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Track engravings dominate the rock art assemblage across Marapikurrinya (Port Hedland) in Northwest Australia, with social change through time linked to changes in how and when this graphic vocabulary is employed. Discrete styles have been identified within the broader engraving body, which is argued to have been produced semi-continuously over the last 7000 years, from the point of sea-level stabilisation in this region. It is proposed that changes in these styles reflect and negotiate environmental, demographic, and social changes. In the most recent stylistic phases, track motifs dominate, and it is argued to reflect change in marking strategy, from localised territorial bounded art to regional social harmonisation. This paper explores the potential functions of track motifs as a vocabulary distinct from other figurative art, using Marapikurrinya as a case study.

Background Monitoring inequalities in non communicable disease risk factor prevalence can help to inform and target effective interventions. The prevalence of current daily smoking, low fruit and vegetable consumption, physical inactivity, and heavy episodic alcohol drinking were quantified and compared across wealth and education levels in low- and middle-income country groups. Methods This study included self-reported data from 232,056 adult participants in 48 countries, derived from the 2002–2004 World Health Survey. Data were stratified by sex and low- or middle-income country status. The main outcome measurements were risk factor prevalence rates reported by wealth quintile and five levels of educational attainment. Socioeconomic inequalities were measured using the slope index of inequality, reflecting differences in prevalence rates, and the relative index of inequality, reflecting the prevalence ratio between the two extremes of wealth or education accounting for the entire distribution. Data were adjusted for confounding factors: sex, age, marital status, area of residence, and country of residence. Results Smoking and low fruit and vegetable consumption were significantly higher among lower socioeconomic groups. The highest wealth-related absolute inequality was seen in smoking among men of low- income country group (slope index of inequality 23.0 percentage points; 95% confidence interval 19.6, 26.4). The slope index of inequality for low fruit and vegetable consumption across the entire distribution of education was around 8 percentage points in both sexes and both country income groups. Physical inactivity was less prevalent in populations of low socioeconomic status, especially in low-income countries (relative index of inequality: (men) 0.46, 95% confidence interval 0.33, 0.64; (women) 0.52, 95% confidence interval 0.42, 0.65). Mixed patterns were found for heavy drinking. Conclusions Disaggregated analysis of the prevalence of non-communicable disease risk factors demonstrated different patterns and varying degrees of socioeconomic inequalities across low- and middle-income settings. Interventions should aim to reach and achieve sustained benefits for high-risk populations.

BackgroundSocioeconomic differentials of tobacco smoking in high-income countries are well described. However, studies to support health policies and place monitoring systems to tackle socioeconomic inequalities in smoking and smokeless tobacco use common in low-and-middle-income countries (LMICs) are seldom reported. We aimed to describe, sex-wise, educational and wealth-related inequalities in tobacco use in LMICs.MethodsWe analysed Demographic and Health Survey data on tobacco use collected from large nationally representative samples of men and women in 54 LMICs. We estimated the weighted prevalence of any current tobacco use (including smokeless tobacco) in each country for 4 educational groups and 4 wealth groups. We calculated absolute and relative measures of inequality, that is, the slope index of inequality (SII) and relative index of inequality (RII), which take into account the distribution of prevalence across all education and wealth groups and account for population size. We also calculated the aggregate SII and RII for low-income (LIC), lower-middle-income (lMIC) and upper-middle-income (uMIC) countries as per World Bank classification.FindingsMale tobacco use was highest in Bangladesh (70.3%) and lowest in Sao Tome (7.4%), whereas female tobacco use was highest in Madagascar (21%) and lowest in Tajikistan (0.22%). Among men, educational inequalities varied widely between countries, but aggregate RII and SII showed an inverse trend by country wealth groups. RII was 3.61 (95% CI 2.83 to 4.61) in LICs, 1.99 (95% CI 1.66 to 2.38) in lMIC and 1.82 (95% CI 1.24 to 2.67) in uMIC. Wealth inequalities among men varied less between countries, but RII and SII showed an inverse pattern where RII was 2.43 (95% CI 2.05 to 2.88) in LICs, 1.84 (95% CI 1.54 to 2.21) in lMICs and 1.67 (95% CI 1.15 to 2.42) in uMICs. For educational inequalities among women, the RII varied much more than SII varied between the countries, and the aggregate RII was 14.49 (95% CI 8.87 to 23.68) in LICs, 3.05 (95% CI 1.44 to 6.47) in lMIC and 1.58 (95% CI 0.33 to 7.56) in uMIC. Wealth inequalities among women showed a pattern similar to that of men: the RII was 5.88 (95% CI 3.91 to 8.85) in LICs, 1.76 (95% CI 0.80 to 3.85) in lMIC and 0.39 (95% CI 0.09 to 1.64) in uMIC. In contrast to men, among women, the SII was pro-rich (higher smoking among the more advantaged) in 13 of the 52 countries (7 of 23 lMIC and 5 of 7 uMIC).InterpretationOur results confirm that socioeconomic inequalities tobacco use exist in LMIC, varied widely between the countries and were much wider in the lowest income countries. These findings are important for better understanding and tackling of socioeconomic inequalities in health in LMIC.

