Impact of COVID-related Discrimination on Psychological Distress and Sleep Disturbances across Race-Ethnicity

COVID-related discrimination towards historically marginalized racial-ethnic groups in the United States has been well-documented; however, its impact on psychological distress and sleep (overall and within specific racial-ethnic groups) is largely unknown. We used data from our nationally representative, online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, Latino, White, and multiracial adults, conducted from 12/2020-2/2021. Participants were asked how often they experienced discriminatory behaviors "because they think you might have COVID-19" (modified Everyday Discrimination Scale). Psychological distress was captured as having experienced anxiety-depression symptoms (Patient Health Questionairre-4, PHQ-4), perceived stress (modified Perceived Stress Scale), or loneliness-isolation ("How often have you felt lonely and isolated?"). Sleep disturbances were measured using the Patient-Reported Outcomes Information System Short Form Sleep Disturbance scale (PROMIS-SF 4a). Overall, 22.1% reported COVID-related discriminatory behaviors (sometimes/always: 9.7%; rarely: 12.4%). 48.4% of participants reported anxiety-depression symptoms (moderate/severe: 23.7% mild: 24.8%), 62.4% reported feeling stressed (moderate/severe: 34.3%; mild: 28,1%), 61.0% reported feeling lonely-isolated (fairly often/very often: 21.3%; almost never/sometimes: 39.7%), and 35.4% reported sleep disturbances (moderate/severe:19.8%; mild: 15.6%). Discrimination was only associated with increased psychological distress among racial-ethnic minorities. For example, COVID-related discrimination was strongly associated with anxiety-depression among Black/African American adults (mild: aOR=2.12, 95% CI=1.43-5.17; moderate/severe: aOR=5.19, 95% CI=3.35-8.05), but no association was observed among White or multiracial adults. Mitigating pandemic-related discrimination could help alleviate mental and sleep health disparities occurring among minoritized racial-ethnic groups.

Age-related differences in the association between financial hardship and weight change during the COVID-19 pandemic

Objective

To examine the association of financial hardship with weight changes in the US during the COVID-19 pandemic.

Methods

We used data from the COVID-19's Unequal Racial Burden survey, a nationally representative, cross-sectional, online survey of diverse adults living in the US, 12/2020-2/2021. This study included 1000 Asian, Black, Latino (half Spanish-speaking), and White adults and 500 American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and multiracial adults (5500 total). Age-specific (18-39, 40-59, ≥60) associations between financial hardship domains and weight change were estimated using multinomial logistic regression, adjusted for demographic and health characteristics.

Results

Financial hardship during the COVID-19 pandemic was prevalent across all age groups (18-39: 76.2 %; 40-59: 75.6 %; ≥60: 50.6 %). Among adults aged 18-39 and ≥ 60 years old, food insecurity was significantly associated with weight loss (18-39: aOR = 1.42, 95 % CI = 1.04, 1.95; ≥60: aOR = 3.67, 95 % CI = 1.50, 8.98). Among all age groups, unmet healthcare expenses was also associated with weight loss (18-39: aOR = 1.31, 95 % CI = 1.01, 1.70; 40-59: aOR = 1.49, 95 % CI = 1.06, 2.08; ≥60: aOR = 1.73, 95 % CI = 1.03, 2.91). Among adults aged 18-39 and ≥ 60 years old, lost income was significantly associated with weight gain (18-39: aOR = 1.36, 95 % CI = 1.09-1.69; ≥60: aOR = 1.46, 95 % CI = 1.04, 2.06), and among adults 40-59 years old, experiencing increased debt was significantly associated with weight gain (aOR = 1.50, 95 % CI = 1.13, 1.99).

Conclusions

For those aged 18-39 and ≥ 60 years old experiencing financial hardship during the COVID-19 pandemic was associated with both weight loss and weight gain. Less correlation was observed among adults aged 40-59.

Discrimination is associated with depression, anxiety, and loneliness symptoms among Asian and Pacific Islander adults during COVID-19 Pandemic

In the United States, Asian and Pacific Islander (A/PI) communities have faced significant discrimination and stigma during the COVID-19 pandemic. We assessed the association between discrimination and depression, anxiety, and loneliness symptoms among Asian or Pacific Islander adults (n = 543) using data from a 116-item nationally distributed online survey of adults (≥ 18 years old) in the United States conducted between 5/2021-1/2022. Discrimination was assessed using the 5-item Everyday Discrimination Scale. Anxiety, depression, and loneliness symptoms were assessed using the 2-item Generalized Anxiety Disorder, 2-item Patient Health Questionnaire, and UCLA Loneliness Scale-Short form, respectively. We used multivariable logistic regression to estimate the association between discrimination and mental health. Overall, 42.7% of participants reported experiencing discrimination once a month or more. Compared with no discrimination, experiencing discrimination once a month was associated with increased odds of anxiety (Adjusted Odds Ratio [aOR] = 2.60, 95% CI = 1.38-4.77), depression (aOR = 2.58, 95% CI = 1.46-4.56), and loneliness (aOR = 2.86, 95% CI = 1.75-4.67). Experiencing discrimination once a week or more was associated with even higher odds of anxiety (aOR = 6.90, 95% CI = 3.71-12.83), depression, (aOR = 6.96, 95% CI = 3.80-12.74), and loneliness (aOR = 6.91, 95% CI = 3.38-13.00). Discrimination is detrimental to mental health, even at relatively low frequencies; however, more frequent discrimination was associated with worse mental health symptoms. Public health interventions and programs targeting anti-A/PI hate and reducing A/PI mental health burden are urgently needed.

