COMPANION WORKBOOK

Exercises to guide the process of immunization inequality monitoring

This Companion Workbook accompanies the Inequality monitoring in immunization eLearning course. The
workbook contains exercises that facilitate the application of the general concepts of health inequality
monitoring to the topic of immunization in a specific context. Corresponding to the steps of the health
inequality monitoring cycle, the Companion Workbook may be used to record personal reflections on key
concepts, or to guide and document group planning sessions for inequality monitoring. Throughout the
workbook there are prompts to make note of key decisions taken at each step of monitoring. This allows
the workbook to serve as a detailed internal record of the monitoring process and the rationale for how
it was undertaken. Ideally, immunization inequality monitoring should be repeated regularly; therefore,
this workbook can serve as a reference for subsequent rounds of monitoring.

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General considerations
Why is immunization inequality monitoring being done? Why now?
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What policy cycles or windows of opportunity are important to keep in mind? (E.g. annual reporting
cycles, programme or policy review cycles, meetings or conventions)
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What groups of people will use the knowledge generated from the monitoring exercise? (E.g. policy-
makers, programme managers, affected communities or groups, non-profit organization
representatives)
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What communities or groups are important to engage to ensure that the interests and needs of
affected populations are represented?
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How will the above communities or groups be involved in defining the scope of monitoring,
interpreting data and disseminating results?
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What mechanisms will be in place to ensure the voices of disadvantaged groups are heard throughout
the process?
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Step 1. Determine scope of monitoring
1A. Decide on the population
What are the major immunization strategies, programmes, policies and plans? What populations do
they address? What relevant populations do they NOT address?
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What are current or recent monitoring activities related to immunization, including community-led
activities? Are there immunization inequality monitoring activities?
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Which populations are under-represented? Over-represented?

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DECISION: What population will your monitoring activity encompass? (Specify the geographical area and
general characteristics of the affected population)
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1B. Identify relevant immunization indicators
How narrowly or broadly do you want to represent the topic of immunization? What is the rationale?
How does this reflect the overall purpose and intended impact of monitoring, including the scope of
practice of the desired knowledge users?
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What are the key immunization outcomes relevant to the population?

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What are the key immunization interventions relevant to the population?

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Which immunization global indicator frameworks could be a source of valid indicators?

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Which tracer indicators, if any, could be selected to represent the situation across a broader aspect of
immunization?
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Are there composite indicators that could be considered?

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DECISION: What immunization indicators are selected for inequality analysis? (List indicators)
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1C. Identify relevant dimensions of inequality
Are the following common dimensions of inequality applicable to the monitoring population and
package of immunization indicators identified above? If so, what subgroups would be expected to be
advantaged or disadvantaged?

Dimension
Applicable? How?
of inequality
Sex Enter text here

Economic Enter text here

status

Education Enter text here

level

Place of Enter text here

residence

Age Enter text here

Subnational Enter text here

region

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What other sources of disadvantage have you witnessed in the monitoring population that might have
an impact on immunization? How can these be reflected in context-specific dimensions of inequality?
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DECISION: What dimensions of inequality are relevant for monitoring inequality in immunization?
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Step 2. Obtain data
2A. Conduct data source mapping
Sheet 1. List of data sources by type

Data source type Name of data source Year(s) of data Notes

collection (representativeness, population,
dataset accessibility, etc.)
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Sheet 2. List data sources next to a unique data source number, and indicate corresponding
dimensions of inequality

Dimensions of inequality
No. Data source Sex Economic Education Place of Age Subnation [other]
(year) status level residence al region

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Sheet 3. Immunization indicators and corresponding unique data source numbers

Immunization indicator Unique data source Notes

numbers (from Sheet 2)
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Sheet 4. Collate information about data sources [insert unique data source numbers from Sheet 2 in
cells]
Dimensions of inequality
Immunization Sex Economic Education Place of Age Subnation [other]
status level residence al region
indicator
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2B. Determine whether sufficient data are currently available
Based on the results of data source mapping, which data sources could be used for inequality
monitoring?
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What are the strengths and weaknesses of candidate data sources? Consider the limitations inherent
to data collection protocol, data quality issues, accessibility and availability of data, date of data
collection (how recent?), existence of comparable data for benchmarking or assessing time trends.
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Where are there gaps in data availability or quality? What could and should be done to address these
gaps?
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Do data sources contain unique identifiers? If applicable, complete Sheet 5.

Sheet 5. List common identifiers to assess the possibility of linking

Common identifier Unique data source number (from Sheet 2)

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DECISION: What data sources will be used for monitoring?

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Step 3. Data analysis
3A. Prepare disaggregated data
How are immunization indicator(s) defined, including, if applicable, the numerator and denominator?
Why were these definitions applied?
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What are the interests and preferences of the affected population in terms of how subgroups are
labelled and categorized? Consider each dimension of inequality identified in STEP 1C.
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Do subgroups have low sample sizes? If so, how will this be addressed?
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What preparations of the dataset are needed to proceed with analysis? Consider: do data need to be
cleaned? How will clustering, weighting and stratification be incorporated in the analysis, in the case
of household survey analysis?
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DECISION: How are immunization indicators and dimensions of inequality defined and categorized?
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3B. Calculate summary measures of inequality
With which summary measures of inequality are you already familiar? What are their strengths and
limitations?
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In what ways would you like to strengthen your capacity to use summary measures and conduct data
analysis?
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How will simple measures of inequality be applied to the analysis? In the table below, select absolute
and relative simple measures of inequality, and indicate which two subgroups will be compared for
each dimension of inequality.