Background Noncommunicable diseases are an increasing health concern worldwide, but particularly in low- and middle-income countries. This study quantified and compared education- and wealth-based inequalities in the prevalence of five noncommunicable diseases (angina, arthritis, asthma, depression and diabetes) and comorbidity in low- and middle-income country groups. Methods Using 2002–04 World Health Survey data from 41 low- and middle-income countries, the prevalence estimates of angina, arthritis, asthma, depression, diabetes and comorbidity in adults aged 18 years or above are presented for wealth quintiles and five education levels, by sex and country income group. Symptom-based classification was used to determine angina, arthritis, asthma and depression rates, and diabetes diagnoses were self-reported. Socioeconomic inequalities according to wealth and education were measured absolutely, using the slope index of inequality, and relatively, using the relative index of inequality. Results Wealth and education inequalities were more pronounced in the low-income country group than the middle-income country group. Both wealth and education were inversely associated with angina, arthritis, asthma, depression and comorbidity prevalence, with strongest inequalities reported for angina, asthma and comorbidity. Diabetes prevalence was positively associated with wealth and, to a lesser extent, education. Adjustments for confounding variables tended to decrease the magnitude of the inequality. Conclusions Noncommunicable diseases are not necessarily diseases of the wealthy, and showed unequal distribution across socioeconomic groups in low- and middle-income country groups. Disaggregated research is warranted to assess the impact of individual noncommunicable diseases according to socioeconomic indicators.

This article examines the context of growing up in rural America and how rural roots shape life chances. The distinctive physical, social, and cultural attributes of rural areas can exacerbate many of the challenges of childhood poverty. Yet rural children have better access to public childcare services and perform as well as urban children on standardized tests. Life trajectories diverge most sharply when rural youths decide whether to leave their home communities. Those who stay typically face limited opportunities for higher education and well-paid, stable employment, whereas those who leave fare remarkably well with respect to their educational, economic, and health outcomes. In sum, growing up in rural America offers distinctive advantages and disadvantages, yet the benefits may accrue primarily to those who leave.

