Economic evaluation of a multi-strategy intervention that improves school-based physical activity policy implementation.

BACKGROUND: Internationally, government policies mandating schools to provide students with opportunities to participate in physical activity are poorly implemented. The multi-component Physically Active Children in Education (PACE) intervention effectively assists schools to implement one such policy. We evaluated the value of investment by health service providers tasked with intervention delivery, and explored where adaptations might be targeted to reduce program costs for scale-up. METHODS: A prospective trial-based economic evaluation of an implementation intervention in 61 primary schools in New South Wales (NSW), Australia. Schools were randomised to the PACE intervention or a wait-list control. PACE strategies included centralised technical assistance, ongoing consultation, principal's mandated change, identifying and preparing in-school champions, educational outreach visits, and provision of educational materials and equipment. Effectiveness was measured as the mean weekly minutes of physical activity implemented by classroom teachers, recorded in a daily log book at baseline and 12-month follow-up. Delivery costs (reported in $AUD, 2018) were evaluated from a public finance perspective. Cost data were used to calculate: total intervention cost, cost per strategy and incremental cost (overall across all schools and as an average per school). Incremental cost-effectiveness ratios (ICERs) were calculated as the incremental cost of delivering PACE divided by the estimated intervention effect. RESULTS: PACE cost the health service provider a total of $35,692 (95% uncertainty interval [UI] $32,411, $38,331) to deliver; an average cost per school of $1151 (95%UI $1046, $1236). Training in-school champions was the largest contributor: $19,437 total; $627 ($0 to $648) average per school. Educational outreach was the second largest contributor: $4992 total; $161 ($0 to $528) average per school. The ICER was $29 (95%UI $17, $64) for every additional minute of weekly physical activity implemented per school. CONCLUSION: PACE is a potentially cost-effective intervention for increasing schools implementation of a policy mandate. The investment required by the health service provider makes use of existing funding and infrastructure; the additional cost to assist schools to implement the policy is likely not that much. PACE strategies may be adapted to substantially improve delivery costs. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12617001265369; Prospectively registered 1st September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373520.

Cost and cost-effectiveness of the 'Stand and Move at Work' multicomponent intervention to reduce workplace sedentary time and cardiometabolic risk.

OBJECTIVE: Few studies have reported the cost and cost-effectiveness of workplace interventions to reduce sedentary time. The purpose of this study was to complete an economic evaluation of a multilevel intervention to reduce sitting time and increase light-intensity physical activity (LPA) among employees. METHODS: We conducted a retrospective within-trial cost and cost-effectiveness analysis (CEA) to compare a 12-month multilevel intervention with (STAND+) and without (MOVE+) a sit-stand workstation, across 24 worksites (N=630 employee participants) enrolled in a cluster randomized clinical trial. We estimated the intervention costs using activity-based costing strategy. The intervention costs were further expressed as per person and per worksite. CEA was conducted using an incremental cost-effectiveness ratio (ICER) metric, expressed as costs for additional unit of sitting time (minute/day), LPA (minutes/day), cardiometabolic risk score, and quality-adjusted life years (QALY) increased/decreased at 12 months. We assessed the cost analysis and CEA from the organizational (ie, employer) perspective with a one-year time horizon. RESULTS: Total intervention costs were $134 and $72 per person, and $3939 and $1650 per worksite for the STAND+ (N worksites = 12; N employees = 354) and MOVE+ (N worksites = 12; N employees = 276) interventions, respectively. The ICER was $1 (95% CI $0.8-1.4) for each additional minute reduction of workplace sitting time (standardized to 8-hour workday); and $4656 per QALY gained at 12 months. There was a modest and non-significant change of loss of work productivity improvement (-0.03 hours, 95% CI -4.16-4.09 hours), which was associated with a $0.34 return for every $1 invested. CONCLUSIONS: The multi-level intervention with sit-stand workstations has the potential to be widely implemented to reduce workplace sitting time. Future research into work productivity outcomes in terms of cost-benefits for employers is warranted.

A Rapid Survey of State and Territorial Public Health Partnerships With Faith-Based Organizations to Promote COVID-19 Vaccination.

