third vaccine doses (DTP1 and DTP3, respectively) collected by the Joint Reporting Process of the World Health Organization and the United Nations Children's Fund. METHODS: Districts in each country were grouped into quintiles according to the proportion of children who dropped out between DTP1 and DTP3 (i.e. the dropout rate). We used six summary measures to quantify inequalities in dropout rates between districts and compared rates with national dropout rates and DTP1 and DTP3 immunization coverage. FINDINGS: The median dropout rate across countries was 2.4% in quintiles with the lowest rate and 14.6% in quintiles with the highest rate. In eight countries, the difference between the highest and lowest quintiles was 14.9 percentage points or more. In most countries, underperforming districts in the quintile with the highest rate tended to lag disproportionately behind the others. This divergence was not evident from looking only at national dropout rates. Countries with the largest inequalities in absolute subnational dropout rate tended to have lower estimated national DTP1 and DTP3 immunization coverage. CONCLUSION: There were marked inequalities in DTP immunization dropout rates between districts in most countries studied. Monitoring dropout at the subnational level could help guide immunization interventions that address inequalities in underserved areas, thereby improving overall DTP3 coverage. The quality of administrative data should be improved to ensure accurate and timely assessment of geographical inequalities in immunization.

Comparison of Wealth-Related Inequality in Tetanus Vaccination Coverage before and during Pregnancy: A Cross-Sectional Analysis of 72 Low- and Middle-Income Countries.

Immunization of pregnant women against tetanus is a key strategy for reducing tetanus morbidity and mortality while also achieving the goal of maternal and neonatal tetanus elimination. Despite substantial progress in improving newborn protection from tetanus at birth through maternal immunization, umbilical cord practices and sterilized and safe deliveries, inequitable gaps in protection remain. Notably, an infant's tetanus protection at birth is comprised of immunization received by the mother during and before the pregnancy (e.g., through childhood vaccination, booster doses, mass vaccination campaigns, or during prior pregnancies). In this work, we examine wealth-related inequalities in maternal tetanus toxoid containing vaccination coverage before pregnancy, during pregnancy, and at birth for 72 low- and middle-income countries with a recent Demographic and Health Survey or Multiple Indicator Cluster Survey (between 2013 and 2022). We summarize coverage levels and absolute and relative inequalities at each time point; compare the relative contributions of inequalities before and during pregnancy to inequalities at birth; and examine associations between inequalities and coverage levels. We present the findings for countries individually and on aggregate, by World Bank country income grouping, as well as by maternal and neonatal tetanus elimination status, finding that most of the inequality in tetanus immunization coverage at birth is introduced during pregnancy. Inequalities in coverage during pregnancy are most pronounced in low- and lower-middle-income countries, and even more so in countries which have not achieved maternal and neonatal tetanus elimination. These findings suggest that pregnancy is a key time of opportunity for equity-oriented interventions to improve maternal tetanus immunization coverage.

Global state of education-related inequality in COVID-19 vaccine coverage, structural barriers, vaccine hesitancy, and vaccine refusal: findings from the Global COVID-19 Trends and Impact Survey.

BACKGROUND: COVID-19 vaccine coverage and experiences of structural and attitudinal barriers to vaccination vary across populations. Education-related inequality in COVID-19 vaccine coverage and barriers within and between countries can provide insight into the hypothesised role of education as a correlate of vaccine access and acceptability. We aimed to characterise patterns of within-country education-related inequality in COVID-19 vaccine indicators across 90 countries. METHODS: This study used data from the University of Maryland Social Data Science Center Global COVID-19 Trends and Impact Survey. Data from 90 countries (more than 14 million participants aged 18 years and older) were included in our analyses. We assessed education-related inequalities globally, across country-income groupings, and nationally for four indicators (self-reported receipt of COVID-19 vaccine, structural barriers to vaccination, vaccine hesitancy, and vaccine refusal) for the study period June 1-Dec 31, 2021. We calculated an absolute summary measure of inequality to assess the latest situation of inequality and time trends and explored the association between government vaccine availability policies and education-related inequality. FINDINGS: Nearly all countries had higher self-reported receipt of a COVID-19 vaccine among the most educated respondents than the least educated respondents. Education-related inequality in structural barriers, vaccine hesitancy, and vaccine refusal varied across countries, and was most pronounced in high-income countries, overall. Low-income and lower-middle-income countries reported widespread experiences of structural barriers and high levels of vaccine hesitancy alongside low levels of education-related inequality. Globally, vaccine hesitancy in unvaccinated people was higher among those with lower education and vaccine refusal was higher among those with higher education, especially in high-income countries. Over the study period, education-related inequalities in self-reported receipt of a COVID-19 vaccine declined, globally and across all country income groupings. Government policies expanding vaccine availability were associated with lower education-related inequality in self-reported receipt of vaccine. INTERPRETATION: This study serves as a baseline for continued inequality monitoring and could help to inform targeted actions for the equitable uptake of vaccines. FUNDING: Gavi, the Vaccine Alliance.

