Education-related Inequalities Research Articles

Measurement and decomposition of education-related inequality in exclusive breastfeeding practice among Ethiopian mothers: applying Wagstaff decomposition analysis

BackgroundHuman breast milk, a naturally balanced source of infant nutrition, promotes optimal growth and health when exclusively fed for 6 months. Exclusive breastfeeding reduces common childhood infections, provides protection against some chronic illnesses, and contributes to achieving several Sustainable Development Goals. Despite its benefits, only 58% of Ethiopian women practice it, and the associated education-related inequality is not well documented. Thus, this study aims to quantify and decompose the education-related inequality in exclusive breastfeeding practice among Ethiopian mothers.MethodsA total of 1,504 weighted samples were studied using a Performance Monitoring for Action Ethiopia longitudinal panel survey dataset (2021–2023). Wagstaff normalized concentration index and its concentration curve were used to assess education-related inequality in exclusive breastfeeding practice. Wagstaff decomposition analysis was performed to decompose the concentration index and identify factors contributing to the observed education-related inequality. Significance was declared at p-value <0.05.ResultsThe overall prevalence of exclusive breastfeeding among Ethiopian women was 57.29% (95% CI: 54.79, 59.80%), with a greater concentration found among women with lower levels of education. This indicates an inequality that favors less educated women (pro-less educated inequality), as demonstrated by the Wagstaff normalized concentration index of −0.058 (95% CI: −0.113, −0.002). Factors that made a significant contribution to the observed education-related inequality in exclusive breastfeeding practice were residence (18.80%), region (29.31%), place of birth (−7.38%), and the wantedness status of the indexed pregnancy (82.58%). The indexed pregnancy’s wantedness was made a more elastic (elasticity = 0.282) contribution.ConclusionThe study identified a small yet significant education-related inequality in exclusive breastfeeding, favoring less educated women. Hence, emphasis should be placed not only on educating women but also on healthy habits that they can leave behind when they learn. Residence, region, place of birth, and indexed pregnancy’s wantedness significantly contributed to the observed education-related inequality. The elasticity value for each factor suggests that policy changes addressing these factors could readily reduce the observed inequality.

Trends and inequalities in modern contraceptive use among women in Sierra Leone, 2008-2019.

Despite the known benefits of modern contraceptives in preventing unwanted pregnancies and reducing unsafe abortions, their use remains low among women of reproductive age in several sub-Saharan African countries, including Sierra Leone. This study investigated the inequalities in modern contraceptive use among women in Sierra Leone based on data from 2008 to 2019. We used data from the Sierra Leone Demographic Health Survey data rounds (2008, 2013, and 2019). The World Health Organization's Health Equity Assessment Toolkit (WHO's HEAT) software was used to calculate both simplemeasures; Difference (D) and Ratio (R) and complex measures of inequality: Population Attributable Risk (PAR) and Population Attributable Fraction (PAF). The inequality assessment was done for five stratifiers: age, economic status, level of education, place of residence, and sub-national province. The study found that the prevalence of modern contraceptive use among women in Sierra Leone increased from 6.7% in 2008 to 20.9% in 2019. There was an increase in age-related inequality from a Difference of 5.9percentage points in 2008 to 7.0percentage points in 2019. PAF decreased from 5.7% in 2008 to 1.6% in 2019, indicating that the national average of modern contraceptive use would have increased by 5.7% in 2008 and 1.6% in 2019in the absence of age-related inequalities. Foreconomic status, the Difference decreased from 14.9percentage points in 2008 to 9.9percentage points in 2019. PAF decreased from 166.3% in 2008 to 23.3% in 2019, indicating that the national average of modern contraceptive use would have increased by 166.3% in 2008 and 23.3%in 2019 inthe absence of economic-related inequalities. For education, theDifference decreased from 15.1percentage points in 2008 to 12.4percentage points in 2019. ThePAF shows that the national average of modern contraceptive use would have reduced from189.8% in 2008to 39.5%in 2019, in the absence of education-related inequality. With respect toplace of residence, theDifference decreased from 10.4percentage points in 2008 to 7.6percentage points in 2019, and PAF decreased from 111.2%in 2008 to 23.0% in 2019. The decline in PAF indicates that the national average of modern contraceptive use would have increased by 111.2% in 2008 and 23.0% in 2019without residence-related inequality. Provincial-related inequality decreased from aDifference of 15.5% in 2008 to 8.5% in 2019. ThePAF results showed adecrease in inequalityfrom 176.3% in 2008 to 16.7% in 2019, indicating that province would contribute 176.3% and 16.7% in 2008 and 2019 respectively to the national average of modern contraceptive use. The use of modern contraceptives among women of reproductive age in Sierra Leone increased between 2008 and 2019reflectingpositive progress in reproductive health initiatives and access to family planning resources.The reductions in inequalitiesrelated to economic status, education, residence, and provinceindicate that efforts to promote equity in contraceptive access are yielding results, although age-related inequalities persist. To build on these advancements, it is recommended that policymakers continue to strengthen educational campaigns and healthcare services, particularly targeting younger women. Additionally, enhancing access to contraceptive methods through community-based programs and addressing socio-economic barriers will be crucial in further reducing inequalities and improving overall reproductive health outcomes in Sierra Leone.

