Misinformation in nutrition through the case of coconut oil: An online before-and-after study.

BACKGROUND AND AIMS: Despite recent scientific evidence indicating absence of cardiometabolic benefit resulting from coconut oil intake, its consumption has increased in recent years, which can be attributed to a promotion of its use on social networks. We evaluated the patterns, reasons and beliefs related to coconut oil consumption and its perceived benefits in an online survey of a population in southern Brazil. METHODS AND RESULTS: We conducted a before-and-after study using an 11-item online questionnaire that evaluated coconut oil consumption. In the same survey, participants who consumed coconut oil received an intervention to increase literacy about the health effects of coconut oil intake. We obtained 3160 valid responses. Among participants who consumed coconut oil (59.1%), 82.5% considered it healthy and 65.4% used it at least once a month. 81.2% coconut oil consumers did not observe any health improvements. After being exposed to the conclusions of a meta-analysis showing that coconut oil does not show superior health benefits when compared to other oils and fats, 73.5% of those who considered coconut oil healthy did not change their opinion. Among individuals who did not consume coconut oil, 47.6% considered it expensive and 11.6% deemed it unhealthy. CONCLUSIONS: Coconut oil consumption is motivated by the responders' own beliefs in its supposed health benefits, despite what scientific research demonstrates. This highlights the difficulty in deconstructing inappropriate concepts of healthy diets that are disseminated in society.

A Novel Score for mHealth Apps to Predict and Prevent Mortality: Further Validation and Adaptation to the US Population Using the US National Health and Nutrition Examination Survey Data Set.

BACKGROUND: The C-Score, which is an individual health score, is based on a predictive model validated in the UK and US populations. It was designed to serve as an individualized point-in-time health assessment tool that could be integrated into clinical counseling or consumer-facing digital health tools to encourage lifestyle modifications that reduce the risk of premature death. OBJECTIVE: Our study aimed to conduct an external validation of the C-Score in the US population and expand the original score to improve its predictive capabilities in the US population. The C-Score is intended for mobile health apps on wearable devices. METHODS: We conducted a literature review to identify relevant variables that were missing in the original C-Score. Subsequently, we used data from the 2005 to 2014 US National Health and Nutrition Examination Survey (NHANES; N=21,015) to test the capacity of the model to predict all-cause mortality. We used NHANES III data from 1988 to 1994 (N=1440) to conduct an external validation of the test. Only participants with complete data were included in this study. Discrimination and calibration tests were conducted to assess the operational characteristics of the adapted C-Score from receiver operating curves and a design-based goodness-of-fit test. RESULTS: Higher C-Scores were associated with reduced odds of all-cause mortality (odds ratio 0.96, P<.001). We found a good fit of the C-Score for all-cause mortality with an area under the curve (AUC) of 0.72. Among participants aged between 40 and 69 years, C-Score models had a good fit for all-cause mortality and an AUC >0.72. A sensitivity analysis using NHANES III data (1988-1994) was performed, yielding similar results. The inclusion of sociodemographic and clinical variables in the basic C-Score increased the AUCs from 0.72 (95% CI 0.71-0.73) to 0.87 (95% CI 0.85-0.88). CONCLUSIONS: Our study shows that this digital biomarker, the C-Score, has good capabilities to predict all-cause mortality in the general US population. An expanded health score can predict 87% of the mortality in the US population. This model can be used as an instrument to assess individual mortality risk and as a counseling tool to motivate behavior changes and lifestyle modifications.

Race, ethnicity, poverty and the social determinants of the coronavirus divide: U.S. county-level disparities and risk factors.

