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Shen Z, Li Q, Wu J, Zhu D, Bai J, Ren R, Zhang J, Li Y, Wang M, Gu J, Li Y, Dong W, Wang H, Sun T, Yang F, Zhou X, Yang J, Tarimo CS, Ma M, Feng Y, Miao Y. Dynamic evolution of COVID-19 vaccine hesitancy over 2021-2023 among Chinese population: Repeated nationwide cross-sectional study. J Med Virol 2024; 96:e29800. [PMID: 39014958 DOI: 10.1002/jmv.29800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/29/2024] [Accepted: 07/04/2024] [Indexed: 07/18/2024]
Abstract
Globally, the rollout of COVID-19 vaccine had been faced with a significant barrier in the form of vaccine hesitancy. This study adopts a multi-stage perspective to explore the prevalence and determinants of COVID-19 vaccine hesitancy, focusing on their dynamic evolutionary features. Guided by the integrated framework of the 3Cs model (complacency, confidence, and convenience) and the EAH model (environmental, agent, and host), this study conducted three repeated national cross-sectional surveys. These surveys carried out from July 2021 to February 2023 across mainland China, targeted individuals aged 18 and older. They were strategically timed to coincide with three critical vaccination phases: universal coverage (stage 1), partial coverage (stage 2), and key population coverage (stage 3). From 2021 to 2023, the surveys examined sample sizes of 29 925, 6659, and 5407, respectively. The COVID-19 vaccine hesitation rates increased from 8.39% in 2021 to 29.72% in 2023. Urban residency, chronic condition, and low trust in vaccine developer contributed to significant COVID-19 vaccine hesitancy across the pandemic. Negative correlations between the intensity of vaccination policies and vaccine hesitancy, and positive correlations between vaccine hesitancy and long COVID, were confirmed. This study provides insights for designing future effective vaccination programs for emerging vaccine-preventable infectious X diseases.
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Affiliation(s)
- Zhanlei Shen
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Quanman Li
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Jian Wu
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Dongfang Zhu
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Junwen Bai
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Ruizhe Ren
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Jingbao Zhang
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Yi Li
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Meiyun Wang
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Henan, China
| | - Jianqin Gu
- School of Medicine, Southern University of Science and Technology, Guangdong, China
| | - Yinfei Li
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Henan, China
| | - Wenyong Dong
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Henan, China
| | - Haipeng Wang
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tao Sun
- Department of Health Policy and Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Fan Yang
- School of Public Health, Fudan University, NHC Key Lab of Health Technology Assessment, Fudan University, Shanghai, China
| | - Xue Zhou
- College of Health Management, Mudanjiang Medical University, Mudanjiang, Heilongjiang, China
| | - Jian Yang
- Department of Global Health, School of Public Health, Peking University, Beijing, China
| | - Clifford Silver Tarimo
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Mingze Ma
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Yifei Feng
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Yudong Miao
- Department of Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
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Miao Y, Shen Z, Li Q, Ma M, Xu D, Tarimo CS, Gu J, Wei W, Zhou X, Zhao L, Feng Y, Wu J, Wang M. Understanding the impact of chronic diseases on COVID-19 vaccine hesitancy using propensity score matching: Internet-based cross-sectional study. J Clin Nurs 2024; 33:2165-2177. [PMID: 38291345 DOI: 10.1111/jocn.16958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/16/2023] [Accepted: 11/26/2023] [Indexed: 02/01/2024]
Abstract
AIMS AND OBJECTIVES To investigate whether chronic diseases are associated with higher COVID-19 vaccine hesitancy and explore factors that influence COVID-19 vaccine hesitancy in patients with chronic diseases. BACKGROUND Vaccine hesitancy has been acknowledged as one of the greatest hazards to public health. However, little information is available about COVID-19 vaccine hesitancy among patients with chronic diseases who may be more susceptible to COVID-19 infection, severe disease or death. METHODS From 6 to 9 August 2021, we performed an internet-based cross-sectional survey with 22,954 participants (14.78% participants with chronic diseases). Propensity score matching with 1:1 nearest neighbourhood was used to reduce confounding factors between patients with chronic diseases and the general population. Using a multivariable logistic regression model, the factors impacting COVID-19 vaccine hesitancy were identified among patients with chronic diseases. RESULTS Both before and after propensity score matching, patients with chronic diseases had higher COVID-19 vaccine hesitancy than the general population. In addition, self-reported poor health, multiple chronic diseases, lower sociodemographic backgrounds and lower trust in nurses and doctors were associated with COVID-19 vaccine hesitancy among patients with chronic diseases. CONCLUSIONS Patients with chronic diseases were more hesitant about the COVID-19 vaccine. Nurses should focus on patients with chronic diseases with poor health conditions, low socioeconomic backgrounds and low trust in the healthcare system. RELEVANCE TO CLINICAL PRACTICE Clinical nurses are recommended to not only pay more attention to the health status and sociodemographic characteristics of patients with chronic diseases but also build trust between nurses and patients by improving service levels and professional capabilities in clinical practice. PATIENT OR PUBLIC CONTRIBUTION Patients or the public were not involved in setting the research question, the outcome measures, or the design or implementation of the study. However, all participants were invited to complete the digital informed consent and questionnaires.
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Affiliation(s)
- Yudong Miao
- Department of Health management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Zhanlei Shen
- Department of Health management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Quanman Li
- Department of Health management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Mingze Ma
- Department of Health management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Dongyang Xu
- Henan Provincial Center for Disease Control and Prevention, Zhengzhou, China
| | - Clifford Silver Tarimo
- Department of Health management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
- Department of Science and Laboratory Technology, Dar es salaam Institute of Technology, Dar es Salaam, Tanzania
| | - Jianqin Gu
- School of Medicine, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Wei Wei
- Henan Provincial People's Hospital, Zhengzhou, Henan, China
- People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xue Zhou
- College of Health Management, Mudanjiang Medical University, Mudanjiang, Heilongjiang, China
| | - Lipei Zhao
- Department of Health management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Yifei Feng
- Department of Health management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Jian Wu
- Department of Health management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
- Henan Province Engineering Research Center of Health Economy & Health Technology Assessment, Zhengzhou, China
| | - Meiyun Wang
- Henan Provincial People's Hospital, Zhengzhou, Henan, China
- People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Yuan HY, Wong WH, Khairunnasa F, Ho HC, Chung GKK. Impacts of income inequality and the mediation role of reporting delays on COVID-19 deaths during 2020 and 2021 in Hong Kong: an observational study. BMJ Open 2024; 14:e078838. [PMID: 38458781 DOI: 10.1136/bmjopen-2023-078838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024] Open
Abstract
OBJECTIVE To estimate the impacts of demographic factors and income disparities on the case fatality rate (CFR) of COVID-19 in Hong Kong, taking into account the influence of reporting delays (ie, the duration between symptom onset and case confirmation). DESIGN Retrospective observational longitudinal study. PARTICIPANTS A total of 7406 symptomatic patients with residence information reported between 23 January 2020 and 2 October 2021. MAIN OUTCOME MEASURES The study examined the disparity in COVID-19 deaths associated with the factors such as age (≥65 vs 0-64 years old groups), gender and the income level of districts (low income vs non-low income). The severe reporting delay (>10 days) was considered as the mediator for mediation analysis. A Cox proportional hazards regression model was constructed. RESULTS We found that CFR was 3.07% in the low-income region, twofold higher than 1.34% in the other regions. Although the severe reporting delay was associated with a hazard ratio (HR) of about 1.9, its mediation effect was only weakly present for age, but not for gender or income level. Hence, high CFR in Hong Kong was largely attributed to the direct effects of the elderly (HR 25.967; 95% CI 14.254 to 47.306) and low income (HR 1.558; 95% CI 1.122 to 2.164). CONCLUSION The disparity in COVID-19 deaths between income regions is not due to reporting delays, but rather to health inequities in Hong Kong. These risks may persist after the discontinuation of test-and-trace measures and extend to other high-threat respiratory pathogens. Urgent actions are required to identify vulnerable groups in low-income regions and understand the underlying causes of health inequities.
