Equal Coverage Research Articles

Automating the optimization of proton PBS treatment planning for head and neck cancers using policy gradient-based deep reinforcement learning.

Proton pencil beam scanning (PBS) treatment planning for head and neck (H&N) cancers is a time-consuming and experience-demanding task where a large number of potentially conflicting planning objectives are involved. Deep reinforcement learning (DRL) has recently been introduced to the planning processes of intensity-modulated radiation therapy (IMRT) and brachytherapy for prostate, lung, and cervical cancers. However, existing DRL planning models are built upon the Q-learning framework and rely on weighted linear combinations of clinical metrics for reward calculation. These approaches suffer from poor scalability and flexibility, that is, they are only capable of adjusting a limited number of planning objectives in discrete action spaces and therefore fail to generalize to more complex planning problems. Here we propose an automatic treatment planning model using the proximal policy optimization (PPO) algorithm in the policy gradient framework of DRL and a dose distribution-based reward function for proton PBS treatment planning of H&N cancers. The planning process is formulated as an optimization problem. A set of empirical rules is used to create auxiliary planning structures from target volumes and organs-at-risk (OARs), along with their associated planning objectives. Special attention is given to overlapping structures with potentially conflicting objectives. These planning objectives are fed into an in-house optimization engine to generate the spot monitor unit (MU) values. A decision-making policy network trained using PPO is developed to iteratively adjust the involved planning objective parameters. The policy network predicts actions in a continuous action space and guides the treatment planning system to refine the PBS treatment plans using a novel dose distribution-based reward function. A total of 34 H&N patients (30 for training and 4 for test) and 26 liver patients (20 for training, 6 for test) are included in this study to train and verify the effectiveness and generalizability of the proposed method. Proton H&N treatment plans generated by the model show improved OAR sparing with equal or superior target coverage when compared with human-generated plans. Moreover, additional experiments on liver cancer demonstrate that the proposed method can be successfully generalized to other treatmentsites. The automatic treatment planning model can generate complex H&N plans with quality comparable or superior to those produced by experienced human planners. Compared with existing works, our method is capable of handling more planning objectives in continuous action spaces. To the best of our knowledge, this is the first DRL-based automatic treatment planning model capable of achieving human-level performance for H&Ncancers.

Implementing targeted vaccination activities to address inequalities in vaccination: a qualitative study.

As the UK COVID-19 vaccination programme progressed, greater emphasis was placed on the implementation of localized targeted vaccination activities to address inequalities in vaccination coverage. This study examines one UK region's approach to the delivery of targeted vaccination activities and identifies key factors influencing implementation. Qualitative interviews were conducted with a purposive sample of key individuals involved in vaccination delivery across Greater Manchester (GM). A rapid analysis approach was adopted. A template based on the Consolidated Framework for Implementation Research helped to guide analysis. Twenty-seven participants were interviewed, from nine of the 10 GM localities. All areas planned to implement targeted vaccination activity, but size and scope varied. Five factors influencing the implementation of targeted vaccination approaches were identified: (i) integrated working; (ii) data availability and monitoring, (iii) engagement with populations and communities, (iv) resources and infrastructure, and (v) external policies and procedures. The study provides wider lessons for future public health interventions around the need for collaborative working, adequately resourced community engagement, appropriate data, long-term workforce/system planning and coherence in policy and messaging. These findings have led to the generation of six key insights for the implementation of future targeted vaccination programmes.

Missed Measles Immunisations Places Individuals and Communities at Risk: The Equity Argument for Including Measles in Under-Immunised Definitions

