Subnational Disparities Research Articles

Epidemiology of Q Fever in Southeast Europe for a 20-Year Period (2002–2021)

This study aimed to assess epidemiological trends of Q fever in six countries of Southeast Europe by analysing surveillance data for 2002–2021 period. In this descriptive analysis, we collected and analysed data on confirmed human Q fever cases, obtained from the national Public Health Institutes of Bosnia and Herzegovina, Croatia, Greece, Montenegro, North Macedonia and Serbia. Overall, 2714 Q fever cases were registered during the 20-year period. The crude average annual notification rate was 0.82 (± 2.06) (95% CI: 0.47–1.16) per 100,000 inhabitants, ranged from 0.06 (± 0.04) (95% CI: 0.04–0.08) /100,000 in Greece to 2.78 (± 4.80) (95% CI: 0.53–5.02) /100,000 in the Republic of Srpska (entity of Bosnia and Herzegovina). Significant declining trends of Q fever age standardized rates were registered in Croatia, the Federation of Bosnia and Herzegovina, North Macedonia and Serbia, with an average annual change of -30.15%; -17.13%; -28.33% and − 24.77%, respectively. An unequal spatial distribution was observed. The highest average age-specific notification rate was reported in the 20–59 age group (0.84 (± 0.40) (95% CI: 0.65–1.02) /100,000). Most cases (53.69%) were reported during the spring. Q fever remains a significant public health threat in this part of Europe. The findings of this study revealed the endemic maintenance of this disease in the including countries, with large regional and subnational disparities in notification rates. A downward trend was found in Q fever notification rates across the study countries with the average notification rate higher than in the EU/EEA, during the same period.

Provincial inequality of China's progress towards universal health coverage: An empirical analysis in 2016-21.

Achieving universal health coverage (UHC) is a crucial target shared by the Sustainable Development Goals (SDGs). As UHC levels are influenced by factors such as the regional economy and resource allocation, subnational evidence in China is urgently needed. This study aimed to monitor provincial progress from 2016 to 2021, thereby informing the development of region-specific strategies. Based on the UHC monitoring framework proposed by the World Health Organization, a UHC index was constructed comprising the service coverage dimension (16 indicators) and financial protection dimension (four indicators). In this observational study, routinely collected health data from 25 provinces (autonomous regions and municipalities) in mainland China were obtained from statistical yearbooks, relevant literature, and nationally representative surveys. The indices were calculated using geometric means. Socioeconomic inequalities among provinces were quantified using the slope index of inequality (SII) and relative index of inequality (RII). From 2016 to 2021, China made laudable progress towards achieving UHC, with the index rising from 56.94 in 2016 to 63.03 in 2021. Most provinces demonstrated better performance in service coverage. Western provinces generally presented faster rates of progress, which were attributed to more substantial increases in financial protection. Despite significant disparities, with the UHC index ranging from 77.94 in Shanghai to 54.61 in Fujian in 2021, the overall equity of UHC has improved across the 25 provinces. SII decreased from 17.78 (95% confidence interval (CI) = 11.64, 23.93) to 12.25 (95% CI = 5.86, 18.63) and RII from 1.38 (95% CI = 1.29, 1.46) to 1.22 (95% CI = 1.16, 1.29). However, the non-communicable disease (NCD) domain experienced a drop in both index score and equity, underscoring the need for prioritised attention. In the context of SDGs and the 'Healthy China 2030' initiative, China has made commendable progress towards UHC, and inter-provincial equity has improved. However, substantial differences persisted. The equitable realisation of UHC necessitates prioritising the enhancement of service capacity and financial protection in less developed regions, particularly by addressing shortages in the general practitioner workforce and mitigating catastrophic payments. Developed regions should focus on preventing NCDs through effective interventions targeting key risk factors. This study provides insights for other countries to adopt comprehensive monitoring frameworks, identify subnational disparities, and introduce targeted policy initiatives.

