The Role of Poverty and Racial Discrimination in Exacerbating the Health Consequences of COVID-19

Reaching Structurally Vulnerable Populations Using Low-Barrier COVID-19 Testing Clinics Co-Created with Community-Based Organizations

BACKGROUND

The COVID-19 pandemic disproportionately affected people from structurally vulnerable communities. There was a need to improve COVID-19 testing in these communities to reduce viral spread and connect to treatment.

OBJECTIVE

We created a partnership between an academic medical center and three community-based organizations (CBOs) to offer low-barrier COVID-19 walk-up testing clinics in Portland, Maine. Our objective was to examine whether the co-created testing clinics reached structurally vulnerable populations.

DESIGN

The clinics offered COVID-19 rapid antigen tests three times a week outside CBO sites from January 2022 to May 2023. Clinic staff administered a brief survey on reason for testing and then instructed participants on how to self-swab. While staff processed the test, participants were invited to complete an additional survey about their demographics and testing perceptions.

PARTICIPANTS

Adults seeking COVID-19 testing with specific outreach to people who are unhoused, immigrants, and low-income and/or uninsured.

MAIN MEASURES

Number of tests conducted and result, reasons for testing, and testing perceptions.

KEY RESULTS

Of 246 completed tests, 18 were positive for COVID-19 (7%). Participants sought testing for a variety of reasons, including symptoms (60%), close contact exposure (29%), and/or need for a negative test result to access services or an activity (33%). Overall, people primarily tested due to symptoms with only 7% testing due to close contact exposure alone. The clinics reached vulnerable populations. Among the 130 people completing the participant survey, 39% were unhoused, 22% spoke a language other than English at home, 23% were uninsured, and 46% earned less than $20,000 in 2019. Qualitative field notes captured key elements of clinics that influenced reach, and how this collaboration with CBOs helped build trust with our target populations.

CONCLUSIONS

Providing low-barrier walk-up clinics partnering with trusted CBOs was observed to be helpful in reaching structurally vulnerable populations for COVID-19 testing.

Adolescents' Mental Health Concerns in Pre- and During COVID-19: Roles of Adverse Childhood Experiences and Emotional Resilience

Limited research has explored the trend of adolescent mental health concerns pre- and during the COVID-19 pandemic and how such mental health concerns are explained by emotional resilience and Adverse Childhood Experiences (ACEs). The purpose of this study is to investigate the prevalence and severity of mental health concerns among U.S. adolescents and examine the mediating role of emotional resilience in the relationship between ACEs and mental health concerns (i.e., anxiety and depression). Using the 2018-2021 National Survey of Children's Health, we analyzed a large sample of 12-17 aged adolescents. Descriptive statistics of the prevalence and severity of mental health concerns were conducted. Further, four separate mediation analyses were conducted to examine the association between ACEs, emotional resilience, and mental health concerns for each year. Two key findings are as follows. First, the prevalence and severity of mental health concerns have shown an upward trend across pre- and during COVID-19. Second, all paths in the mediation models were found to be statistically associated with one another over four years. We used parents' reports for variables of interest; further we used a single item to capture emotional resilience. This study not only demonstrates the trend of adolescent mental health concerns before and during COVID-19 but also highlights the crucial role of emotional resilience as a mediator of ACEs and mental health concerns. Findings emphasize the imperative for prevention and intervention efforts to strengthen adolescents' emotional capacity to cope with childhood adversities and additional life challenges.

A Study on Economic Stressors During the COVID-19 Pandemic Among Intimate Partner and Sexual Violence Survivors in the United States

Systemic racism and racialized poverty are socially produced structural determinants that shape health outcomes during infectious disease outbreaks. Public health emergencies compound vulnerabilities for survivors of intimate partner violence (IPV) and sexual violence (SV) and those who self-identify as people from racial and ethnic minority groups. We describe findings from an online survey designed to collect data on financial conditions faced by survivors of IPV and SV to understand these conditions during the COVID-19 pandemic. Our analyses were limited to a sample of women in the United States (91.4%, n = 523) who reported IPV or SV to whom we refer as survivors. We characterize the differences of economic stressors across White and aggregated categories of self-identified race, i.e., Black and Brown Latinx women and non-Black or non-Brown Latinx women of color, to highlight disparities between White and non-White populations in our sample. Logistic regressions were used to examine the relationships among racial categories, food insecurity, housing insecurity, and economic insecurity during the COVID-19 pandemic. Black and Brown Latinx women survivors were twice as likely as White women to report housing, financial, and economic insecurity during the COVID-19 pandemic. Approximately one-third of all survivors anticipated taking on more debt than they would want to cover their expenses due to COVID-19. The results of this study have implications for public health responses that involve coordinating economic relief measures among populations disparately affected by public health crises and disasters to ensure that the economic needs of the most impacted are addressed.

