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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 47-55

Selection of Urban Health Equity Assessment and Response Tool indicators using item response theory analysis to assess a city health profile in India


1 Department of Community Medicine, Government Medical College, Dr. NTR University of Health Sciences, Ongole, Andhra Pradesh, India
2 Department of Community Medicine, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India

Date of Submission15-Sep-2019
Date of Decision20-Nov-2019
Date of Acceptance02-Apr-2020
Date of Web Publication5-Jun-2020

Correspondence Address:
M Siva Durga Prasad Nayak
Flat No 402, Sai Paanya Residency, Near Sai Baba Temple, Santhapeta, Ongole, Prakasam - 523 001, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_72_19

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  Abstract 


Introduction: City health profile is a useful tool for understanding the health gap and to plan to close the health gap. Of the different tools available to draft a city health profile, the Urban Health Equity Assessment and Response Tool (HEART) developed by the WHO Kobe Centre is one of the best among them. A list of core indicators of the Urban HEART varies from country to country.
Aim: In this scenario, an attempt was made with an aim to choose feasible indicators in the Urban HEART to assess a city health profile in Indian setting.
Material and Methods: The current study is a cross-sectional observational study conducted among different public health experts in India using an online survey technique. An online survey form was created to collect the public health expert's opinion and sent to public health experts. A total of 105 responses were collected.
Statistical Analysis: The average opinion score for each indicator was measured. Item response theory analysis technique was used to calculate the feasibility score to categorize the indicators.
Results: The average score of the 60 indicators ranged from 4.54 to 2.77. The feasibility score ranged from 4.13 to − 0.49. Of 60 indicators, 16 indicators were strongly recommended, 41 were recommended, and 3 indicators were optional indicators. Nineteen were highly feasible, 28 feasible, and 13 were less feasible indicators.
Conclusion: The Urban HEART can be applied in Indian setting. Data collection can be started with feasible indicators and later can be extended to other indicators.

Keywords: Health gap, health indicators, health inequities, urban health, Urban Health Equity Assessment and Response Tool


How to cite this article:
Nayak M S, Narayan K A. Selection of Urban Health Equity Assessment and Response Tool indicators using item response theory analysis to assess a city health profile in India. Indian J Community Fam Med 2020;6:47-55

How to cite this URL:
Nayak M S, Narayan K A. Selection of Urban Health Equity Assessment and Response Tool indicators using item response theory analysis to assess a city health profile in India. Indian J Community Fam Med [serial online] 2020 [cited 2020 Jul 7];6:47-55. Available from: http://www.ijcfm.org/text.asp?2020/6/1/47/286034




  Introduction Top


Global picture of population distribution is very quickly changing because of rapid urbanization in the last three decades.[1] In the year 2007, it was observed that, for the first time throughout the world, people who lived in cities and towns were greater than those who lived in rural areas.[2] The city's promise lies in proximity to health-supporting physical and social infrastructure, to technology, and to jobs, schools, and health-care services. It attracted more number of people to reside in urban areas than in rural areas. Although people are living in proximity to health-care services, the fruits of health-care services are not uniformly distributed and resulted in the health gaps among different areas in a single city. Inequity in health is considered to be unfair because it is generated and maintained by “unjust social arrangements.”[3] The aspiration for closing the health gap in cities can be met by guiding public health policies through evidence and in-depth analysis of inequities, using a participatory and intersectoral approach such as creating a city health profile.[4] City health profile is a useful tool for understanding the health gap and to plan to close the health gap.[5],[6],[7] Drafting city health profile for assessing the current status, planning for interventions, and measuring the changes in the future is a complex process as it includes assessment of many health and other socioeconomic indicators. Several agencies and countries have developed tools for this purpose.[8] The objective of determining core indicators is to provide a clear direction to local governments on key issues to assess when tackling health inequities. They are intended to ease the process of applying the tool and to be comparable across cities and countries. Of the different tools available to draft a city health profile, the Urban Health Equity Assessment and Response Tool (HEART) developed by the WHO Kobe Centre is one of the best among them.[9],[10]

The Urban HEART includes a list of core indicators that were classified into two different groups such as health outcomes and health determinants.[9] According to the Urban HEART, five key criteria were used for identifying core indicators, namely availability of data, strength of indicator to measure inequalities, coverage of a broad spectrum of issues, comparability and universality of indicator, and availability of indicator in other key urban and health tools.[9] In addition to these five key criteria, feasibility of the indicator plays an important role in selection of core indicators of the Urban HEART.