From Fukushima to fossil fuels: Carbon emissions, climate narratives, and grassroots movements in Japan's energy transition

The Fukushima Nuclear Accident triggered an energy predicament in Japan, necessitating initiatives to decarbonise and denuclearise its energy landscape. This shift has intensified reliance on fossil fuels, notably coal, inciting widespread anti-coal disputes throughout the nation. This research scrutinises the dynamics of carbon emissions and their interrelation with climate activism narratives, emphasising the mobilisation of communities to confront issues of inequality and justice. Employing a club convergence methodology, this study analyses the patterns of carbon emissions from fossil fuels across 47 administrative divisions in Japan from 1990 to 2020. This quantitative analysis is enriched with a qualitative content analysis of anti-coal movements, utilising the comprehensive Global Atlas of Environmental Justice (EJAtlas) as a primary resource. The findings disclose pronounced sub-national disparities in energy transitions and carbon emissions. Narratives within anti-coal activism predominantly encompass themes of global warming, air and water pollution, social and cultural impacts, and health repercussions. We find that regions with historically high emissions predominantly embrace narratives of climate and environmental justice, whereas rural regions experiencing escalating emissions integrate these with narratives of peripheralisation. The opposition to technocratic resolutions and the endorsement for transitions to low carbon society are salient within these movements, resonating with the degrowth paradigm advocating for equitable and sustainable alternatives. This research underscores the pivotal role of social movements in mitigating regional emissions disparities and illustrates the evolution of grassroots movements towards embracing sustainable alternatives.

Sub-National Disparities in Indicators of Maternal Mortality in Kenya: Insights from Demographic Health Surveys Towards Attaining SDG 3

Sub-National Disparities in Indicators of Maternal Mortality in Kenya: Insights from Demographic Health Surveys Towards Attaining SDG 3

International Borders, Integration and Economic Development: Evidence from Argentina

This paper analyzes the effects of international borders and of trade agreements on subnational development in Argentina. The identification strategy leverages the Mercosur trade services agreement in 2005, and the different proximity of the districts to the international border with member countries. Two main outcomes are analyzed: economic growth and inequality. For this purpose, an annual panel of districts covering more than two decades (1992-2013) is used. The results show that the presence of an international border has a negative and significant effect on the economic growth of border districts (-0.14 percentage points of GDP annually) but also contributes to reducing inequality compared to districts without a border. On the other hand, a commercial integration agreement tends to partially offset the negative effects on economic growth (+0.04 percentage points of GDP annually). The results of the paper are relevant in terms of trade and development policy recommendations: deepening integration agreements constitutes a potential mechanism to boost growth in the poorest regions and thus reduce subnational disparities.

A small area model to assess temporal trends and sub-national disparities in healthcare quality

Monitoring subnational healthcare quality is important for identifying and addressing geographic inequities. Yet, health facility surveys are rarely powered to support the generation of estimates at more local levels. With this study, we propose an analytical approach for estimating both temporal and subnational patterns of healthcare quality indicators from health facility survey data. This method uses random effects to account for differences between survey instruments; space-time processes to leverage correlations in space and time; and covariates to incorporate auxiliary information. We applied this method for three countries in which at least four health facility surveys had been conducted since 1999 – Kenya, Senegal, and Tanzania – and estimated measures of sick-child care quality per WHO Service Availability and Readiness Assessment (SARA) guidelines at programmatic subnational level, between 1999 and 2020. Model performance metrics indicated good out-of-sample predictive validity, illustrating the potential utility of geospatial statistical models for health facility data. This method offers a way to jointly estimate indicators of healthcare quality over space and time, which could then provide insights to decision-makers and health service program managers.

Sex differences in cause-specific mortality: regional trends in seven European countries, 1996-2019.