Wealth and education-related inequalities in the utilisation of reproductive, maternal, newborn, and child health interventions within scheduled tribes in India: an analysis of Odisha and Jharkhand

BackgroundThe utilisation of Reproductive, Maternal, Newborn and Child Health (RMNCH) services remains lower among the Scheduled Tribes (ST) in India than among the rest of the country’s population. The tribal population’s poorest and least-educated households are further denied access to RMNCH care due to the intersection of their social status, wealth, and education levels. The study analyses the wealth- and education-related inequalities in the utilisation of RMNCH services within the ST population in Odisha and Jharkhand.MethodologyWe have constructed two summary measures, namely, the Co-coverage indicator and a modified Composite Coverage Index (CC), to determine wealth- and education-related inequalities in the utilisation of RMNCH indicators within the ST population in Odisha and Jharkhand. The absolute and relative inequalities with respect to wealth and education within the ST population are estimated by employing the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII).ResultsThe results of the study highlight that access to RMNCH services is easier for women who are better educated and belong to wealthier households. The SII and RII values in the co-coverage indicator and modified CCI exhibit an increase in wealth-related inequalities in Odisha between NFHS-4 (2015-16) and NFHS-5 (2019-21) whereas in Jharkhand, the wealth- and education-related absolute and relative inequalities present a reduction between 2016 and 2021. Among the indicators, utilisation of vaccination was high, while the uptake of Antenatal Care Centre Visits and Vitamin A supplementation should be improved.InterpretationThe study results underscore the urgent need of targeted policies and interventions to address the inequalities in accessing RMNCH services among ST communities. A multi-dimensional approach that considers the socioeconomic, cultural and geographical factors affecting healthcare should be adopted while formulating health policies to reduce inequalities in access to healthcare.

The future burden of type 2 diabetes in Belgium: a microsimulation model

ObjectiveTo forecast the annual burden of type 2 diabetes and related socio-demographic disparities in Belgium until 2030.MethodsThis study utilized a discrete-event transition microsimulation model. A synthetic population was created using 2018 national register data of the Belgian population aged 0–80 years, along with the national representative prevalence of diabetes risk factors obtained from the latest (2018) Belgian Health Interview and Examination Surveys using Multiple Imputation by Chained Equations (MICE) as inputs to the Simulation of Synthetic Complex Data (simPop) model. Mortality information was obtained from the Belgian vital statistics and used to calculate annual death probabilities. From 2018 to 2030, synthetic individuals transitioned annually from health to death, with or without developing type 2 diabetes, as predicted by the Finnish Diabetes Risk Score, and risk factors were updated via strata-specific transition probabilities.ResultsA total of 6722 [95% UI 3421, 11,583] new cases of type 2 diabetes per 100,000 inhabitants are expected between 2018 and 2030 in Belgium, representing a 32.8% and 19.3% increase in T2D prevalence rate and DALYs rate, respectively. While T2D burden remained highest for lower-education subgroups across all three Belgian regions, the highest increases in incidence and prevalence rates by 2030 are observed for women in general, and particularly among Flemish women reporting higher-education levels with a 114.5% and 44.6% increase in prevalence and DALYs rates, respectively. Existing age- and education-related inequalities will remain apparent in 2030 across all three regions.ConclusionsThe projected increase in the burden of T2D in Belgium highlights the urgent need for primary and secondary preventive strategies. While emphasis should be placed on the lower-education groups, it is also crucial to reinforce strategies for people of higher socioeconomic status as the burden of T2D is expected to increase significantly in this population segment.

