Do interventions that improve immunisation uptake also reduce social inequalities in uptake?

Trends and determinants of vaccination among children aged 06-59 months in Bangladesh: country representative survey from 1993 to 2014

Background

Vaccination has important consequences for childhood development, mortality, and inequalities in health and well-being. This research explores the trend of vaccinations coverage from 1993 to 2014 and determines the significant factors for vaccinations coverage in Bangladesh, considering geospatial, socioeconomic, and demographic characteristics.

Methods

This study uses a secondary dataset extracted from the Bangladesh Demographic and Health Survey (BDHS) from 1992 to 93 to 2014. The association between selected independent variables and vaccination coverage of children was examined through the Chi-square test. In addition, unadjusted and adjusted logistic regression approaches were applied to determine the effects of covariates on vaccination status by using the BDHS-2014 dataset.

Results

The results reveal that the trend of the vaccination coverage rate has gradually been increased over the study period. The coverage rate of BCG is observed maximum while the lowest for Measles vaccination among all types of vaccinations. The findings revealed that the significantly lower coverage of all vaccination had been observed in the Sylhet region. Children of higher educated mothers (OR 10.21; CI: 4.10–25.37) and father (OR 8.71; CI: 4.03–18.80), born at health facilities (OR 4.53; CI: 2.4–8.55) and whose mother has media exposure (OR 3.20; CI: 2.22–4.60) have more chance of receiving BCG vaccine. For DPT vaccination coverage, there is a significant difference from children whose mothers have primary (OR 1.7; CI: 1.35–2.15), secondary (OR 3.5; CI: 2.75–4.45), and higher (OR 9.6; CI: 5.28–17.42) educational qualification compared to children of illiterate mothers. Findings demonstrated that children born in wealthier households have a higher likelihood of being immunized against DPT, Polio, and Measles vaccination than children born in the poorest households.

Conclusions

The findings reveal that to enhance and make sustainable the overall country’s vaccination coverage, we should pay more attention to the mother’s education, socioeconomic condition, children’s age, birth order number, having media exposure, place of residence, and religion. The authors think that this finding would be helpful to accelerate the achievement target of Sustainable Development Goals (SDGs) for children’s health in Bangladesh.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11576-0.

Effective interventions to increase routine childhood immunization coverage in low socioeconomic status communities in developed countries: A systematic review and critical appraisal of peer-reviewed literature

OBJECTIVES

Childhood immunization coverage rates are known to be disproportionate according to population's socioeconomic status (SES). This systematic review examined and appraised quality of interventions deemed effective to increase routine childhood immunization uptake in low SES populations in developed countries.

METHODS

A literature search was conducted using Medline, Embase, CINAHL, EBMR, PsycInfo, PubMed, and Health STAR. We systematically searched and critically appraised articles published between January 1990 and December 2019 using the Effective Public Health Practice Project Quality Assessment tool. This systematic review provides a synthesis of the available evidence for childhood immunization interventions deemed effective for low SES parents or families of children ≤ 5 years of age.

SYNTHESIS

The search yielded 3317 records, of which 2975 studies met the inclusion criteria. From the 100 relevant studies, a total of 40 were included. The majority of effective and strongly rated studies synthesized consisted of multi-component interventions. Such interventions addressed access, community-based mobilization, outreach, appointment reminders, education, clinical tracking and incentives, and were language and health literacy appropriate to support low SES parents. Improving access to low SES parents was deemed effective in the vast majority of strongly rated studies. Incorrect contact information of low SES parents due to increased social mobility (i.e. household moves) rendered reminders ineffective, and therefore, updating contact information should be pursued proactively by front-line healthcare providers. In addition, plain language communication with low SES parents regarding immunization was deemed effective in improving immunization uptake.

CONCLUSION

Comprehensive multi-component interventions including improved access, appointment reminders, education and precision health communication are effective for addressing health inequities in immunization coverage amongst marginalized populations. Most low SES parents still believe that the benefits of immunization outweigh the risks.

Inequality in measles vaccination coverage in the "big six" countries of the WHO South-East Asia region

The "big six" countries (Bangladesh, India, Indonesia, Myanmar, Nepal, and Thailand) in the World Health Organization South-East Asia Region (WHO SEAR) are currently facing severe challenges in measles elimination and consequent childhood mortality reduction, with inadequacies and inequalities in the coverage of the measles-containing-vaccine first-dose (MCV1) being major obstacles. However, these issues of inequality in MCV1 coverage have not yet been systematically examined. We used data from the latest Demographic and Health Surveys and Multiple Indicator Cluster Surveys. To provide a comprehensive picture of existing MCV1 coverage gaps, data were disaggregated by geographic location, as well as by socioeconomic and nutritional dimensions. National MCV1 coverage ranged from 77% in Myanmar to 92% in Thailand. Only nine of the 104 sub-national districts had achieved the 95% MCV1 coverage goal as set by the WHO. Geographic inequalities were more pronounced in countries with lower coverage levels. Areas in clusters with poor MCV1 coverage performances as well as disadvantaged socioeconomic profiles require increased attention. Inequalities were evident in all countries, except Thailand, and were more pronounced in the sectors of wealth, education, antenatal care (ANC) status, and vitamin A supplementation (VAS) when compared against the areas of gender and urban/rural residence. Wealth-related inequality in Bangladesh, education-related inequality in Indonesia, ANC-related inequalities in Myanmar and Nepal, and VAS-related inequalities in Indonesia and Myanmar were all noteworthy. Equity-oriented changes in policies focusing on health promotion and integrated interventions among disadvantaged populations need to be implemented in order to increase MCV1 coverage and reduce childhood mortality.

The effects of public health policies on health inequalities in high-income countries: an umbrella review

BACKGROUND

Socio-economic inequalities are associated with unequal exposure to social, economic and environmental risk factors, which in turn contribute to health inequalities. Understanding the impact of specific public health policy interventions will help to establish causality in terms of the effects on health inequalities.

METHODS

Systematic review methodology was used to identify systematic reviews from high-income countries that describe the health equity effects of upstream public health interventions. Twenty databases were searched from their start date until May 2017. The quality of the included articles was determined using the Assessment of Multiple Systematic Reviews tool (AMSTAR).

