Introduction Tuberculosis (TB) remains a significant health burden in 25 low- and middle-income countries. Despite TB being more cost-effective to prevent and treat its funding is disproportionately lower than that of HIV. This study aims to assess the economic costs of TB versus HIV and evaluate the returns on investment in TB prevention compared to HIV.Methods The study uses a microfoundations behavioural model to estimate the economic costs of TB and HIV on households and the economy. We combine data from the WHO Global Tuberculosis Report, the Institute for Health Metrics and Evaluation’s Global Burden of Disease dataset and Demographic Household Surveys among others. The analysis accounts for lost earnings and healthcare expenses in the short and long term.Results The findings indicate that active TB cases result in significant economic losses, with US$13.7 billion in current annual losses, US$17.2 billion in future losses and US$5.7 billion in medical expenses, for a total of US$36.6 billion. In contrast, HIV causes US$5.5 billion in current losses, US$20.9 billion in future losses and leads to medical expenses of US$6.1 billion for a total of US$32.5 billion. There is substantial across-country heterogeneity in the composition of these costs.Conclusion The economic impacts of TB are at least as large as those of HIV, with higher returns on investment in TB prevention. These results advocate for increased funding for TB relative to funding for HIV in these countries because the returns to incremental funding for TB are greater than those for HIV at current funding levels.

Introduction:Childhood immunization is highly cost-effective, yet uptake is shaped by sociocultural and religious influences. In Bauchi State, Nigeria, coverage remains low (Penta3 58.2%; fully vaccinated 22.5% among children aged 12-23 months). Religious leaders shape community norms, but their perspectives on immunization in Bauchi are not well characterized. Guided by Oman and Syme's religion/spirituality and health model, we explored religious leaders' knowledge, beliefs, attitudes, practices and recommendations regarding childhood immunization. Methods:Between December 2022 and January 2023, we conducted semi-structured interviews with 22 religious leaders (all men; 21 Muslim, 1 Christian) purposively sampled across Bauchi State's Local Government Areas. Interviews were conducted in Hausa or English, audio recorded, translated where necessary and transcribed. Sampling continued until thematic saturation. Data were analyzed using codebook thematic analysis informed by Braun and Clarke's analytic phases and organized according to the pre-specified domains of knowledge, beliefs, attitudes, practices and recommendations. Ethical approval was obtained, and all participants provided verbal informed consent. Results:Most leaders described immunization as preventive and compatible with religious teachings. Many reported that observed child health benefits reinforced support and that earlier skepticism had shifted after religious and scientific explanation and lived experience. Persistent misinformation was reported, especially fertility-related and population control narratives. Leaders described three recurring influence practices: visible role modelling, sermon-based messaging aligned with scripture, and community mobilization through religious gatherings and support during outreach activities. Respectful health worker engagement and reliable service delivery appeared to strengthen trust and community uptake. Conclusions:Religious leaders in Bauchi State may be strategic partners for improving vaccine acceptance. Programs should consider structured engagement with religious leaders, bidirectional rumor tracking and response, and support for frontline health workers. Future research should include more diverse leaders and link engagement to measurable outcomes.

As programs for azithromycin mass drug administration (AZ-MDA) to reduce child mortality have begun in some parts of West Africa, it is imperative to understand their financial costs. We combined a micro-costing framework and observations from an implementation-focused sub-study within the AVENIR trials in 80 communities in the Dosso region of Niger to estimate the national health sector financial costs of a scaled-up programmatic approach for azithromycin biannual distribution to children aged 1-59 months of age living in nonurban areas, using the door-to-door modality. Our outcomes of interest were the annual budget at the regional and national levels for Niger and the cost per dose delivered. We found that the annual national budget required for AZ-MDA achieving 90% average coverage would be $12.5 million (M) (95% Uncertainty Interval (UI) $12.2M, $13.0M) translating to $1.59 (95% UI $1.40, $2.30) per dose delivered. Across regions, cost per dose would vary from $1.17 (95% UI $1.03, $1.69) to $3.61 (95% UI $3.20, $5.16), with higher cost per dose expected for more sparsely populated regions. Training costs represented a large fraction (16.4%) of total costs, and integration of training with that for existing health interventions may provide opportunities for efficiency.

