Multiple trophic pathways support fish on floodplains of California's Central Valley.

We used compound-specific isotope analysis of carbon isotopes in amino acids (AAs) to determine the biosynthetic source of AAs in fish from major tributaries to California's Sacramento-San Joaquin river delta (i.e., the Sacramento, Cosumnes and Mokelumne rivers). Using samples collected in winter and spring between 2016 and 2019, we confirmed that algae are a critical component of floodplain food webs in California's Central Valley. Results from bulk stable isotope analysis of carbon and nitrogen in producers and consumers were adequate to characterize a general trophic structure and identify potential upstream and downstream migration into our study site by American shad Alosa sapidissima and rainbow trout Oncorhynchus mykiss, respectively. However, owing to overlap and variability in source isotope compositions, our bulk data were unsuitable for conventional bulk isotope mixing models. Our results from compound-specific carbon isotope analysis of AAs clearly indicate that algae are important sources of organic matter to fish of conservation concern, such as Chinook salmon Oncorhynchus tshawytscha in California's Central Valley. However, algae were not the exclusive source of energy to metazoan food webs. We also revealed that other sources of AAs, such as bacteria, fungi and higher plants, contributed to fish as well. While consistent with the well-supported notion that algae are critical to aquatic food webs, our results highlight the possibility that detrital subsidies might intermittently support metazoan food webs.

Malaria surveillance and case management in remote and indigenous communities of Panama: results from a community-based health worker pilot.

BACKGROUND: Panama is one of eight countries in Mesoamerica that aims to eliminate malaria by 2022. Malaria is concentrated in indigenous and remote regions like Guna Yala, a politically autonomous region where access to health services is limited and cases are predominately detected through intermittent active surveillance. To improve routine access to care, a joint effort was made by Guna Yala authorities and the Ministry of Health to pilot a network of community health workers (CHWs) equipped with rapid diagnostic tests and treatment. The impact of this pilot is described. METHODS: Access to care was measured using the proportion of villages targeted by the effort with active CHWs. Epidemiological impact was evaluated through standard surveillance and case management measures. Tests for differences in proportions or rates were used to compare measures prior to (October 2014-September 2016) and during the pilot (October 2016-September 2018). RESULTS: An active CHW was placed in 39 (95%) of 41 target communities. During the pilot, CHWs detected 61% of all reported cases from the region. Test positivity in the population tested by CHWs (22%) was higher than in those tested through active surveillance, both before (3.8%) and during the pilot (2.9%). From the pre-pilot to the pilot period, annual blood examination rates decreased (9.8 per 100 vs. 8.0 per 100), test positivity increased (4.2% to 8.5%, Χ2 = 126.3, p < 0.001) and reported incidence increased (4.1 cases per 1000 to 6.9 cases per 1000 [Incidence Rate Ratio = 1.83, 95% CI 1.52, 2.21]). The percent of cases tested on the day of symptom onset increased from 8 to 27% and those treated on the day of their test increased from 26 to 84%. CONCLUSIONS: The CHW network allowed for replacement of routine active surveillance with strong passive case detection leading to more targeted and timely testing and treatment. The higher test positivity among those tested by CHWs compared to active surveillance suggests that they detected cases in a high-risk population that had not previously benefited from access to diagnosis and treatment. Surveillance data acquired through this CHW network can be used to better target active case detection to populations at highest risk.

Risk Factors for COVID-19 in College Students Identified by Physical, Mental, and Social Health Reported During the Fall 2020 Semester: Observational Study Using the Roadmap App and Fitbit Wearable Sensors.

