Although lead has been removed from paint and gasoline sold in the U.S., lead exposures persist, with communities of color and residents in urban and low-income areas at greatest risk for exposure. The persistence of and inequities in lead exposures raise questions about the scope and implementation of policies that address lead as a public health concern. To understand the multi-level nature of lead policies, this paper and case study reviews lead policies at the national level, for the state of California, and for Santa Ana, CA, a dense urban city in Southern California. Through a community-academic partnership process, this analysis examines lead exposure pathways represented, the level of intervention , and whether policies address health inequities. Results indicate that most national and state policies focus on establishing hazardous lead exposure levels in settings and consumer products, disclosing lead hazards, and remediating lead paint. Several policies focus on mitigating exposures rather than primary prevention. The persistence of lead exposures indicates the need to identify sustainable solutions to prevent lead exposures in the first place. We close with recommendations to reduce lead exposures across the life course, consider multiple lead exposure pathways, and reduce and eliminate health inequities related to lead. In recent decades, there has been increasing attention amongst communities, environmental agencies, and policymakers to disparate exposures to environmental hazards that have traditionally differentially affected communities of color and low-income communities ,2. The wEvidence linking exposure to lead—a neurotoxin—with adverse health outcomes has yielded policies to prevent the sale of lead-based paint and leaded gasoline to the general public in the U.S. and has contributed to bans on lead plumbing and lead solder in canned goods in the U.S. . DespiteWhat policies hold industries accountable for lead contamination? What policies prevent lead in consumer products and the environment? If a child is found to have high blood lead levels but no action has been taken to reduce lead exposures, what governmental agency is charged with ensuring that public health, health care, and educational systems work together to mitigate and eliminate lead exposures and reduce harm? Are there similar protections for adults with high blood lead levels? How do governmental agencies incorporate scientific evidence to address lead exposures and enforce lead remediation policies? How do residents navigate the systems responsible for mediating or addressing lead exposures? What are the points of entry that activate lead mitigation and remediation? How, if at all, do these policies apply a health inequities framework?Since 2017, our community-academic partnership has been working to understand and address lead exposures in a predominantly Latina/Latino/Latinx community in Santa Ana, California, USA. Our partnership process has surfaced important questions about the roles and responsibilities of governmental entities who construct and implement lead-related policies, and/or respond to lead exposures. For example: Community-academic partnerships are well-positioned to close the gap between community knowledge, scientific evidence, and policies that are needed to promote health and health equity ,26. SeveThrough a community-academic policy assessment process, this paper provides a critical review of lead policies at the national level, for the state of California, and for the city of Santa Ana, CA, a dense urban area in Southern California. By focusing on lead policies across three jurisdictions, this review serves to enhance understanding of how institutions charged with promoting the public’s health are currently addressing lead as a public health concern. It focuses on implications for health inequities, a term that refers to differences in health status that are preventable, systematic, unjust, and actionable . Thus, tChildren are particularly vulnerable to the health impacts of environmental lead due to higher absorption levels, developmentally appropriate hand-to-mouth activity, and child neurocognitive development. Despite strong scientific evidence that no level of lead is safe for young children , childreBlood lead levels are commonly used to measure lead exposure especially in children due to the convenience and the relatively low cost in testing. However, blood lead may not be the best indicator of the full risk for lead-associated toxicity. This is because blood lead has a median biologic half-life of about 1 month, thus mostly reflects recent or current lead exposure levels, while bone lead has a half-life of 20–30 years which better reflects chronic or cumulative exposure levels . In addiLater in the life course, lead exposures are associated with cardiovascular risk, renal problems, and adverse cognitive outcomes for older adults ,51,52,53The literature reviewed above focuses on the health impacts of lead on an individual level, with implications for population health and health inequities. Moving to a family and community health perspective, evidence indicates two key pathways by which lead exposures affect households and multiple generations. First, lead exposures among adults—such as occupational lead exposures—may be transferred to other household members, including children ,57. SecoNationally, blood lead levels have decreased across the United States ,59,60, dAdditionally, lead exposures—commonly assessed by child blood lead levels—are not evenly distributed across the U.S. population. In 2012, the Centers for Disease Control and Prevention classified a reference level of 5 micrograms per deciliter (µg/dL) to indicate children with elevated blood lead levels ,61. BlacThese persistent inequities point to shortcomings of existing lead policies and practices. Addressing these inequities requires policies and practices focused on preventing lead exposures, remediating the source(s) of lead, and mitigating the health consequences of lead exposures, with a focus on promoting health equity. This policy review includes an examination of lead exposure pathways  addressed by lead policies; the level of intervention ; and how, if at all, health inequities are incorporated into lead policies. We find that lead policies largely focus on establishing hazardous lead exposure levels in settings and consumer products, disclosing lead hazards, and remediating lead paint. Several policies focus on mitigating exposures once children have been exposed to lead (as indicated by elevated child blood lead levels), rather than prevention. In light of notable gaps in existing policies, we conclude by discussing recommendations to prevent lead exposures and to promote health equity. What is the distribution of soil lead across Santa Ana? Who is at greater risk for exposure to soil lead? What are the sources of soil lead in Santa Ana? Why are children in Santa Ana more likely than children across California to have elevated blood lead levels? What are policy solutions to mitigate and remediate soil lead? What actions can residents take to protect their wellbeing and to advocate for change? Following a series of formal and informal community conversations, OCEJ and JCC, an emerging environmental justice organization and youth cooperative working towards food sovereignty, respectively, identified a need to further examine soil lead levels in Santa Ana. OCEJ and JCC in turn invited academic partners at UCI with whom there were longstanding and emerging relationships to participate in this planning process. This process culminated in a follow-up study of soil lead levels across the city of Santa Ana, which is currently underway. The (Anti-)Soil Lead Partnership is informed by local community knowledge about environmental concerns, as well as the wisdom of other communities  working to address environmental injustices. Building upon this knowledge, we are continuing to elicit the perspectives and priorities of residents through multiple community engagement strategies, including surveys of adult and youth residents and past and ongoing community forums and dialogues. Our partnership also identified the need to review and analyze lead-related policies in order to identify policy-oriented solutions to prevent, mitigate, and remediate lead exposures. The (Anti-)Soil Lead Project is a community-academic partnership that has been working together since 2017 to understand and address soil lead exposures in Santa Ana, CA, a dense urban area in northern Orange County. Santa Ana is a predominantly Latina/o/x and immigrant community ,71 Tabl, and chiInformed by a shared understanding that youth are inheriting a world that is characterized by multiple environmental injustices, youth organizing has been central to our partnership process. The leadership, wisdom, social imagination, and visions of young people are urgently needed to heal and protect the environment and communities who have been disparately affected by environmental injustices. JCC youth leaders have highlighted questions about the connections of lead exposures to educational outcomes and behaviors that are vulnerable to punishment and policing in the school system in Santa Ana, CA and across California; the criminalization of communities of color who have been affected by environmental injustices; and implications of lead exposures for health across the life span . LikewisWe identified policies at the federal, state , and local  level that address lead prevention, exposures, and/or mitigation. Federal lead-related policies were identified using the Environmental Protection Agency (EPA) website. Laws and executive orders listed under the laws and regulations section of the EPA’s lead webpage were reviewed. California policies were identified using the Childhood Lead Prevention Branch webpage located on the California Department of Public Health website. The decision to use federal and state agency websites to identify lead policies was made to reflect the process communities would undertake to obtain information on lead policies. Specifically, a first step in identifying lead policies involves visiting websites of federal and state agencies tasked with protecting human and environmental health. It should be noted that policies not included in these websites were not reviewed. When considering local lead-related policies, we identified the need to review policies enacted by the local health department and City of Santa Ana, CA. Additionally, youth raised important questions about school district policies pertaining to lead exposures in school and/or programs and policies to mitigate the effects of lead on educational outcomes. Thus, our review of local policies included three jurisdictions: Orange County Healthcare Agency ; City of Santa Ana, CA; and the Santa Ana Unified School District. Two reviewers (first and second author) reviewed the policies to identify the level of intervention addressed ; whether policies addressed health inequities, legacy lead exposures, or current or future lead exposures; the source of lead ; the setting of potential lead prevention or remediation intervention  and implications for health inequities. Co-authors reviewed and discussed this analysis, and identified recommendations for strengthening policies to reduce lead exposures, attend to lead exposures from multiple sources, and address health inequities linked with lead. Presented in In 2013–2017, though one in ten Orange County households (10.7%) had incomes below the federal poverty level, more than one in six Santa Ana households (17.6%) met these criteria. The population across Santa Ana was also younger than patterns across the nation, state of California, and Orange County during this period: More than one-third of Santa Ana residents (35.1%) were 18 years of age or younger, compared to approximately 30% across the U.S., California, and Orange County. Likewise, in 2013–2017 the majority of residents across Santa Ana, CA identified as Latina/o/x (77.3%) and nearly half were born outside of the U.S. (45.0%). Moreover, 78.9% of residents in Santa Ana reported having health insurance over this period, ten percentage points below the average across the U.S., California, and Orange County. For each level of policy intervention , this case study begins with a brief overview of lead-related policies and examines gaps in these policies, with a focus on implications for persistent and emerging health inequities. Federal policies are organized chronologically to illustrate the evolution of lead-related policies, while California