Trends of socioeconomic and geographic inequalities in severe wasting among under-five children in Ethiopia from 2000 to 2019: using the WHO Health Equity Assessment Toolkit

Severe wasting is the deadliest form of wasting caused by a lack of nutritious food and repeated attacks of illness. The World Health Assembly has agreed to reduce severe wasting to less than 5% and 3% by the end of 2025 and 2030. Significant disparities were observed worldwide in progress towards the goal. However, limited evidence of disparity in severe wasting was available in Ethiopia. Therefore, this study aimed to assess trends in socioeconomic and geographic inequalities in severe wasting among under-five children in Ethiopia between 2000 and 2019. The trend in socioeconomic and geographic inequality was assessed using the World Health Organization Health Equity Assessment Toolkit, employing both absolute and relative measures of inequality. Difference (D), ratio (R), slope index inequality (SII), relative concentration index (RCI), and population attributable ratio (PAR) were utilized to assess disparity across wealth, education, residence, and subnational regions. The 95% uncertainty interval (UI) was used to declare the significant change in inequality through time. The proportion of severe wasting increased from 3.8% to 4.7% between 2000 to 2005 and dropped to 2.9% in 2011 to remain constant until 2016. However, the proportion of severe wasting significantly declined to 1.1% in 2019. As indicated by RCI, significant fluctuation in wealth-related inequality was observed in all five survey years but a significant change in wealth-related inequality was observed in 2005 and 2019. Whereas the education-related inequality in RCI of severe wasting steadily increased from −8.8% in 2005 to −24.3% in 2019. And the change was significantly widened from 2011 to 2019. On the other hand, residence-related inequality of severe wasting was observed in 2000 in ratio, difference and PAR summary measures but disappeared in 2019. Between 2000 and 2016, regional inequalities in severe wasting fluctuated between 8.7 in 2005 to 5.9 in 2016 taking the difference as a measure of inequality. Overall, Wealth-related inequality has significantly widened over time with under five children from the richest households being less affected by severe wasting. Education-related inequality was not changed with under five children whose mothers had not attended formal education highly affected by severe wasting. Regional disparity in severe wasting is also exhibited in Ethiopia in all-round surveys with children from Addis Ababa being least affected whereas children from Somalia were highly affected by severe wasting. However, no significant disparity in the type of residence in severe wasting was revealed in Ethiopia. Therefore, special attention should be paid to under-five children living in the poorest households, whose mothers did not attend formal education and children living in Somalia region.

Gender-specific inequalities in coverage of Publicly Funded Health Insurance Schemes in Southern States of India: evidence from National Family Health Surveys

BackgroundPublicly Funded Health Insurance Schemes (PFHIS) are intended to play a role in achieving Universal Health Coverage (UHC). In countries like India, PFHISs have low penetrance and provide limited coverage of services and of family members within households, which can mean that women lose out. Gender inequities in relation to financial risk protection are understudied. Given the emphasis being placed on achieving UHC for all in India, this paper examined intersecting gender inequalities and changes in PFHIS coverage in southern India, where its penetrance is greater and of longer duration.Data and methodsThis study used the fourth (NFHS-4, 2015–16) and fifth (NFHS-5, 2019–21) rounds of India’s National Family Health Survey for five southern states: namely, Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and Telangana. The World Health Organization’s Health Equity Assessment Toolkit (HEAT) Plus and Stata were used to analyse PFHIS coverage disaggregated by seven dimensions of inequality. Ratios and differences for binary dimensions; Between Group Variance and Theil Index for unordered dimensions; Absolute and Relative Concentration Index (RCI) for ordered dimensions were computed separately for women and men.ResultsOverall, PFHIS coverage increased significantly (p < 0.001) among women and men in Andhra Pradesh, and Kerala from NFHS-4 to NFHS-5. Overall, men had higher PFHIS coverage than women, especially in Andhra Pradesh, Tamil Nadu, and Telangana in both surveys. In both absolute and relative terms, PFHIS coverage was concentrated among older women and men across all states; age-related inequalities were higher among women than men in both surveys in Andhra Pradesh, Kerala, and Telengana. The magnitude of education-related inequalities was twice as high as among women in Telangana (RCINFHS-4: -12.23; RCINFHS-5: -9.98) and Andhra Pradesh (RCINFHS-4: -8.05; RCINFHS-5: -7.84) as compared to men in Telangana (RCINFHS-4: -5.58; RCINFHS-5: -2.30) and Andhra Pradesh (RCINFHS-4: -4.40; RCINFHS-5: -3.12) and these inequalities remained in NFHS-5, suggesting that lower education level women had greater coverage. In the latter survey, a high magnitude of wealth-related inequality was observed in women (RCINFHS-4: -15.78; RCINFHS-5: -14.36) and men (RCINFHS-4: -20.42; RCINFHS-5: -13.84) belonging to Kerala, whereas this inequality has decreased from NFHS-4 to NFHS-5., again suggestive of greater coverage among poorer populations. Caste-related inequalities were higher in women than men in both surveys, the magnitude of inequalities decreased between 2015–16 and 2019–20.ConclusionsWe found gender inequalities in self-reported enrolment in southern states with long-standing PFHIS. Inequalities favoured the poor, uneducated and elderly, which is to some extend desirable when rolling out a PFHIS intended for harder to reach populations. However, religion and caste-based inequalities, while reducing, were still prevalent among women. If PFHIS are to truly offer financial risk protection, they must address the intersecting marginalization faced by women and men, while meeting eventual goals of risk pooling, indicated by high coverage and low inequality across population sub-groups.