RESULTS

Twenty-nine systematic reviews were identified reporting 150 unique relevant primary studies. The reviews summarised evidence of all types of primary and secondary prevention policies (fiscal, regulation, education, preventative treatment and screening) across seven public health domains (tobacco, alcohol, food and nutrition, reproductive health services, the control of infectious diseases, the environment and workplace regulations). There were no systematic reviews of interventions targeting mental health. Results were mixed across the public health domains; some policy interventions were shown to reduce health inequalities (e.g. food subsidy programmes, immunisations), others have no effect and some interventions appear to increase inequalities (e.g. 20 mph and low emission zones). The quality of the included reviews (and their primary studies) were generally poor and clear gaps in the evidence base have been highlighted.

CONCLUSIONS

The review does tentatively suggest interventions that policy makers might use to reduce health inequalities, although whether the programmes are transferable between high-income countries remains unclear.

TRIAL REGISTRATION

PROSPERO registration number: CRD42016025283.

Under-vaccinated groups in Europe and their beliefs, attitudes and reasons for non-vaccination; two systematic reviews

BACKGROUND

Despite effective national immunisation programmes in Europe, some groups remain incompletely or un-vaccinated ('under-vaccinated'), with underserved minorities and certain religious/ideological groups repeatedly being involved in outbreaks of vaccine preventable diseases (VPD). Gaining insight into factors regarding acceptance of vaccination of 'under-vaccinated groups' (UVGs) might give opportunities to communicate with them in a trusty and reliable manner that respects their belief system and that, maybe, increase vaccination uptake. We aimed to identify and describe UVGs in Europe and to describe beliefs, attitudes and reasons for non-vaccination in the identified UVGs.

METHODS

We defined a UVG as a group of persons who share the same beliefs and/or live in socially close-knit communities in Europe and who have/had historically low vaccination coverage and/or experienced outbreaks of VPDs since 1950. We searched MEDLINE, EMBASE and PsycINFO databases using specific search term combinations. For the first systematic review, studies that described a group in Europe with an outbreak or low vaccination coverage for a VPD were selected and for the second systematic review, studies that described possible factors that are associated with non-vaccination in these groups were selected.

RESULTS

We selected 48 articles out of 606 and 13 articles out of 406 from the first and second search, respectively. Five UVGs were identified in the literature: Orthodox Protestant communities, Anthroposophists, Roma, Irish Travellers, and Orthodox Jewish communities. The main reported factors regarding vaccination were perceived non-severity of traditional "childhood" diseases, fear of vaccine side-effects, and need for more information about for example risk of vaccination.

CONCLUSIONS

Within each UVG identified, there are a variety of health beliefs and objections to vaccination. In addition, similar factors are shared by several of these groups. Communication strategies regarding these similar factors such as educating people about the risks associated with being vaccinated versus not being vaccinated, addressing their concerns, and countering vaccination myths present among members of a specific UVG through a trusted source, can establish a reliable relationship with these groups and increase their vaccination uptake. Furthermore, other interventions such as improving access to health care could certainly increase vaccination uptake in Roma and Irish travellers.

Forecasted trends in vaccination coverage and correlations with socioeconomic factors: a global time-series analysis over 30 years

BACKGROUND

Incomplete immunisation coverage causes preventable illness and death in both developing and developed countries. Identification of factors that might modulate coverage could inform effective immunisation programmes and policies. We constructed a performance indicator that could quantitatively approximate measures of the susceptibility of immunisation programmes to coverage losses, with an aim to identify correlations between trends in vaccine coverage and socioeconomic factors.

METHODS

We undertook a data-driven time-series analysis to examine trends in coverage of diphtheria, tetanus, and pertussis (DTP) vaccination across 190 countries over the past 30 years. We grouped countries into six world regions according to WHO classifications. We used Gaussian process regression to forecast future coverage rates and provide a vaccine performance index: a summary measure of the strength of immunisation coverage in a country.

FINDINGS

Overall vaccine coverage increased in all six world regions between 1980 and 2010, with variation in volatility and trends. Our vaccine performance index identified that 53 countries had more than a 50% chance of missing the Global Vaccine Action Plan (GVAP) target of 90% worldwide coverage with three doses of DTP (DTP3) by 2015. These countries were mostly in sub-Saharan Africa and south Asia, but Austria and Ukraine also featured. Factors associated with DTP3 immunisation coverage varied by world region: personal income (Spearman's ρ=0·66, p=0·0011) and government health spending (0·66, p<0·0001) were informative of immunisation coverage in the Eastern Mediterranean between 1980 and 2010, whereas primary school completion was informative of coverage in Africa (0·56, p<0·0001) over the same period. The proportion of births attended by skilled health staff correlated significantly with immunisation coverage across many world regions.

INTERPRETATION

Our vaccine performance index highlighted countries at risk of failing to achieve the GVAP target of 90% coverage by 2015, and could aid policy makers' assessments of the strength and resilience of immunisation programmes. Weakening correlations with socioeconomic factors show a need to tackle vaccine confidence, whereas strengthening correlations point to clear factors to address.

FUNDING

UK Engineering and Physical Sciences Research Council.

Effect of socioeconomic deprivation on uptake of measles, mumps and rubella vaccination in Liverpool, UK over 16 years: a longitudinal ecological study

Suboptimal uptake of the measles, mumps and rubella (MMR) vaccine by certain socioeconomic groups may have contributed to recent large measles outbreaks in the UK. We investigated whether socioeconomic deprivation was associated with MMR vaccine uptake over 16 years. Using immunization data for 72,351 children born between 1995 and 2012 in Liverpool, UK, we examined trends in vaccination uptake. Generalized linear models were constructed to examine the relative effect of socioeconomic deprivation and year of birth on MMR uptake. Uptake of MMR1 by age 24 months ranged between 82·5% in 2003 [95% confidence interval (CI) 81·2-83·7] and 93·4% in 2012 (95% CI 92·7-94·2). Uptake of MMR2 by age 60 months ranged between 65·3% (95% CI 64·4-67·4) in 2006 and 90·3% (95% CI 89·4-91·2) in 2012. In analysis adjusted for year of birth and sex, children in the most deprived communities were at significantly greater risk of not receiving MMR1 [risk ratio (RR) 1·70, 95% CI 1·45-1·99] and MMR2 (RR 1·36, 95% CI 1·22-1·52). Higher unemployment and lower household income were significantly associated with low uptake. Contrary to concerns about lower MMR uptake in affluent families, over 16 years, children from the most socioeconomically deprived communities have consistently had the lowest MMR uptake. Targeted catch-up campaigns and strategies to improve routine immunization uptake in deprived areas are needed to minimize the risk of future measles outbreaks.