The TREE Program: Promoting Positive Early Childhood Experiences During Well-Child Visits

This feasibility study evaluated the developmental coaching TREE (Talk Read Engage Encourage) program for historically marginalized children ages 0 to 2 years, embedded within pediatric visits, examining if TREE could enhance caregiver-child interactions and increase pediatric resident report of competency and self-efficacy in coaching caregivers. Using a quasi-experimental design, a convenience sample (n = 167 families) was recruited (79 intervention; 88 control). Follow-up data were obtained from 45% of families (38 intervention; 38 control), impacted by COVID-19 attendance. Analyses demonstrated significant increases in self-reported Parent Verbal Responsivity (d = 0.68; 95% confidence interval [CI] = 0.17 to 1.18; P = .009) by intervention group caregivers. Intervention pediatric residents reported significant increases in promoting positive caregiver-child interactions and confidence in conveying child development (d = -.73; 95% CI = -1.21 to -0.22; P = .003). The TREE program is a promising practice that operationalizes promotion of relational health and positive early childhood experiences within pediatric primary care.

Hospital segregation, critical care strain, and inpatient mortality during the COVID-19 pandemic in New York City

BACKGROUND

Hospital segregation by race, ethnicity, and health insurance coverage is prevalent, with some hospitals providing a disproportionate share of undercompensated care. We assessed whether New York City (NYC) hospitals serving a higher proportion of Medicaid and uninsured patients pre-pandemic experienced greater critical care strain during the first wave of the COVID-19 pandemic, and whether this greater strain was associated with higher rates of in-hospital mortality.

METHODS

In a retrospective analysis of all-payer NYC hospital discharge data, we examined changes in admissions, stratified by use of intensive care unit (ICU), from the baseline period in early 2020 to the first COVID-19 wave across hospital quartiles (265,329 admissions), and crude and risk-adjusted inpatient mortality rates, also stratified by ICU use, in the first COVID wave across hospital quartiles (23,032 inpatient deaths), based on the proportion of Medicaid or uninsured admissions from 2017-2019 (quartile 1 lowest to 4 highest). Logistic regressions were used to assess the cross-sectional association between ICU strain, defined as ICU volume in excess of the baseline average, and patient-level mortality.

RESULTS

ICU admissions in the first COVID-19 wave were 84%, 97%, 108%, and 123% of the baseline levels by hospital quartile 1-4, respectively. The risk-adjusted mortality rates for ICU admissions were 36.4 (CI = 34.7,38.2), 43.6 (CI = 41.5,45.8), 45.9 (CI = 43.8,48.1), and 45.7 (CI = 43.6,48.0) per 100 admissions, and those for non-ICU admissions were 8.6 (CI = 8.3,9.0), 10.9 (CI = 10.6,11.3), 12.6 (CI = 12.1,13.0), and 12.1 (CI = 11.6,12.7) per 100 admissions by hospital quartile 1-4, respectively. Compared with the reference group of 100% or less of the baseline weekly average, ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.17 (95% CI = 1.10, 1.26), 2.63 (95% CI = 2.31, 3.00), and 3.26 (95% CI = 2.82, 3.78) for inpatient mortality, and non-ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.28 (95% CI = 1.22, 1.34), 2.60 (95% CI = 2.40, 2.82), and 3.44 (95% CI = 3.11, 3.63) for inpatient mortality.

CONCLUSIONS

Our findings are consistent with hospital segregation as a potential driver of COVID-related mortality inequities and highlight the need to desegregate health care to address structural racism, advance health equity, and improve pandemic resiliency.

A community psychology for migrant justice: Critically examining border violence and resistance during the COVID-19 syndemic

This article explores the magnifying lenses of the COVID-19 syndemic to highlight how people racialized as migrants and refugees have been-and continue to be-disproportionally harmed. We use empirical evidence collected in our scholarly/activist work in Europe, Africa, South Asia, and the United States to examine migrant injustice as being produced by a combination of power structures and relations working to maintain colonial global orders and inequalities. This is what has been defined as "border imperialism." Our data, complemented by evidence from transnational solidarity groups, show that border imperialism has further intersected with the hygienic-sanitary logics of social control at play during the COVID-19 period. This intersection has resulted in increasingly coercive methods of restraining people on the move, as well as in increased-and new-forms of degradation of their lives, that is, an overall multiplication of border violences. At the same time, however, COVID-19 has provided a unique opportunity for grassroot solidarity initiatives and resistance led by people on the move to be amplified and extended. We conclude by emphasizing the need for community psychologists to take a more vigorous stance against oppressive border imperialist regimes and the related forms of violence they re/enact.

Social Statuses, Perceived Everyday Discrimination and Health and Well-being Before and After COVID-19 Pandemic

This study investigates the impact of COVID-19 pandemic on perceived everyday discrimination using data from the 2018 and 2021 General Social Survey. The study included representative samples of 1,499 adults in 2018 and 2,361 adults in 2021 in the United States. The study found that the overall level of perceived everyday discrimination had a slight decline from 2018 to 2021. However, frequency of being threatened/harassed increased in all racial/ethnic groups and more substantially among Asian Americans and people in the "other race" category. Most social statuses had a similar association with perceived everyday discrimination in 2018 and 2021 (e.g., higher among younger age, homo/bisexual, non-Hispanic Black, U.S. born, divorced/separated). In 2018, perceived discrimination was also higher among Hispanics, people of multiple races, Jews and people of "other religions." In 2021, it was also higher among "other races" and parents who were never married. Perceived everyday discrimination was associated with all health and well-being outcomes. Also, the negative association between perceived discrimination and health and well-being appears to be stronger in 2021 than in 2018. These findings suggest that the pandemic intensified the relationship between perceived everyday discrimination and health and well-being. They point to an urgent need to develop effective efforts to mitigate the harmful impact of discrimination.