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Affiliation(s)
- Hsiang-Yu Yuan
- Department of Biomedical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong
- Centre for Applied One Health Research and Policy Advice, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong
| | - Wing Hei Wong
- Department of Biomedical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong
| | - Fatema Khairunnasa
- Department of Biomedical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong
- Department of Land Surveying and Geo-Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong
- Department of Statistics, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, Bangladesh
| | - Hung Chak Ho
- Department of Public and International Affairs, City University of Hong Kong, Kowloon, Hong Kong
| | - Gary Ka-Ki Chung
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, Hong Kong
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Sha Tin, Hong Kong
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So WWY, Fong TCT, Woo BPY, Yip PSF. Psychosocial and financial well-being mediated the effects of COVID-19 distress on suicidality: a serial mediation model among Hong Kong young adults. Soc Psychiatry Psychiatr Epidemiol 2024; 59:165-174. [PMID: 37270725 PMCID: PMC10239540 DOI: 10.1007/s00127-023-02501-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/24/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE The COVID-19 pandemic has brought significant distress on not only the physical health but also mental health of individuals. The present study investigated the direct and indirect effects from COVID-19 distress to suicidality via psychosocial and financial well-being among young people. METHODS This cross-sectional survey recruited 1472 Hong Kong young people via random sampling in 2021. The respondents completed a phone survey on COVID-19 distress, the four-item Patient Health Questionnaire and items on social well-being, financial well-being, and suicidality. Structural equation modeling (SEM) was conducted to examine the direct and indirect effects of COVID-19 distress on suicidality via psychosocial and financial well-being. RESULTS The direct effect of COVID-19 distress on suicidality was not significant (β = 0.022, 95% CI - 0.097-0.156). The total indirect effect from COVID-19 distress to suicidality was significant and positive (αβγ = 0.150, 95% CI = 0.085-0.245) and accounted for 87% of the total effect (B = 0.172, 95% CI = 0.043-0.341). There were significant specific indirect effects via social well-being and psychological distress, and financial well-being and psychological distress. CONCLUSION The present findings support different pathways from COVID-19 distress to suicidality via functioning in different domains among young people in Hong Kong. Measures are needed to ameliorate the impact on their social and financial well-being to reduce their psychological distress and suicidality.
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Affiliation(s)
- Wendy Wing Yan So
- HKJC Centre for Suicide Research and Prevention, University of Hong Kong, 2/F, HKJC Building for Interdisciplinary Research, Pokfulam, Hong Kong
| | - Ted Chun Tat Fong
- Centre on Behavioral Health, The University of Hong Kong, Pokfulam, Hong Kong
| | - Bowie Po Yi Woo
- HKJC Centre for Suicide Research and Prevention, University of Hong Kong, 2/F, HKJC Building for Interdisciplinary Research, Pokfulam, Hong Kong
| | - Paul Siu Fai Yip
- HKJC Centre for Suicide Research and Prevention, University of Hong Kong, 2/F, HKJC Building for Interdisciplinary Research, Pokfulam, Hong Kong.
- Department of Social Work & Social Administration, University of Hong Kong, Pokfulam, Hong Kong.
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Tan JHI, Goh AXC, Yi H. Health inequity and social determinants of healthcare utilization in the disadvantaged community of Hong Kong. Health Promot Int 2023; 38:daab195. [PMID: 34897425 DOI: 10.1093/heapro/daab195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Access to appropriate healthcare among disadvantaged populations in countries with universal healthcare requires a critical understanding of the relationships between poverty, social exclusion and health in the local context. The qualitative study explored the experiences of healthcare utilization in an inner-city impoverished community living in slum conditions in Hong Kong. Interviews with 40 slum residents in one of the poorest neighbourhoods in the city explored the following domains: experience and perceptions of the community, housing conditions, informal social capital and support system, interactions with community workers, and experiences in utilizing social and healthcare services. Framework analysis was conducted to identify local themes under the model of healthcare utilization: approachability, acceptability, availability and accommodation, affordability and appropriateness. Despite the subsidized public healthcare system, multiple barriers were identified. Low literacy of healthcare systems was prevalent. Specifically, structural barriers relating mainly to the availability, accommodation and affordability of health services were salient to impede access to healthcare. The barriers related to healthcare providers primarily stemmed from the interactions of healthcare providers, perceived stigma and the lack of patient-centred care. In addition, poverty-related sociocultural norms and personal beliefs of healthcare were found to be significant barriers to healthcare access. Despite the well-established subsidized public healthcare system, healthcare inequity was evident. Lack of quality healthcare access needs to be addressed by providing social and educational resources that facilitate collective efficacy for healthcare, community engagement from public sectors and person-centred care with healthcare providers.