Geographical and Socioeconomic Inequalities in Maternal Mortality in Ethiopia.

In Ethiopia, social inequalities are common among women residing in deprived communities and between the poor and the rich. This study aimed to assess geographical and socioeconomic inequalities in maternal mortality using nationally representative data from Ethiopian Demographic and Health Surveys conducted from 2000 to 2019 (inclusive). Four health-related geographical and socioeconomic factors were assessed. Four relative and absolute health-related inequality measures were also used: rate difference, rate ratio, population attributable risk, and population attributable fraction. A total of 61,610 sister siblings were included. The highest reported inequalities in maternal mortality were residence-related (46% in 2005 among rural women), region-related (66% in 2005 among women in Beshangul-Gumuz regional state), education-related (83% in 2011 among women with primary education), and wealth-related (47% in 2000 among poorer women). So, if education-related inequalities in maternal mortality alone had been averted, the national maternal mortality could have been reduced by 52% in 2000, 51% in 2005, 83% in 2011, and 76% in 2016. In conclusion, inequalities in maternal mortality were high and concentrated among poorer women, women with lower educational status, and rural areas. Therefore, reducing the effects of poverty including social determinants of maternal mortality is recommended.

Addressing the social inequities of vaccination: an imperative to close the gap

Addressing the social inequities of vaccination: an imperative to close the gap

Is the socioeconomic inequality in stroke prognosis changing over time and does quality of care play a role?

In a publicly financed healthcare system we aimed to study the development in socioeconomic disparity in ischemic stroke outcomes over time. In addition, we study whether the healthcare system affects these outcomes through the quality of early stroke care when adjustments are made for various patient characteristics incl. comorbidity and stroke severity. Using nationwide, detailed individual-level register-data we analysed how income-related and education-related inequality in 30-day mortality and 30-day readmission risk developed between 2003 and 2018. In addition, focusing on income-related inequality, we applied mediation analyses to estimate the mediating role of quality of acute stroke care on 30-day mortality and 30-day readmission. A total of 97,779 individual ischemic stroke patients were registered in Denmark with a first ever stroke in the study period. Three-point-seven percent died within 30 days of their index-admission and 11.5% were readmitted within 30 days of discharge. The income-related inequality in mortality remained virtually unchanged over time from an RR of 0.53 (95% CI: 0.38; 0.74) in 2003-06 to RR 0.69 (95% CI: 0.53; 0.89)) in 2015-18 when high income was compared to low income (Family income-time interaction: RR 1.00 (95% CI: 0.98-1.03)). A similar but less uniform trend was found for the education-related inequality in mortality (Education-time interaction: RR 1.00 (95% CI: 0.97-1.04)). The income-related disparity in 30-day readmission was smaller than in 30-day mortality and it diminished over time from 0.70 (95% CI: 0.58; 0.83) to 0.97 (95% CI: 0.87; 1.10). The mediation analysis showed no systematic mediating effect of quality of care on neither mortality nor readmission. However, it cannot be ruled out that residual confounding may have washed out some mediating effects. The socioeconomic inequality in stroke mortality and re-admission risk has yet to be eliminated. Additional studies from different settings are warranted in order to clarify the impact of socioeconomic inequality of quality of acute stroke care.

Global state of education-related inequality in COVID-19 vaccine coverage, structural barriers, vaccine hesitancy, and vaccine refusal: findings from the Global COVID-19 Trends and Impact Survey