Racial/ethnic differences in the associations between trust in the U.S. healthcare system and willingness to test for and vaccinate against COVID-19

BACKGROUND

Trust in the healthcare system may impact adherence to recommended healthcare practices, including willingness to test for and vaccinate against COVID-19. This study examined racial/ethnic differences in the associations between trust in the U.S. healthcare system and willingness to test for and vaccinate against COVID-19 during the first year of the pandemic.

METHODS

This cross-sectional study used data from the REACH-US study, a nationally representative online survey conducted among a diverse sample of U.S. adults from January 26, 2021-March 3, 2021 (N = 5,121). Multivariable logistic regression estimated the associations between trust in the U.S. healthcare system (measured as "Always", "Most of the time", "Sometimes/Almost Never", and "Never") and willingness to test for COVID-19, and willingness to receive the COVID-19 vaccine. Racial/ethnic differences in these associations were examined using interaction terms and multigroup analyses.

RESULTS

Always trusting the U.S. healthcare system was highest among Hispanic/Latino Spanish Language Preference (24.9%) and Asian (16.7%) adults and lowest among Multiracial (8.7%) and Black/African American (10.7%) adults. Always trusting the U.S. healthcare system, compared to never, was associated with greater willingness to test for COVID-19 (AOR: 3.20, 95% CI: 2.38-4.30) and greater willingness to receive the COVID-19 vaccine (AOR: 2.68, 95% CI: 1.97-3.65).

CONCLUSIONS

Trust in the U.S. healthcare system was associated with greater willingness to test for COVID-19 and receive the COVID-19 vaccine, however, trust in the U.S. healthcare system was lower among most marginalized racial/ethnic groups. Efforts to establish a more equitable healthcare system that increases trust may encourage COVID-19 preventive behaviors.

Racial and ethnic disparities in the association between financial hardship and self-reported weight change during the first year of the pandemic in the U.S

Studies have shown that financial hardship can impact weight change; however, it is unclear what the economic impact of the COVID-19 pandemic has had on weight change in U.S. adults, or whether racial-ethnic groups were impacted differentially. We estimated the association between financial hardship and self-reported weight change using data from the cross-sectional COVID-19's Unequal Racial Burden (CURB) survey, a nationally representative online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Latino (English- and Spanish-speaking), Native Hawaiian/Pacific Islander, White, and multiracial adults conducted from 12/2020 to 2/2021. Financial hardship was measured over six domains (lost income, debt, unmet general expenses, unmet healthcare expenses, housing insecurity, and food insecurity). The association between each financial hardship domain and self-reported 3-level weight change variable were estimated using multinomial logistic regression, adjusting for sociodemographic and self-reported health. After adjustment, food insecurity was strongly associated with weight loss among American Indian/Alaska Native (aOR = 2.18, 95% CI = 1.05-4.77), Black/African American (aOR = 1.77, 95% CI = 1.02-3.11), and Spanish-speaking Latino adults (aOR = 2.32, 95% CI = 1.01-5.35). Unmet healthcare expenses were also strongly associated with weight loss among Black/African American, English-speaking Latino, Spanish-speaking Latino, and Native Hawaiian/Pacific Islander adults (aORs = 2.00-2.14). Other domains were associated with weight loss and/or weight gain, but associations were not as strong and less consistent across race-ethnicity. In conclusion, food insecurity and unmet healthcare expenses during the pandemic were strongly associated with weight loss among racial-ethnic minority groups. Using multi-dimensional measures of financial hardship provides a comprehensive assessment of the effects of specific financial hardship domains on weight change among diverse racial-ethnic groups.

Positive and negative aspects of the COVID-19 pandemic among a diverse sample of US adults: an exploratory mixed-methods analysis of online survey data

BACKGROUND

The COVID-19 pandemic had a profound social and economic impact across the United States due to the lockdowns and consequent changes to everyday activities in social spaces.

METHODS

The COVID-19's Unequal Racial Burden (CURB) survey was a nationally representative, online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Latino (English- and Spanish-speaking), Native Hawaiian/Pacific Islander, White, and multiracial adults living in the U.S. For this analysis, we used data from the 1,931 participants who responded to the 6-month follow-up survey conducted between 8/16/2021-9/9/2021. As part of the follow-up survey, participants were asked "What was the worst thing about the pandemic that you experienced?" and "Was there anything positive in your life that resulted from the pandemic?" Verbatim responses were coded independently by two coders using open and axial coding techniques to identify salient themes, definitions of themes, and illustrative quotes, with reconciliation across coders. Chi-square tests were used to estimate the association between sociodemographics and salient themes.

RESULTS

Commonly reported negative themes among participants reflected disrupted lifestyle/routine (27.4%), not seeing family and friends (9.8%), and negative economic impacts (10.0%). Positive themes included improved relationships (16.9%), improved financial situation (10.1%), and positive employment changes (9.8%). Differences in themes were seen across race-ethnicity, gender, and age; for example, adults ≥ 65 years old, compared to adults 18-64, were more likely to report disrupted routine/lifestyle (37.6% vs. 24.2%, p < 0.001) as a negative aspect of the pandemic, and Spanish-speaking Latino adults were much more likely to report improved relationships compared to other racial-ethnic groups (31.1% vs. 14.8-18.6%, p = 0.03).

DISCUSSION

Positive and negative experiences during the COVID-19 pandemic varied widely and differed across race-ethnicity, gender, and age. Future public health interventions should work to mitigate negative social and economic impacts and facilitate posttraumatic growth associated with pandemics.

Trends in the management and outcomes of esophageal perforations among racial-ethnic groups

Background

Esophageal perforation (EP) is a life-threatening emergency requiring emergent surgical intervention. Little is known about potential racial-ethnic disparities among patients with EP.