state policies are organized thematically. This structure emerged from themes that surfaced in the policy analysis, suggesting federal policies issue guidelines and mandates for lead abatement and remediation activities and California state policies amplify federal policies, fill gaps, and address unique conditions in the state. Similar to state policies, local policies are organized thematically, reflecting local implementation of state-level policies and/or development of local policies to address local conditions within their jurisdiction. Our partnership process identified the importance of examining policies at the school district level, particularly with respect to questions of how school districts implement or augment federal and state policies regarding levels of lead in areas where children are exposed. While our review did not identify school district policies that explicitly pertained to lead, we have retained this review in the Results section and highlighted gaps in these policies. The discussion section in turn weaves together this multi-level patchwork of lead-related policies to identify gaps across the social-ecological spectrum and enumerate implications for health inequities. As shown in Federal policies primarily focus on remediating lead-based paint hazards, water, and sites that have received official designation as toxic from the Environmental Protection Agency (EPA). The following section describes federal policies that explicitly address lead exposures and includes an assessment of implications for health equity.The Clean Air Act (CAA) was passed by Congress in 1963 and amended in 1970 and 1990; its purpose is to reduce air pollution . Under tThe banning of leaded gasoline dramatically improved blood lead levels among people of all ages and has significantly reduced lead in the air . Yet, thThe Safe Drinking Water Act (SDWA) of 1974 seeks to improve the country’s water system for safe, public consumption and applies to all public water systems . The leaThe purpose of the SDWA is to increase the safety of water consumed by the public, however, the policy may be falling short when it comes to lead. As defined by the SDWA, lead-free pipes, solder, and flux can contain lead. Specifically, solder and flux can contain 0.2% lead, pipes and pipe fittings can contain up to 8% lead, and plumbing fittings and fixtures can consist of 4% lead . HoweverThe Toxic Substances Control Act (TSCA) was passed by Congress in 1976 to regulate new chemicals and chemical mixtures that pose a significant health risk and to provide guidance on the reduction and abatement of existing toxic substances including lead . Since 1Title X was passed in 1992 and requires the disclosure of known lead-based paint and lead-based paint hazards in housing units built prior to 1978 from landlord to tenant, or from seller to purchaser . Sellers2 on floors and 250 µg/ft2 on interior window sills. Lead in soil is classified as hazardous when lead levels are greater than or equal to 400 ppm in soil in children’s play areas or an average of 1200 ppm for soil in the yard (not including children’s play area) [Passed in 2001, the Standards set standards for lead-based paint hazards—lead-based paint, dust, and soil—in pre-1978 homes and in facilities in which children under the age of six spend a significant portion of their day . The Standards identify lead as hazardous when lead in dust is equal to or greater than 40 µg/ftay area) . Chippinay area) .Established by the EPA in 2008, the RRP addresses construction-related activities that would disturb lead-based paint hazards . Under tWhile the TSCA sets penalty maximums for individuals that violate this policy, the Penalty Policy provides guidance to the EPA on appropriate enforcement response and quantifies penalty amounts for violations .Taken together, these policies maintain a narrow scope that falls short in protecting communities at greatest risk for lead exposure. This is evident in the TSCA’s mandate that regulation not impede or “create unnecessary economic barriers to technological innovation” . This poAs with Santa Ana, CA, residents of color and low-income households tend to live in homes constructed before 1978 and in areas characterized by lead in soil and dust ,62,63. TIn 1980, Congress passed the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), also known as Superfund. Under CERCLA, chemical and petroleum companies are taxed to create a fund for cleaning abandoned or uncontrolled hazardous waste sites . The polThis policy supposes a robust EPA structure committed to assessing and remediating contaminated sites and holding responsible parties accountable. This policy privileges the conceptualization of superfund or toxic sites as specific to locations in which an industry is or was located. Missing from this policy is a consideration of broader environmental and community-level impacts, such as the runoff of pollutants into a watershed and the suspension of contaminants into the air and soil, and further to residences, and businesses nearby. Given that toxic sites are largely concentrated in communities of color ,101,102,As is indicated in Housing standards for human occupancy (Section 1941.1) and requirements for the disclosure of lead-based paint hazards to buyers (1102 to 1102.16) are outlined in the California Civil Code. California Health and Safety Codes allow enforcement of civil penalties in the event a child becomes lead poisoned due to the presence of lead hazards in the home (Section 17961); describe actions and proceedings on behalf of the regulating agency and the guilty party in the event of a housing violation (Section 17980); establish reporting requirements for blood lead testing laboratories (Section 124130); establish the definition of lead hazards—deteriorating lead-based paint, lead-contaminated dust, lead-contaminated soil, or disturbing lead-based paint without containment (Section 17920.10); and stipulate that only individuals certified in lead-construction activities can engage in construction activities that would disturb lead and grants local enforcement agencies with the authority to issue cease and desist notices in the event that construction activities are creating lead hazards (105251–105257) .While these policies aim to improve housing conditions by limiting the presence of lead hazards in the home, it remains unclear whom is the responsible party for testing for lead hazards in rental units that are not undergoing renovation. As the codes are currently written, it appears enforcement is only applied in homes undergoing renovation and when children’s blood lead levels exceed 10 µg/dL, the current threshold at which the state requires intervention. Ten micrograms per deciliter far exceeds the Centers for Disease Control and Prevention (CDC) reference level of 5 µg/dL, the level at which the CDC recommends intervention . The onl3 of air average over an eight-hour period; requires the monitoring of employees, the provision of personal protective equipment (PPEs), and communication between employers and employees on the health risks of lead; and the maintenance of records including exposure assessments, medical surveillance, and medical removals [Sections 105185 through 105197 of the California Health and Safety Code establish an occupational lead prevention program to monitor adult lead poisoning cases, establish a registry of these cases, identify sources of lead, investigate take-home exposures, provide training to workers on lead poisoning prevention in occupational settings, and define adult lead poisoning as a blood lead level equal to or greater than 25 µg/dL. The California Health and Safety Codes establish guidelines to accredit trainers leading lead-related construction activity trainings and certify individuals to engage in lead-related construction activities (Section 105250). Title 8 of the California Code of Regulations beginning with section 1531.1 establishes lead exposure maximums for construction work where employees might be exposed to lead—50 µg/mremovals . California’s permissible lead exposure level for adults (25 µg/dL), is less stringent than the 5 µg/dL established by the National Institute of Occupational Safety and Health (NIOSH) . This isThe Lead-Safe Schools Protection Act (1992) called for the development and implementation of a survey to identify public day care facilities, pre-schools, and elementary schools that have lead hazards , estimate the extent of the presence of lead hazards in public daycare facilities, pre-schools, and elementary schools and develop cost-effective measures for remediation (Section 32242), mandate that schools found to have lead hazards inform parents, teachers, and staff (Section 32243), and ban the use of lead-based paint, lead-based plumbing and solders, and any other sources of lead in the construction or renovation of schools (32244). The survey collected risk-factor information from a sample of schools, including “location in relation to high-risk areas, age of the facility, likely use of lead paint in or around the facility, numbers of children enrolled under the age of six, and results of lead screening programs” . The surAlthough the survey was carried out in 1998, it remains unclear if schools assessed to contain lead hazards on their premises were required to remediate the lead source. Section 32243 includes a directive to inform teachers, staff, and parents of the survey results in the event lead was found on the premises of the school within 45 days of the release of the survey results. A similar mandate is not made for lead remediation. The section notes that schools that “undertake any action to abate existing risk factor for lead shall utilize trained and state certified contractors, inspectors, and workers” . This suCalifornia Health and Safety Codes prohibit the sale and manufacture of children’s toys containing lead-based paints or lacquers that exceed the lead content permitted by the federal government (Sections 108550–108580), prohibit the sale of candies with lead levels exceeding the state’s definition of “naturally occurring”—“not avoidable by good agricultural, manufacturing, and procurement practices, or by other practices currently feasible” (Section 110552), and limit the amount of permissible lead and other toxic substances in jewelry to 0.02%-0.06% by weight (Sections 25214.1–25214.4.2). The definition of candy in Section 110552 specifically calls out tamarind and chili, which are typical ingredients in Mexican candies, suggesting only candies containing tamarind and/or chili contain lead and should be the subject of close monitoring. However, a report by the Food and Drug Administration (FDA) identified chocolate, peanuts, and raisins as potential sources of lead in candies consumed by young children . Yet, thEchoing the language of the SDWA, the California Health and Safety Codes require the use of lead-free pipes and fixtures in public water systems or in facilities where water is provided for human consumption (Sections 116875–116880). Similar to the SDWA “lead free” allows for 0.2% lead in solder and flux, 8% lead in pipes and pipe fittings, and 4% lead in plumbing fittings and fixtures . CaliforThe Lead and Copper Rule leaves many questions unanswered, including the extent to which multi-family housing units are included in sampling frames. The rule prioritizes tier 1 sampling sites, which include single-family homes . Multi-fThe Childhood Lead Poisoning Prevention Acts of 1986 and 1989 established California’s Childhood Lead Poisoning Prevention Program, and set guidelines for annual reporting of the prevalence, causes, and geographic occurrence of high blood lead levels among children. The Childhood Lead Poisoning Prevention Act of 1991 established screening protocols for lead testing. According to the act, all children considered “at risk” are to be tested for lead poisoning. The act defines “at risk” as children who spend a large portion of their day in a facility or building built prior to 1978; children who live near a former lead or steel smelter or industrial facility that historically or currently emits lead; children who live near a freeway or a high-traffic street; and children exposed to known sources of lead. The policy also established a fund to support the lead prevention program via fees levied against parties found responsible for lead contamination. The California Health and Safety Codes require testing laboratories to report the results of all blood lead tests they administer to the state electronically and include identifying information on the patient, the ordering