BACKGROUND: Communities with more Black or Hispanic residents have higher coronavirus rates than communities with more White residents, but relevant community characteristics are underexplored. The purpose of this study was to investigate poverty-, race- and ethnic-based disparities and associated economic, housing, transit, population health and health care characteristics. METHODS: Six-month cumulative coronavirus incidence and mortality were examined using adjusted negative binomial models among all U.S. counties (n = 3142). County-level independent variables included percentages in poverty and within racial/ethnic groups (Black, Hispanic, Native American, Asian), and rates of unemployment, lacking a high school diploma, housing cost burden, single parent households, limited English proficiency, diabetes, obesity, smoking, uninsured, preventable hospitalizations, primary care physicians, hospitals, ICU beds and households that were crowded, in multi-unit buildings or without a vehicle. RESULTS: Counties with higher percentages of Black (IRR = 1.03, 95% CI: 1.02-1.03) or Hispanic (IRR = 1.02, 95% CI: 1.01-1.03) residents had more coronavirus cases. Counties with higher percentages of Black (IRR = 1.02, 95% CI: 1.02-1.03) or Native American (IRR = 1.02, 95% CI: 1.01-1.04) residents had more deaths. Higher rates of lacking a high school diploma was associated with higher counts of cases (IRR = 1.03, 95% CI: 1.01-1.05) and deaths (IRR = 1.04, 95% CI: 1.01-1.07). Higher percentages of multi-unit households were associated with higher (IRR = 1.02, 95% CI: 1.01-1.04) and unemployment with lower (IRR = 0.96, 95% CI: 0.94-0.98) incidence. Higher percentages of individuals with limited English proficiency (IRR = 1.09, 95% CI: 1.04-1.14) and households without a vehicle (IRR = 1.04, 95% CI: 1.01-1.07) were associated with more deaths. CONCLUSIONS: These results document differential pandemic impact in counties with more residents who are Black, Hispanic or Native American, highlighting the roles of residential racial segregation and other forms of discrimination. Factors including economic opportunities, occupational risk, public transit and housing conditions should be addressed in pandemic-related public health strategies to mitigate disparities across counties for the current pandemic and future population health events.

Association Between Filgrastim Biosimilar Availability and Changes in Claim Payments and Patient Out-of-Pocket Costs for Biologic Filgrastim Products.

OBJECTIVES: To estimate the effect of filgrastim-sndz market entry on patient out-of-pocket costs and claim payments for filgrastim products. METHODS: This study used a single interrupted time series design with longitudinal, nationally representative, individual-level claims data from IBM MarketScan. Analyses included all outpatient and prescription claims for branded filgrastim (filgrastim and tbo-filgrastim) and biosimilar filgrastim (filgrastim-sndz) from January 1, 2014, to December 31, 2017. Outcomes of interest included changes in monthly claim payments and monthly patient out-of-pocket costs for filgrastim products. RESULTS: In the baseline period (January 2014 to February 2016), insurers paid an average of $472.21 (95% confidence interval [CI]: 465.38-479.03) for 480 mcg of branded filgrastim, whereas patients paid an average of $49.26 (CI: 34.25-64.27). Filgrastim-sndz market entry was associated with a statistically significant and immediate 1-month decrease in insurer payment of $30.77 (95% CI: -40.59 to -20.94) and a significant decrease in monthly insurer payment trend of $3.10 per month (95% CI: -3.90 to -2.31) relative to baseline. Long-term changes in patient out-of-pocket costs were modest and restricted to beneficiaries enrolled in high cost sharing plans. CONCLUSIONS: Biosimilar filgrastim availability led to significant immediate and long-term decreases in claims payments for filgrastim products, supporting efforts to facilitate biosimilar adoption in the United States. Nevertheless, there were only slight changes in patient out-of-pocket costs, restricted to beneficiaries enrolled in high cost sharing plans, suggesting the importance of further work assessing the relationship between biosimilar availability and patient out-of-pocket costs.

Household coping strategies after an adult noncommunicable disease death in Bangladesh.

When facing adverse health from noncommunicable disease (NCD), households adopt coping strategies that may further enforce poverty traps. This study looks at coping after an adult NCD death in rural Bangladesh. Compared with similar households without NCD deaths, households with NCD deaths were more likely to reduce basic expenditure and to have decreased social safety net transfers. Household composition changes showed that there was demographic coping for prime age deaths through the addition of more women. The evidence for coping responses from NCDs in low- and middle-income countries may inform policy options such as social protection to address health-related impoverishment.

The impact of practice guidelines on opioid utilization for injured workers.