BACKGROUND: The COVID-19 pandemic triggered a seismic shift in education to web-based learning. With nearly 20 million students enrolled in colleges across the United States, the long-simmering mental health crisis in college students was likely further exacerbated by the pandemic. OBJECTIVE: This study leveraged mobile health (mHealth) technology and sought to (1) characterize self-reported outcomes of physical, mental, and social health by COVID-19 status; (2) assess physical activity through consumer-grade wearable sensors (Fitbit); and (3) identify risk factors associated with COVID-19 positivity in a population of college students prior to release of the vaccine. METHODS: After completing a baseline assessment (ie, at Time 0 [T0]) of demographics, mental, and social health constructs through the Roadmap 2.0 app, participants were instructed to use the app freely, wear the Fitbit, and complete subsequent assessments at T1, T2, and T3, followed by a COVID-19 assessment of history and timing of COVID-19 testing and diagnosis (T4: ~14 days after T3). Continuous measures were described using mean (SD) values, while categorical measures were summarized as n (%) values. Formal comparisons were made on the basis of COVID-19 status. The multivariate model was determined by entering all statistically significant variables (P<.05) in univariable associations at once and then removing one variable at a time through backward selection until the optimal model was obtained. RESULTS: During the fall 2020 semester, 1997 participants consented, enrolled, and met criteria for data analyses. There was a high prevalence of anxiety, as assessed by the State Trait Anxiety Index, with moderate and severe levels in 465 (24%) and 970 (49%) students, respectively. Approximately one-third of students reported having a mental health disorder (n=656, 33%). The average daily steps recorded in this student population was approximately 6500 (mean 6474, SD 3371). Neither reported mental health nor step count were significant based on COVID-19 status (P=.52). Our analyses revealed significant associations of COVID-19 positivity with the use of marijuana and alcohol (P=.02 and P=.046, respectively) and with lower belief in public health measures (P=.003). In addition, graduate students were less likely and those with ≥20 roommates were more likely to report a COVID-19 diagnosis (P=.009). CONCLUSIONS: Mental health problems were common in this student population. Several factors, including substance use, were associated with the risk of COVID-19. These data highlight important areas for further attention, such as prioritizing innovative strategies that address health and well-being, considering the potential long-term effects of COVID-19 on college students. TRIAL REGISTRATION: ClinicalTrials.gov NCT04766788; https://clinicaltrials.gov/ct2/show/NCT04766788. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/29561.

Using observed incidence to calibrate the transmission level of a mathematical model for Plasmodium vivax dynamics including case management and importation.

In this work, we present a simple and flexible model for Plasmodium vivax dynamics which can be easily combined with routinely collected data on local and imported case counts to quantify transmission intensity and simulate control strategies. This model extends the model from White et al. (2016) by including case management interventions targeting liver-stage or blood-stage parasites, as well as imported infections. The endemic steady state of the model is used to derive a relationship between the observed incidence and the transmission rate in order to calculate reproduction numbers and simulate intervention scenarios. To illustrate its potential applications, the model is used to calculate local reproduction numbers in Panama and identify areas of sustained malaria transmission that should be targeted by control interventions.

Monitoring beliefs and physiological measures in students at risk for COVID-19 using wearable sensors and smartphone technology: Protocol for a mobile health study.

BACKGROUND: The COVID-19 pandemic has impacted lives significantly and greatly affected an already vulnerable population, college students, in relation to mental health and public safety. Social distancing and isolation have brought about challenges to student's mental health. Mobile health apps and wearable sensors may help to monitor students at risk for COVID-19 and support their mental well-being. OBJECTIVE: Through the use of a wearable sensor and smartphone-based survey completion, this study aimed to monitor students at risk for COVID-19. METHODS: We conducted a prospective study of students, undergraduate and graduate, at a public university in the Midwest. Students were instructed to download the Fitbit, Social Rhythms, and Roadmap 2.0 apps onto their personal mobile devices (Android or iOS). Subjects consented to provide up to 10 saliva samples during the study period. Surveys were administered through the Roadmap 2.0 app at five timepoints - at baseline, 1-month later, 2-months later, 3-months later, and at study completion. The surveys gathered information regarding demographics, COVID-19 diagnoses and symptoms, and mental health resilience, with the aim of documenting the impact of COVID-19 on the college student population. RESULTS: This study enrolled 2,158 college students between September 2020 and January 2021. Subjects are currently being followed on-study for one academic year. Data collection and analysis are ongoing. CONCLUSIONS: This study examined student health and well-being during the COVID-19 pandemic. It also assessed the feasibility of wearable sensor use and survey completion in a college student population, which may inform the role of our mobile health tools on student health and well-being. Finally, using wearable sensor data, biospecimen collection, and self-reported COVID-19 diagnosis, our results may provide key data towards the development of a model for the early prediction and detection of COVID-19. CLINICALTRIAL: ClinicalTrials.gov NCT04766788.