physician, the analyzing laboratory, and the test performed (Section 124130); and stipulate that all health insurance plans provide comprehensive preventative care to children, including screening for blood lead levels for children of any age who are determined to be at risk by a medical provider (Section 1367.2). The California Insurance Codes mandate that all health insurances cover the cost of a blood lead test for children (Section 10118.8). Title 17 of the California Code Regulations mandate all children receiving public benefits be screened for lead poisoning at the ages of 12 and 24 months by a health care provider; outline the standard of care, including providing information on the health risks of lead to parents, testing all children who receive public benefits, and assessing the risk of lead poisoning among children not receiving public benefits; and require health care providers to intervene in the event that a child’s blood lead level exceeds 10 µg/dL and are expected to monitor the child until their blood lead level drops below 10 µg/dL .Despite the presence of these policies, nearly three-fourths of children enrolled in Medi-Cal do not have their blood lead levels tested at the ages of 12 and 24 months , indicatNotably, we identified few lead-related policies at the local level. Lead policies enacted and/or implemented within the County are described in The Orange County Childhood Lead Poisoning Prevention Program (CLPP) is implemented by the local Department of Public Health . The publicly stated goals of the Orange County CLPP include the provision of lead poisoning prevention education for caregivers, health care providers, and local agencies, and engaging in outreach to increase lead testing for children who are at heightened risk of lead exposure. Notably, online and in-person public communications through the local CLPP program acknowledge lead exposures through paint and soil, and emphasize lead exposures linked with candy and pottery from Mexico ,119. ThiMinimization of population-based lead exposures—such as lead in paint, soil, and/or water—and an emphasis on potential lead exposures from foods and pottery from Mexico serves to heighten lead-related health inequities in two important ways. First, remediation of lead in paint, water, and soil falls within the purview of governmental agencies. Accordingly, lead exposures through these sources provide the greatest impact on population health and health equity. Given that low-income communities and communities of color are more likely to live in areas that are contaminated by lead ,9,13, foOur policy review sought to identify two policy mechanisms by which lead prevention, mitigation, and/or remediation might unfold in school-based settings: (1) assessments of lead exposures in school settings  and (2) supplemental educational services within school contexts that might become available to students identified as having been exposed to lead. Our review did not identify any lead-specific policies articulated by the Santa Ana Unified School District. Noticeably absent from the school district’s policies regarding individualized education programs , identifA well-established literature documents the association between early life lead exposures and adverse cognitive, behavioral, and academic outcomes ,35,36,38Once the health impacts of lead exposure have been documented for children, the Orange County Childhood Lead Poisoning Prevention Program, implemented through the Orange County Health Care Agency, provides case management services and identification of lead sources . From puNotably, our review did not identify any city-level policies that have been implemented to remediate lead. The paucity of local lead policies may be due in part to the deference of localities to federal and state policies. However, given the place-based nature of residential lead exposures, there is a missed opportunity to leverage local policies to remediate lead sources, in turn ameliorating lead exposures in residential settings over the life course and across generations. There are two local policy opportunities for which we are cautiously optimistic. First, a recent draft of the City of Santa Ana General Plan, which is actively under development, lists a potential policy pertaining to the remediation of health concerns such as lead-based paint within the strategic goal of enhancing and maintaining Santa Ana’s historic areas . Second,The purpose of this review is to examine the state of lead policies at the federal, state, and local levels, drawing upon the urban area of Santa Ana, CA as a case study to identify opportunities for intervention to promote health equity and prevent lead exposures. This multi-level lead policy review has three key findings. First, taken together, the patchwork of federal, state, and local lead policies tends to offer passive approaches to lead remediation and concentrate on lead-based paint in older housing stock. Similarly, policies and lead education programs offer limited attention to lead exposures from multiple sources —exposures that must be addressed from a population health and health equity perspective. Second, lead prevention efforts to date have largely focused on managing lead exposures. For example, rather than assessing – and addressing—lead in the environment, existing policies primarily treat children as an indicator of lead in the environment and in turn may implement mitigation or remediation activities after a designation of lead poisoning. Third, the endurance of lead exposures and inequities in lead exposures indicate a need for vigilance towards policy implementation and policy evaluation, with a focus on health equity. The following sections discuss limitations of lead policies to date and point to promising directions to prevent exposure to lead and reduce and eventually eliminate lead-related health inequities. We close with recommendations to reduce lead exposures, consider multiple lead exposure pathways, and reduce and eliminate health inequities related to lead.First, lead policies are segmented according to: source of lead, setting in which persons have been exposed to lead, and jurisdiction of the policy. This fragmentation of lead policies creates a crisis in which policies fail to address community-wide exposures and the cumulative and compounding effects of exposure to lead from multiple sources throughout the life course. Lead exposures do not occur in isolation or at one point in time. There are several reasons why lead exposures compound: lead exposures are encountered in multiple spheres of day-to-day life ; influence individuals, households, and broader communities; and can affect current and future health status. By focusing on individual households and dwellings, current lead policies miss an opportunity to address community-wide lead exposures. Relatedly, missing from these policies is a focus on lead exposures from current emission sources, such as e-waste recycling or industrial emissions, and historical lead . Despite strong evidence of soil as an important exposure pathway, collectively these policies provide no guidelines for soil remediation beyond the presence of lead-based paint hazards. The fragmentation of lead-related policies, lack of support for remediation, and omission of compounding exposures frameworks contributes to the persistence of lead exposures and inequities in lead exposures. A multi-level and wholistic lens is important for addressing inequities, and is noticeably absent from current lead policies. There are several limitations of these policies, which may contribute to persistent lead exposures for children, communities of color, and low-income communities. Second, absent from lead policies is attention to ongoing and dynamic gentrification processes, which may exacerbate health inequities. For example, lower-income residents and persons of color are more likely to live in older housing that may have lead-based paint and/or have been exposed to historical emissions ,15,16. IThird, despite evidence indicating that there is no safe level of lead exposure, child blood lead levels remain the criterion for activating any lead mitigation or remediation activities. Accordingly, inherent in these policies is the necessary demonstration of harm to child health, which can have lasting health consequences. Indeed, the threshold of lead exposure is high, and documentation of lead poisoning is necessary despite the reality that children are not routinely tested for lead exposure. Furthermore, FDA and HUD-designated “safe” lead exposure levels are linked with adverse health consequences . NoticeaFourth, this policy analysis suggests that the implementation of existing lead policies is relatively weak and passive, contributing to the endurance of lead exposures and lead-related inequities. For example, assessments of lead in the environment  are not activated until a child has been diagnosed as having elevated blood lead levels. However, despite California’s policy mandate to test all children enrolled in Medi-Cal, an insufficient number of children are routinely tested for lead . The incThere are three key recommendations that emerged from our equity-oriented assessment of lead policies. First, to achieve equity, federal and state policies must adopt strategies to prevent individuals from being exposed to lead in the first place, alongside remediating hazardous environments. The legacies that lead leaves on the body indicate that current mitigating strategies  and individual-level remediation strategies  will not fully address the life course health consequences of lead exposures. For example, Rust and colleagues found that removing a portion of lead exposures in a household contributed to a 25% decrease in children’s blood lead levels . These fSecond, policies are needed that address community-wide lead exposure pathways. In a study on the Bunker Hill Superfund site in Idaho, von Lindern and colleagues found that leaded dust in homes contributed 40% to 50% of children’s blood lead levels and approximately 60% of leaded dust in homes originates from community-wide soils, neighbors’ yards, and the home yard . RemediaThird, findings from this policy analysis point to a need to build an intergenerational, intersectional, and inter-sectoral movement to prevent and address lead exposures. The influence of lead exposures across multiple settings and from multiple sources suggest opportunities for bridging environmental, housing, educational, carceral, climate, economic, worker, and health justice initiatives. For example, as communities work to protect and create affordable housing, sustainable solutions lie in affordable, safe housing that is free of lead and other environmental toxins . LikewisAs with all analyses, this assessment has several limitations. First, the policies represented are not exhaustive. For example, federal policies included in this review do not include those implemented by the Food and Drug Administration (FDA) or Housing and Urban Development (HUD). Likewise, at the state and local level, environmental impact reports (EIRs) may include reporting of lead exposures or lead-related activities, though policies that mandate these reports, or government-related responses to the findings of EIRs were not included in this review. Future studies are warranted regarding the outcomes of EIRs, the extent to which communities were engaged in the process, and implications for health equity. Relatedly, our review did not include more granular policies that may affect particular workforces . Second, much of the established literature regarding lead exposures focuses on implications for children, and is quantitative in nature. Qualitative studies are needed that shed light on the complex experiences of living and/or working in communities affected by legacy or ongoing sources of lead; the social, educational, carceral, economic, and health impacts; and implications for individual, family, and community wellbeing across the life course. Findings suggest that current lead policies focus on individual sources of lead rather than cumulative or synergistic exposures, exposure settings, and populations exposed, with limited attention to policy implementation and health equity. Lead policies should incorporate a complex systems perspective, with a focus on cumulative exposures and health equity. Communities of color and low-income communities will continue to be affected disparately by health inequities linked with lead exposures unless we prevent lead exposures in the first place, and to fully remediate sources of lead.


