High-income Areas Research Articles

Disparities in Operative Fixation for Acromioclavicular Joint Injuries: An Analysis of Insurance Status.

Acromioclavicular (AC) joint injury management has historically been guided by the severity and grade of the injury. However, recent debates have emerged regarding the role of surgical intervention for these injuries. Insurance-based disparities in surgical treatment have been well-documented across various orthopedic conditions. This study seeks to determine whether insurance coverage influences the likelihood of undergoing surgical fixation for AC joint dislocation. We conducted a retrospective analysis of the National Readmissions Database (NRD) spanning from 2016 to 2021. Using International Classification of Diseases, Tenth Revision (ICD-10) codes, we identified patients with isolated AC joint dislocation and determined whether they received surgical intervention based on ICD-10 procedural codes. A total of 5,654 cases of AC joint dislocation were identified, of which 219 (3.9%) underwent operative management. Statistical analysis was conducted via univariate analysis using Pearson's chi-square test, followed by multivariable logistic regression to assess the significance of demographic and socioeconomic factors on likelihood of operative intervention. Results were presented as odds ratios (ORs) and 95% confidence intervals. After adjusting for demographic and socioeconomic variables including age, sex, income quartile, and medical comorbidities, patients with Medicaid insurance were significantly less likely to receive surgical intervention for AC joint dislocation compared to those with private insurance (OR 0.51; 95% CI 0.34-0.76; p < 0.01). Furthermore, individuals residing in areas with the highest income quartile by ZIP code exhibited the greatest likelihood of undergoing surgery (OR 1.91; 95% CI 1.27-2.89; p < 0.01), in contrast to those in lower-income areas. This study suggests that patients insured by Medicaid are less likely to undergo surgery for acromioclavicular joint injury compared to those with private insurance. Additionally, patients from higher-income areas were more likely to receive operative treatment. These findings emphasize the need for more standardized treatment guidelines, particularly as the controversy surrounding operative versus nonoperative management of these injuries persists, and no definitive gold standard surgical technique exists. Surgeons must remain vigilant of these biases that may influence clinical decision-making.

Subsidies and affordability: a social approach to water supply tariffs

ABSTRACT This study provides evidence of targeting the performance of subsidies and affordability of water supply services (WSS) in a low-income society marked by disparate socioeconomic indicators. We used sample microdata from the local census regarding income, as well as information about price, tariff structure, water consumption, distribution of consumer units by billed volume ranges, and the average cost of WSS by the service areas (SA) in the Federal District, Brazil, in 2019 and 2020/2021, periods in which there was a transition from the tariff methodology. The results showed average water consumption of 108 L/(inhabitant· day−1) and 399 L/(inhabitant· day1) in the lower and higher-income areas, respectively. Customers with a monthly consumption of less than 27 m3 were subsidized in both tariff cycles. The distribution of subsidies was regressive according to the connection and consumption index in the SA of lower income. Approximately a quarter of the families in the lowest income regions commit more than 3% of their income to consume water in the lifeline block of the WSS tariff structure. Findings also indicate that poorer households headed by women and children are more likely to have water poverty problems.

Processes of obstetrical care and outcomes among Ontario physicians versus non-physicians: a population-based study

ObjectiveWe compared processes of antepartum, intrapartum and postpartum care and obstetrical outcomes between physicians and non-physicians.DesignThis is a population-based retrospective matched cohort study.SettingThe study was conducted in Ontario, Canada.ParticipantsPhysicians and...