Background: Measles is consistently one of the leading causes of death from vaccine-preventable diseases in children, and cases and deaths have increased globally since 2019. While measles often serves as a ‘canary in the coalmine’ for health system weaknesses, global definitions of zero-dose and under-immunised children continue to centre on those who have missed diphtheria-tetanus-pertussis (DTP) containing vaccine. We propose that lack of receipt of measles vaccine is included in global definitions of ‘under-immunised’ children. Methods: We used publicly available WHO/UNICEF estimates of national immunization coverage (WUENIC) data to determine the number and proportion of children missing out on routine immunisations in each country globally in 2019 and 2022. We stratified countries by income status to further investigate inequalities in vaccine coverage between different countries. Results: In 2022, 50% more children missed out on their first dose measles-containing vaccine compared to DTP1, and 96% of these children resided in low-middle income countries (LMICs), highlighting the compounding inequities in measles immunisations globally. Furthermore, countries with the largest number of children missing out on DTP1 were not reflective of countries with the lowest measles immunisation coverage rates, suggesting targeted programs are needed to reach children who are missing out on measles vaccination. Recommendations: Given the high transmissibility and inequitable burden measles outbreaks pose to both at-risk individuals and communities, especially in LMICs, measles immunisation coverage should be included as a key metric when reporting and estimating the number of under-immunised children globally.

Socioeconomic status correlates with COVID-19 vaccination coverage among primary and secondary students in the most populated city of Chile

The burden of COVID-19 was heterogeneous, indicating that the effects of this disease are synergistic with both other non-communicable diseases and socioeconomic status (SES), highlighting its syndemic character. While the appearance of vaccines moderated the pandemic effects, their coverage was heterogeneous too, both when comparing different countries, and when comparing different populations within countries. Of note, once again SES appears to be a correlated factor. We analyzed publicly available data detailing the percentage of school-aged, vaccinated children in different municipalities belonging to the Metropolitan Area (MA) of Santiago, Chile. Vaccination data was compiled per school type, either public, state-subsidized, or private, at three different dates during the COVID-19 pandemic to cover the dispersion of Delta, Omicron, and its subvariants BA.4 and BA.5. We computed the median vaccination ratio for each municipality and school type and calculated their Spearman’s rank correlation coefficient with each one of nine SES indices. The percentage of school-age children who received vaccinations against COVID-19 correlates with SES. This strong correlation is observed in public and state-subsidized schools, but not in private schools. Although inequity in vaccination coverage decreased over time, it remained higher among students enrolled either in public or state-subsidized schools compared to those of private schools. Although available data was insufficient to explore plausible causes behind lower vaccination coverage, it is likely that a combination of factors including the lack of proper information about the importance of vaccination, the lack of incentives for children’s vaccination, low trust in the government, and limited access to vaccines for lower-income people, may all have contributed. These findings raise the need to design better strategies to overcome shortcomings in vaccination campaigns to confront future pandemics.

Small-area variation in child under-vaccination in India: a multilevel analysis of cross-sectional data from 36 states and Union Territories, 707 districts, and 22,349 small-area clusters

India has made exceptional advances in child immunisation, but subnational inequities in vaccination coverage impede attainment of key programmatic goals. Our study provides an up-to-date national portrait of local variations in child vaccination using a comprehensive set of indicators relevant to routine immunisation. Indicators representing unvaccinated (zero-dose) children, incomplete basic immunisation, and vulnerability to measles and polio, were constructed from India's 2019-2021 National Family Health Survey. We used four-level random effects logistic regression models to partition the total outcome variation over state, district and cluster levels, and produce precision-weighted estimates of prevalence across clusters. District-level prevalence and within-district variation using standard deviation measures were derived for each outcome. Boxplots graphically summarised the distribution of precision-weighted mean cluster prevalence by state. The analysis included 87,622 children aged 12-36 months. Clusters accounted for 67.6% (var: 1.36; SE: 0.127) of the variation among zero-dose children, and more than 50% for all indicators. Districts with a higher prevalence of under-vaccination tended to have higher within-district heterogeneity, interpretable as greater within-district child vaccination inequities. For vaccines administered in the first year of life, the northeastern states and Uttar Pradesh had the highest median under-vaccination. Despite India's high aggregate vaccine coverage, the distribution of small-area (cluster) mean prevalence highlighted pockets of low coverage in most states, suggesting ongoing vulnerability to measles and polio. Achieving India's vaccination goals requires a strategic shift towards identification and targeting of low-immunity clusters at the sub-district level. Canadian Institutes of Health Research.