Girls with a slower life history trajectory build a larger body with larger and mechanically stronger bones. Thus, variation in the emergence of slower versus faster life history trajectories during development can have consequences for bone mechanical competence, and hence fracture risk in adulthood. Variation in life history trajectory, specifically relative investment in growth versus reproduction, has been associated with chronic disease risk among women, but whether this scenario extends to skeletal health and fracture risk is unknown. This study investigates the association of life history traits  with female bone outcomes in adulthood.Body size variables, regional muscle and fat areas, and cross-sectional bone size and strength outcomes were obtained from 107 pre-menopausal women encompassing a wide range of physical activity levels. Developmental parameters  were obtained from questionnaires.High birth weight was significantly associated with a proportionately larger body and larger, mechanically stronger bones, independently of physical activity level. It was also positively but non-significantly associated with age at menarche. Later menarche was significantly associated with larger and mechanically stronger bones and substantially less absolute and relative regional subcutaneous fat. Age at menarche exhibited stronger relationships with adult adiposity than did physical activity.Both larger birth weight and later menarche contribute to a slower life history trajectory, which is associated with greater body size, leanness and bone mechanical competence in early adulthood. In contrast, earlier sexual maturity prioritized energy allocation in adiposity over body size and skeletal strength. Thus, the level of maternal investment and the woman’s own life history trajectory shape investment in skeletal properties, with implications for fracture risk later in life. There is now compelling evidence that patterns of nutrition and growth in early life predict diverse components of health in later life. On the one hand, birth weight is inversely associated with the risk of chronic non-communicable disease (NCD) in adulthood , while oThese data can be reinterpreted using a life-history perspective , 9. AccoMore recently, the same explanatory framework has been applied to ‘intrinsic’ components of mortality risk and longevity , 14. GivOn this basis, the pace of life history is predicted to be an important trait shaping the profile of health and disease in adult life. Both the magnitude of nutritional investment during early critical windows and the pace of maturation are predicted to shape adult NCD risk. Indeed, these two traits might be linked, since a faster pace of life history may develop if the quality of early development was poor. Supporting this hypothesis, lower investment in foetal life (proxied by birth weight) was associated with faster maturation, short adult stature, higher levels of body fat and high blood pressure in South Asian women living in the UK . These dMore specifically, the pace of life history should explain differential investment across a range of phenotypic outcomes that orchestrate trade-offs across both somatic traits and life history functions. In a related review article, we argue that the pace of life history of mothers is associated with their body size, composition and metabolic profile, their NCD risk, and their capacity to invest in the next generation . Faster Imax) [The pace of life history is therefore expected to shape not only body size and composition, but also other components of health associated with the life history function categorized as ‘maintenance’ . Here, wImax) . Bone quImax) , but bonImax) . As a reImax) . The spaImax) , and incImax) . Thus, iAll participants were healthy adults, predominantly of European descent living in the United Kingdom, and all were between the ages of 18 and 40 years. The following exclusion criteria were established prior to recruitment and were applied to all subjects: any medical condition or medication known to interfere with bone metabolism, any current or recent (past 12 months) pregnancy or lactation, 18 years of age or younger (for bone scanning only), or post-menopausal status. Participants were divided into two groups according to their current physical activity level, either ‘recreationally active’ or ‘competitive athlete.’ Recreationally active women were those that had never participated in competitive sport, and had no current or past participation in >3 h a week of weight-bearing intensive physical activity. Competitive athletes were those who had been training and competing intensively in rowing, football (soccer), or endurance running for at least the past 3 years. All participants were recruited through the Cambridge University Women’s Boat Club, Women’s Association Football Club, Athletics Club, Hare and Hounds and Triathlon Club, as well as the Cambridge and Coleridge Athletics Club, the Cambridge Triathlon Club, the Beyond the Ultimate Jungle Ultra 2016, the Everest Trail Race 2016, several University of Cambridge colleges and the Graduate Union. Participants were recruited as part of two separate studies approved by the Cambridge University Human Biology Research Ethics Board (HBREC.2015.25 and HBREC.2016.14). Ethical approval for the use of peripheral quantitative computed tomography (pQCT) was obtained from the NHS Health Research Authority NRES Committee East of England—Cambridge East (15/EE/0017). All participants provided written informed consent prior to participation, and filled out a health/activity questionnaire in which developmental parameters such as birth weight and age at menarche were obtained. Data from a total of 111 women were included in the current study , 107 of whom participated in pQCT scanning.Stature was measured to the nearest 0.1 cm using a SECA 274 stadiometer. Body mass was recorded to the nearest 0.1 kg with a SECA electronic scale. Maximum humeral, femoral and tibial lengths and bi-iliac breadths were obtained from participants using sliding calipers according to the methods in International Standards for Anthropometric Assessment . HumeralAll cross-sectional bone and soft tissue data were collected using peripheral quantitative computed tomography  at the PAVE Imaging and Performance Lab in the Department of Archaeology at the University of Cambridge. Cross-sectional images were obtained from midshaft section locations (50% of maximum length) of the left and right humeri, right femur and right tibia, and distal epiphyseal section locations of the right femur and right tibia . The left lower limb bone was scanned instead of the right in the case of previous injuries that may have affected bone or soft tissue morphology. Any scan in which movement artefacts were present affecting the bone and/or soft tissue was removed from analyses.2) at midshaft (50%) and distal (4%) section locations. ToA provides a measure of the total cross-sectional area of the bone and marrow space. Midshaft ToA was assessed using a threshold of 710 mg/cm3 (contour mode 1) to separate the periosteal contour of the cortical bone from the surrounding soft tissue. Distal ToA was assessed using contour mode 1, peel mode 2, with an inner threshold of 280 mg/cm3 (tibia) or 220 mg/cm3 (femur) to separate bone from marrow, and an outer threshold of 540 mg/cm3 to separate cortical bone from muscle. Bone quality was assessed using femoral and tibial total bone density  from the distal epiphysis (4% section location); this was quantified using the same thresholds as above. TBD provides a measure of the mean density of the total bone, including the cortical bone shell and trabecular bone.Quantification of the majority of bone and soft tissue variables was performed with Macro analyses in the manufacturer software . Cross-sectional bone size was assessed through the quantification of total areas . Total muscle area (mm2) was quantified using a threshold of 41 mg/cm3  to peel off the subcutaneous fat, from which the software automatically subtracted ToA. Total fat area (mm2) was automatically calculated as the difference between total limb area and combined total muscle and bone areas.Soft tissue composition was assessed through the quantification of cross-sectional total muscle and total fat areas from the midshaft location of the humerus and femur and the 66% section location of the tibia. Total limb area at these section locations was first assessed using a threshold of −52 mg/cmp; mm4) and the maximum second moment of area, or moment of inertia . SSIp provides a measure of the torsional mechanical strength of the whole bone in cross-section, based on its geometrical and material properties [p was quantified from all midshaft limb sites using a threshold of 710 mg/cm3 (contour mode 4) to separate soft tissue from cortical bone and 400 mg/cm3 to separate cortical bone from marrow. Cross-sectional images of midshaft humeri, femora and tibiae were then imported into ImageJ, and the ‘Optimise Threshold’ function was used to remove soft tissue and marrow. The maximum second moment of area, or moment of inertia , was quantified from these thresholded images using BoneJ, a bone image analysis plug-in [Imax is the second moment of area about the major axis of the cross-section, and reflects maximum bending rigidity of the bone shaft [Bone strength was assessed through the quantification of the polar strength-strain index  being examined. Partial Pearson’s correlations controlling for physical activity were used to assess the relationships between developmental predictors and each of their relationships with body size, body