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Fullman N, Correa GC, Ikilezi G, Phillips DE, Reynolds HW. Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children. Vaccines (Basel) 2023; 11:vaccines11030647. [PMID: 36992231 DOI: 10.3390/vaccines11030647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023] Open
Abstract
Background: Understanding past successes in reaching unvaccinated or “zero-dose” children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. Methods: Focusing on 2000–2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria–tetanus–pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential ‘exemplars’, demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called “neighborhood analyses” were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. Results: From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions—national prevalence and subnational gaps—while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. Conclusions: Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children—especially across variable contexts and different drivers of inequality—could support faster, sustainable advances toward greater vaccination equity worldwide.
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Affiliation(s)
- Nancy Fullman
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - Gustavo C Correa
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
| | - Gloria Ikilezi
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - David E Phillips
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - Heidi W Reynolds
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
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Bergen N, Johns NE, Chang Blanc D, Hosseinpoor AR. Within-Country Inequality in COVID-19 Vaccination Coverage: A Scoping Review of Academic Literature. Vaccines (Basel) 2023; 11:517. [PMID: 36992101 PMCID: PMC10058740 DOI: 10.3390/vaccines11030517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
Since December 2020, COVID-19 vaccines have become increasingly available to populations around the globe. A growing body of research has characterised inequalities in COVID-19 vaccination coverage. This scoping review aims to locate, select and assess research articles that report on within-country inequalities in COVID-19 vaccination coverage, and to provide a preliminary overview of inequality trends for selected dimensions of inequality. We applied a systematic search strategy across electronic databases with no language or date restrictions. Our inclusion criteria specified research articles or reports that analysed inequality in COVID-19 vaccination coverage according to one or more socioeconomic, demographic or geographic dimension of inequality. We developed a data extraction template to compile findings. The scoping review was carried out using the PRISMA-ScR checklist. A total of 167 articles met our inclusion criteria, of which half (n = 83) were conducted in the United States. Articles focused on vaccine initiation, full vaccination and/or receipt of booster. Diverse dimensions of inequality were explored, most frequently relating to age (n = 127 articles), race/ethnicity (n = 117 articles) and sex/gender (n = 103 articles). Preliminary assessments of inequality trends showed higher coverage among older population groups, with mixed findings for sex/gender. Global research efforts should be expanded across settings to understand patterns of inequality and strengthen equity in vaccine policies, planning and implementation.
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Affiliation(s)
- Nicole Bergen
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Nicole E. Johns
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Diana Chang Blanc
- Department of Immunization, Vaccines and Biologicals, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Ahmad Reza Hosseinpoor
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
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3
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Ferreira LZ, Utazi CE, Huicho L, Nilsen K, Hartwig FP, Tatem AJ, Barros AJD. Geographic inequalities in health intervention coverage – mapping the composite coverage index in Peru using geospatial modelling. BMC Public Health 2022; 22:2104. [PMID: 36397019 PMCID: PMC9670533 DOI: 10.1186/s12889-022-14371-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background The composite coverage index (CCI) provides an integrated perspective towards universal health coverage in the context of reproductive, maternal, newborn and child health. Given the sample design of most household surveys does not provide coverage estimates below the first administrative level, approaches for achieving more granular estimates are needed. We used a model-based geostatistical approach to estimate the CCI at multiple resolutions in Peru. Methods We generated estimates for the eight indicators on which the CCI is based for the departments, provinces, and areas of 5 × 5 km of Peru using data from two national household surveys carried out in 2018 and 2019 plus geospatial covariates. Bayesian geostatistical models were fit using the INLA-SPDE approach. We assessed model fit using cross-validation at the survey cluster level and by comparing modelled and direct survey estimates at the department-level. Results CCI coverage in the provinces along the coast was consistently higher than in the remainder of the country. Jungle areas in the north and east presented the lowest coverage levels and the largest gaps between and within provinces. The greatest inequalities were found, unsurprisingly, in the largest provinces where populations are scattered in jungle territory and are difficult to reach. Conclusions Our study highlighted provinces with high levels of inequality in CCI coverage indicating areas, mostly low-populated jungle areas, where more attention is needed. We also uncovered other areas, such as the border with Bolivia, where coverage is lower than the coastal provinces and should receive increased efforts. More generally, our results make the case for high-resolution estimates to unveil geographic inequities otherwise hidden by the usual levels of survey representativeness. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14371-7.