During the COVID-19 pandemic, media accounts emerged describing faith-based organizations (FBOs) working alongside health departments to support the COVID-19 response. In May 2021, the Department of Health and Human Services, Centers for Disease Control and Prevention, and the Association of State and Territorial Health Officials (ASTHO) sent an electronic survey to the 59 ASTHO member jurisdictions and four major US cities to assess state and territorial engagement with FBOs. Findings suggest that public health officials in many jurisdictions were able to work effectively with FBOs during the COVID-19 pandemic to provide essential education and mitigation tools to diverse communities. (Am J Public Health. 2022;112(3):397-400. https://doi.org/10.2105/AJPH.2021.306620).

A Comparison of the Cost-Effectiveness of Lifestyle Interventions in Pregnancy.

OBJECTIVES: Lifestyle interventions during pregnancy improve maternal and infant outcomes. We aimed to compare the cost-effectiveness of 4 antenatal lifestyle intervention types with standard care. METHODS: A decision tree model was constructed to compare lifestyle intervention effects from a novel meta-analysis. The target population was women with singleton pregnancies and births at more than 20 weeks' gestation. Interventions were categorized as diet, diet with physical activity, physical activity, and mixed (lacking structured diet and, or, physical activity components). The outcome of interest was cost per case prevented (gestational diabetes, hypertensive disorders in pregnancy, cesarean birth) expressed as an incremental cost-effectiveness ratio (ICER) from the Australian public healthcare perspective. Scenario analyses were included for all structured interventions combined and by adding neonatal intensive care unit costs. Costs were estimated from published data and consultations with experts and updated to 2019 values. Discounting was not applied owing to the short time horizon. RESULTS: Physical activity interventions reduced adverse maternal events by 4.2% in the intervention group compared with standard care and could be cost saving. Diet and diet with physical activity interventions reduced events by 3.5% (ICER = A$4882) and 2.9% (ICER = A$2020), respectively. Mixed interventions did not reduce events and were dominated by standard care. In scenario analysis, all structured interventions combined and all interventions when including neonatal intensive care unit costs (except mixed) may be cost saving. Probabilistic sensitivity analysis showed that for physical activity and all structured interventions combined, the probability of being cost saving was 58% and 41%, respectively. CONCLUSIONS: Governments can expect a good return on investment and cost savings when implementing effective lifestyle interventions population-wide.

JCL Roundtable. Making prevention a priority.

Clinical lipidology belongs par excellence to the preventive mode of medical practice. This Roundtable brings two long-time advocates of cardiometabolic prevention and a newly minted preventive cardiologist into a discussion that expands their recent JCL editorial on this topic. Atherosclerosis is a single disease process that leads to approximately 25% of deaths in economically advanced nations and a growing fraction of mortality and morbidity in nations with developing and emerging economies. Our discussants suggest that at least 75% of atherosclerotic cardiovascular disease can be prevented. Diet and lifestyle including physical activity are the cornerstones for this effort. Public and private choices about diet-lifestyle are influenced by economics, education (especially in childhood), inequities, technology, misinformation, and trust. Lipid clinics perform well with pharmacologic treatment of lipid disorders and increasingly give attention to hypertension, obesity, and diabetes as needed. Cardiometabolic prevention in the clinic works best through provider teams. Business considerations and exemplary programs are highlighted.

Cost-effectiveness of a Multicomponent Intervention for Hypertension Control in Low-Income Settings in Argentina.