In different countries, a list of core indicators was prepared by examining the existing literature or by reviewing the documents or by conducting workshops or taking the public health expert's opinion. In Indian setting, a list of core indicators to draft a city health profile has not been prepared as yet. In this scenario, an attempt was made to collect the public health expert's opinion on a Likert scale (1–5) to choose feasible indicators in the Urban HEART to assess a city health profile in Indian setting.

Item response theory (IRT) is based on the idea that the probability of a keyed response to an item is a mathematical function of person and item parameters.[11] In the current study, feasibility of the indicator was considered as a latent trait that influences the score of each indicator. The original scores of each indicator ranged between 1 and 5; thus, a polytomous model was used for IRT analysis and shortlisted the indicators based on the feasibility.[12],[13] The core indicators were categorized as “strongly recommended,” “desired,” and “optional” indicators that are locally adaptable.


  Material and Methods Top


The current study is a cross-sectional observational study conducted among different public health experts in India using an online survey technique. Doctors working in the public health sector and/or persons holding diploma or master's degree in public health were considered as public health experts to collect their opinion.

Indicators in the Urban HEART were categorized into two groups such as health outcome indicators and health determinants. Health outcome indicators include maternal and child health indicators and disease-specific morbidity and mortality indicators. Health determinant indicators include physical environment and infrastructure, social and human development, economic, and governance indicators.[9] A list of 29 health outcome indicators and 31 health determinant indicators was prepared from different studies conducted using the Urban HEART in different countries.

A questionnaire was prepared to collect the public health expert's opinion of each indicator in terms of specificity, measurability, attainability, relevance, timebound, and importance of the indicator. Specificity means whether the indicator well defined or unambiguous. Measurability means whether the indicator measures health inequities or not. Achievability means whether the data are available for achieving the indicator or not. Relevance means whether the indicator relevant to assess health inequities in a city or not. Timebound means whether the indicator changes from year to year or not.

Likert scale 1–5 was used to score each indicator in each domain being 1 for low value and 5 for high value. An online survey form was created using the option matrix of Likert scale 1–5 in surveyact.com (http://www.surveyact.com/s/TPjW8Kr4NhcERxNs).[14] A survey form was designed in two pages; the first page included the details of the study and requesting them to give their opinion after giving consent. The second page included matrix of Likert scale 1–5 for all the indicators. The participants who gave consent were redirected to the second page to fill the opinion form. Sample size for an opinion survey is based on the precision of the opinion.[15] Sample size was calculated as 105 using the survey sample calculator given in the https://www.surveysystem.com/sscalc.htm.[16] It was calculated as 96 for at 95% confidence level with 10% marginal error. Ten percent of the sample size was added to avoid incomplete filling of forms.

Public health experts were selected from those registered in public health-related social networking groups such as LinkedIn, Facebook, and WhatsApp groups and the public health researchers registered in the ResearchGate website. All the public health experts in those groups were contacted by sending personal E-mails, InMail messages in the LinkedIn website, posting group messages in LinkedIn groups and WhatsApp groups, and by requesting researchers in the ResearchGate website. The survey link was posted repeatedly for three times in the social networking groups. One month time gap was given to post the link in the social networking groups for each time. Members in the social networking groups were requested to give their opinion. Mails and personal messages were sent two times for requesting their opinion and for gentle reminder to express their opinion. After 1 month from the last post in the social networking group or sending gentle reminder, experts who do not expressed their opinion were considered as nonrespondents. Invitation was sent to more than 1000 public health experts keeping in mind as the response rate for online surveys is generally poor. As the number of public health experts in social networking groups changing from time to time, the total number of invitations was not fixed. A total of 105 responses were collected from different public health experts. Opinion expressed by the public health experts was used for analysis.

Analysis

Calculation of average score

The score given by public health expert for each indicator for all six domains was combined, and the average value of the cumulative score was calculated for each indicator. However, average values of cumulative score alone cannot be considered for prioritizing the indicators because few extreme responses may influence the cumulative average value. Responses given by the public health experts would depend on the feasibility of the indicator in the local context, i.e., latent trait of indicator. To consider this latent trait, IRT analysis was used to prioritize the indicators.