Strengthening international mutual learning in food and nutritional security: the role of Brazil’s G20 presidency

The Global Alliance against hunger and poverty launched by Brazil’s Group of Twenty (G20) Presidency builds on a long history of G20 efforts to address global food and nutritional insecurity. However, unlike previous initiatives, which focused primarily on the G20’s contribution to addressing hunger in low-income countries, the Global Alliance has the potential to innovate significantly, strengthening mutual learning for domestic policy action within G20 countries, while enhancing North-South, South-South (SSC) and Trilateral Development Cooperation (TDC). Hunger and poverty are not limited to lower-income countries. Severe food insecurity increased in every region in 2021, including in high-income areas and across all G20 countries. With reference to the experience of the United Kingdom, we argue that given the universal framing of the Sustainable Development Goals, the fact that the world is currently off track to achieve the goal of Zero Hunger should encourage G20 countries to support multilateral action at the global level while intensifying policy learning to support their own domestic efforts to tackle these challenges. In recent decades, TDC and SSC enabled many Global South countries including Brazil to engage in knowledge-sharing around effective policies to tackle hunger and poverty. We draw on two examples that build on Brazil’s experience with strong civil society and academia engagement; and propose a strategy for enhancing TDC’s potential to foster mutual learning on hunger and poverty reduction among G20 countries, as well as action by G20 members to support other countries and strengthen United Nations (UN) led multilateral efforts. We also discuss risks and opportunities for the Alliance to support scaling up local and national innovations to address entrenched and intersecting inequalities.

Study on the Impact of China’s Pension Insurance System on the Savings Rate of Urban Residents Based on the Preventive Saving Perspective

In the context of population aging, the study of the impact of the pension insurance system on the savings behavior of urban residents can help reduce preventive savings, increase current consumption, and promote the healthy development of the economy. This study constructs a two-period OLG model of the pension insurance system based on the preventive saving perspective using urban panel data of 31 provinces from 2002 to 2021 and conducts empirical analysis through the systematic generalized method of moments. The results show that the pension insurance participation rate was positively correlated with the savings rate, while the pension replacement rate was negatively correlated with the savings rate, and this effect varied significantly across income levels and different levels of aging. Increased participation in high-income areas promoted savings, while increased pension replacement rates in low-income areas reduced savings. The positive correlation between participation rates and savings rates was more pronounced in regions with higher levels of aging, while the opposite was true in regions with lower levels of aging. In addition, the negative correlation between pension replacement ratios and savings rates was particularly pronounced in high-aging regions.

Outdoor physical activity is not associated with better mental health in a sample of predominantly Black people, but spending time in parks is

Spending time outdoors may bolster mental health via relaxation and physical activity. Yet, most studies use self-report and involve majority White samples from higher income areas. Findings may not hold true using device-derived measurement, among minoritized participants, or in low-income neighborhoods. Our objectives were to test whether: i) time spent outdoors in physical activity is associated with mental health; ii) the effect is modified by the positive or negative outdoor conditions (amount of greenness or vacant houses/lots encountered while outdoors); iii) there is a correlation between our measures of outdoor conditions and perceived neighborhood conditions; and iv) there is a different relationship between time spent outdoors in parks (as an indicator of intentional nature exposure) and mental health. The sample of 112 participants (87 % Black/African American persons) from 11 Detroit, MI neighborhoods wore a GPS and accelerometer for one week (May-Oct 2021) and completed a survey. We calculated exposure to greenness, vacant lots/houses while outdoors, and perceived neighborhood aesthetics. We fitted regression models for mental health measures separately and included time spent outdoors in PA, age, sex, and days with high precipitation. We then fitted models stratified by outdoor conditions. Last, we examined whether a similar relationship could be detected for time spent outdoors in parks. On average, ∼30 % of PA was conducted outdoors, and 56 % of outdoor time involved PA. We observed an unexpected positive association between outdoor PA and anxiety (coef: 0.33, 95 % CI: 0.14–0.51), depression (coef: 0.31, 95 % CI: 0.15–0.47), and perceived stress score (coef: 0.18, 95 % CI: 0.07–0.29). When stratified, we found consistent and/or larger associations for those exposed to high levels of vacant homes, high greenness (both aerial and street-level), low levels of vacant lots, and low perceived neighborhood aesthetics. Importantly and in contrast, we observed the opposite trend when examining time spent in parks (coef: −0.05, 95 % CI: −0.10--0.01). These results contrast many studies showing positive relationships between time outdoors and mental health and highlight the need for research with diverse populations and better measures of outdoor conditions and intentionality of greenspace contact.

