Search

A balanced and equitable bus network layout plays a crucial role in the efficient operation of cities. The layout of urban bus networks is influenced by various factors, including urban planning, population size, industrial distribution, and road network layout. Forming a comprehensive indicator system and analyzing the balance and fairness of bus network layouts are key research areas. This paper proposes a framework for quantitatively analyzing the balance and fairness of bus network services from the perspective of bus route service capacity (the maximum passenger transport capacity, the number of bus routes available for transfer, resource allocation), considering the spatial characteristics of urban road networks and surrounding facilities, and utilizing methods such as spatial accessibility and space syntax. A comprehensive index for quantitatively measuring bus routes was constructed. The results show that the comprehensive index values of Xiamen bus routes decrease from the inner island to the outer areas, reflecting a relatively balanced bus network layout in Xiamen. Combining the comprehensive index with various influencing factors, bus routes with high service fairness are characterized by concentrated layouts and dense nearby populations, while routes with scattered layouts and sparse nearby populations exhibit low service fairness. The research results provide fundamental data, theoretical and technical support for analyzing the balance and fairness of the bus network layout in Xiamen., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose: To demonstrate the process and results of an equity analysis of a reproductive health association., Description: A series of quantitative surveys and qualitative interviews were conducted with employees of Planned Parenthood League of Massachusetts (PPLM), assessing different aspects of equity. Amaka Consulting and Evaluation Services, LLC, an external consulting agency, analyzed the results and provided recommendations for improvements., Assessment: Between 25% and 33% of the employees identified as Black, Indigenous, and people of color (BIPOC). Staff expressed a high degree of satisfaction with the organization's alignment to its mission and commitment to equity. Turnover was higher among BIPOC employees, and employees of color were less likely to say they had confidence in senior management. Themes that arose frequently in surveys included the need for increased communication around equity action steps, greater accountability, and work environment issues. Qualitative interviews indicated acknowledgment of diversity, equity, and inclusion (DEI) efforts but feeling that they were not as legitimate as they could be and vocalized a need for more equitable hiring. Recommendations for improvements included tracking feedback around social movements; conducting equity impact assessments; supporting staff through salary, opportunities for advancement, and better supervision; requiring management to attend equity initiatives, and creating equity resources for staff., Conclusion: This study provides a template for other evaluations of equity. Similar to other organizations in the field, this equity analysis suggests that PPLM had a stronger commitment to certain aspects of DEI than others, and that there was a need for improvement in several areas, particularly hiring and management., Competing Interests: Declarations. Ethics Approval and Consent to Participate: Not required, evaluation. Consent for Publication: N/A. Competing Interests: N/A., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To evaluate the current status and equity of older adult resource allocation in the 31 provinces (autonomous regions and municipalities) of mainland China, and to offer recommendations for the optimization of these allocations., Methods: Four key indicators, namely, the number of older adult institutions, employees, professionals, and beds in mainland China in the year 2020, were used and analyzed using various methods and tools, including agglomeration analysis, the Gini coefficient, and the Lorenz Curve. These methods were applied to evaluate the equity of older adult resource allocation across the different provinces (autonomous regions and municipalities) and regions of China, using two dimensions, namely, the geographical area and the older adult population., Results: Overall, the number of older adult resource allocations was found to be increasing in China, while the number of employees with educational levels of junior college or above was relatively low and the population structure was aging. In terms of the equity of older adult resource allocation, the results showed that this was good according to the dimensions of the older adult population but was on the low side based on the dimension of geographical area, and the Gini coefficient of the western region, in particular, was in an alarming state. Different provinces (autonomous regions and municipalities) were found to have an uneven allocation of resources for older adults, with large differences, with some areas having a serious under-allocation of resources, while others showed resource over-allocation., Conclusion: While China's allocation of older adult resources is relatively equitable, there is nevertheless a need to take into account recent changes in the older adult population and strengthen the construction of a reasonably structured, high-quality team of professionals and technicians, as well as consider factors such as geographical area and the older adult population, and rationally allocate older adult resources in the eastern, middle, and western regions, to achieve a balanced allocation in terms of equity and efficiency and enhance social capital, to better satisfy the demands for older adult services in older adults at multiple levels., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Yu, Zhang, Jiang, Jia, Dong and Luo.)

Long-term exposure to PM 2.5 pollution increases the risk of cardiovascular diseases, particularly ischemic heart disease (IHD). Current assessments of the health effects related to PM 2.5 exposure are limited by sparse ground monitoring stations and applicable disease research cohorts, making accurate health effect evaluations challenging. Using satellite-observed aerosol optical depth (AOD) data and the XGBoost-PM25 model, we obtained 1 km scale PM 2.5 exposure levels across China. We quantified the premature mortality caused by PM 2.5 -exposure-induced IHD using the Global Exposure Mortality Model (GEMM) and baseline mortality data. Furthermore, we employed the Gini coefficient, a measure from economics to quantify inequality, to evaluate the distribution differences in health impacts due to PM 2.5 exposure under varying socioeconomic conditions. The results indicate that PM 2.5 concentrations in China are higher in the central and eastern regions. From 2007 to 2022, the national overall level showed a decreasing trend, dropping from 47.41 μg/m 3 to 25.16 μg/m 3 . The number of premature deaths attributable to PM 2.5 exposure increased from 819 thousand in 2007 to 870 thousand in 2022, with fluctuations in certain regions. This increase is linked to population growth and aging because PM 2.5 levels have decreased. The results also indicate disparities in premature mortality from IHD among different economic groups in China from 2007 to 2022, with middle-income groups having a higher cumulative proportion of IHD-related premature deaths compared with high- and low-income groups. Despite narrowing GDP gaps across regions from 2007 to 2022, IHD consistently "favored" the middle-income groups. The highest Gini coefficient was observed in the Northwest (0.035), and the lowest was in the South (0.019). Targeted policy interventions are essential to establish a more equitable atmospheric environment.

Assessing the social and economic vulnerability of populations within a given area is essential for conducting environmental equity evaluations and devising effective public policies to mitigate disparities. However, prevailing indicators used to measure socio-economic vulnerability exhibit several shortcomings. Primarily relying on factor analysis, these indicators face challenges in terms of comparability over time, lack of standardized scales, and inherent limitations associated with composite indicators. To address these shortcomings, we propose a novel approach that estimates the number of potentially vulnerable individuals by constructing a synthetic population. Our methodology, developed using open tools and datasets, offers a scalable solution applicable to the entire Canadian context. The resulting percentage of potentially vulnerable populations demonstrates strong correlations with traditional vulnerability indicators commonly used in Canada, while overcoming their inherent limitations. The generated dataset holds significant potential and serves as a valuable resource for both researchers and governmental organizations. It provides a robust foundation for conducting equity analyses, assessments, and policy evaluations, thereby facilitating evidence-based decision-making processes aimed at promoting social and economic inclusivity., (© 2024. The Author(s).)

Background: Over 80% of blindness in Kenya is due to curable or preventable causes and 7.5 m Kenyans currently need eye services. Embedding sociodemographic data collection into screening programmes could help identify the groups facing systematic barriers to care. We aimed to determine the sociodemographic characteristics that were associated with access among patients diagnosed with an eye problem and referred for treatment in the Vision Impact Programme, currently operating in Meru County., Method: We used an embedded, pragmatic, cross-sectional design. A list of sociodemographic questions was developed with input from key stakeholders. The final question set included the following domains: age, gender, religion, marital status, disability, education, occupation, income, housing, assets, and health insurance. These were integrated into an app that is used to screen, refer, and check-in (register) participants within a major eye screening programme. We gathered data from 4,240 people who screened positive and were referred to their local outreach treatment clinic. We used logistic regression to identify which groups were facing the greatest barriers to accessing care., Results: A quarter of those screened between April - July 2023 were found to have an eye problem and were referred, however only 46% of these people were able to access care. In our fully adjusted model, at the 0.05 level there were no statistically significant differences in the odds of attendance within the domains of disability, health insurance, housing, income, or religion. Strong evidence (p < 0.001) was found of an association between access and age, gender, and occupation; with males, younger adults, and those working in sales, services and manual jobs the least likely to receive care., Conclusions: Access to essential eye services is low and unequal in Meru, with less than a third of those aged 18-44 receiving the care they need. Future work should explore the specific barriers faced by this group., (© 2024. The Author(s).)

