Health Equity Assessment Toolkit Plus (HEAT Plus): software for exploring and comparing health inequalities using uploaded datasets

Trends and inequalities in full immunisation coverage among one-year-olds in Sierra Leone, 2008-2019

BACKGROUND

Full immunisation of children by their first birthday is a crucial public health target. Vaccines protect children from preventable diseases, promoting individual and community health. In Sierra Leone, a country with a history of high childhood mortality rates, achieving full immunisation coverage is a critical step towards a healthier future. This study examined the trends and inequalities in full immunisation coverage among children aged one year in Sierra Leone from 2008 to 2019.

METHODS

Three rounds of the Sierra Leone Demographic and Health Survey (2008, 2013, and 2019) were analysed. A descriptive approach was adopted for the analysis. Simple [difference (D) and ratio (R)] and complex [population attributable risk (PAR) and population attributable fraction (PAF)] measures of inequalities were computed using the World Health Organization's Health Equity Assessment Toolkit (WHO's HEAT) software. The measures were computed separately for each of the three surveys, and their estimates were compared.

RESULTS

The findings revealed that full immunisation coverage for one-year-olds in Sierra Leone increased significantly between 2008 (40.1%) and 2013 (68.3%). However, there was a decrease in coverage in 2019 (56.5%). Region-related inequalities were the largest and increased slightly between 2008 (D = 13.8; R = 1.4; PAF = 17.8, PAR = 7.1) and 2013 (D = 20.7.; R = 1.3; PAF = 14.2, PAR = 9.7) but decreased in 2019 (D = 18.2; R = 1.3; PAF = 15.3, PAR = 8.6). Substantial education-related inequalities were observed in 2008 (D = 10.1, R = 1.2, PAF = 19.4, PAR = 7.7), but this decreased in 2013 (D = 6.7, R = 1.1, PAF = 8.0, PAR = 5.4; and 2019 D = 5.0, R = 1.0, PAF = 4.7, PAR = 2.4). The age and sex of the child appeared to have minimal influence on the overall inequality in immunisation coverage.

CONCLUSION

The study highlights education and region as key contributors to the inequalities. Mothers with lower education were less likely to get their children fully immunised. Immunisation coverage varies significantly across regions, with the Eastern region leading and the Northern region lagging. Age and sex have minimal impact. The government and partner organisations in Sierra Leone should focus outreach programs on these high-risk groups, implement geographically targeted strategies and invest in education and improve access to healthcare facilities. Ensuring vaccine availability, trained personnel, and data collection for monitoring could be useful. There is also the need to develop targeted interventions for regions with lower coverage. These steps are crucial to achieving universal immunisation coverage.

TRIAL REGISTRATION

Registration was not necessary since we analysed a secondary dataset.

Inequalities in utilization of maternal health services in Ethiopia: evidence from the PMA Ethiopia longitudinal survey

Background

Previous studies documented the existence of substantial inequalities in the utilization of maternal health services across different population subgroups in Ethiopia. Regularly monitoring the state of inequality could enhance efforts to address health inequality in the utilization of maternal health services. Therefore, this study aimed to measure the level of inequalities in the utilization of maternal health services in Ethiopia.

Method

The study used data from the Performance Monitoring for Action Ethiopia (PMA Ethiopia) dataset. Longitudinal data was collected from a weighted sample of 1966 postpartum women using multistage stratified cluster sampling techniques between November 2021 to October 2022. We assessed inequality in maternal health services using three indicators: antenatal care four (ANC), skilled birth attendants (SBA), and postnatal care (PNC). Age, economic status, education level, place of residence, and subnational regions were used as dimensions for measuring inequality. The analysis was conducted using Health Equity Assessment Toolkit Plus (HEAT Plus) software. We computed the summary measure of health inequality: Difference (D), Ratio (R), Population Attributable Risk (PAR), and Population Attributable Fraction (PAF).

Result

The simple summary measures of inequality difference (D) reported a high level of inequality in the utilization of maternal health services in ANC four, SBA, and PNC across economic, education, residence, and subnational regions. The difference (D) in maternal health service utilization between advantaged and disadvantaged population groups exceeded 20 percentage points in all four dimensions of inequality for the three maternal health indicators. Similarly, the complex summary measures of inequality (PAR and PAF) also showed high levels of inequality in the utilization of ANC four, SBA, and PNC across all four dimensions of inequality. However, there was no age-related inequality in the use of maternal health services.

Conclusion

A high level of socioeconomic and geographic area related inequality was observed in the utilization of ANC four, SBA, and PNC services in Ethiopia. Women from socioeconomically disadvantaged subgroups and women from disadvantaged geographic areas significantly lagged behind in the utilization of maternal health services. Therefore, implementing targeted interventions for the most disadvantaged groups can help to reduce inequality in accessing maternal health services.

Global health inequalities in the burden of interstitial lung disease and pulmonary sarcoidosis from 1990 to 2021

BACKGROUND

Interstitial lung disease and pulmonary sarcoidosis remain serious medical problems worldwide. This study aims to assess the global burden and health inequalities of interstitial lung disease and pulmonary sarcoidosis between 1990 and 2021.

METHODS

Data on disability-adjusted life years (DALYs) due to interstitial lung disease and pulmonary sarcoidosis were obtained from the Global Burden of Diseases, Injuries and Risk Factors Study 2021. The slope index of inequality (SII) and concentration index were used to assess cross-national health inequality.

RESULTS

There were 2,237,269 (95% uncertainty interval: 1,839,500 to 2,555,200) DALYs due to interstitial lung disease and pulmonary sarcoidosis in males and 1,804,881 DALYs (1,465,707 to 2,216,376) in females in 2021. The age-standardized DALY rate of interstitial lung disease and pulmonary sarcoidosis increased from 37.1 (30.6 to 45.4) per 100,000 in 1990 to 47.6 (41.3 to 53.2) per 100,000 in 2021. Countries with high socio-demographic index (SDI) showed the greatest increase in the age-standardized DALY rate of interstitial lung disease and pulmonary sarcoidosis during the past 32 years (53.4%, 45.1 to 62.2%). The SII increased from 19.6 (95% confidence interval: 11.6 to 27.5) in 1990 to 53.4 (39.7 to 67.1) in 2021. The concentration index increased from 0.15 (0.08 to 0.21) in 1990 to 0.23 (0.16 to 0.32) in 2021.

CONCLUSION

The burden of interstitial lung disease and pulmonary sarcoidosis increased and remained high in the high-SDI quintile. More attention must be given to reducing the burden of interstitial lung disease and pulmonary sarcoidosis.

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.

Global pattern, trend, and cross-country inequality of early musculoskeletal disorders from 1990 to 2019, with projection from 2020 to 2050

BACKGROUND

This study aims to estimate the burden, trends, forecasts, and disparities of early musculoskeletal (MSK) disorders among individuals ages 15 to 39 years.

METHODS

The global prevalence, years lived with disabilities (YLDs), disability-adjusted life years (DALYs), projection, and inequality were estimated for early MSK diseases, including rheumatoid arthritis (RA), osteoarthritis (OA), low back pain (LBP), neck pain (NP), gout, and other MSK diseases (OMSKDs).

FINDINGS

More adolescents and young adults were expected to develop MSK disorders by 2050. Across five age groups, the rates of prevalence, YLDs, and DALYs for RA, NP, LBP, gout, and OMSKDs sharply increased from ages 15-19 to 35-39; however, these were negligible for OA before age 30 but increased notably at ages 30-34, rising at least 6-fold by 35-39. The disease burden of gout, LBP, and OA attributable to high BMI and gout attributable to kidney dysfunction increased, while the contribution of smoking to LBP and RA and occupational ergonomic factors to LBP decreased. Between 1990 and 2019, the slope index of inequality increased for six MSK disorders, and the relative concentration index increased for gout, NP, OA, and OMSKDs but decreased for LBP and RA.

CONCLUSIONS

Multilevel interventions should be initiated to prevent disease burden related to RA, NP, LBP, gout, and OMSKDs among individuals ages 15-19 and to OA among individuals ages 30-34 to tightly control high BMI and kidney dysfunction.