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Affiliation(s)
- Joelle Hwee Inn Tan
- Yong Loo Lin School of Medicine, 10 Medical Drive, National University of Singapore, 117597, Singapore
| | - Amelia Xin Chun Goh
- Yong Loo Lin School of Medicine, 10 Medical Drive, National University of Singapore, 117597, Singapore
| | - Huso Yi
- Saw Swee Hock School of Public Health, 12 Science Drive, National University of Singapore, 117549, Singapore, and National University Health System, Singapore
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Wu J, Shen Z, Li Q, Tarimo CS, Wang M, Gu J, Wei W, Zhang X, Huang Y, Ma M, Xu D, Ojangba T, Miao Y. How urban versus rural residency relates to COVID-19 vaccine hesitancy: A large-scale national Chinese study. Soc Sci Med 2023; 320:115695. [PMID: 36736053 PMCID: PMC9846885 DOI: 10.1016/j.socscimed.2023.115695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/08/2022] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
RATIONALE Although urban-rural residency has been shown to influence individual COVID-19 vaccine hesitancy, the differences between urban and rural China have yet to be uncovered. OBJECTIVE This study aims to assess the current prevalence and factors associated with COVID-19 vaccine hesitancy in urban and rural areas and explore whether the rural versus urban residency is associated with COVID-19 vaccine hesitancy. METHODS A national, cross-sectional, online survey among Chinese urban and rural adults (≥18 years old) was conducted from 6th to August 9, 2021. A questionnaire was used to collect data on sociodemographic factors, perceptions of the COVID-19 pandemic and vaccination status. A multivariable logistic regression model was used to identify the factors that influence COVID-19 vaccine hesitancy. Propensity score matching (PSM) analysis was performed to explore the association between urban versus rural residency and COVID-19 vaccine hesitancy. RESULTS In total, 29,925 participants (80.56% urban participants) were recruited. Urban participants had a higher COVID-19 vaccine hesitancy than their rural counterparts (9.39% vs. 4.26%). After adjusting for potential confounders, we found that COVID-19 vaccine hesitancy among females was lower than that in males in both urban (aOR = 0.78, 95% CI [0.69-0.88]) and rural areas (aOR = 0.54, 95% CI [0.39-0.75]). The lack of trust towards vaccine producers was found to be associated with vaccine hesitancy among the urban participants (aOR = 2.76, 95% CI [2.22-3.43]). The rural floating population had a lower COVID-19 vaccine hesitancy than the rural permanent residents (aOR = 0.58, 95% CI [0.42-0.80]). PSM analysis revealed a 2.38% difference in COVID-19 vaccine hesitancy between urban and rural participants. CONCLUSIONS Urban participants were more hesitant to receive the COVID-19 vaccine than rural participants. Priority should be placed on boosting confidence in the healthcare system to reduce COVID-19 vaccine hesitancy among urban residents. Furthermore, we advocate for extra incentives and vaccination education for rural permanent residents.
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Affiliation(s)
- Jian Wu
- Department of Health Management, College of Public Health, Zhengzhou University, Henan, People's Republic of China; Henan Province Engineering, Research Center of Health Economy & Health Technology Assessment, Zhengzhou, Henan, People's Republic of China
| | - Zhanlei Shen
- Department of Health Management, College of Public Health, Zhengzhou University, Henan, People's Republic of China; Henan Province Engineering, Research Center of Health Economy & Health Technology Assessment, Zhengzhou, Henan, People's Republic of China
| | - Quanman Li
- Department of Health Management, College of Public Health, Zhengzhou University, Henan, People's Republic of China; Henan Province Engineering, Research Center of Health Economy & Health Technology Assessment, Zhengzhou, Henan, People's Republic of China
| | - Clifford Silver Tarimo
- Department of Health Management, College of Public Health, Zhengzhou University, Henan, People's Republic of China; Henan Province Engineering, Research Center of Health Economy & Health Technology Assessment, Zhengzhou, Henan, People's Republic of China; Department of Science and Laboratory Technology, Dar es salaam Institute of Technology, Dar es Salaam, Tanzania
| | - Meiyun Wang
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Henan, People's Republic of China
| | - Jianqin Gu
- School of Medicine, Southern University of Science and Technology, Guangdong, People's Republic of China
| | - Wei Wei
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Henan, People's Republic of China
| | - Xinyu Zhang
- School of Public Health, Tianjin Medical University, Tianjin, People's Republic of China
| | - Yanli Huang
- Manage and service Center of Wuhou Medical Institutes, Sichuan, People's Republic of China
| | - Mingze Ma
- Department of Health Management, College of Public Health, Zhengzhou University, Henan, People's Republic of China; Henan Province Engineering, Research Center of Health Economy & Health Technology Assessment, Zhengzhou, Henan, People's Republic of China
| | - Dongyang Xu
- Department of Health Management, College of Public Health, Zhengzhou University, Henan, People's Republic of China; Henan Province Engineering, Research Center of Health Economy & Health Technology Assessment, Zhengzhou, Henan, People's Republic of China
| | - Theodora Ojangba
- Department of Health Management, College of Public Health, Zhengzhou University, Henan, People's Republic of China; Henan Province Engineering, Research Center of Health Economy & Health Technology Assessment, Zhengzhou, Henan, People's Republic of China
| | - Yudong Miao
- Department of Health Management, College of Public Health, Zhengzhou University, Henan, People's Republic of China; Henan Province Engineering, Research Center of Health Economy & Health Technology Assessment, Zhengzhou, Henan, People's Republic of China.
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Cheung T, Lam JYT, Fong KH, Ho YS, Ho A, Cheng CPW, Sittlington J, Xiang YT, Li TMH. The Effectiveness of Electrical Vestibular Stimulation (VeNS) on Symptoms of Anxiety: Study Protocol of a Randomized, Double-Blinded, Sham-Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4218. [PMID: 36901227 PMCID: PMC10002296 DOI: 10.3390/ijerph20054218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/17/2023] [Accepted: 02/24/2023] [Indexed: 06/18/2023]
Abstract
The prevalence of symptoms of anxiety is increasing, especially during the COVID-19 pandemic. A home use transdermal neurostimulation device might help to minimize the severity of anxiety disorder. To the best of our knowledge, there is no clinical trial using transdermal neurostimulation to treat individuals with symptoms of anxiety in Asia. This gives us the impetus to execute the first study which aims at evaluating the efficacy of Electrical Vestibular Stimulation (VeNS) on anxiety in Hong Kong. This study proposes a two-armed, double-blinded, randomized, sham-controlled trial including the active VeNS and sham VeNS group. Both groups will be measured at baseline (T1), immediately after the intervention (T2), and at the 1-month (T3) and 3-month follow-up (T4). A total of 66 community-dwelling adults aged 18 to 60 with anxiety symptoms will be recruited in this study. All subjects will be computer randomised into either the active VeNS group or the sham VeNS group in a 1:1 ratio. All subjects in each group will receive twenty 30 min VeNS sessions during weekdays, which will be completed in a 4-week period. Baseline measurements and post-VeNS evaluation of the psychological outcomes (i.e., anxiety, insomnia, and quality of life) will also be conducted on all participants. The 1-month and 3-month follow-up period will be used to assess the long-term sustainability of the VeNS intervention. For statistical analysis, ANOVA with repeated measures will be used to analyze data. Missing data were managed with multiple mutations. The level of significance will be set to p < 0.05. Results of this study will be used to determine whether this VeNS device can be considered as a self-help technological device to reduce perceived anxiety in the general population in the community setting. This clinical Trial was registered with the Clinical Trial government, identifier: NCT04999709.
