State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: a multicountry study of household health surveys

Background Immunisation programmes have made substantial contributions to lowering the burden of disease in children, but there is a growing need to ensure that programmes are equity-oriented. We aimed to provide a detailed update about the state of between-country inequality and within-country economic-related inequality in the delivery of three doses of the combined diphtheria, tetanus toxoid, and pertussis-containing vaccine (DTP3), with a special focus on inequalities in high-priority countries. Methods We used data from the latest available Demographic and Health Surveys and Multiple Indicator Cluster Surveys done in 51 low-income and middle-income countries. Data for DTP3 coverage were disaggregated by wealth quintile, and inequality was calculated as diff erence and ratio measures based on coverage in richest (quintile 5) and poorest (quintile 1) household wealth quintiles. Excess change was calculated for 21 countries with data available at two timepoints spanning a 10 year period. Further analyses were done for six high-priority countries—ie, those with low national immunisation coverage and/or high absolute numbers of unvaccinated children. Signifi cance was determined using 95% CIs. Findings National DTP3 immunisation coverage across the 51 study countries ranged from 32% in Central African Republic to 98% in Jordan. Within countries, the gap in DTP3 immunisation coverage suggested pro-rich inequality, with a diff erence of 20 percentage points or more between quintiles 1 and 5 for 20 of 51 countries. In Nigeria, Pakistan, Laos, Cameroon, and Central African Republic, the diff erence between quintiles 1 and 5 exceeded 40 percentage points. In 15 of 21 study countries, an increase over time in national coverage of DTP3 immunisation was realised alongside faster improvements in the poorest quintile than the richest. For example, in Burkina Faso, Cambodia, Gabon, Mali, and Nepal, the absolute increase in coverage was at least 2·0 percentage points per year, with faster improvement in the poorest quintile. Substantial economic-related inequality in DTP3 immunisation coverage was reported in fi ve high-priority study countries (DR Congo, Ethiopia, Indonesia, Nigeria, and Pakistan), but not Uganda. Interpretation Overall, within-country inequalities in DTP3 immunisation persist, but seem to have narrowed over the past 10 years. Monitoring economic-related inequalities in immunisation coverage is warranted to reveal where gaps exist and inform appropriate approaches to reach disadvantaged populations

Socio-economic, demographic and geographic correlates of cigarette smoking among Indonesian adolescents: results from the 2013 Indonesian Basic Health Research (RISKESDAS) survey

Background: The prevalence of adolescent tobacco use in Indonesia is among the highest in the world. Monitoring the extent and distribution of adolescent cigarette smoking is crucial to being able to target prevention and reduction strategies and evaluate the effectiveness of interventions. Objectives: To quantify the prevalence of adolescent cigarette smoking in Indonesia and assess the association with key socio-economic, demographic and geographic factors. Methods: We used data from the 2013 Indonesian Basic Health Research (RISKESDAS) national household survey to quantify the prevalence of cigarette smoking in adolescents aged 10–18 years by sex, age, education, economic status, place of residence and province. We used logistic regression to assess the adjusted association between adolescent smoking and these factors. Results: The overall smoking prevalence among Indonesian  adolescents was 7.2% (95% Confidence Interval/CI: 7.1–7.4). The prevalence was substantially higher among males (14.0%; 95% CI: 13.6–14.4) compared with females (0.2%; 95% CI: 0.1–0.4). After controlling for socio-economic, demographic and geographic characteristics, higher odds of smoking were observed among males (OR = 118.1; 95% CI: 91.2–153.0) as compared to female and among  adolescents aged 13–15 and 16–18 years as compared to those aged 10–12 years (OR = 13.2; 95% CI: 10.8–16.2 and OR = 72.7; 95% CI: 59.1–89.4, respectively). The odds of smoking were greater among adolescents with higher education as compared to those with lower education (OR = 1.3; 95% CI: 1.1–1.4) and adolescents in the poorest quintile had more than twice the odds of smoking compared with adolescents from the richest quintile (OR = 2.5; 95% CI: 2.2–2.8). Conclusion: Smoking prevention and cessation interventions in Indonesia need to be specific considering the sex, age, socioeconomic status and geographic location of adolescents. Ongoing monitoring of adolescent smoking is important for targeting interventions at higher-risk groups and assessing the effectiveness of current tobacco control strategies

Promoting health equity: WHO health inequality monitoring at global and national levels