Introduction: Antenatal care (ANC) interventions improve maternal and neonatal outcomes. However, access to ANC may be inequitable due to sociocultural, monetary and time factors. Examining drivers of ANC disparities may identify those amenable to policy change., Methods: We conducted an ANC services equity analysis in selected public facilities in Geita, Tanzania, where most services are free to the end-user, and Atlantique, Benin, where every visit incurs user fees. Data on total ANC contacts, quality of care (QoC) indicators and wait times were collected from representative household surveys in the catchment of 40 clinics per country and were analysed by education and wealth. We used indices of inequality, concentration indices and Oaxaca-Blinder decompositions to determine the distribution, direction and magnitude of inequalities and their contributing factors. We assessed out-of-pocket expenses and the benefit incidence of government funding., Results: ANC clients in both countries received less than the recommended minimum ANC contacts: 3.41 (95% CI 3.36 to 3.41) in Atlantique and 3.33 (95% CI 3.27 to 3.39) in Geita. Wealthier individuals had more ANC contacts than poorer ones at every education level in both countries; the wealthiest and most educated had two visits more than the poorest, least educated. In Atlantique, ANC attendees receive similar QoC regardless of socioeconomic status. In Geita, there are wide disparities in QoC received by education or wealth. In Atlantique, out-of-pocket expenses for the lowest wealth quintile are 2.7% of annual income compared with 0.8% for the highest, with user fees being the primary expense. In Geita, the values are 3.1% and 0.5%, respectively; transportation is the main expense., Conclusions: Inequalities in total ANC visits favouring wealthier, more educated individuals were apparent in both countries. In Atlantique, reduction of user-fees could improve ANC access. In Geita, training and equipping healthcare staff could improve QoC. Community health services could mitigate access barriers., Competing Interests: Competing interests None declared.

Background: Better geographical accessibility to comprehensive emergency obstetric care (CEmOC) facilities can significantly improve pregnancy outcomes. However, with other factors, such as affordability critical for care access, it is important to explore accessibility across groups. We assessed CEmOC geographical accessibility by wealth status in the 15 most-populated Nigerian cities., Methods: We mapped city boundaries, verified and geocoded functional CEmOC facilities, and assembled population distribution for women of childbearing age and Meta's Relative Wealth Index (RWI). We used the Google Maps Platform's internal Directions Application Programming Interface to obtain driving times to public and private facilities. City-level median travel time (MTT) and number of CEmOC facilities reachable within 60 min were summarised for peak and non-peak hours per wealth quintile. The correlation between RWI and MTT to the nearest public CEmOC was calculated., Results: We show that MTT to the nearest public CEmOC facility is lowest in the wealthiest 20% in all cities, with the largest difference in MTT between the wealthiest 20% and least wealthy 20% seen in Onitsha (26 vs 81 min) and the smallest in Warri (20 vs 30 min). Similarly, the average number of public CEmOC facilities reachable within 60 min varies (11 among the wealthiest 20% and six among the least wealthy in Kano). In five cities, zero facilities are reachable under 60 min for the least wealthy 20%. Those who live in the suburbs particularly have poor accessibility to CEmOC facilities., Conclusions: Our findings show that the least wealthy mostly have poor accessibility to care. Interventions addressing CEmOC geographical accessibility targeting poor people are needed to address inequities in urban settings., (© 2024. The Author(s).)

School-based interventions for the prevention of dating and relationship violence (DRV) and gender-based violence (GBV) take advantage of universal opportunities for intervention. Information on differential effectiveness of interventions is important to assess if they ameliorate or worsen social gradients in specific outcomes. This is especially important in DRV and GBV prevention given the gendered context of these behaviours and their common aetiologies in patriarchal gender norms, and social acceptance in school contexts of sexual harassment, such as catcalling or unwanted groping. We undertook a systematic review of moderation analyses in randomised trials of school-based interventions for DRV and GBV prevention. We searched 21 databases and used supplementary search methods without regard to publication type, language or year of publication, and synthesised moderation tests relating to equity-relevant characteristics (principally sex and prior history of the outcome) for DRV and GBV perpetration and victimisation. Across 23 included outcome evaluations, programme effects on DRV victimisation were not moderated by gender or prior experience of DRV victimisation, but DRV perpetration outcomes were greater for boys, particularly for emotional and physical DRV perpetration. Findings for GBV outcomes were counterintuitive. Our findings suggest that practitioners should carefully monitor local intervention effectiveness and equity to ensure that interventions are working as intended. However, one of the most surprising findings from our analysis-with clear relevance for uncertainties in practice-was that differential impacts by sexuality or sexual minority status were not frequently evaluated., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Objective: To identify and investigate any differences in utilisation of the, Sussex Community NHSFT, Special Care Dental Service (SCDS) across multiple demographic factors, including ethnicity, socio-economic groups and age in the Crawley area., Method: Data were audited for all new patients seen at the Crawley Special Care Dental Centre from November 2020-October 2021. Demographic data were compared to population data from the 2011 Census. Deprivation data, using Index of Multiple Deprivation, were also examined against utilisation and failure to attend appointments., Results: A total of 1250 new patients accessed the Crawley SCDS between November 2020 and October 2021. The data suggests good equity to the service being utilised by the local community; the proportions of patients utilising the service over the course of a year from different ethnic groups reflected the demographic profile of Crawley. The proportion of failed appointments showed no correlation with deprivation decile. There was also no association between ethnic group and proportion of failed appointments., Conclusion: Ensuring equal utilisation of healthcare for all population groups has become a priority for healthcare providers. This audit found minimal inequities in utilisation of the Special Care Dental Service at Crawley., (Copyright© 2023 Dennis Barber Ltd.)

Background While immunization programs across the world have made considerable progress, children and communities continue to be beyond the reach of healthcare services. Globally, they are now referred to as zero-dose (ZD) children (those who have not received a single dose of diphtheria, pertussis, and tetanus-containing vaccine). Pre-COVID-19 pandemic analyses suggest that nearly 50% of vaccine-preventable deaths occur among ZD children. Two-thirds of these children live in extremely poor households suffering from multiple deprivations including lack of access to reproductive health services, water, and sanitation. Hence, ZD children have now been prioritized as a key cohort for identification and integration with the health systems as we build back from the pandemic. Methodology Extracting data from the last two National Family Health Survey (NFHS) rounds (NFHS 4, 2015-2016 and NFHS 5, 2019-2021), this study aims to ascertain the status of ZD children aged 12-23 months in India, the challenges, and the necessary action agenda going forward. Data were analyzed for equity determinants such as gender, place of residence, religion, birth order, caste, and mother's schooling. Key determinants included the change in ZD prevalence at the national, state, and district levels; variations across equity parameters and states with maximum improvements; and disparity across these indicators. A correlation analysis was also conducted to understand the nature of the association between ZD prevalence and critical maternal and child health indicators. Results The overall ZD prevalence between the two rounds was reduced by 4.1% (10.5-6.4%). A total of 26 states in the country reported a ZD prevalence of <10% in NFHS 5 compared to 18 in NFHS 4. In total, 324 districts reported a ZD prevalence of <5%, and 145 districts reported a prevalence of >10%. The equity parameters reflected a slow-footed reduction among ZD for girl children, across urban geographies, firstborn children, mothers with 12 or more years of schooling, and children in families with the highest wealth quintiles. A negative correlation accentuated between the two NFHS rounds was established between first-trimester registration, four or more antenatal visits, institutional deliveries, and ZD prevalence. Conclusions The findings point toward sustained improvement across key equity parameters, however, challenges do exist. Moreover, the impact of the pandemic on immunization programs across the globe and in India is bound to halt and reverse the progress and potentiate further inequities. It is thus imperative that continued and augmented efforts are continued to identify, integrate, and immunize ZD children, families, and communities., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Taneja et al.)