Importance: Hypertension is highly prevalent in low- and middle-income countries, and it is an important preventable risk factor for cardiovascular diseases (CVDs). Understanding the economic benefits of a hypertension control program is valuable to decision-makers. Objective: To evaluate the long-term cost-effectiveness of a multicomponent hypertension management program compared with usual care among patients with hypertension receiving care in public clinics in Argentina from a health care system perspective. Design, Setting, and Participants: This economic evaluation used a Markov model to estimate the cost-effectiveness of a hypertension management program among adult patients with uncontrolled hypertension in a low-income setting. Patient-level data (743 individuals for multicomponent intervention; 689 for usual care) from the Hypertension Control Program in Argentina trial (HCPIA) were used to estimate treatment effects and the risk of CVD. Three health states were included in each strategy: (1) low risk of CVD, (2) high risk of CVD, and (3) death. The total time horizon was the lifetime, and each cycle lasted 6 months. Main Outcomes and Measures: Model inputs were based on trial data and other published sources. Cost and utilities were discounted at a rate of 5% annually. The incremental cost-effectiveness ratio (ICER) between the multicomponent intervention and usual care was calculated using the difference in costs in 2017 international dollars (INT $) divided by the difference in effectiveness in quality-adjusted life-years (QALYs). One-way sensitivity analysis and probabilistic sensitivity analysis were performed to assess the uncertainty and robustness of the results. Results: In the original trial, the 743 participants in the intervention group (349 [47.0%] men) had a mean (SD) age of 56.2 (12.0) years, and the 689 participants in the control group (311 [45.1%] men) had a mean (SD) age of 56.2 (11.7) years. In the base-case analysis, the HCPIA program yielded 8.42 discounted QALYs and accrued INT $3096 discounted costs, while usual care yielded 8.29 discounted QALYs and accrued INT $2473 discounted costs. The ICER for the HCPIA program was INT $4907/QALY gained. The model results remained robust in sensitivity analyses, and the model was most sensitive to parameters of program costs. Conclusions and Relevance: In this study, the HCPIA multicomponent intervention vs usual care was a cost-effective strategy to improve hypertension management and reduce the risk of associated CVD among patients with hypertension who received services at public clinics in Argentina. This intervention program is likely transferable to other settings in Argentina or other lower- and middle-income countries.

Cost effectiveness of a controlled lifestyle intervention for pregnant women with obesity.

BACKGROUND: The Mighty Mums antenatal lifestyle intervention is a person-centered behavioral intervention focusing on nutrition and physical activity for pregnant women with obesity (body mass index [BMI] ≥30). The aim of this study was to evaluate the costs and clinical outcomes of adding the Mighty Mums intervention to standard antenatal care. METHODS: Participants in the intervention group (n = 434) received motivational talks with their midwife and a selection of physical and/or nutritional activities in addition to antenatal care. Control participants (n = 867) from adjacent geographic areas received standard antenatal care. Costs for staff, unit costs for specific activities, and registered costs for specialized antenatal care were analyzed for associations with gestational weight gain and self-reported health. Results are reported for the intention-to-treat (ITT) population and a per protocol (PP) population identified by participation in the intervention. Analyses included bootstrapped linear regressions adjusted for background characteristics that differed significantly between groups. RESULTS: The average costs were SEK 9727 higher (95% confidence interval [CI]: 6677 to 12,777) among participants in the intervention group than in the control ITT population and SEK 8655 (95% CI 4586 to 12,724) higher than in the PP population. The cost increase per 1 kg reduction in gestational weight gain was SEK 12,369 in the ITT population and SEK 7209 for the PP population. CONCLUSION: Participation in the Mighty Mums intervention was associated with higher costs, but also reduced gestational weight gain. The cost per kilogram reduction in gestational weight gain was low, particularly in the PP population. A future decision to implement this behavioral intervention in standard care should take into account society's willingness to pay per unit reduction in gestational weight gain. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov , Identifier: NCT03147079 .

Long-Term Cost-Effectiveness of Smoking Cessation Interventions in People With Mental Disorders: A Dynamic Decision Analytical Model.

OBJECTIVES: People with mental disorders are more likely to smoke than the general population. The objective of this study is to develop a decision analytical model that estimates long-term cost-effectiveness of smoking cessation interventions in this population. METHODS: A series of Markov models were constructed to estimate average lifetime smoking-attributable inpatient cost and expected quality-adjusted life-years. The model parameters were estimated using a variety of data sources. The model incorporated uncertainty through probabilistic sensitivity analysis using Monte Carlo simulations. It also generated tables presenting incremental cost-effectiveness ratios of the proposed interventions with varying incremental costs and incremental quit rates. We used data from 2 published trials to demonstrate the model's ability to make projections beyond the observational time frame. RESULTS: The average smoker's smoking-attributable inpatient cost was 3 times higher and health utility was 5% lower than ex-smokers. The intervention in the trial with a statistically insignificant difference in quit rate (19% vs 25%; P=.2) showed a 45% to 49% chance of being cost-effective compared with the control at willingness-to-pay thresholds of £20 000 to £30 000/quality-adjusted life-years. The second trial had a significant outcome (quit rate 35.9% vs 15.6%; P<.001), and the corresponding probability of the intervention being cost-effective was 65%. CONCLUSIONS: This model provides a consistent platform for clinical trials to estimate the potential lifetime cost-effectiveness of smoking cessation interventions for people with mental disorders and could help commissioners direct resources to the most cost-effective programs. However, direct comparisons of results between trials must be interpreted with caution owing to their different designs and settings.