A framework for evaluating the impact of obesity prevention strategies on socioeconomic inequalities in weight

We developed a theoretical framework to organize obesity prevention interventions by their likely impact on the socioeconomic gradient of weight. The degree to which an intervention involves individual agency versus structural change influences socioeconomic inequalities in weight. Agentic interventions, such as standalone social marketing, increase socioeconomic inequalities. Structural interventions, such as food procurement policies and restrictions on unhealthy foods in schools, show equal or greater benefit for lower socioeconomic groups. Many obesity prevention interventions belong to the agento-structural types of interventions, and account for the environment in which health behaviors occur, but they require a level of individual agency for behavioral change, including workplace design to encourage exercise and fiscal regulation of unhealthy foods or beverages. Obesity prevention interventions differ in their effectiveness across socioeconomic groups. Limiting further increases in socioeconomic inequalities in obesity requires implementation of structural interventions. Further empirical evaluation, especially of agento-structural type interventions, remains crucial.

Geographical inequalities in use of improved drinking water supply and sanitation across Sub-Saharan Africa: mapping and spatial analysis of cross-sectional survey data

BACKGROUND

Understanding geographic inequalities in coverage of drinking-water supply and sanitation (WSS) will help track progress towards universal coverage of water and sanitation by identifying marginalized populations, thus helping to control a large number of infectious diseases. This paper uses household survey data to develop comprehensive maps of WSS coverage at high spatial resolution for sub-Saharan Africa (SSA). Analysis is extended to investigate geographic heterogeneity and relative geographic inequality within countries.

METHODS AND FINDINGS

Cluster-level data on household reported use of improved drinking-water supply, sanitation, and open defecation were abstracted from 138 national surveys undertaken from 1991-2012 in 41 countries. Spatially explicit logistic regression models were developed and fitted within a Bayesian framework, and used to predict coverage at the second administrative level (admin2, e.g., district) across SSA for 2012. Results reveal substantial geographical inequalities in predicted use of water and sanitation that exceed urban-rural disparities. The average range in coverage seen between admin2 within countries was 55% for improved drinking water, 54% for use of improved sanitation, and 59% for dependence upon open defecation. There was also some evidence that countries with higher levels of inequality relative to coverage in use of an improved drinking-water source also experienced higher levels of inequality in use of improved sanitation (rural populations r = 0.47, p = 0.002; urban populations r = 0.39, p = 0.01). Results are limited by the quantity of WSS data available, which varies considerably by country, and by the reliability and utility of available indicators.

CONCLUSIONS

This study identifies important geographic inequalities in use of WSS previously hidden within national statistics, confirming the necessity for targeted policies and metrics that reach the most marginalized populations. The presented maps and analysis approach can provide a mechanism for monitoring future reductions in inequality within countries, reflecting priorities of the post-2015 development agenda. Please see later in the article for the Editors' Summary.

The effectiveness of telephone reminders and home visits to improve measles, mumps and rubella immunization coverage rates in children

INTRODUCTION

In the Saskatoon Health Region (Saskatchewan), only 67.4% of children overall are fully immunized for measles, mumps and rubella (MMR) at 24 months of age, with only 43.7% of low-income children fully immunized.

METHODS

Parents of children who were behind in MMR immunizations were contacted to determine knowledge about, beliefs toward and barriers to immunization. The effectiveness of a telephone reminder system in improving immunization rates in a health region compared with a control health region was determined. Finally, the effectiveness of telephone reminders versus telephone reminders combined with home visits in improving child immunization coverage rates in low-income neighbourhoods was compared.

RESULTS

The survey was completed by 629 parents (69% response rate). Of those, 81.8% were not aware that their child was behind in immunizations. In the Saskatoon Health Region, the MMR immunization coverage increased from 67.4% to 74.0% in the first year of intervention (rate ratio = 1.10; 95% CI 1.08 to 1.12). All four neighbourhood groupings (three urban by income and one rural) had relative increases ranging from 9% to 11%. The control health region observed an immunization coverage increase from 66.5% to 69.2% in the first year (rate ratio = 1.04; 95% CI 1.01 to 1.07). The three low-income neighbourhoods with only telephone reminders had an immunization coverage rate of 48.7% (95% CI 39.5% to 57.8%). The three low-income neighbourhoods that received a telephone reminder and home visit had an immunization coverage rate of 60.5% (95% CI 52.5% to 68.6%).

CONCLUSION

Telephone reminder systems have some benefit in increasing child immunization coverage rates.

Impact of the GP contract on inequalities associated with influenza immunisation: a retrospective population-database analysis

BACKGROUND

Influenza immunisation is recommended for all people aged ≥65 years and younger people with particular chronic diseases. The Quality and Outcomes Framework (QOF) has provided new financial incentives for influenza immunisation since 2004.

AIM

To determine the impact of the 2004 UK General Medical Services contract on the overall uptake of, and socioeconomic inequalities associated with, influenza immunisation.

DESIGN AND SETTING

Retrospective general-practice population database analysis in 15 general practices in Scotland, UK.

METHOD

Changes in influenza-immunisation uptake for those in at-risk groups between 2003-2004 and 2006-2007 were measured, and variation in uptake examined using multilevel modelling.

RESULTS

Uptake rose from 67.9% in 2003-2004 to 71.4% in 2006-2007. The largest increases were seen in those aged <65 years with chronic disease, with uptake rising from 49.6% to 58.4%, but rates remained considerably lower than in those aged ≥65 years. Differences between practices narrowed (median odds ratio [OR] for two patients randomly selected from different practices: 2.13 (95% confidence interval [CI] = 2.00 to 2.26) in 2003-2004 versus 1.44 (95% CI = 1.40 to 1.49) in 2006-2007. However, inequalities in uptake by patient socioeconomic status did not change: adjusted OR for most deprived versus most affluent was 0.75 (95% CI = 0.70 to 0.80) in 2003-2004 versus 0.72 (95% CI = 0.68 to 0.76) in 2006-2007.

CONCLUSION

Overall uptake rose significantly and differences between practices narrowed considerably. However, socioeconomic and age inequalities in influenza immunisation persisted in the first 3 years of the QOF. This contrasts with other ecological analyses, which have concluded that the QOF has reduced inequalities. The impact of financial incentives on inequalities is likely to vary, and some kinds of care may require more targeted improvement activity and support.