Male excess mortality is mostly related to non-biological factors, and is thus of high social- and health-policy concern. Previous research has mainly focused on national patterns, while subnational disparities have been less in the focus. This study takes a spatial perspective on subnational patterns, covering seven European countries at the crossroad between Eastern and Western Europe. We analyze a newly gathered spatially detailed data resource comprising 228 regions with well-established demographic methods to assess the contribution of specific causes of death to the evolution of sex mortality differentials (SMDs) since the mid-1990s. Our results show that declines in SMDs were mostly driven by a reduction of male excess mortality from cardiovascular diseases and neoplasms (about 50-60% and 20-30%, respectively). In Western Europe, trends in deaths from neoplasms contributed more to the reduction of SMDs, while among regions located in Eastern-Central Europe narrowing SMDs were mostly driven by changes in cardiovascular disease-related deaths. Moreover, men show up to three times higher mortality levels from external causes as compared to women in several analyzed regions. But in absolute terms, external deaths play only a minor role in explaining SMDs due to their small contribution to overall mortality. We conclude that examining the regional development of SMDs is useful for introducing targeted social and health policies in order to reduce and prevent mortality inequalities between women and men.

Policy and political challenges for a better world: The United States and China pathways towards the 2030 Agenda

The Agenda 2030 poses critical elements regarding the transition towards a more sustainable development. This paper aims at exploring and comparing the path of sustainable development within the United States and China at the subnational level. An index of Integrated Sustainable Development is introduced to measure local sustainable development on an internationally-comparable scale. This Index is computed both at the national and subnational level and the resulting scores are compared within and across the two countries, also through the adoption of convergence and cluster analysis, allowing to answer four questions: Are the US and China moving towards a sustainable development agenda? Are the current achievements uniformly distributed within the two countries? Are states/provinces converging towards a more uniform level of sustainable development? Do the existing differences and analogies between states and provinces give rise to common clusters across the two countries? The results lead to one robust conclusion: while the US can claim a better result in the national and subnational rankings of sustainable development, China exhibits a more balanced achievement in terms of synergies across Goals and spatial distribution. Nonetheless, both countries are characterized by subnational disparities and scarce achievements of Planet-related Goals. Policy recommendations are discussed accordingly.

Evaluating health policies with subnational disparities: a text-mining analysis of the Urban Employee Basic Medical Insurance Scheme in China.

Subnational disparities in most health systems often defy 'one-size-fits-all' approach in policy implementation. When local authorities implement a national policy in a decentralized context, they behave as a strategic policy actor in specifying the central mandates, selecting appropriate tools and setting key implementation parameters. Local policy discretion leads to diverse policy mixes across regions, thus complicating evidence-based evaluations of policy impacts. When measuring complex policy reforms, mainstream policy evaluation methodologies have tended to adopt simplified policy proxies that often disguise distinct policy choices across localities, leaving the heterogeneous effects of the same generic policy largely unknown. Using the emerging 'text-as-data' methodology and drawing from subnational policy documents, this study developed a novel approach to policy measurement through analysing policy big data. We applied this approach to examine the impacts of China's Urban Employee Basic Medical Insurance (UEBMI) on individuals' out-of-pocket (OOP) spending. We found substantial disparities in policy choices across prefectures when categorizing the UEBMI policy framework into benefit-expansion and cost-containment reforms. Overall, the UEBMI policies lowered enrollees' OOP spending in prefectures that embraced both benefit-expansion and cost-containment reforms. In contrast, the policies produced ill effects on OOP spending of UEBMI enrollees and uninsured workers in prefectures that carried out only benefit-expansion or cost-containment reforms. The micro-level impacts of UEBMI enrolment on OOP spending were conditional on whether prefectural benefit-expansion and cost-containment reforms were undertaken in concert. Only in prefectures that promulgated both types of reforms did UEBMI enrolment reduce OOP spending. These findings contribute to a comprehensive text-mining measurement approach to locally diverse policy efforts and an integration of macro-level policy analysis and micro-level individual analysis. Contextualizing policy measurements would improve the methodological rigour of health policy evaluations. This paper concludes with implications for health policymakers in China and beyond.