Methods

Hospitalizations of adult (≥18 years old) patients admitted with a diagnosis of EP were identified in the 2000-2017 National Inpatient Sample (NIS). Multivariable Cox proportional hazards regression was used to estimate the association between race-ethnicity and inpatient mortality. Inpatient complications were assessed using multivariable logistic regression.

Results

There were an estimated 36,531 EP hospitalizations from 2000-2017. One quarter of hospitalizations were racial or ethnic minorities. Non-Hispanic (NH) White patients were, on average, older (median age 58 vs. 41 and 47 years, respectively, P<0.0001). The rate of EP admissions, per 1,000,000 the United States (US) adults, significantly increased among all groups over time. In-hospital mortality decreased for both NH White and NH Black patients (10.2% to 4.6% and 8.3% to 4.9%, respectively, P<0.0001) but increased for Hispanic patients and patients of other races (2.9% to 4.7% and 3.4% to 6.9%, P<0.0001). NH Black patients were more likely to have sepsis during their hospital course [odds ratio (OR) =1.34; 95% confidence interval (CI): 1.08 to 1.66], and patients of other races (OR =1.44; 95% CI: 1.01 to 2.07) were more likely to have pneumonia. Similar rates of surgical intervention were seen among all racial-ethic groups. After adjustment, inpatient mortality did not differ among racial-ethnic groups.

Conclusions

Rates of EP admissions have increased for all racial-ethnic groups since 2000. Despite similar incidences of inpatient mortality across groups, NH Black and other race patients were more likely to experience postoperative complications, suggesting potential racial-ethnic disparities in quality or access to care.

County-level barriers in the COVID-19 vaccine coverage index and their associations with willingness to receive the COVID-19 vaccine across racial/ethnic groups in the U.S

Background

County-level vaccination barriers (sociodemographic barriers, limited healthcare system resources, healthcare accessibility barriers, irregular healthcare seeking behaviors, history of low vaccination) may partially explain COVID-19 vaccination intentions among U.S. adults. This study examined whether county-level vaccination barriers varied across racial/ethnic groups in the U.S. and were associated with willingness to receive the COVID-19 vaccine. In addition, this study assessed whether these associations differed across racial/ethnic groups.

Methods

This study used data from the REACH-US study, a large online survey of U.S. adults (N = 5,475) completed from January 2021-March 2021. County-level vaccination barriers were measured using the COVID-19 Vaccine Coverage Index. Ordinal logistic regression estimated associations between race/ethnicity and county-level vaccination barriers and between county-level vaccination barriers and willingness to receive the COVID-19 vaccine. Models adjusted for covariates (age, gender, income, education, political ideology, health insurance, high-risk chronic health condition). Multigroup analysis estimated whether associations between barriers and willingness to receive the COVID-19 vaccine differed across racial/ethnic groups.

Results

American Indian/Alaska Native, Black/African American, Hispanic/Latino ELP [English Language Preference (ELP); Spanish Language Preference (SLP)], and Multiracial adults were more likely than White adults to live in counties with higher overall county-level vaccination barriers [Adjusted Odd Ratios (AORs):1.63-3.81]. Higher county-level vaccination barriers were generally associated with less willingness to receive the COVID-19 vaccine, yet associations were attenuated after adjusting for covariates. Trends differed across barriers and racial/ethnic groups. Higher sociodemographic barriers were associated with less willingness to receive the COVID-19 vaccine (AOR:0.78, 95% CI:0.64-0.94), whereas higher irregular care-seeking behavior was associated with greater willingness to receive the vaccine (AOR:1.20, 95% CI:1.04-1.39). Greater history of low vaccination was associated with less willingness to receive the COVID-19 vaccine among Black/African American adults (AOR:0.55, 95% CI:0.37-0.84), but greater willingness to receive the vaccine among American Indian/Alaska Native and Hispanic/Latino ELP adults (AOR:1.90, 95% CI:1.10-3.28; AOR:1.85, 95% CI:1.14-3.01).

Discussion

Future public health emergency vaccination programs should include planning and coverage efforts that account for structural barriers to preventive healthcare and their intersection with sociodemographic factors. Addressing structural barriers to COVID-19 treatment and preventive services is essential for reducing morbidity and mortality in future infectious disease outbreaks.

COVID-19 vaccination willingness and uptake among low-income Black/African American, Latino, and White adults living in the U.S

The purpose of this study was to assess differences in COVID-19 vaccine willingness and uptake between low-income and non-low-income adults and across race-ethnicity. We utilized data from the COVID-19's Unequal Racial Burden online survey, which included baseline (12/17/2020-2/11/2021) and 6-month follow-up (8/13/2021-9/9/2021) surveys. The sample included 1,500 Black/African American, Latino, and White low-income adults living in the U.S. (N = 500 each). A non-low-income cohort was created for comparison (n = 1,188). Multinomial logistic regression was used to assess differences in vaccine willingness and uptake between low-income and non-low-income adults, as well as across race-ethnicity (low-income adults only). Only low-income White adults were less likely to be vaccinated compared to their non-low-income counterparts (extremely willing vs. not at all: OR = 0.58, 95% CI = 0.39-0.86); low-income Black/African American and Latino adults were just as willing or more willing to vaccinate. At follow-up, only 30.2% of low-income adults who reported being unwilling at baseline were vaccinated at follow-up. White low-income adults (63.6%) appeared less likely to be vaccinated, compared to non-low-income White adults (80.9%), low-income Black/African American (70.7%), and low-income Latino adults (72.4%). Distrust in the government (46.6), drug companies (44.5%), and vaccine contents (52.1%) were common among those unwilling to vaccinate. This prospective study among a diverse sample of low-income adults found that low-income White adults were less willing and less likely to vaccinate than their non-low-income counterparts, but this difference was not observed for Black/African American or Latino adults. Distrust and misinformation were prevalent among those who remained unvaccinated at follow-up.