FUNDING

The Global Burden of Disease study is funded by the Bill and Melinda Gates Foundation. The project is funded by the Scientific Research Fund of Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital (2022QN38).

Socioeconomic and residence-based inequalities in adolescent fertility in 39 African countries

INTRODUCTION

Despite the advancement in sexual and reproductive healthcare services and several public health measures aimed at controlling fertility rates, countries in sub-Saharan Africa (SSA) still experience higher adolescent fertility rates than other low-and middle-income countries. This study examined the disparities in adolescent fertility in 39 countries in SSA, focusing on socioeconomic and residence-based dimensions.

METHODS

This study involved a secondary analysis of data obtained from 39 recent Demographic and Health Surveys conducted in SSA. The measures of difference (D), ratio (R), population attributable fraction (PAF), and population attributable risk (PAR) were estimated using the Health Equity Assessment Tool (HEAT) software version 3.1 developed by the World Health Organization. The measures: D, R, PAF, and PAR were used to examine the inequalities in adolescent fertility across the socioeconomic and residence-based dimensions.

RESULTS

Out of the 39 countries included in the study, Guinea (D=27.70), Niger (D=27.50), Nigeria (D=23.90), and Côte d'Ivoire (D=23.60) exhibited the most significant residence-based inequalities in the rate of adolescent fertility, with the higher rate observed among adolescents in rural areas. Rwanda was the sole country that showed a slight inclination towards rural inequality in terms of the rate of adolescent fertility, with a value of D = -0.80. The burden of adolescent fertility was disproportionately higher among young women with low economic status across all the countries, exacerbating wealth-based inequities. The countries with the largest absolute discrepancies were Nigeria (D=44.70), Madagascar (D=41.10), Guinea (D=41.00), and Cameroon (D=40.20). We found significant disparities in educational attainment contributing to unequal inequalities in adolescent fertility, particularly among young women who lack access to formal education. Countries such as Madagascar (D=59.50), Chad (D=55.30), Cameroon (D=54.60), and Zimbabwe (D=50.30) had the most significant absolute disparities.

CONCLUSION

This study revealed that young women residing in rural areas, those in households with low economic status and those with limited educational opportunities experience a disproportionately high burden of adolescent fertility across the 39 countries in SSA. The current findings offer valuable information to governmental entities at all levels regarding the need to ensure the provision of equitable, accessible, and dependable sexual and reproductive health services to the populace, particularly for young women. Therefore, the various stakeholders need to enhance the effectiveness of health policies and legislation pertaining to adolescent women living in rural areas, those from economically disadvantaged households, and those with limited or no access to formal education. Such interventions could potentially reduce adolescent fertility rates and mitigate the adverse maternal and child outcomes associated with high adolescent fertility in SSA.

Demographic and economic inequality of antenatal care coverage in 4 African countries with a high maternal mortality rate

BACKGROUND

Maternal deaths are concentrated in low and middle-income countries, and Africa accounts for over 50% of the deaths. Women from socioeconomically disadvantaged households have higher morbidity and mortality rates and lower access to maternal health services. Understanding and addressing these inequalities is crucial for achieving the Sustainable Development Goals and improving maternal health outcomes. This study examines the demographic and economic disparities in the utilization of antenatal care (ANC) in four countries with high maternal mortality rates in Africa, namely Nigeria, Chad, Liberia, and Sierra Leone.

METHOD

The study utilised data from Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) from Nigeria, Chad, Liberia, and Sierra Leone. The data was obtained from the Health Equity Assessment Toolkit (HEAT) database. The study examined ANC service utilisation inequality in four dimensions such as economic status, education, place of residence, and subnational region across different subgroups by using four summary measures (Difference (D), Absolute Concentration Index (ACI), Population Attributable Risk (PAR), and Population Attributable Factor (PAF)).

RESULT

A varying level of inequality in ANC coverage across multiple survey years was observed in Nigeria, Chad, Liberia, and Sierra Leone. Different regions and countries exhibit varying levels of inequality. Disparities were prominent based on educational attainment and place of residence. Higher level of inequality was generally observed among individuals with higher education and those residing in urban areas. Inequality in ANC coverage was also observed by economic status, subnational region, and other factors in Nigeria, Chad, Liberia, and Sierra Leone. ANC coverage is generally higher among the richest quintile subgroup, indicating inequality. Nigeria and Chad show the highest levels of inequality in ANC coverage across multiple measures. Sierra Leone displays some variation with higher coverage among the poorest quintile subgroup.

CONCLUSION AND RECOMMENDATION

Inequalities in ANC coverage exist across age groups and survey years in Nigeria, Chad, Liberia, and Sierra Leone. Disparities are prominent based on education, residence, and economic status. Efforts should focus on improving access for vulnerable groups, enhancing education and awareness, strengthening healthcare infrastructure, and addressing economic disparities.

Magnitude and trends in inequalities in healthcare-seeking behavior for pneumonia and mortality rate among under-five children in Bangladesh: Evidence from nationwide cross-sectional survey 2007 to 2017

Background and Aims

Bangladesh did not have enough evidence on the current estimates and trend in inequities in the under-five mortality rate (U5MR). There is also a shortage of evidence on trends and inequalities in healthcare-seeking for pneumonia among under-five children (U5C) in Bangladesh. Hence, this study investigated the inequalities in U5MR and health care seeking for pneumonia in U5C through socioeconomic and geographic disparities in Bangladesh between 2007 and 2017.

Methods

Data from 2007, 2011, 2014, and 2017 Bangladesh Demographic and Health surveys were analyzed using the Health Equity Assessment Toolkit (HEAT) software by World Health Organization (WHO). The data on U5MR and healthcare-seeking for pneumonia were first disaggregated into five equity dimensions: wealth status, education, child sex, place of residence, and administrative divisions. Second, using summary metrics such as difference (D), population attributable risk (PAR), ratio (R), and population attributable fraction (PAF), inequalities were assessed.

Results

The U5MR declined from 73.9 deaths per 1000 live births in 2007 to 48.6 deaths in 2017, while the prevalence of healthcare-seeking for pneumonia in U5C fluctuated over time (34.6% in 2007, 35.4% in 2011, 42.0% in 2014, and 39.8% in 2017). Profound socioeconomic and geographic disparities in U5MR and the prevalence of healthcare-seeking for pneumonia in U5C favored the wealthy, educated, and urban residents. At the same time, the Sylhet division showed the worst situation for U5MR. There were also sex-related disparities in U5MR (PAR = -4.5, 95% confidence interval: -5.3 to -3.7) with higher risk among male children than females.

Conclusion

These results indicate that improving disadvantaged women, such as the poor, uneducated, and rural inhabitants, who exhibit disproportionate disparities in U5MR and healthcare-seeking behavior is important. To reduce childhood mortality, it is essential to improve healthcare-seeking for pneumonia among U5C. Facilitating women for better education and economic encompasses would help reducing disparity.

Inequalities in early initiation of breastfeeding in Bangladesh: an estimation of relative and absolute measures of inequality

BACKGROUND

Evidence suggested that inequalities based on education, wealth status, place of residence, and geographical regions significantly influence the key breastfeeding indicators including early initiation of breastfeeding. This study aimed to estimate the trends and magnitude of inequalities in early initiation of breastfeeding practice in Bangladesh from 2004 to 2017 applying both absolute and relative measures of inequality.

METHODS

We used data from the last five Bangladesh Demographic Health Survey (BDHS) from 2004 to 2017 to measure the inequalities in early initiation of breastfeeding practice using the WHO's Health Equity Assessment Toolkit (HEAT) software. Following summary measures were estimated to measure the inequalities: Population Attributable Risk (PAR), Population Attributable Fraction (PAF), Difference (D), and Ratio (R) where the equity dimensions were wealth status, education level, sex of child, place of residence, and subnational regions (divisions). For each measure, point estimates along with a 95% confidence interval (CI) were reported.