Summary Select relevant Indicate two subgroups to be compared for each dimension of
measure measures inequality (e.g. economic status: wealth quintiles 1 and 5)
characteristic
Absolute  Difference Enter text here

Relative  Ratio Enter text here

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How will complex measures of inequality be applied to the analysis? In the table below, categorize
each dimension of inequality as ordered or non-ordered, select absolute and relative complex
measures of inequality, and indicate what two subgroups will be compared for each dimension of
inequality.

Categorize
Indicate dimensions of
dimensions of
Summary measure inequality to which
inequality as Select relevant measures a
characteristics relevant measures will
ordered or non-
be applied
ordered
Ordered:  Absolute concentration index
→ Enter text here
Absolute
→ Enter text here Weighted  Slope index of inequality
→ Enter text here
by
→ Enter text here population  Relative concentration index
→ Enter text here
share
Relative
→ Enter text here  Relative index of inequality
→ Enter text here
→ Enter text here Equal
(Not available)
weighting
 Between-group standard
deviation → Enter text here

 Between group variance

→ Enter text here
 Mean difference from best
Absolute
performing subgroup
→ Enter text here
(weighted)
Weighted
by  Mean difference from mean
Non-ordered:
population (weighted) → Enter text here
share
→ Enter text here
 Coefficient of variation
→ Enter text here
→ Enter text here
 Index of disparity
→ Enter text here
→ Enter text here Relative
 Mean log deviation
→ Enter text here
→ Enter text here
 Theil index
→ Enter text here
 Mean difference from best
performing subgroup
→ Enter text here
(unweighted)
Absolute
Equal
 Mean difference from mean
weighting
(unweighted) → Enter text here

 Index of disparity
Relative → Enter text here
(unweighted)

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  Population attributable risk
Weighted Absolute → Enter text here
Either ordered or by
 Population attributable
non-ordered population
Relative fraction → Enter text here
share
a Thislist includes common complex measures featured in the WHO Health Equity Assessment Toolkit (HEAT) and is
not a comprehensive list of all summary measures of inequality. For more information see
https://www.who.int/data/gho/health-equity/assessment_toolkit

DECISION: What summary measures of inequality will be calculated as part of monitoring?

Enter text here

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Step 4. Report results
Note that some of the questions for this step may need to be revisited once STEP 3 (data analysis) has
been completed.

4A. Define the purpose of reporting and its target audience

What goals and objectives do you hope to achieve through reporting?
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What audience(s) does reporting need to reach to achieve these goals and objectives?
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What are the general characteristics of the audience(s)? Consider their skills (including reading level),
prior knowledge, needs, priorities and interests.
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DECISION: What is the purpose of reporting and who is reporting targeted at?
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4B. Select the scope of reporting
What are the most recent available data about the latest status of inequality in immunization?
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If data are available for earlier time point(s), are they reasonably comparable with the most recent
data? How would reporting time trends align with the purpose of reporting?
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What data are available for benchmarking across different populations, indicators or health topics?
How would reporting benchmarking align with the purpose of reporting?
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DECISION: What data will be used to report the latest status of inequality? If applicable, how will trend
over time and benchmarking be reported?
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4C. Define the technical content
What patterns can be identified in disaggregated data estimates for immunization indicators across
population subgroups?
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What main conclusions are supported by simple pairwise measures of inequality?

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Do complex measures support these same conclusions? If not, where are the differences?
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How much technical detail is warranted for the specified target audience?
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DECISION: In addition to disaggregated data, which summary measures of inequality will be reported?
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4D. Decide upon the methods of presenting data
Bearing in mind the decisions of STEPS 4A-C, what are the advantages and disadvantages of using the
following tools to present immunization data in support of the conclusions?

Tool Advantage Disadvantage

Text Enter text here Enter text here

Tables Enter text here Enter text here

Figures Enter text here Enter text here

Maps Enter text here Enter text here

Interactive visuals Enter text here Enter text here

What other tools would be effective to present data?

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DECISION: Which tool(s) will be used to present the results?

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4E. Adhere to best practices of reporting
What background information about immunization policies, programmes and practices does the
target audience need to know?
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What limitations are pertinent to the data sources, analysis and interpretation? How can they be
communicated transparently?
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Are there items on the best practices of reporting checklist that cannot be fulfilled? If so, why?
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DECISION: Which best practices of reporting, if any, were not followed? Why?
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Step 5. Knowledge translation
Knowledge translation ensures the results of inequality monitoring are communicated to decision makers
and translated into policy and practice. Throughout this Companion Workbook, some initial knowledge
translation considerations have been embedded in the previous steps of the inequality monitoring cycle.
See the manual for an introduction to the topic of knowledge translation, which includes recommended
resources for further reading.

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