This paper aims to understand the impact of COVID-19 on three mental health outcomes-anxiety, depression, and mental health service use. Specifically, whether the associations between social and economic variables and these outcomes are exacerbated or buffered among equity-seeking groups in Saskatchewan. We analyzed secondary datasets of Saskatchewan adults from population-based national surveys conducted by Mental Health Research Canada (MHRC) on three occasions: cycle 2 (August 2020), cycle 5 (February 2021), and cycle 7 (June 2021). We examined temporal changes in the prevalence of anxiety, depression, and service utilization. Using the responses from 577 respondents in cycle 5 dataset (as it coincides with the peak of 2nd wave), we performed multinomial logistic regression. The policy implications of the findings were explored empirically through a World Café approach with 30 service providers, service users and policy makers in the province. The prevalence of anxiety and depression remained steady but high. Mental health services were not accessed by many who need it. Participants reporting moderate or severe anxiety were more likely to be 30-49 years old, women, and immigrants who earned less than $20,000 annually. Immigrants with either college or technical education presented with a lesser risk of severe anxiety. Factors associated with moderate or severe depression were younger age (<50 years), low household income, as well as immigrants with lower levels of education. Racialized groups had a lower risk of severe depression if they were under 30 years. Students and retirees also had a lower risk of severe depression. Canadian-born residents were more likely to require mental health supports but were not accessing them, compared to immigrants. Our analysis suggests mental health outcomes and service utilization remain a problem in Saskatchewan, especially among equity-seeking groups. This study should help drive mental health service redesign towards a client-centred, integrated, and equity-driven system in Saskatchewan., Competing Interests: The authors declare no conflict of interest.

Background: Direct and time costs of accessing and using health care may limit health care access, affect welfare loss, and lead to catastrophic spending especially among poorest households. To date, limited attention has been given to time and transport costs and how these costs are distributed across patients, facility and service types especially in poor settings. We aimed to fill this knowledge gap., Methods: We used data from 1407 patients in 150 facilities in Tanzania. Data were collected in January 2012 through patient exit-interviews. All costs were disaggregated across patients, facility and service types. Data were analysed descriptively by using means, medians and equity measures like equity gap, ratio and concentration index., Results: 71% of patients, especially the poorest and rural patients, accessed care on foot. The average travel time and cost were 30 minutes and 0.41USD respectively. The average waiting time and consultation time were 47 min and 13 min respectively. The average medical cost was 0.23 USD but only18% of patients paid for health care. The poorest and rural patients faced substantial time burden to access health care (travel and waiting) but incurred less transport and medical costs compared to their counterparts. The consultation time was similar across patients. Patients spent more time travelling to public facilities and dispensaries while incurring less transport cost than accessing other facility types, but waiting and consultation time was similar across facility types. Patients paid less amount in public than in private facilities. Postnatal care and vaccination clients spent less waiting and consultation time and paid less medical cost than antenatal care clients., Conclusions: Our findings reinforce the need for a greater investment in primary health care to reduce access barriers and cost burdens especially among the worse-offs. Facility's construction and renovation and increased supply of healthcare workers and medical commodities are potential initiatives to consider. Other initiatives may need a multi-sectoral collaboration., (© 2022. The Author(s).)

Background: Global obesity estimates show a steadily increasing pattern across socioeconomic and geographical divides, especially among women. Our analysis tracked and described obesity trends across multiple equity dimensions among women of reproductive age (15-49 y) in 11 sub-Saharan African (SSA) countries during 1994-2015., Methods: This study consisted of a cross-sectional series analysis using nationally representative demographic and health surveys (DHS) data. The countries included were Cameroon, Comoros, Congo, Cote d'Ivoire, Ghana, Kenya, Lesotho, Nigeria, Senegal, Zambia and Zimbabwe. The data reported are from a reanalysis conducted using the WHO Health Equity Assessment Toolkit that assesses inter- and intra-country health inequalities across socioeconomic and geographical dimensions. We generated equiplots to display intra- and inter-country equity gaps., Results: There was an increasing trend in obesity among women of reproductive age across all 11 SSA countries. Obesity increased unequally across wealth categories, place of residence and educational measures of inequality. The wealthiest, most educated and urban dwellers in most countries had a higher prevalence of obesity. However, in Comoros, obesity did not increase consistently with increasing wealth or education compared with other countries. The most educated and wealthiest women in Comoros had lower obesity rates compared with their less wealthy and less well-educated counterparts., Conclusion: A window of opportunity is presented to governments to act structurally and at policy level to reduce obesity generally and prevent a greater burden on disadvantaged subpopulation groups in sub-Saharan Africa., (© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Purpose: To examine potential indicators of health need for primary care in spatial equity research, and evidence of the Inverse Care Law in the Waikato region of New Zealand., Methods: A cross-sectional analysis of 7 health need indicators (ambulatory sensitive hospitalizations; cancer rate; mortality rate; New Zealand index of multiple deprivation-health domain; age; New Zealand index of deprivation; smoking rate) that were identified through a systematic review was carried out. Values of indicators were mapped and analyzed using geographic information systems (GIS). Spearman's correlations were calculated between indicators, and clusters of high need were identified through spatial autocorrelation. The impact of incorporating indicator-based weightings into an accessibility model was tested using analysis of variance and Spearman's correlations. General practice service spatial equity was assessed by comparing clusters of high access versus need, and quantified through the Gini coefficient., Findings: Ambulatory sensitive hospitalization (ASH) rates were significantly correlated with all indicators. Health needs were significantly clustered, but incorporating indicator weightings into the spatial accessibility analysis did not impact accessibility scores. A misalignment of access and need, and a Gini coefficient of 0.281 suggest that services are not equitably distributed., Conclusion: ASH rates seem a robust indicator of health need. However, data access issues may restrict their use. Area-level socioeconomic deprivation measures incorporate some social determinants of health, and they have potential for wider use. High need clusters vary spatially according to the indicator used. GIS techniques can identify "hot-spots" of need, but these can be masked in accessibility models., (© 2020 National Rural Health Association.)

The onset of the COVID-19 pandemic has accelerated the growth of e-commerce and home deliveries. Automated parcel lockers are a way to improve delivery efficiency, but despite their rapid growth, little is known about their accessibility and equity impacts. Among e-commerce players in the U.S., Amazon stands out by its large market share. This research studies the location of Amazon lockers in Portland, Oregon utilizing highway, land use, employment, and sociodemographic datasets. Geographical tools and cluster analysis are utilized to estimate accessibility and equity metrics. Lockers tend to be located in mixed-use areas and can be utilized by a large percentage of the population. However, the equity metrics indicate that the current distribution of lockers could be improved to reach traditionally underserved populations. Given the environmental and economic advantages of lockers, policymakers should encourage the expansion of this type of last mile solution to avoid market failures in areas that are currently underserved., (© 2021 Elsevier Ltd. All rights reserved.)

Kilkari is one of the largest maternal mobile messaging programmes in the world. It makes weekly prerecorded calls to new and expectant mothers and their families from the fourth month of pregnancy until 1-year post partum. The programme delivers reproductive, maternal, neonatal and child health information directly to subscribers' phones. However, little is known about the reach of Kilkari among different subgroups in the population, or the differentiated benefits of the programme among these subgroups. In this analysis, we assess differentials in eligibility, enrolment, reach, exposure and impact across well-known proxies of socioeconomic position-that is, education, caste and wealth. Data are drawn from a randomised controlled trial (RCT) in Madhya Pradesh, India, including call data records from Kilkari subscribers in the RCT intervention arm, and the National Family Health Survey-4, 2015. The analysis identifies that disparities in household phone ownership and women's access to phones create inequities in the population eligible to receive Kilkari, and that among enrolled Kilkari subscribers, marginalised caste groups and those without education are under-represented. An analysis of who is left behind by such interventions and how to reach those groups through alternative communication channels and platforms should be undertaken at the intervention design phase to set reasonable expectations of impact. Results suggest that exposure to Kilkari has improved levels of some health behaviours across marginalised groups but has not completely closed pre-existing gaps in indicators such as wealth and education., Competing Interests: Competing interests: All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare that the research reported was funded by the Bill and Melinda Gates Foundation. AG, SC and PD are employed by BBC Media Action; one of the entities supporting program implementation. The authors do not have other relationships and are not engaged in activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Unequal allocation of medical physician resource represents one of major problems in the current medical service management in China and many other countries. This study is designed to analyze the current distribution of physicians in 31 provincial administrative regions in China, to estimate the fairness of the distribution of physicians and provide a theoretical basis for the improvement of the allocation of physicians., Methods: This study took physicians from 31 provincial administrative regions in China as the study objects, and the data were obtained from the China Health Statistics Yearbook 2019 and the official website of the National Bureau of Statistics of China. Calculation of the Gini coefficient (G) and the Theil index (T) were carried out by drawing the Lorenz curve. The fairness of present physician location in 31 provincial administrative regions in China was analyzed from the perspective of distribution by both population and service area., Results: The Gini coefficients of medical physicians in China are 0.003 and 0.88 by population and by service area, respectively. This shows that the distribution of medical physicians is fair basing on population, and there is little difference in the number of physicians per 1000 population in different regions. However, the physician distribution basing on service area is highly unfair and shows a large gap in the number of physicians per square kilometer between different regions. In general, Beijing, Zhejiang, Shanghai, Jiangsu, Shandong, and Tianjin are higher than the overall level of 31 provincial administrative regions. In addition, the number of medical physicians in Zhejiang, Shandong, Beijing and Jiangsu is over-provisioned., Conclusion: Bridging the number of medical physicians in different regions is a key step to improve the equity of physicians' resource allocation. Thus, findings from this study emphasize the need to take more measures to reduce physician quality differences between regions, balance and coordinate medical resources. This will increase the access of all citizens to quality medical services.