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Affiliation(s)
- Teris Cheung
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China
- The Mental Health Research Centre, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Joyce Yuen Ting Lam
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Kwan Hin Fong
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Yuen Shan Ho
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Alex Ho
- Integrated Services for Persons with Disabilities, Christian Family Service Centre, Hong Kong SAR, China A
| | | | - Julie Sittlington
- School of Biomedical Sciences, Ulster University, Coleraine BT52 1SA, UK
| | - Yu-Tao Xiang
- Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macau SAR, China
| | - Tim Man Ho Li
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR, China
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Fung KK, Hung SL, Chan YC. Community social work in Hong Kong during COVID-19: Intervention strategies to address social injustices. INTERNATIONAL SOCIAL WORK 2023; 66:219-232. [PMID: 38603311 PMCID: PMC9742723 DOI: 10.1177/00208728221137952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
In Hong Kong, professional social workers made their presence felt when they delivered a variety of services at the height of the pandemic. Social workers who were working in community development projects or who had adopted community work approaches have become the major service providers when the availability and accessibility of other types of social services have been seriously impeded. This article reports on a qualitative research study conducted to examine (1) how community social workers have planned and implemented services, (2) their use of information and communication technologies (ICTs), and (3) ideas for addressing injustices in disaster management work.
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Wang F, Zeng Y, Liu L, Onega T. Disparities in spatial accessibility of primary care in Louisiana: From physical to virtual accessibility. Front Public Health 2023; 11:1154574. [PMID: 37143988 PMCID: PMC10151773 DOI: 10.3389/fpubh.2023.1154574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/20/2023] [Indexed: 05/06/2023] Open
Abstract
Telehealth has been widely employed and has transformed how healthcare is delivered in the United States as a result of COVID-19 pandemic. While telehealth is utilized and encouraged to reduce the cost and travel burden for access to healthcare, there are debates on whether telehealth can promote equity in healthcare services by narrowing the gap among diverse groups. Using the Two-Step Floating Catchment Area (2SFCA) and Two-Step Virtual Catchment Area (2SVCA) methods, this study compares the disparities of physical and virtual access to primary care physicians (PCPs) in Louisiana. Both physical and virtual access to PCPs exhibit similar spatial patterns with higher scores concentrated in urban areas, followed by low-density and rural areas. However, the two accessibility measures diverge where broadband availability and affordability come to play an important role. Residents in rural areas experience additive disadvantage of even more limited telehealth accessibility than physical accessibility due to lack of broadband service provision. Areas with greater Black population proportions tend to have better physical accessibility, but such an advantage is eradicated for telehealth accessibility because of lower broadband subscription rates in these neighborhoods. Both physical and virtual accessibility scores decline in neighborhoods with higher Area Deprivation Index (ADI) values, and the disparity is further widened for in virtual accessibility compared to than physical accessibility. The study also examines how factors such as urbanicity, Black population proportion, and ADI interact in their effects on disparities of the two accessibility measures.
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Affiliation(s)
- Fahui Wang
- The Pinkie Gordon Lane Graduate School, Louisiana State University, Baton Rouge, LA, United States
- Department of Geography and Anthropology, Louisiana State University, Baton Rouge, LA, United States
- *Correspondence: Fahui Wang,
| | - Yutian Zeng
- Department of Geography and Anthropology, Louisiana State University, Baton Rouge, LA, United States
| | - Lingbo Liu
- Department of Urban Planning, School of Urban Design, Wuhan University, Wuhan, China
- Center for Geographic Analysis, Harvard University, Cambridge, MA, United States
| | - Tracy Onega
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, United States
- Huntsman Cancer Institute, Salt Lake City, UT, United States
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10
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Siu JYM. The Role of Social and Cultural Values in Pandemic Control in a Chinese Community: An Ethnographic Study on the Construction and Stigmatization of "Others" in Severe Acute Respiratory Syndrome (SARS) and COVID-19 in Hong Kong. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13517. [PMID: 36294097 PMCID: PMC9603597 DOI: 10.3390/ijerph192013517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/19/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Studies have widely reported that social and cultural values serve as constraints in controlling the spread of an epidemic. However, I argue that a social and cultural value system is a double-edged sword and can motivate people's preventive health behaviors. Few studies have examined the positive role of social and cultural values in promoting epidemic control. METHODS Using the severe acute respiratory syndrome outbreak in 2003 and the COVID-19 pandemic that began in 2020 in Hong Kong as examples, the present study performed participant observation in Hong Kong from January to June 2003 and from January 2020 to May 2022; in-depth individual semi-structured interviews were conducted with 70 participants between February 2021 and March 2022. RESULTS Social and cultural values serve as informal social control mechanisms in manipulating people's adoption of preventive health behaviors that can assist in epidemic control. Specifically, the construction and stigmatization of the "others" groups and the traditional cultural values based on the capitalist ideology were noted to facilitate control measures against the two outbreaks in Hong Kong. CONCLUSION These two outbreaks reinforced the embedded social and cultural values of the capitalist ideology of Hong Kong, which increased the vulnerability of disadvantaged social groups to stigmatization.
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Affiliation(s)
- Judy Yuen-man Siu
- Department of Applied Social Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong, China;
- Interdisciplinary Centre for Qualitative Research, The Hong Kong Polytechnic University, Hong Kong, China
- Research Centre for Sharp Vision, The Hong Kong Polytechnic University, Hong Kong, China
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11
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Jiang Z, Yip KM, Zhang X, Deng J, Wong W, So HK, Ngai ECH. Identifying the High-Risk Population for COVID-19 Transmission in Hong Kong Leveraging Explainable Machine Learning. Healthcare (Basel) 2022; 10:healthcare10091624. [PMID: 36141236 PMCID: PMC9498847 DOI: 10.3390/healthcare10091624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
The worldwide spread of COVID-19 has caused significant damage to people’s health and economics. Many works have leveraged machine learning models to facilitate the control and treatment of COVID-19. However, most of them focus on clinical medicine and few on understanding the spatial dynamics of the high-risk population for transmission of COVID-19 in real-world settings. This study aims to investigate the association between population features and COVID-19 transmission risk in Hong Kong, which can help guide the allocation of medical resources and the implementation of preventative measures to control the spread of the pandemic. First, we built machine learning models to predict the number of COVID-19 cases based on the population features of different tertiary planning units (TPUs). Then, we analyzed the distribution of cases and the prediction results to find specific characteristics of TPUs leading to large-scale outbreaks of COVID-19. We further evaluated the importance and influence of various population features on the prediction results using SHAP values to identify indicators for high-risk populations for COVID-19 transmission. The evaluation of COVID-19 cases and the TPU dataset in Hong Kong shows the effectiveness of the proposed methods. The top three most important indicators are identified as people in accommodation and food services, low income, and high population density.
