Improving average health and persisting health inequities--towards a justice and fairness platform for health policy making in Asia

Vaccine equity in low and middle income countries: a systematic review and meta-analysis

BACKGROUND

Evidence to date has shown that inequality in health, and vaccination coverage in particular, can have ramifications to wider society. However, whilst individual studies have sought to characterise these heterogeneities in immunisation coverage at national level, few have taken a broad and quantitative view of the contributing factors to heterogeneity in immunisation coverage and impact, i.e. the number of cases, deaths, and disability-adjusted life years averted. This systematic review aims to highlight these geographic, demographic, and sociodemographic characteristics through a qualitative and quantitative approach, vital to prioritise and optimise vaccination policies.

METHODS

A systematic review of two databases (PubMed and Web of Science) was undertaken using search terms and keywords to identify studies examining factors on immunisation inequality and heterogeneity in vaccination coverage. Inclusion criteria were applied independently by two researchers. Studies including data on key characteristics of interest were further analysed through a meta-analysis to produce a pooled estimate of the risk ratio using a random effects model for that characteristic.

RESULTS

One hundred and eight studies were included in this review. We found that inequalities in wealth, education, and geographic access can affect vaccine impact and vaccination dropout. We estimated those living in rural areas were not significantly different in terms of full vaccination status compared to urban areas but noted considerable heterogeneity between countries. We found that females were 3% (95%CI[1%, 5%]) less likely to be fully vaccinated than males. Additionally, we estimated that children whose mothers had no formal education were 28% (95%CI[18%,47%]) less likely to be fully vaccinated than those whose mother had primary level, or above, education. Finally, we found that individuals in the poorest wealth quintile were 27% (95%CI [16%,37%]) less likely to be fully vaccinated than those in the richest.

CONCLUSIONS

We found a nuanced picture of inequality in vaccination coverage and access with wealth disparity dominating, and likely driving, other disparities. This review highlights the complex landscape of inequity and further need to design vaccination strategies targeting missed subgroups to improve and recover vaccination coverage following the COVID-19 pandemic.

TRIAL REGISTRATION

Prospero, CRD42021261927.

Equity at a time of pandemic

Health promotion has long aspired for a world where all people can live to their full potential. Yet, COVID-19 illuminates dramatically different consequences for populations bearing heavy burdens of systemic disadvantage within countries and between the Global South and Global North. Many months of pandemic is entrenching inequities that reveal themselves in the vastly differential distribution of hospitalization and mortality, for example, among racialized groups in the USA. Amplified awareness of the intimate relationship between health, social structures, and economy opens a window of opportunity to act on decades of global commitments to prioritize health equity. Choices to act (or not act) are likely to accelerate already vast inequities within and between countries as rapidly as the COVID-19 pandemic itself. Recognizing the inherently global nature of this pandemic, this article explores how determinants of equity are embedded in global responses to it, arguing that these determinants will critically shape our global futures. This article aims to stimulate dialogue about equity-centered health promoting action during a pandemic, using the Canadian Coalition for Global Health Research (CCGHR) Principles for Global Health Research to examine equity considerations at a time of pandemic. Attentiveness to power and the relationship between political economy and health are argued as central to identifying and examining issues of equity. This article invites dialogue about how equity-centered planning, decision-making and action could leverage this massive disruption to society to spark a more hopeful, just, and humane collective future.

COVID-19 and food systems in Pacific Island Countries, Papua New Guinea, and Timor-Leste: Opportunities for actions towards the sustainable development goals

CONTEXT

The COVID-19 pandemic has impacted global food systems. This has led to different strategies by communities, governments, and businesses involved in food systems to mitigate and adapt to the unfolding pandemic. Small Island Developing States are particularly exposed to the conflation of risks from COVID-19 disease, economic downturns, underlying climate vulnerabilities and biosecurity risks.

OBJECTIVE

Our study aimed to identify the food systems vulnerabilities, impacts, and opportunities for supporting resilience and sustainable development in selected Pacific Island countries, Papua New Guinea, and Timor-Leste. The study focused on the impacts from the first six months of the pandemic (February-July 2020), with remote data collection and analysis done between May and July 2020.

METHODS

We conducted 67 interviews, and triangulated information with desktop and news sources emerging at the time. We present results on the effect on smallholder livelihoods, supply chains, governance, communities and employment. Overall, the major impacts of COVID-19 have been on economies, posing risks to future food security and further hampering progress towards key Sustainable Development Goals.

RESULTS AND CONCLUSIONS

We found that unemployment and economic contraction have been the most severe effects to date, with long-term consequences for food value chains and smallholder farmers. Disruptions to tourism, labour migration, and remittances have led to varying socio-economic impacts throughout the region. Vulnerable groups, notably women, urban poor, and youth, have been disproportionately affected by unemployment. Timor-Leste has had some social protection measures, whereas in Pacific Countries these have been varied. The lockdowns and State of Emergency initially influenced the distribution and marketing of food, but local food economies are starting to stabilise. The continued functioning of international food supply chains reduced the risk of food insecurity in high import dependent nations, notably import dependent countries like Tuvalu and Kiribati.

SIGNIFICANCE

The results have significance for three recovery pathways. The first recovery pathway relates to revisiting value chains in light of restricted travel. The second recovery pathway exists through leveraging the adaptive capacities of communities to stimulate innovative agriculture that also integrates climate adaptation and nutrition. The third recovery pathway relates to addressing the structural challenges that perpetuate inequalities and poverty while finding new ways of implementing inclusive policies and research. Our study presents a set of comparative examples of managing a food system shock that can inform future systems-oriented research and policy for sustainable development.