RESULTS

An uprising pattern in the prevalence of early initiation of breastfeeding was found, where early initiation of breastfeeding increased from 24.9% to 2004 to 59.0% in 2017. We found significant wealth-driven inequalities in early initiation of breastfeeding practice in every wave of survey favoring the poorest wealth quintile (in 2017, D -10.5; 95% CI -16.6 to -4.3). We also identified geographical disparities in early initiation of breastfeeding practice (in 2017, PAF 11.1; 95% CI 2.2 to 19.9) favoring the Rangpur (65.5%), and Sylhet (65.3%) divisions. Education-related disparities were observed in 2004 only, but not in later survey years, which was due to a much lower level of adherence among those with secondary or higher education. There were no significant disparities in early initiation of breastfeeding based on the urban vs. rural residence and sex of the child.

CONCLUSIONS

The highest attention should be placed in Bangladesh to attain the WHO's 100% recommendation of timely initiation of breastfeeding. This study emphasizes on addressing the existing socioeconomic and geographic inequalities. Awareness-raising outreach programs focusing the mothers from wealthier sub-groups and divisions with lower prevalence should be planned and implemented by the joint effort of the government and non-government organizations.

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.

Comparing Multivariate with Wealth-Based Inequity in Vaccination Coverage in 56 Countries: Toward a Better Measure of Equity in Vaccination Coverage

INTRODUCTION

Following a call from the World Health Organization in 2017 for a methodology to monitor immunization coverage equity in line with the 2030 Agenda for Sustainable Development, this study applies the Vaccine Economics Research for Sustainability and Equity (VERSE) vaccination equity toolkit to measure national-level inequity in immunization coverage using a multidimensional ranking procedure and compares this with traditional wealth-quintile based ranking methods for assessing inequity. The analysis covers 56 countries with a most recent Demographic & Health Survey (DHS) between 2010 and 2022. The vaccines examined include Bacillus Calmette-Guerin (BCG), Diphtheria-Tetanus-Pertussis-containing vaccine doses 1 through 3 (DTP1-3), polio vaccine doses 1-3 (Polio1-3), the measles-containing vaccine first dose (MCV1), and an indicator for being fully immunized for age with each of these vaccines.

MATERIALS & METHODS

The VERSE equity toolkit is applied to 56 DHS surveys to rank individuals by multiple disadvantages in vaccination coverage, incorporating place of residence (urban/rural), geographic region, maternal education, household wealth, sex of the child, and health insurance coverage. This rank is used to estimate a concentration index and absolute equity coverage gap (AEG) between the top and bottom quintiles, ranked by multiple disadvantages. The multivariate concentration index and AEG are then compared with traditional concentration index and AEG measures, which use household wealth as the sole criterion for ranking individuals and determining quintiles.

RESULTS

We find significant differences between the two sets of measures in almost all settings. For fully-immunized for age status, the inequities captured using the multivariate metric are between 32% and 324% larger than what would be captured examining inequities using traditional metrics. This results in a missed coverage gap of between 1.1 and 46.4 percentage points between the most and least advantaged.

CONCLUSIONS

The VERSE equity toolkit demonstrated that wealth-based inequity measures systematically underestimate the gap between the most and least advantaged in fully-immunized for age coverage, correlated with maternal education, geography, and sex by 1.1-46.4 percentage points, globally. Closing the coverage gap between the bottom and top wealth quintiles is unlikely to eliminate persistent socio-demographic inequities in either coverage or access to vaccines. The results suggest that pro-poor interventions and programs utilizing needs-based targeting, which reflects poverty only, should expand their targeting criteria to include other dimensions to reduce systemic inequalities, holistically. Additionally, a multivariate metric should be considered when setting targets and measuring progress toward reducing inequities in healthcare coverage.

Comparative characteristics of developing morphofunctional features of schoolchildren from different climatic and geographical regions

OBJECTIVES

Adaptation processes in body of schoolchildren, along with study load and social factors, are determined by influence of climatic and geographical factors of residence region. This research has been undertaken to study the morphofunctional characteristics of schoolchildren at the age of 7-17 years.

METHODS

The research involved 880 schoolchildren of both sexes in age from 7 to 17 years, studying in secondary school №22 in Pavlodar (Kazakhstan) and secondary school №7 in Kyzylorda (Kazakhstan). The Quetelet index of northern schoolchildren was within the norm but higher compared to southern peers.

RESULTS

The Quetelet index was within the normal range for all schoolchildren, but higher among northerners. The indicator of the life index in the boys of the south was higher up to 10 years, then the adaptive possibilities of breathing decreased; in the girls in the north this indicator was higher in all periods, except for 8-9 years. The physical performance index (PWC170/kg) was higher in children from the southern region.

CONCLUSIONS

This study revealed significant geographical differences in the morphofunctional development of children. The obtained data served allowed establishing the "Electronic map of schoolchildren's health" and indicated the need for systematic accounting of schoolchildren's health indicators for effective development of differentiated prevention programs.

Socioeconomic inequality in overweight/obesity among US children: NHANES 2001 to 2018

Background

Previous research has found that the prevalence of childhood overweight/obesity varies depending on household income, ethnicity, and sex. The goal of our research is to examine changes over time in socioeconomic inequality and the prevalence of overweight/obesity among American children under five by sex and ethnicity.

Methods

This cross-sectional analysis used data from the National Health and Nutrition Examination Surveys (NHANES) collected from 2001-02 to 2017-18. Overweight/obesity in children under five [Body Mass Index (BMI)-for-age z-score >2 standard deviations] was defined according to the World Health Organization (WHO) growth reference standard. The slope inequality index (SII) and the concentration index (CIX) were used to measure the socioeconomic inequality in overweight/obesity.

Results

Between 2001-02 and 2011-12, childhood overweight/obesity in the United States decreased from 7.3% to 6.3%, and had increased to 8.1% by 2017-18. However, this pattern varied widely by ethnicity and sex. For both the 2015-16 and 2017-18 surveys, overweight/obesity was more concentrated in the poorest household quintile for overall Caucasian children ((SII = -11.83, IC 95% = -23.17, -0.49 and CIX = -7.368, IC 95% = -13.92, -0.82) and (SII = -11.52, IC 95% = -22.13, -0.91 and CIX = -7.24, IC 95% = -13.27, -1.21), respectively) and for males of other ethnicities [(SII = -13.93, IC 95% = -26.95, -0.92) and CIX = -8.55, IC 95% = -0.86, -16.25] and (SII = -21.19, IC 95% = -40.65, -1.74) and CIX = -13.11, IC 95% = -1.42, -24.80), respectively). In the last three surveys, overweight/obesity was also more concentrated in the poorest household quintile for the overall children of other ethnicities. With the exception of African American females in the 2013-14 survey, for whom overweight/obesity was significantly concentrated in a quintile of the richest households (SII = 12.60, 95% CI = 0.24, 24.97 and CIX = 7.86, 95% CI = 15.59, 0.12); overweight/obesity was found to be concentrated in the richest household quintile for overall African American children, but not significantly so.

Conclusions

Our findings give an update and reinforce the notion that overweight/obesity in children under the age of five has increased and that related wealth inequalities are a public health problem in the United States.

Action on the social determinants for advancing health equity in the time of COVID-19: perspectives of actors engaged in a WHO Special Initiative

Since the 2008 publication of the reports of the Commission on Social Determinants of Health and its nine knowledge networks, substantial research has been undertaken to document and describe health inequities. The COVID-19 pandemic has underscored the need for a deeper understanding of, and broader action on, the social determinants of health. Building on this unique and critical opportunity, the World Health Organization is steering a multi-country Initiative to reduce health inequities through an action-learning process in 'Pathfinder' countries. The Initiative aims to develop replicable and reliable models and practices that can be adopted by WHO offices and UN staff to address the social determinants of health to advance health equity. This paper provides an overview of the Initiative by describing its broad theory of change and work undertaken in three regions and six Pathfinder countries in its first year-and-a-half. Participants engaged in the Initiative describe results of early country dialogues and promising entry points for implementation that involve model, network and capacity building. The insights communicated through this note from the field will be of interest for others aiming to advance health equity through taking action on the social determinants of health, in particular as regards structural determinants.