composition and bone variables. Multiple regression analyses were used to test for the extent to which developmental parameters reflecting maternal investment (birth weight) and maturational rate (age at menarche), as well as physical activity , predicted adult body size, body composition and skeletal variables. The relative distribution of fat and muscle within section slices was assessed using standardized residuals from linear regression of mean total fat area relative to mean total muscle area. All statistical analyses were conducted in SPSS version 23.All data distributions were checked for normality using the Kolmogorov-Smirnov test, histograms and assessments of skewness and standard error. Data were not size-standardized prior to analyses, as the contribution of life history parameters to shaping the absolute size and strength of the tibia was of interest. Non-normal data were natural log transformed prior to analyses. Independent samples Imax). Birth weight was not significantly associated with any muscle or fat variables or TBD. The strongest relationships between birth weight and bone outcomes were documented in the weight-bearing lower limb, particularly the femur, with few significant relationships documented in the non-weight-bearing upper limb.Summary descriptive statistics for age and developmental predictors among the full 111 participants  are presented in r = 0.164, P = 0.113; p, midshaft humeral and femoral Imax). Age at menarche was also strongly and significantly negatively associated with absolute and relative subcutaneous fat areas throughout the body . Age at menarche was not significantly associated with bone density (TBD). The strongest relationships between age at menarche and bone were again documented in the femur.Birth weight and age at menarche were positively, but not significantly, correlated . Age at menarche did not significantly predict any tibial bone outcome. In the humeri , both sport participation and development (birth weight and/or age at menarche) contributed to predictions of length and midshaft Imax, while sport participation was the sole significant predictor of midshaft ToA and SSIp.The results of regressions investigating the role of developmental (birth weight and age at menarche) and behavioural (sport participation) predictors of lower limb bone size, strength and soft tissue parameters are presented in In all limb segments analysed, age at menarche was most strongly associated with adiposity. Age at menarche was significantly negatively associated with total fat areas and fat/muscle area ratios across all upper and lower limb sites, and was also a significant predictor of total fat area and fat to muscle area in the upper arms, thigh and calf. Age at menarche was the sole significant predictor of mean adiposity in both upper limbs, and was a stronger predictor of thigh and calf adiposity than was sport participation. In contrast, sport participation was the sole predictor of total muscle area at all sites examined.The current study documents the associations of life history traits reflecting maternal investment and maturational rate with indices of body composition and the mechanical competence of the adult female skeleton. We found that variation in female life history strategy, specifically relative investment during development in growth and maintenance versus reproduction, is associated with bone mechanical competence in adulthood, extending the influence of both maternal investment and maturational rate to bone fracture risk.P = 0.113). One contributing factor may have been the lack of availability of gestational age, preventing us from evaluating fetal weight gain in terms of the time available for maternal investment.Our results show that higher maternal investment contributes to greater growth in the next generation, a marker of a slower life history trajectory , as indichildhood adiposity and age at menarche, as adult adiposity is more strongly associated with the former than the latter [prior to the onset of puberty, is associated with an earlier age at menarche [Our other marker of a faster life history trajectory, earlier maturation, was likewise associated with the diversion of resources towards adiposity and the earlier attainment of sexual maturity, suggesting greater investment in short-term survival and reproduction. It is likely that the relationship between earlier menarche and greater adult adiposity documented here indirectly reflects the relationship between e latter . Relativmenarche , 29, andmenarche  and an emenarche , 33, 34.As posited by Wells , the pacOf relevance to our primary outcome, the faster developmental trajectory associated with these maternal factors not only results in a smaller body with more adipose tissue, but it also builds a mechanically weaker skeleton in absolute terms. We therefore provide empirical data supporting the hypothesis that life history trajectory shapes components of health associated with ‘maintenance’ , namely Higher birth weight and later age at menarche are both associated with longer limb bones that are wider in cross-section at the epiphyses and/or at the midshaft. This arrangement has biomechanical implications for bone strength: bending and torsion are the most mechanically relevant strains acting on the lower limb bones during locomotion, and these strains increase proportionately outwards as distance from the neutral centroid or bending axis of the cross-section increases , 26. As relatively strong, by either adding new bone tissue, or redistributing existing bone, as far as possible from the neutral bending axis or centroid [Various environmental factors, such as mechanical loading, can alter the basic size-strength relationship of a limb bone shaft, such that a small bone can become centroid , 37–42. centroid .Variation in skeletal plasticity in response to developmental and environmental factors is evident in the results of the current study as well. Even when controlling for athletic participation, the high functional plasticity of the tibial midshaft in this group of women, comprised in large part of competitive athletes, is evident: there are few significant relationships between developmental parameters and bone outcomes at the tibial midshaft, especially relative to the bone’s more highly canalized parameters , and relative to the femoral midshaft. Similarly, in regression analyses, birth weight is a significant predictor of developmentally canalized variables like tibial length and distal tibial epiphyseal bone area, but the influence of physical activity vastly outweighs that of developmental parameters at the tibial midshaft, where sport participation is the sole significant predictor of midshaft size and mechanical competence. This highlights the role of development in shaping the absolute size and strength of the tibia, and the essential contribution of subsequent physical activity in then increasing relative strength to meet mechanical demands.N = 49) reported very little history of upper limb loading, past involvement was reported in the following activities among the other athletes recruited (N = 62), involving at least 4+ h a week for ≥ 1 year and often at a competitive level: weight-training, rowing, field and ice hockey, rugby, netball, boxing, kayaking, cricket, rounders, tennis, gymnastics, lacrosse, volleyball, karate/martial arts and cheerleading/tumbling. As a result, humeral morphology among many of the women in the study group is likely reflecting substantial adaptation to mechanical loading, so relative differences in loading between the upper and lower limbs may be minimized. However, when controlling for physical activity in partial correlation analyses, the influence of development on the morphology of the humerus did occasionally differ from that of the weight-bearing lower limb bones. For example, birth weight was significantly associated with ToA in the femur and tibia but not the humeri, which may be reflecting an influence of body size and shape on lower limb bone cross-sectional size.A similar pattern is documented in the humerus, despite the non-weight-bearing environment of the upper limb. When incorporating the influence of sport participation with that of developmental factors on humeral outcomes, birth weight is a significant predictor of bone length, but the influence of physical activity again vastly outweighs that of developmental parameters at midshaft. The similarity in the relationships between physical activity, development and bone outcomes in the humerus and tibia, despite the non-weight-bearing environment of the former, may be due in part to the relatively high upper limb loading of the women included in the current study. Though control subjects and soccer players . The extent to which birth weight is indicative of maternal investment during foetal life would be improved if the duration of gestation could have been taken into account. Birth weight for gestational age provides a marker of the rate of foetal growth, and is strongly predictive of cardiovascular health later in life . Both geThough physical activity is one of the main determinants of adult female bone strength, the significant contributions of maternal investment and maturational rate to bone mechanical competence, independent of activity level, extend the influence of life history trajectory to size-dependent markers of fracture risk as well. Consistent with a broader model , a sloweThe research leading to these results has received funding from the European Research Council under the European Union’s Seventh Framework Programme (FP/2007-2013)/ERC Grant Agreement n.617627 (J.T.S.).