Inability to get needed health care during the COVID-19 pandemic among a nationally representative, diverse population of U.S. adults with and without chronic conditions

BACKGROUND

Delays in health care have been observed in the U.S. during the COVID-19 pandemic; however, the prevalence of inability to get needed care and potential disparities in health care access have yet to be assessed.

METHODS

We conducted a nationally representative, online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Latino (English- and Spanish-speaking), Native Hawaiian/Pacific Islander, White, and multiracial adults between 12/2020-2/2021 (baseline) and 8/16/2021-9/9/2021 (6-month follow-up). Participants were asked "Since the start of the pandemic, was there any time when you did not get medical care that you needed?" Those who responded "Yes" were asked about the type of care and the reason for not receiving care. Poisson regression was used to estimate the association between sociodemographics and inability to receive needed care; all analyses were stratified by chronic condition status. Chronic conditions included: chronic obstructive pulmonary disease (COPD), heart conditions, type 2 diabetes, chronic kidney disease or on dialysis, sickle cell disease, cancer, and immunocompromised state (weakened immune system).

RESULTS

Overall, 20.0% of participants at baseline and 22.7% at follow-up reported not getting needed care. The most common reasons for being unable to get needed care included fear of COVID-19 (baseline: 44.1%; follow-up: 47.2%) and doctors canceled appointment (baseline: 25.3%; follow-up: 14.1%). Routine care (baseline: 59.9%; follow-up: 62.6%) and chronic care management (baseline: 31.5%; follow-up: 30.1%) were the most often reported types of delayed care. Fair/poor self-reported physical health was significantly associated with being unable to get needed care despite chronic condition status (≥ 1 chronic condition: aPR = 1.36, 95%CI = 1.04-1.78); no chronic conditions: aPR = 1.52, 95% CI = 1.28-1.80). The likelihood of inability to get needed care differed in some instances by race/ethnicity, age, and insurance status. For example, uninsured adults were more likely to not get needed care (≥ 1 chronic condition: aPR = 1.76, 95%CI = 1.17-2.66); no chronic conditions: aPR = 1.25, 95% CI = 1.00-1.56).

CONCLUSIONS

Overall, about one fifth of participants reported being unable to receive needed care at baseline and follow-up. Delays in receiving needed medical care may exacerbate existing conditions and perpetuate existing health disparities among vulnerable populations who were more likely to have not received needed health care during the pandemic.

Telehealth access, willingness, and barriers during the COVID-19 pandemic among a nationally representative diverse sample of U.S. adults with and without chronic health conditions

INTRODUCTION

During the COVID-19 pandemic, telehealth services represented a critical tool in maintaining continuity and access to care for adults in the USA. However, despite improvements in access and utilization during the pandemic, disparities in telehealth utilization have persisted. It is unclear what role access and willingness to use telehealth play in telehealth disparities.

METHODS

We used data from the nationally representative COVID-19's Unequal Racial Burden (CURB) survey, an online survey conducted between December 2020 and February 2021, n = 5500. Multivariable Poisson regression was used to estimate the prevalence of perceived telehealth access and willingness to use telehealth services among adults with and without chronic conditions.

RESULTS

Overall, 60.1% of adults with and 38.7% of adults without chronic conditions reported having access to telehealth. After adjustment, adults with chronic conditions were more likely to report telehealth access (adjusted prevalence ratio [aPR] = 1.35, 95% confidence interval [CI] = 1.21-1.50). Most adults with and without chronic conditions reported being willing to use telehealth services (85.1% and 79.8%, respectively), and no significant differences in willingness were observed across chronic condition status (aPR = 1.03, 95% CI = 0.95-1.13). Perceived telehealth access appeared to be a predictor of telehealth willingness in both groups (chronic conditions: aPR = 1.22, 95% CI = 0.97-1.54; no chronic conditions: aPR = 1.37, 95% CI = 1.22-1.54). The prevalence of perceived barriers to telehealth was low, with the majority reporting no barriers (chronic conditions = 51.4%; no chronic conditions = 61.4%).

DISCUSSION

Perceived access to telehealth was associated with telehealth willingness. Investing in approaches that increase telehealth accessibility and awareness is needed to improve access to telehealth for adults with and without chronic conditions.

COVID-19 vaccination willingness and uptake among rural Black/African American, Latino, and White adults

PURPOSE

The purpose of this study was to assess differences in COVID-19 vaccine willingness and uptake between rural and nonrural adults, and within rural racial-ethnic groups.

METHODS

We utilized data from the COVID-19's Unequal Racial Burden online survey, which included 1,500 Black/African American, Latino, and White rural adults (n = 500 each). Baseline (12/2020-2/2021) and 6-month follow-up (8/2021-9/2021) surveys were administered. A cohort of nonrural Black/African American, Latino, and White adults (n = 2,277) was created to compare differences between rural and nonrural communities. Multinomial logistic regression was used to assess associations between rurality, race-ethnicity, and vaccine willingness and uptake.

FINDINGS

At baseline, only 24.9% of rural adults were extremely willing to be vaccinated and 28.4% were not at all willing. Rural White adults were least willing to be vaccinated, compared to nonrural White adults (extremely willing: aOR = 0.44, 95% CI = 0.30-0.64). At follow-up, 69.3% of rural adults were vaccinated; however, only 25.3% of rural adults who reported being unwilling to vaccinate were vaccinated at follow-up, compared to 95.6% of adults who were extremely willing to be vaccinated and 76.3% who were unsure. Among those unwilling to vaccinate at follow-up, almost half reported distrust in the government (52.3%) and drug companies (46.2%); 80% reported that nothing would change their minds regarding vaccination.