Implementation of a quality improvement programme using the Active Patient Link call and recall system to improve timeliness and equity of childhood vaccinations: protocol for a mixed-methods evaluation

INTRODUCTION

Call and recall systems provide actionable intelligence to improve equity and timeliness of childhood vaccinations, which have been disrupted during the COVID-19 pandemic. We will evaluate the effectiveness, fidelity and sustainability of a data-enabled quality improvement programme delivered in primary care using an Active Patient Link Immunisation (APL-Imms) call and recall system to improve timeliness and equity of uptake in a multiethnic disadvantaged urban population. We will use qualitative methods to evaluate programme delivery, focusing on uptake and use, implementation barriers and service improvements for clinical and non-clinical primary care staff, its fidelity and sustainability.

METHODS AND ANALYSIS

This is a mixed-methods observational study in 284 general practices in north east London (NEL). The target population will be preschool-aged children eligible to receive diphtheria, tetanus and pertussis (DTaP) or measles, mumps and rubella (MMR) vaccinations and registered with an NEL general practice. The intervention comprises an in-practice call and recall tool, facilitation and training, and financial incentives. The quantitative evaluation will include interrupted time Series analyses and Slope Index of Inequality. The primary outcomes will be the proportion of children receiving at least one dose of a DTaP-containing or MMR vaccination defined, respectively, as administered between age 6 weeks and 6 months or between 12 and 18 months of age. The qualitative evaluation will involve a 'Think Aloud' method and semistructured interviews of stakeholders to assess impact, fidelity and sustainability of the APL-Imms tool, and fidelity of the implementation by facilitators.

ETHICS AND DISSEMINATION

The research team has been granted permission from data controllers in participating practices to use deidentified data for audit purposes. As findings will be specific to the local context, research ethics approval is not required. Results will be disseminated in a peer-reviewed journal and to stakeholders, including parents, health providers and commissioners.

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.

Assessing the social patterning and magnitude of inequalities in sexual violence among young women in Uganda: Findings from 2016 demographic and health survey

Sexual violence (SV) is a significant global public health problem. To develop effectively targeted interventions to prevent SV and allocate resources equitably requires identifying the most vulnerable groups and the magnitude of these social inequities. However, these data are currently lacking. Using the Uganda Demographic and Health Survey, we examined SV among all young women and ever-married young women. We conducted univariate and bivariate analyses to characterise the prevalence and social patterning of SV, and then utilised the World Health Organization Health Equity Assessment Toolkit (HEAT) to assess the magnitude of social inequities in SV. At the national level, 5.5% among all young women and 20.5% of ever-married young women had experienced SV. For all young women, the largest inequities in SV were based on sub-national region of residence. Among the ever-married young women, we found profound education, wealth and place-based inequities in SV, which favoured young women with higher education, in wealthier households, and within central regions of Uganda. Our findings suggest a need for regionally targeted multi-sectoral interventions that take into consideration that multiple intersecting social dimensions such as education, poverty and the safe built environment, to address young women's risk for SV.

A standardized approach for measuring multivariate equity in vaccination coverage, cost-of-illness, and health outcomes: Evidence from the Vaccine Economics Research for Sustainability & Equity (VERSE) project

Following a call from the World Health Organization in 2017 for a methodology to monitor immunization coverage equity in line with the 2030 Agenda for Sustainable Development, this study outlines a standardized approach for measuring multivariate equity in vaccine coverage, economic impact, and health outcomes. The Vaccine Economics Research for Sustainability & Equity (VERSE) composite vaccination equity measurement approach is derived from literature on the measurement of socioeconomic inequality combined with measures of direct unfairness in healthcare access. The final metrics take the form of a concentration index for vaccination coverage where individuals are ranked by multivariate unfairness in access and an absolute equity gap representing the difference in coverage between the top and bottom quintiles of individuals ranked by multivariate unfairness in access. Regression decomposition is applied to the concentration index to determine each factor's relative influence on observed inequity. These methods are applied to India's National Family Health Survey (NFHS) from 2015 to 2016 to assess the equity in being fully-immunized for age vaccination coverage and zero-dose status. The multivariate absolute equity gap is 0.120 (SE: 003) and 0.371 (SE: 0.008) for zero-dose status and fully-immunized for age, respectively. Therefore, the most disadvantaged quintile is 12 percentage points more likely to be zero-dose than the most advantaged quintile and 37.1 percentage points less likely to be fully immunized. The primary correlate of unfair disadvantage for both outcomes is maternal education accounting for 27.4% and 19.1% of observed inequality. The VERSE model provides a standardized approach for measuring multivariate vaccine coverage equity. It also allows policymakers to determine the relative magnitude of factors influencing multivariate equity rather than only the correlates of socioeconomic or bivariate equity. This framework could be adapted to track equitable progress toward Universal Health Coverage (UHC) or outcomes beyond the vaccine space.

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This study outlines a standardized approach and toolkit for measuring multivariate inequality in vaccination coverage.

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The model isolates unfair from fair correlates of inequality in coverage.

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Application to India shows maternal education is the factor most associated with vaccine inequity.

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Greater inequality exists for being fully-immunized for age than being zero-dose in India.

Ethnic inequalities in reproductive, maternal, newborn and child health interventions in Ecuador: A study of the 2004 and 2012 national surveys

BACKGROUND

Analysis of health inequalities by ethnicity is critical to achieving the Sustainable Development Goals. In Ecuador, similar to other Latin American countries, indigenous and afro-descendant populations have long been subject to racism, discrimination, and inequitable treatment. Although in recent years, Ecuador has made progress in health indicators, particularly those related to the coverage of Reproductive, Maternal, Neonatal and Child Health (RMNCH) interventions, little is known as to whether inequalities by ethnicity persist.

METHODS

Analysis was based on two nationally representative health surveys (2004 and 2012). Ethnicity was self-reported and classified into three categories (Indigenous/Afro-Ecuadorian/Mixed ancestry). Coverage data for six RMNCH health interventions were stratified for each ethnic group by level of education, area of residence and wealth quintiles. Absolute inequality measures were computed and multivariate analysis using Poisson regression was undertaken.

FINDINGS

In 2012, 74.4% of women self-identifying as indigenous did not achieve the secondary level of education and 50.7% were in the poorest quintile (Q1); this profile was relatively unchanged since 2004. From 2004 to 2012, the coverage of RMNCH interventions increased for all ethnic groups, and absolute inequality decreased. However, in 2012, regardless of education level, area of residence and wealth quintiles, ethnic inequalities remained for almost all RMNCH interventions. Indigenous women had 24% lower prevalence of modern contraceptive use (Prevalence ratio [PR] = 0.76; 95% IC: 0.7-0.8); 28% lower prevalence of antenatal care (PR = 0.72; 95% IC: 0.6-0.8); and 35% lower prevalence of skilled birth attendance and institutional delivery (PR = 0.65; 95% IC: 0.6-0.7 and PR = 0.65; 95% IC: 0.6-0.7 respectively), compared with the majority ethnic group in the country.

INTERPRETATION

While the gaps have narrowed, indigenous people in Ecuador continue in a situation of structural racism and are left behind in terms of access to RMNCH interventions. Strategies to reduce ethnic inequalities in the coverage services need to be collaboratively redesigned/co-designed.

FUNDING

This paper was made possible with funds from the Bill & Melinda Gates Foundation [Grant Number: INV-007,594/OPP1148933].

Geographic and socioeconomic inequalities in cesarean birth rates in Peru: A comparison between 2009 and 2018

BACKGROUND

There is a global concern about the high rates of cesarean birth (CB). This study aimed to investigate the geographic and socioeconomic inequalities in CB rates in the Peruvian population.

METHODS

We conducted a population-based study using the Peruvian Demographic and Family Health Surveys (ENDES, the Spanish acronym for Encuesta Demográfica y de Salud Familiar) between 2009 and 2018. ENDES reported data from births registered in the five years preceding survey execution. For the years 2009 (n = 10 289) and 2018 (n = 23 077), we calculated the weighted rates of CB among variables such as natural geographic domain (Coast, Andean, or Amazon), area of residence (rural or urban), wealth index quintile (quintile 1 is poorest, and quintile 5 is richest), and educational level. To assess inequalities, we calculated the concentration index (CIs), the slope index of inequality (SII), and the relative index of inequality (RII).