Background: Crowdsourcing was recognized as having the potential to collect information rapidly, inexpensively and accurately. U-Report is a mobile empowerment platform that connects young people all over the world to information that will change their lives and influence decisions. Previous studies of U-Report's effectiveness highlight strengths in the timeliness, low cost and high credibility for collecting and sending information, however they also highlight areas to improve on concerning data representation. EquityTool has developed a simpler approach to assess the wealth quintiles of respondents based on fewer questions derived from large household surveys such as Multiple Indicators Cluster Surveys (MICS) and Demographic and Health Surveys (DHS)., Methods: The methodology of Equity Tool was adopted to assess the socio-economic profile of U-Reporters (ie, enrolled participants of U-Report) in Bangladesh. The RapidPro flow collected the survey responses and scored them against the DHS national wealth index using the EquityTool methodology. This helped placing each U-Reporter who completed all questions into the appropriate wealth quintile., Results: With 19% of the respondents completing all questions, the respondents fell into all 5 wealth quintiles, with 79% in the top-two quintiles and only 21% in the lower-three resulting in an Equity Index of 53/100 where 100 is completely in line with Bangladesh equity distribution and 1 is the least in line. An equitable random sample of 1828 U-Reporters from among the regular and frequent respondents was subsequently created for future surveys and the sample has an Equity Index of 98/100., Conclusions: U-Report in Bangladesh does reach the poorest quintiles while the initial recruitment skews to respondents towards better off families. It is possible to create an equitable random sub-sample of respondents from all five wealth quintiles and thus process information and data for future surveys. Moving forward, U-Reporters from the poorly represented quintiles may be incentivized to recruit peers to increase equity and representation. In times of COVID-19, U-Report in combination with the EquityTool has the potential to enhance the quality of crowdsourced data for statistical analysis., Competing Interests: Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interest., (Copyright © 2021 by the Journal of Global Health. All rights reserved.)

Background: Manitoba is a central Canadian province with annual rates of new HIV infections consistently higher than the Canadian average. National surveillance statistics and data from the provincial HIV care program suggest that epidemiological heterogeneity exists across Manitoba. New HIV cases are disproportionately reported among females, Indigenous-identifying individuals, and those with a history of injection drug use. Given the heterogeneity in acquisition, it is of interest to understand whether this translates into inequalities in HIV care across Manitoba., Methods: A sample of 703 participants from a clinical cohort of people living with HIV in Manitoba, with data current to the end of 2017, was used to conduct cross-sectional, disaggregated analyses of the HIV care cascade to identify heterogeneity in service coverage and clinical outcomes among different groups receiving HIV care in Manitoba. Equiplots are used to identify and visualize inequalities across the cascade. Exploratory multivariable logistic regression models quantify associations between equity variables (age, sex, geography, ethnicity, immigration status, exposure category) and progression along the cascade. Adjusted odds ratios (AOR) and 95% confidence intervals (95%CI) are reported., Results: Equity analyses highlight inequalities in engagement in and coverage of HIV-related health services among cohort participants. Equiplots illustrate that the proportion of participants in each cascade step is greater for those who are older, white, non-immigrants, and report no history of injection drug use. Compared to those living in Winnipeg, participants in eastern Manitoba have greater odds of achieving virologic suppression (AOR[95%CI] = 3.8[1.3-11.2]). The odds of Indigenous participants being virologically suppressed is half that of white participants (AOR[95%CI] = 0.5[0.3-0.7]), whereas African/Caribbean/Black participants are significantly less likely than white participants to be in care and retained in care (AOR[95%CI] = 0.3[0.2-0.7] and 0.4[0.2-0.9], respectively)., Conclusions: Inequalities exist across the cascade for different groups of Manitobans living with HIV; equiplots are an innovative method for visualizing these inequalities. Alongside future research aiming to understand why inequalities exist across the cascade in Manitoba, our equity analyses can generate hypotheses and provide evidence to inform patient-centred care plans that meet the needs of diverse client subgroups and advocate for policy changes that facilitate more equitable HIV care across the province.

Introduction: While much of the literature on homelessness is centred on the experience of men, women make up over one-quarter of Canada's homeless population. Research has shown that women experiencing homelessness are often hidden (i.e. provisionally housed) and have different pathways into homelessness and different needs as compared to men. The objective of this research is to identify evidence-based interventions and best practices to better support women experiencing or at risk of homelessness., Methods: We conducted a scoping review with a gender and equity analysis. This involved searching MEDLINE, CINAHL, PsycINFO and other databases for systematic reviews and randomized trials, supplementing our search through reference scanning and grey literature, followed by a qualitative synthesis of the evidence that examined gender and equity considerations., Results: Of the 4102 articles identified on homelessness interventions, only 4 systematic reviews and 9 randomized trials were exclusively conducted on women or published disaggregated data enabling a gender analysis. Interventions with the strongest evidence included post-shelter advocacy counselling for women experiencing homelessness due to intimate partner violence, as well as case management and permanent housing subsidies (e.g. tenant-based rental assistance vouchers), which were shown to reduce homelessness, food insecurity, exposure to violence and psychosocial distress, as well as promote school stability and child well-being., Conclusion: Much of the evidence on interventions to better support women experiencing homelessness focusses on those accessing domestic violence or family shelters. Since many more women are experiencing or at risk of hidden homelessness, population-based strategies are also needed to reduce gender inequity and exposure to violence, which are among the main structural drivers of homelessness among women., Competing Interests: No competing interests are declared by the authors.

The contradiction between the supply and demand of public medical resources in China is serious. On the basis of the "graded diagnosis and treatment" model, the Chinese government divides the medical grade and adjusts the allocation of medical facilities so as to alleviate the adverse impact of these issues on residents' health. Although the government tries to guide residents' medical treatment according to the level of medical facilities, there are differences between residents' medical treatment mode and policy rules in reality. Therefore, it is of great significance to explore spatial differences in accessibility to medical services for residents on the basis of the actual medical behavior. This article takes Shaanxi province as the research area, and uses the improved node cost network analysis method with the space-time distance model and the two-step floating catchment area method, respectively, to analyze the spatial differences of accessibility to three-level medical services and evaluate the equity of accessibility in different areas and groups in Shaanxi. Results showed that the overall level of accessibility to primary medical services in the province is good, and spatial distribution is balanced; the polarization of accessibility to secondary and tertiary medical services is a serious issue, and within the research area, a band-shaped multicore spatial structure was formed with the built-up areas of various cities as high-level centers of accessibility. Provincial residents have poor equity to access three-level medical services, and the equity of accessibility to primary medical services is better than that to highly specialized medical services. There is no obvious gap between accessibility to three-level medical services for the aging and the nonaging populations in Shaanxi, but the unfair phenomenon between agricultural and the nonagricultural populations is prominent. In addition, this article found that the improvement in traffic conditions can produce space-time convergence and effectively weaken spatial deprivation. Therefore, developing public transportation is an effective approach to improve the equity of accessibility to medical services.