Validation of the Prevention Impacts Simulation Model (PRISM).

INTRODUCTION: Demonstrating the validity of a public health simulation model helps to establish confidence in the accuracy and usefulness of a model's results. In this study we evaluated the validity of the Prevention Impacts Simulation Model (PRISM), a system dynamics model that simulates health, mortality, and economic outcomes for the US population. PRISM primarily simulates outcomes related to cardiovascular disease but also includes outcomes related to other chronic diseases that share risk factors. PRISM is openly available through a web application. METHODS: We applied the model validation framework developed independently by the International Society of Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making modeling task force to validate PRISM. This framework included model review by external experts and quantitative data comparison by the study team. RESULTS: External expert review determined that PRISM is based on up-to-date science. One-way sensitivity analysis showed that no parameter affected results by more than 5%. Comparison with other published models, such as ModelHealth, showed that PRISM produces lower estimates of effects and cost savings. Comparison with surveillance data showed that projected model trends in risk factors and outcomes align closely with secular trends. Four measures did not align with surveillance data, and those were recalibrated. CONCLUSION: PRISM is a useful tool to simulate the potential effects and costs of public health interventions. Results of this validation should help assure health policy leaders that PRISM can help support community health program planning and evaluation efforts.

Promoting Mental Health and Psychological Thriving in University Students: A Randomized Controlled Trial of Three Well-Being Interventions.

This study aimed to address the decline in mental health on U.S. university campuses by examining the effects of three interventions. University students suffer from high levels of anxiety, depression, and suicide. Counseling centers on university campuses are struggling to meet increased demand. The cost to students and universities could be buffered by offering preventative, psychoeducational, and skill-building training programs that promote mental health and psychological thriving. To date, the research literature has not yielded systematically evaluated and recommendable preventative mental health and well-being programs for university students. In a registered, randomized controlled trial, 131 university students were either placed in a non-intervention control group (N = 47) or received training in one of three 30-hour, eight-week semester-long well-being programs: SKY Campus Happiness ("SKY"; N = 29), Foundations of Emotional Intelligence ("EI"; N = 21) or Mindfulness-Based Stress Reduction ("MBSR"; N = 34). Compared to the control group and controlling for variance of baseline measurements and multiple comparisons, SKY Campus Happiness showed the greatest impact, benefiting six outcomes: depression, stress, mental health, mindfulness, positive affect and social connectedness. EI benefited one outcome: mindfulness. The MBSR group showed no change. Delivering SKY or EI to university students may be a cost-effective and efficient way to proactively and preventatively address mental health for university students and reduce the financial strain on universities.

Isotopic and genetic methods reveal the role of the gut microbiome in mammalian host essential amino acid metabolism.

Intestinal microbiota perform many functions for their host, but among the most important is their role in metabolism, especially the conversion of recalcitrant biomass that the host is unable to digest into bioavailable compounds. Most studies have focused on the assistance gut microbiota provide in the metabolism of carbohydrates, however, their role in host amino acid metabolism is poorly understood. We conducted an experiment on Mus musculus using 16S rRNA gene sequencing and carbon isotope analysis of essential amino acids (AAESS) to quantify the community composition of gut microbiota and the contribution of carbohydrate carbon used by the gut microbiome to synthesize AAESS that are assimilated by mice to build skeletal muscle tissue. The relative abundances of Firmicutes and Bacteroidetes inversely varied as a function of dietary macromolecular content, with Firmicutes dominating when mice were fed low-protein diets that contained the highest proportions of simple carbohydrates (sucrose). Mixing models estimated that the microbial contribution of AAESS to mouse muscle varied from less than 5% (threonine, lysine, and phenylalanine) to approximately 60% (valine) across diet treatments, with the Firmicute-dominated microbiome associated with the greatest contribution. Our results show that intestinal microbes can provide a significant source of the AAESS their host uses to synthesize structural tissues. The role that gut microbiota play in the amino acid metabolism of animals that consume protein-deficient diets is likely a significant but under-recognized aspect of foraging ecology and physiology.