PURPOSE:We examined how exposure and engagement with CyberRwanda, a digital family planning and reproductive health intervention for Rwandan adolescents, influenced the intervention's impact. METHODS:A 3-arm cluster randomized hybrid type 2 effectiveness-implementation trial was conducted among 6,078 students in 60 secondary schools from 2021 to 2023. Schools were randomized 1:1:1 to CyberRwanda self-service (self-guided tablet access to digital platform), facilitated (self-guided and group tablet access plus in-person activities), or control. Intention-to-treat analyses demonstrated no impact of CyberRwanda on the primary outcomes of childbearing, contraceptive use, and HIV testing; however, several secondary outcomes relating to knowledge, attitudes, self-efficacy, and behavior were significantly improved in one or both CyberRwanda arms. In the present analysis, we estimate dose-response, per-protocol, and complier average causal effects to determine CyberRwanda's impact on effectiveness outcomes among participants with varying levels of exposure (any: ≥1 month, low: <12 months, and high: ≥12 months) and engagement (high frequency users: used CyberRwanda many times vs. low frequency users: did not use CyberRwanda or used only once or a few times). We also assessed individual, implementation, and school-level characteristics associated with high exposure and engagement to understand the factors that influence use. RESULTS:Overall, 91.6% of participants were exposed to CyberRwanda. Of these, 61.1% were exposed for ≥12 months and 31.7% were high frequency users. Negligible effects were detected among participants with <12 months of exposure; however, the ≥12-month exposure subgroup had significant improvements on every secondary outcome that was improved in the full sample but with stronger effect sizes, including contraceptive use among sexually active participants (60.0% CyberRwanda vs. 49.4% control, prevalence difference: 0.12, 95% confidence interval: 0.05, 0.20). The complier average causal effect analysis revealed that contraceptive use among sexually active participants increased by 40 percentage-points for high frequency users with ≥12 months of CyberRwanda exposure versus control. No effects were observed on the primary outcomes. High exposure and high engagement were more common among males and younger participants; high frequency users were also more likely not to report tablet-related challenges. DISCUSSION:Exposure and engagement were the primary drivers of CyberRwanda's impact, underscoring the importance of prioritizing access to and engagement with digital platforms to maximize effectiveness.

The global health community has recognized the importance of integrating and sustaining health programs within national health systems rather than managing stand-alone 'vertical' interventions. Corresponding with these objectives, international aid donors are embracing the principle of localization. Voluntary Medical Male Circumcision (VMMC) in Zimbabwe is a large vertical HIV prevention program that was primarily funded through development assistance for health. Program stakeholders want to sustainably integrate VMMC into routine health services so that the program will continue to be a cost-effective HIV prevention strategy. The research team studied the effectiveness of a district-level intervention to empower local stakeholders in this integration effort. To evaluate this intervention, the research team conducted a document review of district-level work plans, combined with a survey administered to district teams assessing sustainability capacity of the program. Over a two-year period, Task Teams in all five intervention districts successfully integrated the VMMC program by reducing barriers and leveraging opportunities in other parts of the health system. Key outcomes impacted all WHO health system building blocks, including enhanced leadership and governance, improved service delivery through better access and acceptability, an expanded health workforce through training, more efficient use of medical technologies, improved data quality, and the mobilization of local funds to support program financing and sustainability. The sustainability survey showed a reduction in funding stability but a significant increase in communications, program adaptation, and organizational capacity. By institutionalizing participatory work planning, fostering local ownership, and mobilizing resources, the project demonstrated a successful model for integrating, scaling, and sustaining VMMC services. Other health programs in low- and middle-income countries seeking to integrate and sustain health services at subnational levels should consider this diagonal, bottom-up model to promote local leadership development and health system strengthening.