Randomised controlled trial and economic evaluation of a targeted cancer awareness intervention for adults living in deprived areas of the UK.

BACKGROUND: Cancer outcomes are poor in socioeconomically deprived communities, with low symptom awareness contributing to prolonged help-seeking and advanced disease. Targeted cancer awareness interventions require evaluation. METHODS: This is a randomised controlled trial involving adults aged 40+ years recruited in community and healthcare settings in deprived areas of South Yorkshire and South-East Wales. INTERVENTION: personalised behavioural advice facilitated by a trained lay advisor. CONTROL: usual care. Follow-up at two weeks and six months post-randomisation. PRIMARY OUTCOME: total cancer symptom recognition score two weeks post-randomisation. RESULTS: Two hundred and thirty-four participants were randomised. The difference in total symptom recognition at two weeks [adjusted mean difference (AMD) 0.6, 95% CI: -0.03, 1.17, p = 0.06] was not statistically significant. Intervention participants reported increased symptom recognition (AMD 0.8, 95% CI: 0.18, 1.37, p = 0.01) and earlier intended presentation (AMD -2.0, 95% CI: -3.02, -0.91, p < 0.001) at six months. "Lesser known" symptom recognition was higher in the intervention arm (2 weeks AMD 0.5, 95% CI: 0.03, 0.97 and six months AMD 0.7, 95% CI: 0.16, 1.17). Implementation cost per participant was £91.34, with no significant between-group differences in healthcare resource use post-intervention. CONCLUSIONS: Improved symptom recognition and earlier anticipated presentation occurred at longer-term follow-up. The ABACus Health Check is a viable low-cost intervention to increase cancer awareness in socioeconomically deprived communities. CLINICAL TRIAL REGISTRATION: ISRCTN16872545.

Addition of Financial Incentives to Mailed Outreach for Promoting Colorectal Cancer Screening: A Systematic Review and Meta-analysis.

Importance: Although screening decreases incidence of and mortality from colorectal cancer (CRC), screening rates are low. Health-promoting financial incentives may increase uptake of cancer screening. Objective: To evaluate the relative and absolute benefit associated with adding financial incentives to the uptake of CRC screening. Data Sources: PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to July 31, 2020. Keywords and Medical Subject Headings terms were used to identify published studies on the topic. The search strategy identified 835 studies. Study Selection: Randomized clinical trials (RCTs) were selected that involved adults older than 50 years who were eligible for CRC screening, who received either various forms of financial incentives along with mailed outreach or no financial incentives but mailed outreach and reminders alone, and who reported screening completion by using recommended tests at different time points. Observational or nonrandomized studies and a few RCTs were excluded. Data Extraction and Synthesis: The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Data were abstracted and risk of bias was assessed by 2 independent reviewers. Random-effects meta-analysis was conducted, heterogeneity was examined through subgroup analysis and metaregression, and quality of evidence was appraised. Main Outcomes and Measures: The primary outcome was CRC screening completion within 12 months of receiving the intervention. Results: A total of 8 RCTs that were conducted in the United States and reported between January 1, 2014, and December 31, 2020, were included. The trials involved 110 644 participants, of whom 53 444 (48.3%) were randomized to the intervention group (received financial incentives) and 57 200 (51.7%) were randomized to the control group (received no financial incentives). Participants were predominantly male, with 59 113 men (53.4%). Low-quality evidence (rated down for risk of bias and heterogeneity) suggested that adding financial incentives may be associated with a small benefit of increasing CRC screening vs no financial incentives (odds ratio [OR], 1.25; 95% CI, 1.05-1.49). With mailed outreach having a 30% estimated CRC screening completion rate, adding financial incentives may increase the rate to 33.5% (95% CI, 30.8%-36.2%). On metaregression, the magnitude of benefit decreased as the proportion of participants with low income and/or from racial/ethnic minority groups increased. No significant differences were observed by type of behavioral economic intervention (fixed amount: OR, 1.26 [95% CI, 1.05-1.52] vs lottery: OR, 1.06 [95% CI, 0.80-1.40]; P = .32), amount of incentive (≤$5: OR, 1.09 [95% CI, 1.01-1.18] vs >$5: OR, 1.25 [95% CI, 1.02-1.54]; P = .22), or screening modality (stool-based test: OR, 1.14 [95% CI, 0.92-1.41] vs colonoscopy: OR, 1.63 [95% CI, 1.01-2.64]; P = .18). Conclusions and Relevance: Adding financial incentives appeared to be associated with a small benefit of increasing CRC screening uptake, with marginal benefits in underserved populations with adverse social determinants of health. Alternative approaches to enhancing CRC screening uptake are warranted.