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Bauer C, Zhang K, Xiao Q, Lu J, Hong YR, Suk R. County-Level Social Vulnerability and Breast, Cervical, and Colorectal Cancer Screening Rates in the US, 2018. JAMA Netw Open 2022; 5:e2233429. [PMID: 36166230 PMCID: PMC9516325 DOI: 10.1001/jamanetworkopen.2022.33429] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Area-level factors have been identified as important social determinants of health (SDoH) that impact many health-related outcomes. Less is known about how the social vulnerability index (SVI), as a scalable composite score, can multidimensionally explain the population-based cancer screening program uptake at a county level. OBJECTIVE To examine the geographic variation of US Preventive Services Task Force (USPSTF)-recommended breast, cervical, and colorectal cancer screening rates and the association between county-level SVI and the 3 screening rates. DESIGN, SETTING, AND PARTICIPANTS This population-based cross-sectional study used county-level information from the Centers for Disease Control and Prevention's PLACES and SVI data sets from 2018 for 3141 US counties. Analyses were conducted from October 2021 to February 2022. EXPOSURES Social vulnerability index score categorized in quintiles. MAIN OUTCOMES AND MEASURES The main outcome was county-level rates of USPSTF guideline-concordant, up-to-date breast, cervical, and colorectal screenings. Odds ratios were calculated for each cancer screening by SVI quintile as unadjusted (only accounting for eligible population per county) or adjusted for urban-rural status, percentage of uninsured adults, and primary care physician rate per 100 000 residents. RESULTS Across 3141 counties, county-level cancer screening rates showed regional disparities ranging from 54.0% to 81.8% for breast cancer screening, from 69.9% to 89.7% for cervical cancer screening, and from 39.8% to 74.4% for colorectal cancer screening. The multivariable regression model showed that a higher SVI was significantly associated with lower odds of cancer screening, with the lowest odds in the highest SVI quintile. When comparing the highest quintile of SVI (SVI-Q5) with the lowest quintile of SVI (SVI-Q1), the unadjusted odds ratio was 0.86 (95% posterior credible interval [CrI], 0.84-0.87) for breast cancer screening, 0.80 (95% CrI, 0.79-0.81) for cervical cancer screening, and 0.72 (95% CrI, 0.71-0.73) for colorectal cancer screening. When fully adjusted, the odds ratio was 0.92 (95% CrI, 0.90-0.93) for breast cancer screening, 0.87 (95% CrI, 0.86-0.88) for cervical cancer screening, and 0.86 (95% CrI, 0.85-0.88) for colorectal cancer screening, showing slightly attenuated associations. CONCLUSIONS AND RELEVANCE In this cross-sectional study, regional disparities were found in cancer screening rates at a county level. Quantifying how SVI associates with each cancer screening rate could provide insight into the design and focus of future interventions targeting cancer prevention disparities.
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Affiliation(s)
- Cici Bauer
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston School of Public Health, Houston
| | - Kehe Zhang
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston School of Public Health, Houston
| | - Qian Xiao
- Department of Epidemiology, Human Genetics and Environmental Health, The University of Texas Health Science Center at Houston School of Public Health, Houston
| | - Jiachen Lu
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston School of Public Health, Houston
| | - Young-Rock Hong
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville
- UFHealth Cancer Center, Gainesville, Florida
| | - Ryan Suk
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston
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Kirkby K, Bergen N, Schlotheuber A, Sodha SV, Danovaro-Holliday MC, Hosseinpoor AR. Subnational inequalities in diphtheria-tetanus-pertussis immunization in 24 countries in the African Region. Bull World Health Organ 2021; 99:627-639. [PMID: 34475600 PMCID: PMC8381099 DOI: 10.2471/blt.20.279232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 06/10/2021] [Accepted: 06/10/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To analyse subnational inequality in diphtheria-tetanus-pertussis (DTP) immunization dropout in 24 African countries using administrative data on receipt of the first and third vaccine doses (DTP1 and DTP3, respectively) collected by the Joint Reporting Process of the World Health Organization and the United Nations Children's Fund. METHODS Districts in each country were grouped into quintiles according to the proportion of children who dropped out between DTP1 and DTP3 (i.e. the dropout rate). We used six summary measures to quantify inequalities in dropout rates between districts and compared rates with national dropout rates and DTP1 and DTP3 immunization coverage. FINDINGS The median dropout rate across countries was 2.4% in quintiles with the lowest rate and 14.6% in quintiles with the highest rate. In eight countries, the difference between the highest and lowest quintiles was 14.9 percentage points or more. In most countries, underperforming districts in the quintile with the highest rate tended to lag disproportionately behind the others. This divergence was not evident from looking only at national dropout rates. Countries with the largest inequalities in absolute subnational dropout rate tended to have lower estimated national DTP1 and DTP3 immunization coverage. CONCLUSION There were marked inequalities in DTP immunization dropout rates between districts in most countries studied. Monitoring dropout at the subnational level could help guide immunization interventions that address inequalities in underserved areas, thereby improving overall DTP3 coverage. The quality of administrative data should be improved to ensure accurate and timely assessment of geographical inequalities in immunization.