Gender norms have been posited to impact intimate partner violence (IPV), but there is scant evidence of the longitudinal association between community-level gender norms and IPV. Using longitudinal data on 3,965 married girls surveyed in India, we fitted mixed-effects ordinal and binary logistic regression models for physical IPV intensity and occurrence of sexual IPV. We found a 26% increase in the odds that women experience frequent physical IPV per one unit increase in greater community-level equitable gender norms. We did not find an association between community-level equitable gender norms and sexual IPV. Findings suggest that the relationship between gender norms and physical and sexual IPV differs, indicating the need for tailored interventions for different types of IPV.

To estimate the effect of economic recessions on health inequality, with a focus on identifying recessions that have a health component. This retrospective observational study uses the interannual rate of change in gross domestic product (GDP) as an indicator of economic conditions, and life expectancy at birth among Mexican states as a measure of health inequality. We calculated the Gini coefficient of life expectancy for the period 1980 to 2021 and examined its relationship with identified recessions through graphical analysis and an interrupted time series model. The disparity in life expectancy at birth between states decreased over the study period. However, the Gini coefficient of life expectancy showed an inverse relationship with the interannual rate of GDP change, indicating increased inequality during economic recessions, with the most pronounced effect observed during the COVID-19-associated recession in 2020. Economic recessions have detrimental effects on health, exacerbating pre-existing inequalities. It is crucial to implement protection mechanisms targeted at socially vulnerable populations to mitigate these effects and prevent the widening of health inequalities. Recessions increase mortality and exacerbate health inequalities: Economic recessions not only lead to higher mortality rates but also amplify health disparities across different regions, with vulnerable populations disproportionately affected. The COVID-19 recession unequally impacted life expectancy: The recession caused by the COVID-19 pandemic exacerbated existing inequalities in life expectancy across Mexican states, further widening the health gap between more and less advantaged populations.

Introduction The transition of voluntary medical male circumcision (VMMC), an HIV prevention service, in Zimbabwe from a donor-funded to a government-owned programme involves the collective efforts and alignment of national and subnational government leaders, managers, healthcare providers, village health workers, community members, donors and implementing partners. We sought to understand stakeholders’ perspectives on barriers, facilitators and recommendations as a vertical HIV prevention programme transitioned to an integrated, government-led model.Methods We conducted 54 semistructured stakeholder interviews at the national and subnational levels. Interviews were audio recorded, transcribed and thematically analysed.Results Participants highlighted a range of psychological and structural barriers and facilitators to integrating and sustaining the VMMC programme. Respondents mentioned financing and staffing barriers to integration, particularly a lack of domestic resources, the transition from a fee-for-service to a facility-based performance model and staff attrition. Notably, resistance to changing the VMMC programme’s operations was a significant barrier that may be tied to individual psychological barriers such as loss of power and job security. Donors and partners continued to control the funding for VMMC. Ideally, the Ministry of Health and Child Care should have more autonomy over these decisions. At the subnational level, there is an opportunity for increased responsibility and a greater sense of ownership through the decentralisation of governance.Conclusions To ensure successful integration and local ownership of VMMC as an HIV prevention programme, stakeholders must address both psychological and structural barriers while aligning their perspectives on the transition. Individual providers have valid concerns about their financial security and the burden of additional responsibilities without adequate compensation. It is crucial for donors and partners to reduce their involvement and oversight. Additionally, resolving the financial barriers that prevent the government from having complete control of the programme will require empowering local government stakeholders to fully take ownership.

Incarcerated populations experienced high rates of SARS-CoV-2 infection and death during early phases of the COVID-19 pandemic. To evaluate vaccine effectiveness in the carceral context, we investigated the first outbreak of COVID-19 in a California state prison following widespread rollout of vaccines to residents in early 2021. We identified a cohort of 733 state prison residents presumed to be exposed between May 14 and June 22, 2021. 46.9 % (n = 344) were vaccinated, primarily with two doses of mRNA-1273 (n = 332, 93.6 %). In total, 92 PCR-positive cases were identified, of which 14 (14.5 %) occurred among mRNA-1273 vaccinated residents. No cases required hospitalization. All nine isolates collected belonged to the Alpha (B.1.1.7) variant. We used Cox proportional hazard regression to estimate vaccine effectiveness for at least one dose of any vaccine at the start of the outbreak. Vaccine effectiveness was 86 % (95 % CI: 75 %-97 - 97 %) against PCR-confirmed infection, with similar results for symptomatic infection. Higher rates of building-level vaccine uptake were associated with a lower overall rate of PCR-confirmed infection and symptomatic infection among unvaccinated residents. Among unvaccinated residents who lived in shared cells at the time of presumed exposure, exposure to a vaccinated cellmate was associated with a 38% (95% CI: 0.37, 1.04) lower hazard rate of PCR-confirmed infection over the study period. In this outbreak involving the Alpha SARS-CoV-2 variant, vaccination conferred direct and possibly indirect protection against SARS-CoV-2 infection and symptomatic COVID-19. Our results support the importance of vaccine uptake in mitigating outbreaks and severe disease in the prison setting and the consideration of community vaccination levels in policy and infection response.