CONCLUSIONS

By August 2021, almost 70% of rural adults were vaccinated. However, distrust and misinformation were prevalent among those unwilling to vaccinate at follow-up. To continue to effectively combat COVID-19 in rural communities, we need to address misinformation to increase COVID-19 vaccination rates.

Racial/Ethnic Disparities in Financial Hardship During the First Year of the Pandemic

Introduction

The economic impact of the COVID-19 pandemic has been substantial, yet little is known about the financial effects resulting from lost employment or financial hardship racial-ethnic disparities.

Methods

We conducted a nationally representative, online survey of 5500 English- and Spanish-speaking American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, Latino, White, and multiracial adults, from December 2020 to February 2021. Six financial hardship domains were measured (lost income, debt, unmet expenses, unmet health care expenses, housing insecurity, and food insecurity). Prevalence of financial hardship among each racial-ethnic group was estimated using multivariable Poisson regression.

Results

Overall, 70.3% reported experiencing financial hardship; debt (57.6%), lost income (44.5%), and unmet expenses (33.7%) were most common. American Indian/Alaska Native (adjusted prevalence ratio [aPR]=1.19, 95% confidence interval [CI]=1.04 to 1.35), Black/African American (aPR=1.18, 95% CI=1.06 to 1.32), Latino (English-speaking: aPR=1.15, 95% CI=1.01 to 1.31; Spanish-speaking: aPR=1.27, 95% CI=1.12 to 1.45), and Native Hawaiian/Pacific Islander (aPR=1.21, 95% CI=1.06 to 1.38) adults were more likely to experience financial hardship, compared with White adults. American Indian/Alaska Native, Black/African American, Spanish-speaking Latino, and Native Hawaiian/Pacific Islander adults were also more likely to report hardship in almost all hardship domains (e.g., housing insecurity: aPRs=1.37-1.91).

Conclusions

Racial/ethnic minorities were more likely to experience financial hardship during the pandemic. The prevalence of lost income was similar across most racial/ethnic groups, suggesting that preexisting wealth disparities led to some groups being less able to handle the economic shocks caused by the COVID-19 pandemic. Financial hardship may be underestimated for communities without English or Spanish fluency. Without intervention, financial hardship will likely exacerbate wealth disparities in the United States.

Financial hardship, sleep disturbances, and their relationship among men and women in the United States during the COVID-19 pandemic

OBJECTIVE

In the United States (US), the health and financial consequences of COVID-19 have disproportionately impacted women and minoritized racial-ethnic groups. Yet, few US studies have investigated financial hardship during the COVID-19 pandemic and sleep health disparities. Our objective was to investigate associations between financial hardship and sleep disturbances during the COVID-19 pandemic by gender and race and ethnicity in the United States.

METHODS

We used the nationally representative COVID-19's Unequal Racial Burden cross-sectional survey data collected among 5339 men and women from 12/2020 to 2/2021. Participants reported financial hardship (eg, debt, employment/work loss) since the pandemic began and completed the Patient-Reported Outcomes Management Information System Short Form 4a for sleep disturbances. Prevalence ratios (PRs) and 95% confidence intervals were estimated using adjusted, weighted Poisson regression with robust variance.

RESULTS

Most (71%) participants reported financial hardship. Prevalence of moderate to severe sleep disturbances was 20% overall, higher among women (23%), and highest among American Indian/Alaska Native (29%) and multiracial adults (28%). Associations between financial hardship and moderate to severe sleep disturbances (PR = 1.52 [95% confidence interval: 1.18, 1.94]) did not differ by gender but varied by race and ethnicity: associations were strongest among Black/African American (PR = 3.52 [1.99,6.23]) adults.

CONCLUSIONS

Both financial hardship and sleep disturbances were prevalent, and their relationships were strongest among certain minoritized racial-ethnic groups, particularly Black/African American adults. Interventions that alleviate financial insecurity may reduce sleep health disparities.

Financial Hardship and Psychological Distress During the Pandemic: A Nationally Representative Survey of Major Racial-Ethnic Groups in the United States

Introduction

While financial hardship has been consistently linked to psychological distress, little research exists on associations between financial hardship experienced during the pandemic and mental health.

Methods

We conducted a nationally representative, online survey of American Indian/Alaska Native, Asian, Black/African American, Latino (English and Spanish speaking), Native Hawaiian/Pacific Islander, White, and multiracial adults, 12/2020-2/2021 (n=5500). Six financial hardship domains were measured (lost income, debt, unmet expenses, unmet health care expenses, housing insecurity, and food insecurity). Psychological distress measures included anxiety-depression symptoms (Patient Health Questionnaire-4), perceived stress (modified Perceived Stress Scale), and loneliness-isolation ("In the past month, how often have you felt lonely and isolated?"). Associations between financial hardship and psychological distress were estimated using multinomial logistic regression.

Results

Overall, 70.3% of participants reported experiencing financial hardship (substantial hardship: 21.3%; some hardship: 27.4%; and a little hardship: 21.6%), with Spanish-speaking Latino (87.3%) and Native Hawaiian/Pacific Islander (79.2%) adults being most likely. Debt (57.6%), lost income (44.5%), and unmet expenses (33.7%) were the most common. There was a dose-response association between financial hardship and moderate/severe anxiety-depression symptoms (a little hardship: adjusted odds ratio [aOR]=1.42, 95% confidence interval [CI]=1.12-1.80; some hardship: aOR=3.21, 95% CI=2.58-3.98; and substantial hardship: aOR=8.15, 95% CI=6.45-10.29). Similar dose-response trends were observed with perceived stress and loneliness-isolation. No racial-ethnic difference in the association between financial hardship during the pandemic and psychological distress was seen.