Knowledge of the risk indicators of aggressive periodontitis (AgP) will help clinicians to better diagnose the disease, put a treatment plan that involves modification of modifiable risk indicators, understand non-modifiable risk indicators, and may potentially serve as an aid in developing preventive programs. The objective of the present study was to assess risk indicators of aggressive periodontitis (AgP) in Jordan including socio-demographic factors, oral hygiene habits, smoking, family history and parents’ consanguinity.A total of 162 patients (81 AgP and 81 controls), attending the Periodontology clinic at Jordan University of Science and Technology, Dental Teaching Centre, were interviewed and examined. All AgP subjects had full periodontal and radiographic examination. The data recorded included socio-demographic and economic variables, oral hygiene and smoking habits, family history and parents’ consanguinity.Most AgP patients were young females, had ≤12 years of education, lived in urban areas and brushed their teeth ≥ once daily. Risk indicators of AgP included: age > 35 years, female gender and positive family history.Risk indicators associated with AgP in this study population were: age > 35 years, female gender and positive family history of periodontal disease. Periodontitis is a multifactorial disease characterized by attachment and bone loss around teeth. The incidence and progression of the disease are influenced by the interaction of genetic, microbial and environmental factors such as dental plaque (biofilm), age, gender, ethnicity, systemic diseases, smoking, psychological, genetic polymorphisms and social factors –3. The AA systematic review of literature by Susin et al., (2014) on the epidemiology and demographics of AgP , has demThe risk indicators examined in this study included demographic and socioeconomic factors, oral hygiene habits, smoking, family history and parents’ consanguinity. The reason for selecting these specific risk indicators is the strong association between them and periodontitis, as demonstrated by other researchers .The present study is a case-control study, which involved 162 patients attending Jordan University of Science and Technology (JUST) Dental Teaching Center (DTC) in Irbid. The subjects included were ≥ 14 years of age and denied having any medical problems. The disease group consisted of 81 AgP patients and the control group consisted of 81 periodontitis-free subjects.Patients who reported any medical or physiologic condition associated with periodontitis and listed in the latest AAP classification , includiThis study was conducted in full accordance with ethical principles of the World Medical Association Declaration of Helsinki .Approval for this study was obtained from the Ethical Committee in the Deanship of Scientific Research, IRB, JUST, and informed consent forms for interview and examination were signed by all subjects and the parents of subjects under the age of 18 years. For each subject, a questionnaire was completed and included: age, gender, occupation, education level, presence of periodontal problems among other family members, parents’ consanguinity, smoking habits, and oral hygiene habits.Full mouth periodontal examination was carried out which included measurement of Clinical Attachment Level (CAL), the gingival index (GI) of Löe and Silness  and the The control sample consisted of 81 periodontitis-free Jordanian subjects, none of which demonstrated attachment or bone loss at any site. The control subjects received full periodontal examination to confirm that they were periodontitis-free.P ≤ 0.05).Data were entered into a personal computer and analyzed using the Statistical Package for Social Sciences (SPSS) software version 11.0 . Frequency distribution, means and standard deviations were calculated. Independent t- and chi square tests were used for comparison among groups as appropriate. Furthermore, multivariate logistic regression model analyses, analyzing the association between explanatory (independent) and dependant variables, were performed to test the association of the outcomes with the independent variables that were included in the models by using backward stepwise Wald method (BSTEP). In this BSTEP method, all the possible variables were entered into the model. The independent variables specified in the variables list were then tested for possible removal from the model one by one at each step, based on the level of significance in the Wald statistics. The variable with the smallest significance composed to PIN (probability for entry) (0.05) was left in the model. If the significance level was greater than POUT  (0.1) the variable was removed. The algorithm stopped when no more variables could be entered or removed. Adjusted odds ratios (OR) were generated corresponding to 95% confidence intervals (CI) for all significant variables. The level of significance was set at (P = < 0.0001). The majority of AgP patients were females  of the participants in this study were females. Females represented most of the AgP group, as opposed to controls, where the number of males was higher. The multivariate logistic regression analysis revealed that females were about four times more likely to have AgP, in agreement with some studies on Caucasians , 17.A recent comprehensive review of the literature on the prevalence and demographics of AgP by Susin et al.  showed tThe majority of AgP patients had received ≤12 years of education . Previous studies have reported that education and place of residence are important factors in periodontal health but education has a greater influence on the level of periodontitis , 20. MosDental plaque is the principal etiologic factor of periodontitis as demonstrated by the early studies of Löe and co-workers . In the With regard to the presence of local etiologic factors, although the oral hygiene habits reported by the AgP and control groups were comparable, the AgP patients demonstrated higher plaque scores and attachment loss. AgP has been associated in the literature with minimal amounts of plaque , which iEvidence suggests a very strong association between smoking and gingival tissue status, periodontal tissue loss and severity of periodontitis , 25. In Although smoking is a well-known and universally accepted risk factor for the initiation, progression and severity of periodontitis , the resIt is well recognized that AgP aggregates in families , 15, 27.In the present study, more than half of AgP patients reported periodontal problems among other family members, and by that, significantly differed from controls, in agreement with other studies . FamiliaThe followings risk indicators were associated significantly with AgP in comparison with controls: age > 35 years (indicating the cumulative effect of AgP), female gender and positive family history of periodontal problems. With respect to education, AgP patients have studied for a significantly lower number of years that control subjects, which emphasizes the role of education in prevention of periodontal diseases. AgP patients had significantly greater PI, GI, and periodontal destruction than controls. The Oral hygiene of the study population was poor, which points to a great need for construction of nationwide educational and preventive programs.


Current methods for measuring intervention coverage for reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) do not adequately capture the quality of services delivered. Without information on the quality of care, it is difficult to assess whether services provided will result in expected health improvements. We propose a six-step coverage framework, starting from a target population to (1) service contact, (2) likelihood of services, (3) crude coverage, (4) quality-adjusted coverage, (5) user-adherence-adjusted coverage and (6) outcome-adjusted coverage. We support our framework with a comprehensive review of published literature on effective coverage for RMNCH+N interventions since 2000. We screened 8103 articles and selected 36 from which we summarised current methods for measuring effective coverage and computed the gaps between ‘crude’ coverage measures and quality-adjusted measures. Our review showed considerable variability in data sources, indicator definitions and analytical approaches for effective coverage measurement. Large gaps between crude coverage and quality-adjusted coverage levels were evident, ranging from an average of 10 to 38 percentage points across the RMNCH+N interventions assessed. We define effective coverage as the proportion of individuals experiencing health gains from a service among those who need the service, and distinguish this from other indicators along a coverage cascade that make quality adjustments. We propose a systematic approach for analysis along six steps in the cascade. Research to date shows substantial drops in effective delivery of care across these steps, but variation in methods limits comparability of the results. Advancement in coverage measurement will require standardisation of effective coverage terminology and improvements in data collection and methodological approaches. Most reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) intervention coverage indicators—the proportion of the population in need of an intervention that receives it—monitored for decades do not capture the quality of delivery of the interventions and therefore provide only weak links with actual health benefits received by the population in need.An increasing number of studies attempt to measure effective coverage indicators that also capture the quality of care and quantify the gaps between crude coverage and quality-adjusted measures.Our comprehensive review of the literature shows evidence of large coverage quality gaps in RMNCH+N, but the definitions, terminologies, analytical methodologies used vary widely, limiting the interpretability and comparability of the results.Building on previous frameworks and our review of current practices, we propose an organising framework to harmonise terminologies and methodological approaches for the measurement of a coverage cascade, and a definition of effective coverage as ‘the proportion of individuals experiencing health gains from a service among those who need the service’.Monitoring intervention coverage, defined as the proportion of the population in need of a health intervention who receives it, is essential for tracking progress towards universal health coverage—an aim of Sustainable Development Goal 3. Although the coverage of many interventions along the continuum of care for women’s, children’s and adolescents’ health has increased in the past decade, there is increasing evidence that national coverage indicators may overstate the health benefits of the programme because of poor quality of services.Advancement in coverage measurement requires a shift from tracking ‘crude’ or ‘contact’ coverage to effective coverage, accounting for the quality of services and their impact on people’s health. Crude coverage indicators provide no indication about the quality of interventions, whereas contact coverage simply captures contact with a provider as a proxy for adequate receipt of the needed service. In recent years, an increasing number of studies have quantified the alarming gaps between crude or contact coverage indicators and those that measure the receipt and benefits from high-quality services (effective coverage indicators).The definition and measurement of effective coverage varies between studies. There is a need for standard terminology and methods for coverage measurement. We propose a framework for the measurement of effective coverage, apply it in our systematic review of the literature and provide examples of how the framework can be operationalised for reproductive, maternal, newborn, and child health and nutrition (RMNCH+N).In general, the term effective coverage incorporates not just receipt of services but also their quality. Quality of care comprises several domains traditionally organised into inputs , the process of service delivery  and outcomes, including health benefits as well as patient satisfaction.Building on the Tanahashi framework, we propose a cascade framework that defines  and orgaWe reviewed the published literature since 2000 to support our framework for measuring dimensions of quality-adjusted or effective coverage. A total of 8103 publications on coverage of RMNCH+N since the year 2000 were obtained from PubMed and screened see . In all,10.1136/bmjgh-2018-001297.supp1Supplementary dataOf the 32 retained articles, 31 were carried out between 2010 and 2017, 22 since 2015. The bulk of the articles reviewed focused on antenatal care , nutrition (10 articles) and infancy (seven articles) . StudiesFew studies reported crude and adjusted coverage measures for interventions for the pre-pregnancy and birth periods. For pre-pregnancy, one study relied on use of modern contraceptives among women aged 15–49 years as crude measure and linked with a facility survey input measure to adjust for quality.Most analyses of ANC have relied on women’s recall of number of ANC visits and selected interventions received to measure service contact