Critical Review of Healthcare Policy Innovations: Transforming Global Health Delivery Systems

This paper reviews recent contributions to the development of healthcare policies and analyzes their implications for the ongoing and future changes in healthcare delivery systems worldwide. It looks at how policy innovations that seek to solve persistent issues and problems relating to healthcare, such as access, quality, and costs, are achieved. There is a particular emphasis on the coming collaborative ideas like UHC, accounts receivable systems, MACRA, MAC-P, and RECOVERY models, as well as digital health technology. These innovations are analyzed for their effectiveness in enhancing the health of patients, the general cost of the provision of healthcare, and the total satisfaction of the patient. Through comparisons of national and international policy changes, the paper shows the strengths and weaknesses of these reforms. It also points to some of the areas that need better improvement in healthcare systems all over the world. The main topics, such as health inequalities, the involvement of private-public partnerships, and technology, are presented so that the reader gets a clear picture of all the existing problems. Thus, the study indicates there have been strides made towards attaining the objectives of increasing coverage of health facilities and the quality of delivered health care; however, continued effort is required to remove barriers restricted by race and ethnicity to guarantee equal coverage for every society. In the same tone, the paper outlines recommendations that may be put to use and implemented in future reforms of healthcare policies in order to enhance healthcare delivery systems, operational efficiency, and stability in the global market.

Healthcare Policy and Equity in Tracheostomy Care: Navigating Access, Advocacy, and Reform

The evolving U.S. healthcare landscape poses significant challenges for individuals requiring tracheostomy care, their families, and healthcare teams. These patients, their care partners, and health professionals face significant medical and social challenges, necessitating coordinated, long-term support to maintain health, prevent complications, and enhance quality of life. While policies like the Affordable Care Act (ACA) and Medicaid expansion have reduced uninsured rates and improved access to critical services, sustaining these gains relies on the renewal of subsidies that broaden coverage. Systemic barriers—including coverage gaps, inequities, and administrative inefficiencies—persist. This commentary explores how healthcare reforms, including Medicaid expansion, enhanced ACA subsidies, and Medicare policy adjustments, can address these barriers. It also highlights the disproportionate burden on low-income and minority populations, as well as the strain on healthcare teams managing complex care needs. Advocacy efforts should focus on expanding coverage, reducing costs, and addressing social determinants of health to promote equitable, high-quality care for all patients.

Trends and inequalities in BCG immunisation coverage among one-year-olds in Sierra Leone, 2008–2019