COVID-19 vaccine coverage and experiences of structural and attitudinal barriers to vaccination vary across populations. Education-related inequality in COVID-19 vaccine coverage and barriers within and between countries can provide insight into the hypothesised role of education as a correlate of vaccine access and acceptability. We aimed to characterise patterns of within-country education-related inequality in COVID-19 vaccine indicators across 90 countries. This study used data from the University of Maryland Social Data Science Center Global COVID-19 Trends and Impact Survey. Data from 90 countries (more than 14 million participants aged 18 years and older) were included in our analyses. We assessed education-related inequalities globally, across country-income groupings, and nationally for four indicators (self-reported receipt of COVID-19 vaccine, structural barriers to vaccination, vaccine hesitancy, and vaccine refusal) for the study period June 1-Dec 31, 2021. We calculated an absolute summary measure of inequality to assess the latest situation of inequality and time trends and explored the association between government vaccine availability policies and education-related inequality. Nearly all countries had higher self-reported receipt of a COVID-19 vaccine among the most educated respondents than the least educated respondents. Education-related inequality in structural barriers, vaccine hesitancy, and vaccine refusal varied across countries, and was most pronounced in high-income countries, overall. Low-income and lower-middle-income countries reported widespread experiences of structural barriers and high levels of vaccine hesitancy alongside low levels of education-related inequality. Globally, vaccine hesitancy in unvaccinated people was higher among those with lower education and vaccine refusal was higher among those with higher education, especially in high-income countries. Over the study period, education-related inequalities in self-reported receipt of a COVID-19 vaccine declined, globally and across all country income groupings. Government policies expanding vaccine availability were associated with lower education-related inequality in self-reported receipt of vaccine. This study serves as a baseline for continued inequality monitoring and could help to inform targeted actions for the equitable uptake of vaccines. Gavi, the Vaccine Alliance.

Inequalities in successful tobacco cessation and tobacco cessation attempts: Evidence from eight Sub-Saharan African countries.

Tobacco consumption is a contributing and modifiable risk factor for non-communicable diseases. In high-income countries, tobacco cessation attempts, and their success, are concentrated among the socio-economically advantaged, resulting in a skewed burden of disease. However, there is a paucity of evidence on the distribution of tobacco cessation in low- and middle-income countries. The objective of this study is to measure and decompose wealth- and education-related inequalities in tobacco cessation in eight Sub-Saharan African countries. The study applies Erreygers' corrected concentration indices and decomposition methods to the most recent Global Adult Tobacco Surveys in Botswana, Cameroon, Ethiopia, Kenya, Nigeria, Senegal, Tanzania, and Uganda. We find that across countries, successful tobacco cessation, as well as tobacco cessation attempts, are concentrated among wealthier and better-educated individuals. Differences in socio-economic status, urban or rural residence, and not knowing or believing that tobacco consumption leads to serious illness contributes to these inequalities. Governments in our sample of countries can do more to support socio-economically disadvantaged smokers in their efforts to quit smoking, including by making an effort to align each country's smoking cessation strategy with the guidelines outlined in the World Health Organization's Framework Convention on Tobacco Control.

Education-related inequalities in beliefs and behaviors pertaining to COVID-19 non-pharmaceutical interventions

BackgroundThe coronavirus pandemic has exposed existing social inequalities in relation to disease preventive behaviors, risk of exposure, testing and healthcare access, and consequences as a result of illness and containment measures across different population groups. However, due to a lack of data, to date there has been limited evidence of the extent of such within-country inequalities globally.MethodsWe examined education-related inequalities in four COVID-19 prevention and testing indicators within 90 countries, using data from the University of Maryland Social Data Science Center Global COVID-19 Trends and Impact Survey, in partnership with Facebook, over the period 1 June 2021 to 31 December 2021. The overall level of education-related inequalities, as well as how they differ across country income groups and how they have changed over time were analyzed using the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII). We also assessed whether these education-related inequalities were associated with government policies and responses.ResultsEducation-related inequalities in beliefs, mask wearing, social distancing and testing varied across the study countries. Mask wearing and beliefs in the effectiveness of social distancing and mask wearing were overall more common among people with a higher level of education. Even after controlling for other sociodemographic and health-related factors, social distancing practice was higher among the most educated in low/lower middle income countries, but was higher overall among the least educated in high income countries. Overall there were low education-related inequalities in COVID-19 testing, though there was variation across countries.ConclusionsThe study highlights important within-country education-related differences in COVID-19 beliefs, preventive behaviors and testing, as well as differing trends across country income groups. This has implications for considering and targeting specific population groups when designing public health interventions and messaging during the COVID-19 pandemic and future health emergencies.