and crude coverage or quality-adjusted coverage and the gap between these two measures.For immunisation during infancy, crude coverage measures were based on vaccination information from recall or cards from household survey. Quality-adjusted coverage included serological tests to detect specific vaccine-related antibodies.Plasmodiumfalciparum to compare with the use of long-lasting insecticide-treated bednets.Five studies analysed childhood interventions focusing on care seeking and treatment for child illness such as diarrhoea, fever and symptoms of acute respiratory infection, and use of insecticide-treated bednets. In addition to careseeking coverage, three of these studies measured process-adjusted coverage from recall of procedures and treatment received.Nutrition publications were mostly small-scale studies relying predominantly on recall of food consumption by women and children.This review of effective coverage analyses showed considerable variability in study methods, including data sources, indicator definitions and analytical approaches, and not always consistent with the logical flow of our proposed framework see . The greThe largest variation in methods was observed in estimates of quality-adjusted estimates. Three types of data sources were used: self-report via the same population-based survey used for defining crude coverage, assessment of specimen samples collected during the survey  and a separate sample of health facilities or, in one case, food available at local markets. Indicators of quality differed across nearly every study and included binary indicators of receipt of a single service , binary indicators of multiple elements , and, least commonly, proportions of care available or delivered . Analytic approaches differed for studies linking individuals surveyed in households to external information such as health facility assessments: three studies linked individuals to facilities directly using health records,In the absence of a standard organising framework to guide the measurement of coverage indicators that adjust for quality dimensions, researchers have developed their own methods and adjustment approaches, focusing on specific components of quality of care, often relying on WHO-recommended standards for care provision.Advancement in coverage measurement faces numerous challenges, reflected in the studies reviewed. Although these studies generally show a substantial drop in coverage when comparing contact or crude coverage to quality-adjusted measures, definitions, methods and approaches used are heterogeneous and inconsistent. Quality of care is a multidimensional construct that includes inputs, processes and outcomes and experience of care from the patient perspective. Due to lack of consensus on measurement, the operational definition used to assess measures that adjust for quality mostly depends on available data and study objectives. There are currently few standards in items or procedures, in terms of their composition and number, included in quality adjustment, whether for inputs, processes or outcomes. Studies have considered either single interventions and/or a combination of procedures using simple arithmetic averages. Thus, measures that adjust for quality, and therefore the gap between crude coverage and effective coverage, do not compare from one study to another. Similarly, for studies that have combined household and facility survey data to derive adjusted measures, there are no standard approaches for linking these datasets. Some studies have used geocoordinates for an ecological linkage, whereas others have used the type of facility and/or administrative area.Current studies have in most cases been opportunistic, often relying on secondary data from household interviews and facility surveys. Studies that have used primary standalone data collection were often of small scale, covering few districts. Consequently, each stage of the continuum of care for RMNCH+N is not equally covered, nor are all steps of the cascade framework captured. The area most covered is ANC due to widely available data on ANC content from household and facility surveys. No study assessed whether adjusting for dimensions of quality was associated with impact or with loss of effectiveness or impact.The proposed cascade framework offers an organising approach for improving consistency and definitions across studies attempting to measure quality-adjusted coverage, as well as the interpretation on these measures. Although the cascade approach is intuitive for most interventions or packages of interventions, there may be situations where the coverage measures do not decrease monotonically along the steps. This is mainly the case for user-adjusted adherence, which can occur even though services were not delivered according to standard. In such cases, independent serial cross-sectional coverage measures at each step may not decrease along the steps. Such issue will, however, disappear when the coverage measure of each step effectively depends on the realisation of previous steps.Biomarkers and cohort registration approaches are central in the cascade frameworks used in programmes for the prevention of mother to child HIV transmission, HIV antiretroviral treatment and tuberculosis diagnosis and treatment.Three critical recommendations stem out of our review. First, terminologies and definitions used for monitoring effective coverage must be standardised and harmonised across the RMNCH+N at global level and within the scientific community. Only then will the coverage cascade and effective coverage measures be more easily interpreted, meta-analysed and communicated to countries resulting in policy and programmatic action. Our proposed framework, which is sufficiently broad and applicable to all components of the RMNCH continuum, offers such standardisation.Second, measuring each step on the framework will require improvements in data collection at both household and facility levels, as well as investment in stable national and subnational surveillance systems. Measuring populations in need from household surveys will require innovations in data collection, including for example biomarkers. Data sources for estimating coverage at national, regional and global levels have relied mainly on national household surveys, driven primarily by the DHSs initiated in the mid-1980s and the MICSs implemented since mid-1990s.Third, approaches that link household-based data with health facility data are increasingly popular, but priority must also be given to analytical techniques for the linking and computation of valid measures of effective coverage.While the evidence based on methods for effective coverage measurement must be expanded, it is critical that the global community, including national data collection programmes such as DHS, MICS, SARA, SPA, prioritises reporting of each step of the proposed cascade framework in RMNCH+N. Measurement to better monitor, understand and act on the gaps in effective coverage is required to make significant progress towards universal health coverage with quality services for women’s and children’s health.


Impairments in social cognition have been described in several psychiatric and neurological disorders. Given the importance of the relationship between social cognition and functioning and quality of life in these disorders, there is a growing interest in social cognition remediation interventions. The aim of this study was to carry out a systematic mapping review to describe the state of the art in social cognition training and remediation interventions.Publications from 2006 to 2016 on social cognition interventions were reviewed in four databases: Scopus, PsycINFO, PubMed and Embase. From the initial result set of 3229 publications, a final total of 241 publications were selected.The study revealed an increasing interest in social cognition remediation interventions, especially in the fields of psychiatry and psychology, with a gradual growth in the number of publications. These were frequently published in high impact factor journals and underpinned by robust scientific evidence. Most studies were conducted on schizophrenia, followed by autism spectrum disorders. Theory of mind and emotional processing were the focus of most interventions, whilst a limited number of studies addressed attributional bias and social perception. Targeted interventions in social cognition were the most frequent practice in the selected papers, followed by non-specific treatment interventions and broad-based interventions.Research in social cognition remediation interventions is growing. Further studies are needed on attributional bias and social perception remediation programs, while the comparative efficacy of different interventions also remains unclear. Social cognition refers to the mental operations involved in social interactions, including processes of perceiving, interpreting, and generating responses to the intentions, dispositions, and behaviors of others –6. SociaThe last decade has seen a significant increase in research on social cognition and the strategies for its pharmacological and psychosocial treatment. A recent systematic mapping review of pharmacological interventions in social cognition deficits  shows anSocial Cognition Psychometric Evaluation (SCOPE) study have defined social cognition as a multidimensional construct that includes four core domains: emotional processing, social perception, attributional style/bias, and theory of mind [Several non-pharmacological approaches designed to enhance social cognition abilities have also been developed. Some treatment interventions approach social cognition as a unitary construct, but emphasis has recently been placed on a multidimensional structure of social cognition. Initiatives such as the  of mind –25. In t of mind –27, haveAlthough several reviews have focused on the usefulness of different social cognition remediation interventions –31, to oThe aim of the present study was to describe the state of the art in social cognition remediation interventions following a systematic mapping review approach, to provide researchers and clinicians with a global picture on social cognition remediation interventions for psychiatric and other medical conditions.The present mapping review has been conducted for several reasons. The first is to perform a broad analysis of the literature on social cognition remediation interventions, with the aim of providing an overview of existing proposals according to a classification criterion. The second is, if possible, to identify existing research gaps in social cognition rehabilitation intervention programs to plan future research, while the third is to identify topics and areas for future systematic literature reviews focused on smaller research areas.Template for a Mapping Study Protocol [Research directives defines the study protocol and identifies the dimensions to be analyzed and the research questions to be answered. (b) Data collection gathers relevant papers in accordance with the inclusion and exclusion criteria defined in the protocol. Finally, (c) Results maps the existing literature in line with the defined criteria and answers the research questions. Note that the PRISMA checklist [Template for a Mapping Study Protocol is provided in The steps described in the Protocol –40 were hecklist  has not In this section, the definition of the research protocol and the description of the research questions is presented. The protocol included the study topic ; its rationale (previously mentioned); preliminary research questions; and search strategy, selection criteria, and data extraction form. Finally, the protocol included an overview of selected papers in terms of their publication venues and years.The four research questions (RQ) for this systematic mapping review and their rationale were:How many papers have been published on social cognition remediation interventions? Is there any temporal trend? What is their level of scientific evidence?RQ1. As previously discussed, deficits in social cognition are commonly found in psychiatric disorders such as autism, depressive disorder, bipolar disorder, and schizophrenia. Due to the prevalence and/or severity of these disorders, and the limited efficacy of pharmacological interventions –43, the In what areas of medical knowledge and related disciplines has research on social cognition remediation programs been conducted?RQ2. Deficits in social cognition are not exclusive to psychiatric disorders. Several neurological disorders such as behavioral-variant frontotemporal dementia , traumatWhich domains of social cognition are the focus of research in social cognition remediation?RQ3. Social cognition is considered a multidimensional construct. There is some consensus regarding critical domains of social cognition as four partially overlapping domains  –25:Theory of mind is defined as the ability to recognize intentions, dispositions, and beliefs in oneself and others [d others . Theory d others –54. Theod others .Social perception consists of the ability to identify social rules, roles, and goals [nd goals –57. Socind goals –59.Attributional bias/style describes the way in which individuals