Disparity in childhood immunizations

BACKGROUND

Incomplete immunization coverage is common in low-income families and Aboriginal children in Canada.

OBJECTIVE

To determine whether child immunization coverage rates at two years of age were lower in low-income neighbourhoods of Saskatoon, Saskatchewan.

METHODS

Parents who were and were not behind in child immunization coverage were contacted to determine differences in knowledge, beliefs and opinions on barriers and solutions. A multivariate regression model was designed to determine whether Aboriginal cultural status was associated with being behind in childhood immunizations after controlling for low-income status.

RESULTS

Reviewing the past five years in Saskatoon, the six low-income neighbourhoods had complete child immunization coverage rates of 43.7% (95% CI 41.2 to 45.9) for measles-mumps-rubella, and 42.6% (95% CI 40.1 to 45.1) for diphtheria, pertussis, tetanus, polio and Haemophilus influenzae type B. The five affluent neighbourhoods had 90.6% (95% CI 88.9 to 92.3) immunization coverage rates for measles-mumps-rubella, and 78.6% (95% CI 76.2 to 81.0) for diphtheria, pertussis, tetanus, polio and H influenzae type B. Parents who were behind in immunization coverage for their children were more likely to be single, of Aboriginal or other (non-Caucasian or non-Aboriginal) cultural status, have lower family income and have significant differences in reported beliefs, barriers and potential solutions. In the final regression model, Aboriginal cultural status was no longer associated with lower immunization status.

INTERPRETATION

Child immunization coverage rates in Saskatoon's six low-income neighbourhoods were approximately one-half the rate of the affluent neighbourhoods. The covariates with the strongest independent association with complete childhood immunization status were low income and other cultural status. Aboriginal cultural status was not associated with low child immunization rates after controlling for income status.

Childhood swine flu vaccination uptake in a Welsh general practice: a prospective study

BACKGROUND

Immunisation of infants is effective and benefits the health of the children immunised as well as the community where uptake is high. Any social inequality in uptake will worsen any social inequalities that already exist.

AIM

To investigate the demographic characteristics of families attending for swine flu vaccination.

DESIGN AND SETTING

A prospective study in a semi-rural general practice in South Wales.

METHOD

Data were collected by questionnaire, and logistic regression models were used to test for associations between potential risk factors (including family demographic characteristics and the child's previous vaccination history) and swine flu vaccination uptake.

RESULTS

No evidence was found of any significant associations between potential risk factors and the outcome.

CONCLUSION

This suggests that social inequality did not affect vaccination uptake in this sample.

A hierarchical analysis of social determinants of measles vaccination coverage in Austrian schoolchildren

BACKGROUND

Numerous socio-economic and demographic factors have been identified as being associated with low vaccination coverage in children. However, the complex interrelation between these factors is not fully understood. We focused our study on the less well-established associations of familial resources for child care with vaccination coverage and their interrelationship with socio-demographic factors.

METHODS

This cross-sectional study (n = 2386) focuses on parental social status and on resources for child care as determinants of measles vaccination coverage of schoolchildren aged 6-13 years in Styria, Austria. In order to reveal the relationships among these factors, an analysis based on a conceptual hierarchical model was performed. The so-called graphical modelling approach was used for the multivariate analysis of the hierarchically structured determinants.

RESULTS

The findings indicate that vaccination coverage is directly associated with a large number of children in the family (P < 0.0001) and directly as well as indirectly associated with a low level of education of the father (P < 0.001). All other included child-care resources are only indirectly associated with a low coverage, whereby the number of children acts as main mediating factor.

CONCLUSIONS

The results suggest that vaccination programmes should mainly focus on families with many children or parents of low educational level and not on the whole population.

Explicit incorporation of equity considerations into economic evaluation of public health interventions

Health equity is one of the main avowed objectives of public health policy across the world. Yet economic evaluations in public health (like those in health care more generally) continue to focus on maximizing health gain. Health equity considerations are rarely mentioned. Health economists rely on the quasi-egalitarian value judgment that ‘a QALY is a QALY’ – that is QALYs are equally weighted and the same health outcome is worth the same no matter how it is achieved or to whom it accrues. This value judgment is questionable in many important circumstances in public health. For example, policy-makers may place rather little value on health outcomes achieved by infringing individual liberties or by discriminating on the basis of age, sex, or race. Furthermore, there is evidence that a majority of the general public wish to give greater weight to health gains accruing to children, the severely ill, and, to a lesser extent, the socio-economically disadvantaged. This paper outlines four approaches to explicit incorporation of equity considerations into economic evaluation in public health: (i) review of background information on equity, (ii) health inequality impact assessment, (iii) analysis of the opportunity cost of equity, and (iv) equity weighting of health outcomes. The first three approaches can readily be applied using standard methods of health technology assessment, where suitable data are available; whereas approaches for generating equity weights remain experimental. The potential benefits of considering equity are likely to be largest in cases involving: (a) interventions that target disadvantaged individuals or communities and are also relatively cost-ineffective and (b) interventions to encourage lifestyle change, which may be relatively ineffective among ‘hard-to-reach’ disadvantaged groups and hence may require re-design to avoid increasing health inequalities.

Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework

BACKGROUND

The quality and outcomes framework is a financial incentive scheme that remunerates general practices in the UK for their performance against a set of quality indicators. Incentive schemes can increase inequalities in the delivery of care if practices in affluent areas are more able to respond to the incentives than are those in deprived areas. We examined the relation between socioeconomic inequalities and delivered quality of clinical care in the first 3 years of this scheme.

METHODS

We analysed data extracted automatically from clinical computing systems for 7637 general practices in England, data from the UK census, and data for characteristics of practices and patients from the 2006 general medical statistics database. Practices were grouped into equal-sized quintiles on the basis of area deprivation in their locality. We calculated overall levels of achievement, defined as the proportion of patients who were deemed eligible by the practices for whom the targets were achieved, for 48 clinical activity indicators during the first 3 years of the incentive scheme (from 2004-05 to 2006-07).