Introduction: Early access to adequate antenatal care (ANC) from skilled providers is crucial for detecting and preventing obstetric complications of pregnancy. We aimed to assess factors associated with the utilisation of the new WHO ANC guidelines including the recommended number, on time initiation and adequate components of ANC contacts in Myanmar., Methods: We examined data from 2943 mothers aged 15-49 years whose most recent birth occurred in the last 5 years prior to the 2015-2016 Myanmar Demographic and Health Survey. Factors associated with utilisation of the new WHO recommended ANC were explored using multinomial logistic regression and multivariate models. We used marginal standardisation methods to estimate the predicted probabilities of the factors significantly associated with the three measures of ANC., Results: Approximately 18% of mothers met the new WHO recommended number of eight ANC contacts. About 58% of the mothers received adequate ANC components, and 47% initiated ANC within the first trimester of pregnancy. The predicted model shows that Myanmar could achieve 70% coverage of adequate components of ANC if all women were living in urban areas. Similarly, if ANC was through private health facilities, 63% would achieve adequate components of ANC. Pregnant women from urban areas (adjusted risk ratio (aRR): 4.86, 95% CI 2.44 to 9.68) were more than four times more likely to have adequate ANC components compared with women from rural areas. Pregnant women in the highest wealth quintile were three times more likely to receive eight or more ANC contacts (aRR: 3.20, 95% CI 1.61 to 6.36) relative to mothers from the lowest wealth quintile. On time initiation of the first ANC contact was fourfold for mothers aged 30-39 years relative to adolescent mothers (aRR: 4.07, 95% CI 1.53 to 10.84)., Conclusion: The 2016 WHO ANC target is not yet being met by the majority of women in Myanmar. Our results highlight the need to address health access inequity for women who are from lower socioeconomic groups, or are younger, and those living in rural areas., Competing Interests: Competing interests: The authors declare no conflicts of interest., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Transport accessibility experienced by an individual depends on their needs and abilities, as represented by their individual characteristics, such as age, income and gender. Although important from an equity perspective, the individual component of accessibility is currently ignored in most transport equity studies. This paper evaluates the impact of including individual characteristics into logsum-based accessibility measures for transport equity analysis. Using data from the London Travel Demand Survey (LTDS) 2011-13, two alternate logsum measures of accessibility are specified - with and without individual characteristics. An empirical analysis of spatial, social and economic equity is conducted using both the measures, and the outcomes are compared. The results clearly demonstrate that ignoring individual characteristics in logsum measures of accessibility can lead to unreliable outcomes for social and economic equity analysis, but do not add significant value when aggregated across large geographical zones for spatial equity analysis. Overall, ignoring individual characteristics masks the disparity in distribution of accessibility, as measured by the Gini index. Although not straightforward, the difference between accessibility patterns using the two logsum measures also yields insights into the possible causes of inequity, which can provide actionable inputs to policy makers. The study highlights that personal needs and abilities are often responsible for accessibility variations among individuals and ignoring them can result in a misleading picture of equity, as demonstrated quantitatively in this paper., (© 2020 The Authors.)

[This corrects the article DOI: 10.1371/journal.pmed.1002326.].

Background: Health care utilization is one of the key indicators in measuring performance of health care services. Strong brand equity suggests positive correlation with great attraction for consumers to use a product. Design and Methods: A cross-sectional study was conducted to identify the effects of brand equity to health care utilization. 381 students were selected by simple random sampling. Multiple logistic regression tests were used to analyze the influence between variables. Results: Findings showed that there was an influence between brand equity and health care utilization (P=0.001). In the three attributes, brand equity was known to have an influence to the utilization of health care. The highest influence of the three attributes was brand association (Exp (B) = 2.501). Conclusions: It can be concluded that brand equity affects patient visits to AHCC showing that the brand equity significantly influence patient visits. Promotion to create familiarity and good impression was required to enhance brand equity and increase health care utilization., Competing Interests: Conflict of interest: The authors declare no conflict of interest., (©Copyright: the Author(s).)

Background: Universal Health Coverage (UHC) remains a critical public health goal that continues to elude many countries of the global south. As countries strive for its attainment, it is important to track progress in various subregions of the world to understand current levels and mechanisms of progress for shared learning. Our aim was to compare multidimensional equity gaps in access to skilled attendant at birth (SAB) and coverage of the third dose of Diphtheria-Tetanus-Pertussis (DTP3) across 14 West African countries., Methods: The study was a cross sectional comparative analysis that used publicly available, nationally representative health surveys. We extracted data from Demographic and Health Surveys, and Multiple Indicator Cluster Surveys conducted between 2010 and 2017 in Benin, Burkina Faso, Cote d' Ivoire, The Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone and Togo. The World Health Organization's Health Equity Assessment Toolkit (HEAT Plus) software was used to evaluate current levels of intra-country equity in access to SAB and DTP3 coverage across four equity dimensions (maternal education, location of residence, region within a country and family wealth status)., Results: There was a general trend of higher levels of coverage for DTP3 compared to access to SAB in the subregion. Across the various dimensions of equity, more gaps appear to have been closed in the subregion for DTP3 compared to SAB. The analysis revealed that countries such as Sierra Leone, Liberia and Ghana have made substantial progress towards equitable access for the two outcomes compared to others such as Nigeria, Niger and Guinea., Conclusion: In the race towards UHC, equity should remain a priority and comparative progress should be consistently tracked to enable the sharing of lessons. The West African subregion requires adequate government financing and continued commitment to move toward UHC and close health equity gaps.

Objective: To analyze the regional allocation of the resources from the Brazilian Popular Pharmacy Program, taking into account the relative availability of the program and the potential needs of the region., Methods: Data from the National Health Survey of the Annual Report of Social Information and the administrative database of the program were used to create a non-parametric indicator of coverage using multiple data envelopment analysis technique. This indicator considers the relative availability of the program, taking into account equal access to equal needs (equity based on regional needs). The analysis of this indicator shows if the regions that most need pharmaceutical assistance are those that receive more resources from the Brazilian Popular Pharmacy Program., Results: The states belonging to the richest regions of the country, Southeast and South, present wider relative coverage of the Brazilian Popular Pharmacy Program compared to poorer localities. In addition, the inequalities observed between locations are better explained by inefficiency in the transfer of resources to the basic component of pharmaceutical care than by the Brazilian Popular Pharmacy Program itself. According to the model, a 43.76% increase in the transfer to the basic component of pharmaceutical care would be required in order to improve equity, whereas the increase required by the Brazilian Popular Pharmacy Program is equivalent to 22.71%., Conclusions: Although the Brazilian Popular Pharmacy Program seeks to reduce the socioeconomic inequalities observed in access to pharmaceutical care, which integrates health care services, regional disparities in access to medicine persist. These regional differences are attributed mostly to allocation failures and problems in managing the conventional pharmaceutical care cycle provided through SUS pharmacies.

Background: Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi's equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya., Methods: We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach., Results: Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date., Conclusions: If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity.