explain or interpret different social facts or infer the causes of social events [l events . AttribuEmotional processing refers to the ability to perceive, recognize and manage emotional information [ormation . Emotionormation –61.Interventions on social cognition remediation may be focused on one or several social cognition domains. Thus, identifying the most frequently studied domains will help researchers recognize the domains that might need further investigation.What types of interventions are employed in social cognitive remediation?RQ4. Although various forms of interventions may potentially improve social cognition, three main types of training and remediation interventions have been distinguished :Targeted interventions specifically directed at improving one or more domains of social cognition. Targeted interventions are often subcategorized, including “targeted” and “comprehensive” interventions. “Targeted” refers to brief interventions for a single aspect of social cognition. “Comprehensive” refers to programs that leverage all the elements of an extended training program in order to improve multiple domains of social cognition, typically including practice for the generalization of acquired skills for everyday life. Notice that the present work does not provide this subclassification.Broad-based interventions, including social cognition training in a broader approach oriented towards improving social cognition, neurocognition and/or social skills.Non-specific interventions, which do not target social cognition but may produce a positive effect on one or more of its domains.Classifying published papers according to three main types of interventions facilitates an overview of the specificity of the interventions in social cognition remediation.With the aim of including relevant and excluding irrelevant papers, the search strategy of this study involved querying reference databases with customized search strings, followed by manual filtering of the query results using predefined inclusion and exclusion criteria. Five researchers were involved in executing the search strategy.To minimize the risk of missing relevant papers on social cognition remediation, four reference databases were queried: Scopus (Elsevier), PsycINFO , PubMed  and Embase (Elsevier).The keywords for the search string were identified by following mainly research questions RQ3 and RQ4. The first part of the search string was composed of words related to social cognition, using the nomenclature described under RQ3, while the second part included remediation and its synonyms  related to the types of interventions deduced from RQ4. Finally, all items in our search string were interleaved with or/and statements, to make sure that all relevant papers were retrieved. The final search string was:  AND (“rehabilitation” OR “remediation” OR “therapy” OR “treatment” OR “training” OR “enhancement”). It should be highlighted that no truncation was used in the terms of the final search string for the following reasons: First, not all reference databases enable this option, and using it would drastically deviate the number of records obtained of some database in comparison to others. Second, in the case of Scopus database, for instance, the number of initial results would become intractable . In each reference database, the complete string was queried in the title, abstract, and keywords fields.The selection criteria of published studies comprised the following inclusion and exclusion criteria:I1. Papers focusing on social cognition deficits and their treatment.I2. Papers published between January 1, 2006, and December 31, 2016.I3. Papers focusing on social cognition training and remediation interventions.Inclusion criteria:E1. Grey literature, because of their unclear peer review process: editorials, extended abstracts, tutorials, tool demos, doctoral symposium papers, research abstracts, book chapters, proceedings, keynote talks, workshop reports, and technical reports.E2. Systematic reviews  and survey papers were not considered eligible for inclusion. We were only interested in first-hand experimental research work.E3. Papers from venues other than medicine, psychology, neuroscience and/or biomedicine .E4. Papers not related to research with human subjects.E5. Papers based on pharmacological interventions for social cognition deficits.Exclusion criteria:Inclusion criterion I2 deserves an explanation. It is usual to consider publications published within the last ten in similar systematic mapping studies. Therefore, we started our study with publications from 2006, which provided around 150 papers as the starting point of the search. Moreover, there are two reasons to end the study in 2016. First, systematic mappings study complete years, and it is not feasible to close a year before the third quarter of the following one, mainly due to delays inherent to data management in search engines. Thus, work on the study was started during the final months of 2017. Second, performing this systematic mapping study was a vast task that continued into 2018.In relation to exclusion criterion E1, let us highlight that it does not limit the potential to determine interest in the topic, as we have verified the same tendency in the growth of the number of publications including and excluding grey literature. For the under study, grey literature represents around 22% of annual publications.The steps described in At this point, the 1233 references were filtered again by the same two researchers, who independently screened the full content of each paper. As in the preceding step, when a researcher was unsure whether to keep or remove a paper, or there was no agreement between the two researchers, the paper was presented in another session for discussion and a final decision. This step thus produced the final set of 241 references. To ensure that no references were missed during the process, a series of earlier –63 and mA final number of 241 papers  . Other areas of knowledge were child and adolescent psychiatry and psychotherapy (22 papers), neurology (6 papers), physical medicine and rehabilitation (6 papers), and public health medicine (4 papers).According to the area of knowledge of the publishing journal, 132 of the 241 included papers were published in journals classified as related to medicine. As shown in Furthermore, as can be seen in Which domains of social cognition are the focus of research in social cognition remediation?RQ3. Theory of mind was the most frequently studied domain with 146 publications, followed by 131 articles in emotional processing, 60 articles in attributional bias and 33 papers in social perception see . AlthougStudies with IB level of evidence were the most frequently found for each domain of social cognition. As can be observed in and the mental disorder they focus on, most publications in all four domains alluded to schizophrenia spectrum and other psychotic disorders. Autism spectrum disorder was the second most studied disorder  was the focus of 16 publications, followed by Training of Affect Recognition (TAR) and Conversation-Based Intervention, both with 7 papers, Mind Reading and SummerMAX with 6 publications each, and Mentalization-Based Therapy (MBT), Micro-Expression Training Tool (METT) and The Theory of Mind Training with 4 publications each  with 11 publications, as shown in Integrated Psychological Therapy (IPT) with 4 articles. Auditory Training with Cognitive Social Training plus Social Cognition Training (AT + SCT) followed with 3 papers, and Cognitive Pragmatic Treatment (CPT) and REHACOP with 2 papers each. The rest of the papers on broad-based interventions are available in the supplementary material online . The results show the current situation of this field of knowledge, both with the areas that have received more attention, as well as those that show little research development. The present study adds to the recently published systematic mapping review on pharmacological interventions for social cognition improvement , providiA total of 241 papers were selected from the initial 3229 non-repeated publications obtained from four databases . The number of papers published per year on social cognition training and remediation interventions clearly increased throughout the studied period, especially in the last four years. This is an indicator of the growing interest in social cognition non-pharmacological treatment approaches, which may be related to the scant effectiveness of pharmacological treatments in improving social cognition deficits.US Agency for Healthcare Research and Quality Agency [In terms of the level of scientific evidence as defined by the y Agency , of the Schizophrenia Research with 19 papers , and Journal of Autism and Developmental Disorders with 10 papers . Moreover, of the top eight most popular publication venues, five (comprising 42 of the 62 papers) were first-quartile journals. The fact that papers were published in high-impact journals may be related to the high level of scientific evidence previously indicated.Referring to publication venues, it is interesting to note that most studies were disseminated in journals with a high impact factor. Journals with the highest number of papers on this topic were two journals in the first quartile of their area of knowledge: Regarding areas of medical knowledge and related disciplines with research on social cognition training and remediation, most publications belonged to the field of Medicine, especially to Adult Psychiatry, followed by Child and Adolescent Psychiatry and Psychotherapy. Psychology was the discipline with the second-greatest number of publications in social cognition remediation. The fact that impairments in social cognition frequently appear in numerous psychiatric disorders might explain why most studies belong to Adult and Child/Adolescent areas of Psychiatry and Psychology.Concerning social cognition domains, most of the published papers targeted theory of mind, followed by emotional processing. Previously published reviews centered on schizophrenia and other related disorders showed that emotional processing was the focus of most publications –31,63. NSocial Cognition and Interaction Training (SCIT). SCIT targets three domains of social cognition: theory of mind, emotional processing and attributional bias [Training of Affect Recognition (TAR) [Conversation-Based Intervention [Mind Reading [SummerMAX [Mentalization-Based Therapy (MBT) [Micro-Expression Training Tool (METT) [The Theory of Mind Training [Cognitive Enhancement Therapy (CET) [Integrated Psychological Therapy (IPT) [Auditory Training with Cognitive Social Training plus Social Cognition Training (AT + SCT) [REHACOP [Cognitive and Behavioral Therapies. Nevertheless, although publications on certain interventions were more numerous than others, the results show the existence of a considerable number of different interventions for improving social cognition. This may be partly due to the existence of different domains of social cognition, but also due to the limited number of comparative studies.The results regarding the types of social cognition training and remediation interventions show that the majority of publications refer to targeted interventions. This finding is in line with previous publications showing a greater number of papers related to targeted interventions compared to other types of interventions . In the nal bias . Other ton (TAR) , Conversrvention , Mind Re Reading , SummerMummerMAX , Mentalipy (MBT) , Micro-El (METT) , and TheTraining . Among bpy (CET) . CET conpy (CET) . Other lpy (IPT) , AuditorT + SCT)  and REHA[REHACOP . FinallyThe present systematic mapping review has some risks and limitations. One of the risks implied in all systematic mapping reviews is related to selective reporting bias . To miniFinally, the risk of likely inaccuracy in data extraction and misclassification was mitigated as classification and extraction data processes were performed independently by two researchers, and a consensus decision including the study coordinator was made in the event of no agreement between these two researchers.To our knowledge, this is the first systematic mapping review describing social cognition remediation interventions. Our results show a growing interest in non-pharmacological treatments of social cognition, as can be demonstrated by the increase in the number of papers published over the studied period, their high level of scientific evidence, and their dissemination in journals with a high impact factor. Most studies are from the fields of psychiatry and psychology, with schizophrenia spectrum disorders and autism spectrum disorders being the two most studied conditions. Theory of mind was the most frequently studied domain of social cognition, followed by emotional processing. Targeted interventions were the most frequently studied, especially SCIT. Future research should be conducted on attributional bias and domains of social perception, with the comparative efficacy of different social cognition interventions also being an interesting future line of research.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S1 File(PDF)Click here for additional data file.