Purpose: CyberRwanda is a digital health intervention designed to increase knowledge of family planning and reproductive health (FP/RH) and access to youth -friendly services in Rwanda. Methods: Sixty schools in eight districts were randomized 1:1:1 to one of two CyberRwanda implementation models -self-service (tablet -only) or facilitated (tablet, activity booklet, peer facilitators) -or to control. Students aged 12-19 years were randomly selected to participate. Baseline and 12 -month midline surveys assessed intermediate (secondary) outcomes of FP/RH and HIV knowledge, attitudes/beliefs, self -ef ficacy, and behavior. Prevalence differences (PDs) were estimated using generalized linear mixed models. Results: There were 5,767 midline participants (51% female, mean/median age: 16 years, 29.9% sexually active). Those in CyberRwanda schools had higher knowledge of emergency contraception (57.3% vs. 47.5%, PD: 0.09, 95% con fidence interval [CI]: 0.05-0.13); greater con fidence in providing consent (73.3% vs. 68.1%, PD: 0.05, 95% CI: 0.01-0.08), negotiating partner 's contraceptive use (88.3% vs. 85.0%, PD: 0.03, 95% CI: 0.01-0.06), and accessing/using contraceptive services (95.6% vs. 91.8%, PD: 0.03, 95% CI: 0.02-0.05); and more favorable views on FP/RH services (54.5% vs. 48.5%, PD: 0.06, 95% CI: 0.02-0.11) and condoms (76.9% vs. 71.3%, PD: 0.06, 95% CI: 0.03-0.08) compared to control. No signi ficant differences in HIV/fertility knowledge, con fidence in accessing HIV testing, or condom use were observed. Discussion: CyberRwanda increased FP/RH knowledge, supportive attitudes/beliefs, self -ef ficacy, and behavior at 12 months. The 24 -month endline analysis will reveal whether CyberRwanda 's bene fits on intermediate outcomes result in changes to the primary outcomes, including contraception use and childbearing. (c) 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access article under the CC BY -NC -ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

BackgroundType 2 diabetes elevates the risk of severe outcomes in COVID-19 patients, with multiple studies reporting higher case fatality rates. Metformin is a widely used medication for glycemic management. We hypothesize that improved adherence to metformin may lower COVID-19 post-infection mortality risk in this group. Utilizing data from the Mexican Social Security Institute (IMSS), we investigate the relationship between metformin adherence and mortality following COVID-19 infection in patients with chronic metformin prescriptions.MethodsThis is a retrospective cohort study consisting of 61,180 IMSS beneficiaries who received a positive polymerase chain reaction (PCR) or rapid test for SARS-CoV-2 and had at least two consecutive months of metformin prescriptions prior to the positive test. The hypothetical intervention is improved adherence to metformin, measured by proportion of days covered (PDC), with the comparison being the observed metformin adherence values. The primary outcome is all-cause mortality following COVID-19 infection. We defined the causal parameter using shift intervention, an example of modified treatment policies. We used the targeted learning framework for estimation of the target estimand.FindingsAmong COVID-19 positive patients with chronic metformin prescriptions, we found that a 5% and 10% absolute increase in metformin adherence is associated with a respective 0.26% (95% CI: −0.28%, 0.79%) and 1.26% (95% CI: 0.72%, 1.80%) absolute decrease in mortality risk.InterpretationSubject to the limitations of a real-world data study, our results indicate a causal association between improved metformin adherence and reduced COVID-19 post-infection mortality risk.