BACKGROUND: Opioid use is rising in the US and may cause special problems in workers compensation cases, including addiction and preventing a return to work after an injury. OBJECTIVE: This study evaluates a physician-level intervention to curb opioid usage. An insurer identified patients with out-of-guideline opioid utilization and called the prescribing physician to discuss the patient's treatment protocol. RESEARCH DESIGN: This study uses a differences-in-differences study design with a propensity-score-matched control group. Medical and pharmaceutical claims data from 2005 to 2011 were used for analyses. RESULTS: Following the intervention, the use of opioids increased for the intervention group and there is little impact on medical spending. CONCLUSIONS: Counseling physicians about patients with high opioid utilization may focus more attention on their care, but did not impact short-term outcomes. More robust interventions may be needed to manage opioid use. PERSPECTIVE: While the increasing use of opioids is of growing concern around the world, curbing the utilization of these powerfully addictive narcotics has proved elusive. This study examines a prescribing guidelines intervention designed to reduce the prescription of opioids following an injury. The study finds that there was little change in the opioid utilization after the intervention, suggesting interventions along other parts of the prescribing pathway may be needed.

Towards sustainable partnerships in global health: the case of the CRONICAS Centre of Excellence in Chronic Diseases in Peru.

Human capital requires opportunities to develop and capacity to overcome challenges, together with an enabling environment that fosters critical and disruptive innovation. Exploring such features is necessary to establish the foundation of solid long-term partnerships. In this paper we describe the experience of the CRONICAS Centre of Excellence in Chronic Diseases, based at Universidad Peruana Cayetano Heredia in Lima, Peru, as a case study for fostering meaningful and sustainable partnerships for international collaborative research. The CRONICAS Centre of Excellence in Chronic Diseases was established in 2009 with the following Mission: "We support the development of young researchers and collaboration with national and international institutions. Our motivation is to improve population's health through high quality research." The Centre's identity is embedded in its core values - generosity, innovation, integrity, and quality- and its trajectory is a result of various interactions between multiple individuals, collaborators, teams, and institutions, which together with the challenges confronted, enables us to make an objective assessment of the partnership we would like to pursue, nurture and support. We do not intend to provide a single example of a successful partnership, but in contrast, to highlight what can be translated into opportunities to be faced by research groups based in low- and middle-income countries, and how these encounters can provide a strong platform for fruitful and sustainable partnerships. In defiant contexts, partnerships require to be nurtured and sustained. Acknowledging that all partnerships are not and should not be the same, we also need to learn from the evolution of such relationships, its key successes, hurdles and failures to contribute to the promotion of a culture of global solidarity where mutual goals, mutual gains, as well as mutual responsibilities are the norm. In so doing, we will all contribute to instil a new culture where expectations, roles and interactions among individuals and their teams are horizontal, the true nature of partnerships.

Identifying barriers to move to better health coverage: preferences for health insurance benefits among the rural poor population in La Guajira, Colombia.

Even though access to health insurance in Colombia has improved since the implementation of the 1993 health reforms (Law 100), universal coverage has not yet been accomplished. There is still a segment of the population under the low-income (subsidized) health insurance policy or without health insurance altogether. The purpose of this research was to identify preferences and behavior regarding health insurance among the subsidized rural population in La Guajira, Colombia, and to understand why that population remains under the subsidized health insurance policy. The field experiment gathered information from 400 households regarding their socioeconomic situation, health conditions, and preferences for health insurance characteristics. Results suggest that the surveyed population gives priority to expanded family coverage, physician and hospital choice, and access to specialists, rather than to attributes associated with co-payments or premiums. That indicates that people value healthcare benefits and family coverage more than health insurance expenses, and policy makers could use these preferences to enroll subsidized population into the contributory regime.

Low rural health insurance take-up in a universal coverage system: perceptions of health insurance among the uninsured in La Guajira, Colombia.