BackgroundBacillus Calmette-Guérin (BCG) vaccination is a cornerstone of childhood immunisation programs, protecting against tuberculosis (TB), a major public health concern. Sierra Leone, a West African nation, faces challenges in achieving equitable and high BCG immunisation coverage. This study delves into the trends and inequalities in BCG coverage among one-year-old children in Sierra Leone between 2008 and 2019.MethodsThree rounds of data from the Sierra Leone Demographic and Health Surveys (2008, 2013, and 2019) were used to analysed to examine the inequalities in BCG coverage. Simple measures of inequality [Difference (D) and Ratio (R)] and complex measures of inequality [Population Attributable Ratio (PAR) and Fraction (PAF)] were calculated in the World Health Organization’s Health Equity Assessment Toolkit (WHO’s HEAT) software. The measures were calculated separately for each of the three surveys for age groups of women, level of education, economic status, residential areas, gender, and sub-national provinces, and their estimates were compared.ResultsThe findings revealed that BCG immunisation coverage in Sierra Leone has increased significantly from 2008 (82.0%) to 2019 (96.3%). Age-related inequalities between children of older mothers (20-49) and younger mothers (15-19) increased from a Difference of -4.7 percentage points in 2008 to 4.8 percentage points in 2019. The PAF increased from zero in 2008 to 0.4% in 2019. This means that in the absence of age-related inequalities, the national average of BCG immunisation coverage would have increased by 0.4%. Economic-related inequalities between children of mothers in Quintile 5 (richest) and Quintile 1 (poorest) decreased from a Difference of 9.2 percentage points in 2008 to 1.2 percentage points in 2019. Educational-related inequalities between children of mothers with secondary/higher education and no education decreased from a Difference of 14.1 percentage points in 2008 to 0.4 percentage points in 2019. The PAF decreased from 13.3% in 2008 to 0.2% in 2019, indicating that without educational-related inequalities the setting average of BCG immunisation coverage would have increased by 0.2%. Place of residence-related inequalities between children of mothers living in urban areas and rural areas decreased from a Difference of 9.3 percentage points in 2008 to 0.7 percentage points in 2019. The PAF decreased from 8.5% in 2008 to 0.5% in 2019 indicating that the national average of BCG immunisation coverage would have increased by 0.5% without place of residence-related inequalities. The sex of the child-related inequalities between male and female children decreased from a Difference of 5.4 percentage points in 2008 to 0.7 percentage points in 2019. The PAF decreased from 3.3% in 2008 to 0.4% in 2019 indicating that the national average of BCG immunisation coverage would have increased by 0.4% without sex of the child-related inequalities. Provincial inequalities decreased from a Difference of 18.5 percentage points in 2008 to 2.3 percentage points in 2019. The PAF decreased from 14.3% in 2008 to 1.1% in 2019 indicating that the national average of BCG immunisation coverage would have increased by 1.1% without provincial inequalities.ConclusionThe findings indicate a substantial improvement in BCG immunisation coverage in Sierra Leone among one-year-olds, reflecting successful public health initiatives. However, age-related inequalities have worsened, with coverage among children of younger mothers declining relative to those of older mothers, suggesting a need for targeted interventions for this population. In contrast, economic, educational, sex, and place of residence-related inequalities have notably decreased, indicating progress in equitable access to immunisation across different socioeconomic strata. Additionally, provincial inequalities have decreased significantly, yet a difference of 2.3 percentage points remains, highlighting the need for continued efforts to ensure that all provinces, receive adequate healthcare resources and outreach. The absence of economic-related inequality by 2019 is particularly encouraging, as it suggests that economic barriers to immunisation have been effectively addressed. Furthermore, the reduction in educational and provincial inequalities highlights the effectiveness of strategies aimed at improving access and awareness in underserved areas.

Modeling HPV self-sampling impact on cervical cancer in East African immigrants

IntroductionCervical cancer screening uptake among East African immigrants (EAI) in the US is low. Offering self-collected samples for human papillomavirus (HPV) testing increases screening coverage among underserved populations, but the potential impact on cervical cancer incidence and mortality is understudied. MethodsA Markov cohort state-transition model was used to predict the impact of primary HPV screening with self-sampling on cervical cancer incidence and mortality among EAI women in Washington state. The model estimated cervical cancer cases and deaths for a hypothetical cohort from ages 25-80 years under alternative screening, diagnostic colposcopy and treatment scenarios. Base case scenarios compared primary HPV testing by clinician-sampling exclusively (standard-of-care, SOC) with self-sampling exclusively, assuming higher screening coverage (70% vs. 63%) but lower colposcopy adherence with self-sampling (67% vs. 83%) with equal treatment coverage of 85%, based on Washington state patient data. Sensitivity analyses with varied coverages, and also the combinations of the two strategies were evaluated. The model was developed and fitted between 2022 and 2024 ResultsIn the base case scenario, an exclusive self-sampling strategy results in 4% higher cervical cancer incidence and mortality compared to the SOC. Self-sampling results in lower cancer incidence and mortality if colposcopy adherence is raised to the level of the SOC and/or if coverage is increased beyond 90%. In scenarios combining clinician- with self-sampling, the benefits of reaching more women with self-sampling are attenuated if more than 34% of screening is done by self-sampling. ConclusionsSelf-sampling has the potential to improve cervical cancer prevention for underserved populations. The impact of the strategy can be enhanced with stronger linkage to follow-up care.

Influenza Vaccination, Household Composition, and Race-Based Differences in Influenza Incidence: An Agent-Based Modeling Study.

