title: Equity monitoring for social marketing: use of wealth quintiles and the concentration index for decision making in HIV prevention, family planning, and malaria programs.
abstract: BACKGROUND
  The majority of social marketing programs are intended to reach the poor. It is therefore essential that social marketing organizations monitor the health equity of their programs and improve targeting when the poor are not being reached. Current measurement approaches are often insufficient for decision making because they fail to show a program's ability to reach the poor and demonstrate progress over time. Further, effective program equity metrics should be benchmarked against a national reference population and consider exposure, not just health outcomes, to measure direct results of implementation. This study compares two measures of health equity, concentration indices and wealth quintiles, using a defined reference population, and considers benefits of both measures together to inform programmatic decision making.
  
  
  METHODS
  Three datasets from recent cross-sectional behavioral surveys on malaria, HIV, and family planning from Nepal and Burkina Faso were used to calculate concentration indices and wealth quintiles. Each sample was standardized to national wealth distributions based on recent Demographic and Health Surveys. Wealth quintiles were generated and concentration indices calculated for health outcomes and program exposure in each sample. Chi-square and t-tests were used to assess statistical significance of results.
  
  
  RESULTS
  Reporting wealth quintiles showed that recipients of Population Services International (PSI) interventions were wealthier than national populations. Both measures indicated that desirable health outcomes were usually concentrated among wealthier populations. Positive and significant concentration indices in all three surveys indicated that wealth and program exposure were correlated; however this relationship was not necessarily linear. In analyzing the equity of modern contraceptive use stratified by exposure to family planning messages in Nepal, the outcome was equitable (concentration index = 0.006, p = 0.68) among the exposed, while the wealthy were more likely to use modern contraceptives (concentration index = 0.071, p < 0.01) among the unexposed.
  
  
  CONCLUSIONS
  Using wealth quintiles and concentration indices together for equity monitoring improves usability of findings for decision making. Applying both metrics, and analyzing equity of exposure along with health outcomes, provides results that have statistical and programmatic significance. Benchmarking equity data against national data improves generalizability. This approach benefits social marketers and global health implementers to improve strategic decision making and programs' ability to reach the poor.
authors.affiliation: Population Services International, Washington, DC, USA. nchakraborty@psi.org
authors.forename: Nirali M
authors.initials: NM
authors.lastname: Chakraborty
authors.forename: Rebecca
authors.initials: R
authors.lastname: Firestone
authors.forename: Nicole
authors.initials: N
authors.lastname: Bellows
mesh_terms: D002050:Burkina Faso; D003430:Cross-Sectional Studies; D003659:Decision Making, Organizational; D005193:Family Planning Services / Q000458:organization & administration*; D015658:HIV Infections / Q000517:prevention & control*; D054625:Healthcare Disparities; D006801:Humans; D008288:Malaria / Q000517:prevention & control*; D009390:Nepal; D015397:Program Evaluation / Q000379:methods*; D040241:Social Marketing; D012959:Socioeconomic Factors
references.citation: Niger J Clin Pract. 2007 Dec;10(4):272-82
references.pmid: 18293634
references.citation: Lancet. 2012 Mar 31;379(9822):1225-33
references.pmid: 22464386
references.citation: Lancet. 2005 Mar 19-25;365(9464):1099-104
references.pmid: 15781105
references.citation: Soc Sci Med. 2008 Apr;66(7):1614-26
references.pmid: 18222588
references.citation: Int J Equity Health. 2011 Aug 19;10:33
references.pmid: 21854584
references.citation: Int J Equity Health. 2010 Apr 03;9:9
references.pmid: 20361875
references.citation: Health Policy Plan. 2008 Nov;23(6):465-75
references.pmid: 18796500
references.citation: Bull World Health Organ. 2007 Oct;85(10):745-54
references.pmid: 18038055
references.citation: Sex Health. 2012 Mar;9(1):44-50
references.pmid: 22348632
references.citation: Bull World Health Organ. 2000;78(1):19-29
references.pmid: 10686730
references.citation: J Epidemiol Community Health. 2009 Nov;63(11):871-7
references.pmid: 19406742
references.citation: Demography. 2001 Feb;38(1):115-32
references.pmid: 11227840
references.citation: Bull World Health Organ. 2006 Jul;84(7):519-27
references.pmid: 16878225
references.citation: Lancet. 2003 Jul 19;362(9379):233-41
references.pmid: 12885488
references.citation: Soc Sci Med. 2011 May;72(9):1420-8
references.pmid: 21470733
references.citation: J Epidemiol Community Health. 2003 Apr;57(4):254-8
references.pmid: 12646539