Maternity leave reduces neonatal and infant mortality rates in high-income countries. However, the impact of maternity leave on infant health has not been rigorously evaluated in low- and middle-income countries (LMICs). In this study, we utilized a difference-in-differences approach to evaluate whether paid maternity leave policies affect infant mortality in LMICs. We used birth history data collected via the Demographic and Health Surveys to assemble a panel of approximately 300,000 live births in 20 countries from 2000 to 2008; these observational data were merged with longitudinal information on the duration of paid maternity leave provided by each country. We estimated the effect of an increase in maternity leave in the prior year on the probability of infant (<1 y), neonatal (<28 d), and post-neonatal (between 28 d and 1 y after birth) mortality. Fixed effects for country and year were included to control for, respectively, unobserved time-invariant confounders that varied across countries and temporal trends in mortality that were shared across countries. Average rates of infant, neonatal, and post-neonatal mortality over the study period were 55.2, 30.7, and 23.0 per 1,000 live births, respectively. Each additional month of paid maternity was associated with 7.9 fewer infant deaths per 1,000 live births (95% CI 3.7, 12.0), reflecting a 13% relative reduction. Reductions in infant mortality associated with increases in the duration of paid maternity leave were concentrated in the post-neonatal period. Estimates were robust to adjustment for individual, household, and country-level characteristics, although there may be residual confounding by unmeasured time-varying confounders, such as coincident policy changes. More generous paid maternity leave policies represent a potential instrument for facilitating early-life interventions and reducing infant mortality in LMICs and warrant further discussion in the post-2015 sustainable development agenda. From a policy planning perspective, further work is needed to elucidate the mechanisms that explain the benefits of paid maternity leave for infant mortality.

Starting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS). This program provides pregnant women with vouchers that can be exchanged for health services from eligible public and private sector providers. In this study, we examined whether access to the MHVS was associated with maternal health services utilization, stillbirth, and neonatal and infant mortality. We used information on pregnancies and live births between 2000 to 2016 reported by women 15 to 49 years of age surveyed as part of the Bangladesh Demographic and Health Surveys. Our analytic sample included 23,275 pregnancies lasting at least 7 months for analyses of stillbirth and between 15,125 and 21,668 live births for analyses of health services use, neonatal, and infant mortality. With respect to live births occurring prior to the introduction of the MHVS, 31.3%, 14.1%, and 18.0% of women, respectively, reported receiving at least 3 antenatal care visits, delivering in a health institution, and having a skilled birth attendant at delivery. Rates of neonatal and infant mortality during this period were 40 and 63 per 1,000 live births, respectively, and there were 32 stillbirths per 1,000 pregnancies lasting at least 7 months. We applied a difference-in-differences design to estimate the effect of providing subdistrict-level access to the MHVS program, with inverse probability of treatment weights to address selection into the program. The introduction of the MHVS program was associated with a lagged improvement in the probability of delivering in a health facility, one of the primary targets of the program, although associations with other health services were less evident. After 6 years of access to the MHVS, the probabilities of reporting at least 3 antenatal care visits, delivering in a health facility, and having a skilled birth attendant present increased by 3.0 [95% confidence interval (95% CI) = -4.8, 10.7], 6.5 (95% CI = -0.6, 13.6), and 5.8 (95% CI = -1.8, 13.3) percentage points, respectively. We did not observe evidence consistent with the program improving health outcomes, with probabilities of stillbirth, neonatal mortality, and infant mortality decreasing by 0.7 (95% CI = -1.3, 2.6), 0.8 (95% CI = -1.7, 3.4), and 1.3 (95% CI = -2.5, 5.1) percentage points, respectively, after 6 years of access to the MHVS. The sample size was insufficient to detect smaller associations with adequate precision. Additionally, we cannot rule out the possibility of measurement error, although it was likely nondifferential by treatment group, or unmeasured confounding by concomitant interventions that were implemented differentially in treated and control areas. In this study, we found that the introduction of the MHVS was positively associated with the probability of delivering in a health facility, but despite a longer period of follow-up than most extant evaluations, we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Further work and engagement with stakeholders is needed to assess if the MHVS has affected the quality of care and health inequalities and whether the design and eligibility of the program should be modified to improve maternal and neonatal health outcomes.