Objectives. To estimate the effect of influenza vaccination disparities. Methods. We compared symptomatic influenza cases between Black and White races in 2 scenarios: (1) race- and age-specific vaccination coverage and (2) equal vaccination coverage. We also compared differences in household composition between races. We used the Framework for Reconstructing Epidemiological Dynamics, an agent-based model that assigns US Census‒based age, race, households, and geographic location to agents (individual people), in US counties of varying racial and age composition. Results. Influenza cases were highest in counties with higher proportions of children. Cases were up to 30% higher in Black agents with both race-based and race-equal vaccination coverage. Compared with corresponding categories of White households, cases in Black households without children were lower and with children were higher. Conclusions. Racial disparities in influenza cases persisted after equalizing vaccination coverage. The proportion of children in the population contributed to the number of influenza cases regardless of race. Differences in household composition may provide insight into racial differences and offer an opportunity to improve vaccination coverage to reduce influenza burden for both races. (Am J Public Health. Published online ahead of print November 14, 2024:e1-e8. https://doi.org/10.2105/AJPH.2024.307878).

Analysis of Trends in Immunization Coverage Inequalities Among Children Aged 12–23 Months in Guinea: Data from Demographic and Health Surveys in 2005, 2012, and 2018

Background: The aim of this study was to describe trends in inequalities in full immunization of children aged 12 to 23 months and to identify associated socioeconomic factors. Methods: A secondary analysis was carried out using data from three Demographic and Health Surveys (DHS) conducted in 2005, 2012 and 2018 in the Republic of Guinea. The concentration, or Lorenz curve, and associated index were used to measure inequalities over time. Multivariate logistic regression was employed to identify socioeconomic factors associated with full vaccination of children aged 12 to 23 months. Results: The study found a strongly positive overall concentration index (CI > 0.5) for complete vaccination of children aged 12 to 23 months, indicating inequalities in favor of wealthier households. This inequality decreased in 2012 but increased again in 2018. Children from wealthy families were nearly twice as likely to be fully vaccinated compared to children from very poor families (adjusted OR 1.79, 95% CI: 1.38 - 2.32). Conclusion: This study revealed significant inequalities favoring wealthy families in the use of immunization services by children aged 12 to 23 months in Guinea. It also underscores the need for planning and implementing strategies to reduce these inequalities in access to and use of immunization services.

Mapping inequalities in health service coverage in Africa: a scoping review

ObjectiveIn this scoping review, we aim to consolidate the evidence on inequalities in service coverage in Africa using a comprehensive set of stratifiers. These stratifiers include place of residence, race/ethnicity/culture/language,...

International cooperation for the decarbonization of energy-intensive industries: unlocking the full potential

ABSTRACT This article investigates the state of global governance for the deep decarbonization of energy-intensive industries (EIIs) and identifies key options for mobilizing the so far underexploited potential of this global governance. Focusing on four main EIIs (i.e. iron and steel, cement and concrete, chemicals, and aluminium) the analysis is advanced in three steps. First, we establish the theoretical potential of international institutions to address the main barriers to EII decarbonization focusing on six main governance functions. Second, the article provides an up-to-date account of the global governance landscape for EII decarbonization and the contribution it has made to addressing the main barriers. This assessment also identifies major gaps and underexploited potentials of global governance. Finally, we systematically appraise key options for advancing global governance for EII decarbonization based on clear assessment criteria (membership, institutional capacity, legitimacy, feasibility). The major findings are that: (a) global governance has advanced significantly in the 2020s across all governance functions, in particular through the emergence of several initiatives focused on industrial decarbonization, including the recent Climate Club; (b) key priorities for advancing global EII decarbonization concern rules for collective action, means of implementation, landscape orchestration/coordination, and a more equal coverage of different sub-sectors and regions. We argue that the main barrier to addressing these priorities is rooted in (geo)politics rather than a lack of suitable institutions. Consequently, the global governance for EII decarbonization may best be advanced through incrementally developing existing rather than creating major new institutions.