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Affiliation(s)
- Katherine Kirkby
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Nicole Bergen
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Anne Schlotheuber
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Samir V Sodha
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | | | - Ahmad Reza Hosseinpoor
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
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Wang Z, Chan KY, Poon AN, Homma K, Guo Y. Construction of an area-deprivation index for 2869 counties in China: a census-based approach. J Epidemiol Community Health 2020; 75:114-119. [PMID: 33037046 DOI: 10.1136/jech-2020-214198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/06/2020] [Accepted: 08/24/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND A paucity of data has made it challenging to construct a deprivation index at the lowest administrative, or county, level in China. An index is required to guide health equity monitoring and resource allocation to regions of greatest need. This study used China's 2010 census data to construct a county-level area-deprivation index (CADI). METHODS Data for 2869 counties from China's 2010 census were used to generate a CADI. Eleven indicators across four domains of deprivation were selected for principal component analysis with standardisation of the first principal component. Sensitivity analysis was used to test whether the population size and weighting method affected the index's robustness. Deprived counties identified by the CADI were then compared with China's official list of poverty-stricken counties. RESULTS The first principal component explained 60.38% of the total variation in the deprivation indicators. The CADI ranged from the least deprived value of -2.71 to the most deprived value of 2.92, with SD of 1. The CADI was found to be robust against county-level population size and different weighting methods. When compared with the official list of poverty-stricken counties in China, the deprived counties identified by the CADI were found to be even more deprived. CONCLUSION Constructing a robust area-deprivation index for China at the county level based on population census data is feasible. The CADI is a potential policy tool to identify China's most deprived areas. In the future, it may support health equity monitoring and comparison at the national and subnational levels.
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Affiliation(s)
- Zhicheng Wang
- Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China.,Vanke School of Public Health, Tsinghua University, Beijing, China.,Research Centre for Public Health, School of Medicine, Tsinghua University, Beijing, China
| | - Kit Yee Chan
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK .,Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - Adrienne N Poon
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Medicine, School of Medicine & Health Sciences, George Washington University, Washington, DC, USA
| | - Kirsten Homma
- Department of Medicine, School of Medicine & Health Sciences, George Washington University, Washington, DC, USA.,Department of Medicine, New York Presbyterian - Columbia University, New York, NY, USA
| | - Yan Guo
- Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China
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Bhatia A, Krieger N, Victora C, Tuladhar S, Bhabha J, Beckfield J. Analyzing and improving national and local child protection data in Nepal: A mixed methods study using 2014 Multiple Indicator Cluster Survey (MICS) data and interviews with 18 organizations. CHILD ABUSE & NEGLECT 2020; 101:104292. [PMID: 31855666 DOI: 10.1016/j.chiabu.2019.104292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/11/2019] [Accepted: 11/20/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Globally, progress to improve data on child protection outcomes has been slower than efforts to improve data on child nutrition, vaccination and development outcomes in the under-five age group. The Sustainable Development Goals included several child protection targets further necessitating the need to track progress on child protection, but few studies have examined the varied data landscape for child protection within countries. OBJECTIVE This mixed-methods study aims to examine (1) the prevalence of child protection outcomes in Nepal, (2) the types of data the child protection sector uses, and (3) recommendations to improve the collection, analysis and use of child protection data. PARTICIPANTS AND SETTING We used: (a) secondary data from the nationally-representative 2014 Nepal MICS which surveyed over 13,000 households to measure the national prevalence of child labor, child marriage, and violent discipline, and (b) primary data from 18 qualitative key informant interviews with organizations in Nepal's child protection sector. METHODS We conducted descriptive quantitative analyses of the secondary data and thematic inductive and deductive qualitative analyses of transcripts of key informant interviews. RESULTS The burden of violent discipline (82%), child labor (37%), child marriage (12%), and their co-occurrence is high in Nepal. Respondents described using a range of data sources which included: large-scale surveys, case data from the police, court system, newspapers, community consultations, and child participation. Recommendations to improve data included developing a national child protection information system, ensuring the definitions of child protection outcomes were comparable across data sources, and improving the dissemination of data.
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Affiliation(s)
- Amiya Bhatia
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA.
| | - Nancy Krieger
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA.
| | - Cesar Victora
- International Center for Equity in Health, Federal University of Pelotas, Mal. Deodoro, 1160, 3d Floor, Zip Code: 96020-220, Pelotas RS, Brazil.
| | | | - Jacqueline Bhabha
- FXB Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA.
| | - Jason Beckfield
- Department of Sociology, Harvard University, William James Hall, 33 Kirkland Street, Cambridge, MA 02138, USA.