Socioeconomic inequalities in low birth weight in South Asia: A comparative analysis using Demographic and Health Surveys

BackgroundLow Birth Weight (LBW) continues to be a prominent universal cause of various short- and long-term health hazards throughout infancy and adulthood. However, no study has revealed the socioeconomic inequalities in LBW among South Asian countries. This study assesses the socioeconomic inequalities among under-five South Asian children with LBW. MethodsSecondary data were derived from six (Afghanistan, Bangladesh, India, Maldives, Nepal, and Pakistan) nationally representative South Asian Demographic and Health Surveys conducted between 2015 and 2021, and included 170,547 under-five years of age children. The study employed the concentration curve and concentration index to assess the socioeconomic inequalities of those with LBW. Additionally, mixed-effect logistic regression was applied to determine the factors associated with LBW. ResultsA significant negative concentration index indicates the wealth-related and education-related inequalities of LBW among under-five South Asian children. LBW is highly concentrated in the socio-economically poor section of the society. Our study found statistically significant negative concentration index in all South Asian countries: Afghanistan (Education: -0.108), Bangladesh (wealth: -0.070 & education: -0.083), India (wealth: -0.059 & education: -0.052), Nepal (by wealth: -0.064 & by education: -0.080), and Pakistan (by wealth: -0.080 & by education: -0.095). Findings from the mixed-effects logistic regression model also show that children from the poorest quintiles (AOR: 1.53, 95% CI: 1.41–1.67) and illiterate mothers (AOR: 1.39, 95% CI: 1.29–1.51) had higher odds of being afflicted with LBW compared to the wealthiest quintiles and educated mothers respectively. Women's pregnancy assessments, such as antenatal care utilisation, iron supplementation intake, and normal delivery mode, are significantly correlated with decreased odds of children's LBW. ConclusionThere exists a strong association between LBW cases and socioeconomic inequalities among South-Asian children below five years of age. This indicates the urgent need for health education and prenatal care services for women from Afghanistan, Bangladesh, India, Nepal, and Pakistan, especially those with lower socioeconomic status.

Socioeconomic Inequalities in Self-Perceived Oral Health Among College-Going Students in Karachi, Pakistan

Background: Oral health inequalities are becoming a major threat to public health, and they excessively burden disadvantaged communities, especially within low and middle-income countries. This study explored the socioeconomic inequalities in self-perceived oral health behaviors among college-going students in Karachi, Pakistan. Methods: A cross-sectional study was conducted among 328 college-going students using a convenient sampling technique from three different socioeconomic groups including urban slums, middle, and rich class neighborhoods. Oral health was assessed using three measures: daily tooth brushing, weekly sweet consumption, and substance abuse. Socio-economic inequalities were measured using binary logistic regression (odds ratios), relative index of inequality, and slope index of inequality. Results: Out of 328 participants, 56.4% perceived their oral health as fair, 24.1% good, 14.9% poor, while only 4.6% had an excellent perception of oral health. Significant inequalities were found regarding oral health behaviours with fraternal income, occupation, and education level. Education-related absolute inequalities among college-going students were1.28(95% CI -2.19, -0.36 p-value&lt;0.01), -1.34(95% CI -2.16, -0.52, p-value&lt;0.01), -1.43(95% CI -2.70, -0.15, p-value&lt;0.01) with tooth brushing, high sweet consumption, and substance abuse respectively. Similarly, income and occupation-related absolute inequalities were also existent. Conclusions: In Pakistan, data among college-going students regarding oral healthcare is scarce. Significant inequalities were found in oral health behaviours among college-going students. Thus, there is a need to design equity-based health system provisions specifically to address the needs of poor segments of society.

Socioeconomic Inequality in Health Domains in Oman: Evidence from Oman World Health Survey

&#x0D; Socioeconomic inequality in health domains is a major challenge in public health in both developed and developing countries. The objective of this study was to assess the socioeconomic inequalities in various health domains in Oman. Data for the study was obtained from the 2008 World Health Survey in Oman, which covered a nationally representative sample of 3,370 Omani adults. Overall self-rated health (SRH) status and the functional difficulties with eight health domains: mobility; self-care, pain and discomfort, cognition, interpersonal activities, vision, sleep and energy, and affect, were used as the outcome variables. Level of education and wealth quintiles were used as the proxy measures of the socioeconomic status (SES). Both descriptive and inferential statistical techniques were used for data analysis. The results revealed significant socioeconomic inequalities in health outcomes for most of the health domains and for overall SRH in Oman. Adults with no education as well as with poorest wealth quintiles had significantly higher rate of poor health. For most of the health domains, a descending gradient in the prevalence of poor health with the level of education and wealth quintiles have been observed. However, education-related inequalities in poor health across the eight domains and the overall health status were found to be more pronounced and consistent than the wealth-related inequalities in poor health. Wealth quintiles showed no significant association with overall SRH and many health domains. The prevailing educational and wealth related inequalities in health underscores the need for policy-making in regard to reduce the inequalities in specific domains of health and overall health. There is a need for research to examine the ways in which socioeconomic factors mediate changes in health domains as well as overall health. The results from this study are of relevance to public health policymakers in developing interventions for specific health domains and overall health status.