RESULTS

The CB rates by year were 21.4% (95% confidence interval [CI]: 20.0-22.9) in 2009 and 34.5% (95% CI: 33.4-35.5) in 2018. Women living in urban and coastal regions and with a higher education level had the highest CB rates. All the CIs were positive, reflecting a prowealthy inequality in CB rates, and both SII and RII were positive, indicating a gap between the use of cesarean in women in the higher wealth quintile compared with those in the lower quintile.

CONCLUSIONS

Cesarean birth rates have increased by 60% during the last decade in Peru. The richest wealth quintiles had the highest CB rates during the study years, which were well above global recommendations.

Interactive Visualization Applications in Population Health and Health Services Research: Systematic Scoping Review

BACKGROUND

Simple visualizations in health research data, such as scatter plots, heat maps, and bar charts, typically present relationships between 2 variables. Interactive visualization methods allow for multiple related facets such as numerous risk factors to be studied simultaneously, leading to data insights through exploring trends and patterns from complex big health care data. The technique presents a powerful tool that can be used in combination with statistical analysis for knowledge discovery, hypothesis generation and testing, and decision support.

OBJECTIVE

The primary objective of this scoping review is to describe and summarize the evidence of interactive visualization applications, methods, and tools being used in population health and health services research (HSR) and their subdomains in the last 15 years, from January 1, 2005, to March 30, 2019. Our secondary objective is to describe the use cases, metrics, frameworks used, settings, target audience, goals, and co-design of applications.

METHODS

We adapted standard scoping review guidelines with a peer-reviewed search strategy: 2 independent researchers at each stage of screening and abstraction, with a third independent researcher to arbitrate conflicts and validate findings. A comprehensive abstraction platform was built to capture the data from diverse bodies of literature, primarily from the computer science and health care sectors. After screening 11,310 articles, we present findings from 56 applications from interrelated areas of population health and HSR, as well as their subdomains such as epidemiologic surveillance, health resource planning, access, and use and costs among diverse clinical and demographic populations.

RESULTS

In this companion review to our earlier systematic synthesis of the literature on visual analytics applications, we present findings in 6 major themes of interactive visualization applications developed for 8 major problem categories. We found a wide application of interactive visualization methods, the major ones being epidemiologic surveillance for infectious disease, resource planning, health service monitoring and quality, and studying medication use patterns. The data sources included mostly secondary administrative and electronic medical record data. In addition, at least two-thirds of the applications involved participatory co-design approaches while introducing a distinct category, embedded research, within co-design initiatives. These applications were in response to an identified need for data-driven insights into knowledge generation and decision support. We further discuss the opportunities stemming from the use of interactive visualization methods in studying global health; inequities, including social determinants of health; and other related areas. We also allude to the challenges in the uptake of these methods.

CONCLUSIONS

Visualization in health has strong historical roots, with an upward trend in the use of these methods in population health and HSR. Such applications are being fast used by academic and health care agencies for knowledge discovery, hypotheses generation, and decision support.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/14019.

Socioeconomic inequalities in effective service coverage for reproductive, maternal, newborn, and child health: a comparative analysis of 39 low-income and middle-income countries

BACKGROUND

Reducing socioeconomic inequalities in access to good quality health care is key for countries to achieve Universal Health Coverage. This study aims to assess socioeconomic inequalities in effective coverage of reproductive, maternal, newborn and child health (RMNCH) in low- and middle-income countries (LMICs).

METHODS

Using the most recent national health surveys from 39 LMICs (between 2014 and 2018), we calculated coverage indicators using effective coverage care cascade that consists of service contact, crude coverage, quality-adjusted coverage, and user-adherence-adjusted coverage. We quantified wealth-related and education-related inequality using the relative index of inequality, slope index of inequality, and concentration index.

FINDINGS

The quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, in particular for postnatal care (64 percentage points [pp], p-value<0·0001), family planning (48·7 pp, p<0·0001), and antenatal care (43·6 pp, p<0·0001) outcomes. Upper-middle-income countries had higher effective coverage levels compared with low- and lower-middle-income countries in family planning, antenatal care, delivery care, and postnatal care. Socioeconomic inequalities tend to be wider when using effective coverage measurement compared with crude and service contact measurements. Our findings show that upper-middle-income countries had a lower magnitude of inequality compared with low- and lower-middle-income countries.

INTERPRETATION

Reliance on the average contact coverage tends to underestimate the levels of socioeconomic inequalities for RMNCH service use in LMICs. Hence, the effective coverage measurement using a care cascade approach should be applied. While RMNCH coverages vary considerably across countries, equitable improvement in quality of care is particularly needed for lower-middle-income and low-income countries.

FUNDING

None.

Trends in obesity by socioeconomic status among non-pregnant women aged 15-49 y: a cross-sectional, multi-dimensional equity analysis of demographic and health surveys in 11 sub-Saharan Africa countries, 1994-2015

BACKGROUND

Global obesity estimates show a steadily increasing pattern across socioeconomic and geographical divides, especially among women. Our analysis tracked and described obesity trends across multiple equity dimensions among women of reproductive age (15-49 y) in 11 sub-Saharan African (SSA) countries during 1994-2015.

METHODS

This study consisted of a cross-sectional series analysis using nationally representative demographic and health surveys (DHS) data. The countries included were Cameroon, Comoros, Congo, Cote d'Ivoire, Ghana, Kenya, Lesotho, Nigeria, Senegal, Zambia and Zimbabwe. The data reported are from a reanalysis conducted using the WHO Health Equity Assessment Toolkit that assesses inter- and intra-country health inequalities across socioeconomic and geographical dimensions. We generated equiplots to display intra- and inter-country equity gaps.

RESULTS

There was an increasing trend in obesity among women of reproductive age across all 11 SSA countries. Obesity increased unequally across wealth categories, place of residence and educational measures of inequality. The wealthiest, most educated and urban dwellers in most countries had a higher prevalence of obesity. However, in Comoros, obesity did not increase consistently with increasing wealth or education compared with other countries. The most educated and wealthiest women in Comoros had lower obesity rates compared with their less wealthy and less well-educated counterparts.

CONCLUSION

A window of opportunity is presented to governments to act structurally and at policy level to reduce obesity generally and prevent a greater burden on disadvantaged subpopulation groups in sub-Saharan Africa.

Geography as a Determinant of Health: Health Services Utilization of Pediatric Respiratory Illness in a Canadian Province

Respiratory diseases contribute to high healthcare utilization rates among children. Although social inequalities play a major role in these conditions, little is known about the impact of geography as a determinant of health, particularly with regard to the difference between rural and urban centers. A regional geographic analysis was conducted using health repository data on singleton births between 2005 and 2010 in Alberta, Canada. Data were aggregated according to regional health sub-zones in the province and standardized prevalence ratios (SPRs) were determined for eight respiratory diseases (asthma, influenza, bronchitis, bronchiolitis, croup, pneumonia, and other upper and other lower respiratory tract infections). The results indicate that there are higher rates of healthcare utilization in northern compared to southern regions and in rural and remote regions compared to urban ones, after accounting for both material and social deprivation. Geography plays a role in discrepancies of healthcare utilization for pediatric respiratory diseases, and this can be used to inform the provision of health services and resource allocation across various regions.

Socio-economic and geographical inequalities in adolescent fertility rate in Ghana, 1993-2014

BACKGROUND

Despite public health interventions to control adolescent fertility, it remains high in sub-Saharan Africa. Ghana is one of the countries in sub-Saharan Africa with the highest adolescent fertility rates. We examined the trends and socio-economic and geographical patterns of disparities in adolescent fertility in Ghana from 1993 to 2014.