We conducted a cluster-randomized hybrid effectiveness-implementation study of CyberRwanda, a digital family planning and reproductive health intervention for Rwandan adolescents. Sixty schools were randomized 1:1:1 to control or to one of two implementation models-self-service (self-guided access on tablets) or facilitated (peer-led clubs plus tablet access) with no masking. Eligible participants were aged 12-19 years, in secondary school levels 1 or 2, and willing to provide consent or assent/parental consent and contact information for follow-up. In 2021, 6,078 randomly selected adolescents were enrolled. At 24 months, 91.3% of participants were retained and included in the primary intention-to-treat analyses (control, n = 1,845; self-service, n = 1,849 and facilitated, n = 1,858). There were no adverse events related to the study. CyberRwanda did not affect the primary outcomes of modern contraceptive use (prevalence ratio (PR) = 1.04; 95% confidence interval (CI) = 0.76, 1.42), childbearing (PR = 1.33; 95% CI = 0.71, 2.50) and HIV testing (PR = 1.00; 95% CI = 0.91, 1.11) in the full sample. Significantly higher modern contraceptive use observed in the CyberRwanda facilitated arm in a prespecified analysis of sexually active participants suggests that longer-term evaluation is needed to examine effects as more of the study population becomes sexually active and has increased demand for contraception. ClinicalTrials.gov registration: NCT04198272. An implementation trial conducted across 60 schools in Rwanda found that CyberRwanda, a digital, school-based intervention, did not affect the primary outcomes of modern contraceptive use, childbearing and HIV testing among adolescents but was associated with higher contraceptive use among sexually active participants.

AbstractThe global health community has recognized the importance of integrating and sustaining health programs and forming equitable partnerships. Corresponding with these objectives, international aid donors are embracing the principle of localization. The Voluntary Medical Male Circumcision (VMMC) in Zimbabwe is a large vertical HIV prevention program primarily funded through development assistance for health. Program stakeholders want to sustainably integrate VMMC into routine health services so that the program will continue to be a cost-effective HIV prevention strategy through 2030. The purpose of this paper is to describe a bottom-up process of sustainably integrating the program into routine health services through an approach that empowers local stakeholders. At the district level, we facilitated changes to accelerate integration and sustainability. To evaluate our intervention, we used a mixed methods design comprising analysis of district-level work plans with qualitative and quantitative indicators, combined with a survey assessing sustainability capacity of the program, administered at midline and endline to district teams. In all five pilot districts we facilitated the transition of VMMC into the government’s district administration, resulting in a locally owned and managed program, while also strengthening individual and team capacity. We observed improvements across all World Health Organization health system building blocks, suggesting that the intervention strengthened the overall health system. The sustainability survey showed a reduction in funding stability but a significant increase in communications, program adaptation, and organizational capacity. Compared to traditional top-down change initiatives, the participatory approach to integration was an effective way of addressing specific VMMC challenges at the district level whilst maintaining management and oversight at provincial and national levels. Other health programs in low- and middle-income countries seeking to integrate and sustain health services at subnational levels should consider this diagonal, bottom-up model to promote local leadership development and health system strengthening.

Investment in health has been proposed as a mechanism to promote upward social mobility. Previous analyses have reported inconsistent estimates of the returns to investment in health in Mexico based on different models for different years. We aim to estimate returns for Mexico using data from four time points Adult height and labor income are drawn from the periodical national health and nutrition surveys-a group of relatively standardized surveys-that are representative of individuals living in the country in 2000, 2006, 2012 & 2018. These surveys collect anthropometric measurements and information on individuals' labor income. We estimated Mincerian models separately for men and women using OLS, Heckman, instrumental variables, and Heckman with instrumental variables models. Our results indicate significant and positive returns to health for the four surveys, similar in magnitude across years for women and with variations for men. By 2018, returns to health were about 7.4% per additional centimeter in height for females and 9.3% for males. Investments in health and nutrition during childhood and adolescence that increase health capital-measured as adult height-may promote social mobility in Mexico and similar countries to the extent that these investments differentially increase health capital among the poor.