1202-P: Disparities in Incidence of Diagnosed Diabetes in Rural United States, 2011–2018

US rural, compared to non-rural, populations have diabetes health disparities. However, it is unknown if there are rural disparities in incident diabetes. We used CDC data on incidence of diagnosed diabetes in adults aged ≥20 years, available for 97.5% of US counties (n=3145/3226) . Trends in the annual age-adjusted incident diabetes rate per 1000 adults (AADR) were assessed by weighted least squares regression. Year was fitted nonlinearly with a spline function, and AADR fold-change was tested by a model-based contrast of 20vs. 2018. The average AADR of 8.7 (95% CI 8.6-8.7) ranged from 9.3 (in 2011) to 8.3 (in 2013) and 8.9 (in 2018) , and concealed subnational disparities based on rurality (Figure) . In 2018, compared with 2011, the AADR decreased for large central metro counties (most urban) with AADR fold-change of 0.92 (0.91-0.93) but increased for noncore counties (most rural) with AADR fold-change of 1. (1.01-1.08) (both P<.01) . The AADR declined in counties with intermediate rurality except for micropolitan counties (no change; P=.56) . When stratified by region, the largest rural disparity in AADR was observed in the South, with smaller disparities in other regions. In summary, from 2011-2018, rural counties had the highest overall AADR. The overall disparity in trends based on county rurality and the disparity in incidence in the rural South and rural West highlight areas for diabetes primary prevention interventions. Disclosure K.R. Bailey: None. M.M. Mielke: Consultant; Biogen, LabCorp. A. Vella: Advisory Panel; Crinetics Pharmaceuticals, Inc., Rezolute, Inc., vTv Therapeutics, Zealand Pharma A/S. Other Relationship; Novo Nordisk. Funding National Institute on Minority Health and Health Disparities (NIH K23 MD016230)

Finding gaps in routine TB surveillance activities in Bangladesh.

SUMMARYBACKGROUND :TB was the leading cause of death from a single infectious pathogen globally between 2014 and 2019. Fine-scale estimates of TB prevalence and case notifications can be combined to guide priority-setting for strengthening routine surveillance activities in high-burden countries. We produce policy-relevant estimates of the TB epidemic at the second administrative unit in Bangladesh.METHODS :We used a Bayesian spatial framework and the cross-sectional National TB Prevalence Survey from 2015–2016 in Bangladesh to estimate prevalence by district. We used case notifications to calculate prevalence-to-notification ratio, a key metric of under-diagnosis and under-reporting.RESULTS :TB prevalence rates were highest in the north-eastern districts and ranged from 160 cases per 100,000 (95% uncertainty interval [UI] 80–310) in Jashore to 840 (UI 690–1020) in Sunamganj. Despite moderate prevalence rates, the Rajshahi and Dhaka Divisions presented the highest prevalence-to-notification ratios due to low case notifications. Resolving subnational disparities in case detection could lead to 26,500 additional TB cases (UI 8,500–79,400) notified every year.CONCLUSION :This study is the first to produce and map subnational estimates of TB prevalence and prevalence-to-notification ratios, which are essential to target prevention and treatment efforts in high-burden settings. Reaching TB cases currently missing from care will be key to ending the TB epidemic.

The heterogeneous regional effect of mobility on Coronavirus spread

The Coronavirus (COVID-19) pandemic struck global society in 2020. The pandemic required the adoption of public policies to control spread of the virus, underlining the mobility restrictions. Several studies show that these measures have been effective. Within the topic of Coronavirus spread, this original paper analyses the effect of mobility on Coronavirus spread in a heterogeneous regional context. A multiple dynamic regression model is used to control sub-national disparities in the effect of mobility on the spread of the Coronavirus, as well as to measure it at the context of Spanish regions. The model includes other relevant explanatory factors, such as wind speed, sunshine hours, vaccinated population and social awareness. It also develops a new methodology to optimise the use of Google trends data. The results reveal heterogeneity among regions, which has important implications for current and future pandemic containment strategies.