FINDINGS

Median overall reported achievement was 85.1% (IQR 79.0-89.1) in year 1, 89.3% (86.0-91.5) in year 2, and 90.8% (88.5-92.6) in year 3. In year 1, area deprivation was associated with lower levels of achievement, with median achievement ranging from 86.8% (82.2-89.6) for quintile 1 (least deprived) to 82.8% (75.2-87.8) for quintile 5 (most deprived). Between years 1 and 3, median achievement increased by 4.4% for quintile 1 and by 7.6% for quintile 5, and the gap in median achievement narrowed from 4.0% to 0.8% during this period. Increase in achievement during this time was inversely associated with practice performance in previous years (p<0.0001), but was not associated with area deprivation (p=0.062).

INTERPRETATION

Our results suggest that financial incentive schemes have the potential to make a substantial contribution to the reduction of inequalities in the delivery of clinical care related to area deprivation.

Selection bias in enrollment to a programme aimed at the secondary prevention of ischaemic heart disease in general practice: a cohort study

OBJECTIVE

To evaluate differences between adults who participated in a secondary prevention of ischaemic heart disease (IHD) programme and those who did not.

DESIGN

Population-based cohort study.

SETTING

A random selection of 12 Irish general practices.

PARTICIPANTS

A total of 493 adults with IHD identified in 2000/2001.

INTERVENTION

Medical records search and postal questionnaires in 2000/2001 and 2005/2006.

MAIN OUTCOME MEASURES

Differences in demographic characteristics and indicators of process of care and risk factor management between participants and non-participants.

RESULTS

Multiple logistic regression confirmed that female gender was associated with a reduced likelihood of participation in the secondary prevention programme [odds ratio (OR) 0.53 (95% CI: 0.32-0.87)], while an adequately controlled total cholesterol level was associated with an increased likelihood of enrollment [OR 1.82 (95% CI: 1.18-2.80)].

CONCLUSIONS

There is limited evidence that biases, which have been shown to affect participation in research, also affect participation in care programmes in everyday practice. A gender bias appears to have affected the enrollment of participants for the secondary preventive programme considered by this study, with enrollment favouring men with well-managed cholesterol. Reimbursement dependent upon patient adherence may incentivise the enrollment of adherent patients, although the influence of patient choice is unclear: the need to maintain records relating to patients who opt out of such interventions is thus highlighted.

Vaccine uptake: New tools for investigating changes in age distribution and predicting final values

Knowing the age at which children are immunised, and detecting any changes gives important insight into aspects of parental decision-making and health service delivery. Estimating likely final vaccine uptake is also important; to ensure adequate population protection and indicate if any additional immunisation activity is required. We present two new applications of existing methodologies to facilitate these aims. Firstly, to enable easier visualisation of age at vaccine uptake, we have applied the technique of Kernel density estimates to detecting potential delays in childhood vaccination. Secondly, we present a method for predicting likely final vaccine uptake, from early data. Both give vital policy information on, for example, new vaccines and existent programmes, such as MMR vaccination.

Targeting services to reduce social inequalities in utilisation: an analysis of breast cancer screening in New South Wales

BACKGROUND

Many jurisdictions have used public funding of health care to reduce or remove price at the point of delivery of services. Whilst this reduces an important barrier to accessing care, it does nothing to discriminate between groups considered to have greater or fewer needs. In this paper, we consider whether active targeted recruitment, in addition to offering a 'free' service, is associated with a reduction in social inequalities in self-reported utilization of the breast screening services in NSW, Australia.

METHODS

Using the 1997 and 1998 NSW Health Surveys we estimated probit models on the probability of having had a screening mammogram in the last two years for all women aged 40-79. The models examined the relative importance of socio-economic and geographic factors in predicting screening behaviour in three different needs groups - where needs were defined on the basis of a woman's age.

RESULTS

We find that women in higher socio-economic groups are more likely to have been screened than those in lower groups for all age groups. However, the socio-economic effect is significantly less among women who were in the actively targeted age group.

CONCLUSION

This indicates that recruitment and follow-up was associated with a modest reduction in social inequalities in utilisation although significant income differences remain.

Age, sex, material deprivation and respiratory mortality

The aim of this study was to examine the effects of age, sex and social deprivation on mortality rates for respiratory infection. An ecological study was undertaken, using official public health mortality data and population census data for the West Midlands health region, UK. Postcodes at the time of death were used to assign Townsend deprivation scores and the resulting deprivation quintile. Poisson regression analysis was used to estimate the association between respiratory mortality, deprivation quintile, age and sex. In most age groups there was a statistically significant trend of increasing mortality with increasing deprivation. The relative risk for the most deprived was highest in the 45-64 year age-group (RR=4.4, 95% CI 4.0, 4.8). However, the absolute risks were greater in those aged 75-84 years (RR=1.3, 95% CI 1.3, 1.4) where the annual death rate was 669 per 100,000. Consistently higher mortality rates were seen in males. These results suggest that the risk of mortality from respiratory infection varies by sex and generally increases with increasing age and deprivation quintile. The identified association between deprivation and mortality from respiratory infections is consistent with the effect of deprivation on many other diseases. Addressing the social determinants of ill health may help to reduce the high burden of respiratory mortality in the UK. However, individual level studies and examination of other areas are needed to explain the mechanisms by which deprivation increases the risk of mortality from respiratory infection, and thereby identify target groups for effective interventions.

Impact of adverse publicity on MMR vaccine uptake: a population based analysis of vaccine uptake records for one million children, born 1987-2004

AIMS

To determine the impact of adverse publicity on MMR uptake and measles susceptibility, including whether vaccination is delayed and the role of deprivation.

METHODS

A population database for all Scotland containing immunisation records for over one million children (n = 1,079,327) born 1987-2004 was analysed. MMR uptake was determined by birth cohort and deprivation category. "Final" uptake (at approx age 6 years) was predicted by linear regression by birth cohort. Measles susceptibility in 1998 and 2003 was determined by postcode sector and district for cohorts combined to construct nursery and primary school age groups.

RESULTS

There is evidence of a slight rise in late uptake, but insufficient to compensate for underlying declines. Late vaccination continues to be associated with deprivation, while the most affluent tend to be vaccinated promptly, or not at all. Predicted figures for "final" MMR1 uptake are over 90%, but under 95%. Measles susceptibility has increased significantly in nursery children, with an eightfold rise in the number of districts with greater than 20% susceptibility in this group (from 3 to 25).

