Ahmad Reza Hosseinpoor’s research while affiliated with World Health Organization WHO and other places

Background: Monitoring immunization inequalities is crucial for achieving equity in vaccine coverage. Summary measures of health inequality provide a single numerical expression of immunization inequality. However, the impact of different summary measures on conclusions about immunization inequalities has not been thoroughly studied. Methods: We used disaggregated data from household surveys conducted in 92 low- and middle-income countries between 2013 and 2022. Inequality was assessed for two indicators of childhood immunization coverage [three doses of combined diphtheria, tetanus, and pertussis (DTP) vaccine and non-receipt of DTP vaccine or “zero-dose”] across three dimensions of inequality (place of residence, economic status, and subnational region). We calculated 16 summary measures of health inequality and compared the results. Results: These measures of inequality showed more similarities than differences, but the choice of measure can affect inequality assessment. Absolute and relative measures sometimes produced differing results, showing the importance of using both types of measures when assessing immunization inequality. Outliers influenced differences and ratios, but the effect of outlier estimates was moderated through the use of complex measures, which consider all subgroups and their population sizes. The choice of appropriate complex measure depends on the audience, interpretation, and outlier sensitivity. Conclusions: Summary measures are useful for assessing changes in inequality over time and making comparisons across different geographical areas and vaccines, but assumptions and value judgements made when selecting summary measures of inequality should be made explicit in research.

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.

The year 2024 marks the 50th anniversary of the World Health Organization (WHO) Expanded Program on Immunization (EPI) [...]

Immunization through vaccines among children has contributed to improved childhood survival and health outcomes globally. However, vaccine coverage among children is unevenly distributed across settings and populations. The measurement of inequalities is essential for understanding gaps in vaccine coverage affecting certain sub-populations and monitoring progress towards achieving equity. Our study aimed to characterize the methods of reporting inequalities in childhood vaccine coverage, inclusive of the settings, data source types, analytical methods, and reporting modalities used to quantify and communicate inequality. We conducted a scoping review of publications in academic journals which included analyses of inequalities in vaccination among children. Literature searches were conducted in PubMed and Web of Science and included relevant articles published between 8 December 2013 and 7 December 2023. Overall, 242 publications were identified, including 204 assessing inequalities in a single country and 38 assessing inequalities across more than one country. We observed that analyses on inequalities in childhood vaccine coverage rely heavily on Demographic Health Survey (DHS) or Multiple Indicator Cluster Surveys (MICS) data (39.3%), and papers leveraging these data had increased in the last decade. Additionally, about half of the single-country studies were conducted in low- and middle-income countries. We found that few studies analyzed and reported inequalities using summary measures of health inequality and largely used the odds ratio resulting from logistic regression models for analyses. The most analyzed dimensions of inequality were economic status and maternal education, and the most common vaccine outcome indicator was full vaccination with the recommended vaccine schedule. However, the definition and construction of both dimensions of inequality and vaccine coverage measures varied across studies, and a variety of approaches were used to study inequalities in vaccine coverage across contexts. Overall, harmonizing methods for selecting and categorizing dimensions of inequalities as well as methods for analyzing and reporting inequalities can improve our ability to assess the magnitude and patterns of inequality in vaccine coverage and compare those inequalities across settings and time.

We assessed socioeconomic inequalities in social protection coverage among the public, men and women living with the human immunodeficiency virus (MLHIV, WLHIV), and adolescent girls and young women (AGYW). We used population-based data from Cameroon, Côte d’Ivoire, Ethiopia, Eswatini, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. We constructed concentration curves (CC) and computed concentration indices (CIX) for each country and population group. A CC represents the cumulative percentage of social protection coverage plotted on the y-axis against the cumulative proportion of the population—ranked by socioeconomic status from the poorest to the richest—on the x-axis. The CIX quantifies the concentration of social protection coverage among the poor or the rich. The sample size ranged from 10,197 in Eswatini to 29,577 in Tanzania. Social protection coverage among the public varied from 5.2% (95% Confidence Interval 4.5%–6.0%) in Ethiopia to 39.9% (37.0%–42.8%) in Eswatini. It ranged from 6.9% (5.7%–8.4%) MLHIV in Zambia to 45.0% (41.2–49.0) among WLHIV in Namibia. Among AGYW, it varied from 4.4% (3.6–5.3) in Ethiopia to 44.6% (40.8–48.5) in Eswatini. Socioeconomic inequalities in social protection coverage favored the poor in 11/13 countries surveyed. It favored the rich in Cameroon and was undefined in Côte d’Ivoire. The CIX in these 11 countries ranged from −0.080 (p = 0.002) among the public in Malawi to −0.372 (p< 0.001) among WLHIV in Zimbabwe. In 8 of these 11 countries, ≥15% of people from the poorest households reported receiving social protection. Only in countries with higher levels of social protection coverage did most people from the poorest households achieve high coverage. Social protection coverage was low and favored the poor. Pro-poor social protection is insufficient to reach the poor. Research is required to reach the poorest households with social protection in Africa.

