Megastudy shows that reminders boost vaccination but adding free rides does not.

Encouraging routine COVID-19 vaccinations is likely to be a crucial policy challenge for decades to come. To avert hundreds of thousands of unnecessary hospitalizations and deaths, adoption will need to be higher than it was in the autumn of 2022 or 2023, when less than one-fifth of Americans received booster vaccines1,2. One approach to encouraging vaccination is to eliminate the friction of transportation hurdles. Previous research has shown that friction can hinder follow-through3 and that individuals who live farther from COVID-19 vaccination sites are less likely to get vaccinated4. However, the value of providing free round-trip transportation to vaccination sites is unknown. Here we show that offering people free round-trip Lyft rides to pharmacies has no benefit over and above sending them behaviourally informed text messages reminding them to get vaccinated. We determined this by running a megastudy with millions of CVS Pharmacy patients in the United States testing the effects of (1) free round-trip Lyft rides to CVS Pharmacies for vaccination appointments and (2) seven different sets of behaviourally informed vaccine reminder messages. Our results suggest that offering previously vaccinated individuals free rides to vaccination sites is not a good investment in the United States, contrary to the high expectations of both expert and lay forecasters. Instead, people in the United States should be sent behaviourally informed COVID-19 vaccination reminders, which increased the 30-day COVID-19 booster uptake by 21% (1.05 percentage points) and spilled over to increase 30-day influenza vaccinations by 8% (0.34 percentage points) in our megastudy. More rigorous testing of interventions to promote vaccination is needed to ensure that evidence-based solutions are deployed widely and that ineffective but intuitively appealing tools are discontinued.

Last-mile delivery increases vaccine uptake in Sierra Leone.

Less than 30% of people in Africa received a dose of the COVID-19 vaccine even 18 months after vaccine development1. Here, motivated by the observation that residents of remote, rural areas of Sierra Leone faced severe access difficulties2, we conducted an intervention with last-mile delivery of doses and health professionals to the most inaccessible areas, along with community mobilization. A cluster randomized controlled trial in 150 communities showed that this intervention with mobile vaccination teams increased the immunization rate by about 26 percentage points within 48-72 h. Moreover, auxiliary populations visited our community vaccination points, which more than doubled the number of inoculations administered. The additional people vaccinated per intervention site translated to an implementation cost of US $33 per person vaccinated. Transportation to reach remote villages accounted for a large share of total intervention costs. Therefore, bundling multiple maternal and child health interventions in the same visit would further reduce costs per person treated. Current research on vaccine delivery maintains a large focus on individual behavioural issues such as hesitancy. Our study demonstrates that prioritizing mobile services to overcome access difficulties faced by remote populations in developing countries can generate increased returns in terms of uptake of health services3.

Government subsidy and benefit distribution mechanisms for transportation PPP projects: An evolutionary game perspective.

Public-private partnerships (PPP), as an important model for collaboration between the public and private sectors, is an urgent and critical topic due to the serious financial losses of governments involved in transportation PPP projects in recent years. Current research focuses on the government subsidy model, in which the effective implementation of government subsidies relies on the design of incentives for stakeholder behavior. Although the positive externalities are strong, they are prone to the problem of "free riding," which leads to low project performance and challenges in compensating for the government's financial losses. Therefore, this study proposes a novel dynamic subsidy mechanism that can be adjusted based on actual changes in transportation demand and that is linked to project performance. We use evolutionary game theory to construct a two-party evolutionary game model of the government and social capital, focusing on the stability and influencing factors of these interactions. Our research unveils that reaching specific thresholds in both the incentive coefficient and benefit distribution ratio induces an "positive management-negative management" shift in the behavior of involved parties, leading to enhanced project outcomes. Notably, fluctuations in operational quality substantially enhance the efficiency of the active management of private sector, with no discernible impact on the subsidy efficiency of the government. Therefore, our study provides a theoretical framework for improving the revenue allocation and government subsidy mechanism, which has theoretical and practical implications for enhancing the effect of government incentives and improving the quality of operational social capital.