CONCLUSIONS

Increased measles susceptibility in nursery children is concerning, particularly in the most vulnerable areas. These figures are likely to increase in the future, as MMR uptake has not yet returned to the previous higher level. Increased susceptibility levels can also be expected in primary schools in the future, as levels of late uptake are insufficient to compensate. Predicted figures for "final" MMR1 uptake are under the herd immunity threshold and campaigns may be required to increase uptake among future primary school children.

Material deprivation, hospitalisation and adverse events temporally associated with immunisation

We examined hospital admissions for illness temporally associated with childhood immunisations to determine the influence of material deprivation. Children aged <5 years hospitalised in the West Midlands were identified using ICD10 codes (Y580-Y599) from April 1995 through March 2000. Material deprivation was measured using the Townsend score. Children from deprived areas were at increased risk (OR = 4.49, 95% CI 3.14-7.78) compared to children from affluent areas and, were more likely to be admitted following immunisation with pertussis vaccine (OR = 5.91, 95% CI 2.69-12.29). Further research is required to determine the contribution of healthcare providers and parents to this health differential.

Social deprivation and hospital admission for respiratory infection: an ecological study

STUDY OBJECTIVE

To examine the relationship between social deprivation and risk of hospital admission for respiratory infection.

METHODS AND SUBJECTS

Ecological study using hospital episode statistics and population census data. Cases were residents of the West Midlands Health Region admitted to hospital with a diagnosis of respiratory infection, acute respiratory infection, pneumonia or influenza over a 5-year period. Postcodes of cases were used to assign Townsend deprivation scores; these were then ranked and divided into five deprivation categories. Poisson regression analysis was used to estimate the magnitude of effect for associations between deprivation category and hospital admission by age and admitting diagnosis.

MAIN RESULTS

There were 136755 admissions for respiratory infection, equivalent to an annual admission rate of 27.1 per 1000 population (95% CI = 26.9-27.2). Deprivation was associated with increased admission rates for all respiratory infection (P < 0.0001) and affected all age-groups. The greatest effect was in the 0-4 years age-group with admission rates 91% higher in the most deprived children compared to the least deprived. Hospital admissions for acute respiratory infection and pneumonia were both significantly associated with deprivation (P < 0.0001).

CONCLUSIONS

Respiratory infection is associated with social inequalities in all age-groups, particularly in children. Prevention of respiratory infection could make an important contribution to reducing health inequalities.

Why do parents decide against immunization? The effect of health beliefs and health professionals

OBJECTIVES

To explore the knowledge, attitudes and concerns with respect to immunization and vaccine-preventable infections in parents whose children have not completed the recommended course of immunization.

SETTING

Parents of children resident in the London Borough of Hackney.

METHODS

Children born between 1 January 1999 and 15 February 1999 were identified from the child health database, and cases were defined as those who had defaulted for one or more primary immunization by 18 months of age. After validation of immunization status from health records, questionnaires were sent to parents. Ten respondents from this sample were interviewed.

RESULTS

Questionnaires were sent to 129 parents of children identified as not completing the recommended immunization course. Nine questionnaires were returned 'address unknown', and 76 parents returned the completed questionnaire. The response rate from known residents was 76/110 (69%). Eight parents stated that their child had been immunized, leaving 68 questionnaires available for further analysis. Measles, mumps, rubella (MMR) and meningococcal C were most frequently omitted, usually because of concerns about vaccine safety. Twenty-three out of 68 respondents perceived that having their child immunized with a particular vaccine was more risky than non-immunization, particularly for MMR and meningococcal C vaccines. Those who agreed to be interviewed were notably concerned about the MMR vaccine, but not immunization in general. They perceived the information provided by health professionals to be poor.

CONCLUSIONS

The decision-making process around childhood immunization is complex. Parents require information that is up to date, tailored to their individual needs and provided by health professionals who are well informed.

Cervical screening and health inequality in England in the 1990s

STUDY OBJECTIVE

s: To examine changing inequality in the coverage of cervical screening and its relation to organisational aspects of primary care and to inequality in cervical cancer incidence and mortality.

DESIGN

Retrospective time trends analysis (1991-2001) of screening coverage and cervical cancer incidence and mortality in England.

SETTING

The 99 district health authorities in England, as defined by 1999 boundaries were used to create a time series of incidence and mortality rates from cervical cancer per 100 000 population. A subset of 60 district health authorities were used to construct a time series of screening coverage data and GP and practice characteristics. Health authorities were categorised into one of three "deprivation" groups using the Townsend Deprivation Index.

PARTICIPANTS

Women aged <35 and 35-64 were selected from health authority populations as the main focus of the study.

RESULTS

Cervical cancer screening coverage was consistently higher in affluent areas from 1991-9 but ratio rates of inequality between affluent and deprived health authorities narrowed over time. The increase in coverage in deprived areas was most closely associated with an increase in the number of practice nurses. Cervical cancer incidence and mortality rates were consistently higher in deprived health authorities, but inequality decreased. Screening coverage and cervical cancer rates were highly negatively correlated in deprived health authorities.

CONCLUSION

A primary health care intervention such as an organised programme of cervical screening can contribute to reducing inequality in population health.

What are the most effective ways of improving population health through transport interventions? Evidence from systematic reviews

STUDY OBJECTIVE

To review systematic review literature that describes the effectiveness of transport interventions in improving population health.

METHODS

Systematic review methodology was used to evaluate published and unpublished systematic reviews in any language that described the measured health effects of any mode of transport intervention.

MAIN RESULTS

28 systematic reviews were identified. The highest quality reviews indicate that the most effective transport interventions to improve health are health promotion campaigns (to prevent childhood injuries, to increase bicycle and motorcycle helmet use, and to promote children's car seat and seatbelt use), traffic calming, and specific legislation against drink driving. Driver improvement and education courses are associated with increases in crash involvement and violations.

CONCLUSIONS

Systematic reviews are able to provide evidence about effective ways of improving health through transport related interventions and also identify well intentioned but harmful interventions. Valuable additional information may exist in primary studies and systematic reviews have a role in evaluating and synthesising their findings.

General practitioner services in primary care groups in England: is there inequity between service availability and population need?