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Martínez P, Contreras D, Moreno M. Safe mobility, socioeconomic inequalities, and aging: A 12-year multilevel interrupted time-series analysis of road traffic death rates in a Latin American country. PLoS One 2020; 15:e0224545. [PMID: 31910212 PMCID: PMC6946134 DOI: 10.1371/journal.pone.0224545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 10/16/2019] [Indexed: 11/18/2022] Open
Abstract
As the resources for road safety in developing countries are scarce and unevenly distributed, vulnerable road users -such as the elderly- may be particularly at risk of road traffic deaths. To date, the impact of road safety measures over the rate of road traffic deaths in older adults (60 years or older), considering the within-country socioeconomic inequalities, has not been explored in developing nations. This study takes the Chilean case as an example -with its 2005 traffic law reform as one of the road safety measures investigated-, in which open data available from official national sources for all its 13 regions over the 2002-2013 period were used for a multilevel interrupted time-series analysis. A statistically significant secular reduction of the rates of road traffic deaths in the elderly population was found (incidence rate ratio [IRR] 0.95, 95% confidence interval [CI] 0.91 to 0.99), but no evidence for a significant intercept or slope change after the traffic law reform was observed. Regions with the highest number of traffic offenses prosecuted in local police courts had lower rates of road traffic deaths in older adults (IRR 0.95, 95% CI 0.90 to 1.00), and those regions in the third (IRR 1.61, 95% CI 1.16 to 2.25) and the fifth (IRR 1.66, 95% CI 1.08 to 2.54) quintiles of socioeconomic deprivation had higher rates of road traffic deaths in the elderly. Such findings strongly support the conceptualization of the road safety of seniors in developing countries as a social equity issue, with implications for the design of traffic regulations and road environments.
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Affiliation(s)
- Pablo Martínez
- CITIAPS, Universidad de Santiago de Chile, Santiago, Chile
- Escuela de Psicología, Facultad de Humanidades, Universidad de Santiago de Chile, Santiago, Chile
- Departamento de Psiquiatría y Salud Mental, Hospital Clínico Universidad de Chile, Santiago, Chile
- Instituto Milenio para la Investigación en Depresión y Personalidad (MIDAP), Santiago, Chile
- Núcleo Milenio para Mejorar la Salud Mental de Adolescentes y Jóvenes (Imhay), Santiago, Chile
- * E-mail:
| | | | - Mónica Moreno
- CITIAPS, Universidad de Santiago de Chile, Santiago, Chile
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Coates MM, Kamanda M, Kintu A, Arikpo I, Chauque A, Mengesha MM, Price AJ, Sifuna P, Wamukoya M, Sacoor CN, Ogwang S, Assefa N, Crampin AC, Macete EV, Kyobutungi C, Meremikwu MM, Otieno W, Adjaye-Gbewonyo K, Marx A, Byass P, Sankoh O, Bukhman G. A comparison of all-cause and cause-specific mortality by household socioeconomic status across seven INDEPTH network health and demographic surveillance systems in sub-Saharan Africa. Glob Health Action 2019; 12:1608013. [PMID: 31092155 PMCID: PMC6534200 DOI: 10.1080/16549716.2019.1608013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background: Understanding socioeconomic disparities in all-cause and cause-specific mortality can help inform prevention and treatment strategies. Objectives: To quantify cause-specific mortality rates by socioeconomic status across seven health and demographic surveillance systems (HDSS) in five countries (Ethiopia, Kenya, Malawi, Mozambique, and Nigeria) in the INDEPTH Network in sub-Saharan Africa. Methods: We linked demographic residence data with household survey data containing living standards and education information we used to create a poverty index. Person-years lived and deaths between 2003 and 2016 (periods varied by HDSS) were stratified in each HDSS by age, sex, year, and number of deprivations on the poverty index (0–8). Causes of death were assigned to each death using the InterVA-4 model based on responses to verbal autopsy questionnaires. We estimated rate ratios between socioeconomic groups (2–4 and 5–8 deprivations on our poverty index compared to 0–2 deprivations) for specific causes of death and calculated life expectancy for the deprivation groups. Results: Our pooled data contained almost 3.5 million person-years of observation and 25,038 deaths. All-cause mortality rates were higher among people in households with 5–8 deprivations on our poverty index compared to 0–2 deprivations, controlling for age, sex, and year (rate ratios ranged 1.42 to 2.06 across HDSS sites). The poorest group had consistently higher death rates in communicable, maternal, neonatal, and nutritional conditions (rate ratios ranged 1.34–4.05) and for non-communicable diseases in several sites (1.14–1.93). The disparities in mortality between 5–8 deprivation groups and 0–2 deprivation groups led to lower life expectancy in the higher-deprivation groups by six years in all sites and more than 10 years in five sites. Conclusions: We show large disparities in mortality on the basis of socioeconomic status across seven HDSS in sub-Saharan Africa due to disparities in communicable disease mortality and from non-communicable diseases in some sites. Life expectancy gaps between socioeconomic groups within sites were similar to the gaps between high-income and lower-middle-income countries. Prevention and treatment efforts can benefit from understanding subpopulations facing higher mortality from specific conditions.