Item response theory

IRT is based on the idea that the probability of a keyed response to an item is a mathematical function of person and item parameters.[11] In the current study, feasibility of the indicator was considered as a latent trait that influences the score of each indicator. Feasibility of indicators was defined as possibility for implementation of the tool to assess health inequity of a city in India. The original scores of each indicator ranged between 1 and 5; thus, a polytomous model was used for IRT analysis and the indicators shortlisted based on the feasibility.[12],[13] The core indicators were categorized as “strongly recommended,” “desired,” and “optional” indicators that are locally adaptable.

Calculation of feasibility score

In the current study, feasibility was considered as latent trait, i.e., discrimination, that influences the score of each indicator. The average scores of each indicator ranged between 1 and 5; thus, multidimensional IRT analysis was used to categorize indicators. R software was used for IRT analysis.[17] IRT analysis of polytomous variables can be done using “mirt” package; thus, “mirt” package was installed in R software and used for analysis. As the data are a unidimensional polytomous data, a generalized partial credit model was used for IRT analysis.[17]


  Results Top


More than 1000 public health experts were requested to express their opinion, and only 105 public health experts gave their opinion. The response rate is very poor. After repeated requests posted in social networking groups and personalized messages sent through E-mails, 105 public health experts gave their opinion. The average score of the 60 indicators ranged from 4.54 to 2.77 [Table 1]. Infant mortality rate had the highest average score, and noise pollution had the lowest average score. Among the 29 health outcome indicators, 10 indicators had an average score more than 4 and 19 indicators had an average score in between 3 and 4. Among 31 health determinants, 6 indicators had an average score more than 4, 22 indicators had an average score in between 3 and 4, and 3 indicators had an average score <3.
Table 1: Average opinion score and feasibility score of sixty indicators of Urban Health Equity Assessment and Response Tool

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The feasibility score ranged from 4.13 to − 0.49. The incidence of malaria had a high feasibility score, and the density of cell phone towers had the least feasibility score. Among the 29 health outcome indicators, 17 indicators had a feasibility score more than 2 and 12 indicators had a feasibility score in between 0 and 2. Among the 31 health determinant indicators, 16 indicators had a feasibility score in between 0 and 2 and 15 indicators had a feasibility score <0.

[Table 2] depicts the matrix of indicators based on the recommendation of public health experts and feasibility of the indicator. Of 60 indicators, 16 indicators were strongly recommended indicators having a cumulative average score more than 4, 41 indicators were recommended indicators having a cumulative average score in between 3 and 4, and 3 indicators were optional indicators having a cumulative average score <3. Among the 16 strongly recommended indicators, 6 are highly feasible indicators having a feasibility score more than 2, 5 were feasible indicators having a feasibility score in between 0 and 2, and the remaining 5 were less feasible indicators having a feasibility score <0. Among the 41 desired indicators, 13 were highly feasible indicators, 22 were feasible indicators, and the remaining 6 were less feasible indicators. Among the 3 optional indicators, there were no highly feasible indicators: 1 was feasible indicator and 2 were less feasible indicators.
Table 2: Categorization of sixty indicators of Urban Health Equity Assessment and Response Tool based on indicator average opinion score and feasibility score

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Proportion of pregnant women registered for ANC, proportion of pregnant women suffering with severe anemia, infant mortality rate, under-five mortality rate, incidence of malaria, and incidence of TB are strongly recommended and highly feasible indicators. Maternal mortality ratio, neonatal mortality ratio, incidence of HIV cases, incidence of vaccine-preventable diseases, and subcenter population ratio are strongly recommended and feasible indicators. Primary health center population ratio, government hospital population ratio, government doctor population ratio, government ambulance population ratio, and Anganwadi population ratio are strongly recommended but less feasible indicators. Noise pollution, density of cell phone towers, and MP seat population ratio were optional indicators.