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Affiliation(s)
- Zhihan Jiang
- Department of Electrical and Electronic Engineering, Faculty of Engineering, The University of Hong Kong, Hong Kong 999077, China
| | - Ka-Man Yip
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong 999077, China
| | - Xinchen Zhang
- Department of Electrical and Electronic Engineering, Faculty of Engineering, The University of Hong Kong, Hong Kong 999077, China
| | - Jing Deng
- Department of Electrical and Electronic Engineering, Faculty of Engineering, The University of Hong Kong, Hong Kong 999077, China
| | - Wilfred Wong
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong 999077, China
| | - Hung-Kwan So
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong 999077, China
| | - Edith C. H. Ngai
- Department of Electrical and Electronic Engineering, Faculty of Engineering, The University of Hong Kong, Hong Kong 999077, China
- Correspondence:
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12
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Wong ELY, Li J, Yuen S, Lai AHY, Cheung AWL, Yau PSY, Yeoh EK. Vulnerable populations during COVID-19 response: Health-related quality of life among Chinese population and its influence due to socio-demographic factors and loneliness. Front Public Health 2022; 10:857033. [PMID: 36081475 PMCID: PMC9446419 DOI: 10.3389/fpubh.2022.857033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/06/2022] [Indexed: 01/21/2023] Open
Abstract
Background Infection control policy affected people's wellbeing during the COVID-19 pandemic, especially those vulnerable populations. This study aimed to compare the health-related quality of life (HRQoL) of the Hong Kong (HK) Chinese population under the pandemic with the normative profiles and explore its influencing factors, including socio-demographic characteristics, loneliness, and the interaction between them. Methods A cross-sectional questionnaire survey (301 online and 202 in-person) was conducted between June and December 2020 among the adult Chinese population during the 2nd wave of COVID-19 in HK. HRQoL was measured by a Hong Kong validated EQ-5D-5L instrument (EQ-5D-5L HK). Loneliness was measured by a single-item question regarding the frequency of the participants reporting feeling lonely and their subjective social status was measured by the MacArthur Scale of Subjective Social Status. A series of Tobit regressions was conducted. The interaction terms between socio-demographics and loneliness were also examined to decide their association with HRQoL. Results A total of 503 responses were collected. The level of HRQoL of the respondents was significantly lower than the referred norms profile among the local general population. The findings identified that younger age, single, a higher subjective social status, and a lower level of loneliness were significantly associated with better HRQoL. Moreover, age and marital status were significant moderators in the relationship between loneliness and HRQoL. Conclusion The present study found that some population groups face additional vulnerabilities during the pandemic in terms of declined HRQoL. In addition, reducing loneliness can protect the HRQoL during the pandemic, especially among older people. This article provides useful information for policy-makers to design and promote effective services or provide education to improve the connection of people and recover from the global pandemic.
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Affiliation(s)
- Eliza Lai-Yi Wong
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China,*Correspondence: Eliza Lai-Yi Wong
| | - Jia Li
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Shannon Yuen
- Faculty of Social Sciences, Developmental and Educational Psychology, Leiden University, Leiden, Netherlands
| | - Angel Hor-Yan Lai
- Department of Applied Social Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Annie Wai-Ling Cheung
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Peter Sen-Yung Yau
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Eng-Kiong Yeoh
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
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13
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Buckley PR, Edwards D, Ladika A, Steeger CM, Hill KG. Implementing Evidence-Based Preventive Interventions During a Pandemic. GLOBAL IMPLEMENTATION RESEARCH AND APPLICATIONS 2022; 2:266-277. [PMID: 35813089 PMCID: PMC9255843 DOI: 10.1007/s43477-022-00047-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/01/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Pamela R. Buckley
- Institute of Behavioral Science, University of Colorado Boulder, UCB 483, Boulder, CO 80309 USA
| | - Dan Edwards
- Evidence-Based Associates, 1221 Taylor St NW, Washington, DC 20011 USA
| | - Amanda Ladika
- Institute of Behavioral Science, University of Colorado Boulder, UCB 483, Boulder, CO 80309 USA
| | - Christine M. Steeger
- Institute of Behavioral Science, University of Colorado Boulder, UCB 483, Boulder, CO 80309 USA
| | - Karl G. Hill
- Institute of Behavioral Science, University of Colorado Boulder, UCB 483, Boulder, CO 80309 USA
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14
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Lee LCB. Shifting Ethics of Care in Hong Kong. ARTS IN PSYCHOTHERAPY 2022. [DOI: 10.1016/j.aip.2022.101916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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15
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Chan SM, Lam LCW, Law WY, Hung SF, Chan WC, Chen EYH, Chung GKK, Chan YH, Chung RYN, Wong H, Yeoh EK, Woo J. Inequalities in Psychiatric Morbidity in Hong Kong and Strategies for Mitigation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:7095. [PMID: 35742339 PMCID: PMC9222799 DOI: 10.3390/ijerph19127095] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/03/2022] [Accepted: 06/08/2022] [Indexed: 02/01/2023]
Abstract
This study explores the social gradient of psychiatric morbidity. The Hong Kong Mental Morbidity Survey (HKMMS), consisting of 5719 Chinese adults aged 16 to 75 years, was used. The Chinese version of the Revised Clinical Interview Schedule (CIS-R) was employed for psychiatric assessment of common mental disorders (CMD). People with a less advantaged socioeconomic position (lower education, lower household income, unemployment, small living area and public rental housing) had a higher prevalence of depression and anxiety disorder. People with lower incomes had worse physical health (OR 2.01, 95% CI 1.05-3.82) and greater odds of having CMD in the presence of a family history of psychiatric illnesses (OR 1.67, 95% CI 1.18-2.36). Unemployment also had a greater impact for those in lower-income groups (OR 2.67; 95% CI 1.85-3.85), whereas no significant association was observed in high-income groups (OR 0.56; 95% CI 0.14-2.17). Mitigating strategies in terms of services and social support should target socially disadvantaged groups with a high risk of psychiatric morbidity. Such strategies include collaboration among government, civil society and business sectors in harnessing community resources.
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Affiliation(s)
- Siu-Ming Chan
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China; (S.-M.C.); (G.K.-K.C.); (Y.-H.C.); (R.Y.-N.C.); (H.W.); (E.-K.Y.)
- Department of Social and Behavioural Sciences, City University of Hong Kong, Hong Kong SAR, China
| | - Linda Chiu-Wa Lam
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR, China; (L.C.-W.L.); (W.-Y.L.); (S.-F.H.)
| | - Wing-Yan Law
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR, China; (L.C.-W.L.); (W.-Y.L.); (S.-F.H.)
| | - Se-Fong Hung
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR, China; (L.C.-W.L.); (W.-Y.L.); (S.-F.H.)
| | - Wai-Chi Chan
- Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China; (W.-C.C.); (E.Y.-H.C.)
| | - Eric Yu-Hai Chen
- Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China; (W.-C.C.); (E.Y.-H.C.)
| | - Gary Ka-Ki Chung
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China; (S.-M.C.); (G.K.-K.C.); (Y.-H.C.); (R.Y.-N.C.); (H.W.); (E.-K.Y.)
| | - Yat-Hang Chan
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China; (S.-M.C.); (G.K.-K.C.); (Y.-H.C.); (R.Y.-N.C.); (H.W.); (E.-K.Y.)
| | - Roger Yat-Nork Chung
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China; (S.-M.C.); (G.K.-K.C.); (Y.-H.C.); (R.Y.-N.C.); (H.W.); (E.-K.Y.)