Evaluating COVID-19 Risk to Essential Workers by Occupational Group: A Case Study in Massachusetts

Occupational exposure to SARS-CoV-2 varies by profession, but "essential workers" are often considered in aggregate in COVID-19 models. This aggregation complicates efforts to understand risks to specific types of workers or industries and target interventions, specifically towards non-healthcare workers. We used census tract-resolution American Community Survey data to develop novel essential worker categories among the occupations designated as COVID-19 Essential Services in Massachusetts. Census tract-resolution COVID-19 cases and deaths were provided by the Massachusetts Department of Public Health. We evaluated the association between essential worker categories and cases and deaths over two phases of the pandemic from March 2020 to February 2021 using adjusted mixed-effects negative binomial regression, controlling for other sociodemographic risk factors. We observed elevated COVID-19 case incidence in census tracts in the highest tertile of workers in construction/transportation/buildings maintenance (Phase 1: IRR 1.32 [95% CI 1.22, 1.42]; Phase 2: IRR: 1.19 [1.13, 1.25]), production (Phase 1: IRR: 1.23 [1.15, 1.33]; Phase 2: 1.18 [1.12, 1.24]), and public-facing sales and services occupations (Phase 1: IRR: 1.14 [1.07, 1.21]; Phase 2: IRR: 1.10 [1.06, 1.15]). We found reduced case incidence associated with greater percentage of essential workers able to work from home (Phase 1: IRR: 0.85 [0.78, 0.94]; Phase 2: IRR: 0.83 [0.77, 0.88]). Similar trends exist in the associations between essential worker categories and deaths, though attenuated. Estimating industry-specific risk for essential workers is important in targeting interventions for COVID-19 and other diseases and our categories provide a reproducible and straightforward way to support such efforts.

Inequalities in health outcomes of SARS-CoV-2 infection by migration status in Barcelona, Spain

Background

Migrants are a vulnerable population at risk of worse health outcomes due to legal status, language barriers, and socioeconomic and cultural factors. Considering the conflicting literature on the subject, it is important to further explore the extent and nature of these inequalities.

Objective

The aim of this study is to compare health outcomes associated with SARS-CoV-2 infection between Spanish native and migrant population living in Barcelona.

Methods

Observational retrospective cohort study including all adult cases of SARS-CoV-2 infection who visited a tertiary hospital in Barcelona between the 1st March 2020 and the 31st March 2022. We established the following five health outcomes: the presence of symptomatology, hospitalisation, intensive care unit admission, use of mechanical ventilation, and in-hospital 30-day mortality (IHM). Using Spanish natives as a reference, Odds Ratios (OR) with 95% confidence interval (95%CI) were calculated for migrants by multivariate logistic regression and adjusted by sociodemographic and clinical factors.

Results

Of 11,589 patients (46.8% females), 3,914 were born outside of Spain, although 34.8% of them had legal citizenship. Most migrants were born in the Americas Region (20.3%), followed by other countries in Europe (17.2%). Migrants were younger than natives (median 43 [IQR 33-55] years vs. 65 [49-78] years) and had a higher socioeconomic privation index, less comorbidities, and fewer vaccine doses. Adjusted models showed migrants were more likely to report SARS-CoV-2 symptomatology with an adjusted OR of 1.36 (95%CI 1.20-1.54), and more likely to be hospitalised (OR 1.11 [IC95% 1.00-1.23], p < 0.05), but less likely to experience IHM (OR 0.67 [IC95% 0.47-0.93], p < 0.05).

Conclusion

Characteristics of migrant and native population differ greatly, which could be translated into different needs and health priorities. Native population had higher odds of IHM, but migrants were more likely to present to care symptomatic and to be hospitalised. This could suggest disparities in healthcare access for migrant population. More research on health disparities beyond SARS-CoV-2 in migrant populations is necessary to identify gaps in healthcare access and health literacy.

Avoidance of medical care among American Indians with a history of cancer during the coronavirus pandemic

Objectives

Assess the percentage of cancer-related appointment delays, cancelations, and the unavailability of medications experienced by American Indian participants during the COVID-19 pandemic.

Methods

This cross-sectional survey study was completed between October 2020 and July 2021 by 360 individuals with cancer who lived in California and Oklahoma. Binary and multivariate logistic regression analysis was completed in SAS 9.4.

Results

During the initial Covid-19 pandemic, almost one-third (30%) of respondents delayed cancer-related appointments, 42% canceled cancer-related appointments, and one-quarter (24%) were unable to access prescription medications or over-the-counter medications (27%) due to COVID-19. People who underwent testing for COVID-19 were five times more likely to delay a medical appointment [adjusted odds ratio (aOR) = 5.3, 95% CI:2.4, 11.7] and people who followed three or more social distancing measures were more than six times more likely to cancel medical appointments (aOR:6.3, 95% CI:2.9, 13.9).

