With generally low coverage of in the reach of public health interventions in Nepal and inequality in access to these interventions, it is critical for program implementers to be able to monitor health equity within programs, specifically in who is reached and outcomes achieved. This is especially critical for social marketing organizations aiming to promote the use of health products and services among poorer populations. We measure health equity in exposure and behavioral outcomes for two large-scale social marketing programs addressing malaria control and reproductive health.
We used data from recent behavioral surveys conducted by PSI Nepal to monitor on-going programs. A 2010 household survey occurred during the second year of a three-year campaign promoting insecticide treated bednets (ITNs) in 13 malaria-endemic districts (n=1503). A second household survey took place in 2011, during the third year of a program promoting use of long-acting contraceptive methods and medication abortion in 47 districts (n=1036). A household asset index was calculated in the 2010 Nepal Demographic and Health Survey to create a national wealth distribution. The asset index for each PSI sample was standardized to this national distribution. Wealth quintiles and concentration indices (CI) using this asset index were calculated for bednet use by pregnant women and children under five years of age plus use of modern contraception. Similar analyses were conducted for measures of intervention exposure: seeing a PSI-branded poster on bednets, receiving an in-home visit from a malaria prevention outreach worker, hearing a PSI-branded mass media message on IUDs, and seeing a PSI-branded poster promoting IUDs. Chi-square and t-tests were used to assess statistical significance.
PSI samples were wealthier than the DHS population. In the malaria study, the largest cluster of observations was in middle income quintiles, with less than 20% of observations in the poorest and wealthiest quintiles. The reproductive health survey found fewer observations in the poorest quintile (8%) and the most observations in the wealthiest quintile (34%). Poorer children were significantly more likely to have slept under an ITN than the richest (χ2 p=0.006 for independence between quintiles and outcome; CI=-0.035, p<0.01). For pregnant women, sleeping under any net was significantly associated with greater wealth (χ2 p=0.002; CI=0.044, p<0.01), but the distribution of ITN use was equitable (χ2 p=0.191; CI=0.031, p=0.17). Contraceptive use was greater in wealthier quintiles (χ2 p=0.001; CI= 0.056,p<0.01). Intervention exposure tended to be greater among wealthier quintiles across all measures of exposure. Differences between wealthy and poor were particularly marked for recall of a PSI-branded poster promoting IUDs (χ2 p<0.001; CI= 0.149,p<0.01). Contraceptive use was more equitably distributed among those exposed (χ2 p=0.63; CI= 0.006,p>0.05) than those not exposed (χ2 p=0.09, CI= 0.071,p<0.05).
Although programmatic exposure tended to be greater among wealthier groups, distribution of behavioral outcomes in several instances was equitable or favored the poor. Equity monitoring can be used to adjust implementation strategies to ensure programs are reaching target populations as intended
- Populations Served
- Children Under 5, Women of Reproductive Age
- Health Areas
- Child Health, Contraception, Malaria
- Communicating for Social Change, Developing Markets, Franchising for Health
- Resource Types
- HIV Prevention, Long-Acting Reversible Contraception, Long-Lasting Insecticide-Treated Nets (LLIN), Malaria Prevention, Short-Term Contraception