Estimating Costs of Implementing Stroke Systems of Care and Data-Driven Improvements in the Paul Coverdell National Acute Stroke Program.

PURPOSE AND OBJECTIVES: We evaluated the costs of implementing coordinated systems of stroke care by state health departments from 2012 through 2015 to help policy makers and planners gain a sense of the potential return on investments in establishing a stroke care quality improvement (QI) program. INTERVENTION APPROACH: State health departments funded by the Paul Coverdell National Acute Stroke Program (PCNASP) implemented activities to support the start and proficient use of hospital stroke registries statewide and coordinate data-driven QI efforts. These efforts were aimed at improving the treatment and transition of stroke patients from prehospital emergency medical services (EMS) to in-hospital care and postacute care facilities. Health departments provided technical assistance and data to support hospitals, EMS agencies, and posthospital care agencies to carry out small, rapid, incremental QI efforts to produce more effective and efficient stroke care practices. EVALUATION METHODS: Six of the 11 PCNASP-funded state health departments in the United States volunteered to collect and report programmatic costs associated with implementing the components of stroke systems of care. Six health departments reported costs paid directly by Centers for Disease Control and Prevention-provided funds, 5 also reported their own in-kind contributions, and 4 compiled data from a sample of their partners' estimated costs of resources, such as staff time, involved in program implementation. Costs were analyzed separately for PCNASP-funded expenditures and in-kind contributions by the health department by resource category and program activity. In-kind contributions by partners were also analyzed separately. RESULTS: PCNASP-funded expenditures ranged from $790,123 to $1,298,160 across the 6 health departments for the 3-year funding period. In-kind contributions ranged from $5,805 to $1,394,097. Partner contributions (n = 22) ranged from $3,912 to $362,868. IMPLICATIONS FOR PUBLIC HEALTH: Our evaluation reports costs for multiple state health departments and their partners for implementing components of stroke systems of care in the United States. Although there are limitations, our findings represent key estimates that can guide future program planning and efforts to achieve sustainability.

Estimating the Relative Impact of Clinical and Preventive Community-Based Interventions: An Example Based on the Community Transformation Grant Program.

INTRODUCTION: Public health focuses on a range of evidence-based approaches for addressing chronic conditions, from individual-level clinical interventions to broader changes in policies and environments that protect people's health and make healthy living easier. This study examined the potential long-term impact of clinical and community interventions as they were implemented by Community Transformation Grant (CTG) program awardees. METHODS: We used the Prevention Impacts Simulation Model, a system dynamics model of cardiovascular disease prevention, to simulate the potential 10-year and 25-year impact of clinical and community interventions implemented by 32 communities receiving a CTG program award, assuming that program interventions were sustained during these periods. RESULTS: Sustained clinical interventions implemented by CTG awardees could potentially avert more than 36,000 premature deaths and $3.2 billion in discounted direct medical costs (2017 US dollars) over 10 years and 109,000 premature deaths and $8.1 billion in discounted medical costs over 25 years. Sustained community interventions could avert more than 24,000 premature deaths and $3.4 billion in discounted direct medical costs over 10 years and 88,000 premature deaths and $9.1 billion in discounted direct medical costs over 25 years. CTG clinical activities had cost-effectiveness of $302,000 per death averted at the 10-year mark and $188,000 per death averted at the 25-year mark. Community interventions had cost-effectiveness of $169,000 and $57,000 per death averted at the 10- and 25-year marks, respectively. CONCLUSION: Clinical interventions have the potential to avert more premature deaths than community interventions. However, community interventions, if sustained over the long term, have better cost-effectiveness.

Simulated impacts and potential cost effectiveness of Communities Putting Prevention to Work: Tobacco control interventions in 21 U.S. communities, 2010-2020.