Conclusion

This study identifies delays, cancelations, and medication inaccessibility people identifying as American Indian faced during the coronavirus pandemic. Disparities in healthcare delivery could contribute to increased morbidity and mortality rates of cancer.

Access to COVID-19 testing by individuals with housing insecurity during the early days of the COVID-19 pandemic in the United States: a scoping review

Introduction

The COVID-19 pandemic focused attention on healthcare disparities and inequities faced by individuals within marginalized and structurally disadvantaged groups in the United States. These individuals bore the heaviest burden across this pandemic as they faced increased risk of infection and difficulty in accessing testing and medical care. Individuals experiencing housing insecurity are a particularly vulnerable population given the additional barriers they face. In this scoping review, we identify some of the barriers this high-risk group experienced during the early days of the pandemic and assess novel solutions to overcome these barriers.

Methods

A scoping review was performed following PRISMA-Sc guidelines looking for studies focusing on COVID-19 testing among individuals experiencing housing insecurity. Barriers as well as solutions to barriers were identified as applicable and summarized using qualitative methods, highlighting particular ways that proved effective in facilitating access to testing access and delivery.

Results

Ultimately, 42 studies were included in the scoping review, with 143 barriers grouped into four categories: lack of cultural understanding, systemic racism, and stigma; medical care cost, insurance, and logistics; immigration policies, language, and fear of deportation; and other. Out of these 42 studies, 30 of these studies also suggested solutions to address them.

Conclusion

A paucity of studies have analyzed COVID-19 testing barriers among those experiencing housing insecurity, and this is even more pronounced in terms of solutions to address those barriers. Expanding resources and supporting investigators within this space is necessary to ensure equitable healthcare delivery.

Weighted Lottery to Equitably Allocate Scarce Supply of COVID-19 Monoclonal Antibody

Importance

Equitable allocation of scarce medications is an important health policy goal. There are few data about attempts to achieve equitable allocation in the community setting.

Objective

To describe the development and use of a weighted lottery to allocate a scarce supply of tixagevimab with cilgavimab as preexposure prophylaxis to COVID-19 for immunocompromised individuals and examine whether this promoted equitable allocation to disadvantaged populations.

Design, Setting, and Participants

This quality improvement study analyzed a weighted lottery process from December 8, 2021, to February 23, 2022, that assigned twice the odds of drug allocation of 450 tixagevimab with cilgavimab doses to individuals residing in highly disadvantaged neighborhoods according to the US Area Deprivation Index (ADI) in a 35-hospital system in Pennsylvania, New York, and Maryland. In all, 10 834 individuals were eligible for the lottery. Weighted lottery results were compared with 10 000 simulated unweighted lotteries in the same cohort performed after drug allocation occurred.

Main Outcomes

Proportion of individuals from disadvantaged neighborhoods and Black individuals who were allocated and received tixagevimab with cilgavimab.

Results

Of the 10 834 eligible individuals, 1800 (16.6%) were from disadvantaged neighborhoods and 767 (7.1%) were Black. Mean (SD) age was 62.9 (18.8) years, and 5471 (50.5%) were women. A higher proportion of individuals from disadvantaged neighborhoods was allocated the drug in the ADI-weighted lottery compared with the unweighted lottery (29.1% vs 16.6%; P < .001). The proportion of Black individuals allocated the drug was greater in the weighted lottery (9.1% vs 7.1%; P < .001). Among the 450 individuals allocated tixagevimab with cilgavimab in the ADI-weighted lottery, similar proportions of individuals from disadvantaged neighborhoods accepted the allocation and received the drug compared with those from other neighborhoods (27.5% vs 27.9%; P = .93). However, Black individuals allocated the drug were less likely to receive it compared with White individuals (3 of 41 [7.3%] vs 118 of 402 [29.4%]; P = .003).

Conclusions and Relevance

The findings of this quality improvement study suggest an ADI-weighted lottery process to allocate scarce resources is feasible in a large health system and resulted in more drug allocation to and receipt of drug by individuals who reside in disadvantaged neighborhoods. Although the ADI-weighted lottery also resulted in more drug allocation to Black individuals compared with an unweighted process, they were less likely to accept allocation and receive it compared with White individuals. Further strategies are needed to ensure that Black individuals receive scarce medications allocated.

Racial/Ethnic Disparities in Vicarious and Direct COVID-19-Related Discrimination and Vigilance

INTRODUCTION

The high visibility of COVID-19-related discrimination underscores the importance of understanding the psychological harms associated with vicariously and directly experiencing such incidents. In this observational study, both vicariously and directly experienced COVID-19-related discrimination and their association with heightened concerns about discrimination and vigilance were examined in U.S. adults who use commercial tobacco.

METHODS

Data were from a nationally representative sample of adults who currently or formerly used commercial tobacco products (N=1,700; mean age=43 years) from an online survey panel administered in January-February 2021 (analyzed in 2021-2022). Participants reported vicariously and directly experienced COVID-19-related discrimination, concern about experiencing such discrimination, and heightened vigilance. Weighted multivariable linear and logistic regression models were used to examine the associations among these variables.