"Leaving no one behind" is at the heart of the agenda of the Sustainable Development Goals, requiring that health systems be vigilant to how interventions can be accessed equitably by all, including population subgroups that face exclusion. In the World Health Organization (WHO) South-East Asia Region, inequalities can be found across and within countries but there has been a growing commitment to examining and starting to tackle them. Over the past decade in particular, WHO has been developing an armamentarium of tools to enable analysis of health inequalities and action on health equity. Tools include the Health Equity Assessment Toolkit in built-in database and upload database editions, as well as the Innov8 tool for reorientation of national health programmes. Countries across the region have engaged meaningfully in the development and application of these tools, in many cases aligning them with, or including them as part of, ongoing efforts to examine inequities in population subgroups domestically. This paper reflects on these experiences in Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand, where efforts have ranged from workshops to programme reorientation; the creation of assemblies and conferences; and collation of evidence through collaborative research, reviews/synthesis and conferences. This promising start must be maintained and expanded, with greater emphasis on building capacity for interpretation and use of evidence on inequalities in policy-making. This may be further enhanced by the use of innovative mixed methodologies and interdisciplinary approaches to refine and contextualize evidence, with a concomitant shift in attention, developing solutions to redress inequities and anchor health reform within communities. There are many lessons to be learnt in this region, as well as mounting political and popular will for change., Competing Interests: None

Understanding differences in the wealth status of patients can inform planning decisions aimed at providing affordable access to high quality care to all. This study assesses differences in the wealth status of clients of family planning and child health services by health sector. It also describes reason for facility choice, cost of services, and the proportion of additional clients of these services, and assesses if there are any differences by health sector. A cross-sectional survey of 2,173 clients from 96 health facilities in urban areas of 6 counties in Kenya was conducted, stratified by health facility type. The 4 strata were public, faith-based, private for profit, and social franchise. Client wealth was benchmarked to the national and urban population of the 2014 Kenya Demographic and Health Survey (DHS), and assessed using the EquityTool. There were significant differences in the client wealth distribution between facility types, and public sector facilities served a significantly higher proportion of poor clients than other types of facilities. In all three non-public facility types, more than 25% of clients were from the poorest two wealth quintiles, without significant differences between facility types. No facility type stands out as expanding access to health services more than another. Results show that social franchises do better at reaching the poor than earlier studies have indicated, though not as well as faith-based and public facilities. Findings suggest that private providers remain important within the larger health system, more so for family planning than childhood illness management. In urban areas with significant facility choice, this study quantifies differences in client wealth across four health sectors. Incorporating these findings into policy and programmatic interventions can improve equity in access to and use of quality health services.

Background: Cigarette smoking is the leading cause of preventable death and disease in the United States. Smoking prevalence is higher in rural areas than in metropolitan areas, due partly to differences in access to cessation treatment. With internet use at 89% of all US adults, digital approaches could increase use of cessation treatment and reduce smoking., Objective: We investigated the extent to which smokers from rural areas use a digital cessation resource. We compared the geographic distribution of registered users of a free Web-based smoking cessation program with the geographic distribution of US smokers., Methods: We mapped user-provided ZIP codes to Rural-Urban Continuum Codes. A total of 59,050 of 118,574 users (49.80%) provided valid ZIP codes from 2013 to 2017. We used US National Survey of Drug Use and Health data from 2013 to 2017 to compare the geographic distribution of our sample of Web-based cessation users with the geographic distribution of US smokers. Reach ratios and 95% confidence intervals quantified the extent to which rural smokers' representation in the sample was proportionate to their representation in the national smoking population. Reach ratios less than 1 indicate underrepresentation., Results: Smokers from rural areas were significantly underrepresented in 2013 (reach ratio 0.89, 95% CI 0.87-0.91) and 2014 (reach ratio 0.89, 95% CI 0.86-0.92), proportionally represented in 2015 (reach ratio 1.08, 95% CI 1.02-1.14) and 2016 (reach ratio 1.03, 95% CI 0.94-1.14), and proportionally overrepresented in 2017 (reach ratio 1.16, 95% CI 1.12-1.21). Smokers from Large Metro areas were proportionally represented in 2013 and 2014 but underrepresented in 2015 (reach ratio 0.97, 95% CI 0.94-1.00), 2016 (reach ratio 0.89, 95% CI 0.85-0.94), and 2017 (reach ratio 0.89, 95% CI 0.86-0.91)., Conclusions: Results suggest that smokers from rural areas are more than proportionally reached by a long-standing digital cessation intervention. The underrepresentation of smokers from Large Metro areas warrants further study., (©Michael S Amato, Amanda L Graham. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 24.10.2018.)

Background: A key component of universal health coverage is the ability to access quality healthcare without financial hardship. Poorer individuals are less likely to receive care than wealthier individuals, leading to important differences in health outcomes, and a needed focus on equity. To improve access to healthcare while minimizing financial hardships or inequitable service delivery we need to understand where individuals of different wealth seek care. To ensure progress toward SDG 3, we need to specifically understand where individuals seek reproductive, maternal, and child health services., Methods: We analyzed Demographic and Health Survey data from Bangladesh, Cambodia, DRC, Dominican Republic, Ghana, Haiti, Kenya, Liberia, Mali, Nigeria, Senegal and Zambia. We conducted weighted descriptive analyses on current users of modern FP and the youngest household child under age 5 to understand and compare country-specific care seeking patterns in use of public or private facilities based on urban/rural residence and wealth quintile., Results: Modern contraceptive prevalence rate ranged from 8.1% to 52.6% across countries, generally rising with increasing wealth within countries. For relatively wealthy women in all countries except Ghana, Liberia, Mali, Senegal and Zambia, the private sector was the dominant source. Source of FP and type of method sought across facilities types differed widely across countries. Across all countries women were more likely to use the public sector for permanent and long-acting reversible contraceptive methods. Wealthier women demonstrated greater use of the private sector for FP services than poorer women. Overall prevalence rates for diarrhea and fever/ARI were similar, and generally not associated with wealth. The majority of sick children in Haiti did not seek treatment for either diarrhea or fever/ARI, while over 40% of children with cough or fever did not seek treatment in DRC, Haiti, Mali, and Senegal. Of all children who sought care for diarrhea, more than half visited the public sector and just over 30% visited the private sector; differences are more pronounced in the lower wealth quintiles., Conclusions: Use of the private sector varies widely by reason for visit, country and wealth status. Given these differences, country-specific examination of the role of the private sector furthers our understanding of its utility in expanding access to services across wealth quintiles and providing equitable care.

Background: The Chinese government has long been committed to eliminating the inequality in the utilization of health services; however, it still lacks an analysis or measurement of the economy-related inequality in the utilization of women's health services., Methods: The economy-related utilization of health services in women aged 15 years and above was assessed by the horizontal inequity index of a two-week outpatient rate and annual inpatient rate from the 5th National Health Service Survey of Shaanxi Province. The concentration index of each factor was decomposed into the contribution of each factor to the economic-related inequality of health service utilization based on the Probit regression model., Results: The horizontal inequity indexes of the two-week outpatient rate was 0.0493, and the horizontal inequity indexes of the annual impatient rate was 0.0869. The contributions of economic status to the two indexes were 190.71% and 115.80%, respectively. Economic status, age, basic medical insurance, educational status, marital status, urban/rural area, and self-rated health were the main impact factors that affected the inequality in women's health services utilization in Shaanxi., Conclusions: Health service utilization was different between women with different social demographic characteristics, and unequal health service utilization is evident among women in Shaanxi.

Objective: This study sought to examine the sources of inequity in health examination service utilization by women from underdeveloped areas in western China., Methods: Based on data from the 5th National Health Service Survey in Shaanxi province, women's utilization of health examination services was examined according to gynecological, cervical smear, and breast examination rates. The equity of health examination service utilization by 15- to 64-year-old women and the factors contributing to inequity were determined using the health concentration index, decomposition of the concentration index, and the horizontal inequity index., Results: The examination rates for gynecological, cervical smear, and breast exams for 15- to 64-year-old women in Shaanxi province were 40.61%, 27.08%, and 24.59%, respectively. The horizontal inequity indices of gynecological, cervical smear, and breast examination rates were 0.0480, 0.0423, and 0.0764, respectively, and each examination rate was higher for wealthy individuals. The contribution rates of economic status to the inequalities in gynecological, cervical smear, and breast examination rates were 65.80%, 74.31%, and 56.49%, respectively. The contribution rates of educational status to the inequalities in gynecological, cervical smear, and breast examination rates were 21.01%, 14.83% and 30.00%, respectively. The contribution rates of age to the inequalities in gynecological, cervical smear, and breast examination rates were 25.77%, 26.55%, and 18.40%, respectively., Conclusions: Women's health examination rates differed between populations with different socio-demographic characteristics. There is pro-wealth inequality in each examination rate. This study found that financial status, age, and education level were the main reasons for the unequal utilization of health examination services.