Enhancing supply chain relationships in the circular economy: Strategies for a green centralized supply chain with deteriorating products.

This article introduces a green centralized supply chain in a two-stage stochastic programming model using deteriorating products. The model reduces the cost of purchasing, transporting, storing, product recovery and shortages. This cuts down on greenhouse emission related to transportation, product recovery, and recycling programs. On the basis of this, we explore the utilization of the circular economy to the damages that could occur from used products. Furthermore, revenue sharing and quantity discount contracts are examined in the business models between the members of the supply chain and the external manufacturer. Demand is assumed to be uncertain, and scenarios are created to account this. The model specifies the optimal order quantities, transportation modes and contract terms that minimize costs and environmental impacts. Numerical examples analyze the trade-offs between economic and environmental objectives under different supply chain parameters. The results provide insights for circular supply chains that reconcile economic incentives with environmental responsibility for deteriorating product.

Health Benefits of Strategies for Carbon Mitigation in US Transportation, 2017‒2050.

Objectives. To quantify health benefits and carbon emissions of 2 transportation scenarios that contrast optimum levels of physical activity from active travel and minimal air pollution from electric cars. Methods. We used data on burden of disease, travel, and vehicle emissions in the US population and a health impact model to assess health benefits and harms of physical activity from transportation-related walking and cycling, fine particulate pollution from car emissions, and road traffic injuries. We compared baseline travel with walking and cycling a median of 150 weekly minutes for physical activity, and with electric cars that minimized carbon pollution and fine particulates. Results. In 2050, the target year for carbon neutrality, the active travel scenario avoided 167 000 deaths and gained 2.5 million disability-adjusted life years, monetized at $1.6 trillion using the value of a statistical life. Carbon emissions were reduced by 24% from baseline. Electric cars avoided 1400 deaths and gained 16 400 disability-adjusted life years, monetized at $13 billion. Conclusions. To achieve carbon neutrality in transportation and maximize health benefits, active travel should have a prominent role along with electric vehicles in national blueprints. (Am J Public Health. 2022; 112(3):426-433. https://doi.org/10.2105/AJPH.2021.306600).

Incentives for Uptake of and Adherence to Outpatient Stroke Rehabilitation Services: A 3-Arm Randomized Controlled Trial.

OBJECTIVE: To determine if rehabilitation uptake and adherence can be increased by providing coordinated transportation (increased convenience) and eliminating out-of-pocket costs (reduced expense). DESIGN: Three-arm randomized controlled trial. SETTING: Stroke units of 2 Singapore tertiary hospitals. PARTICIPANTS: Singaporeans or permanent residents 21 years or older who were diagnosed as having stroke and were discharged home with physician's recommendation to continue outpatient rehabilitation (N=266). INTERVENTIONS: A Transportation Incentives arm (T), which provides free transportation services, a Transportation & Sessions Incentives arm (T&S), offering free transportation and prescribed stroke rehabilitation sessions, and a control arm, Education (E), consisting of a stroke rehabilitation educational program. MAIN OUTCOME MEASURES: The primary study outcome was uptake of outpatient rehabilitation services (ORS) among patients poststroke and key predefined secondary outcomes being number of sessions attended and adherence to prescribed sessions. RESULTS: Uptake rate of ORS was 73.0% for E (confidence interval [CI], 63.8%-82.3%), 81.8% for T (CI, 73.8%-89.8%), and 84.3% for T&S (CI, 76.7%-91.8%). Differences of T and T&S vs E were not statistically significant (P=.22 and P=.10, respectively). However, average number of rehabilitation sessions attended were significantly higher in both intervention arms: 5.50±7.65 for T and 7.51±9.52 for T&S vs 3.26±4.22 for control arm (E) (T vs E: P=.017; T&S vs E: P<.001). Kaplan-Meier analysis indicated that persistence was higher for T&S compared with E (P=.029). CONCLUSIONS: This study has demonstrated a possibility in increasing the uptake of and persistence to stroke ORS with free transportation and sessions. Incentivizing survivors of stroke to take up ORS is a new strategy worthy of further exploration for future policy change in financing ORS or other long-term care services.