Wealth- and education-related inequalities in minimum dietary diversity among Indonesian infants and young children: a decomposition analysis

ABSTRACT Background Over the last two decades, Indonesia has experienced remarkable economic growth. However, the percentage of infants and young children meeting the minimum dietary diversity (MDD) criteria has stagnated. Despite the growing body of evidence of the association between MDD and socioeconomic factors, there is little information about socioeconomic inequalities in MDD in Indonesia. Objectives The current study seeks to quantify the wealth- and education-related inequalities in MDD among infants and young children in Indonesia and determine the contribution of different factors to these disparities. Methods We included a total of 5038 children aged 6–23 months of the 2017 Indonesia Demographic and Health Survey. We measured wealth- and education-related inequalities using the concentration curve and Wagstaff normalised concentration index. Using a concentration index decomposition analysis, we then examined factors contributing to wealth- and education-related inequalities in MDD. Results The concentration indices by household wealth and maternal education were 0.220 (p < 0.001) and 0.192 (p < 0.001), respectively, indicating more concentration of inequalities among the advantaged population. The decomposition analysis revealed that household wealth (29.8%), antenatal care (ANC) visits (16.6%), paternal occupation (15.1%), and maternal education (11.8%) explained the pro-rich inequalities in MDD in Indonesia. Maternal education (26.1%), household wealth (19.1%), ANC visits (14.9%), and paternal occupation (10.9%) made the most considerable contribution to education-related inequalities in MDD. Conclusions There is substantial wealth- and education-related inequalities in MDD. Our findings suggest an urgent need to address the underlying causes of not reaching dietary diversity by promoting infant and young child feeding equity in Indonesia.

Intersecting sex-related inequalities in self-reported testing for and prevalence of Non-Communicable Disease (NCD) risk factors in Kerala

BackgroundNon-Communicable Diseases (NCDs) are among India’s top burdens, particularly in states like Kerala, which is at an advanced stage of the epidemiological transition. Evidence in India points towards intersectional inequalities in risk factors of NCDs and testing, both of which are understudied in Kerala. We estimated the self-reported testing and prevalence of key NCD risk factors—blood pressure (BP) and blood glucose (BG) comparing Kerala men and women across educational, wealth, religion, as well as caste and tribal status subgroups.MethodA multistage random sample survey of 3398 women and 2982 men aged 30 years and over was administered in 4 districts of Kerala from July to October 2019. Descriptive analysis for men and women was undertaken using survey weights. Slope index of Inequality and Relative Concentration Index for wealth and education related inequalities, and, Weighted Mean Difference from Mean and Index of Disparity for caste and tribal status, as well as religion related inequalities were calculated using World Health Organisation’s Health Equity Assessment Toolkit Plus and Stata 12.ResultsA significantly higher proportion of women reported BP and BG testing by medical personnel in the previous year than men (BP Testing among Women (BPTw): 90.3% vs BP Testing among Men (BPTM):80.8%, BG Testing among Women (BGTw): 86.2% vs BG Testing among Women (BGTM):78.3%). Among those tested, more women (11.2%) than men (7.9%) reported High Blood Pressure (HBP) but not High Blood Glucose (HBG). Testing for BP was concentrated among less-educated women while BG testing was concentrated among both less educated women and men. HBP and HBG were concentrated among less educated and wealthier groups. Although sex differences were insignificant across caste and tribal status and religion subgroups, magnitude of inequalities was high for HBP and HBG.ConclusionDistinct patterns of sex inequalities were present in self-reported testing and prevalence of NCD risk factors in Kerala. Education and wealth seem to be associated with testing while prevalence appeared to vary by religious groups. Given the low rates of illiteracy, it is encouraging but maybe a data artefact that a small population of less-educated persons was getting tested; however, exclusion of poor groups and inequalities by other dimensions raise concerns. Further exploration is needed to understand underlying mechanisms of these inequalities to ensure we leave no one behind.

The 45 and Up Study: reflecting on contributions to global evidence using case studies on cardiovascular disease and smoking.