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Affiliation(s)
- Matthew M Coates
- a Department of Global Health and Social Medicine, Program in Global Noncommunicable Diseases and Social Change , Harvard Medical School , Boston , USA
| | | | - Alexander Kintu
- c Department of Global Health and Population , Harvard T.H. Chan School of Public Health , Boston , USA
| | - Iwara Arikpo
- b INDEPTH Network , Accra , Ghana.,d Cross River Health & Demographic Surveillance System (CRHDSS) , University of Calabar , Calabar , Nigeria
| | - Alberto Chauque
- b INDEPTH Network , Accra , Ghana.,e Centro de Investigação em Saúde da Manhiça (CISM) , Mozambique
| | - Melkamu Merid Mengesha
- b INDEPTH Network , Accra , Ghana.,f College of Health and Medical Sciences , Haramaya University , Harar , Ethiopia
| | - Alison J Price
- b INDEPTH Network , Accra , Ghana.,g Department of Population Health , London School of Hygiene & Tropical Medicine , London , UK.,h Malawi Epidemiology and Intervention Research Unit , Lilongwe , Malawi
| | - Peter Sifuna
- b INDEPTH Network , Accra , Ghana.,i US Army Medical Research Directorate-Kenya (USAMRD-K)/Kenya Medical Research Institute (KEMRI) , Kisumu , Kenya
| | - Marylene Wamukoya
- b INDEPTH Network , Accra , Ghana.,j African Population and Health Research Center , Nairobi , Kenya
| | - Charfudin N Sacoor
- b INDEPTH Network , Accra , Ghana.,e Centro de Investigação em Saúde da Manhiça (CISM) , Mozambique
| | - Sheila Ogwang
- b INDEPTH Network , Accra , Ghana.,i US Army Medical Research Directorate-Kenya (USAMRD-K)/Kenya Medical Research Institute (KEMRI) , Kisumu , Kenya
| | - Nega Assefa
- b INDEPTH Network , Accra , Ghana.,f College of Health and Medical Sciences , Haramaya University , Harar , Ethiopia
| | - Amelia C Crampin
- b INDEPTH Network , Accra , Ghana.,g Department of Population Health , London School of Hygiene & Tropical Medicine , London , UK.,h Malawi Epidemiology and Intervention Research Unit , Lilongwe , Malawi
| | - Eusebio V Macete
- b INDEPTH Network , Accra , Ghana.,e Centro de Investigação em Saúde da Manhiça (CISM) , Mozambique
| | - Catherine Kyobutungi
- b INDEPTH Network , Accra , Ghana.,j African Population and Health Research Center , Nairobi , Kenya
| | - Martin M Meremikwu
- b INDEPTH Network , Accra , Ghana.,d Cross River Health & Demographic Surveillance System (CRHDSS) , University of Calabar , Calabar , Nigeria
| | - Walter Otieno
- b INDEPTH Network , Accra , Ghana.,i US Army Medical Research Directorate-Kenya (USAMRD-K)/Kenya Medical Research Institute (KEMRI) , Kisumu , Kenya.,k Department of Paediatrics and Child Health , Maseno University School of Medicine , Kisumu , Kenya
| | | | - Andrew Marx
- a Department of Global Health and Social Medicine, Program in Global Noncommunicable Diseases and Social Change , Harvard Medical School , Boston , USA
| | - Peter Byass
- b INDEPTH Network , Accra , Ghana.,m Department of Epidemiology and Global Health , Umeå University , Umeå , Sweden.,n Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa.,o Institute of Applied Health Sciences , University of Aberdeen , Aberdeen , Scotland
| | - Osman Sankoh
- b INDEPTH Network , Accra , Ghana.,p Statistics Sierra Leone , Freetown , Sierra Leone.,q College of Medicine and Allied Health Sciences , University of Sierra Leone , New England , Sierra Leone.,r School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Gene Bukhman
- a Department of Global Health and Social Medicine, Program in Global Noncommunicable Diseases and Social Change , Harvard Medical School , Boston , USA.,s Division of Global Health Equity , Brigham and Women's Hospital , Boston , MA , USA.,t Partners In Health , Boston , MA , USA
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10
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Costa C, Freitas Â, Stefanik I, Krafft T, Pilot E, Morrison J, Santana P. Evaluation of data availability on population health indicators at the regional level across the European Union. Popul Health Metr 2019; 17:11. [PMID: 31391120 PMCID: PMC6686464 DOI: 10.1186/s12963-019-0188-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/22/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The ability to measure regional health inequalities across Europe and to build adequate population health indices depends significantly on the availability of reliable and comparable data at the regional level. Within the scope of the EU-funded project EURO-HEALTHY, a Population Health Index (PHI) was built. This model aggregates 39 indicators considered relevant by experts and stakeholders to evaluate and monitor population health on the regional level within the European Union (269 regions). The aim of this research was to assess the data availability for those indicators. As a subsequent aim, an adequate protocol to overcome issues arising from missing data will be presented, as well as key messages for both national and European statistical authorities meant to improve data collection on population health. METHODS The methodology for the study includes three consecutive phases: (i) assessing the data availability for the respective indicators at the regional level for the last year available (ii) applying a protocol for missing data and completing the database and (iii) developing a scoring system ranging from 0 (no data available; worst) to 1 (all data available; best) to evaluate the availability of data by indicator and EU region. RESULTS Although the missing data on the set of the PHI indicators was significant, the mean availability score for the EURO-HEALTHY PHI indicators is 0.8 and the regional availability score is 0.7, which reveal the strength of the indicators as well as the data completeness protocol for missing data. CONCLUSIONS This study provides a comprehensive data availability assessment for population health indicators from multiple areas of concern, at the EU regional level. The results highlight that the data completeness protocol and availability scores are suitable tools to apply on any indicator's data source mapping. It also raises awareness to the urgent need for sub-national data in several domains and for closing the data gaps between and within countries. This will require policies clearly focused on improving equity between regions and a coordinated effort from the producers of data (the EU28 national statistics offices and EUROSTAT) and the stakeholders who design policies at EU, regional and local level.