Transportation cost as a barrier to contraceptive use among women initiating treatment for HIV in Tanzania.

Transportation cost is a barrier to HIV treatment, yet no studies have examined its association with contraceptive use among women living with HIV. We analyzed cross-sectional data from women attending three public healthcare facilities in Shinyanga, Tanzania where they initiated antiretroviral therapy for HIV infection in the previous 90 days; all facilities offered free contraception. Women self-reported current contraceptive use and the round-trip cost of transportation to the facility. Among 421 women aged 18-49, 86 (20.4%) were using any modern contraceptive method, of which half were using modern methods other than condoms. Women who paid more than 2,000 Tanzanian shillings for transportation had a significantly lower prevalence of any modern method use than women who paid nothing (9.1% vs. 21.3%; adjusted difference: -12.9; 95% confidence interval: -21.3, -4.4). A similar difference was observed for non-condom modern method use. We conclude that high transportation cost may impede contraceptive use even among women accessing HIV treatment.

Environmental-economic approach to optimization of transport communication in megacities.

The paper presents the results of the study on the transport systems in metropolises by stating the interdisciplinary problems and prospects of applying the environmental and economic approach to the optimization of transport communication in megacities. The main problems of transport communications in large cities have been considered. The world experience in managing transport systems is analyzed. Priority directions for the implementation of environmental and economic tasks of transport industry management using the economic and mathematical approach have been established. It has been established that the performance indicators of the functioning of the megalopolis transport system depend on the work of the service provider. The most effective solution is to ensure that vehicles are working properly, that the vehicles are fully loaded and that they are on schedule. Performance indicators of the functioning of the megalopolis transport system on the part of the consumer of services: the coefficient of determination was 0.9493, the static probability p = 0.2067 standard deviation was 7.9428, the variance did not exceed 0.1015. The correlation of actual and planned results exceeded r2>0.7051; and was described by the equation y = 1.6746 + 0.844x. Logistic models for performance improvement of the transportation system were offered.

Who is Biking for? Urban Bikeshare Networks' Responses to the COVID-19 Pandemic, Disparities in Bikeshare Access, and a Way Forward.

Black, Latinx, and Indigenous people have contracted the SARS-CoV-2 virus and died of COVID-19 at higher rates than White people. Individuals rated public transit, taxis, and ride-hailing as the modes of transportation putting them at greatest risk of COVID-19 infection. Cycling may thus be an attractive alternative for commuting. Amid the increase in bikeshare usage during the early months of the pandemic, bikeshare companies made changes to membership requirements to increase accessibility, targeting especially essential workers. Essential workers in the United States are disproportionately Black and Latinx, underpaid, and reliant on public transit to commute to work. We document changes made by bikeshare companies, including benefits to various groups of essential workers, and we discuss such changes in the context of longstanding racial disparities in bikeshare access. While well intended, the arbitrary delineation in eligibility for such benefits by class of essential workers unwittingly curtailed access for many who may have benefited most. Given that equity in bikeshare is an important tool to improve access to safe transportation, critical changes in the distribution, accessibility, and usability of bikeshare networks is essential. Bikeshare companies, city planners, and policy makers should collaborate with community-based bike advocates to implement changes, as vocalized by those most in need of alternative forms of transportation.

Patient-initiated follow-up after treatment for low risk endometrial cancer: a prospective audit of outcomes and cost benefits.