RESULTS

Overall, 69% of individuals reported exposure to vicarious COVID-19-related discrimination, and 22% reported directly experiencing COVID-19-related discrimination. Asian, Hispanic, and Black individuals reported higher levels of concern and vigilance than White individuals (p<0.05). Vicariously and directly experienced COVID-19-related discrimination was independently associated with concern about experiencing COVID-19-related discrimination in the entire sample and within each racial and ethnic group (p<0.05). This concern was associated with increased vigilance (p<0.05) and was stronger in those exposed to vicarious COVID-19-related discrimination than in those who were not (p<0.05).

CONCLUSIONS

COVID-19-related discrimination may undermine the psychological well-being of those who are exposed to it vicariously as well as those who experience it directly and may also make individuals feel vulnerable and unsafe. Interventions to prevent and reduce the impact of COVID-19-related discrimination may have wide-reaching societal benefits.

Racial disparity and regional variance in healthcare utilization among patients with lung cancer in US hospitals during 2016-2019

BACKGROUND

Lung cancer health disparities are related to various patient factors. This study describes regional differences in healthcare utilization and racial characteristics to identify high-risk areas. This study aimed to identify regions and races at greater risk for lung cancer health disparities based on differences in healthcare utilization, measured here by hospital charges and length of stay.

METHODS

The National Inpatient Sample of the United States was used to identify patients with lung cancer (n = 92,159, weighted n = 460,795) from 2016 to 2019. We examined the characteristics of the patient sample and the association between the racial and regional variables and healthcare utilization, measured by hospital charges and length of stay. The multivariate sample weighted linear regression model estimated how racial and regional variables are associated with healthcare utilization.

RESULTS

Out of 460,795 patients, 76.4% were white, and 40.2% were from the South. The number of lung cancer patients during the study periods was stable. However, hospital charges were somewhat increased, and the length of stay was decreased during the study period. Sample weighted linear regression results showed that Hispanic & Asian patients were associated with 21.1% and 12.3% higher hospital charges than White patients. Compared with the Northeast, Midwest and South were associated with lower hospital charges, however, the West was associated with higher hospital charges.

CONCLUSION

Minority groups and regions are at an increased risk for health inequalities because of differences in healthcare utilization. Further differences in utilization by insurance type may exacerbate the situation for some patients with lung cancer. Hospital managers and policymakers working with these patient populations in identified areas should strive to address these disparities through special prevention programs and targeted financial assistance.

Examining the Relationship between Anti-Black Racism, Community and Police Violence, and COVID-19 Vaccination

In 2020, the COVID-19 pandemic emerged against a backdrop of long-standing racial inequities that contributed to significant disparities in COVID-19 mortality, morbidity, and eventually, vaccination rates. COVID-19 also converged with two social crises: anti-Black racism and community and police violence. The goal of this study was to examine the associations between community violence, police violence, anti-Black racism, and COVID-19 vaccination. Survey data were collected from a sample of 538 Black residents of Chicago between September 2021 and March 2022. Structural equation modeling was used to test associations between neighborhood violence, police violence, racism, medical mistrust, trust in COVID-related information, depressive symptoms, and having received a COVID-19 vaccination. In line with predictions, neighborhood violence had a significant indirect effect on vaccination via trust in COVID-related information from a personal doctor. Additionally, racism had a significant indirect effect on vaccination via trust in COVID-related information from a personal doctor, as well as via medical mistrust and trust in COVID-related information from a personal doctor. These findings add to the growing body of literature demonstrating the importance of medical mistrust when examining COVID-19 vaccination disparities. Furthermore, this study highlights the importance of considering how social and structural factors such as violence and racism can influence medical mistrust.

Exploring the intersections of structural inequities and health disparities: the challenge and opportunity of recognizing racism as a public health crisis

Although increasingly being recognized as a driver of poor health and health inequities, there is limited research on the pervasive effects of racism on population health. In this editorial, we set the context and invite contributions for a BMC Public Health Collection of articles titled, "Racism as Public Health Crisis."

Environmental and Mobility Strategies During Early COVID-19: Insights From an Empirical Study Focusing on Park Visitations in El Paso, TX

OBJECTIVES

We explored the importance of environmental and mobility strategies during early COVID-19 by age and ethnicity and investigated predictors of park visitations considering the COVID-19 impacts.

BACKGROUND

Parks are safe and accessible venues to stay active and reduce social isolation, which is especially important considering COVID-19 and the associated lockdowns.

METHODS

We analyzed online survey data from 683 residents (collected July 2020) of El Paso, TX, and objective measures of neighborhood park characteristics. Chi-square tests and mixed-effects logistic regression analyses were performed to examine the environmental/mobility strategies, personal and environmental factors, and park visitations, considering the COVID-19 impacts.

RESULTS

The percentage of those who visited (1+ times/week) parks or trails/paths in the neighborhood dropped from 41.7% to 19.5% since the start of COVID-19 (OR = 0.015, p < .001). Before COVID-19, middle-aged and older adults were less likely to visit parks than younger adults, while this difference became insignificant during early COVID-19. Hispanic adults were more likely to visit parks than non-Hispanics both before and during early COVID-19. Positive environmental predictors of park visitations included park availability in the neighborhood, proximity to the closest park, seeing people being physically active in the neighborhood, and neighborhood aesthetics.