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Affiliation(s)
- Claudia Costa
- Centre of Studies in Geography and Spatial Planning (CEGOT), Department of Geography and Tourism, University of Coimbra, 3004-530 Coimbra, Portugal
| | - Ângela Freitas
- Centre of Studies in Geography and Spatial Planning (CEGOT), Department of Geography and Tourism, University of Coimbra, 3004-530 Coimbra, Portugal
| | - Iwa Stefanik
- Centre of Studies in Geography and Spatial Planning (CEGOT), Department of Geography and Tourism, University of Coimbra, 3004-530 Coimbra, Portugal
| | - Thomas Krafft
- Faculty of Health, Medicine and Life Sciences (FHML), Care and Public Health Research Institute (CAPHRI), Department of Health, Ethics and Society, Maastricht University, Maastricht, The Netherlands
| | - Eva Pilot
- Faculty of Health, Medicine and Life Sciences (FHML), Care and Public Health Research Institute (CAPHRI), Department of Health, Ethics and Society, Maastricht University, Maastricht, The Netherlands
| | - Joana Morrison
- Research Department of Epidemiology and Public Health, University College London, London, UK
| | - Paula Santana
- Centre of Studies in Geography and Spatial Planning (CEGOT), Department of Geography and Tourism, University of Coimbra, 3004-530 Coimbra, Portugal
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Victora C, Boerma T, Requejo J, Mesenburg MA, Joseph G, Costa JC, Vidaletti LP, Ferreira LZ, Hosseinpoor AR, Barros AJD. Analyses of inequalities in RMNCH: rising to the challenge of the SDGs. BMJ Glob Health 2019; 4:e001295. [PMID: 31297251 PMCID: PMC6590961 DOI: 10.1136/bmjgh-2018-001295] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/19/2019] [Accepted: 02/25/2019] [Indexed: 01/31/2023] Open
Abstract
The Sustainable Development Goal (SDG) 17.18 recommends efforts to increase the availability of data disaggregated by income, gender, age, race, ethnicity, migratory status, disability and geographic location in developing countries. Surveys will continue to be the leading data source for disaggregated data for most dimensions of inequality. We discuss potential advances in the disaggregation of data from national surveys, with a focus on the coverage of reproductive, maternal, newborn and child health indicators (RMNCH). Even though the Millennium Development Goals were focused on national-level progress, monitoring initiatives such as Countdown to 2015 reported on progress in RMNCH coverage according to wealth quintiles, sex of the child, women’s education and age, urban/rural residence and subnational geographic regions. We describe how the granularity of equity analyses may be increased by including additional stratification variables such as wealth deciles, estimated absolute income, ethnicity, migratory status and disability. We also provide examples of analyses of intersectionality between wealth and urban/rural residence (also known as double stratification), sex of the child and age of the woman. Based on these examples, we describe the advantages and limitations of stratified analyses of survey data, including sample size issues and lack of information on the necessary variables in some surveys. We conclude by recommending that, whenever possible, stratified analyses should go beyond the traditional breakdowns by wealth quintiles, sex and residence, to also incorporate the wider dimensions of inequality. Greater granularity of equity analyses will contribute to identify subgroups of women and children who are being left behind and monitor the impact of efforts to reduce inequalities in order to achieve the health SDGs.
