Impact of health system strengthening on delivery strategies to improve child immunisation coverage and inequalities in rural Madagascar

BackgroundTo reach global immunisation goals, national programmes need to balance routine immunisation at health facilities with vaccination campaigns and other outreach activities (eg, vaccination weeks), which boost coverage at particular times and help reduce geographical inequalities. However, where routine immunisation is weak, an over-reliance on vaccination campaigns may lead to heterogeneous coverage. Here, we assessed the impact of a health system strengthening (HSS) intervention on the relative contribution of routine immunisation and outreach activities to reach immunisation goals in rural Madagascar.MethodsWe obtained data from health centres in Ifanadiana district on the monthly number of recommended vaccines (BCG, measles, diphtheria, tetanus and pertussis (DTP) and polio) delivered to children, during 2014–2018. We also analysed data from a district-representative cohort carried out every 2 years in over 1500 households in 2014–2018. We compared changes inside and outside the HSS catchment in the delivery of recommended vaccines, population-level vaccination coverage, geographical and economic inequalities in coverage, and timeliness of vaccination. The impact of HSS was quantified via mixed-effects logistic regressions.ResultsThe HSS intervention was associated with a significant increase in immunisation rates (OR between 1.22 for measles and 1.49 for DTP), which diminished over time. Outreach activities were associated with a doubling in immunisation rates, but their effect was smaller in the HSS catchment. Analysis of cohort data revealed that HSS was associated with higher vaccination coverage (OR between 1.18 per year of HSS for measles and 1.43 for BCG), a reduction in economic inequality, and a higher proportion of timely vaccinations. Yet, the lower contribution of outreach activities in the HSS catchment was associated with persistent inequalities in geographical coverage, which prevented achieving international coverage targets.ConclusionInvestment in stronger primary care systems can improve vaccination coverage, reduce inequalities and improve the timeliness of vaccination via increases in routine immunisations.

Regional variations in hepatocellular carcinoma incidence, routes to diagnosis, treatment and survival in England

Background Hepatocellular carcinoma (HCC) incidence, management and survival across England were examined to determine if geographical inequalities exist. Method 15,468 HCC cases diagnosed 2010–2016 were included. Age-standardised incidence rates, net survival and proportions receiving potentially curative treatment and presenting through each route to diagnosis adjusted for age at diagnosis, sex and area-based deprivation quintile, were calculated overall and by Cancer Alliance. Results HCC incidence rates increased in men from 6.2 per 100,000 in 2010 to 8.8 in 2016, and in women from 1.5 to 2.2. The highest incidence rates, found in parts of the North of England and London, were nearly double the lowest. The adjusted proportion presenting as an emergency ranged 27–41% across Cancer Alliances. Odds increased with increasing deprivation quintile and age. Only one in five patients received potentially curative treatment (range 15–28%) and odds decreased with increasing deprivation and age. One-year survival in 2013–2016 ranged 38–53%. Conclusion This population-based, nationwide analysis demonstrates clear differences in HCC incidence, management and survival across England. It highlights socioeconomic-associated variation and the need for improvement in early diagnosis and curative treatment of HCC. This research should assist policymakers, service providers and clinicians to identify regions where additional training, services and resources would be best directed.

Geographical inequalities in COVID-19 mortality: a scoping review protocol

Objective The objective of this scoping review is to understand what is known in relation to geographical inequalities in COVID-19 mortality. Introduction: COVID-19 has occurred against a backdrop of existing social and economic inequalities in health. The impact of the pandemic has been examined across various intersections of health inequalities such as age, gender, ethnicity, and occupation. However, spatial inequalities have been less explored. Therefore, this review aims to identify and synthesise what is known on geographical inequalities in COVID-19 mortality globally. Inclusion criteria: Following standard scoping review methodology the inclusion criteria will be guided by Population, Concept, Context (PCC). Population: children and adults (all ages); Concept: Area-level inequalities in COVID-19 mortality; Context: any country, at any level (neighbourhood, town, city, municipality, region). Any published, peer-reviewed study written in English that focuses on all three elements of the PCC inclusion criteria will be included. Methods Searches will be conducted in (host sites given in parentheses) Medline (Ovid), Embase (Ovid), Science Citation Index Expanded and Social Science Citation Index (Web of Science) and limited to dates ranging from 1st January 2020 to December 31st 2021. Reference lists of all relevant papers will be searched for additional studies. All titles and abstracts will be screened in Rayyan. Primary studies focusing on COVID-19 mortality rates disaggregated by any measure of area-level deprivation will be selected for full text review. Data relating to study design, population, location, outcomes, and results by deprivation will be extracted using standardised extraction forms. Identified papers meeting the inclusion criteria will be tabulated, synthesised thematically and a narrative constructed to describe the evidence base of geographical inequalities in COVID-19 mortality.

Geographical inequalities in the evolution of the COVID-19 pandemic: An ecological study of inequalities in mortality in the first wave and the effects of the first national lockdown in England

Objectives This is the first study to examine how geographical inequalities in COVID–19 mortality rates evolved in England, and whether the first national lockdown modified them. This analysis provides important lessons to inform public health planning to reduce inequalities in any future pandemics. Design Longitudinal ecological study Setting 307 Lower-tier local authorities in England Primary outcome measure Age-standardised COVID–19 mortality rates by local authority and decile of index of multiple deprivation. Results Local authorities that started recording COVID–19 deaths earlier tended to be more deprived, and more deprived authorities saw faster increases in their death rates. By 2020–04–06 (week 15, the time the March 23rd lockdown could have begun affecting deaths) the cumulative death rate in local authorities in the two most deprived deciles of IMD was 54% higher than the rate in the two least deprived deciles. By 2020–07–04 (week 27), this gap had narrowed to 29%. Thus, inequalities in mortality rates by decile of deprivation persisted throughout the first wave, but reduced somewhat during the lockdown. Conclusions This study found significant differences in the dynamics of COVID–19 mortality at the local authority level, resulting in inequalities in cumulative mortality rates during the first wave of the pandemic. The first lockdown in England was fairly strict – and the study found that it particularly benefited those living in the more deprived local authorities. Care should be taken to implement lockdowns early enough, in the right places – and at a sufficiently strict level – to maximally benefit all communities, and reduce inequalities.

Determinants of geographical inequalities in domestic water supply across city of Pune, India

The water supply system in the city of Pune is affected due to the fast and chaotic development in and around the city. The quantity of per capita water supply and hours of supply per day varies substantially across the city. Some central parts of the city are benefited from a large availability of water as compared to peripheral areas. This research employed Ordinary Least Squares (OLS) Regression, Geographically Weighted Regression (GWR), and the new version of GWR termed as Multi-scale Geographically Weighted Regression (MGWR) models to better understand the factors behind observed spatial patterns of water supply distribution and to predict water supply in newly merged and proposed villages in the Pune city's periphery. Results showed statistical significance of slope; distance from service reservoirs; and water supply hour. MGWR and GWR models improved our results (adjusted R2: 0.916 and 0.710 respectively) significantly over those of the OLS model (adjusted R2: 0.252) and proved how local conditions influence variables. The maps of GWR display how a particular variable is highly important in some areas but less important in other parts of the city. The results from the current study can help decision-makers to make appropriate decisions for future planning to achieve Sustainable Development Goal number 6 (SDG #6), which focuses on achieving universal and equitable access to safe and affordable drinking water for all.