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.

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.

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.

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.

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.

Correction: Schlotheuber, A.; Hosseinpoor, A.R. Summary Measures of Health Inequality: A Review of Existing Measures and Their Application. Int. J. Environ. Res. Public Health 2022, 19, 3697.

Several errors were introduced after proofreading, and the authors hence wish to make the following corrections to this paper [...].

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.

Economic-Related Inequalities in Zero-Dose Children: A Study of Non-Receipt of Diphtheria-Tetanus-Pertussis Immunization Using Household Health Survey Data from 89 Low- and Middle-Income Countries.

Despite advances in scaling up new vaccines in low- and middle-income countries, the global number of unvaccinated children has remained high over the past decade. We used 2000-2019 household survey data from 154 surveys representing 89 low- and middle-income countries to assess within-country, economic-related inequality in the prevalence of one-year-old children with zero doses of diphtheria-tetanus-pertussis (DTP) vaccine. Zero-dose DTP prevalence data were disaggregated by household wealth quintile. Difference, ratio, slope index of inequality, concentration index, and excess change measures were calculated to assess the latest situation and change over time, by country income grouping for 17 countries with high zero-dose DTP numbers and prevalence. Across 89 countries, the median prevalence of zero-dose DTP was 7.6%. Within-country inequalities mostly favored the richest quintile, with 19 of 89 countries reporting a rich-poor gap of ≥20.0 percentage points. Low-income countries had higher inequality than lower-middle-income countries and upper-middle-income countries (difference between the median prevalence in the poorest and richest quintiles: 14.4, 8.9, and 2.7 percentage points, respectively). Zero-dose DTP prevalence among the poorest households of low-income countries declined between 2000 and 2009 and between 2010 and 2019, yet economic-related inequality remained high in many countries. Widespread economic-related inequalities in zero-dose DTP prevalence are particularly pronounced in low-income countries and have remained high over the previous decade.

Summary Measures of Health Inequality: A Review of Existing Measures and Their Application.

Measuring and monitoring health inequalities is key to achieving health equity. While disaggregated data are commonly used to assess differences in health between different population subgroups, summary measures of health inequality also play a vital role in monitoring health inequalities. Building on disaggregated data, they quantify the level of inequality in a single number and are useful to compare inequality over time and across different health indicators, programmes and settings. We provide a comprehensive overview of existing summary measures of health inequality, including their definition, calculation, interpretation and application. The use of these measures is illustrated based on an example from the WHO's Health Equity Monitor database using the WHO's Health Equity Assessment Toolkit (HEAT) software. We discuss the strengths and limitations of different measures and provide guidance for selecting suitable summary measures for analysing health inequalities and communicating results. Summary measures of health inequality should form an integral part of health inequality monitoring to inform equity-oriented policies and programmes.

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.

Measuring health inequalities in the context of sustainable development goals.

Transforming our world: the 2030 agenda for sustainable development promotes the improvement of health equity, which entails ongoing monitoring of health inequalities. The World Health Organization has developed a multistep approach to health inequality monitoring consisting of: (i) determining the scope of monitoring; (ii) obtaining data; (iii) analysing data; (iv) reporting results; and (v) implementing changes. Technical considerations at each step have implications for the results and conclusions of monitoring and subsequent remedial actions. This paper presents some technical considerations for developing or strengthening health inequality monitoring, with the aim of encouraging more robust, systematic and transparent practices. We discuss key aspects of measuring health inequalities that are relevant to steps (i) and (iii). We highlight considerations related to the selection, measurement and categorization of dimensions of health inequality, as well as disaggregation of health data and calculation of summary measures of inequality. Inequality monitoring is linked to health and non-health aspects of the 2030 agenda for sustainable development, and strong health inequality monitoring practices can help to inform equity-oriented policy directives.