Discussion

Financial hardship has had a major impact on psychological distress during the pandemic; moreover, while no racial-ethnic difference in the effect of financial hardship was observed, because racial-ethnic minorities experienced greater hardship, financial hardship may exacerbate psychological distress disparities.

Regarding "Neoadjuvant Versus Adjuvant Chemotherapy for Resectable Metastatic Colon Cancer in Non-academic and Academic Programs"

This letter to the editor expresses concerns related to immortal time bias that may partially account for recently published study results.

Depression Symptoms, Perceived Stress, and Loneliness During the COVID-19 Pandemic Among Diverse US Racial-Ethnic Groups

Introduction

Studies have reported increases in psychological distress during the COVID-19 pandemic. This study aimed to estimate associations between race-ethnicity and psychological distress during the COVID-19 pandemic among nationally representative samples of all major racial-ethnic groups in the United States.

Methods

We conducted a nationally representative cross-sectional survey between December 2020 and February 2021 of Asian, black/African American, Latino (English and Spanish speaking), American Indian/Alaska Native, Native Hawaiian/Pacific Islander, white, and multiracial adults (n=5500). Distress measures included: anxiety-depression (Patient Health Questionnaire-4 [PHQ-4]), stress (modified Perceived Stress Scale), and loneliness-isolation (frequency felt lonely and isolated). Multinomial logistic regression models estimated associations between race-ethnicity and psychological distress, adjusting for demographic and health characteristics.

Results

Overall, 23.7% reported moderate/severe anxiety-depression symptoms, 34.3% reported moderate/severe stress, and 21.3% reported feeling lonely-isolated fairly/very often. Compared with white adults and adjusting for covariates, the prevalence of moderate/severe anxiety-depression was significantly lower among Asian (adjusted odds ratio [aOR]=0.44, 95% confidence interval [CI]=0.34-0.58), black (aOR=0.49, 95% CI=0.38-0.63), English-speaking Latino (aOR=0.62, 95% CI=0.45-0.85), Spanish-speaking Latino (aOR=0.31, 95% CI=0.22-0.44), and Native Hawaiian/Pacific Islander (aOR=0.66, 95% CI=0.49-0.90) adults. Similar trends were seen for moderate/severe stress and feeling lonely-isolated fairly/very often. Worse distress profiles of American Indian/Alaska Native and multiracial adults were attenuated after adjustment.

Conclusions

Minoritized groups tended to have less distress than white adults. Collective experiences of cumulative disadvantage could engender shared resiliency/normalization among these groups.

Disparities in telehealth access, not willingness to use services, likely explain rural telehealth disparities

PURPOSE

Although telehealth access and utilization have increased during the pandemic, rural and low-income disparities persist. We sought to assess whether access or willingness to use telehealth differed between rural and non-rural and low-income and non-low-income adults and measure the prevalence of perceived barriers.

METHODS

We conducted a cross-sectional study using COVID-19's Unequal Racial Burden (CURB) online survey (December 17, 2020-February 17, 2021), which included 2 nationally representative cohorts of rural and low-income Black/African American, Latino, and White adults. Non-rural and non-low-income participants from the main, nationally representative sample were matched for rural versus non-rural and low-income versus non-low-income comparisons. We measured perceived telehealth access, willingness to use telehealth, and perceived telehealth barriers.

FINDINGS

Rural (38.6% vs 44.9%) and low-income adults (42.0% vs 47.4%) were less likely to report telehealth access, compared to non-rural and non-low-income counterparts. After adjustment, rural adults were still less likely to report telehealth access (adjusted prevalence ratio [aPR] = 0.89, 95% CI = 0.79-0.99); no differences were seen between low-income and non-low-income adults (aPR = 1.02, 95% CI = 0.88-1.17). The majority of adults reported willingness to use telehealth (rural = 78.4%; low-income = 79.0%), with no differences between rural and non-rural (aPR = 0.99, 95% CI = 0.92-1.08) or low-income versus non-low-income (aPR = 1.01, 95% CI = 0.91-1.13). No racial/ethnic differences were observed in willingness to use telehealth. The prevalence of perceived telehealth barriers was low, with the majority reporting no barriers (rural = 57.4%; low-income = 56.9%).

CONCLUSIONS

Lack of access (and awareness of access) is likely a primary driver of disparities in rural telehealth use. Race/ethnicity was not associated with telehealth willingness, suggesting that equal utilization is possible once granted access.

Race/ethnicity-specific associations between breastfeeding information source and breastfeeding rates among U.S. women

BACKGROUND

Despite evidence of the impact of breastfeeding information on breastfeeding rates, it is unknown if information sources and impact vary by race/ethnicity, thus this study assessed race/ethnicity-specific associations between breastfeeding information sources and breastfeeding.

METHODS

We used data from the 2016-2019 Pregnancy Risk Assessment Monitoring System. Race/ethnicity-stratified multinomial logistic regression was used to estimate associations between information source (e.g., family/friends) and breastfeeding rates (0 weeks/none, < 10 weeks, or ≥ 10 weeks; < 10 weeks and ≥ 10 weeks = any breastfeeding). All analyses were weighted to be nationally representative.

RESULTS

Among 5,945,018 women (weighted), 88% reported initiating breastfeeding (≥ 10 weeks = 70%). Information from family/friends (< 10 weeks: aORs = 1.58-2.14; ≥ 10 weeks: aORs = 1.63-2.64) and breastfeeding support groups (< 10 weeks: aORs = 1.31-1.76; ≥ 10 weeks: aORs = 1.42-2.77) were consistently associated with breastfeeding and duration across most racial/ethnic groups; effects were consistently smaller among Alaska Native, Black, and Hispanic women (vs White women). Over half of American Indian and one-quarter of Black women reported not breastfeeding/stopping breastfeeding due to return to school/work concerns.