Prevalence, incidence and years of life adjusted for disability due to depressive disorders in Mexico: Results of the Global Burden of Disease Study 2019

• Although depressive disorders are one of the primary causes of non-fatal health losses worldwide, there are few research examining the burden of mental illnesses in middle- and low-income nations, particularly in Latin America. • Mexico lacks a systematic register of mental diseases, particularly depressive illnesses, and a comprehensive mental health care program. • The prevalence, incidence, and years of life adjusted for disability as a result of depressive disorders have increased significantly across the country, primarily among women. • Over the thirty-year period studied (1990–2019), subnational disparities in the burden of disability attributable to depressive disorders have grown significantly, with the poorest states seeing the greatest rates. Depressive disorders (DD) represent one of the most common contributors to non-fatal health loss in the world, especially in low- and middle-income countries. The objective of this study was to analyze the burden of DD in Mexico between 1990 and 2019 by sex, states, age groups and socio-demographic index (SDI). Secondary analysis based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Data on prevalence, incidence, and years lived with disability (YLD) due to DD were obtained. A joinpoint regression analysis was performed to describe the changes in the trend of YLD rates due to DD. Nationwide prevalence of DD increased 121.5%, from 2.1 million persons (UI 1,8-2,3) in 1990, to 4.6 million persons (UI 4,1-5,0) in 2019. The standardized rate of YLD due to DD differs widely by age group and sex, with notably higher values in young people and women. Between 1990 and 2019, Campeche, Quinta Roo, Tabasco, and Yucatán have the highest rates, while the Estado de México, Sinaloa, and Ciudad de México have the lowest. As part of the fundamental and universal access to health, attention to mental health, including DD, must be handled more effectively by the Mexican health system. Its care should be addressed on a regular basis at all levels of care.

Sub-national disparities in accessing anti-malarial drug treatment in eastern Indonesia

BackgroundPoor access to health care providers was among the contributing factors to less prompt and ineffective malaria treatment. This limitation could cause severe diseases in remote areas. This study examined the sub-national disparities and predictors in accessing anti-malarial drug treatment among adults in Eastern Indonesia.MethodsThe study analyzed a subset of the 2018 National Basic Health Survey conducted in all 34 provinces in Indonesia. We extracted socio-demographic data of 4655 adult respondents diagnosed with malaria in the past 12 months in five provinces in Eastern Indonesia. The association between socio-demographic factors and the access to anti-malarial drug treatment was assessed using logistic regression.ResultsOver 20% of respondents diagnosed with malaria within last 12 months admitted that they did not receive anti-malarial drug treatment (range 12–29.9%). The proportion of untreated cases was 12.0% in East Nusa Tenggara, 29.9% in Maluku, 23.1% in North Maluku, 12.7% in West Papua, and 15.6% in Papua. The likelihood of receiving anti-malarial drug treatment was statistically lower in Maluku (adjusted OR = 0.258; 95% CI 0.161–0.143) and North Maluku (adjusted OR = 0.473; 95% CI 0.266–0.840) than those in Eastern Nusa Tenggara (reference). Urban respondents were less likely to receive malaria treatment than rural (adjusted OR = 0.545; 95% CI 0.431–0.689).ConclusionsThis study found that there were sub-national disparities in accessing anti-malarial drug treatment in Eastern Indonesia, with a high proportion of untreated malaria cases across the areas. Findings from this study could be used as baseline information to improve access to anti-malarial drug treatment and better target malaria intervention in Eastern Indonesia.

The impact of child health interventions and risk factors on child survival in Kenya, 1993\u20132014: a Bayesian spatio-temporal analysis with counterfactual scenarios