CONCLUSIONS

Proximately located parks, trails, and paths well integrated into residential communities, and high aesthetic quality of the neighborhood are the potential features of pandemic-resilient communities and should be considered an important national priority to maintain and promote the health and well-being of the population, especially during pandemics like COVID-19.

Pandemics erode poverty alleviation process: Impact on productive livelihood and poverty return

Pandemics such as COVID-19 threaten income growth by disrupting productive activities for households, especially those who have just escaped from poverty. We provide empirical evidence on how pandemic disproportionately threatens the rural productive livelihood based on 48 months of household production electricity consumption data. The results show that after COVID-19, the productive livelihood activities of 51.11% households who have just overcome poverty have returned to the level before poverty alleviation. Their productive livelihood activities dropped by 21.81% on average during the national COVID-19 epidemic and by 40.57% during the regional epidemic. The households with lower income, lower level of education and less labor force even suffer more. We estimate 3.74% decline in income owing to the decrease in productive activities, resulting in 5.41% of households potentially falling back into poverty. This study provides an important reference for countries being at risk of returning to poverty after pandemic.

Evaluation of Inequities in Cancer Treatment Delay or Discontinuation Following SARS-CoV-2 Infection

IMPORTANCE

There is a disproportionately greater burden of COVID-19 among Hispanic and non-Hispanic Black individuals, who also experience poorer cancer outcomes. Understanding individual-level and area-level factors contributing to inequities at the intersection of COVID-19 and cancer is critical.

OBJECTIVE

To evaluate associations of individual-level and area-level social determinants of health (SDOH) with delayed or discontinued cancer treatment following SARS-CoV-2 infection.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, registry-based cohort study used data from 4768 patients receiving cancer care who had positive test results for SARS-CoV-2 and were enrolled in the American Society for Clinical Oncology COVID-19 Registry. Data were collected from April 1, 2020, to September 26, 2022.

EXPOSURES

Race and ethnicity, sex, age, and area-level SDOH based on zip codes of residence at the time of cancer diagnosis.

MAIN OUTCOMES AND MEASURES

Delayed (≥14 days) or discontinued cancer treatment (any cancer treatment, surgery, pharmacotherapy, or radiotherapy) and time (in days) to restart pharmacotherapy.

RESULTS

A total of 4768 patients (2756 women [57.8%]; 1558 [32.7%] aged ≥70 years at diagnosis) were included in the analysis. There were 630 Hispanic (13.2%), 196 non-Hispanic Asian American or Pacific Islander (4.1%), 568 non-Hispanic Black (11.9%), and 3173 non-Hispanic White individuals (66.5%). Compared with non-Hispanic White individuals, Hispanic and non-Hispanic Black individuals were more likely to experience a delay of at least 14 days or discontinuation of any treatment and drug-based treatment; only estimates for non-Hispanic Black individuals were statistically significant, with correction for multiple comparisons (risk ratios [RRs], 1.35 [95% CI, 1.22-1.49] and 1.37 [95% CI, 1.23-1.52], respectively). Area-level SDOH (eg, geography, proportion of residents without health insurance or with only a high school education, lower median household income) were associated with delayed or discontinued treatment. In multivariable Cox proportinal hazards regression models, estimates suggested that Hispanic (hazard ratio [HR], 0.87 [95% CI, 0.71-1.05]), non-Hispanic Asian American or Pacific Islander (HR, 0.79 [95% CI, 0.46-1.35]), and non-Hispanic Black individuals (HR, 0.81 [95% CI, 0.67-0.97]) experienced longer delays to restarting pharmacotherapy compared with non-Hispanic White individuals.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that race and ethnicity and area-level SDOH were associated with delayed or discontinued cancer treatment and longer delays to the restart of drug-based therapies following SARS-CoV-2 infection. Such treatment delays could exacerbate persistent cancer survival inequities in the United States.

Racial and Socioeconomic Characteristics Associated with the use of Telehealth Services Among Adults With Ambulatory Sensitive Conditions

Introduction

The COVID-19 pandemic led to a major transition for patients from routine ambulatory-care-based in-person primary care visits to telehealth visits to manage chronic diseases. However, it remains unclear the extent to which individuals access telehealth services and whether such utilization varies along neighborhood characteristics, especially among racial minorities. This study aims to examine the association of outpatient telehealth utilization with sociodemographic, clinical, and neighborhood characteristics among adults with ambulatory care sensitive conditions (ACSCs) during the COVID-19 pandemic.

Methods

We included adults treated for an ACSC between March 5, 2020, and December 31, 2020, at a single ambulatory-care-based healthcare system, which serves a large population of low-income patients in the South region of the United States (i.e., Memphis, TN, Metropolitan Statistical Area). Telehealth utilization was defined by outpatient procedural codes and providers' notes on the type of visits. Generalized linear mixed models were used to examine the association of sociodemographic, clinical, and neighborhood factors with telehealth utilization in the overall cohort and the racial subpopulations.