METHODS

Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the 1993-2014 Ghana Demographic and Health surveys were analyzed. First, we disaggregated adolescent fertility rates (AFR) by four equity stratifiers: wealth index, education, residence and region. Second, we measured the inequality through summary measures, namely Difference (D), Population Attributable Risk (PAR), Ratio (R) and Population Attributable Fraction (PAF). A 95 % confidence interval was constructed for point estimates to measure statistical significance.

RESULTS

We observed substantial absolute and relative wealth-driven inequality in AFR (PAR=-47.18, 95 % CI; -49.24, -45.13) and (PAF= -64.39, 95 % CI; -67.19, -61.59) respectively in favour of the economically advantaged subpopulations. We found significant absolute (D = 69.56, 95 % CI; 33.85, 105.27) and relative (R = 3.67, 95 % CI; 0.95, 6.39) education-based inequality in AFR, with higher burden of AFR among disadvantaged subpopulations (no formal education). The Ratio measure (R = 2.00, 95 % CI; 1.53, 2.47) indicates huge relative pro-urban disparities in AFR with over time increasing pattern. Our results also show absolute (D, PAR) and relative (R, PAF) inequality in AFR across subnational region, between 2003 and 2014. For example, in the 2014 survey, the PAR measure (D=-28.22, 95 % CI; -30.58, -25.86) and the PAF measure (PAF=-38.51, 95 % CI; -41.73, -35.29) indicate substantial absolute and relative regional inequality.

CONCLUSIONS

This study has indicated the existence of inequality in adolescent fertility rate in Ghana, with higher ferlitiy rates among adolescent girls who are poor, uneducated, rural residents and those living in regions such as Northern, Brong Ahafo, and Central region, with increasing disparity over the time period of the study. There is the need for policy interventions that target adolescent girls residing in the rural areas and those in the low socioeconomic subgroups to enable the country to avert the high maternal/newborn morbidity and mortality usually associated with adolescent childbearing.

Can health information through mobile phones close the divide in health behaviours among the marginalised? An equity analysis of Kilkari in Madhya Pradesh, India

Kilkari is one of the largest maternal mobile messaging programmes in the world. It makes weekly prerecorded calls to new and expectant mothers and their families from the fourth month of pregnancy until 1-year post partum. The programme delivers reproductive, maternal, neonatal and child health information directly to subscribers' phones. However, little is known about the reach of Kilkari among different subgroups in the population, or the differentiated benefits of the programme among these subgroups. In this analysis, we assess differentials in eligibility, enrolment, reach, exposure and impact across well-known proxies of socioeconomic position-that is, education, caste and wealth. Data are drawn from a randomised controlled trial (RCT) in Madhya Pradesh, India, including call data records from Kilkari subscribers in the RCT intervention arm, and the National Family Health Survey-4, 2015. The analysis identifies that disparities in household phone ownership and women's access to phones create inequities in the population eligible to receive Kilkari, and that among enrolled Kilkari subscribers, marginalised caste groups and those without education are under-represented. An analysis of who is left behind by such interventions and how to reach those groups through alternative communication channels and platforms should be undertaken at the intervention design phase to set reasonable expectations of impact. Results suggest that exposure to Kilkari has improved levels of some health behaviours across marginalised groups but has not completely closed pre-existing gaps in indicators such as wealth and education.

Trends in under-five mortality rate disaggregated across five inequality dimensions in Ghana between 1993 and 2014

OBJECTIVES

Globally, there has been a considerable decline in under-five mortality in the past years. However, it remains a critical issue among low- and middle-income countries, especially in sub-Saharan Africa. In Ghana, under-five mortality is a critical public health issue that requires national interventions. In the present study, we examined the trends of under-five mortality in Ghana from 1993 to 2014.

METHODS

Using the World Health Organization's Health Equity Assessment Toolkit, we analyzed data from the 1993-2014 Ghana Demographic and Health surveys. We disaggregated the under-five mortality rate by five equity stratifiers: wealth index, education, sex, place, and region of residence. We measured the inequality through summary measures, namely difference, population attributable risk, ratio and population attributable fraction.

RESULTS

In 1993, under-five mortality among children in poor households (172.90, uncertainty intervals [UIs = 153.21-194.53]) was more than twice the proportion of children from the richest households who died before their 5th birthday (74.96; UI = 60.31-92.81) and this trend continued until 2008. However, in 2014, the poorest had the lowest rate (30.91, UI = 78.70-104.80). Children of women with no formal education consistently recorded the highest burden of under-five mortality. Although in 2014 the gap appeared to have narrowed, children of mothers with no formal education record the highest under-five mortality rate (91.61; UI = 79.73-105.07) compared with those with secondary or higher education (54.34; UI = 46.24-63.77). Under-five mortality was higher among rural residents throughout the years. Men repeatedly had the greatest share of under-five mortality with the highest prevalence occurring in 1993 (137.52; UI = 123.51-152.85) and the lowest occurring in 2014 (77.40; UI = 69.15-86.54). The Northern region consistently accounted for the greatest proportion of under-five mortality.

CONCLUSION

Ghana has experienced a decline in under-five mortality from 1993 to 2014. Context-specific appropriate interventions are necessary for various disadvantaged sub-populations with risks of health disparities.

District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018

Introduction

Despite renewed commitment to universal health coverage and health system strengthening (HSS) to improve access to primary care, there is insufficient evidence to guide their design and implementation. To address this, we conducted an impact evaluation of an ongoing HSS initiative in rural Madagascar, combining data from a longitudinal cohort and primary health centres.

Methods

We carried out a district representative household survey at the start of the HSS intervention in 2014 in over 1500 households in Ifanadiana district, and conducted follow-up surveys at 2 and 4 years. At each time point, we estimated maternal, newborn and child health coverage; economic and geographical inequalities in coverage; and child mortality rates; both in the HSS intervention and control catchments. We used logistic regression models to evaluate changes associated with exposure to the HSS intervention. We also estimated changes in health centre per capita utilisation during 2013 to 2018.

Results

Child mortality rates decreased faster in the HSS than in the control catchment. We observed significant improvements in care seeking for children under 5 years of age (OR 1.23; 95% CI 1.05 to 1.44) and individuals of all ages (OR 1.37, 95% CI 1.19 to 1.58), but no significant differences in maternal care coverage. Economic inequalities in most coverage indicators were reduced, while geographical inequalities worsened in nearly half of the indicators.

Conclusion

The results demonstrate improvements in care seeking and economic inequalities linked to the early stages of a HSS intervention in rural Madagascar. Additional improvements in this context of persistent geographical inequalities will require a stronger focus on community health.

Socioeconomic inequalities in tobacco smoking in women aged 15-54 in Iran: a multilevel model

Significant evidence suggests an inverse relationship between socioeconomic status and tobacco smoking, where inequality is visible among different social and economic strata. The aim of this study was to investigate the prevalence and economic and social inequalities in tobacco smoking in women aged 15-54 in Iran. This study is a cross-sectional study. Sampling in this study was a randomized clustered multistage sampling with equal clusters. A total of 35,305 women aged 15-55 enrolled in the study. Data analysis was in two stages. In the first stage, the social and economic inequalities were investigated using the concentration index and concentration curve method, and in the second method, and multilevel method was used to identify the determinants. The prevalence of tobacco smoking in women was 12.24%. The concentration index for smoking was CI = -0.07 [95% CI (-0.09, -0.05)], which represents smoking in people with low socioeconomic status. The results of the multilevel analysis indicated that the marital status of people over the age of 35 and the economic class was related to smoking in women. Inequality in tobacco smoking in women is to the interest of the well-off group, and this inequality varies in different provinces. Marital status, place of residence, age and socioeconomic status of women are factors influencing the prevalence of tobacco smoking in women, and these issues should be noticed to reduce inequalities.

Visual Analytic Tools and Techniques in Population Health and Health Services Research: Scoping Review

BACKGROUND

Visual analytics (VA) promotes the understanding of data with visual, interactive techniques, using analytic and visual engines. The analytic engine includes automated techniques, whereas common visual outputs include flow maps and spatiotemporal hot spots.

OBJECTIVE

This scoping review aims to address a gap in the literature, with the specific objective to synthesize literature on the use of VA tools, techniques, and frameworks in interrelated health care areas of population health and health services research (HSR).