BackgroundDuring the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The contribution of changing risk factors and intervention coverage on the sub-national changes in U5M remains poorly defined.MethodsSub-national county-level data on U5M and 43 factors known to be associated with U5M spanning 1993 and 2014 were assembled. Using a Bayesian ecological mixed-effects regression model, the relationships between U5M and significant intervention and infection risk ecological factors were quantified across 47 sub-national counties. The coefficients generated were used within a counterfactual framework to estimate U5M and under-five deaths averted (U5-DA) for every county and year (1993–2014) associated with changes in the coverage of interventions and disease infection prevalence relative to 1993.ResultsNationally, the stagnation and increase in U5M in the 1990s were associated with rising human immunodeficiency virus (HIV) prevalence and reduced maternal autonomy while improvements after 2006 were associated with a decline in the prevalence of HIV and malaria, increase in access to better sanitation, fever treatment-seeking rates and maternal autonomy. Reduced stunting and increased coverage of early breastfeeding and institutional deliveries were associated with a smaller number of U5-DA compared to other factors while a reduction in high parity and fully immunised children were associated with under-five lives lost. Most of the U5-DA occurred after 2006 and varied spatially across counties. The highest number of U5-DA was recorded in western and coastal Kenya while northern Kenya recorded a lower number of U5-DA than western. Central Kenya had the lowest U5-DA. The deaths averted across the different regions were associated with a unique set of factors.ConclusionContributions of interventions and risk factors to changing U5M vary sub-nationally. This has important implications for targeting future interventions within decentralised health systems such as those operated in Kenya. Targeting specific factors where U5M has been high and intervention coverage poor would lead to the highest likelihood of sub-national attainment of sustainable development goal (SDG) 3.2 on U5M in Kenya.

Trends and sub-national disparities in TB notifications in India: Insights from HMIS data

Background/objectivesTuberculosis (TB) is a public health crisis across the globe, especially in the developing world including India. Around 27% of 10 million TB cases and 33% of 1.2 million TB deaths were contributed from India alone during 2018. Present study aims to estimate TB notification rates at national and sub-national levels up to District administrative blocks, which is very important with policy perspective. MethodsThe study mainly uses data from India's Health Management Information System (HMIS) for three consecutive years, 2017-18, 2018-19 and 2019-20. TB notification rates were calculated for India up to the lowest administrative level of health Districts. GIS maps were being used for mapping District-wise TB notification rates for 2017-18 and 2019-20. ResultsResults show that TB notification rates have increased from 152/lakh population in 2017-18 to 197 in 2019-20, an increase of 30%. Similarly, the increasing trends in TB notification rates were also observed at State as well as District level. However, wide rural-urban and public-private differences were observed in TB notification rates. Further, results illustrated huge inter-State and inter-District variations; and half of the TB cases in India were contributed only by six larger States. ConclusionsThe findings of the study shows the increasing notification in India since 2017-18, which is a clear indication of the efforts put in the TB program to achieve targets and goals committed to end TB by 2025. In this regard present estimates based on HMIS data significantly contributes to the policy formulation even at the lowest administrative level of health Districts.

National and Subnational Trends in Mortality and Causes of Death in Chinese Children and Adolescents Aged 5–19 Years From 1953 to 2016

PurposeWe aimed to analyze the recent trends of mortality and rankings of causes of death in Chinese children and adolescents from 1953 to 2016. MethodsData on mortality and causes of death in Chinese children and adolescents aged 5–19 years were extracted from the China Health Statistics Yearbook and the Global Burden of Disease Study from 1953 to 2016. Mortality variations were analyzed by year, age, sex, province, and causes of death. ResultsThe mortality of Chinese children and adolescents aged 5–19 years declined steadily from 1953 (366.03/100,000) to 2016 (27.21), with the largest reduction in adolescents aged 15–19 years and the smallest reduction in those aged 10–14 years. Large subnational disparities for all-cause mortality existed in national 31 provinces with higher mortality in western regions compared with eastern regions, but with narrowing disparities between 1981 and 2010. Injuries dominated the causes of death compared with noncommunicable diseases and communicable, maternal and neonatal, and nutritional diseases from 1990 (58.13/100,000 vs. 32.10 and 14.31) to 2016 (22.65 vs. 13.00 and 2.93). In 2016, the leading three causes of death were road injuries (8.30/100,000), drowning (7.25), and leukemia (2.60). Drowning was the leading cause of death for 5- to 14-year-olds, but road injuries have been the leading cause for 15- to 19-year-olds of both sexes since 2010. ConclusionsAlthough mortality in Chinese adolescents now stands at just 7% of rates in the 1950s, there is a need to address continuing inequalities across sex, economic status, and region.