OBJECTIVE: Recurrence of low-risk endometrioid endometrial cancer is rare, and traditional hospital follow-up has a cost to both the patient and the healthcare system, without evidence of benefit. We examined the uptake of patient-initiated follow-up, pattern of recurrences, and survival for women following surgical treatment of low-risk endometrial cancer and compared estimated costs with hospital follow-up. METHODS: This study was a prospective audit of outcomes following implementation of a patient-initiated follow-up policy in a UK-based gynecological cancer center for women with low-risk endometrial cancer treated surgically (International Federation of Gynecology and Obstetrics (FIGO) stage 1A, G1-2) from January 2010 to December 2015. Women were identified following multidisciplinary team meetings and data were collected from the electronic cancer register, paper, and electronic clinical records. Health service costs were calculated based on standard tariffs for follow-up appointments; patient costs were estimated from mileage traveled from home postcode and parking charges. Progression-free survival and overall survival were assessed. Estimated financial costs to the health service and patients of hospital follow-up were compared with actual patient-initiated follow-up costs. RESULTS: A total of 129 women were offered patient-initiated follow-up (declined by four; accepted by another 11 after hospital follow-up for 6 months to 3.5 years) with median follow-up of 60.7 months (range 1.4-109.1 months). Ten women recurred: four vaginal vault recurrences (all salvaged), three pelvic recurrences (all salvaged), and three distant metastatic disease (all died). Five-year disease-specific survival was 97.3%. Ten women in the cohort died: three from endometrial cancer and seven from unrelated causes. The cost saving to the health service of patient-initiated follow-up compared with a traditional hospital follow-up regimen was £116 403 (median £988.60 per patient,range £0-£1071). Patients saved an estimated £7122 in transport and parking costs (median £57.22 per patient,range £4.98-£147.70). CONCLUSION: Patient-initiated follow-up for low risk endometrial cancer has cost benefits to both health service and patients. Those with pelvic or vault recurrence had salvageable disease, despite patient-initiated follow-up.

Does free public transit increase physical activity and independent mobility in children? Study protocol for comparing children's activity between two Finnish towns with and without free public transit.

BACKGROUND: Children's habitual physical activity, including active travel and catching public transit (walking and cycling to and from destinations), and independent mobility (mobility without an adult) have decreased. Public transit trips are physically active and can provide access to hobbies independent of parents, but there is no device-measured data about children's total physical activity time following the introduction of free public transit. Our aim is to compare physical activity and independent mobility between children living in two Finnish towns, one with a recently introduced free public transit system, and the other without free public transit. METHODS: The city of Mikkeli has provided free public transit for all comprehensive school children since 2017. Various districts from Mikkeli, and the reference town of Kouvola (towns from South-Eastern Finland with a comparative population size and geographical structure), are selected based on their accessibility and the availability of public transit services. Samples of 10-12-year-old children will be recruited through primary schools. We will compare moderate-to-vigorous physical activity time, sitting time (a thigh-worn Fibion® device) and independent mobility (a participatory mapping method, PPGIS) of children: 1) who live in towns with and without free public transit, 2) who live and go to school in districts with high vs. low perceived and objective access to free public transit, and 3) who report using vs. not using free public transit. In addition, ethnography will be used to get insights on the social and cultural effects of the free public transit on children's and parent's everyday life. DISCUSSION: There is a need for scalable solutions that can increase children's physical activity independent of their socioeconomic background or place of residence. This project will give information on how a political action to provide free public transit for children is associated with their total physical activity time and independent mobility patterns, therefore providing highly relevant information for political decision-making and for promoting independent physical activity in children.

The experience of transportation to visit a nursing home resident: A case study.

Maintaining social connections in the community can be accomplished through transportation access and opportunities. This includes relationships between family and residents in nursing homes. Previous research supports the relationship between transportation, social support, and visitation of residents in nursing homes (NHs), however no empirical research to date explores this relationship of family member transportation as a means to visit their loved one in this setting. Guided by a case study approach, a sample of 11 (N = 11) family members of residents in nursing homes across North Central Texas were selected to develop an in-depth understanding of transportation access and mobility, as it relates to visitation of residents in nursing facilities. Analyses revealed the following seven themes: Car access, Alternative modes, Flexibility, Travel time, Actual cost, Collateral cost, and Health and Mobility. Findings from this study uncover how cost, both actual cost and collateral cost, are greatly linked to car access, transportation access, and opportunities to visit, as well as the impact each of these features, and emergent themes, related to transportation have on maintained or fractured relationships of family and residents in nursing homes. This article concludes with implications for future research and social work practice.