To describe the attributes that have underscored the success of the 45 and Up Study (the Study) and demonstrate its value by reflecting on two case studies: our research on socioeconomic inequalities in cardiovascular disease; and the harms of smoking. Type of program or service: The Study is the largest study of healthy ageing in Australia, and one of the biggest in the world; it recruited 267 357 participants aged 45 years and older from NSW, Australia from 2005 to 2009. For more than 15 years, it has provided high-quality evidence on a broad range of public health related issues. We reflect on its value using two research case studies. Four key attributes have enabled the success of the Study: its establishment as a collaborative resource, including early and ongoing engagement with researchers and policy and practice partners; its large scale, which makes it ideally suited to quantify associations between risk factors and health outcomes, including for high priority populations; high quality self-reported survey data; and linkage to routinely collected administrative data, including specialised data. Novel Australian findings on cardiovascular disease (CVD) and smoking illustrate how the Study has contributed to national and international evidence, informing policy and practice. Results on CVD demonstrated individual-level education-related inequalities in CVD incidence and mortality, and greater use of pharmacotherapy for secondary prevention of CVD, in people with low versus high socioeconomic status. In terms of smoking, Study data showed that current smokers have around three times the mortality of never-smokers; that even "light" smoking of <14 cigarettes per day doubles mortality; that quitting is beneficial at any age; that smoking increases the risk of multiple cancer types; and that smoking causes half of deaths in Aboriginal and Torres Strait Islander adults aged 45 years and over and more than one-third of all deaths in the population. This evidence has been used by more than 50 government and non-government organisations, including contributing to legislation, policy and national and international monitoring and reporting. The Study has fulfilled a vital role in public health research and practice in Australia, providing locally relevant data to enable research on health issues of importance, including health inequity. Through ongoing partnerships, the Study's data has contributed to international scientific evidence and been used to inform public health policy and practice. It has also been used as a focus for collaboration and capacity building.

Inequalities in Knowledge About COVID-19 in the Kingdom of Saudi Arabia.

Background: As the world is still being ravaged by the coronavirus disease 2019 (COVID-19) pandemic, the first line of prevention lies in understanding the causative and preventive factors of the disease. However, given varied socioeconomic circumstances, there may be some inequality in the level of proper knowledge of COVID-19. Despite a proliferation of studies on COVID-19, the extent and prevalence of inequalities in knowledge about COVID-19 in Saudi Arabia are not known. Most related studies have only focused on understanding the determinants of COVID-19 knowledge. Therefore, the aim of this study was to assess the socioeconomic inequalities in knowledge regarding COVID-19 in Saudi Arabia.Methods: Data were extracted from an online cross-sectional self-reported questionnaire conducted on the knowledge about COVID-19 from 3,388 participants. Frequencies and graphs were used to identify the level and distribution of inequality in knowledge about COVID-19. Concentration curves and concentration indices were further used to assess and quantify the income- and education-related inequality in knowledge about COVID-19.Results: The level of COVID-19 knowledge was high among the surveyed sample, although the extent of knowledge varied. The findings further suggest the existence of socioeconomic inequality in obtaining proper knowledge about COVID-19, indicating that inequality in comprehensive knowledge is disproportionately concentrated among the wealthy (concentration index = 0.016; P < 0.001) and highly educated individuals (concentration index = 0.003; P = 0.029) in Saudi Arabia.Conclusions: There is inequality in the level of knowledge about COVID-19 among the more socioeconomically privileged population of Saudi Arabia. Given that COVID-19 cases ebb and flow in different waves, it is important that proper policies be put in place that will help in improving knowledge among the lower income and less educated individuals, leading to behavior that can help reduce transmission.

Socioeconomic inequalities in effective service coverage for reproductive, maternal, newborn, and child health: a comparative analysis of 39 low-income and middle-income countries.

BackgroundReducing socioeconomic inequalities in access to good quality health care is key for countries to achieve Universal Health Coverage. This study aims to assess socioeconomic inequalities in effective coverage of reproductive, maternal, newborn and child health (RMNCH) in low- and middle-income countries (LMICs).MethodsUsing the most recent national health surveys from 39 LMICs (between 2014 and 2018), we calculated coverage indicators using effective coverage care cascade that consists of service contact, crude coverage, quality-adjusted coverage, and user-adherence-adjusted coverage. We quantified wealth-related and education-related inequality using the relative index of inequality, slope index of inequality, and concentration index.FindingsThe quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, in particular for postnatal care (64 percentage points [pp], p-value<0·0001), family planning (48·7 pp, p<0·0001), and antenatal care (43·6 pp, p<0·0001) outcomes. Upper-middle-income countries had higher effective coverage levels compared with low- and lower-middle-income countries in family planning, antenatal care, delivery care, and postnatal care. Socioeconomic inequalities tend to be wider when using effective coverage measurement compared with crude and service contact measurements. Our findings show that upper-middle-income countries had a lower magnitude of inequality compared with low- and lower-middle-income countries.InterpretationReliance on the average contact coverage tends to underestimate the levels of socioeconomic inequalities for RMNCH service use in LMICs. Hence, the effective coverage measurement using a care cascade approach should be applied. While RMNCH coverages vary considerably across countries, equitable improvement in quality of care is particularly needed for lower-middle-income and low-income countries.FundingNone.