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Abstract Background Physical activity (PA) is associated with positive health outcomes over the entire life course. Many community-based interventions that promote PA focus on implementing incremental changes to existing facilities and infrastructure. The objective of this study was to determine if such upgrades were associated with increases in children’s PA. Methods Two cohorts of 3- to 15-year-old children (n = 599) living in 4 low-income New Jersey cities were followed during 2- to 5-year periods from 2009 to 2017. Data on children’s PA were collected at 2 time points (T1 and T2) from each cohort using telephone survey of parents; data on changes to existing PA facilities were collected yearly from 2009 to 2017 using Open Public Records Act requests, publicly available data sources, and interviews with key stakeholders. PA changes were categorized into six domains (PA facility, park, trail, complete street, sidewalk, or bike lane) and coded as new opportunity, renovated opportunity, or amenity. A scale variable capturing all street-related upgrades (complete street, sidewalk, and bike lane) was constructed. PA was measured as the number of days per week the child engaged in at least 60 min of PA. The association between change in PA between T1 and T2, ranging from − 7 to + 7, and changes to the PA environment was modeled using weighted linear regression controlling for PA at T1, child age, sex, race, as well as household and neighborhood demographic and socioeconomic characteristics. Results While most measures of the changes to the PA environment were not associated with change in PA between T1 and T2, the street-related upgrades were positively associated with the change in PA; specifically, for each additional standard deviation in street upgrades within a 1-mile radius of their homes, the change in PA was 0.42 (95% CI: 0.02, 0.82; p = 0.039) additional days. This corresponds to an 11% increase over the mean baseline value (3.8 days). Conclusions The current study supports funding of projects aimed at improving streets and sidewalks in cities, as it was shown that incremental improvements to the PA environment near children’s homes will likely result in increased PA among children.

Summary: Background: The Lancet Commission on Global Surgery (LCoGS) surgical indicators have given the surgical community metrics for objectively characterizing the disparity in access to surgical healthcare. However, aggregate national statistics lack sufficient specificity to inform strengthening plans at the community level. We performed a second-stage analysis of Colombian surgical system service delivery to inform the development of resource- and context-sensitive interventions to inform a revision of the Decennial Public Health Plan for access inequity resolution. Methods: Data from the year 2016 to inform total operative volume (TOV) and 30-day non-risk adjusted peri-operative mortality (POMR) were collected from the Colombian national health information system. TOV and POMR were sub-characterized by demographics, urgency, service line, disease pathology and facility location. Findings: In 2016, aggregate national mortality was 0·87%, while mortality attributable to elective and emergency surgery was 0·73% and 1·30%, respectively. The elderly experienced a 5·6-fold higher mortality, with 4·2% undergoing an operation within 30 days of dying. Individuals undergoing hepatobiliary, thoracic, cardiac, and neurosurgical operations experienced the highest mortality rates while obstetrics, general surgery, orthopaedics, and urology performed the largest procedure volume. Finally, analysis of operation and service line specific POMR reveals opportunities for improvement. Interpretation: This granular second-stage analysis provides actionable data which is fundamental to the development of resource and context-sensitive interventions to address gaps and inequities in surgical system service delivery. Furthermore, this analysis validates the modeling underlying development of the LCoGS indicators. These data will inform the assessment of implementation priorities and revision of the Colombian Decennial Public Health Plan. Funding: None.

Summary: Background: Surgical, anaesthetic, and obstetric (SAO) health-care system strengthening is needed to address the emergency and essential surgical care that approximately 5 billion individuals lack globally. To our knowledge, a complete, non-modelled national situational analysis based on the Lancet Commission on Global Surgery surgical indicators has not been done. We aimed to undertake a complete situation analysis of SAO system preparedness, service delivery, and financial risk protection using the core surgical indicators proposed by the Commission in Colombia, an upper-middle-income country. Methods: Data to inform the six core surgical system indicators were abstracted from the Colombian national health information system and the most recent national health survey done in 2007. Geographical access to a Bellwether hospital (defined as a hospital capable of providing essential and emergency surgery) within 2 h was assessed by determining 2 h drive time boundaries around Bellwether facilities and the population within and outside these boundaries. Physical 2 h access to a Bellwether was determined by the presence of a motor vehicle suitable for individual transportation. The Department Administrativo Nacional de Estadística population projection for 2016 and 2018 was used to calculate the SAO provider density. Total operative volume was calculated for 2016 and expressed nationally per 100 000 population. The total number of postoperative deaths that occurred within 30 days of a procedure was divided by the total operative volume to calculate the all-cause, non-risk-adjusted postoperative mortality. The proportion of the population subject to impoverishing costs was calculated by subtracting the baseline number of impoverished individuals from those who fell below the poverty line once out-of-pocket payments were accounted for. Individuals who incurred out-of-pocket payments that were more than 10% of their annual household income were considered to have experienced catastrophic expenditure. Using GIS mapping, SAO system preparedness, service delivery, and cost protection were also contextualised by socioeconomic status. Findings: In 2016, at least 7·1 million people (15·1% of the population) in Colombia did not have geographical access to SAO services within a 2 h driving distance. SAO provider density falls short of the Commission's minimum target of 20 providers per 100 000 population, at an estimated density of 13·7 essential SAO health-care providers per 100 000 population in 2018. Lower socioeconomic status of a municipality, as indicated by proportion of people enrolled in the subsidised insurance regime, was associated with a smaller proportion of the population in the municipality being within 2 h of a Bellwether facility, and the most socioeconomically disadvantaged municipalities often had no SAO providers. Furthermore, Colombian providers appear to be working at or beyond capacity, doing 2690–3090 procedures per 100 000 population annually, but they have maintained a relatively low median postoperative mortality of 0·74% (IQR 0·48–0·84). Finally, out-of-pocket expenses for indirect health-care costs were a key barrier to accessing surgical care, prompting 3·1 million (6·4% of the population) individuals to become impoverished and 9·5 million (19·4% of the population) individuals to incur catastrophic expenditures in 2007. Interpretation: We did a non-modelled, indicator-based situation analysis of the Colombian SAO system, finding that it has not yet met, but is working towards achieving, the targets set by the Lancet Commission on Global Surgery. The observed interdependence of these indicators and correlation with socioeconomic status are consistent with well recognised factors and outcomes of social, health, and health-care inequity. The internal consistency observed in Colombia's situation analysis validates the use of the indicators and has now informed development of an early national SAO plan in Colombia, to set a data-informed stage for implementation and evaluation of timely, safe, and affordable SAO health care, within the National Public Health Decennial Plan, which is due in 2022. Funding: Zoll Medical.