This study examined the coverage of minor surgery, child health surveillance and chronic disease management for asthma and diabetes in relation to population need and key organisational features of general practice in the 481 primary care groups (PCGs) in England. PCG-level summary scores were developed to estimate the relative availability of all four services and their relative importance in discriminating between high and low levels of service provision. The coverage of services was widespread and, in such circumstances, there was no systematic evidence of poorer service availability for PCGs with higher population need (the 'inverse care' law). Rather this relation was localised, being most predominant for PCGs covering London and its suburbs. In these PCGs, there was no association between indicators of lack of capacity, such as single-handed practice, and levels of service provision.

Why reduce health inequalities?

It is well known that social, cultural and economic factors cause substantial inequalities in health. Should we strive to achieve a more even share of good health, beyond improving the average health status of the population? We examine four arguments for the reduction of health inequalities.1 Inequalities are unfair. Inequalities in health are undesirable to the extent that they are unfair, or unjust. Distinguishing between health inequalities and health inequities can be contentious. Our view is that inequalities become "unfair" when poor health is itself the consequence of an unjust distribution of the underlying social determinants of health (for example, unequal opportunities in education or employment).2 Inequalities affect everyone. Conditions that lead to marked health disparities are detrimental to all members of society. Some types of health inequalities have obvious spillover effects on the rest of society, for example, the spread of infectious diseases, the consequences of alcohol and drug misuse, or the occurrence of violence and crime.3 Inequalities are avoidable. Disparities in health are avoidable to the extent that they stem from identifiable policy options exercised by governments, such as tax policy, regulation of business and labour, welfare benefits and health care funding. It follows that health inequalities are, in principle, amenable to policy interventions. A government that cares about improving the health of the population ought therefore to incorporate considerations of the health impact of alternative options in its policy setting process.3 Interventions to reduce health inequalities are cost effective. Public health programmes that reduce health inequalities can also be cost effective. The case can be made to give priority to such programmes (for example, improving access to cervical cancer screening in low income women) on efficiency grounds. On the other hand, few programmes designed to reduce health inequalities have been formally evaluated using cost effectiveness analysis. We conclude that fairness is likely to be the most influential argument in favour of acting to reduce disparities in health, but the concept of equity is contested and susceptible to different interpretations. There is persuasive evidence for some outcomes that reducing inequalities will diminish "spill over" effects on the health of society at large. In principle, you would expect that differences in health status that are not biologically determined are avoidable. However, the mechanisms giving rise to inequalities are still imperfectly understood, and evidence remains to be gathered on the effectiveness of interventions to reduce such inequalities.

Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services

This paper presents the results of systematic reviews of the effectiveness, applicability, other effects, economic impact, and barriers to use of selected population-based interventions intended to improve vaccination coverage. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis for recommendations by the Task Force on Community Preventive Services (the Task Force) regarding the use of these selected interventions. The Task Force recommendations are presented on pp. 92-96 of this issue.

The distribution of health and income: a theoretical framework

A general framework is developed to analyse variations in the distribution of population health, where individual health is modelled as a function of income, conditional upon the level of another factor such as health-related behaviour. Results are derived for the response of the level of average health in a population and the degree of health inequality to alternative health promotion policies and equiproportionate income growth. Qualitative results are shown to depend on characteristics of the individual health production functions and the frequency distribution of the other factor at each income level. These results are independent of the distribution of income. The discussion focuses on the implications of these results for contemporary research into inequalities in health and income.

Does increased investment in coronary angiography and revascularisation reduce socioeconomic inequalities in utilisation?

OBJECTIVES

To investigate whether additional resources for tertiary cardiology services, aimed at increasing coronary angiography and revascularisation rates, can improve socioeconomic equity of utilisation.

DESIGN

Cross sectional ecological study, using the Super Profile classification of enumeration districts and ischaemic heart disease (IHD) standardised mortality ratios (SMR) as a proxy for need. The degree of equity before the provision of extra resources was determined using data for April 1992 to March 1994, and the corresponding picture after, using data for April 1994 to March 1996.

SETTING

South Humberside (United Health-Grimsby and Scunthorpe Health Authority, a district of the former Yorkshire Region, before the April 1996 boundary changes).

SUBJECTS

Patients with a primary diagnosis of IHD aged > or = 25 years who underwent investigation by angiography, or treatment by coronary artery bypass grafting or percutaneous transluminal coronary angioplasty, as a primary procedure.

MAIN RESULTS

In 1992/4, before concerted intervention, both investigation and revascularisation rates, although increasing, were low in Grimsby and Scunthorpe district compared with most other districts in the Yorkshire Region. Also, there was a decreasing trend across Super Profile Lifestyle groups from the Affluent Achievers to the Have-Nots despite a two-fold increase in SMRs indicating the greater need of the more deprived. After appointing a consultant general physician with an interest in cardiology in the Scunthorpe district general hospital in 1994; arranging for both the Grimsby physician and the Scunthorpe physician to undertake angiography at a neighbouring district tertiary cardiology centre in 1995; together with significant additional health authority investment in cardiac procedures in 1995/6, district rates increased considerably, (a 41% increase in investigation and a 47% increase in revascularisation rates). Also, after additional resource input began, the trend for angiographies across socioeconomic groups clearly became more equitable, although increased equity for revascularisations is less apparent.

CONCLUSION

Early indications are that additional resources for tertiary cardiology may have reduced socioeconomic inequities in angiography, without being specifically targeted at the needier, more deprived groups. Improvement in socioeconomic equity of utilisation of revascularisation is not yet clear, although data for April 1996 to March 1998 (after a lengthier intervention period) may confirm improved equity. Should this not be so, it might be necessary to specifically target resources to the deprived to increase equity in revascularisation.

Immunisation coverage at a well-baby clinic in the United Arab Emirates

The United Arab Emirates Survey of Immunisation Coverage by UNICEF in 1990 showed that the coverage for UAE infants up to one year of age was 60%. The objective of this study was to determine factors associated with attendance and immunisation uptake at a well-baby clinic. A birth cohort of 665 infants were selected and their records examined to determine the factors such as gender, distance of housing area from clinic and access to other primary health care facilities. Only 22% attended all the scheduled visits and 54.3% of the sample completed the immunisation program within the correct time. The distance the infant lived from the clinic was the only factor significantly affecting immunisation uptake. The identification and targeting of groups at high risk of delayed completion of the immunisation program is a necessary risk factor in improving future surveillance.

Randomised controlled trial of the use of a modified postal reminder card on the uptake of measles vaccination

OBJECTIVE

To determine whether rewording postal reminder cards according to the "health belief model", a theory about preventive health behaviour, would help to improve measles vaccination rates.