Out of pocket expenditure and its associated factors in neonates admitted to neonatal intensive care unit of tertiary care government hospital of Agra District, Uttar Pradesh.

BACKGROUND: Neonatal health remains a thrust area of public health, and an increased out-of-pocket expenditure (OOPE) may hamper efforts toward universal health coverage. Public spending on health remains low and insurance schemes few, thereby forcing impoverishment upon individuals already close to poverty line. OBJECTIVE: To determine catastrophic health expenditure (CHE) in neonates admitted to the government neonatal intensive care unit (NICU) and factors associated with of out-of-pocket expenditure. METHODS: This cross-sectional study was conducted in a governmental NICU at Agra from May 2017 to April 2018. A sample of 450 neonatal admissions was studied. Respondents were interviewed for required data. OOPE included costs at NICU, intervening health facilities, and transport as well. SPSS version (23.0 Trial) and Epi Info were used for analysis. RESULTS: Of the 450 neonates analyzed, the median total OOPE was Rs. 3000. CHE was found among 55.8% of cases with 22% spending more than their household monthly income. On binary logistic regression, a higher total OOPE of Rs. 3000 or more was found to be significantly associated with higher odds of residing outside Agra (adjusted odds ratio [AOR] = 1.829), delay in first cry (AOR = 1.623), referral points ≥3 (AOR = 3.449), private sector as first referral (AOR = 2.476), and when treatment was accorded during transport (AOR = 1.972). CONCLUSIONS: OOPE on neonates amounts to a substantial figure and is more than the country average. This needs to be addressed sufficiently and comprehensively through government schemes, private enterprises, and public-private partnerships.

Chimeric antigen receptor-T cell therapy manufacturing: modelling the effect of offshore production on aggregate cost of goods.

Cell and gene therapies have demonstrated excellent clinical results across a range of indications with chimeric antigen receptor (CAR)-T cell therapies among the first to reach market. Although these therapies are currently manufactured using patient-derived cells, therapies using healthy donor cells are in development, potentially offering avenues toward process improvement and patient access. An allogeneic model could significantly reduce aggregate cost of goods (COGs), potentially improving market penetration of these life-saving treatments. Furthermore, the shift toward offshore production may help reduce manufacturing costs. In this article, we examine production costs of an allogeneic CAR-T cell process and the potential differential manufacturing costs between regions. Two offshore locations are compared with regions within the United States. The critical findings of this article identify the COGs challenges facing manufacturing of allogeneic CAR-T immunotherapies, how these may evolve as production is sent offshore and the wider implication this trend could have.

Provider and household costs of Plasmodium vivax malaria episodes: a multicountry comparative analysis of primary trial data.

OBJECTIVE: To determine household and health-care provider costs associated with Plasmodium vivax infection across a range of endemic settings. METHODS: We collected cost data alongside three multicentre clinical trials of P. vivax treatment in Afghanistan, Brazil, Colombia, Ethiopia, Indonesia, Philippines, Peru, Thailand and Viet Nam conducted between April 2014 to December 2017. We derived household costs from trial participant surveys administered at enrolment and again 2 weeks later to determine the costs of treatment and transportation, and the number of days that patients and their household caregivers were unable to undertake their usual activities. We determined costs of routine care by health-care providers by micro-costing the resources used to diagnose and treat P. vivax at the study sites. FINDINGS: The mean total household costs ranged from 8.7 United States dollars (US$; standard deviation, SD: 4.3) in Afghanistan to US$ 254.7 (SD: 148.4) in Colombia. Across all countries, productivity losses were the largest household cost component, resulting in mean indirect costs ranging from US$ 5.3 (SD: 3.0) to US$ 220.8 (SD: 158.40). The range of health-care provider costs for routine care was US$ 3.6-6.6. The cost of administering a glucose-6-phosphate-dehydrogenase rapid diagnostic test, ranged from US$ 0.9 to 13.5, consistently lower than the costs of the widely-used fluorescent spot test (US$ 6.3 to 17.4). CONCLUSION: An episode of P. vivax malaria results in high costs to households. The costs of diagnosing and treating P. vivax are important inputs for future cost-effectiveness analyses to ensure optimal allocation of resources for malaria elimination.