Background: A sugar-sweetened beverage (SSB) tax in Mexico has been effective in reducing consumption of SSBs, with larger decreases for low-income households. The health and financial effects across socioeconomic groups are important considerations for policy-makers. From a societal perspective, we assessed the potential cost-effectiveness, health gains, and financial impacts by socioeconomic position (SEP) of a 20% SSB tax for Australia., Methods and Findings: Australia-specific price elasticities were used to predict decreases in SSB consumption for each Socio-Economic Indexes for Areas (SEIFA) quintile. Changes in body mass index (BMI) were based on SSB consumption, BMI from the Australian Health Survey 2011-12, and energy balance equations. Markov cohort models were used to estimate the health impact for the Australian population, taking into account obesity-related diseases. Health-adjusted life years (HALYs) gained, healthcare costs saved, and out-of-pocket costs were estimated for each SEIFA quintile. Loss of economic welfare was calculated as the amount of deadweight loss in excess of taxation revenue. A 20% SSB tax would lead to HALY gains of 175,300 (95% CI: 68,700; 277,800) and healthcare cost savings of AU$1,733 million (m) (95% CI: $650m; $2,744m) over the lifetime of the population, with 49.5% of the total health gains accruing to the 2 lowest quintiles. We estimated the increase in annual expenditure on SSBs to be AU$35.40/capita (0.54% of expenditure on food and non-alcoholic drinks) in the lowest SEIFA quintile, a difference of AU$3.80/capita (0.32%) compared to the highest quintile. Annual tax revenue was estimated at AU$642.9m (95% CI: $348.2m; $1,117.2m). The main limitations of this study, as with all simulation models, is that the results represent only the best estimate of a potential effect in the absence of stronger direct evidence., Conclusions: This study demonstrates that from a 20% tax on SSBs, the most HALYs gained and healthcare costs saved would accrue to the most disadvantaged quintiles in Australia. Whilst those in more disadvantaged areas would pay more SSB tax, the difference between areas is small. The equity of the tax could be further improved if the tax revenue were used to fund initiatives benefiting those with greater disadvantage.

Background: Afghanistan has made great strides in the coverage of health services across the country but coverage of key indicators remains low nationally and whether the poorest households are accessing these services is not well understood., Methods: We analyzed the Afghanistan Mortality Survey 2010 on utilization of inpatient and outpatient care, institutional delivery and antenatal care by wealth quintiles. Concentration indexes (CIs) were generated to measure the inequality of using the four services. Additional analyses were conducted to examine factors that explain the health inequalities (e.g. age, gender, education and residence)., Results: Among households reporting utilization of health services, public health facilities were used more often for inpatient care, while they were used less for outpatient care. Overall, the utilization of inpatient and outpatient care, and antenatal care was equally distributed among income groups, with CIs of 0.04, 0.03 and 0.08, respectively. However, the poor used more public facilities while the wealthy used more private facilities. There was a substantial inequality in the use of institutional delivery services, with a CI of 0.31. Poorer women had a lower rate of institutional deliveries overall, in both public and private facilities, compared to the wealthy. Location was an important factor in explaining the inequality in the use of health services., Conclusions: The large gap between the rich and poor in access to and utilization of key maternal services, such as institutional delivery, may be a central factor to the high rates of maternal mortality and morbidity and impedes efforts to make progress toward universal health coverage. While poorer households use public health services more often, the use of public facilities for outpatient visits remains half that of private facilities. Pro-poor targeting as well as a better understanding of the private sector's role in increasing equitable coverage of maternal health services is needed. Equity-oriented approaches in health should be prioritized to promote more inclusive health system reforms.

Background: This study aimed to improve on previous modelling work to determine the health gain, cost-utility and health equity impacts from home safety assessment and modification (HSAM) for reducing injurious falls in older people., Methods: The model was a Markov macrosimulation one that estimated quality-adjusted life-years (QALYs) gained. The setting was a country with detailed epidemiological and cost data (New Zealand (NZ)) for 2011. A health system perspective was taken and a discount rate of 3% was used (for both health gain and costs). Intervention effectiveness estimates came from a Cochrane systematic review and NZ-specific intervention costs were from a randomised controlled trial., Results: In the 65 years and above age group, the HSAM programme cost a total of US$98 million (95% uncertainty interval (UI) US$65 to US$139 million) to implement nationally and the accrued net health system costs were US$74 million (95% UI: cost saving to US$132 million). Health gains were 34 000 QALYs (95% UI: 5000 to 65 000). The incremental cost-effectiveness ratio (ICER) was US$6000 (95% UI: cost saving to US$13 000), suggesting that HSAM is highly cost-effective. Targeting HSAM only to older people with previous injurious falls and to older people aged 75 years and above were also cost-effective (ICERs=US$1000 and US$11 000, respectively). There was no evidence for differential cost-effectiveness by gender or by ethnicity (Indigenous New Zealanders: Māori vs non-Māori)., Conclusions: As per other studies, this modelling study indicates that the provision of an HSAM intervention produces considerable health gain and is highly cost-effective among older people. Targeting this intervention to older people with previous injurious falls is a promising initial approach before any scale up., Trial Registration Number: ACTRN12609000779279., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Urban green space is an important ecological landscape, whose spatial distribution plays a significant role in improving the eco-environment and people's living quality. This study was initia-ted from the perspective of supply and demand balance to evaluate the equity of distribution of urban parks, drawing on previous research, and introduced an integrated framework for evaluating the equity of urban public facilities using spatial multi-analysis. A method concerning gravity model to assess the equity of urban green space was introduced, taking the effect of boundary into account. The case study area was the Futian District of Shenzhen and its 2000 m buffer area. Then, some optimizations were suggested for better allocation of the green space. The results showed that the equity of Futian District was low. The equity of community parks was lowest, followed by that of regional parks, while the countryside ecological parks owned the highest equity. About 50% of the Futian district area was in a state of balance between supply and demand and the rest were in a state of insufficient supply. Greening rate and space allocation of parks and road traffic systems should be improved to better plan the green space in Futian District. For urban green space planning, the parks of small area should be paid more attention to meet the needs of residents for daily recreation. By taking the effect of boundary into account, we observed that the residential area on the edge of the study area could enjoy the park green space, and the green space in the boundary area outside the region would be also shared by residents on both sides of the administrative boundary.

Background: Undernutrition is highly prevalent among infants in Uganda. Optimal infant feeding practices may improve nutritional status, health, and survival among children., Objective: Our study evaluates the socioeconomic distribution of exclusive breastfeeding (EBF) and growth outcomes among infants included in a trial, which promoted EBF by peer counselors in Uganda., Design: Twenty-four clusters comprising one to two communities in Uganda were randomized into intervention and control arms, including 765 mother-infant pairs (PROMISE-EBF trial, 200608, ClinicalTrials.gov no. NCT00397150). Intervention clusters received the promotion of EBF by peer counselors in addition to standard care. Breastfeeding and growth outcomes were compared according to wealth quintiles and intervention/control arms. Socioeconomic inequality in breastfeeding and growth outcomes were measured using the concentration index 12 and 24 weeks postpartum. We used the decomposition of the concentration index to identify factors contributing to growth inequality at 24 weeks., Results: EBF was significantly concentrated among the poorest in the intervention group at 24 weeks postpartum, concentration index -0.060. The control group showed a concentration of breastfeeding among the richest part of the population, although not statistically significant. Stunting, wasting, and underweight were similarly significantly concentrated among the poorest in the intervention group and the total population at 24 weeks, but showing non-significant concentrations for the control group., Conclusion: This study shows that EBF can be successfully promoted among the poor. In addition, socioeconomic inequality in growth outcomes starts early in infancy, but the breastfeeding intervention was not strong enough to counteract this influence.

Background: One of the important aspects of equity in health is equality in the distribution of resources in this sector. The present study aimed to assess the distribution of hospital beds in Shiraz in 2014., Methods: In this retrospective cross-sectional study, the population density index and fair distribution of beds were analyzed by Lorenz curve and Gini coefficient, respectively. Descriptive data were analyzed using Excel software. We used Distributive Analysis Stata Package (DASP) in STATA software, version 12, for computing Gini coefficient and drawing Lorenz curve., Results: The Gini coefficient was 0.68 in the population. Besides, Gini coefficient of hospital beds' distribution based on population density was 0.70, which represented inequality in the distribution of hospital bedsamong the nine regions of Shiraz., Conclusion: Although the total number of hospital beds was reasonable in Shiraz, distribution of these resources was not fair, and inequality was observed in their distribution among the nine regions of Shiraz.