CONCLUSIONS

Associations between breastfeeding information source and breastfeeding rates vary across race/ethnicity. Culturally tailored breastfeeding information and support from family/friends and support groups could help reduce breastfeeding disparities. Additional measures are needed to address disparities related to concerns about return to work/school.

Impact of COVID-related policies on gunshot wound assault hospitalizations in the United States: a statewide time series analysis

BACKGROUND

The CDC recently reported that firearm homicide rates in the United States increased in 2020, particularly among Black/African American individuals and men 25-44 years old. It is unclear whether firearm hospitalizations also increased, and more importantly, what impact the COVID-19 pandemic and COVID-related policies had. Using the North Carolina Trauma Registry, a statewide registry of trauma admissions to eighteen North Carolina hospitals, we calculated weekly GSW hospitalization rates from 1/2019 to 12/2020, overall and stratified by race-ethnicity, age, and sex. Interrupted time-series design and segmented linear regression were used to estimate changes in weekly hospitalization rates over time after (1) U.S. declaration of a public health emergency; (2) statewide Stay-at-Home order; (3) Stay-at-Home order lifted with restrictions (Phase 2: Safer-at-Home); and (4) further lifting of restrictions (Phase 2.5: Safer-at-Home). Non-GSW assault hospitalizations were used as a control to assess whether trends were observed across all assault hospitalizations or if effects were specific to gun violence.

FINDINGS

Overall, 47.3% (n = 3223) of assault hospitalizations were GSW. Among GSW hospitalizations, median age was 27 years old (interquartile range [IQR] 21-25), 86.2% were male, and 49.5% occurred after the U.S. declared a public health emergency. After the Stay-at-Home order was implemented, weekly GSW hospitalization rates began increasing substantially among Black/African American residents (weekly trend change = 0.775, 95% CI = 0.254 to 1.296), peaking at an average 15.6 hospitalizations per 1,000,000 residents. Weekly hospitalization rates declined after restrictions were lifted but remained elevated compared to pre-COVID levels in this group (average weekly rate 10.6 per 1,000,000 at the end of 2020 vs. 8.9 per 1,000,000 pre-pandemic). The Stay-at-Home order was also associated with increasing GSW hospitalization rates among males 25-44 years old (weekly trend change = 1.202, 95% CI = 0.631 to 1.773); rates also remained elevated among 25-44-year-old males after restrictions were lifted in 2020 (average weekly rate 10.1 vs. 7.9 per 1,000,000). Non-GSW hospitalization rates were relatively stable in 2020.

CONCLUSIONS

The COVID-19 pandemic and statewide Stay-at-Home orders appeared to have placed Black/African American residents and men ages 25-44 at higher risk for GSW hospitalizations, exacerbating pre-existing disparities. Persistent gun violence disparities must be addressed.

Effect of Stay-at-Home orders and other COVID-related policies on trauma hospitalization rates and disparities in the USA: a statewide time-series analysis

BACKGROUND

To combat the coronavirus pandemic, states implemented several public health policies to reduce infection and transmission. Increasing evidence suggests that these prevention strategies also have had a profound impact on non-COVID healthcare utilization. The goal of this study was to determine the impact of a statewide Stay-at-Home order and other COVID-related policies on trauma hospitalizations, stratified by race/ethnicity, age, and sex.

METHODS

We used the North Carolina Trauma Registry, a statewide registry of trauma hospitalizations for 18 hospitals across North Carolina, including all North Carolina trauma centers, to calculate weekly rates of assault, self-inflicted, unintentional motor vehicle collision (MVC), and other unintentional injury hospitalizations between January 1, 2019, and December 31, 2020. Interrupted time-series design and segmented linear regression were used to estimate changes in hospitalization rates after several COVID-related executive orders, overall and stratified by race/ethnicity, age, and sex. Changes in hospitalization rates were assessed after 1) USA declaration of a public health emergency; 2) North Carolina statewide Stay-at-Home order; 3) Stay-at-Home order lifted with restrictions (Phase 2: Safer-at-Home); and 4) further lifting of restrictions (Phase 2.5: Safer-at-Home).

RESULTS

There were 70,478 trauma hospitalizations in North Carolina, 2019-2020. In 2020, median age was 53 years old and 59% were male. Assault hospitalization rates (per 1,000,000 NC residents) increased after the Stay-at-Home order, but substantial increases were only observed among Black/African American residents (weekly trend change = 1.147, 95% CI = 0.634 to 1.662) and 18-44-year-old males (weekly trend change = 1.708, 95% CI = 0.870 to 2.545). After major restrictions were lifted, assault rates decreased but remained elevated compared to pre-COVID levels. Unintentional non-MVC injury hospitalizations decreased after the USA declared a public health emergency, especially among women ≥ 65 years old (weekly trend change = -4.010, 95% CI = -6.166 to -1.855), but returned to pre-pandemic levels within several months.

CONCLUSIONS

Statewide Stay-at-Home orders placed Black/African American residents at higher risk of assault hospitalizations, exacerbating pre-existing disparities. Males 18-44 years old were also at higher risk of assault hospitalization. Fear of COVID-19 may have led to decreases in unintentional non-MVC hospitalization rates, particularly among older females. Policy makers must anticipate policy-related harms that may disproportionately affect already disadvantaged communities and develop mitigation approaches.