Corruption and emigration from the Western Balkans: evidence from a dynamic system GMM model (2012-2022)

According to neoclassical models, migration takes place when there is a strong probability that individuals will recoup their human capital investments. As a result, workers typically move from low-income to high-income areas and the larger the expected income gap between areas, the higher the number of migrants. In countries where corruption is endemic, jobs are often secured through political connections and bribes. This will lead to a higher unemployment level as well as to a lower return to human capital. Consequently, a significant proportion of the population considers emigration as the only path to succeed. The present study is focused on the impact of corruption on emigration from six Western Balkan countries. A System Generalized Method of Moments is estimated to analyze migrant stocks in 28 receiving countries during the period from 2012 to 2022. We suggest that corruption can directly influence migration stocks in receiving countries.

Air pollution and the mystery of high household savings in China

Despite consumption being a key measure of residential welfare, the relationship of the residential savings rates, an inverse proxy for household consumption, with air pollution is unclear. This study empirically examines the impact of air pollution on household savings rates, and the underlying mechanism. The results reveal that worsening air pollution significantly increases household savings rates; this finding holds under alternative variable specifications and employing instrumental variables to address endogeneity issues. The mechanism analysis demonstrates that air pollution enhances household savings rates through health risks. Heterogeneity analysis indicates that in developed areas with more comprehensive public medical service systems, the positive effect of air pollution on household savings rates weakens in second-tier cities and above as well as in high-income areas. Furthermore, improvements in commercial insurance coverage mitigates the positive effect of air pollution on household savings rates. Overall, this study explains the high savings phenomenon among Chinese households from an environmental perspective. The Chinese government should encourage the use of renewable energy, improve air pollution control, and reduce the inhibitory effects of air pollution on residential consumption.

Geospatial Analysis of Pediatric Burns Reveals Opportunities for Injury Prevention

BackgroundGeospatial analysis is useful for identifying hot spots for preventable injuries and for informing prevention efforts. We hypothesize that specific populations of children in South Florida are at increased risk of burn injury. MethodsWe used a regional burn center registry to geocode burn cases treated from July 2013 to December 2022 for patients <18 years. Spatial analysis was utilized to identify high-density areas and potential spatial clusters of patients living in Palm Beach, Broward, and Miami-Dade Counties. Sociodemographic factors, burn etiology, and physiologic characteristics were analyzed using geospatial and statistical analyses. Results689 patients (58% male, median age 2 [1–8] years) were identified. The annual incidence of burns was 5.5 per 100,000 children. There was no seasonal variation in injury patterns. Most patients were Black (51%) and non-Hispanic (73%). Scald burns (72%) represented the most common etiology, followed by flame (10%) and contact with hot objects (9%). Most patients (58%) required inpatient admission. Scald and contact burns occurred in younger patients compared to other mechanisms (median [IQR] age: 2 [1–6] vs. 8 [4–12] years, p < 0.001). Race, ethnicity, and insurance status were not associated with inpatient admission (all p > 0.05). Overall, there was a higher rate of pediatric burn injuries affecting Black residents, with a paucity of injuries in predominately high-income areas. ConclusionsA disproportionate amount of pediatric burn injuries occur in low-income and predominantly Black neighborhoods. Additionally, scald and contact burns are a target for injury prevention in South Florida. These data may inform public health implementation to reduce morbidity in vulnerable populations. Level of EvidenceLevel III. Type of StudyRetrospective comparative study.

Mapping Nutritional Inequality: A Primary Socio-Spatial Analysis of Food Deserts in Santiago de Chile

This study investigates the socio-spatial distribution of food deserts in Santiago de Chile, aiming to understand how urban planning and socioeconomic factors influence access to nutritious food. Employing geospatial analysis techniques with data from OpenStreetMap and the 2017 Census, the research identifies areas within Santiago where access to healthy food is limited. The novelty of this study lies in its application of spatial autocorrelation methods, specifically Local Indicators of Spatial Association (LISA), to reveal clusters of nutritional inequality. The findings indicate significant concentrations of food deserts in both lower socioeconomic peripheral areas and, surprisingly, in some high-income central areas. These results suggest that both poverty and urban infrastructure, including car dependency, play critical roles in shaping access to healthy food. By highlighting over two million residents affected by food deserts, the study underscores the urgent need for integrated urban planning and public health strategies. This research contributes to the understanding of urban nutritional inequality and provides a replicable methodological framework for other cities. The implications extend beyond Santiago, offering insights into how urban design can be leveraged to improve public health outcomes through better access to nutritious food.