Despite enacting a universal healthcare system in 1993, many Colombians do not participate. Understanding perceptions of the system could help the government market certain features or adjust benefits in order to increase enrollment. Using La Guajira, Colombia, as a case study, we surveyed uninsured rural households regarding insurance preferences, values and beliefs, and perceptions of available services. Four hundred heads of households responded in La Guajira, Colombia. Respondents reported high levels of long-term uninsurance. Overall, the quality of services in the government-run system is perceived as better than being uninsured, but there appear to be constraints on enrollment. Rural Colombians value more family coverage and better choice of physicians, but offering better benefits may not be enough. Many cited access barriers, so reducing these barriers may also increase enrollment. Further surveys in other parts of Colombia should be undertaken to confirm results.

Health inequalities and development plans in Iran; an analysis of the past three decades (1984-2010).

INTRODUCTION: Reducing inequalities in health care is one of the main challenges in all countries. In Iran as in other oil-exporting upper middle income countries, we expected to witness fewer inequalities especially in the health sector with the increase in governmental revenues. METHODS: This study presents an inequalities assessment of health care expenditures in Iran. We used data from the Household Income and Expenditure Survey (HIES) in Iran from 1984-2010. The analysis included 308,735 urban and 342,532 rural households. RESULTS: The results suggest heightened inequality in health care expenditures in Iran over the past three decades, including an increase in the gap between urban and rural areas. Furthermore, inflation has affected the poor more than the rich. The Kakwani progressivity index in all years is positive, averaging 0.436 in rural and 0.470 in urban areas during the time period of analysis. Compared to inequality in income distribution over the last 30 years, health expenditures continuously show more inequality and progressivity over the same period of time. CONCLUSIONS: According to the result of our study, during this period Iran introduced four National Development Plans (NDPs); however, the NDPs failed to provide sustainable strategies for reducing inequalities in health care expenditures. Policies that protect vulnerable groups should be prioritized.

Suggesting global insights to local challenges: expanding financing of rehabilitation services in low and middle-income countries.

Purpose: Following the rapid transition to non-communicable diseases, increases in injury, and subsequent disability, the world-especially low and middle-income countries (LMICs)-remains ill-equipped for increased demand for rehabilitative services and assistive technology. This scoping review explores rehabilitation financing models used throughout the world and identifies "state of the art" rehabilitation financing strategies to identify opportunities and challenges to expand financing of rehabilitation. Material and methods: We searched peer-reviewed and grey literature for articles containing information on rehabilitation financing in both LMICs and high-income countries. Results: Forty-two articles were included, highlighting various rehabilitation financing mechanism which involves user fees and other innovative payment as bundled or pooled schemes. Few studies explore policy options to increase investment in the supply of services. Conclusion: this paper highlights opportunities to expand rehabilitation services, namely through promotion of private investment, improvement in provider reimbursement mechanism as well as expanding educational grants to bolster labor supply incentive, and the investment in public and private insurance schemes. Mechanisms of reimbursement are frequently based on global budget and salary which are helpful to control cost escalation but represent important barriers to expand supply and quality of services.

Factors and Perceptions Associated with Post-Pandemic Food Sourcing and Dietary Patterns among Urban Corner Store Customers in Baltimore, Maryland.

OBJECTIVE: Diet-related disease is rising, disproportionately affecting minority communities in which small food retail stores swamp supermarkets. Barriers to healthy food access were exacerbated by the pandemic. We examined the following: (1) individual- and household-level factors in a sample of Baltimore community members who regularly shop at corner stores and (2) how these factors are associated with indicators of dietary quality. DESIGN: Cross-sectional data were collected using an online survey to capture sociodemographics, anthropometrics, and food sourcing, spending, and consumption patterns. Concurrent quantitative and qualitative analyses were conducted in Stata 18 and ATLAS.ti. SETTING: This study was set in Baltimore, Maryland, USA. PARTICIPANTS: The participants included adults (n = 127) living or working in Baltimore who identified as regular customers of their neighborhood corner store. RESULTS: The respondents were majority Black and low-income, with a high prevalence of food insecurity (62.2%) and overweight/obesity (66.9%). Most (82.76%) shopped in their neighborhood corner store weekly. One-third (33.4%) of beverage calories were attributed to sugar-sweetened beverages, and few met the recommended servings for fruits and vegetables or fiber (27.2% and 10.4%, respectively). Being Black and not owning a home were associated with lower beverage and fiber intake, and not owning a home was also associated with lower fruit and vegetable intake. Food insecurity was associated with higher beverage intake, while WIC enrollment was associated with higher fruit and vegetable and fiber intakes. Open-ended responses contextualized post-pandemic food sourcing and consumption in this setting. CONCLUSIONS: This paper helps characterize the consumers of a complex urban food system. The findings will inform future strategies for consumer-engaged improvement of local food environments.