Objective Conflicting evidence for the association between COVID-19 and adverse perinatal outcomes exists. This study examined the associations between maternal COVID-19 during pregnancy and adverse perinatal outcomes including preterm birth (PTB), low birth weight (LBW), small-for-gestational age (SGA), large-for-gestational age (LGA) and fetal death; as well as whether the associations differ by trimester of infection.Design and setting The study used a retrospective Mexican birth cohort from the Instituto Mexicano del Seguro Social (IMSS), Mexico, between January 2020 and November 2021.Participants We used the social security administrative dataset from IMSS that had COVID-19 information and linked it with the IMSS routine hospitalisation dataset, to identify deliveries in the study period with a test for SARS-CoV-2 during pregnancy.Outcome measures PTB, LBW, SGA, LGA and fetal death. We used targeted maximum likelihood estimators, to quantify associations (risk ratio, RR) and CIs. We fit models for the overall COVID-19 sample, and separately for those with mild or severe disease, and by trimester of infection. Additionally, we investigated potential bias induced by missing non-tested pregnancies.Results The overall sample comprised 17 340 singleton pregnancies, of which 30% tested positive. We found that those with mild COVID-19 had an RR of 0.89 (95% CI 0.80 to 0.99) for PTB and those with severe COVID-19 had an RR of 1.53 (95% CI 1.07 to 2.19) for LGA. COVID-19 in the first trimester was associated with fetal death, RR=2.36 (95% CI 1.04, 5.36). Results also demonstrate that missing non-tested pregnancies might induce bias in the associations.Conclusions In the overall sample, there was no evidence of an association between COVID-19 and adverse perinatal outcomes. However, the findings suggest that severe COVID-19 may increase the risk of some perinatal outcomes, with the first trimester potentially being a high-risk period.

Objectives We aim to quantify shifts in hospitalisation and mortality and how those were related to the first three phases of the epidemic and individuals’ demographics and health profile among those with a positive test for SARS-CoV-2 treated at the Mexican Social Security Institute’s facilities from March 2020 to October 2021. Design Retrospective observational study using interrupted time series analysis to identify changes in hospitalisation rate and case fatality rate (CFR) by epidemic wave. Setting Data from the Mexican Institute of Social Security’s (IMSS) Online Influenza Epidemiological Surveillance System (SINOLAVE) that include all individuals that sought care at IMSS facilities all over Mexico. Participants All individuals included in the SINOLAVE with a positive PCR or rapid test for SARS-CoV-2. Primary and secondary outcome measures Monthly test positivity rates, hospitalisation rates, CFRs and prevalence of relevant comorbidities by age group. Results From March 2020 to October 2021, the CFR declined between 1% and 3.5%; the declines were significant for those 0–9, 20–29, 30–39, 40–49 and 70 and older. The decline was steep during the first wave and was less steep or was temporarily reversed at the beginning of the second and third waves (changes in the trend of about 0.3% and 3.8%, and between 0.7% and 3.8%, respectively, for some age groups), but then continued to the end of the analytical period. Prevalence of diabetes, hypertension and obesity among patients testing positive also declined—two for most age groups (reductions of up to 10 percentage points for diabetes, 12 percentage points for hypertension and 19 percentage points for obesity). Conclusion Data suggest that the decrease in COVID-19 fatality rate is at least partially explained by a change in the profile of those contracting the disease, that is, a falling proportion of individuals with comorbidities across all age groups.