Areal differences in the rate of operative care for cancer of the head and neck within one hospital district in Northern Finland

Abstract Aim The relationship between socioeconomic status (SES) and cancers of the head and neck has been described previously. The present study investigated areal differences in the rate of operative care of cancers of the head and neck in terms of SES and rural–urban areas. Methods This retrospective cohort study included operations performed in Northern Finland between 1 January 2014 and 31 December 2019. SES and the rurality of the residence was determined using postal codes. Results Patients from the low-income areas were older and had higher American Society of Anesthesiologists classification than patients from middle- and high-income areas. The number of operated thyroid and parotid gland tumours was higher in the high-income areas (n = 36 [33.0%] vs n = 21 [18.8%] and n = 330 [28.6%], p = 0.049). Patients living in low- or median-income areas were more likely to live in rural areas than patients living in high-income areas (n = 55 [49.1%] and n = 62 [59.0%] vs n = 44 [40.4%], p = 0.024). The age-weighted rate of operations was higher in low-income areas than in high-income areas (29.3 [23.9–29.3] vs 17.9 [14.5–21.2]), and the age-weighted rate of free-flap surgery was highest in the low-income areas (16.8 [12.4–21.2] vs 8.2 [5.7–10.6] and 9.6 [7.0–12.1] /100,000 inhabitants/year). Conclusion There are significant areal differences in the rate of ablative head and neck surgery. Significantly higher rates were found in low-income areas and in rural areas.

Metagenomics analysis of sewage for surveillance of antimicrobial resistance in South Africa.

Our 24-month study used metagenomics to investigate antimicrobial resistance (AMR) abundance in raw sewage from wastewater treatment works (WWTWs) in two municipalities in Gauteng Province, South Africa. At the AMR class level, data showed similar trends at all WWTWs, showing that aminoglycoside, beta-lactam, sulfonamide and tetracycline resistance was most abundant. AMR abundance differences were shown between municipalities, where Tshwane Metropolitan Municipality (TMM) WWTWs showed overall higher abundance of AMR compared to Ekurhuleni Metropolitan Municipality (EMM) WWTWs. Also, within each municipality, there were differing trends in AMR abundance. Notably, within TMM, certain AMR classes (macrolides and macrolides_streptogramin B) were in higher abundance at a WWTW serving an urban high-income area, while other AMR classes (aminoglycosides) were in higher abundance at a WWTW serving a semi-urban low income area. At the AMR gene level, all WWTWs samples showed the most abundance for the sul1 gene (encoding sulfonamide resistance). Following this, the next 14 most abundant genes encoded resistance to sulfonamides, aminoglycosides, macrolides, tetracyclines and beta-lactams. Notably, within TMM, some macrolide-encoding resistance genes (mefC, msrE, mphG and mphE) were in highest abundance at a WWTW serving an urban high-income area; while sul1, sul2 and tetC genes were in highest abundance at a WWTW serving a semi-urban low income area. Differential abundance analysis of AMR genes at WWTWs, following stratification of data by season, showed some notable variance in six AMR genes, of which blaKPC-2 and blaKPC-34 genes showed the highest prevalence of seasonal abundance differences when comparing data within a WWTW. The general trend was to see higher abundances of AMR genes in colder seasons, when comparing seasonal data within a WWTW. Our study investigated wastewater samples in only one province of South Africa, from WWTWs located within close proximity to one another. We would require a more widespread investigation at WWTWs distributed across all regions/provinces of South Africa, in order to describe a more comprehensive profile of AMR abundance across the country.