Transformer notre monde: le programme de développement durable à l'horizon 2030 promeut l'amélioration de l'équité en santé, ce qui implique un suivi continu des inégalités en matière de santé. L'Organisation mondiale de la Santé a élaboré une approche pour le suivi des inégalités en santé qui comprend plusieurs étapes: (i) déterminer la portée du suivi; (ii) collecter des données; (iii) analyser les données; (iv) communiquer les résultats; et (v) mettre en œuvre des changements. À chaque étape, des considérations techniques ont des conséquences sur les résultats et les conclusions du suivi et sur les mesures correctives qui en résultent. Ce document présente certaines considérations techniques pour le développement ou le renforcement du suivi des inégalités en santé, dans l'objectif d'encourager des pratiques plus fiables, plus systématiques et plus transparentes. Nous examinons des aspects clés de la mesure des inégalités en santé à prendre en compte dans les étapes (i) et (iii). Nous mettons en avant des considérations en lien avec la sélection, la mesure et la catégorisation des dimensions des inégalités en matière de santé, ainsi que la ventilation des données sur la santé et le calcul de mesures synthétiques des inégalités. Le suivi des inégalités est lié à des aspects sanitaires et non sanitaires du Programme de développement durable à l'horizon 2030, et des pratiques rigoureuses de suivi des inégalités en matière de santé peuvent contribuer à éclairer les directives axées sur l'équité.

Transformar nuestro mundo: el plan de 2030 para el desarrollo sostenible promueve la mejora de la igualdad en la salud, lo que implica un seguimiento continuo de las desigualdades en salud. La Organización Mundial de la Salud ha desarrollado un enfoque de múltiples pasos para el seguimiento de la desigualdad en la salud que consiste en: (i) determinar el alcance del seguimiento; (ii) obtener datos; (iii) analizar los datos; (iv) informar sobre los resultados; e (v) implementar los cambios. Las consideraciones técnicas de cada paso tienen implicaciones para los resultados y las conclusiones del seguimiento y las acciones correctivas subsiguientes. En este documento se presentan algunas consideraciones técnicas para desarrollar o fortalecer el seguimiento de la desigualdad en la salud, con el fin de fomentar prácticas más robustas, sistemáticas y transparentes. Se analizan aspectos clave de la medición de las desigualdades en la salud relevantes para los pasos (i) y (iii). Se destacan las consideraciones relacionadas con la selección, la medición y la categorización de las dimensiones de la desigualdad en la salud, así como la desagregación de los datos de salud y el cálculo de medidas sintetizadas de desigualdad. El seguimiento de la desigualdad está vinculado a los aspectos sanitarios y no sanitarios del programa de desarrollo sostenible de 2030, y unas prácticas rigurosas de seguimiento de la desigualdad en la salud pueden ayudar a fundamentar las directrices políticas orientadas a la igualdad.

Subnational regional inequality in access to improved drinking water and sanitation in Indonesia: results from the 2015 Indonesian National Socioeconomic Survey (SUSENAS).

BACKGROUND: Universal and equitable access to safe and affordable drinking water and adequate sanitation and hygiene in Indonesia are vital to ensure healthy lives and promote well-being for all at all ages. OBJECTIVES: To quantify subnational regional inequality in access to improved drinking water and sanitation in Indonesia. METHODS: Data about access to improved drinking water and sanitation were derived from the 2015 Indonesian National Socioeconomic Survey (SUSENAS) and disaggregated by 510 districts across the 34 provinces of Indonesia. Two summary measures of inequality, mean difference from mean and weighted index of disparity, were calculated to quantify within-province absolute and relative inequality, respectively. RESULTS: While the majority of Indonesian households had access to improved drinking water (71.0%) and sanitation (62.1%), there were large variations between and within provinces. Access to improved drinking water ranged from 93.4% in DKI Jakarta to 41.1% in Bengkulu, and access to improved sanitation ranged from 89.3% in Jakarta to 23.9% in East Nusa Tenggara. Provinces with similar numbers of districts and similar overall averages showed variable levels of absolute and/or relative inequality. Certain districts reported very low levels of access to improved drinking water and/or sanitation. CONCLUSIONS: There are inequalities in access to improved drinking water and sanitation by subnational region in Indonesia. Monitoring within-country inequality in these indicators serves to identify underserved areas, and is useful for developing approaches to improve inequalities in access that can help Indonesia make progress towards the 2030 Agenda for Sustainable Development.