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Affiliation(s)
- Cesar Victora
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil.,International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Ties Boerma
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - Gary Joseph
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Janaína Calu Costa
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Luis Paulo Vidaletti
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | - Ahmad Reza Hosseinpoor
- Partnership for Maternal, Newborn & Child Health, World Health Organization, Geneva, Switzerland
| | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
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12
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Bergen N, Ruckert A, Kulkarni MA, Abebe L, Morankar S, Labonté R. Subnational health management and the advancement of health equity: a case study of Ethiopia. Glob Health Res Policy 2019; 4:12. [PMID: 31131331 PMCID: PMC6524326 DOI: 10.1186/s41256-019-0105-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/09/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Health equity is a cross-cutting theme in the United Nations 2030 Agenda for Sustainable Development, and a priority in health sector planning in countries including Ethiopia. Subnational health managers in Ethiopia are uniquely positioned to advance health equity, given the coordination, planning, budgetary, and administration tasks that they are assigned. Yet, the nature of efforts to advance health equity by subnational levels of the health sector is poorly understood and rarely researched. This study assesses how subnational health managers in Ethiopia understand health equity issues and their role in promoting health equity and offers insight into how these roles can be harnessed to advance health equity. METHODS A descriptive case study assessed perspectives and experiences of health equity among subnational health managers at regional, zonal, district and Primary Health Care Unit administrative levels. Twelve in-depth interviews were conducted with directors, vice-directors, coordinators and technical experts. Data were analyzed using thematic analysis. RESULTS Subnational managers perceived geographical factors as a predominant concern in health service delivery inequities, especially when they intersected with poor infrastructure, patriarchal gender norms, unequal support from non-governmental organizations or challenging topography. Participants used ad hoc, context-specific strategies (such as resource-pooling with other sectors or groups and shaming-as-motivation) to improve health service delivery to remote populations and strengthen health system operations. Collaboration with other groups facilitated cost sharing and access to resources; however, the opportunities afforded by these collaborations, were not realized equally in all areas. Subnational health managers' efforts in promoting health equity are affected by inadequate resource availability, which restricts their ability to enact long-term and sustainable solutions. CONCLUSIONS Advancing health equity in Ethiopia requires: extra support to communities in hard-to-reach areas; addressing patriarchal norms; and strategic aligning of the subnational health system with non-health government sectors, community groups, and non-governmental organizations. The findings call attention to the unrealized potential of effectively coordinating governance actors and processes to better align national priorities and resources with subnational governance actions to achieve health equity, and offer potentially useful knowledge for subnational health system administrators working in conditions similar to those in our Ethiopian case study.
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Affiliation(s)
- Nicole Bergen
- University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| | - Arne Ruckert
- University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| | | | - Lakew Abebe
- Jimma University, PO Box 378, Jimma, Ethiopia
| | | | - Ronald Labonté
- University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
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13
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Transnational wealth-related health inequality measurement. SSM Popul Health 2018; 6:259-275. [PMID: 30426063 PMCID: PMC6222170 DOI: 10.1016/j.ssmph.2018.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/10/2018] [Accepted: 10/14/2018] [Indexed: 11/30/2022] Open
Abstract
The study of international differences in wealth-related health inequalities has traditionally consisted of country-by-country comparisons using own-country relative measures of socioeconomic status, which effectively ignores absolute differences in both wealth and health that can differ between and within countries. To address these limitations, we propose an alternative approach: that of constructing a transnational measure of wealth-related health inequality. To illustrate the limitations of the country-by-country approach, we simulate the impact of changes in wealth and health inequalities both between and within countries on cross-country measures of health inequality and find at least five errors that may arise using country-by-country methods. We then empirically demonstrate the transnational approach to wealth-related health inequalities between and within Haiti and the Dominican Republic, the two constituent countries of the island of Hispaniola, using data from their respective Demographic and Health Surveys. Transnational socioeconomic rankings reveal a large and increasing divergence in wealth between the two countries, which would be ignored using the county-by-country approach. We find that wealth-related inequalities in long-term children’s health outcomes are larger than inequalities in short-term health outcomes, and decompositions of the influence of place-based variables on these inequalities reveal country of residence to be the most important factor for long-term outcomes, while urban/rural residence and subnational regions are more important for short-term health outcomes. The significance of this novel methodological approach in relation to conventional health inequality research, including hidden dimensions of wealth-related health inequalities, for example the urbanized “middle class” distribution of HIV and a hidden unequal burden of wasting among children uncovered by the transnational approach are discussed, and errors in gauging changes in inequality over time using a country-by-country approach are highlighted. Using the transnational approach can help to measure important trends in wealth-related health inequalities across countries that more commonly used methods traditionally overlook. Simulated data reveals limitations in measuring health inequalities across countries. We calculate transnational measures of SES-related health inequalities for Hispaniola. Country residence drives child health inequalities, subregions drive HIV inequality. Hidden HIV and wasting inequalities are uncovered with the transnational approach. Country-by-country methods misidentify secular transnational inequality trends.