Immunization of pregnant women against tetanus is a key strategy for reducing tetanus morbidity and mortality while also achieving the goal of maternal and neonatal tetanus elimination. Despite substantial progress in improving newborn protection from tetanus at birth through maternal immunization, umbilical cord practices and sterilized and safe deliveries, inequitable gaps in protection remain. Notably, an infant’s tetanus protection at birth is comprised of immunization received by the mother during and before the pregnancy (e.g., through childhood vaccination, booster doses, mass vaccination campaigns, or during prior pregnancies). In this work, we examine wealth-related inequalities in maternal tetanus toxoid containing vaccination coverage before pregnancy, during pregnancy, and at birth for 72 low- and middle-income countries with a recent Demographic and Health Survey or Multiple Indicator Cluster Survey (between 2013 and 2022). We summarize coverage levels and absolute and relative inequalities at each time point; compare the relative contributions of inequalities before and during pregnancy to inequalities at birth; and examine associations between inequalities and coverage levels. We present the findings for countries individually and on aggregate, by World Bank country income grouping, as well as by maternal and neonatal tetanus elimination status, finding that most of the inequality in tetanus immunization coverage at birth is introduced during pregnancy. Inequalities in coverage during pregnancy are most pronounced in low- and lower-middle-income countries, and even more so in countries which have not achieved maternal and neonatal tetanus elimination. These findings suggest that pregnancy is a key time of opportunity for equity-oriented interventions to improve maternal tetanus immunization coverage.

Inequality in access to services is a global problem mainly impacting the poorest populations. The role of social protection in reducing inequalities is recognized, but few studies have investigated whether social protection benefits people facing considerable socioeconomic inequalities. We assessed inequalities in receiving social protection among the public, men and women living with human immunodeficiency virus (PLHIV), and adolescent girls and young women (AGYW), using population-based data from 13 African countries. We constructed concentration curves and computed concentration indices (CIX) for each country and population group. We also conducted a desk review of social protection in the studied countries where information was available on the characteristics of social protection programs and their access by the general population, PLHIV, and AGYW. The sample size ranged from 10,197 in Eswatini to 29,577 in Tanzania. Women comprised 60% or more of PLHIV in the surveyed countries. 50%–70% of the respondents were unemployed, except in Cameroon, Kenya, and Uganda, where less than 50% were unemployed. Generally, the proportion of respondents from wealth quintile one (Q1), the poorest 20% of households, was like that from Q2–Q5. The proportion of the general population receiving social protection varied from 5.2% (95% Confidence Interval 4.5%–6.0%) in Ethiopia to 39.9% (37.0%–42.8%) in Eswatini. Among PLHIV, the proportion receiving social protection varied from 6.9% (5.7%–8.4%) among men living with HIV in Zambia to 45.0% (41.2–49.0) among women living with HIV in Namibia. Among AGYW, the proportion varied from 4.4% (3.6–5.3) in Ethiopia to 44.6% (40.8–48.5) in Eswatini. In general, 15% or less of the respondents from Q1 reported receiving social protection in eight countries (i.e., Cameroon, Côte d'Ivoire, Ethiopia, Kenya, Malawi, Tanzania, Uganda, and Zambia), with 10% or less in three countries (Cameroon, Côte d'Ivoire, and Ethiopia); 15%–20% in Rwanda, 30% in Zimbabwe, 40% in Lesotho, and more than 50% in Eswatini and Namibia. Among the wealthiest quintiles (Q5), the proportion receiving social protection ranged from 3.6% (2.6%–5.0%) in Ethiopia to 19.7% (16.25–23.8%) in Namibia. Only in countries with higher social protection coverage did the proportion of the poorest wealth quintile households reached also high. Socioeconomic inequalities in receiving social protection favored the poor in 11 out of 13 countries and the rich in Cameroon and were undefined in Côte d'Ivoire. The CIX values for socioeconomic inequalities in receiving social protection in these 11 countries ranged from −0.080 (p=0.002) among the general population in Malawi to −0.372 (p< 0.001) among WLHIV in Zimbabwe. However, in 8 countries (Cameroon, Côte d'Ivoire, Ethiopia, Kenya, Malawi, Tanzania, Uganda, and Zambia) of these 11 countries, 15% or less of the population from the poorest wealth quintile received social protection. In the countries surveyed, access to social protection for the general population, MLHIV and WLHIV, and AGYW was generally low but favored people from poor households. However, pro-poor social protection, although necessary, is not sufficient to ensure that people from the poorest households receive social protection. Further research is required to identify and reach people from the poorest households with social protection in sub-Saharan Africa.

Objective To examine inequalities in the coverage of reproductive and maternal health interventions in low- and middle-income countries and territories using a composite index of socioeconomic deprivation status. Methods We obtained data on education and living standards from national household surveys conducted between 2015 and 2019 to calculate socioeconomic deprivation status. We assessed the coverage of reproductive and maternal health interventions, using three indicators: (i) demand for family planning satisfied with modern methods; (ii) women who received antenatal care in at least four visits; and (iii) the presence of a skilled attendant at delivery. Absolute and relative inequalities were evaluated both directly and using the slope index of inequality and the concentration index. Findings In the 73 countries and territories with available data, the median proportions of deprivation were 41% in the low-income category, 11% in the lower-middle-income category and less than 1% in the upper-middle-income category. The coverage analysis, conducted for 48 countries with sufficient data, showed consistently lower median coverage among deprived households across all health indicators. The coverage of skilled attendant at delivery showed the largest inequalities, where coverage among the socioeconomically deprived was substantially lower in almost all countries. Antenatal care visits and demand for family planning satisfied with modern methods also showed significant disparities, favouring the less deprived population. Conclusion The findings highlight persistent disparities in the coverage of reproductive and maternal health interventions, requiring efforts to reduce those disparities and improve coverage, particularly for skilled attendant at delivery.