Trends and inequalities in antenatal care coverage in Benin (2006–2017): an application of World Health Organization’s Health Equity Assessment Toolkit

IntroductionBetween 2006 and 2017, antenatal care (ANC) coverage in Benin declined, potentially exacerbating inequalities and substantiating the need for health inequality monitoring. This study examines inequalities in ANC attendance in Benin, disaggregated by women’s age, educational level, economic status, place of residence, region of residence, and the extent to which they have changed over time.MethodsThree rounds of the Benin Demographic and Health Surveys (2006, 2011–12, and 2017–18) were analyzed to examine inequalities in ANC coverage. An exploratory descriptive approach was adopted for the analysis. Simple [difference (D) and ratio (R)] and complex [population attributable risk (PAR) and population attributable fraction (PAF)] measures of inequalities were computed using the World Health Organization’s Health Equity Assessment Toolkit (WHO’s HEAT) online platform. The measures were computed separately for each of the three surveys, and their estimates were compared.ResultsThe findings revealed an 8.4% decline in at least four ANC visits between 2006 and 2017–18. The decline occurred irrespective of age, educational status, economic status, place of residence, and region. Region-related inequalities were the largest and increased slightly between 2006 (D = 54.6; R = 2.6; PAF = 47.8, PAR = 29.0) and 2017–18 (D = 55.8; R = 3.1; PAF = 57.2, PAR = 29.8). Education (2006: D = 31.3, R = 1.6, PAF = 40.5, PAR = 24.5; 2017–18: D = 25.2, R = 1.6, PAF = 34.9, PAR = 18.1) and rural-urban (2006: D = 16.8, R = 1.3, PAF = 17.8, PAR = 10.8; 2017–18: D = 11.2, R = 1.2, PAF = 13.1, PAR = 6.8) inequalities reduced while economic status inequalities did not improve (2006: D = 48, R = 2.2, PAF = 44.5, PAR = 26.9; 2017–18: D = 43.9, R = 2.4, PAF = 45.0, PAR = 23.4). Age inequalities were very minimal.ConclusionANC inequalities remain deeply ingrained in Benin. Addressing their varying levels requires comprehensive strategies that encompass both supply—and demand-side interventions, focusing on reaching uneducated women in the poorest households and those residing in rural areas and Atacora.

Disparities in access to water, sanitation, and hygiene (WASH) services and the status of SDG-6 implementation across districts and states in India

IntroductionAccess to affordable and improved Water, Sanitation, and Hygiene (WASH) facilities is essential for people's daily lives, and it is the primary goal of Sustainable Development Goal 6 (SDG-6). However, achieving this goal is a significant challenge for many countries, including India. The aim of this study is to assess the progress made towards achieving SDG-6 targets in Indian districts, states, and Union Territories (UTs) and to identify clusters by measuring spatial inequality of WASH coverage in India. Aim and objectiveThe primary objective of this study is to measure the progress made towards achieving the SDG-6 targets for WASH facilities in Indian districts, states, and UTs. To fulfill this objective, the study used the household data of the National Family Health Survey-5 (NFHS-5) conducted from 2019 to 21. Data and methodsThe study used the household data of NFHS-5, which is a nationally representative survey that provides information on household and individual-level characteristics related to health and nutrition. The study identified the variables associated with WASH and created a composite index to measure WASH coverage separately and combined. The study used Gini coefficient to show WASH inequality, and Moran's statistics were used to show spatial dependency. ResultThe study found that the inequality of improved water coverage sources in Indian districts was high. Western and northeastern districts need to catch up in terms of achieving the SDG-6 targets. The value of the Gini coefficient (0.29) indicates that inequality in sanitation coverage is also high. All states have reached close to SDG-6 achievement in hygiene indicators. Goa, Sikkim, Andaman & Nicobar Islands, and Lakshadweep are close to the overall WASH coverage achievements of SDG-6. However, Jharkhand, Orissa, Tripura, Assam, and Rajasthan are behind in meeting the goal of SDG-6. ConclusionThe study suggests that more government initiatives and investments are needed to increase the availability, accessibility, and affordability of WASH facilities to improve WASH conditions in western and northeastern Indian districts. The localization or bottom-up approach by giving responsibility to rural and urban local bodies can also help enforce the achievement of SDG-6. The findings of this study can be used to guide policymakers in developing targeted interventions to improve WASH conditions and reduce inequality in India.

Surface chlorination of IrO2(110) by HCl.