Recent studies on transit service through an equity lens have captured broad trends from the literature and national-level data or analyzed disaggregate data at the local level. This study integrates these methods by employing a geostatistical analysis of new transit access and income data compilations from the Environmental Protection Agency. By using a national data set, this study demonstrates a method for income-based transit equity analysis and provides results spanning nine large auto-oriented cities in the US. Results demonstrate variability among cities' transit services to low-income populations, with differing results when viewed at the regional and local levels. Regional-level analysis of transit service hides significant variation through spatial averaging, whereas the new data employed in this study demonstrates a block-group scale equity analysis that can be used on a national-scale data set. The methods used can be adapted for evaluation of transit and other modes' transportation service in areas to evaluate equity at the regional level and at the neighborhood scale while controlling for spatial autocorrelation. Transit service equity planning can be enhanced by employing local Moran's I to improve local analysis.

Background: Methods to measure or quantify equity in health care remain scarce, if not difficult to interpret. A novel method to measure health equity is presented, applied to gender health equity, and illustrated with an example of timing of angiography in patients following a hospital admission for an acute coronary syndrome., Methods: Linked administrative hospital discharge and survey data was used to identify a retrospective cohort of patients hospitalized with Acute Coronary Syndrome (ACS) between 2002 and 2008 who also responded to the Canadian Community Health Survey (CCHS), was analyzed using decision trees to determine whether gender impacted the delay to angiography following an ACS., Results: Defining a delay to angiography as 1 day or more, resulted in a non-significant difference in an equity score of 0.14 for women and 0.12 for men, where 0 and 1 represents perfect equity and inequity respectively. Using 2 and 3 day delays as a secondary outcome resulted in women and men producing scores of 0.19 and 0.17 for a 2 day delay and 0.22 and 0.23 for a 3 day delay., Conclusions: A technique developed expressly for measuring equity suggests that men and women in Ontario receive equitable care in access to angiography with respect to timeliness following an ACS.

Introduction: If an intervention is not well spatially targeted, appropriate levels of uptake, efficacy, long-term compliance and improved health outcomes are unlikely to be attained. Effective health interventions should seek to achieve not only absolute improvements in health but also to reduce inequity. There is often a disparity whereby preventative interventions are more likely to be successful amongst the more affluent, a process which has been coined the 'inverse prevention law'. Physical inactivity is known to be socially patterned and disproportionately prevalent in disadvantaged communities yet there is a lack of clear evidence on which interventions have the potential to influence inequity. Walking groups have been found to have multiple health benefits and increase physical activity. In England the major facilitator is a not for profit organisation which has 70,000 regular walkers and is lay led with 10,000 volunteers. The aim of this study was to evaluate the extent to which walking groups operated in those places with the greatest health need and whether consequently the scheme has the potential to influence health inequity., Method: The work used a spatial approach whereby geographical variations in walking group provision within the 326 local authorities in England (mean population 163,410) were linked to health and socio-economic measures of population need., Results: Generally, greater need was not associated with higher provision of the walking group intervention. Although the magnitude of differences was small, provision of the intervention tended to be poorest in those local authorities with the greatest health need, as measured by our indicators., Conclusions: Without targeting those areas with greater health and socio-economic need, there is a concern that walking groups may not be set up in areas that need them most. There is therefore a potential that this intervention could, albeit in a small way, widen inequity between local authorities. However small-scale and well-intentioned, interventions need to be evaluated for their potential impact on inequity.

Introduction: Pneumonia and diarrhoea disproportionately affect children in resource-poor settings. Integrated community case management (iCCM) involves community health workers treating diarrhoea, pneumonia and malaria. Studies on impact of iCCM on appropriate treatment and its effects on equity in access to the same are limited. The objective of this study was to measure the impact of integrated community case management (iCCM) as the first point of care on uptake of appropriate treatment for children with a classification of pneumonia (cough and fast breathing) and/or diarrhoea and to measure the magnitude and distribution of socioeconomic status related inequality in use of iCCM., Methods: Following introduction of iCCM, data from cross-sectional household surveys were examined for socioeconomic inequalities in uptake of treatment and use of iCCM among children with a classification of pneumonia or diarrhoea using the Erreygers' corrected concentration index (CCI). Propensity score matching methods were used to estimate the average treatment effects on the treated (ATT) for children treated under the iCCM programme with recommended antibiotics for pneumonia, and ORS plus or minus zinc for diarrhoea., Findings: Overall, more children treated under iCCM received appropriate antibiotics for pneumonia (ATT = 34.7%, p < 0.001) and ORS for diarrhoea (ATT = 41.2%, p < 0.001) compared to children not attending iCCM. No such increase was observed for children receiving ORS-zinc combination (ATT = -0.145, p < 0.05). There were no obvious inequalities in the uptake of appropriate treatment for pneumonia among the poorest and least poor (CCI = -0.070; SE = 0.083). Receiving ORS for diarrhoea was more prevalent among the least poor groups (CCI = 0.199; SE = 0.118). The use of iCCM for pneumonia was more prevalent among the poorest groups (CCI = -0.099; SE = 0.073). The use of iCCM for diarrhoea was not significantly different among the poorest and least poor (CCI = -0.073; SE = 0.085)., Conclusion: iCCM is a potentially equitable strategy that significantly increased the uptake of appropriate antibiotic treatment for pneumonia and ORS for diarrhoea, but not the uptake of zinc for diarrhoea. For maximum impact, interventions increasing zinc uptake should be considered when scaling up iCCM programmes.

Introduction: Mozambique launched its revitalized community health programme in 2010 in response to inequitable coverage and quality of health services. The programme is focused on health promotion and disease prevention, with 20 % of community health workers' (known in Mozambique as Agentes Polivalentes Elementares (APEs)) time spent on curative services and 80 % on activities promoting health and preventing illness. We set out to conduct a health system and equity analysis, exploring experiences and expectations of APEs, community members and healthcare workers supervising APEs., Methods: This exploratory qualitative study captured the perspectives of a range of participants including women caring for children under 5 years (service clients), community leaders, service providers (APEs) and their supervisors. Participants in the Moamba and Manhiça districts, located in Maputo Province (Mozambique), were selected purposively. In total, 29 in-depth interviews and 9 focus group discussions were conducted in the local language and/or Portuguese. A framework approach was used for analysis, assisted by NVivo10 software., Results: Our analysis revealed that health equity is viewed as linked to the quality and coverage of the APE programme. Demand and supply factors interplay to shape health equity. The availability of responsive and appropriate services led to tensions between community expectations for curative services (and APEs' willingness to perform them) and official policy focusing APE efforts mainly on preventive services and health promotion. The demand for more curative services by community members is a result of having limited access to healthcare services other than those offered by APEs., Conclusion: This study highlights the need to pay attention to the determinants of demand and supply of community interventions in health, to understand the opportunities and challenges of the difficult interface role played by APEs and to create communication among stakeholders in order to build a stronger, more effective and equitable community programme.

Aim: To determine financial barriers that impede the utilization of screening and treatment services for breast cancer among Nigerian women from different socioeconomic groups., Materials and Methods: A descriptive study was carried out in 2013 among women attending the oncology clinic of a tertiary institution in Enugu, Southeast Nigeria. Data were collected from 270 women using an interviewer-administered questionnaire. The links between the influence of socioeconomic factors on barriers to the utilization of breast cancer screening and treatment services were examined., Results: A total of 270 women were studied. The mean age was 34.69 (Standard deviation = 5.07) years. Half of the study participants were single 141 (51.3%), while 105 (38.2%) were married. Cost of medical treatment and not having insurance coverage was major financial barriers to utilization of screening and treatment services. The least poor and poor socioeconomic status (SES) groups utilized screening services and treatment more frequently than the very poor and poorest SES groups ( P = 0.034). There was no significant difference in the utilization of the different treatment options among the different socioeconomic groups with the exception of surgery (χ² = 11.397; P = 0.000)., Conclusion: Financial barriers limit the ability of women, especially the poorest SES group, to utilize screening and treatment services for early diagnosis and treatment of breast cancer. Interventions that will improve financial risk protection for women with breast cancer or at risk of breast cancer are needed to ensure equitable access to screening and treatment services.