Design of an innovative digital application to facilitate access to healthy foods in low-income urban settings.

Background: Under-resourced urban minority communities in the United States are characterized by food environments with low access to healthy foods, high food insecurity, and high rates of diet-related chronic disease. In Baltimore, Maryland, low access to healthy food largely results from a distribution gap between small food sources (retailers) and their suppliers. Digital interventions have the potential to address this gap, while keeping costs low. Methods: In this paper, we describe the technical (I) front-end design and (II) back-end development process of the Baltimore Urban food Distribution (BUD) application (app). We identify and detail four main phases of the process: (I) information architecture; (II) low and high-fidelity wireframes; (III) prototype; and (IV) back-end components, while considering formative research and a pre-pilot test of a preliminary version of the BUD app. Results: Our lessons learned provide valuable insight into developing a stable app with a user-friendly experience and interface, and accessible cloud computing services for advanced technical features. Conclusions: Next steps will involve a pilot trial of the app in Baltimore, and eventually, other urban and rural settings nationwide. Once iterative feedback is incorporated into the app, all code will be made publicly available via an open source repository to encourage adaptation for desired communities. Trial Registration: ClinicalTrials.gov NCT05010018.

Examining Opportunities to Increase Savings From Medicare Price Negotiations.

Importance: Allowing the US Centers for Medicare & Medicaid Services to negotiate prescription drug prices for Medicare may improve drug affordability. Objective: To estimate savings from Medicare price negotiation under the Inflation Reduction Act (IRA) and examine opportunities to increase savings. Design, Setting, and Participants: This cross-sectional, population-based study used data from 2020 Medicare prescription drug claims. The study was conducted and data were analyzed in 2022. Exposures: Eligibility for Medicare price negotiation under the IRA and alternative criteria. Main Outcomes and Measures: Minimum savings under the IRA's eligibility criteria were estimated and compared with savings within alternative scenarios, including (1) selecting drugs for negotiation based on net spending after rebates rather than gross spending; (2) extending eligibility to drugs with biosimilar or generic competitors; (3) reducing the minimum years since US Food and Drug Administration approval for eligibility; and (4) changing 2 or 3 of these factors. Estimated savings were calculated at different levels of scale-up of price negotiation under the IRA, from 10 Part D drugs in 2026 to 60 Part B and D drugs in 2029. Gross spending was calculated using the US Centers for Medicare & Medicaid Services 2020 Medicare drug spending dashboard. Rebates were estimated using SSR Health data. Information on FDA approvals, generics, and biosimilars was obtained from FDA websites. Results: Under IRA rules, estimated minimum savings from price negotiation in 2026 for 10 Part D drugs would be $3.2 billion. For 2029 for 60 Part D and B drugs, estimated savings were $16.0 billion. Selecting drugs for negotiation based on net rather than gross spending would be associated with estimated savings of $4.6 billion (a 45% increase) in 2026 and $18.9 billion (an 18% increase) in 2029. Including drugs with generic competitors or biosimilars would be associated with an estimated savings of $6.6 billion (a 109% increase) in 2026 and $24.9 billion (a 56% increase) in 2029. Making both changes would be associated with savings of $9.5 billion (a 200% increase) in 2026 and $28.3 billion (a 77% increase) in 2029. A sensitivity analysis suggested that reducing the required number of years since marketing approval by 2 years would be associated with increased estimated savings of 4% when 10 Part D drugs are negotiated and 12% when 60 Part D and B drugs are negotiated. Changing all 3 criteria would be associated with the greatest increase in estimated savings in 2029 (119% increase when 10 Part D drugs are negotiated and 93% increase for 60 Part D and B drugs). Conclusions and Relevance: The results of this cross-sectional study suggest that adjusting the eligibility criteria for Medicare prescription drug price negotiation to permit inclusion of drugs with biosimilar or generic competitors and selecting drugs based on net rather than gross spending may be a promising approach to substantially increase estimated savings.