METHODS

Using the 2018 PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, the review focuses on peer-reviewed journal articles and full conference papers from 2005 to March 2019. Two researchers were involved at each step, and another researcher arbitrated disagreements. A comprehensive abstraction platform captured data from diverse bodies of the literature, primarily from the computer and health sciences.

RESULTS

After screening 11,310 articles, findings from 55 articles were synthesized under the major headings of visual and analytic engines, visual presentation characteristics, tools used and their capabilities, application to health care areas, data types and sources, VA frameworks, frameworks used for VA applications, availability and innovation, and co-design initiatives. We found extensive application of VA methods used in areas of epidemiology, surveillance and modeling, health services access, use, and cost analyses. All articles included a distinct analytic and visualization engine, with varying levels of detail provided. Most tools were prototypes, with 5 in use at the time of publication. Seven articles presented methodological frameworks. Toward consistent reporting, we present a checklist, with an expanded definition for VA applications in health care, to assist researchers in sharing research for greater replicability. We summarized the results in a Tableau dashboard.

CONCLUSIONS

With the increasing availability and generation of big health care data, VA is a fast-growing method applied to complex health care data. What makes VA innovative is its capability to process multiple, varied data sources to demonstrate trends and patterns for exploratory analysis, leading to knowledge generation and decision support. This is the first review to bridge a critical gap in the literature on VA methods applied to the areas of population health and HSR, which further indicates possible avenues for the adoption of these methods in the future. This review is especially important in the wake of COVID-19 surveillance and response initiatives, where many VA products have taken center stage.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/14019.

Social inequalities in tobacco-attributable mortality in Spain. The intersection between age, sex and educational level

INTRODUCTION

First study of social inequalities in tobacco-attributable mortality (TAM) in Spain considering the joint influence of sex, age, and education (intersectional perspective).

METHODS

Data on all deaths due to cancer, cardiometabolic and respiratory diseases among people aged ≥35 years in 2016 were obtained from the Spanish Statistical Office. TAM was calculated based on sex-, age- and education-specific smoking prevalence, and on sex-, age- and disease-specific relative risks of death for former and current smokers vs lifetime non-smokers. As inequality measures, the relative index of inequality (RII) and the slope index of inequality (SII) were calculated using Poisson regression. The RII is interpreted as the relative risk of mortality between the lowest and the highest educational level, and the SII as the absolute difference in mortality.

RESULTS

The crude TAM rate was 55 and 334 per 100,000 in women and men, respectively. Half of these deaths occurred among people with the lowest educational level (27% of the population). The RII for total mortality was 0.39 (95%CI: 0.35-0.42) in women and 1.61 (95%CI: 1.55-1.67) in men. The SII was -41 and 111 deaths per 100,000, respectively. Less-educated women aged <55 years and men (all ages) showed an increased mortality risk; nonetheless, less educated women aged ≥55 had a reduced risk.

CONCLUSIONS

TAM is inversely associated with educational level in men and younger women, and directly associated with education in older women. This could be explained by different smoking patterns. Appropriate tobacco control policies should aim to reduce social inequalities in TAM.

Inequalities in measles immunization coverage in Ethiopia: a cross-sectional analysis of demographic and health surveys 2000-2016

Background

Ethiopia has low measles immunization coverage and little is known about the disparities surrounding what coverage is provided. This study assessed disparities in measles immunization and its change over time using the four Ethiopia Demographic and Health Surveys conducted between 2000 and 2016.

Methods

This is a cross-sectional analysis of data using Ethiopia Demographic and Health Surveys (EDHS) conducted between 2000 and 2016. We used the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) to present the inequalities. Four measures of inequality were calculated: Difference (D), Ratio (R), Population Attributable Fraction (PAF) and Population Attributable Risk (PAR). The results were disaggregated by wealth, education, residence, sex and sub-national regions and 95% Uncertainty Intervals (UIs) were computed for each point estimate to boost confidence of the findings.

Results

Measles immunization coverage was higher among the richest and secondary and above schools’ subgroup by nearly 30 to 31 percentage points based on point estimates (D = 31%; 95% CI; 19.48, 42.66) and 29.8 percentage points (D = 29.8%; 95% CI; 16.57, 43.06) as compared to the poorest and no education subgroup respectively in the 2016 survey. Still, in the 2016 survey, substantial economic status (PAF = 36.73; 95%CI: 29.78, 43.68), (R = 1.71; 95%CI: 1.35, 2.08), education status (PAF = 45.07; 95% CI: 41.95, 48.18), (R = 1.60; 95% CI: 1.30, 1.90), place of residence (PAF = 39.84, 95% CI: 38.40, 41.27), (R = 1.47, 95% CI: 1.20, 1. 74) and regional (PAF = 71.35, 95% CI: 31.76, 110.95), (R = 3.09, 95%CI: 2.01, 4.17) inequality were observed with both simple and complex measures. There was no statistically significant difference in the prevalence of measles immunization between male and female children in all the studied years, as indicated, for instance, by measures of PAF in 2000 (PAF = 0; 95%CI: − 6.79, 6.79), 2005 (PAF = 0; 95%CI: − 6.04, 6.04), 2011(PAF = 0; 95%CI: − 3.79, 3.79) and 2016 (PAF = 2.66; − 1.67; 6.99). Overall, the inequality of measles immunization narrowed significantly by at least some of the measures between the first and the last survey periods across all the studied subgroups.

Conclusions

National, regional and district levels of government should make a pledge to reduce inequalities in coverage of measles immunization. Equity-sensitive strategies, sufficient human and financial resources as well as continued research and monitoring of immunization coverage inequalities are necessary to achieve related sustainable development goals.

Access to skilled attendant at birth and the coverage of the third dose of diphtheria-tetanus-pertussis vaccine across 14 West African countries - an equity analysis

BACKGROUND

Universal Health Coverage (UHC) remains a critical public health goal that continues to elude many countries of the global south. As countries strive for its attainment, it is important to track progress in various subregions of the world to understand current levels and mechanisms of progress for shared learning. Our aim was to compare multidimensional equity gaps in access to skilled attendant at birth (SAB) and coverage of the third dose of Diphtheria-Tetanus-Pertussis (DTP3) across 14 West African countries.

METHODS

The study was a cross sectional comparative analysis that used publicly available, nationally representative health surveys. We extracted data from Demographic and Health Surveys, and Multiple Indicator Cluster Surveys conducted between 2010 and 2017 in Benin, Burkina Faso, Cote d' Ivoire, The Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone and Togo. The World Health Organization's Health Equity Assessment Toolkit (HEAT Plus) software was used to evaluate current levels of intra-country equity in access to SAB and DTP3 coverage across four equity dimensions (maternal education, location of residence, region within a country and family wealth status).

RESULTS

There was a general trend of higher levels of coverage for DTP3 compared to access to SAB in the subregion. Across the various dimensions of equity, more gaps appear to have been closed in the subregion for DTP3 compared to SAB. The analysis revealed that countries such as Sierra Leone, Liberia and Ghana have made substantial progress towards equitable access for the two outcomes compared to others such as Nigeria, Niger and Guinea.

CONCLUSION

In the race towards UHC, equity should remain a priority and comparative progress should be consistently tracked to enable the sharing of lessons. The West African subregion requires adequate government financing and continued commitment to move toward UHC and close health equity gaps.

Social inequalities in cardiovascular mortality in Spain from an intersectional perspective

INTRODUCTION AND OBJECTIVES

There is an interaction between age, sex, and educational level, among other factors, that influences mortality. To date, no studies in Spain have comprehensively analyzed social inequalities in cardiovascular mortality by considering the joint influence of age, sex, and education (intersectional perspective).

METHODS

Study of all deaths due to all-cause cardiovascular disease, ischemic heart disease, heart failure, and cerebrovascular disease among people aged ≥ 30 years in Spain in 2015. Data were obtained from the Spanish Office of Statistics. The relative index of inequality (RII) and the slope index of inequality (SII) were calculated by using Poisson regression models with age-adjusted mortality. The RII is interpreted as the relative risk of mortality between the lowest and the highest educational level, and the SII as the absolute difference in mortality.