The Timing, the Treatment, the Question: Comparison of Epidemiologic Approaches to Minimize Immortal Time Bias in Real-World Data Using a Surgical Oncology Example

BACKGROUND

Studies evaluating the effects of cancer treatments are prone to immortal time bias that, if unaddressed, can lead to treatments appearing more beneficial than they are.

METHODS

To demonstrate the impact of immortal time bias, we compared results across several analytic approaches (dichotomous exposure, dichotomous exposure excluding immortal time, time-varying exposure, landmark analysis, clone-censor-weight method), using surgical resection among women with metastatic breast cancer as an example. All adult women diagnosed with incident metastatic breast cancer from 2013-2016 in the National Cancer Database were included. To quantify immortal time bias, we also conducted a simulation study where the "true" relationship between surgical resection and mortality was known.

RESULTS

24,329 women (median age 61, IQR 51-71) were included, and 24% underwent surgical resection. The largest association between resection and mortality was observed when using a dichotomized exposure [HR, 0.54; 95% confidence interval (CI), 0.51-0.57], followed by dichotomous with exclusion of immortal time (HR, 0.62; 95% CI, 0.59-0.65). Results from the time-varying exposure, landmark, and clone-censor-weight method analyses were closer to the null (HR, 0.67-0.84). Results from the plasmode simulation found that the time-varying exposure, landmark, and clone-censor-weight method models all produced unbiased HRs (bias -0.003 to 0.016). Both standard dichotomous exposure (HR, 0.84; bias, -0.177) and dichotomous with exclusion of immortal time (HR, 0.93; bias, -0.074) produced meaningfully biased estimates.

CONCLUSIONS

Researchers should use time-varying exposures with a treatment assessment window or the clone-censor-weight method when immortal time is present.

IMPACT

Using methods that appropriately account for immortal time will improve evidence and decision-making from research using real-world data.

Minimally invasive, benign foregut surgery is not associated with long-term, persistent opioid use postoperatively: an analysis of the IBM® MarketScan® database

BACKGROUND

It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use.

METHODS

Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression.

RESULTS

A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively.

CONCLUSIONS

Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.

Surgical site infection after open lower extremity revascularization associated with doubled rate of major limb amputation

OBJECTIVE

Surgical site infection (SSI) after open lower extremity revascularization is a relatively common complication associated with increased hospital stays, graft infection, and in severe cases, graft loss. Although the short-term effects of SSI can be significant, it has not been considered a complication that increases major limb amputation. The purpose of this study was to determine the association of SSI with outcomes in patients undergoing surgical revascularization for peripheral arterial disease.

METHODS

We analyzed nationwide Vascular Quality Initiative (VQI) data from the infrainguinal bypass module from 2003 to 2017. The cohort included adults who underwent open lower extremity bypass for symptomatic peripheral arterial disease and had at least one follow-up record. Weighted Kaplan-Meier curves and Cox proportional hazards regression were used to assess the association between SSI and 1-year mortality and major limb amputation. Inverse-probability of treatment weights were used to account for differences in demographics and patient characteristics and allow for 'adjusted' Kaplan-Meier curves.

RESULTS

The analysis included 21,639 patients, and 1155 (5%) had a reported SSI within 30 days of surgery. Patients with SSI were more likely be obese (41% vs 30%), but there were no other clinically relevant differences between demographics, comorbidities, and bypass details. After weighting, patients with SSI were almost twice as likely to undergo major amputation by 6 months (hazard ratio, 1.84; 95% confidence interval, 1.07-3.17). The association with SSI and increased amputation rates persisted at 1 year. The association of SSI on amputation was no different based on preoperative Rutherford class (P = .91). The association between SSI and 1-year mortality rate was not statistically significant (hazard ratio, 1.15; 95% confidence interval, 0.91-1.46).

CONCLUSIONS

SSI is more common in obese patients, and patients who develop an SSI are observed to have a significantly increased rate of limb amputation after open lower extremity revascularization.

Perceived general, mental, and physical health of Latinos in the United States following adoption of immigrant-inclusive state-level driver's license policies: a time-series analysis

Background

In the United States (U.S.), several states have laws that allow individuals to obtain driver’s licenses regardless of their immigration status. Possession of a driver’s license can improve an individual’s access to social programs, healthcare services, and employment opportunities, which could lead to improvements in perceived mental and physical health among Latinos living in the U.S.

Methods

Using Behavioral Risk Factor Surveillance System data (2011–2019) for Latinos living in the U.S. overall (immigration status was not available), we compared the average number of self-reported perceived poor mental and physical health days/month, and general health status (single-item measures) before (January 2011-June 2013) and after implementation (July 2015-December 2019) of immigrant-inclusive license policies using interrupted time-series analyses and segmented linear regression, and a control group of states in which such policies were not implemented. We also compared the average number of adults reporting any perceived poor mental or physical health days (≥ 1 day/month) using a similar approach.

Results

One hundred twenty-three thousand eight hundred seven Latino adults were included; 66,805 lived in states that adopted immigrant-inclusive license policies. After implementation, average number of perceived poor physical health days significantly decreased from 4.30 to 3.80 days/month (immediate change = -0.64, 95% CI = -1.10 to -0.19). The proportion reporting ≥ 1 perceived poor physical and mental health day significantly decreased from 41 to 34% (OR = 0.89, 95% CI = 0.80–1.00) and from 40 to 33% (OR = 0.84, 95% CI = 0.74–0.94), respectively.

Conclusions

Among all Latinos living in the U.S., immigrant-inclusive license policies were associated with fewer perceived poor physical health days per month and fewer adults experiencing poor physical and mental health. Because anti-immigrant policies can harm Latino communities regardless of immigration status and further widen health inequities, implementing state policies that do not restrict access to driver licenses based on immigrant status documentation could help address upstream drivers of such inequities.