In 2010, the Centers for Disease Control and Prevention (CDC) funded communities to implement policy, systems, and environmental (PSE) changes under the Communities Putting Prevention to Work (CPPW) program to make it easier for people to make healthier choices to prevent chronic disease. Twenty-one of 50 funded communities implemented interventions intended to reduce tobacco use. To examine the potential cost-effectiveness of tobacco control changes implemented under CPPW from a healthcare system perspective, we compared program cost estimates with estimates of potential impacts. We used an existing simulation model, the Prevention Impacts Simulation Model (PRISM), to estimate the potential cumulative impact of CPPW tobacco interventions on deaths and medical costs averted through 2020. We collected data on the costs to implement CPPW tobacco interventions from 2010 to 2013. We adjusted all costs to 2010 dollars. CPPW tobacco interventions cost $130.5 million across all communities, with an average community cost of $6.2 million. We found $735 million in potentially averted medical costs cumulatively from 2010 through 2020 because of the CPPW-supported interventions. If the CPPW tobacco control PSE changes are sustained through 2020 without additional funding after 2013, we find that medical costs averted will likely exceed program costs by $604 million. Our results suggest that the medical costs averted through 2020 may more than offset the initial investment in CPPW tobacco control interventions, implying that such interventions may be cost saving, especially over the long term.

Standardized Cost Estimates for Home Visiting: Pilot Study of the Home Visiting Budget Assistance Tool (HV-BAT).

Purpose Using a standardized approach and metrics to estimate home visiting costs across multiple evidence-based models and regions could improve the consistency and accuracy of cost estimates, allow stakeholders to observe trends in cost allocation, analyze how home visiting costs vary, and develop future program budgets. Between October 2015 and December 2018, we developed and pilot-tested the Home Visiting Budget Assistance Tool (HV-BAT) to standardize the collection of home visiting program costs and analyze costs for local implementing agencies (LIAs). Methods We recruited LIAs that implemented at least one of nine evidence-based home visiting models in 15 states implementing the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program. LIAs reported their costs to implement a home visiting model using the HV-BAT and provided feedback on the tool. We estimated annual total cost and cost per family served for each LIA, examined cost summary statistics for the sample, and analyzed whether and how LIA characteristics affected home visiting costs using regression analyses. Results Of the 168 LIAs invited to participate in the HV-BAT pilot study, 75 agreed to participate, and 45 across 14 states completed the HV-BAT. We estimated home visiting costs of approximately $8500 per family per year, but costs varied across LIAs (range $1970-$39,770; standard deviation = $5794). The marginal cost of adding a family declined as the number of families served by an LIA increased. Feedback from LIAs indicated that users had difficulty providing some details on costs (e.g., mileage for specific services), needed more detailed instructions, and desired a summary of subtotals and total costs reported in the HV-BAT. Conclusions The HV-BAT provides an approach to standardize cost data collection for home visiting programs. Pilot study results indicate that there may be significant economies of scale for home visiting services. This study provides preliminary estimates of costs that can help in program planning and budgeting.

Costs of community-based interventions from the Community Transformation Grants.

Limited data are available on the costs of evidence-based community-wide prevention programs. The objective of this study was to estimate the per-person costs of strategies that support policy, systems, and environmental changes implemented under the Community Transformation Grants (CTG) program. We collected cost data from 29 CTG awardees and estimated program costs as spending on labor; consultants; materials, travel, and services; overhead activities; partners; and the value of in-kind contributions. We estimated costs per person reached for 20 strategies. We assessed how per-person costs varied with the number of people reached. Data were collected in 2012-2015, and the analysis was conducted in 2015-2016. Two of the tobacco-free living strategies cost less than $1.20 per person and reached over 6 million people each. Four of the healthy eating strategies cost less than $1.00 per person, and one of them reached over 6.5 million people. One of the active living strategies cost $2.20 per person and reached over 7 million people. Three of the clinical and community preventive services strategies cost less than $2.30 per person, and one of them reached almost 2 million people. Across all 20 strategies combined, an increase of 10,000 people in the number of people reached was associated with a $0.22 reduction in the per-person cost. Results demonstrate that interventions, such as tobacco-free indoor policies, which have been shown to improve health outcomes have relatively low per-person costs and are able to reach a large number of people.

Engineering waterborne Pseudomonas aeruginosa out of a critical care unit.