Mental health service use among mothers and other birthing parents during the COVID-19 pandemic in Ontario, Canada

BackgroundParents have reported increased symptoms of depression and anxiety during the COVID-19 pandemic. This study evaluated changes in mental health and addiction (MHA)-related health service use among mothers and other birthing parents during the COVID-19 pandemic. MethodsWe conducted a repeated cross-sectional study using health administrative data in Ontario, Canada. The population included all mothers and birthing parents (≥1 child aged 1–18, no children <1 to exclude postpartum parents) between January 2016 and December 2021. We compared rates of MHA-related outpatient physician visits, hospitalizations, and emergency department (ED) visits during COVID-19 (March 2020–December 2021) to pre-COVID-19 (pre-March 2020). ResultsMHA-related outpatient visit rates increased by 17 % (rate ratio (RR) 1.17, 95 % CI 1.16–1.18) during COVID-19. Monthly utilization rates remained higher than expected across the COVID-19 period. MHA-related ED visit rates remained lower than expected during COVID-19, while MHA-related hospitalization rates returned to expected levels by August 2020. The largest relative increases in MHA-related outpatient visits during COVID-19 were in mothers and other birthing parents living in higher income (RR 1.20, 95 % CI 1.19–1.22) or urban areas (RR 1.20, 95 % CI 1.18–1.21), with children aged 1–3 years (RR 1.23, 95 % CI 1.20–1.25) and with no history of MHA-related health service use (RR 1.20, 95 % CI 1.19–1.21). LimitationsThis study only captured physician-delivered MHA-related health service use. ConclusionsThe COVID-19 pandemic was associated with an increase in MHA-related outpatient visits among mothers and other birthing parents. These findings point to the need for improvements in mental health service access.

Socioeconomic factors and rural-urban differences in patients undergoing emergency laparotomy

Background: Emergency laparotomy (EL) is a common surgical procedure with high rates of mortality and complications. Socioeconomic circumstances and regional differences have an influence on the utilization of care and outcomes in many diagnostic groups, but there are only few studies focusing on their effect in EL population. The aim of this study was to examine the socioeconomic and regional differences in the rate of EL within one tertiary care hospital district. Methods: Retrospective single-center study of 573 patients who underwent EL in Oulu University Hospital between May 2015 and December 2017. The postal code area of each patient’s home address was used to determine the socioeconomic status and rurality of the location of residence. Results: The age adjusted rate of EL was higher in patients from low-income areas compared to patients from high-income areas (1.46 ((95% CI 1,27-1.64)) vs. 1.15 ((95% CI, 0.96-1.34))). The rate of EL was higher in rural areas compared to urban areas (1.29 (95% CI 1.17-1.41 vs. 1.42 (1.18-1.67) ). Peritonitis was more common in patients living in low-income areas. There were no differences in operation types or mortality between the groups. Conclusions: The study findings suggest that there are socioeconomic and regional differences in the need of EL. The patients living in low-income areas had a higher rate of EL and a higher rate of peritonitis. These differences cannot be explained by patient demographics or comorbidities alone.

The great equalizer? Mixed effects of social infrastructure on diverse encounters in cities

Casual encounters with diverse groups of people in urban spaces have been shown to foster social capital and trust, leading to higher quality of life, civic participation, and community resilience to hazards. To promote such diverse encounters and cultivate social ties, policymakers develop social infrastructure sites, such as community centers, parks, and plazas. However, their effects on the diversity of encounters, compared to baseline sites (e.g., grocery stores), have not been fully understood. In this study, we use a large-scale, privacy-enhanced mobility dataset of >120 K anonymized mobile phone users in the Boston area to evaluate the effects of social infrastructure sites on the observed frequencies of inter-income and inter-race encounters. Contrary to our intuition that all social infrastructure sites promote diverse encounters, we find the effects to be mixed and more nuanced. Overall, parks and social businesses promote more inter-income encounters, while community spaces promote more same-income encounters, but each produces opposite effects for inter-race encounters. Parks and community spaces located in low-income neighborhoods were shown to result in higher inter-income and inter-race encounters compared to ordinary sites, respectively, however, their associations were insignificant in high-income areas. These empirical results suggest that the type of social infrastructure and neighborhood traits may alter levels of diverse encounters.