Results

Among the 13,962 adults with ACSCs, 8583 (62.5%) used outpatient telehealth services. Patients who were older, female, with mental disorders, and who had more comorbidities had higher rates of telehealth services (p < .05). Controlling for covariates, we observed 75.2% and 23.1% increased use of telehealth services among Hispanics and other race groups, respectively, compared to Whites. Patients who commuted more than 30 minutes to health facilities were slightly less likely to use telehealth services [OR: 0.994 (0.991,0.998)]. Racial minorities (Blacks and Hispanics) with mental disorders were more likely to use telehealth service when compared to Whites.

Discussion

We found that among patients being treated for ACSCs, the use of telehealth services was highly prevalent in Hispanic patients in general and were more pronounced among both Hispanics and Black patients who have mental disorders.

The role of discrimination in the relation between COVID-19 sequelae, psychological distress, and work impairment in COVID-19 survivors

Perceived discrimination and work impairment are commonly observed in COVID-19 survivors, but their relationship has not been well understood. We aimed to evaluate the role of discrimination in the development of psychological distress and work impairment in COVID-19 survivors. From April 2020 to November 2021, 309 patients were recruited at two designated COVID-19 hospitals in Japan. Participants completed a standardized questionnaire including COVID-19 sequelae, psychological distress, impairments in work performance and perceived discrimination. The majority of participants (62.5%) experienced one or more COVID-19 sequelae. Psychological distress was observed in 36.9% and work impairment in 37.9%. In multivariate logistic regression analyses, COVID-19 sequelae and discrimination were associated with both psychological distress and work impairment. Mediation analysis demonstrated that the direct effect of sequelae on work impairment was non-significant after accounting for psychological distress, suggesting that the effect of sequelae on work impairment was mainly mediated through psychological distress. These findings were replicated in a subgroup analysis limited to patients with mild COVID-19. We conclude that discrimination plays an important role in the development of psychological distress and work impairment, and that both discrimination and psychological distress should be targets of intervention in COVID-19 survivors.

Examining Disparities and Excess Cardiovascular Mortality Before and During the COVID-19 Pandemic

OBJECTIVE

To investigate the patterns and demographic features of cardiovascular disease (CVD) death and subtypes myocardial infarction (MI), stroke, and heart failure in the pre-COVID-19 era (2018-2019) vs during the COVID-19 pandemic (2020-2021) in the United States.

METHODS

In this cross-sectional study, we used the US Multiple Cause of Death files for 2018 to 2021 to examine the trend of excess cause-specific deaths using International Classification of Diseases, Tenth Revision codes for CVD (I00 to I99), MI (I21 and I22), stroke (I60 to I69), and heart failure (I42 and I50). Our primary outcome was excess mortality from CVD and its 3 subtypes (MI, stroke, and heart failure) between prepandemic (2018-2019) and pandemic (2020-2021) years. We performed a subgroup analysis on race and month-to-month and year-to-year variation using χ² analysis to test statistical significance.

RESULTS

Overall, 3,598,352 CVD deaths were analyzed during the study period. There was a 6.7% excess CVD mortality, 2.5% MI mortality, and 8.5% stroke mortality during the COVID-19 pandemic (2020-2021) compared with the prepandemic era (2018-2019). Black individuals had higher excess CVD mortality (13.8%) than White individuals (5.1%; P<.001). This remained consistent across subtypes of CVD, including MI (9.6% vs 1.0%; P<.001), stroke (14.5% vs 6.9%; P<.001), and heart failure (5.1% vs -1.2%; P<.001).

CONCLUSION

There has been a significant rise in CVD and subtype-specific mortality during the COVID-19 pandemic that has been persistent despite 2 years since the onset of the pandemic. Excess CVD mortality has disproportionately affected Black compared with White individuals. Further studies targeting and eliminating health care disparities are necessary.

Diskriminierungssensible Sprache in der Forschung zu Migration und Gesundheit – eine Handreichung

Hintergrund

In der Public-Health-Forschung ist Migration als eine Determinante von Gesundheit zunehmend in den Fokus gerückt. Verantwortungsvolle Forschung in diesem Bereich setzt eine antidiskriminierende Vorgehensweise in der Durchführung, Berichterstattung und Ergebnisdissemination voraus. Ein diskriminierungssensibler Sprachgebrauch ist dabei ein zentrales Element. Handreichungen hierzu gibt es im deutschsprachigen Raum für den Bereich Public Health bisher nicht.

Methoden

Im Rahmen des Projektes Improving Health Monitoring in Migrant Populations (IMIRA) am Robert Koch-Institut wurde eine Handreichung zu antidiskriminierender Sprache in der Forschung zu Migration und Gesundheit entwickelt, die aus einem Leitfaden und einer Übersicht über relevante Begriffe und Konzepte besteht. Die Bedarfe, Inhalte und Form dazu wurden in einem Aktionsforschungsprozess mit Projektmitarbeitenden aus dem IMIRA-Projekt erarbeitet.

Ergebnisse

Der Leitfaden zeigt 5 Grundprinzipien für einen antidiskriminierenden Sprachgebrauch auf: 1. Generalisierungen und Verallgemeinerungen vermeiden, 2. diskriminierungssensibel formulieren, 3. Selbst- und Fremdbezeichnungen berücksichtigen, 4. Begriffe unterliegen einem ständigen Wandel und 5. eigene Unsicherheiten offen kommunizieren. Die Übersicht, welche online als „Living Document“ zur Verfügung steht, beinhaltet Begriffe und Konzepte, die im Zusammenhang mit dem Thema Gesundheit und Migration häufig verwendet werden.