Determinants of subnational disparities in antenatal care utilisation: a spatial analysis of demographic and health survey data in Kenya

BackgroundThe spatial variation in antenatal care (ANC) utilisation is likely associated with disparities observed in maternal and neonatal deaths. Most maternal deaths are preventable through services offered during ANC; however, estimates of ANC coverage at lower decision-making units (sub-county) is mostly lacking. In this study, we aimed to estimate the coverage of at least four ANC (ANC4) visits at the sub-county level using the 2014 Kenya Demographic and Health Survey (KDHS 2014) and identify factors associated with ANC utilisation in Kenya.MethodsData from the KDHS 2014 was used to compute sub-county estimates of ANC4 using small area estimation (SAE) techniques which relied on spatial relatedness to yield precise and reliable estimates at each of the 295 sub-counties. Hierarchical mixed-effect logistic regression was used to identify factors influencing ANC4 utilisation. Sub-county estimates of factors significantly associated with ANC utilisation were produced using SAE techniques and mapped to visualise disparities.ResultsThe coverage of ANC4 across sub-counties was heterogeneous, ranging from a low of 17% in Mandera West sub-county to over 77% in Nakuru Town West and Ruiru sub-counties. Thirty-one per cent of the 295 sub-counties had coverage of less than 50%. Maternal education, household wealth, place of delivery, marital status, age at first marriage, and birth order were all associated with ANC utilisation. The areas with low ANC4 utilisation rates corresponded to areas of low socioeconomic status, fewer educated women and a small number of health facility deliveries.ConclusionSuboptimal coverage of ANC4 and its heterogeneity at sub-county level calls for urgent, focused and localised approaches to improve access to antenatal care services. Policy formulation and resources allocation should rely on data-driven strategies to guide national and county governments achieve equity in access and utilisation of health interventions.

Trends of National and Subnational Incidence of Childhood Cancer Groups in Iran: 1990-2016.

Background: Childhood cancer is a double-edged sword, considering its high rate of response to treatment despite a high vulnerability to develop future malignancies in survivors. Thus, multidisciplinary preventive, curative, and supportive strategies must be incorporated in childhood cancer care that require understanding the distribution and trend of cancer in the target population. In this article, we aimed to report the national and subnational trends of childhood cancer incidence in Iran from 1990 to 2016, and mortality/incidence ratio (MIR), which, to our knowledge, have not been reported in previous literature.Method: Data on the incidence and mortality rates were collected from the National and Subnational Burden of Diseases project. We employed a two-stage spatiotemporal model to estimate cancer incidences by sex, age, province, and year based on the primary dataset of national death registration system. National and subnational age and gender-specific trends as well as MIR were calculated.Result: The age-standardized incidence rate had a steady increasing trend for cancers in both female [annual percent change (APC), 1.6%] and male (APC, 2.1%) patients. Not only there was an increasing trend in most provinces but also there was a 40% divergence in age-standardized incidence rate at subnational levels. Leukemia, lymphoma, neoplasms of the central nervous system (CNS), digestive tract, endocrine gland, and urinary tract were the leading causes of cancer comprising more than half of all cancers. There was a remarkable general decrease in MIR by 75% as a proxy of care quality.Conclusion: Regarding the increased trend of childhood cancer incidence, there is an essential need to address the etiologic factors and establish preventive plans for childhood cancers. Despite the favorable outcomes observed in cancer care, commensurate health resource allocation must be applied to diminish the subnational disparities.

Subnational Disparities in EU Law Use: Exploring the GEOCOURT Dataset

[We present a new dataset compiling the geographic coordinates of the entire universe of courts that have passed on cases to the European Court of Justice over the lifetime of the European Union. The GEOCOURT Dataset allows the exploration of spatial disparities and clustering effects across time, member states and tiers of courts. Exploration of our new dataset reveals that involvement in the preliminary ruling procedure tends to be concentrated in a relatively small subset of regions within member states, often the region hosting the country's capital. We also consider several regional attributes associated with Article 267 use, which point out avenues for future research. Controlling for country and region fixed effects, we show that peak courts, GDP, population and capital along with with indicators of economic well-being and integration in cross-border trade are positively associated with referral propensity.