Vaccination assessments using the Demographic and Health Survey, 2005-2018: a scoping review

OBJECTIVE

To characterise studies which have used Demographic and Health Survey (DHS) datasets to evaluate vaccination status.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases including PubMed, EBSCOhost and POPLINE, from 2005 to 2018.

STUDY SELECTION

All English studies with vaccination status as the outcome and the use of DHS data.

DATA EXTRACTION

Studies were selected using a predetermined list of eligibility criteria and data were extracted independently by two authors. Data related to the study population, the outcome of interest (vaccination) and commonly seen predictors were extracted.

RESULTS

A total of 125 articles were identified for inclusion in the review. The number of countries covered by individual studies varied widely (1-86), with the most published papers using data from India, Nigeria, Pakistan and Ethiopia. Many different definitions of full vaccination were used although the majority used a traditional schedule recommended in the WHO's Expanded Programme on Immunisation. We found studies analysed a wide variety of predictors, but the most common were maternal education, wealth, urbanicity and child's sex. Most commonly reported predictors had consistent relationships with the vaccination outcome, outside of sibling composition.

CONCLUSIONS

Researchers make frequent use of the DHS dataset to describe vaccination patterns within one or more countries. A clearer idea of past use of DHS can inform the development of more rigorous studies in the future. Researchers should carefully consider whether a variable needs to be included in the multivariable model, or if there are mediating relationships across predictor variables.

Connecting knowledge with action for health equity: a critical interpretive synthesis of promising practices

Connecting knowledge with action (KWA) for health equity involves interventions that can redistribute power and resources at local, national, and global levels. Although there is ample and compelling evidence on the nature, distribution, and impact of health inequities, advancing health equity is inhibited by policy arenas shaped by colonial legacies and neoliberal ideology. Effective progress toward health equity requires attention to evidence that can promote the kind of socio-political restructuring needed to address root causes of health inequities. In this critical interpretive synthesis, results of a recent scoping review were broadened to identify evidence-informed promising practices for KWA for health equity. Following screening procedures, 10 literature reviews and 22 research studies were included in the synthesis. Analysis involved repeated readings of these 32 articles to extract descriptive data, assess clarity and quality, and identify promising practices. Four distinct kinds of promising practices for connecting KWA for health equity were identified and included: ways of structuring systems, ways of working together, and ways of doing research and ways of doing knowledge translation. Our synthesis reveals that advancing health equity requires greater awareness, dialogue, and action that aligns with the what is known about the causes of health inequities. By critically reflecting on dominant discourses and assumptions, and mobilizing political will from a more informed and transparent democratic exercise, knowledge to action for health equity can be achieved.

Twenty Years of Progress on Maternal and Child Health in the Philippines: An Equity Lens

This article assesses trends and inequalities in maternal and child health in the Philippines between 1993 and 2013, using 6 national household surveys, and also compares the Philippines' performance to 15 other Asia-Pacific countries. Thirteen indicators of child health outcomes and maternal and child health interventions are examined. Two measures of inequality are used: the absolute difference between the poorest and wealthiest quintile, and the concentration index. Coverage of all indicators has improved, both on average and among the poorest quintile; however, increases are very small for child health interventions (especially immunization coverage). By the first measure of inequality, all indicators show narrowing inequalities. By the second measure, inequality has fallen only for maternal health interventions. Compared with other 15 other developing Asia-Pacific countries, the Philippines performs among the best on the child health outcomes examined and above average on maternal health interventions (except family planning), but only at or below average on child health interventions.

Paternal Factors and Inequity Associated with Access to Maternal Health Care Service Utilization in Nepal: A Community Based Cross-Sectional Study

Background

The threat of maternal mortality can be reduced by increasing use of maternal health services. Maternal death and access to maternal health care services are inequitable in low and middle income countries.The aim of this study is to assess associated paternal factors and degree of inequity in access to maternal health care service utilization.

Methods

Analysis illustrates on a cross-sectional household survey that followed multistage-cluster sampling. Concentration curve and indices were calculated. Binary logistic regression analysis was executed to account paternal factors associated with the utilization of maternal health services. Path model with structural equation modeling (SEM) examined the predictors of antenatal care (ANC) and institutional delivery.

Results

The finding of this study revealed that 39.9% and 45.5% of the respondents’ wives made ANC visits and utilized institutional delivery services respectively. Men with graduate and higher level of education were more likely (AOR: 5.91, 95% CI; 4.02, 8.70) to have ANC of their wives than men with no education or primary level of education. Men with higher household income (Q5) were more likely (1.99, 95% CI; 1.39, 2.86) to have ANC for their wives. Similarly, higher household income (Q5) also determined (2.74, 95% CI; 1.81, 4.15) for institutional delivery of their wives. Concentration curve and indices also favored rich than the poor. SEM revealed that ANC visit was directly associated to institutional delivery.

Conclusions

Paternal factors like age, household wealth, number of children, ethnicity, education, knowledge of danger sign during pregnancy, and husband’s decision making for seeking maternal and child health care are crucial factors associated to maternal health service utilization. Higher ANC coverage predicts higher utilization of the institutional delivery. Wealthier population is more concentrated to maternal health services. The inequities between the poor and the rich are necessary to be addressed through effective policy and programs.