Improving COVID-19 vaccine uptake: a message co-design process for a national mHealth intervention in Colombia.

BACKGROUND: COVID-19 vaccination is a global priority. Latin American countries have some of the highest COVID-19 death rates worldwide with vaccination hampered by a variety of reasons, including mis- and disinformation, vaccine hesitancy, and vaccine supply constraints. Addressing vaccine hesitancy through effective messages has been found to help increase vaccine uptake. Participatory processes could be used to co-design health messages for this purpose. OBJECTIVE: This article describes the methodology used to co-design evidence-based audio messages to be deployed in a cohort of individuals through an interactive voice response (IVR) mobile phone survey intervention, aimed towards increasing vaccination uptake in an adult population in Colombia. METHODS: Participants of the COVID-19 vaccination message co-design process included a sample of the general population of the country, representatives of the funder organisation, and research team members. The co-design process consisted of four phases: (1) formative quantitative and qualitative research, (2) message drafting based on the results of the formative research, (3) message content evaluation, and (4) evaluation of the voices to deliver the audio messages; and was informed by reflexive meetings. RESULTS: Three categories of evidence-based audio messages were co-designed, each corresponding to an arm of the mHealth intervention: (1) factual messages, (2) narrative messages, and (3) mixed messages. An additional fourth arm with no message was proposed for control. The iterative co-design process ended with a total of 14 audio messages recorded to be deployed via the intervention. CONCLUSIONS: Co-developing health messages in response to health emergencies is possible. Adopting more context-relevant, participatory, people-centred, and reflexive multidisciplinary approaches could help develop solutions that are more responsive to the needs of populations and public health priorities. Investing resources in message co-design is deemed to have a greater potential for influencing behaviours and improving health outcomes.

Caregiving and elderly health in Mexico.

Using the National Mexican Health and Aging Study panel dataset, the authors estimate the effect of having informal care on the probability of dying and on the change in elderly health over a two-year period. Three measures of functional health were used: self-reported health, activities of daily living, and instrumental activities of daily living. We develop an empirical strategy that relies on the panel structure of the dataset to sort out the possible correlation between unobservable characteristics that affect both elderly health and an individual's decision to provide informal care. Our findings suggest that informal care provided by daughters reduces the probability of dying. In addition, informal care provided by daughters reduces the probability of having a decline in activities of daily living and instrumental activities of daily living, while it has no effect on the observed changes in self-reported health status. The protective effect of informal care provided by sons is not statistically significant for any health outcomes. A discussion of the policy options to increase elderly health and to improve the role of caregivers is included.

The price paradox of biosimilar-like long-acting insulin.

OBJECTIVES: To describe the uptake and out-of-pocket (OOP) costs of Basaglar, the first long-acting insulin biosimilar, in a commercially insured population in the United States. STUDY DESIGN: Retrospective analysis of commercial pharmacy claims and pharmacy co-payment offsets. METHODS: We assessed Basaglar uptake by examining trends in the composition of the long-acting insulin market in the United States from 2014 to 2018. As patient demographics and plan type may be important determinants of biosimilar uptake, we also assessed characteristics of all long-acting insulin users by drug. We examined Basaglar OOP costs by assessing mean OOP costs per claim for users of Basaglar and other long-acting insulins, overall and by plan type, and the number and source of co-payment offsets for Basaglar and other insulin glargine products from Basaglar market entry through 2018. We used multivariate linear models to examine the relationship between Basaglar OOP expenditures and insurer-negotiated amounts, overall and by plan type. RESULTS: Basaglar experienced a rapid uptake. However, there was no evidence that Basaglar users had lower OOP costs than reference product (Lantus) users. CONCLUSIONS: Given our results and the approval of the first interchangeable biosimilar, we recommend the empirical evaluation of biosimilar cost savings to patients and insurers prior to promoting their automatic substitution.