OBJECTIVE: To describe engineering and holistic interventions on water outlets contaminated with Pseudomonas aeruginosa and the observed impact on clinical P. aeruginosa patient isolates in a large Intensive Care Unit (ICU). DESIGN: Descriptive study. SETTING: Queen Elizabeth Hospital Birmingham (QEHB), part of University Hospitals Birmingham (UHB) NHS Foundation Trust is a tertiary referral teaching hospital in Birmingham, UK and provides clinical services to nearly 1 million patients every year. METHODS: Breakpoint models were used to detect any significant changes in the cumulative yearly rates of clinical P. aeruginosa patient isolates from August 2013-December 2016 across QEHB. RESULTS: Water sampling undertaken on the ICU indicated 30% of the outlets were positive for P. aeruginosa at any one time. Molecular typing of patient and water isolates via Pulsed Field Gel Electrophoresis suggested there was a 30% transmission rate of P. aeruginosa from the water to patients on the ICU. From, February 2014, QEHB implemented engineering interventions, consisting of new tap outlets and PALL point-of-use filters; as well as holistic measures, from February 2016 including a revised tap cleaning method and appropriate disposal of patient waste water. Breakpoint models indicated the engineering and holistic interventions resulted in a significant (p<0.001) 50% reduction in the number of P. aeruginosa clinical patient isolates over a year. CONCLUSION: Here we demonstrate that the role of waterborne transmission of P. aeruginosa in an ICU cannot be overlooked. We suggest both holistic and environmental factors are important in reducing transmission.

Escapes in copepods: comparison between myelinate and amyelinate species.

Rapid conduction in myelinated nerves keeps distant parts of large organisms in timely communication. It is thus surprising to find myelination in some very small organisms. Calanoid copepods, while sharing similar body plans, are evenly divided between myelinate and amyelinate taxa. In seeking the selective advantage of myelin in these small animals, representatives from both taxa were subjected to a brief hydrodynamic stimulus that elicited an escape response. The copepods differed significantly in their ability to localize the stimulus: amyelinate copepods escaped in the general direction of their original swim orientation, often ending up closer to the stimulus. However, myelinate species turned away from the stimulus and distanced themselves from it, irrespective of their original orientation. We suggest that faster impulse conduction of myelinated axons leads to better precision in the timing and processing of sensory information, thus allowing myelinate copepods to better localize stimuli and respond appropriately.

A comprehensive investigation of mesophotic coral ecosystems in the Hawaiian Archipelago.

Although the existence of coral-reef habitats at depths to 165 m in tropical regions has been known for decades, the richness, diversity, and ecological importance of mesophotic coral ecosystems (MCEs) has only recently become widely acknowledged. During an interdisciplinary effort spanning more than two decades, we characterized the most expansive MCEs ever recorded, with vast macroalgal communities and areas of 100% coral cover between depths of 50-90 m extending for tens of km2 in the Hawaiian Archipelago. We used a variety of sensors and techniques to establish geophysical characteristics. Biodiversity patterns were established from visual and video observations and collected specimens obtained from submersible, remotely operated vehicles and mixed-gas SCUBA and rebreather dives. Population dynamics based on age, growth and fecundity estimates of selected fish species were obtained from laser-videogrammetry, specimens, and otolith preparations. Trophic dynamics were determined using carbon and nitrogen stable isotopic analyses on more than 750 reef fishes. MCEs are associated with clear water and suitable substrate. In comparison to shallow reefs in the Hawaiian Archipelago, inhabitants of MCEs have lower total diversity, harbor new and unique species, and have higher rates of endemism in fishes. Fish species present in shallow and mesophotic depths have similar population and trophic (except benthic invertivores) structures and high genetic connectivity with lower fecundity at mesophotic depths. MCEs in Hawai'i are widespread but associated with specific geophysical characteristics. High genetic, ecological and trophic connectivity establish the potential for MCEs to serve as refugia for some species, but our results question the premise that MCEs are more resilient than shallow reefs. We found that endemism within MCEs increases with depth, and our results do not support suggestions of a global faunal break at 60 m. Our findings enhance the scientific foundations for conservation and management of MCEs, and provide a template for future interdisciplinary research on MCEs worldwide.

Intervention Costs From Communities Putting Prevention to Work.