- CUHK Institute of Ageing, The Chinese University of Hong Kong, Hong Kong SAR, China
- School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hung Wong
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China; (S.-M.C.); (G.K.-K.C.); (Y.-H.C.); (R.Y.-N.C.); (H.W.); (E.-K.Y.)
- Department of Social Work, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Eng-Kiong Yeoh
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China; (S.-M.C.); (G.K.-K.C.); (Y.-H.C.); (R.Y.-N.C.); (H.W.); (E.-K.Y.)
- School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jean Woo
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China; (S.-M.C.); (G.K.-K.C.); (Y.-H.C.); (R.Y.-N.C.); (H.W.); (E.-K.Y.)
- CUHK Institute of Ageing, The Chinese University of Hong Kong, Hong Kong SAR, China
- School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
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Connecting the Dots in Emerging Mast Cell Research: Do Factors Affecting Mast Cell Activation Provide a Missing Link between Adverse COVID-19 Outcomes and the Social Determinants of Health? Med Sci (Basel) 2022; 10:medsci10020029. [PMID: 35736349 PMCID: PMC9228930 DOI: 10.3390/medsci10020029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/09/2022] [Accepted: 05/24/2022] [Indexed: 02/07/2023] Open
Abstract
Evidence continues to emerge that the social determinants of health play a role in adverse outcomes related to COVID-19, including increased morbidity and mortality, increased risk of long COVID, and vaccine adverse effects. Therefore, a more nuanced understanding of the biochemical and cellular pathways of illnesses commonly associated with adverse social determinants of health is urgently needed. We contend that a commitment to understanding adverse outcomes in historically marginalized communities will increase community-level confidence in public health measures. Here, we synthesize emerging literature on mast cell disease, and the role of mast cells in chronic illness, alongside emerging research on mechanisms of COVID illness and vaccines. We propose that a focus on aberrant and/or hyperactive mast cell behavior associated with chronic underlying health conditions can elucidate adverse COVID-related outcomes and contribute to the pandemic recovery. Standards of care for mast cell activation syndrome (MCAS), as well as clinical reviews, experimental research, and case reports, suggest that effective and cost-efficient remedies are available, including antihistamines, vitamin C, and quercetin, among others. Primary care physicians, specialists, and public health workers should consider new and emerging evidence from the biomedical literature in tackling COVID-19. Specialists and researchers note that MCAS is likely grossly under-diagnosed; therefore, public health agencies and policy makers should urgently attend to community-based experiences of adverse COVID outcomes. It is essential that we extract and examine experiential evidence of marginalized communities from the broader political–ideological discourse.
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Physical and Psychological Health Behavior Changes During the COVID-19 Pandemic that May Inform Surgical Prehabilitation: a Narrative Review. CURRENT ANESTHESIOLOGY REPORTS 2022; 12:109-124. [PMID: 35194411 PMCID: PMC8855650 DOI: 10.1007/s40140-022-00520-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 12/23/2022]
Abstract
Purpose of Review Multimodal prehabilitation aims to improve preoperative health in ways that reduce surgical complications and expedite post-operative recovery. However, the extent to which preoperative health has been affected by the COVID-19 pandemic is unclear and evidence for the mitigating effects of prehabilitation in this context has not been elucidated. The COVID-19 pandemic has forced a rapid reorganization of perioperative pathways. Delayed diagnosis and surgery have caused a backlog of cases awaiting surgery increasing the risk of more complex procedures due to disease progression. Poor fitness and preoperative deconditioning are predictive of surgical complications and may be compounded by pandemic-related restrictions to accessing supportive services. The COVID-19 pandemic has forced a rapid reorganization of perioperative pathways. This narrative review aims to summarize the understanding of the effects of the COVID-19 pandemic on preoperative health and related behaviors and their implication for the need and delivery for prehabilitation to engender improved surgical outcomes. A literature search of Medline was conducted for articles related to preoperative health, prehabilitation, and surgical outcomes published between December 1, 2020 and January 31, 2021. Additional hand searches for relevant publications within the included literature were also conducted through October 15, 2021. Recent Findings The COVID-19 pandemic, and measures designed to reduce the spread of the virus, have resulted in physical deconditioning, deleterious dietary changes, substance misuse, and heightened anxiety prior to surgery. Due to the adverse health changes prior to surgery, and often protracted waiting time for surgery, there is likely an elevated risk of peri- and post-operative complications. A small number of prehabilitation services and research programmes have been rapidly adapted or implemented to address these needs. Summary During the COVID-19 pandemic to date, people undergoing surgery have faced a triple threat posed by extended wait times for surgery, reduced access to supportive services, and an elevated risk of poor outcomes. It is imperative that healthcare providers find ways to employ evidence-based prehabilitation strategies that are accessible and safe to mitigate the negative impact of the pandemic on surgical outcomes. Attention should be paid to cohorts most affected by established health inequities and further exacerbated by the pandemic.
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18
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Chung GKK, Strong C, Chan YH, Chung RYN, Chen JS, Lin YH, Huang RY, Lin CY, Ko NY. Psychological Distress and Protective Behaviors During the COVID-19 Pandemic Among Different Populations: Hong Kong General Population, Taiwan Healthcare Workers, and Taiwan Outpatients. Front Med (Lausanne) 2022; 9:800962. [PMID: 35242778 PMCID: PMC8885588 DOI: 10.3389/fmed.2022.800962] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/03/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The novel coronavirus disease 2019 (COVID-19) caused psychological distress and changed human living styles. However, rare studies have examined the psychological distress and protective behaviors across different populations. Therefore, the present study aimed to assess psychological distress, protective behaviors, and potential predictors of psychological distress and protective behaviors across the Hong Kong general population, Taiwan healthcare workers, and Taiwan outpatients. METHODS A cross-sectional design was used to recruit participants from Hong Kong and Taiwan. Telephone interviews were carried out for Hong Kong participants (n = 1,067; 30.2% male participants); online surveys were used for Taiwan healthcare workers (n = 500; 8.0% male participants) and Taiwan outpatients (n = 192; 32.8% male participants). All the participants completed questions on psychological distress and protective behaviors. Multiple linear regressions and multivariable logistic regressions were employed to explore the potential predictors of psychological distress and protective behaviors, respectively. RESULTS Hong Kong participants had significantly lower levels of psychological distress than Taiwan participants [mean (SD) = 0.16 (0.39) vs. 0.47 (0.59) in healthcare workers and 0.46 (0.65) in outpatients; p < 0.001]. Hong Kong participants (51.7%) and Taiwan outpatients had more people showing fear of COVID-19 (52.0%) than Taiwan healthcare providers (40.8%; p < 0.001). Moreover, Hong Kong participants engaged the most in protective behaviors, followed by Taiwan healthcare providers and Taiwan outpatients (p < 0.001). Moreover, being a female, fear of COVID-19 and worry about personal savings were associated with protective behaviors in general. CONCLUSIONS Despite the greater COVID-19 severity and fear of COVID-19 in Hong Kong, the general population in Hong Kong experienced less psychosocial distress with higher compliance to protective behaviors than the other groups in Taiwan.