Determinants of housing demands and residential rent costs in an emerging city in Southern Nigeria

Housing is vital to human experience. It is the basis and foci of daily activities. In Asaba, a strategically located, fast-growing metropolis, city officials are confronted by myriads of urban planning issues, one of which is provision of urban housing. This study attempted to identify the determinants of housing demands and costs of residential rents within the city (Asaba). In this study, the ex-post facto and survey designs were deployed. The data for the study comprised of the primary (questionnaire data) and secondary (historical housing data) types. For effective questionnaire administration, the study area was stratified into high, medium and low income areas. The Analysis of Variance (ANOVA) and the Spearman's rank correlation coefficient were deployed for data analyses. The results indicated that the key determinants of residential housing demand and costs were ease of access to public transport (69 %), nearness to security formations (80 %) and higher demand for houses in supply (75.8 %); and the Spearman's rank correlation showed that these factors were significant at P < 0.05. Other factors such as availability of electricity and access to water supply were not significant determinants of choice of housing at P > 0.05. This is due to the fact that the whole region lacks adequate electricity supply and water is self-harnessed through boreholes. ANOVA showed that there was a significant temporal variation in the cost of residential housing rents at p<0.05 (F-69.03; sig 0.000). Consequently, this study recommends that there is need for the decentralisation of the city; which should be realised by an efficient development of the suburbs to high standards that would meet the requirements of prospective renters. Policy development and establishment of basic facilities in the suburbs, would help actualise this decentralization. Also, collaboration between government and private developers could yield more supply in the housing stuck, consequently reducing costs of housing.

Insect herbivory on Acer rubrum varies across income and urbanization gradients in the D.C. metropolitan area

Urbanization has increased wealth disparity within the United States, impacting the urban landscape and species interactions. In particular, the interactions between street trees and the arthropod communities that live among them may be modified by both human population densities across urban to suburban locations, as well as income levels within these areas. We examined the effect of land use type (urban vs. suburban) and median household income on variation in leaf damage and arthropod abundance of red maples (Acer rubrum) in the District of Columbia metropolitan region. We compared these levels of leaf damage to rates observed in a nearby temperate deciduous forest. We predicted leaf damage would be positively correlated with urbanization (forested < suburban < urban) and negatively correlated with neighborhood income level (low > medium > high). Instead, we observed higher levels of leaf damage on trees in the forest environment compared to the urban and suburban areas. Leaves from urban medium and high-income areas were less likely to exhibit herbivore damage than those from suburban areas. Of the leaves with damage, those in urban high-income and suburban low-income areas exhibited the most leaf area missing. These trends may be related to specific factors associated with urbanization and income level, such as impervious surface coverage and tree coverage. This study highlights differences in biotic interactions across individual neighborhoods and the importance of including socio-economic variables when examining species interactions in urban environments.

How Does Agricultural Green Transformation Improve Residents’ Health? Empirical Evidence from China

Promoting green and sustainable agriculture is of great significance for ensuring food security and addressing global challenges. Meanwhile, health has increasingly become a global concern. Nutrition and health are the purpose of agricultural production. As two major global issues, how agriculture empowers human health has long been discussed. Based on the provincial panel data of China from 2003 to 2021, this paper studies the impact of agricultural green transformation (AGT) on residents’ health and explores its impact mechanism. The empirical results show that: (1) AGT in China has significantly reduced the average mortality rate and maternal mortality rate and significantly increased the average life expectancy, indicating that AGT in China has significantly improved the health level. The conclusions of robustness testing methods such as replacing AGT indicators and controlling endogeneity are still valid; and (2) The impact of AGT on residents’ health depends on the regional economic level, and there is a threshold effect. Compared with low-income areas, the positive effects of AGT in high-income areas on residents’ health are more pronounced; and (3) Agricultural carbon emissions play an intermediary effect between AGT and residents’ health, and AGT can improve residents’ health by reducing carbon emissions. The level of local education development plays a moderating role in the relationship between AGT and residents’ health. Agricultural policy implications include enhancing the ability to protect and utilize agricultural resources, promoting the green and low-carbon transformation of agriculture, and taking a more scientific and systematic approach towards the complex diversity of health risk factors.