INTRODUCTION: In 2010, the Centers for Disease Control and Prevention funded 50 communities to participate in the Communities Putting Prevention to Work (CPPW) program. CPPW supported community-based approaches to prevent or delay chronic disease and promote wellness by reducing tobacco use and obesity. We collected the direct costs of CPPW for the 44 communities funded through the American Recovery and Reinvestment Act (ARRA) and analyzed costs per person reached for all CPPW interventions and by intervention category. METHODS: From 2011 through 2013, we collected quarterly data on costs from the 44 CPPW ARRA-funded communities. We estimated CPPW program costs as spending on labor; consultants; materials, travel, and services; overhead activities; and partners plus the value of in-kind donations. We estimated communities' costs per person reached for each intervention implemented and compared cost allocations across communities that focused on reducing tobacco use, or obesity, or both. Analyses were conducted in 2014; costs are reported in 2012 dollars. RESULTS: The largest share of CPPW total costs of $363 million supported interventions in communities that focused on obesity ($228 million). Average costs per person reached were less than $5 for 84% of tobacco-related interventions, 88% of nutrition interventions, and 89% of physical activity interventions. Costs per person reached were highest for social support and services interventions, almost $3 for tobacco­use interventions and $1 for obesity prevention interventions. CONCLUSIONS: CPPW cost estimates are useful for comparing intervention cost per person reached with health outcomes and for addressing how community health intervention costs vary by type of intervention and by community size.

Community-Based Interventions to Decrease Obesity and Tobacco Exposure and Reduce Health Care Costs: Outcome Estimates From Communities Putting Prevention to Work for 2010-2020.

INTRODUCTION: In 2010, the Centers for Disease Control and Prevention (CDC) launched Communities Putting Prevention to Work (CPPW), a $485 million program to reduce obesity, tobacco use, and exposure to secondhand smoke. CPPW awardees implemented evidence-based policy, systems, and environmental changes to sustain reductions in chronic disease risk factors. This article describes short-term and potential long-term benefits of the CPPW investment. METHODS: We used a mixed-methods approach to estimate population reach and to simulate the effects of completed CPPW interventions through 2020. Each awardee developed a community action plan. We linked plan objectives to a common set of interventions across awardees and estimated population reach as an early indicator of impact. We used the Prevention Impacts Simulation Model (PRISM), a systems dynamics model of cardiovascular disease prevention, to simulate premature deaths, health care costs, and productivity losses averted from 2010 through 2020 attributable to CPPW. RESULTS: Awardees completed 73% of their planned objectives. Sustained CPPW improvements may avert 14,000 premature deaths, $2.4 billion (in 2010 dollars) in discounted direct medical costs, and $9.5 billion (in 2010 dollars) in discounted lifetime and annual productivity losses through 2020. CONCLUSION: PRISM results suggest that large investments in community preventive interventions, if sustained, could yield cost savings many times greater than the original investment over 10 to 20 years and avert 14,000 premature deaths.

Understanding Barriers for Communicating Injury Prevention Messages and Strategies Moving Forward: Perspectives from Community Stakeholders.

OBJECTIVES: The primary objective of this study was to elicit the perspectives of direct care providers on barriers and facilitators to communicating injury prevention messages to parents/caregivers of children under 4 years of age. The secondary objective was to examine characteristics of an injury prevention messaging strategy preferred by direct care providers. DESIGN AND SAMPLE: This qualitative study was conducted across four regions in Ontario Canada. Fifty-nine direct care providers were purposefully sampled and data interpreted using focus group analysis. MEASURES: Transcripts were analyzed verbatim using content and discourse analysis. RESULTS: Several barriers to communicating injury prevention messages were identified encompassing (a) role, (b) parental, (c) social determinants, and (d) evidence impediments. In an effort to offset some of these barriers, participants endorsed the development of a tailored multicomponent injury prevention strategy adopting action-based messages. CONCLUSION: The results of this study provide an in-depth exploration of direct care providers perceptions that can inform the design of materials and dissemination strategies to help increase and optimize access to injury prevention information. Injury prevention messages should be action-oriented, specifically tailored to the stage of child development, and disseminated through both face-to-face interactions and mobile technology.