Cost-effectiveness analysis of a multiple health behaviour change intervention in people aged between 45 and 75 years: a cluster randomized controlled trial in primary care (EIRA study).

BACKGROUND: Multiple health behaviour change (MHBC) interventions that promote healthy lifestyles may be an efficient approach in the prevention or treatment of chronic diseases in primary care. This study aims to evaluate the cost-utility and cost-effectiveness of the health promotion EIRA intervention in terms of MHBC and cardiovascular reduction. METHODS: An economic evaluation alongside a 12-month cluster-randomised (1:1) controlled trial conducted between 2017 and 2018 in 25 primary healthcare centres from seven Spanish regions. The study took societal and healthcare provider perspectives. Patients included were between 45 and 75 years old and had any two of these three behaviours: smoking, insufficient physical activity or low adherence to Mediterranean dietary pattern. Intervention duration was 12 months and combined three action levels (individual, group and community). MHBC, defined as a change in at least two health risk behaviours, and cardiovascular risk (expressed in % points) were the outcomes used to calculate incremental cost-effectiveness ratios (ICER). Quality-adjusted life-years (QALYs) were estimated and used to calculate incremental cost-utility ratios (ICUR). Missing data was imputed and bootstrapping with 1000 replications was used to handle uncertainty in the modelling results. RESULTS: The study included 3062 participants. Intervention costs were €295 higher than usual care costs. Five per-cent additional patients in the intervention group did a MHBC compared to usual care patients. Differences in QALYS or cardiovascular risk between-group were close to 0 (- 0.01 and 0.04 respectively). The ICER was €5598 per extra health behaviour change in one patient and €6926 per one-point reduction in cardiovascular risk from a societal perspective. The cost-utility analysis showed that the intervention increased costs and has no effect, in terms of QALYs, compared to usual care from a societal perspective. Cost-utility planes showed high uncertainty surrounding the ICUR. Sensitivity analysis showed results in line with the main analysis. CONCLUSION: The efficiency of EIRA intervention cannot be fully established and its recommendation should be conditioned by results on medium-long term effects. TRIAL REGISTRATION: Clinicaltrials.gov NCT03136211 . Registered 02 May 2017 - Retrospectively registered.

Daily steps and healthcare costs in Japanese communities.

Physical inactivity is a pandemic that requires intensive, usually costly efforts for risk reduction of related chronic diseases. Nevertheless, it is challenging to determine the effectiveness of physical activity in healthcare cost reduction based on existing literature. Therefore, this study aimed to investigate the impact of physical activity (daily steps) on healthcare costs utilising the data retrieved from a health promotion project (the e-wellness Project, held in three municipalities in Japan). Evaluating the effects of daily steps, measured by pedometers, on healthcare costs by a quasi-experimental approach among participants aged 40-75 years (about 4000 person-years of observation, between 2009 and 2013), we found that a one-step-increase in the annual average daily step reduced outpatient healthcare costs by 16.26 JPY (≒ 0.11 GBD) in the short run. Based on the assumption of a dynamic relationship between the health statuses in multiple years, the long-run effects of daily steps on healthcare costs were estimated at 28.24 JPY (≒ 0.20 GBD). We determined the health benefits of walking in a sample of middle-aged and older Japanese adults by our findings that an increase in step counts reduced healthcare costs.

Active Kids: evaluation protocol for a universal voucher program to increase children's participation in organised physical activity and sport.