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Affiliation(s)
- Gary Ka-Ki Chung
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Carol Strong
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yat-Hang Chan
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Roger Yat-Nork Chung
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Jung-Sheng Chen
- Department of Medical Research, E-Da Hospital, Kaohsiung, Taiwan
| | - Yi-Hsuan Lin
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ru-Yi Huang
- Department of Family and Community Medicine, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chung-Ying Lin
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Biostatistics Consulting Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Nai-Ying Ko
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Zelner J, Masters NB, Naraharisetti R, Mojola SA, Chowkwanyun M, Malosh R. There are no equal opportunity infectors: Epidemiological modelers must rethink our approach to inequality in infection risk. PLoS Comput Biol 2022; 18:e1009795. [PMID: 35139067 PMCID: PMC8827449 DOI: 10.1371/journal.pcbi.1009795] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Mathematical models have come to play a key role in global pandemic preparedness and outbreak response: helping to plan for disease burden, hospital capacity, and inform nonpharmaceutical interventions. Such models have played a pivotal role in the COVID-19 pandemic, with transmission models—and, by consequence, modelers—guiding global, national, and local responses to SARS-CoV-2. However, these models have largely not accounted for the social and structural factors, which lead to socioeconomic, racial, and geographic health disparities. In this piece, we raise and attempt to clarify several questions relating to this important gap in the research and practice of infectious disease modeling: Why do epidemiologic models of emerging infections typically ignore known structural drivers of disparate health outcomes? What have been the consequences of a framework focused primarily on aggregate outcomes on infection equity? What should be done to develop a more holistic approach to modeling-based decision-making during pandemics? In this review, we evaluate potential historical and political explanations for the exclusion of drivers of disparity in infectious disease models for emerging infections, which have often been characterized as “equal opportunity infectors” despite ample evidence to the contrary. We look to examples from other disease systems (HIV, STIs) and successes in including social inequity in models of acute infection transmission as a blueprint for how social connections, environmental, and structural factors can be integrated into a coherent, rigorous, and interpretable modeling framework. We conclude by outlining principles to guide modeling of emerging infections in ways that represent the causes of inequity in infection as central rather than peripheral mechanisms.
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Affiliation(s)
- Jon Zelner
- Dept. of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
- Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Nina B. Masters
- Dept. of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Ramya Naraharisetti
- Dept. of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
- Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Sanyu A. Mojola
- Dept. of Sociology, School of Public and International Affairs & Office of Population Research, Princeton University, Princeton, New Jersey, United States of America
| | - Merlin Chowkwanyun
- Dept. of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Ryan Malosh
- Dept. of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
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Chung RYN, Chung GKK, Chan SM, Chan YH, Wong H, Yeoh EK, Allen J, Woo J, Marmot M. Socioeconomic inequality in mental well-being associated with COVID-19 containment measures in a low-incidence Asian globalized city. Sci Rep 2021; 11:23161. [PMID: 34848754 PMCID: PMC8633192 DOI: 10.1038/s41598-021-02342-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/03/2021] [Indexed: 02/05/2023] Open
Abstract
The COVID-19 pandemic exposes and amplifies pre-existing inequalities even in places with relatively well-controlled outbreaks such as Hong Kong. This study aimed to explore whether the socioeconomically disadvantaged fare worse via various types of worry in terms of their mental health and well-being. Between September and October 2020, 1067 adults in Hong Kong were recruited via a cross-sectional population-wide telephone survey. The inter-relationship between deprivation, types of worry, mental health disorders, and subjective well-being was assessed using structural equation modelling. Results showed significant total effects of deprivation on worries about being infected (p = 0.002), economic activities and livelihood (p < 0.001), and personal savings (p < 0.001), as well as mental health disorders (p < 0.001) and subjective well-being (p < 0.001). Specifically, worry about economic activities and livelihood partly mediated the total effect of deprivation on mental health disorders (p = 0.004), whereas worry about personal savings and worry about economic activities and livelihood partially mediated the total effect of deprivation on subjective well-being (p = 0.007 and 0.002, respectively). Socioeconomic inequality, particularly in mental health and well-being, could be exacerbated via people's economic concerns during the pandemic, which was largely induced by the COVID-19 containment measures rather than the pandemic per se given the relatively low COVID-19 incidence in Hong Kong.
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Affiliation(s)
- Roger Yat-Nork Chung
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China.
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China.
- CUHK Institute of Ageing, The Chinese University of Hong Kong, Hong Kong SAR, China.
- 4/F, School of Public Health and Primary Care, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR, China.
| | - Gary Ka-Ki Chung
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Siu-Ming Chan
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
- CityU Department of Social and Behavioural Sciences, The City University of Hong Kong, Hong Kong SAR, China
| | - Yat-Hang Chan
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hung Wong
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Social Work, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Eng Kiong Yeoh
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jessica Allen
- Department of Epidemiology and Public Health, UCL Institute of Health Equity, UCL Research, London, UK
| | - Jean Woo
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
- CUHK Institute of Ageing, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Michael Marmot
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Epidemiology and Public Health, UCL Institute of Health Equity, UCL Research, London, UK
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21
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Yasmin F, Najeeb H, Asghar MS, Ullah I, Islam SMS. Increased COVID-19 infection risk, COVID-19 vaccine inaccessibility, and unacceptability: Worrisome trio for patients with substance abuse disorders. J Glob Health 2021; 11:03106. [PMID: 34671459 PMCID: PMC8501395 DOI: 10.7189/jogh.11.03106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Farah Yasmin
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Hala Najeeb
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Sohaib Asghar
- Department of Internal Medicine, Dow University Hospital - Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan
| | - Irfan Ullah
- Department of Internal Medicine, Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Sheikh Mohammed Shariful Islam
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Faculty of Health, Deakin University, Burwood, Australia
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22
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Bouchet A, Boucher J, Schutzbach K, Senn N, Genton B, Vernez D. Which strategy for using medical and community masks? A prospective analysis of their environmental impact. BMJ Open 2021; 11:e049690. [PMID: 34489285 PMCID: PMC8423512 DOI: 10.1136/bmjopen-2021-049690] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 08/16/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The use of personal protective equipment, especially medical masks, increased dramatically during the COVID-19 crisis. Medical masks are made of synthetic materials, mainly polypropylene, and a majority of them are produced in China and imported to the European market. The urgency of the need has so far prevailed over environmental considerations. OBJECTIVE Assess the environmental impact of different strategies for the use of face mask. METHOD A prospective analysis was conducted to assess the environmental impact of different strategies for the use of medical and community masks. Eight scenarios, differentiating the typologies of masks and the modes of reuse are compared using three environmental impact indicators: the Global Warming Potential (GWP100), the ecological scarcity (UBP method, from German 'Umweltbelastungpunkte') and the plastic leakage (PL). This study attempts to provide clear recommendations that consider both the environmental impact and the protective effectiveness of face masks used in the community. RESULTS The environmental impact of single-use masks is the most unfavourable, with a GWP of 0.4-1.3 kg CO2 eq., depending on the transport scenario, and a PL of 1.8 g, for a 1 month protection against COVID-19. The use of home-made cotton masks and prolonged use of medical masks through wait-and-reuse are the scenarios with the lowest impact. CONCLUSION The use of medical masks with a wait and reuse strategy seems to be the most appropriate when considering both environmental impact and effectiveness. Our results also highlight the need to develop procedures and the legal/operational framework to extend the use of protective equipment during a pandemic.