DESIGN

A randomised controlled trial, with blind assessment of outcome status. Parents of children due for their first measles vaccination were randomised to one of two groups, one receiving the health belief model reminder card, the other receiving the usual, neutrally worded card. The proportion of children subsequently vaccinated in each group over a five week period was ascertained from clinical (provider based) records.

SETTING

A local government operated public vaccination clinic.

PARTICIPANTS

Parents of 259 children due for measles vaccination.

MAIN RESULTS

The proportion of children vaccinated in the health belief model card group was 79% compared with 67% of those sent the usual card (95% CI, 2% to 23%), a modest but important improvement.

CONCLUSION

This study illustrates how the effectiveness of a minimal and widely practised intervention to promote vaccination compliance can be improved with negligible additional effort.

The use of targets to improve the performance of health care providers: a discussion of government policy

The aim of this discussion paper is to examine the advantages and drawbacks of employing targets, or performance indicators, to improve the performance of those delivering health care services. The paper is based on an examination of two target-setting policies initiated by Government: the 1992 Health of the Nation strategy and the 1990 General Practitioners' Contract. It is argued that the introduction of both the General Practitioners' Contract and the Health of the Nation have indeed been accompanied by improvements in performance, however, there are a number of problems with targets. They tend to focus on those things that are most easily measured, and they may foster complacency on the part of providers who have already achieved upper target limits, and defensiveness on the part of those performing badly. National targets may skew local priorities; they may also be unrealistic and unattainable for particular, less privileged population groups. They may serve to widen inequalities in health, and can exacerbate the 'inverse care law' by encouraging providers to direct their efforts at the more advantaged sections of society, where such efforts are more likely to pay off in terms of overall improvements in the target level achieved. Finally, the achievement of some targets will not necessarily result in better health outcomes. The paper concludes that a target-setting approach to improving the quality of care must be based on the use of appropriate indicators, and must take account of differences between more and less advantaged sections of society.

Casting the screening net: separating big fish from little fish

Screening tests are a rapidly growing part of medical practice. If we are going to make the best use of resources, screening tests need to be considered in terms of effectiveness, efficiency and equity. We present a framework as a way to think about screening programmes. The framework expands on existing literature that recognizes two categories of screening: universal and opportunistic. By adding the dimension of 'selectivity', we identify four categories of screening: active non-selective (universal or mass screening), active selective, opportunistic non-selective and opportunistic selective. We illustrate the framework by categorizing screening recommendations for high serum cholesterol levels. We conclude there is no one ideal strategy for screening that simultaneously satisfies criteria of effectiveness, efficiency and equity. However, our framework allows a systematic consideration and balancing of these objectives in the development and assessment of screening programs. In this way, it may assist decision-makers by making this trade-off more explicit.

Living conditions, inequalities in health, human rights and security: a European perspective in a global context

This paper examines the living conditions and inequalities affecting health, human rights and security in developed Western countries. Possible remedies based on experience in Sandwell Health District, West Midlands, are considered and analogies drawn with global initiatives.

A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health

OBJECTIVE

To review the available evidence in order to identify effective interventions which health services alone or in collaboration with other agencies could use to reduce inequalities in health.

METHODS

A search of the literature was undertaken using a number of databases including Medline (from 1990), Applied Social Science Index and Abstracts (1987-1994), and the System for Information on Grey Literature in Europe (1984-1994), on a large range of key words. Studies were included if they assessed interventions designed to reduce inequalities in health or improve the health of a population group relevant to the review, and could be carried out by a health service alone or in collaboration with other agencies. Only studies evaluating interventions using an experimental design were included. Papers in any language were considered. In addition, systematic reviews of the research on the effectiveness of health promotion and the treatment of conditions where there are significant health inequalities were identified in order to illustrate the potential for reducing inequalities in health.

RESULTS

94 studies were identified which satisfied all the inclusion criteria and 21 reviews were included. A number of interventions have been shown to improve the health of groups who are disadvantaged by socio-economic class, ethnicity or age and, if properly targeted, could be expected to reduce health inequalities. If a health intervention is being used, there should be evidence that it has an impact on health status. Attention should then be given to the way in which the intervention is delivered and the characteristics of a programme to promote implementation. Characteristics of successful interventions specifically aimed at reducing health differentials include: systematic and intensive approaches to delivering effective health care; improvement in access and prompts to encourage the use of services; strategies employing a combination of interventions and those involving a multi-disciplinary approach; ensuring interventions address the expressed or identified needs of the target population; and the involvement of peers in the delivery of interventions. However, these characteristics alone are not sufficient for success, nor are they universally necessary.

CONCLUSIONS

Although it is likely that the most significant contributions to reducing health inequalities will be in improving economic and social conditions and the physical environment, there are interventions which health services, either alone or in collaboration with other agencies, can use to reduce inequalities in health.

Primary care and health care reform: the need to reflect before reforming

The system of primary care in the UK National Health Service appears to have become popular amongst policy makers worldwide. This is surprising given the poor knowledge base regarding the care provided and its cost effectiveness. It is necessary for policy makers to identify which health care interventions are effective and cost effective, and develop knowledge about how behaviour can be changed and cost effective interventions adopted in routine medical practice. Trials of pharmaceuticals in primary care therapeutic areas reveal a poor knowledge base about clinical effectiveness and often fail to include economic aspects. Initiatives such as the UK general practice fundholding scheme, the general practitioner contract and the Health of the Nation targets were not based on empirical evidence and have not been subject to adequate evaluation. If health care reforms elsewhere are to include emphasis on primary care, policy goals must be clearly articulated and the knowledge base informing efficient delivery of primary care must be improved.

Equity in the NHS. Monitoring and promoting equity in primary and secondary care

Although need is often assumed to be the most important factor in determining the use of health services, there are many inequities in the provision and use of NHS services in both primary and secondary care. For example, existing data from district child health information services have been combined with census data for small areas to show wide variations in immunisation rates between affluent and deprived areas. Purchasers of health care are already responsible for assessing health needs and evaluating services, and the process of monitoring equity is a logical extension of these activities. Routine data sources used to collect activity data in both primary and secondary care can be used to assess needs for care and monitor how well these needs are met. Purchasers and providers should collaborate to improve the usefulness of these routine data and to develop a framework for monitoring and promoting equity more systematically.