Docked bikeshare: a review of the interrelationship between socio-economic disadvantage and the built environment

ABSTRACT Promoted for their contribution towards decarbonising transport, encouraging modal shift, and improving health outcomes, bikeshare schemes (BSS) have developed worldwide. However, evidence suggests that fixed docking stations are often disproportionately located in white, high-income and high employment areas. Consequently, certain (often disadvantaged) communities may not be able to benefit as much as others from BSS. Interrelated issues concerning the built environment and socio-economic disadvantage include inequities related to population and residential accessibility, cycle lane access, docking station density and location, integration with public transport, access to city centres, universities, and unsafe areas. The paper reviews these aspects and discusses their implications for docking station planning practices that incorporate built environment insights and facilitate equitable access and use. Future research directions pertaining to examining the interrelationship between the built environment and disadvantage are suggested.

Global disparities in immunotherapy clinical trials: A comprehensive analysis of low- and middle-income countries over the past decade.

1606 Background: Immunotherapy (IO) has largely impacted cancer treatment over the last decade, yet its accessibility and representation in clinical trials remain severely limited in low- and middle- income countries. We investigated the involvement of these countries in IO cancer trials, analyzing country-specific rates and influencing factors. Methods: Data was obtained from clinicaltrials.gov. Advanced search focused on cancer interventional studies from 12/31/2013 to 01/01/2024 with specific IO treatments. Only completed trials were included. Studies unrelated to immunotherapy or cancer were excluded. Country trial rates were calculated per 100k population. Statistical analysis used Chi-square test for nominal data. Results: Of 1593 trials, 1282 were included in the final analysis. Of world’s 217 countries and regions (World Bank) 72 (33.2%) participated in IO cancer trials in the last decade. Zero country from low-income group was involved in the trials. Only 2.4% (31) of all trials, included lower-middle-income countries (LMICs). Out of 54 LMICs, only 8 were represented: Ukraine, Philippines, India, Guatemala, Egypt, Vietnam, Morocco, and Eswatini (Swaziland). Ukraine led this group with 16 trials, while the remaining 7 were included in less than 10 trials each. Upper-middle-income countries (UMICs) were included in 21.3% (273) of trials. Out of 54 UMICs, 22 were involved in the trials; China led this group (174), followed by Russia (69), Brazil (52), Mexico and Turkey (41 each). Among the top 30 countries with the highest trial participation, none included LMICs, and only 5 were UMICs. Of 81 high-income countries (HICs) 42 participated in IO trials. USA was involved in over 65% of all trials (840), followed by Spain (222), France (193), and Canada (180). However, population-adjusted rates varied, with European HICs like Latvia (2.16), Belgium (1.09), Norway (0.87) among 25 other countries, showing higher rates than USA (0.25). Majority of trials done solely in one country were also from USA (65%), and China (79%). A significant link was found between the economic status of participating countries and the funding source of trials (p&lt;0.00001). Industry funded 28 of 31 (90%) trials in LMICs, indicating a reliance on industry funding in these regions. Industry favored adult-only over pediatric-inclusive trials (p&lt;0.0001). Out of 80 trials (6.24%) including children, 22 were industry-funded. Exclusively pediatric IO trials were only 4 (0.3%) of all IO trials. LMICs participated in 3.75% (3) of all pediatric-inclusive trials. Conclusions: Countries with low economic status and children with cancer from both low- and high-income areas are largely underrepresented in IO cancer trials globally. More inclusive IO trials across age groups and LMICs are vital to implement trial results in real-world settings and close the care gap.