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Affiliation(s)
- Alexandre Bouchet
- EA - Environmental Action, Research Consultancy, Lausanne, Switzerland
| | - Julien Boucher
- EA - Environmental Action, Research Consultancy, Lausanne, Switzerland
- University of Applied Sciences and Arts Western Switzerland, Yverdon-les-Bains, Switzerland
| | - Kevin Schutzbach
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Nicolas Senn
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Blaise Genton
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - David Vernez
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
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23
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Heslop P, Byrne V, Calkin R, Huxor A, Sadoo A, Sullivan B. Deaths of people with intellectual disabilities: Analysis of deaths in England from COVID-19 and other causes. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2021; 34:1630-1640. [PMID: 34272793 PMCID: PMC8420486 DOI: 10.1111/jar.12914] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 05/03/2021] [Accepted: 05/15/2021] [Indexed: 12/26/2022]
Abstract
Background People with intellectual disabilities experience significant health inequities. The aim of this report is to understand the circumstances leading to death from COVID‐19 in people with intellectual disabilities. Method Local areas in England prioritised reviewing 200 deaths of adults with intellectual disabilities. Of these, approximately 80% were required to be deaths from suspected or confirmed COVID‐19 as this was the focus of the study; the remainder from other causes. All deaths occurred between 2 March2020 and 9 June 2020. Results People with intellectual disabilities differed from the general population in their symptoms of COVID‐19 and age at death. The overall quality of care was rated similar to other deaths of people with intellectual disabilities. Concerns were raised relating to recognising acute deterioration and do not attempt cardio‐pulmonary resuscitation decisions. Conclusions Service improvements are indicated in the ways in which people with intellectual disabilities encounter COVID‐19 and experience the disease.
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Affiliation(s)
- Pauline Heslop
- Norah Fry Centre for Disability Studies, School for Policy Studies, University of Bristol, Bristol, UK
| | - Victoria Byrne
- Norah Fry Centre for Disability Studies, School for Policy Studies, University of Bristol, Bristol, UK
| | - Rachel Calkin
- Norah Fry Centre for Disability Studies, School for Policy Studies, University of Bristol, Bristol, UK
| | - Avon Huxor
- Computer Science, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Annie Sadoo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Brian Sullivan
- Norah Fry Centre for Disability Studies, School for Policy Studies, University of Bristol, Bristol, UK
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24
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Kelly JD, Bravata DM, Bent S, Wray CM, Leonard SJ, Boscardin WJ, Myers LJ, Keyhani S. Association of Social and Behavioral Risk Factors With Mortality Among US Veterans With COVID-19. JAMA Netw Open 2021; 4:e2113031. [PMID: 34106264 PMCID: PMC8190626 DOI: 10.1001/jamanetworkopen.2021.13031] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE The US Department of Veterans Affairs (VA) offers programs that reduce barriers to care for veterans and those with housing instability, poverty, and substance use disorder. In this setting, however, the role that social and behavioral risk factors play in COVID-19 outcomes is unclear. OBJECTIVE To examine whether social and behavioral risk factors were associated with mortality among US veterans with COVID-19 and whether this association might be modified by race/ethnicity. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained data from the VA Corporate Data Warehouse to form a cohort of veterans who received a positive COVID-19 test result between March 2 and September 30, 2020, in a VA health care facility. All veterans who met the inclusion criteria were eligible to participate in the study, and participants were followed up for 30 days after the first SARS-CoV-2 or COVID-19 diagnosis. The final follow-up date was October 31, 2020. EXPOSURES Social risk factors included housing problems and financial hardship. Behavioral risk factors included current tobacco use, alcohol use, and substance use. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality in the 30-day period after the SARS-CoV-2 or COVID-19 diagnosis date. Multivariable logistic regression was used to estimate odds ratios, clustering for health care facilities and adjusting for age, sex, race, ethnicity, marital status, clinical factors, and month of COVID-19 diagnosis. RESULTS Among 27 640 veterans with COVID-19 who were included in the analysis, 24 496 were men (88.6%) and the mean (SD) age was 57.2 (16.6) years. A total of 3090 veterans (11.2%) had housing problems, 4450 (16.1%) had financial hardship, 5358 (19.4%) used alcohol, and 3569 (12.9%) reported substance use. Hospitalization occurred in 7663 veterans (27.7%), and 1230 veterans (4.5%) died. Housing problems (adjusted odds ratio [AOR], 0.96; 95% CI, 0.77-1.19; P = .70), financial hardship (AOR, 1.13; 95% CI, 0.97-1.31; P = .11), alcohol use (AOR, 0.82; 95% CI, 0.68-1.01; P = .06), current tobacco use (AOR, 0.85; 95% CI, 0.68-1.06; P = .14), and substance use (AOR, 0.90; 95% CI, 0.71-1.15; P = .41) were not associated with higher mortality. Interaction analyses by race/ethnicity did not find associations between mortality and social and behavioral risk factors. CONCLUSIONS AND RELEVANCE Results of this study showed that, in an integrated health system such as the VA, social and behavioral risk factors were not associated with mortality from COVID-19. Further research is needed to substantiate the potential of an integrated health system to be a model of support services for households with COVID-19 and populations who are at risk for the disease.
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Affiliation(s)
- J. Daniel Kelly
- San Francisco VA Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco
| | - Dawn M. Bravata
- US Department of Veterans Affairs, Health Services and Development, Center for Health Information and Communication, Indianapolis, Indiana
- Department of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Veterans Affairs Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Stephen Bent
- San Francisco VA Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Charlie M. Wray
- San Francisco VA Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Samuel J. Leonard
- Department of Medicine, University of California, San Francisco, San Francisco
| | - W. John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Laura J. Myers
- US Department of Veterans Affairs, Health Services and Development, Center for Health Information and Communication, Indianapolis, Indiana
| | - Salomeh Keyhani
- San Francisco VA Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco
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