  Discussion Top


The WHO Kobe Centre stated that indicators selection in the Urban HEART will be based on the five criteria. They also stated that opinion survey is not recommended to select the indicators.[9] A study conducted by Georgia State University did the examination of existing literature for selection of indicators.[18] In Indonesia, the indicators were selected based on the document reviews and consultation with stakeholders.[19] In Iran, a workshop was conducted to develop a Tehran model of the Urban HEART based on the opinion of participants.[20] The same technique was followed in Kenya also.[21] In the Philippines, the selection of indicators is based on document review, focus group discussion and key informant interview guides, and an on-site observation checklist.[22] In Sri Lanka, the indicators were discussed and approved at a stakeholder meeting.[23] In Canada, members of the research team developed a set of guidelines that were used to test each of the selected indicators for representativeness, variability, quality, integrity, reliability, and validity. Preliminary results regarding the testing of indicators were then shared with the steering committee for input. The final set of indicators was submitted to the steering committee for approval after they were tested and validated.[24] The selection of these indicators by the steering committee members was based on policy directives. However, in the current study, an innovative approach was used for selection of indicators. All the public health experts were contacted instead of considering the opinion of few preselected experts. It eliminates the bias in the opinion expressed by the public health experts. In Vietnam, the list was the result of a process of discussion among technical workgroup members, taking into account of the real situation in the pilot sites.[25] In the current study, indicators were selected based on the public health expert's opinion instead of document reviews and literature reviews, which is more valuable. Gathering more number of public health experts at one place to conduct meeting or workshop is not feasible; thus, an online survey technique was used to collect their opinion.

In the current study, the same categories used in the Urban HEART by the WHO Kobe Centre were used to categorize selected indicators. The Tehran model of the Urban HEART had one additional category, i.e., nutrition under in health determinant indicator group.[20] In the current study, it was not used as it is indicated by socioeconomic development of the area.

The WHO Kobe Centre used infant mortality rate, diabetes, tuberculosis, and road traffic injuries as core health outcome indicators of the Urban HEART.[9] In the current study, 29 indicators listed as health outcome indicators; among them, 10 indicators were selected as strongly recommended feasible indicators. Proportion of pregnant women registered for ANC, proportion of pregnant women suffering with severe anemia, maternal mortality ratio, neonatal mortality rate, infant mortality rate, Under-five mortality rate, incidence of vaccine-preventable diseases, incidence of malaria, incidence of TB, and incidence of HIV were selected as strongly recommended feasible indicators.

The WHO Kobe Centre used access to safe water, access to improve sanitation, completion of primary education, skilled birth attendance, fully immunized children, prevalence of tobacco smoking, unemployment, and government spending on health determinant indicators of the Urban HEART.[9] In the current study, 31 indicators listed as health outcome indicators; among them, 6 indicators were selected as strongly recommended feasible indicators. Primary health center population ratio, government hospital population ratio, government doctor population ratio, government ambulance population ratio, subcenter population ratio, and Anganwadi center population ratio were selected as strongly recommended feasible indicators. In the studies conducted in different settings, they used their own list of indicators. The differences might be because of locally prevalent health problems.

In the current study, the range of cumulative average score was 4.54–2.77. Except three indicators, all had a cumulative average score more than 3. It indicated that according to public health experts' opinion, all the indicators should be included in the Urban HEART. However, some indicators have high feasibility and some indicators had less feasibility. [Figure 1] and [Table 3] depict that, among the 60 indicators, some indicators can be measured with readily available data within health sector and some indicators need combination of data from health sector and other departments. However, some indicators such as health determinants need data from external sources; among these health determinants which need data from external sources, data for some indicators was readily available and mechanism to be started for data collection for some other indicators. There is no mechanism to collect the data from external departments regularly. As they are important health determinants, a mechanism should be setup in health department to collect these data regularly. Then, only health inequities can be easily assessed.
Figure 1: Categorization of sixty indicators of the Urban Health Equity Assessment and Response Tool based on availability of data from health sector and from other departments

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Table 3: Categorization of sixty indicators of Urban Health Equity Assessment and Response Tool based on availability of data from health sector and from other departments

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Strengths of the currents study are gathering more than 100 public health experts' opinion in selecting the indicators of the Urban HEART. It increases the diversity in the opinion, and results are more valuable.[26] They are not influenced by any one. IRT analysis analyzed the underlying latent trait in selecting the indicators by different public health experts. Limitations of the study are experience of the public health expert and geographical location of the expert. Experience of public health experts has an influence on response. Some of the public health experts may not know about some indicators. Thus, they skipped some indicators while giving their opinion. However, it was not possible to separate public health experts having more experience in the social networking groups. Another limitation was that opinion was collected from public health experts throughout the country. Health problems are not the same throughout the country. Thus, opinion expressed by them will differ.


  Conclusion Top


The Urban HEART can be applied in Indian setting to assess a city health profile. Among the sixty selected indicators, all the indicators should be included in the Urban HEART. Sixteen indicators were strongly recommended indicators, 41 indicators are desired indicators, and 3 are optional indicators. Data collection can be started with feasible indicators and later can be extended to other indicators.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.



 
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