The ability to controllably chlorinate metal-oxide surfaces can provide opportunities for designing selective oxidation catalysts. In the present study, we investigated the surface chlorination of IrO2(110) by HCl using temperature programmed reaction spectroscopy (TPRS), x-ray photoelectron spectroscopy (XPS), and density functional theory (DFT) calculations. We find that exposing IrO2(110) to HCl, followed by heating to 650K in ultrahigh vacuum, produces nearly equal quantities of on-top and bridging Cl atoms on the surface, Clt and Clbr, where the Clbr atoms replace O-atoms that are removed from the surface by H2O formation. After HCl adsorption at 85K, only H2O desorbs at low Cl coverages during TPRS, but HCl begins to desorb in increasing yields as the Cl coverage is increased above about 0.5 monolayer (ML). The desorption of Cl2 was not observed under any conditions, in good agreement with the high barrier for this reaction predicted by DFT. A maximum Cl coverage of 1 ML, with nearly equal coverages of Clt and Clbr atoms, could be generated by reacting HCl with IrO2(110) in UHV. Our results suggest that a kinetic competition between recombinative HCl and H2O desorption under the conditions studied limits the saturation Cl coverage to a value less than the 2 ML maximum predicted by thermodynamics. XPS further shows that the partitioning of Cl between the Clt and Clbr states can be altered by subjecting partially chlorinated IrO2(110) to reductive or oxidative treatments, demonstrating that the Cl site population can change dynamically in response to the gas environment. Our results provide insights for understanding the chlorination of IrO2(110) by HCl and can enable future experimental studies to determine how Cl-modification alters the surface chemical reactivity of IrO2(110) and potentially enhances selectivity toward partial oxidation chemistry.

Spatial clusters and social inequities in COVID-19 vaccine coverage among children in Brazil.

This study examined the spatial distribution and social inequalities in COVID-19 vaccine coverage among children aged 5-11 in Brazil. First and second dose vaccine coverage was calculated for all Brazilian municipalities and analyzed by geographic region and deciles based on human development index (HDI-M) and expected years of schooling at 18 years of age. Multilevel models were used to determine the variance partition coefficient, and bivariate local Moran's I statistic was used to assess spatial association. Results showed significant differences in vaccine coverage rates among Brazilian municipalities, with lower coverage in the North and Midwest regions. Municipalities with lower HDI and expected years of schooling had consistently lower vaccine coverage rates. Bivariate clustering analysis identified extensive concentrations of municipalities in the Northern and Northeastern regions with low vaccine coverage and low human development, while some clusters of municipalities in the Southeast and South regions with low coverage were located in areas with high HDI-M. These findings highlight the persistent municipal-level inequalities in vaccine coverage among children in Brazil and the need for targeted interventions to improve vaccine access and coverage in underserved areas.

Inequality in Childhood Immunization Coverage: A Scoping Review of Data Sources, Analyses, and Reporting Methods.

Immunization through vaccines among children has contributed to improved childhood survival and health outcomes globally. However, vaccine coverage among children is unevenly distributed across settings and populations. The measurement of inequalities is essential for understanding gaps in vaccine coverage affecting certain sub-populations and monitoring progress towards achieving equity. Our study aimed to characterize the methods of reporting inequalities in childhood vaccine coverage, inclusive of the settings, data source types, analytical methods, and reporting modalities used to quantify and communicate inequality. We conducted a scoping review of publications in academic journals which included analyses of inequalities in vaccination among children. Literature searches were conducted in PubMed and Web of Science and included relevant articles published between 8 December 2013 and 7 December 2023. Overall, 242 publications were identified, including 204 assessing inequalities in a single country and 38 assessing inequalities across more than one country. We observed that analyses on inequalities in childhood vaccine coverage rely heavily on Demographic Health Survey (DHS) or Multiple Indicator Cluster Surveys (MICS) data (39.3%), and papers leveraging these data had increased in the last decade. Additionally, about half of the single-country studies were conducted in low- and middle-income countries. We found that few studies analyzed and reported inequalities using summary measures of health inequality and largely used the odds ratio resulting from logistic regression models for analyses. The most analyzed dimensions of inequality were economic status and maternal education, and the most common vaccine outcome indicator was full vaccination with the recommended vaccine schedule. However, the definition and construction of both dimensions of inequality and vaccine coverage measures varied across studies, and a variety of approaches were used to study inequalities in vaccine coverage across contexts. Overall, harmonizing methods for selecting and categorizing dimensions of inequalities as well as methods for analyzing and reporting inequalities can improve our ability to assess the magnitude and patterns of inequality in vaccine coverage and compare those inequalities across settings and time.

