Many qualitative research studies acknowledge the possibility of social desirability bias (a tendency to present reality to align with what is perceived to be socially acceptable) as a limitation that creates complexities in interpreting findings. Drawing on experiences conducting interviews and focus groups in rural Ethiopia, this article provides an empirical account of how one research team developed and employed strategies to detect and limit social desirability bias. Data collectors identified common cues for social desirability tendencies, relating to the nature of the responses given and word choice patterns. Strategies to avoid or limit bias included techniques for introducing the study, establishing rapport, and asking questions. Pre-fieldwork training with data collectors, regular debriefing sessions, and research team meetings provided opportunities to discuss social desirability tendencies and refine approaches to account for them throughout the research. Although social desirability bias in qualitative research may be intractable, it can be minimized.

Promoting health equity: WHO health inequality monitoring at global and national levels

Noncommunicable diseases are an increasing health concern worldwide, but particularly in low- and middle-income countries. This study quantified and compared education- and wealth-based inequalities in the prevalence of five noncommunicable diseases (angina, arthritis, asthma, depression and diabetes) and comorbidity in low- and middle-income country groups.

Immunisation programmes have made substantial contributions to lowering the burden of disease in children, but there is a growing need to ensure that programmes are equity-oriented. We aimed to provide a detailed update about the state of between-country inequality and within-country economic-related inequality in the delivery of three doses of the combined diphtheria, tetanus toxoid, and pertussis-containing vaccine (DTP3), with a special focus on inequalities in high-priority countries. We used data from the latest available Demographic and Health Surveys and Multiple Indicator Cluster Surveys done in 51 low-income and middle-income countries. Data for DTP3 coverage were disaggregated by wealth quintile, and inequality was calculated as difference and ratio measures based on coverage in richest (quintile 5) and poorest (quintile 1) household wealth quintiles. Excess change was calculated for 21 countries with data available at two timepoints spanning a 10 year period. Further analyses were done for six high-priority countries-ie, those with low national immunisation coverage and/or high absolute numbers of unvaccinated children. Significance was determined using 95% CIs. National DTP3 immunisation coverage across the 51 study countries ranged from 32% in Central African Republic to 98% in Jordan. Within countries, the gap in DTP3 immunisation coverage suggested pro-rich inequality, with a difference of 20 percentage points or more between quintiles 1 and 5 for 20 of 51 countries. In Nigeria, Pakistan, Laos, Cameroon, and Central African Republic, the difference between quintiles 1 and 5 exceeded 40 percentage points. In 15 of 21 study countries, an increase over time in national coverage of DTP3 immunisation was realised alongside faster improvements in the poorest quintile than the richest. For example, in Burkina Faso, Cambodia, Gabon, Mali, and Nepal, the absolute increase in coverage was at least 2·0 percentage points per year, with faster improvement in the poorest quintile. Substantial economic-related inequality in DTP3 immunisation coverage was reported in five high-priority study countries (DR Congo, Ethiopia, Indonesia, Nigeria, and Pakistan), but not Uganda. Overall, within-country inequalities in DTP3 immunisation persist, but seem to have narrowed over the past 10 years. Monitoring economic-related inequalities in immunisation coverage is warranted to reveal where gaps exist and inform appropriate approaches to reach disadvantaged populations. None.

Transforming our world: the 2030 agenda for sustainable development promotes the improvement of health equity, which entails ongoing monitoring of health inequalities. The World Health Organization has developed a multistep approach to health inequality monitoring consisting of: (i) determining the scope of monitoring; (ii) obtaining data; (iii) analysing data; (iv) reporting results; and (v) implementing changes. Technical considerations at each step have implications for the results and conclusions of monitoring and subsequent remedial actions. This paper presents some technical considerations for developing or strengthening health inequality monitoring, with the aim of encouraging more robust, systematic and transparent practices. We discuss key aspects of measuring health inequalities that are relevant to steps (i) and (iii). We highlight considerations related to the selection, measurement and categorization of dimensions of health inequality, as well as disaggregation of health data and calculation of summary measures of inequality. Inequality monitoring is linked to health and non-health aspects of the 2030 agenda for sustainable development, and strong health inequality monitoring practices can help to inform equity-oriented policy directives.

Monitoring inequalities in health is fundamental to the equitable and progressive realization of universal health coverage (UHC). A successful approach to global inequality monitoring must be intuitive enough for widespread adoption, yet maintain technical credibility. This article discusses methodological considerations for equity-oriented monitoring of UHC, and proposes recommendations for monitoring and target setting. Inequality is multidimensional, such that the extent of inequality may vary considerably across different dimensions such as economic status, education, sex, and urban/rural residence. Hence, global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence) as well as sex. For a given dimension of inequality, subgroups for monitoring must be formulated taking into consideration applicability of the criteria across countries and subgroup heterogeneity. For economic-related inequality, we recommend forming subgroups as quintiles, and for urban/rural inequality we recommend a binary categorization. Inequality spans populations, thus appropriate approaches to monitoring should be based on comparisons between two subgroups (gap approach) or across multiple subgroups (whole spectrum approach). When measuring inequality absolute and relative measures should be reported together, along with disaggregated data; inequality should be reported alongside the national average. We recommend targets based on proportional reductions in absolute inequality across populations. Building capacity for health inequality monitoring is timely, relevant, and important. The development of high-quality health information systems, including data collection, analysis, interpretation, and reporting practices that are linked to review and evaluation cycles across health systems, will enable effective global and national health inequality monitoring. These actions will support equity-oriented progressive realization of UHC.