Fazit

Die Handreichung soll Forschende dafür sensibilisieren und dabei unterstützen, Sprache antidiskriminierend anzuwenden. Dies geht mit einer Reflexion der eigenen Sprache einher und stärkt verantwortungsvolle Forschung zum Thema Migration und Gesundheit. Die Nutzung und der Nutzen der Handreichung können Gegenstand zukünftiger Evaluationen sein.

Differences in mortality in Switzerland by citizenship during the first and second COVID-19 waves: Analysis of death statistics

Background

Early in the COVID-19 pandemic, it became apparent that members of marginalized populations and immigrants were also at risk of being hospitalized and dying more frequently from COVID-19. To examine how the pandemic affected underserved and marginalized populations, we analyzed data on changes in the number of deaths among people with and without Swiss citizenship during the first and second SARS-CoV-2 waves.

Method

We analyzed the annual number of deaths from the Swiss Federal Statistical Office from 2015 to 2020, and weekly data from January 2020 to May 2021 on deaths of permanent residents with and without Swiss citizenship, and we differentiated the data through subdivision into age groups.

Results

People without Swiss citizenship show a higher increase in the number of deaths in 2020 than those who were Swiss citizens. The increase in deaths compared to the previous year was almost twice as high for people without Swiss citizenship (21.8%) as for those with it (11.4%). The breakdown by age group indicates that among people between the ages of 64 and 75, those without Swiss citizenship exhibited an increase in mortality (21.6%) that was four times higher than that for people with Swiss citizenship (4.7%).

Conclusion

This study confirms that a highly specialized health care system, as is found in Switzerland, does not sufficiently guarantee that all parts of the population will be equally protected in a health crisis such as COVID-19.

Racial Bias Beliefs Related to COVID-19 Among Asian Americans, Native Hawaiians, and Pacific Islanders: Findings From the COVID-19 Effects on the Mental and Physical Health of Asian Americans and Pacific Islanders Survey Study (COMPASS)

BACKGROUND

During the COVID-19 pandemic, there have been increased reports of racial biases against Asian American and Native Hawaiian and Pacific Islander individuals. However, the extent to which different Asian American and Native Hawaiian and Pacific Islander groups perceive and experience (firsthand or as a witness to such experiences) how COVID-19 has negatively affected people of their race has not received much attention.

OBJECTIVE

This study used data from the COVID-19 Effects on the Mental and Physical Health of Asian Americans and Pacific Islanders Survey Study (COMPASS), a nationwide, multilingual survey, to empirically examine COVID-19-related racial bias beliefs among Asian American and Native Hawaiian and Pacific Islander individuals and the factors associated with these beliefs.

METHODS

COMPASS participants were Asian American and Native Hawaiian and Pacific Islander adults who were able to speak English, Chinese (Cantonese or Mandarin), Korean, Samoan, or Vietnamese and who resided in the United States during the time of the survey (October 2020 to May 2021). Participants completed the survey on the web, via phone, or in person. The Coronavirus Racial Bias Scale (CRBS) was used to assess COVID-19-related racial bias beliefs toward Asian American and Native Hawaiian and Pacific Islander individuals. Participants were asked to rate the degree to which they agreed with 9 statements on a 5-point Likert scale (ie, 1=strongly disagree to 5=strongly agree). Multivariable linear regression was used to examine the associations between demographic, health, and COVID-19-related characteristics and perceived racial bias.

RESULTS

A total of 5068 participants completed the survey (mean age 45.4, SD 16.4 years; range 18-97 years). Overall, 73.97% (3749/5068) agreed or strongly agreed with ≥1 COVID-19-related racial bias belief in the past 6 months (during the COVID-19 pandemic). Across the 9 racial bias beliefs, participants scored an average of 2.59 (SD 0.96, range 1-5). Adjusted analyses revealed that compared with Asian Indians, those who were ethnic Chinese, Filipino, Hmong, Japanese, Korean, Vietnamese, and other or multicultural had significantly higher mean CRBS scores, whereas no significant differences were found among Native Hawaiian and Pacific Islander individuals. Nonheterosexual participants had statistically significant and higher mean CRBS scores than heterosexual participants. Compared with participants aged ≥60 years, those who were younger (aged <30, 30-39, 40-49, and 50-59 years) had significantly higher mean CRBS scores. US-born participants had significantly higher mean CRBS scores than foreign-born participants, whereas those with limited English proficiency (relative to those reporting no limitation) had lower mean CRBS scores.

CONCLUSIONS

Many COMPASS participants reported racial bias beliefs because of the COVID-19 pandemic. Relevant sociodemographic contexts and pre-existing and COVID-19-specific factors across individual, community, and society levels were associated with the perceived racial bias of being Asian during the pandemic. The findings underscore the importance of addressing the burden of racial bias on Asian American and Native Hawaiian and Pacific Islander communities among other COVID-19-related sequelae.