RESULTS

The RII for all-cause cardiovascular mortality was 1.88 (95%CI, 1.80-1.96) in women and 1.44 (95%CI, 1.39-1.49) in men. The SII was 178.46 and 149.43 deaths per 100 000, respectively. The greatest inequalities were observed in ischemic heart disease and heart failure in younger women, with a RII higher than 4. There were no differences between sexes in inequalities due to cerebrovascular disease.

CONCLUSIONS

Cardiovascular mortality is inversely associated with educational level. This inequality mostly affects premature mortality due to cardiac causes, especially among women. Monitoring this problem could guide the future Cardiovascular Health Strategy in the National Health System, to reduce inequality in the first cause of death.

[Homicides in young people and social inequalities in Mexico, 2017Homicídios em jovens e desigualdades sociais no México, 2017]

OBJECTIVE

Assess the association between social and economic conditions and homicide rates in young people between 10 and 24 years of age in Mexico in 2017.

METHODS

This ecological study looked at the social inequalities associated with homicides in the population 10-24-year-old population in 2017 in Mexico, using secondary data sources for deaths by homicide in each Mexican state. Social inequalities in health were studied by measuring absolute and relative inequality gaps. Mortality rates were estimated using Poisson regression models.

RESULTS

In 2017, there were 8,094 homicides in the target population, predominantly in men (86.7%). There was high variance in inequality between states. Unemployment in the population over 12 years of age, households composed of people who are not family members, low school attendance rates, and income below the poverty line showed significant association with homicide rates.

CONCLUSIONS

There is a strong association between social determinants and homicides in the study population. Policies and intersectoral actions should be implemented to help bridge inequality gaps and achieve better living conditions and higher levels of well-being and health for people and their communities.

Visual Analytic Tools and Techniques in Population Health and Health Services Research: Protocol for a Scoping Review

BACKGROUND

Visual analytics (VA) promotes the understanding of data using visual, interactive techniques and using analytic and visual engines. The analytic engine includes machine learning and other automated techniques, whereas common visual outputs include flow maps and spatiotemporal hotspots for studying service gaps and disease distribution. The principal objective of this scoping review is to examine the state of science on VA and the various tools, strategies, and frameworks used in population health and health services research (HSR).

OBJECTIVE

The purpose of this scoping review is to develop an overarching global view of established techniques, frameworks, and methods of VA in population health and HSR. The main objectives are to explore, map, and synthesize the literature related to VA in its application to the two main focus areas of health care.

METHODS

We will use established scoping review methods to meet the study objective. As the use of the term visual analytics is inconsistent, one of the major challenges was operationalizing the concepts for developing the search strategy, based on the three main concepts of population health, HSR, and VA. We included peer reviewed and grey literature sources from 2005 till March 2019 in the search. Independent teams of researchers will screen the titles, abstracts and full text articles, whereas an independent researcher will arbiter conflicts. Data will be abstracted and presented using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist and explanation by two independent researchers.

RESULTS

As of late August 2019, the scoping review is in the full-text screening stage. Data synthesis will follow and the first results are expected to be submitted for publication in December 2019. In this protocol, the methods for undertaking this scoping review are detailed. We present how we operationalized the varied concepts of population health, health services, and VA. The main results of the scoping review will synthesize peer reviewed and grey literature sources on the main methods of VA in the interrelated fields of population health and health services research from January 2005 till March 2019.

CONCLUSIONS

VA is being increasingly used and integrated with emerging technologies to support decision making using large data sets. This scoping review of the VA tools, strategies, and frameworks applied to population health and health services aims to increase awareness of this approach for uptake by decision makers working within and toward developing learning health systems globally.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14019.

Subnational regional inequality in the public health development index in Indonesia

Background: Achieving the Sustainable Development Goal of ‘ensuring healthy lives and promoting well-being for all at all ages’ necessitates regular monitoring of inequality in the availability of health-related infrastructure and access to services, and in health risks and outcomes.

Objectives: To quantify subnational regional inequality in Indonesia using a composite index of public health infrastructure, services, behavioural risk factors and health outcomes: the Public Health Development Index (PHDI).

Methods: PHDI is a composite index of 30 public health indicators from across the life course and along the continuum of care. An overall index and seven topic-specific sub-indices were calculated using data from the 2013 Indonesian Basic Health Survey (RISKESDAS) and the 2011 – Village Potential Survey (PODES). These indices were analysed at the national, province and district levels. Within-province inequality was calculated using the Weighted Index of Disparity (IDISW).

Results: National average PHDI overall index was 54.0 (out of a possible 100); scores differed between provinces, ranging from 43.9 in Papua to 65.0 in Bali. Provinces in western regions of Indonesia tended to have higher overall PHDI scores compared to eastern regions. Large variations in province averages were observed for the non-communicable diseases sub-index, environmental health sub-index and infectious diseases sub-index. Provinces with a similar number of districts and with similar overall scores on the PHDI index showed different levels of relative within-province inequality. Greater within-province relative inequalities were seen in the environmental health and health services provisions sub-indices as compared to other indices.

Conclusions: Achieving the goal of ensuring healthy lives and promoting well-being for all at all ages in Indonesia necessitates having a more focused understanding of district-level inequalities across a wide range of public health infrastructure, service, risk factor and health outcomes indicators, which can enable geographical comparison while also revealing areas for intervention to address health inequalities.

Building capacity for health equity analysis in the WHO South-East Asia Region

"Leaving no one behind" is at the heart of the agenda of the Sustainable Development Goals, requiring that health systems be vigilant to how interventions can be accessed equitably by all, including population subgroups that face exclusion. In the World Health Organization (WHO) South-East Asia Region, inequalities can be found across and within countries but there has been a growing commitment to examining and starting to tackle them. Over the past decade in particular, WHO has been developing an armamentarium of tools to enable analysis of health inequalities and action on health equity. Tools include the Health Equity Assessment Toolkit in built-in database and upload database editions, as well as the Innov8 tool for reorientation of national health programmes. Countries across the region have engaged meaningfully in the development and application of these tools, in many cases aligning them with, or including them as part of, ongoing efforts to examine inequities in population subgroups domestically. This paper reflects on these experiences in Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand, where efforts have ranged from workshops to programme reorientation; the creation of assemblies and conferences; and collation of evidence through collaborative research, reviews/synthesis and conferences. This promising start must be maintained and expanded, with greater emphasis on building capacity for interpretation and use of evidence on inequalities in policy-making. This may be further enhanced by the use of innovative mixed methodologies and interdisciplinary approaches to refine and contextualize evidence, with a concomitant shift in attention, developing solutions to redress inequities and anchor health reform within communities. There are many lessons to be learnt in this region, as well as mounting political and popular will for change.

[Fertility in adolescent women and social inequalities in Mexico, 2015Fecundidade entre adolescentes e desigualdades sociais no México, 2015]

OBJECTIVE

To determine the association between teenage pregnancy and socioeconomic factors and to estimate social inequalities among adolescents in Mexico in 2015.

METHODS

A study involving women from 15 to 19 years of age was conducted using data from birth records for 2015. The fertility rate was determined and disaggregated by quintiles for each socioeconomic variable. Absolute and relative measures of inequality were estimated; negative binomial regression analysis was used to obtain risk ratios and 95% confidence intervals.

RESULTS

The fertility rate was 73.21 births per 1000 women between the ages of 15 and 19 years in Mexico. Coahuila was the state with the highest birth rate (99.3 per 1000 adolescents). A statistically significant association was found between fertility rate and the gap in access to health services, especially in quintile 5 (risk ratio [RR] = 45.68), whereas a greater association with the gap in education was found in quintile 4 (RR = 27.36). No significant differences were found in terms of the gap in access to social security.

CONCLUSIONS

Marginalization and poverty are significantly associated with teenage pregnancy and fertility rate. However, wide inequalities exist among the different social groups, making it necessary to implement actions geared towards promoting measures to improve the social, political, and economic environment.

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.