BACKGROUND:The COVID-19 pandemic has progressed rapidly, with the emergence of new virus variants that pose challenges in treating infected individuals. In Mexico, four epidemic waves have been recorded with varying disease severity. To understand the heterogeneity in clinical presentation over time and the sensitivity and specificity of signs and symptoms in identifying COVID-19 cases, an analysis of the changes in the clinical presentation of the disease was conducted.AIM:To analyze the changes in the clinical presentation of COVID-19 among 3.38 million individuals tested for SARS-CoV-2 at the Mexican Social Security Institute (IMSS) from March 2020 to October 2021 and evaluate the predictivity of signs and symptoms in identifying COVID-19 cases.METHODS:A retrospective analysis of clinical presentation patterns of COVID-19 among individuals treated at IMSS was performed, contrasting the signs and symptoms among SARS-CoV-2-positive individuals with those who tested negative for the virus but had respiratory infection symptoms. The sensitivity and specificity of each sign and symptom in identifying SARS-CoV-2 infection were estimated.RESULTS:The set of signs and symptoms reported for COVID-19-suspected patients treated at IMSS were not highly specific for SARS-CoV-2 positivity. The signs and symptoms exhibited variability based on age and epidemic wave. The area under the receiver operating characteristic (ROC) curve was 0.62 when grouping the five main symptoms (headache, dyspnea, fever, arthralgia, and cough). Most of the individual symptoms had ROC values close to 0.5 (16 out of 22 between 0.48 and 0.52), indicating non-specificity.CONCLUSIONS:The results highlight the difficulty in making a clinical diagnosis of COVID-19 due to the lack of specificity of signs and symptoms. The variability of clinical presentation over time and among age groups highlights the need for further research to differentiate whether the changes are due to changes in the virus, who is becoming infected, or the population, particularly with respect to prior infection and vaccination status.

ObjectiveTo compare group and individual psychedelic-assisted therapy in terms of clinician time, costs and patient access.MethodsUsing 2023 data from two group therapy trial sites, one using 3,4-Methylenedioxymethamphetamine (MDMA) to treat posttraumatic stress disorder (PTSD), and one using psilocybin to treat major depressive disorder (MDD), we compared overall variable costs, clinician costs and clinician time required by therapy protocols utilizing groups versus individual patient therapy. Using published literature, we estimated the prevalence of adults with PTSD and MDD eligible for treatment with psychedelic therapy and projected the savings in time and cost required to treat these prevalent cases.ResultsGroup therapy saved 50.9% of clinician costs for MDMA-PTSD and 34.7% for psilocybin-MDD, or $3,467 and $981 per patient, respectively. To treat all eligible PTSD and MDD patients in the U.S. in 10 years with group therapy, 6,711 fewer full-time equivalent (FTE) clinicians for MDMA-PTSD and 1,159 fewer for FTE clinicians for psilocybin-MDD would be needed, saving up to $10.3 billion and $2.0 billion respectively, discounted at 3% annually.ConclusionAdopting group therapy protocols where feasible would significantly reduce the cost of psychedelic-assisted therapies. By enhancing the number of patients served per clinician, group therapy could also ameliorate the anticipated shortage of appropriately trained clinicians, thereby accelerating access to these promising new therapies.

Eating last is a gendered cultural norm in which the youngest daughters-in-law are expected to eat last after serving others in the household, including men and in-laws. Using women's eating last as an indicator of women's status, we studied the association between eating last and women's mental health. Using four rounds of prospective cohort data of 18-25-year-old newly married women (n = 200) cohabiting with mothers-in-law between 2018 and 2020 in the Nawalparasi district of Nepal, we examined the association between women eating last and depressive symptom severity (measured using 15-item Hopkins Symptom Checklist for Depression; HSCL-D). Twenty-five percent of women reported eating last always. The prevalence of probable depression using the established cutoff was 5.5%, consistent with the prevalence of depression in the general population. Using a hierarchical mixed-effects linear regression model, we found that women who always ate last had an expected depressive symptom severity (0-3 on HSCL-D) 0.24 points (95% confidence interval [CI]: 0.13-0.36) greater compared to women who did not eat last when adjusted for demographic variables, household food insecurity, and secular trends. Sensitivity analysis using logistic regression also suggested that women who eat last have greater odds of having probable depression (adjusted odds ratio [AOR] = 4.05; 95% CI: 1.32-12.44). We explored if the association between eating last and depressive symptom severity was moderated by household food insecurity and did not observe evidence of moderation, underscoring the significance of eating last as a woman's status indicator. Our study findings highlight that newly young married women in Nepal are a vulnerable group.