Inequalities in Immunization against Maternal and Neonatal Tetanus: A Cross-Sectional Analysis of Protection at Birth Coverage Using Household Health Survey Data from 76 Countries.

Substantial progress in maternal and neonatal tetanus elimination has been made in the past 40 years, with dramatic reductions in neonatal tetanus incidence and mortality. However, twelve countries have still not achieved maternal and neonatal tetanus elimination, and many countries that have achieved elimination do not meet key sustainability thresholds to ensure long-lasting elimination. As maternal and neonatal tetanus is a vaccine-preventable disease (with coverage of the infant conferred by maternal immunization during and prior to pregnancy), maternal tetanus immunization coverage is a key metric for monitoring progress towards, equity in, and sustainability of tetanus elimination. In this study, we examine inequalities in tetanus protection at birth, a measure of maternal immunization coverage, across 76 countries and four dimensions of inequality via disaggregated data and summary measures of inequality. We find that substantial inequalities in coverage exist for wealth (with lower coverage among poorer wealth quintiles), maternal age (with lower coverage among younger mothers), maternal education (with lower coverage among less educated mothers), and place of residence (with lower coverage in rural areas). Inequalities existed for all dimensions across low- and lower-middle-income countries, and across maternal education and place of residence across upper-middle-income countries. Though global coverage changed little over the time period 2001-2020, this obscured substantial heterogeneity across countries. Notably, several countries had substantial increases in coverage accompanied by decreases in inequality, highlighting the need for equity considerations in maternal and neonatal tetanus elimination and sustainability efforts.

Association between childhood immunisation coverage and proximity to health facilities in rural settings: a cross-sectional analysis of Service Provision Assessment 2013-2014 facility data and Demographic and Health Survey 2015-2016 individual data in Malawi.

OBJECTIVES: Despite significant progress in childhood vaccination coverage globally, substantial inequality remains. Remote rural populations are recognised as a priority group for immunisation service equity. We aimed to link facility and individual data to examine the relationship between distance to services and immunisation coverage empirically, specifically using a rural population. DESIGN AND SETTING: Retrospective cross-sectional analysis of facility data from the 2013-2014 Malawi Service Provision Assessment and individual data from the 2015-2016 Malawi Demographic and Health Survey, linking children to facilities within a 5 km radius. We examined associations between proximity to health facilities and vaccination receipt via bivariate comparisons and logistic regression models. PARTICIPANTS: 2740 children aged 12-23 months living in rural areas. OUTCOME MEASURES: Immunisation coverage for the six vaccines included in the Malawi Expanded Programme on Immunization schedule for children under 1 year at time of study, as well as two composite vaccination indicators (receipt of basic vaccines and receipt of all recommended vaccines), zero-dose pentavalent coverage, and pentavalent dropout. FINDINGS: 72% (706/977) of facilities offered childhood vaccination services. Among children in rural areas, 61% were proximal to (within 5 km of) a vaccine-providing facility. Proximity to a vaccine-providing health facility was associated with increased likelihood of having received the rotavirus vaccine (93% vs 88%, p=0.004) and measles vaccine (93% vs 89%, p=0.01) in bivariate tests. In adjusted comparisons, how close a child was to a health facility remained meaningfully associated with how likely they were to have received rotavirus vaccine (adjusted OR (AOR) 1.63, 95% CI 1.13 to 2.33) and measles vaccine (AOR 1.62, 95% CI 1.11 to 2.37). CONCLUSION: Proximity to health facilities was significantly associated with likelihood of receipt for some, but not all, vaccines. Our findings reiterate the vulnerability of children residing far from static vaccination services; efforts that specifically target remote rural populations living far from health facilities are warranted to ensure equitable vaccination coverage.

Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries.

The role of gender inequality in childhood immunization is an emerging area of focus for global efforts to improve immunization coverage and equity. Recent studies have examined the relationship between gender inequality and childhood immunization at national as well as individual levels; we hypothesize that the demonstrated relationship between greater gender equality and higher immunization coverage will also be evident when examining subnational-level data. We thus conducted an ecological analysis examining the association between the Subnational Gender Development Index (SGDI) and two measures of immunization-zero-dose diphtheria-tetanus-pertussis (DTP) prevalence and 3-dose DTP coverage. Using data from 2010-2019 across 702 subnational regions within 57 countries, we assessed these relationships using fractional logistic regression models, as well as a series of analyses to account for the nested geographies of subnational regions within countries. Subnational regions were dichotomized to higher gender inequality (top quintile of SGDI) and lower gender inequality (lower four quintiles of SGDI). In adjusted models, we find that subnational regions with higher gender inequality (favoring men) are expected to have 5.8 percentage points greater zero-dose prevalence than regions with lower inequality [16.4% (95% confidence interval (CI) 14.5-18.4%) in higher-inequality regions versus 10.6% (95% CI 9.5-11.7%) in lower-inequality regions], and 8.2 percentage points lower DTP3 immunization coverage [71.0% (95% CI 68.3-73.7%) in higher-inequality regions versus 79.2% (95% CI 77.7-80.7%) in lower-inequality regions]. In models accounting for country-level clustering of gender inequality, the magnitude and strength of associations are reduced somewhat, but remain statistically significant in the hypothesized direction. In conjunction with published work demonstrating meaningful associations between greater gender equality and better childhood immunization outcomes in individual- and country-level analyses, these findings lend further strength to calls for efforts towards greater gender equality to improve childhood immunization and child health outcomes broadly.

Gender-Related Inequality in Childhood Immunization Coverage: A Cross-Sectional Analysis of DTP3 Coverage and Zero-Dose DTP Prevalence in 52 Countries Using the SWPER Global Index.

Gender-related barriers to immunization are key targets to improve immunization coverage and equity. We used individual-level demographic and health survey data from 52 low- and middle-income countries to examine the relationship between women's social independence (measured by the Survey-based Women's emPowERment (SWPER) Global Index) and childhood immunization. The primary outcome was receipt of three doses of the diphtheria-tetanus-pertussis vaccine (DTP3) among children aged 12-35 months; we secondarily examined failure to receive any doses of DTP-containing vaccines. We summarized immunization coverage indicators by social independence tertile and estimated crude and adjusted summary measures of absolute and relative inequality. We conducted all analyses at the country level using individual data; median results across the 52 examined countries are also presented. In crude comparisons, median DTP3 coverage was 12.3 (95% CI 7.9; 16.3) percentage points higher among children of women with the highest social independence compared with children of women with the lowest. Thirty countries (58%) had a difference in coverage between those with the highest and lowest social independence of at least 10 percentage points. In adjusted models, the median coverage was 7.4 (95% CI 5.0; 9.1) percentage points higher among children of women with the highest social independence. Most countries (41, 79%) had statistically significant relative inequality in DTP3 coverage by social independence. The findings suggest that greater social independence for women was associated with better childhood immunization outcomes, adding evidence in support of gender-transformative strategies to reduce childhood immunization inequities.

Reporting immunization coverage inequalities in Pakistan.

BACKGROUND: Immunization coverage in Pakistan is unequally distributed. Understanding the current status of reporting of immunization coverage inequalities in Pakistan can help to identify gaps and opportunities for strengthened monitoring and reporting. AIMS: To assess the published literature on immunization coverage inequality measurement and reporting in Pakistan. METHODS: We performed a literature search in PubMed in April 2019 to obtain articles reporting inequalities in immunization coverage in Pakistan. A data extraction rubric was applied to collate information about data sources, immunization indicators and dimensions of inequality. RESULTS: We included 42 studies in our analysis. Most studies reported data from household surveys or research studies. Dimensions of inequality reflected geography (primarily provinces/territories), economic status, place of residence, education level, sex and occupation. District-level comparisons were featured in 5 studies that were subnational in scope. CONCLUSIONS: Expanded monitoring at district level is warranted as a major way forward in characterizing immunization inequalities in Pakistan.