OBJECTIVE: Background: Regular participation in physical activity during childhood and adolescence is important for good health. There is strong evidence of the physical and psychosocial benefits associated with recreational physical activity in these age groups, specifically in the context of organised sport. Most children in New South Wales (NSW), Australia, do not meet the recommended guidelines for physical activity, with financial cost commonly cited as a barrier to the initiation and maintenance of sport. The Active Kids program is a major policy initiative introduced in 2018 that aimed to overcome this barrier by implementing a statewide sport voucher scheme, allowing all NSW school-enrolled children (1.2 million) initial access to a $100 annual contribution towards organised sport and physical activity, with concurrent evaluation over the initial 4-year phase of the program. STUDY TYPE: This paper presents the protocol for evaluation of the Active Kids program, including an assessment of program impact on children's organised sport participation and recreational physical activity level, and analysis of the correlates of participation at individual, state and national levels. METHODS: A quasi-experimental and mixed-method evaluation will be used to examine the patterns of organised sport and recreational physical activity behaviour and the correlates associated with sports participation, voucher uptake and program reach. Sociodemographic information will be collected for each child who registers for a voucher. The effects of this program on children's health-enhancing physical activity, engagement with the sport sector, self-efficacy and social influences on participation will be monitored through a cohort study. Acceptability, engagement and experience of the voucher program will be assessed from both user and provider perspectives. Additionally, effects of the program on families' annual sport-related expenditure will be assessed. RESULTS AND CONCLUSION: It is anticipated that the implementation of the NSW Government's Active Kids program will increase participation in recreational physical activity among NSW children. The results of this evaluation will contribute to the evidence base and policy directions for sport voucher programs in Australia and internationally.

Development, Status Quo, and Challenges to China's Health Informatization During COVID-19: Evaluation and Recommendations.

By applying advanced health information technology to the health care field, health informatization helps optimize health resource allocation, improve health care services, and realize universal health coverage. COVID-19 has tested the status quo of China's health informatization, revealing challenges to the health care system. This viewpoint evaluates the development, status quo, and practice of China's health informatization, especially during COVID-19, and makes recommendations to address the health informatization challenges. We collected, assessed, and evaluated data on the development of China's health informatization from five perspectives-health information infrastructure, information technology (IT) applications, financial and intellectual investment, health resource allocation, and standard system-and discussed the status quo of the internet plus health care service pattern during COVID-19. The main data sources included China's policy documents and national plans on health informatization, commercial and public welfare sources and websites, public reports, institutional reports, and academic papers. In particular, we extracted data from the 2019 National Health Informatization Survey released by the National Health Commission in China. We found that China developed its health information infrastructure and IT applications, made significant financial and intellectual informatization investments, and improved health resource allocations. Tested during COVID-19, China's current health informatization system, especially the internet plus health care system, has played a crucial role in monitoring and controlling the pandemic and allocating medical resources. However, an uneven distribution of health resources and insufficient financial and intellectual investment continue to challenge China's health informatization. China's rapid development of health informatization played a crucial role during COVID-19, providing a reference point for global pandemic prevention and control. To further promote health informatization, China's health informatization needs to strengthen top-level design, increase investment and training, upgrade the health infrastructure and IT applications, and improve internet plus health care services.

Panorama del gasto en comunicación social en salud: un caso del sector salud en México, 2015-2017.

Objetivo. Describir y analizar el gasto de la Secretaría de Salud asociado con iniciativas de comunicación social de las campañas de prevención de enfermedades transmitidas por vectores (Zika, chikunguña y dengue) y la evaluación de impacto o resultados. Material y métodos. La in-formación se obtuvo de 690 contratos de prestación de servicios de comunicación social (2015-2017), asociados con dos declaraciones de emergencia epidemiológica (EE- 2-2015 y EE-1-2016). Resultados. Se concluye una débil evaluación de impacto del gasto público. No existe evidencia suficiente que demuestre la correspondencia del gasto en comunicación social con la efectividad y cumplimiento de las campañas. Conclusiones. Los hallazgos permiten definir recomendaciones para vigilar, transparentar y hacer más eficiente el gasto público. Existe información pública sobre el gasto; sin embargo, es necesario garantizar mecanismos de transparencia, trazabilidad de contratos y evaluación de impacto de las campañas.