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14
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Hosseinpoor AR, Bergen N, Schlotheuber A, Boerma T. National health inequality monitoring: current challenges and opportunities. Glob Health Action 2018; 11:1392216. [PMID: 29460696 PMCID: PMC5827767 DOI: 10.1080/16549716.2017.1392216] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
National health inequality monitoring needs considerably more investment to realize equity-oriented health improvements in countries, including advancement towards the Sustainable Development Goals. Following an overview of national health inequality monitoring and the associated resource requirements, we highlight challenges that countries may encounter when setting up, expanding or strengthening national health inequality monitoring systems, and discuss opportunities and key initiatives that aim to address these challenges. We provide specific proposals on what is needed to ensure that national health inequality monitoring systems are harnessed to guide the reduction of health inequalities.
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Affiliation(s)
- Ahmad Reza Hosseinpoor
- a Department of Information, Evidence and Research , World Health Organization , Geneva , Switzerland
| | - Nicole Bergen
- b Faculty of Health Sciences , University of Ottawa , Ottawa , Canada
| | - Anne Schlotheuber
- a Department of Information, Evidence and Research , World Health Organization , Geneva , Switzerland
| | - Ties Boerma
- c Department of Community Health Sciences , University of Manitoba , Winnipeg , Canada
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15
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Matheson A, Bourke C, Verhoeven A, Khan MI, Nkunda D, Dahar Z, Ellison-Loschmann L. Lowering hospital walls to achieve health equity. BMJ 2018; 362:k3597. [PMID: 30237307 PMCID: PMC6146487 DOI: 10.1136/bmj.k3597] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Hospitals have a pivotal role in reducing health inequities for indigenous people and other marginalised groups, argue Anna Matheson and colleagues
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Affiliation(s)
- Anna Matheson
- Te Pūnaha Matatini, School of Health Sciences, Massey University, Wellington, New Zealand
| | - Chris Bourke
- Australian Healthcare and Hospitals Association, Deakin West, ACT, Australia
| | - Alison Verhoeven
- Australian Healthcare and Hospitals Association, Deakin West, ACT, Australia
| | - M Imran Khan
- Maternal Newborn and Child Health, Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | | | - Zaib Dahar
- People's Primary Healthcare Initiative, Karachi, Pakistan
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16
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Huang Y, Shallcross D, Pi L, Tian F, Pan J, Ronsmans C. Ethnicity and maternal and child health outcomes and service coverage in western China: a systematic review and meta-analysis. LANCET GLOBAL HEALTH 2018; 6:e39-e56. [DOI: 10.1016/s2214-109x(17)30445-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 09/07/2017] [Accepted: 10/05/2017] [Indexed: 11/17/2022]
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17
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Afifah T, Nuryetty MT, Cahyorini, Musadad DA, Schlotheuber A, Bergen N, Johnston R. Subnational regional inequality in access to improved drinking water and sanitation in Indonesia: results from the 2015 Indonesian National Socioeconomic Survey (SUSENAS). Glob Health Action 2018; 11:1496972. [PMID: 30067161 PMCID: PMC6084489 DOI: 10.1080/16549716.2018.1496972] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 06/30/2018] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Tin Afifah
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | | | - Cahyorini
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Dede Anwar Musadad
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Anne Schlotheuber
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | - Nicole Bergen
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Richard Johnston
- Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, Geneva, Switzerland
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Hosseinpoor AR, Schlotheuber A, Nambiar D, Ross Z. Health Equity Assessment Toolkit Plus (HEAT Plus): software for exploring and comparing health inequalities using uploaded datasets. Glob Health Action 2018; 11:1440783. [PMID: 29974823 PMCID: PMC6041818 DOI: 10.1080/16549716.2018.1440783] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 02/11/2018] [Indexed: 12/02/2022] Open
Abstract
As a key step in advancing the sustainable development goals, the World Health Organisation (WHO) has placed emphasis on building capacity for measuring and monitoring health inequalities. A number of resources have been developed, including the Health Equity Assessment Toolkit (HEAT), a software application that facilitates the assessment of within-country health inequalities. Following user demand, an Upload Database Edition of HEAT, HEAT Plus, was developed. Launched in July 2017, HEAT Plus allows users to upload their own databases and assess inequalities at the global, national or subnational level for a range of (health) indicators and dimensions of inequality. The software is open-source, operates on Windows and Macintosh platforms and is readily available for download from the WHO website. The flexibility of HEAT Plus makes it a suitable tool for both global and national inequality assessments. Further developments will include interactive graphs, maps and translation into different languages.
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Affiliation(s)
- Ahmad Reza Hosseinpoor
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | - Anne Schlotheuber
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | | | - Zev Ross
- ZevRoss Spatial Analysis, Ithaca, NY, USA
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