Background: Health equity is a priority in the post-2015 sustainable development agenda and other major health initiatives. The World Health Organization (WHO) has a history of promoting actions to achieve equity in health, including efforts to encourage the practice of health inequality monitoring. Health inequality monitoring systems use disaggregated data to identify disadvantaged subgroups within populations and inform equity-oriented health policies, programs, and practices. Objective: This paper provides an overview of a number of recent and current WHO initiatives related to health inequality monitoring at the global and/or national level. Design: We outline the scope, content, and intended uses/application of the following: Health Equity Monitor database and theme page; State of inequality: reproductive, maternal, newborn, and child health report; Handbook on health inequality monitoring: with a focus on low- and middle-income countries; Health inequality monitoring eLearning module; Monitoring health inequality: an essential step for achieving health equity advocacy booklet and accompanying video series; and capacity building workshops conducted in WHO Member States and Regions. Conclusions: The paper concludes by considering how the work of the WHO can be expanded upon to promote the establishment of sustainable and robust inequality monitoring systems across a variety of health topics among Member States and at the global level

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

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

Health Equity Assessment Toolkit (HEAT): software for exploring and comparing health inequalities in countries

Abstract Background It is widely recognised that the pursuit of sustainable development cannot be accomplished without addressing inequality, or observed differences between subgroups of a population. Monitoring health inequalities allows for the identification of health topics where major group differences exist, dimensions of inequality that must be prioritised to effect improvements in multiple health domains, and also population subgroups that are multiply disadvantaged. While availability of data to monitor health inequalities is gradually improving, there is a commensurate need to increase, within countries, the technical capacity for analysis of these data and interpretation of results for decision-making. Prior efforts to build capacity have yielded demand for a toolkit with the computational ability to display disaggregated data and summary measures of inequality in an interactive and customisable fashion that would facilitate interpretation and reporting of health inequality in a given country. Methods To answer this demand, the Health Equity Assessment Toolkit (HEAT), was developed between 2014 and 2016. The software, which contains the World Health Organization’s Health Equity Monitor database, allows the assessment of inequalities within a country using over 30 reproductive, maternal, newborn and child health indicators and five dimensions of inequality (economic status, education, place of residence, subnational region and child’s sex, where applicable). Results/Conclusion HEAT was beta-tested in 2015 as part of ongoing capacity building workshops on health inequality monitoring. This is the first and only application of its kind; further developments are proposed to introduce an upload data feature, translate it into different languages and increase interactivity of the software. This article will present the main features and functionalities of HEAT and discuss its relevance and use for health inequality monitoring

El monitoreo orientado a la equidad en el contexto de la cobertura universal de salud

El monitoreo de las desigualdades en la salud es fundamental para el logro progresivo y equitativo de la cobertura universal de salud. Para que tenga éxito, el monitoreo global de las desigualdades debe ser lo suficientemente intuitivo a fin de que pueda adoptarse ampliamente y debe mantener al mismo tiempo su credibilidad técnica. En este artículo se analizan algunas consideraciones metodológicas para el monitoreo de la cobertura universal de salud orientado a la equidad y se proponen recomendaciones con respecto al monitoreo y el establecimiento de metas. La desigualdad es multidimensional, de modo que el grado de desigualdad puede variar considerablemente entre distintas dimensiones, como la posición económica, la educación, el sexo y la residencia urbana o rural. Por ello, el monitoreo global debe incluir dimensiones complementarias de la desigualdad (como la posición económica y la residencia urbana o rural) y el sexo. Para una dimensión dada de la desigualdad, deben establecerse subgrupos para el monitoreo considerando la aplicabilidad de los criterios entre los países y la heterogeneidad de los subgrupos. En el caso de la desigualdad asociada a la posición económica, recomendamos formar subgrupos utilizando quintiles y para la desigualdad por residencia urbana o rural, recomendamos una categorización binaria. La desigualdad abarca las poblaciones, por lo que los enfoques apropiados para el monitoreo deben basarse en comparaciones entre dos subgrupos (enfoque de brecha) o entre múltiples subgrupos (enfoque de gradiente o espectro completo). Al medirse la desigualdad, las mediciones absolutas y relativas deben comunicarse al mismo tiempo, junto con los datos desagregados; la desigualdad debe informarse junto con el promedio nacional. Recomendamos establecer metas que se basen en reducciones proporcionales de la desigualdad absoluta en los grupos poblacionales. Crear la capacidad de monitorear las desigualdades en la salud es oportuno, pertinente e importante. El desarrollo de sistemas de información de salud de alta calidad, incluidas la recolección, el análisis y la interpretación de los datos y las prácticas de presentación de informes vinculadas a los ciclos de revisión y evaluación en los sistemas de salud, permitirá realizar un monitoreo eficaz de las desigualdades en la salud a escala mundial y nacional. Estas medidas apoyarán el logro progresivo de la cobertura universal de salud orientado a la equidad