Inequalities in Complementary Feeding Programs in Randomized Intervention and Nonintervention Areas after Program Implementation in Bangladesh, Ethiopia, and Vietnam

BackgroundChildren in the 6–23-mo age group need to consume adequate energy and nutrients for healthy growth, brain development, cognition, and future productivity. Yet, large deficits remain. Complementary feeding practices can be improved on a large scale, but whether interventions reach and benefit disadvantaged mothers is not known. ObjectivesTo assess inequalities in complementary feeding practices and coverage following large-scale program implementation in 3 low- and middle-income countries. MethodsWe re-analyzed evaluation data from randomized controlled studies conducted in Bangladesh, Ethiopia, and Vietnam and calculated socioeconomic inequality using Erreygers index for intervention and nonintervention areas. Intervention coverage indicators were developed in each country for interpersonal communication, community mobilization, agricultural extension, and media. We compared the direction and magnitude of inequalities in intervention and nonintervention areas. ResultsAt the endline, coverage, and practices related to complementary feeding were better in intervention areas, but coverage and practices favored the better-off and more educated mothers. In Bangladesh, only 5, and in Vietnam, only 1 out of 16 coverage variables measured favored disadvantaged mothers or were neutral; in Ethiopia, out of 18 coverage variables measured, 11 favored disadvantaged mothers or were neutral, and in all 3 countries, only 5–6 variables out of 16 that were measured favored disadvantaged mothers or were neutral. ConclusionsInequalities exist both in how children in the 6–23-mo age group are fed and in programs aimed at improving complementary feeding practices. Programs favor the better-off and more educated mothers. We need to better understand context-specific program barriers and tailor targeted interventions to reach disadvantaged mothers.

Ethnic inequalities in coverage and use of women’s cancer screening in Peru

ObjectiveThis study aimed to assess ethnic inequalities in the coverage and utilization of cancer screening services among women in Peru.MethodsData from the 2017–2023 Demographic and Family Health Survey in Peru were analyzed to evaluate ethnic disparities in screening coverage for breast and cervical cancer, including clinical breast examination (CBE), Pap smear test (PST), and mammography. Measures such as the GINI coefficient and Slope Index of Inequality (SII) were used to quantify coverage and utilization disparities among ethnic groups.ResultsThe study included 70,454 women aged 30–69. Among women aged 40–69, 48.31% underwent CBE, 84.06% received PST, and 41.69% underwent mammography. It was found inequalities in coverage for any cancer screening (GINI: 0.10), mammography (GINI: 0.21), CBE (GINI: 0.19), and PST (GINI: 0.06), in 25 Peruvian regions. These inequalities were more pronounced in regions with larger populations of Quechua, Aymara, and Afro-Peruvian women. In rural areas, Quechua or Aymara women (SII: -0.83, -0.95, and − 0.69, respectively) and Afro-Peruvian women (SII: -0.80, -0.92, and − 0.58, respectively) experienced heightened inequalities in the uptake of CBE, mammography, and PST, respectively. Like Quechua or Aymara women (SII: -0.50, SII: -0.52, and SII: -0.50, respectively) and Afro-Peruvian women (SII: -0.50, SII: -0.58, and SII: -0.44, respectively) with only a primary education.ConclusionEthnic inequalities affect breast and cervical cancer screening coverage across regions in Peru. In Quechua, Aymara, and Afro-Peruvian women the uptake of mammography, CBE, and PST was less frequently than their white or mestizo counterparts. These inequalities are attributed to sociodemographic conditions such as lower education levels and residence in rural or non-capital areas.