Importance of the Supplemental Nutrition Assistance Program in Rural America.

There is great interest in reshaping the Supplemental Nutrition Assistance Program (SNAP) so that it better supports family nutrition, and an array of program changes have been proposed.We note the importance of considering the unique needs of rural SNAP participants when considering and implementing these changes. We also describe the SNAP-related needs and challenges unique to rural SNAP participants, and through this lens we discuss changes to SNAP that have been proposed and special considerations related to each. The special considerations we identified include allowing canned, frozen, and dried fruits and vegetables as eligible items in financial incentive programs in rural areas; changing direct education programming to address transportation-related barriers many rural families face in attending in-person classes; and supporting rigorous research to evaluate the potential benefits and unintended consequences of proposed program changes for which scant high-quality evaluation data exist.Evaluation studies should include rural SNAP participants so that effects in this important population group are known.

Health Care While Homeless: Barriers, Facilitators, and the Lived Experiences of Homeless Individuals Accessing Health Care in a Canadian Regional Municipality.

Persons struggling with housing remain significantly disadvantaged when considering access to health care. Effective advocacy for their needs will require understanding the factors which impact their health care, and which of those most concern patients themselves. A qualitative descriptive study through the lens of a transformative framework was used to identify barriers and facilitators to accessing health care as perceived by people experiencing homelessness in the regional municipality of Niagara, Canada. In-person, semi-structured interviews with 16 participants were completed, and inductive thematic analysis identified nine barriers and eight facilitators. Barriers included affordability, challenges finding primary care, inadequacy of the psychiatric model, inappropriate management, lack of trust in health care providers, poor therapeutic relationships, systemic issues, and transportation and accessibility. Facilitators included accessibility of services, community health care outreach, positive relationships, and shelters coordinating health care. Knowledge of the direct experiences of marginalized individuals can help create new health policies and enhance the provision of clinical care.

Telehealth for the Assessment of Patients Referred for Pediatric Urological Care: A Preliminary Cost Savings Analysis and Satisfaction Survey.

Background: Almost one-fifth of the population of Saudi Arabia lives in rural areas and may still lack access to specialty healthcare. Because of the growing demand for telehealth services, we initiated the virtual clinic (VC) concept for new referrals to the pediatric urology clinic (PUC), the primary tertiary care unit in Riyadh. Methods: We conducted a retrospective analysis of costs and timing involved with the VC practice for a 1-year period. The cost analysis is based on savings realized by patients as a result of the VC evaluation. A 15-question nonvalidated satisfaction survey was also conducted by an independent observer. Results: Of 105 patients assessed through the VC program, 44 were accepted for surgery and further investigation. The number of trips to the center saved by the virtual encounter were 203, resulting in a savings of 740,950 Saudi Arabian Riyals (SAR) minus the cost of the VC. The cost of conducting most of the investigations at the referring hospital instead of the PUC represented a savings of 639,970 SAR. Thus, the overall cost savings to patient and family and to the PUC was 1,311,570 SAR. An additional benefit was the reduction in the time for treatment from 6.6 to 3.9 months. The overall satisfaction rate was 89%. Conclusions: Although preliminary, our study indicates that telemedicine can achieve a cost savings without compromising the safety or adversely affecting patient management. Further studies should more clearly define the benefits and any limitations, and reveal how the technology could be used most effectively.