Background Heartburn, chest pain, and regurgitation are characteristics of gastroesophageal reflux disease. The standard treatment in Norway is proton pump inhibitors (PPIs), but surgical alternatives such as Nissen fundoplication are pursued when medical management proves ineffective. RefluxStop is an implantable device presenting a new approach to restoration of the antireflux barrier. The aim of this study is to evaluate the cost-effectiveness of RefluxStop against Nissen fundoplication and PPI-based medical management (MM) in Norway. Methods A Markov model was adapted from a published cost-effectiveness analysis developed for the UK NHS assessing the cost-effectiveness of RefluxStop in comparison with PPI-based MM and Nissen fundoplication. The perspective of the Norwegian healthcare payer, lifetime horizon, one-month cycle length, and a 4% annual discount rate for costs and health-benefits were used. Health states included in the model were initial MM, MM relapse, follow-on surgery, reoperations, MM with a higher dose, Barrett’s esophagus, esophageal cancer, and death. Adverse events related to MM and surgeries were included with benefits measured in quality-adjusted life-years (QALYs). Norwegian diagnostic-related group tariffs and literature were used as sources for unit costs. Clinical efficacy data for RefluxStop was based on an ongoing clinical study and comparator treatments were informed by published studies. Deterministic and probabilistic sensitivity analyses were used to address uncertainty of the parameter estimates. Results Compared to PPI-based MM and Nissen fundoplication, the base case incremental cost-effectiveness ratios (ICERs) of RefluxStop were NOK 68,262 and NOK 79,543 per QALY gained, respectively. The results of the model were robust to variation in individual inputs with exception of monthly failure rate of RefluxStop relative to Nissen fundoplication. RefluxStop demonstrated a significantly high probability of cost-effectiveness at the cost-effectiveness threshold of NOK 275,000 per QALY gained, with probabilities of 100% and 92% against PPI-based MM and Nissen fundoplication, respectively. Conclusion The RefluxStop device is highly likely to be cost-effective compared to PPI-based MM and Nissen fundoplication in Norway. Further study is required to assess the real-world long-term safety and efficacy of this novel device.

Objectives Gastroesophageal reflux disease (GERD) is estimated to affect up to one-quarter of the Italian population, generating immense treatment costs. An emergent surgical treatment involving implantation of a nonactive device, RefluxStop, is offered at a number of hospitals in Italy and several other European countries. Published clinical outcomes of this device from the Conformité Européenne (CE)-mark clinical trial and real-world settings are consistently encouraging and with a favorable safety profile. This study evaluated the cost-effectiveness of RefluxStop compared with the current medical and surgical standards of care in Italy. Methods A Markov model recently developed for use in the United Kingdom was adapted to the Italian healthcare payer’s perspective, covering the GERD treatment field. The model incorporated a lifetime horizon, one-month cycle length, and a 3% annual discount rate. Standards of care to be compared to the RefluxStop procedure included proton pump inhibitor (PPI)-based medical management, laparoscopic Nissen fundoplication, and magnetic sphincter augmentation (MSA). The mutually exclusive health states of the model comprised PPI use, PPI relapse, follow-on surgery, reoperation, high-dose PPI, Barrett’s esophagus, esophageal cancer, and death. The model included adverse events (AEs) associated with PPIs and surgeries and quantified the benefits in terms of quality-adjusted life years (QALYs). Unit costs were derived from the Italian diagnosis-related group (DRG) tariffs and the literature. Additional clinical efficacy data on standard-of-care treatments were derived from published literature. Model uncertainty was evaluated using deterministic and probabilistic sensitivity analyses. Results RefluxStop demonstrated a lifetime cost difference relative to PPIs, Nissen fundoplication, and MSA of €8,788, €5,312, and €376 per patient, respectively. The corresponding QALY gains per patient were 2.87, 0.79, and 2.20, respectively. Base-case analysis established corresponding incremental cost-effectiveness ratios (ICERs) of €3,067, €6,712, and €171 per QALY gained, against PPIs, Nissen fundoplication, and MSA, respectively. At a cost-effectiveness threshold of €50,000 per QALY gained, RefluxStop was predicted to be cost-effective against both PPIs and MSA with a probability of 100% and against Nissen fundoplication with a probability of 97%. Sensitivity analysis confirmed the robustness of the model. Conclusion The implementation of RefluxStop in the Italian national health service is highly likely to be cost-effective compared to standard medical and surgical options for GERD, providing an opportunity for healthcare optimization in Italy.