Trajectories of prices in generic drug markets: what can we infer from looking at trajectories rather than average prices?

BACKGROUND: Well-functioning competitive markets are key to controlling generic drug prices. This is important since over 90% of all drugs sold in the US are generics. Recently, there have been examples of large price increases in the generic market. METHODS: This paper examines price trajectories for generic drugs using a group-based trajectory modelling approach (GBTM). We fit the model using quarterly price information in the IBM MarketScan claims database for the past decade. RESULTS: We identify three dominant price trajectories for this period: rapid increase trajectories, slow decline and rapid decline. Most generic drugs show a slow or a rapid decline in price trajectories. However, around 17% of all generic drugs show rapid price increase trajectories. CONCLUSIONS: As Congress is exploring an excise tax on drugs whose list price increases faster than the rate of inflation, we discuss what drugs would be most likely to be affected by this law.

The Baltimore Urban Food Distribution (BUD) App: Study Protocol to Assess the Feasibility of a Food Systems Intervention.

Low-income urban communities in the United States commonly lack ready access to healthy foods. This is due in part to a food distribution system that favors the provision of high-fat, high-sugar, high-sodium processed foods to small retail food stores, and impedes their healthier alternatives, such as fresh produce. The Baltimore Urban food Distribution (BUD) study is a multilevel, multicomponent systems intervention that aims to improve healthy food access in low-income neighborhoods of Baltimore, Maryland. The primary intervention is the BUD application (app), which uses the power of collective purchasing and delivery to affordably move foods from local producers and wholesalers to the city's many corner stores. We will implement the BUD app in a sample of 38 corner stores, randomized to intervention and comparison. Extensive evaluation will be conducted at each level of the intervention to assess overall feasibility and effectiveness via mixed methods, including app usage data, and process and impact measures on suppliers, corner stores, and consumers. BUD represents one of the first attempts to implement an intervention that engages multiple levels of a local food system. We anticipate that the app will provide a financially viable alternative for Baltimore corner stores to increase their stocking and sales of healthier foods, subsequently increasing healthy food access and improving diet-related health outcomes for under-resourced consumers. The design of the intervention and the evaluation plan of the BUD project are documented here, including future steps for scale-up. Trial registration #: NCT05010018.

Cost-Effectiveness of the COVID-19 Test, Trace and Isolate Program in Colombia.

BACKGROUND: During the COVID-19 pandemic, Test-Trace-Isolate (TTI) programs have been recommended as a risk mitigation strategy. However, many governments have hesitated to implement them due to their costs. This study aims to estimate the cost-effectiveness of implementing a national TTI program to reduce the number of severe and fatal cases of COVID-19 in Colombia. METHODS: We developed a Markov simulation model of COVID-19 infection combined with a Susceptible-Infected-Recovered structure. We estimated the incremental cost-effectiveness of a comprehensive TTI strategy compared to no intervention over a one-year horizon, from both the health system and the societal perspective. Hospitalization and mortality rates were retrieved from Colombian surveillance data. We included program costs of TTI intervention, health services utilization, PCR diagnosis test, productivity loss, and government social program costs. We used the number of deaths and quality-adjusted life years (QALYs) as health outcomes. Sensitivity analyses were performed. FINDINGS: Compared with no intervention, the TTI strategy reduces COVID-19 mortality by 67%. In addition, the program saves an average of $1,045 and $850 per case when observed from the social and the health system perspective, respectively. These savings are equivalent to two times the current health expenditures in Colombia per year. INTERPRETATION: The TTI program is a highly cost-effective public health intervention to reduce the burden of COVID-19 in Colombia. TTI programs depend on their successful and speedy implementation. FUNDING: This study was supported by the Colombian Ministry of Health through award number PUJ-04519-20 received by EPQ AVO and SDS declined to receive any funding support for this study. The contents are the responsibility of all the individual authors.