COVID-19 Disparities and Vaccine Hesitancy in Black Americans: What Ethical Lessons Can Be Learned?

Demographic Differences in Emergency Room Epistaxis Treatment Patterns and Outcomes

OBJECTIVE

Investigate the association between demographic characteristics and emergency department (ED) epistaxis management and outcomes.

STUDY DESIGN

Retrospective cohort study.

SETTING

TriNetX US collaborative database.

METHODS

Adults presenting to the ED for epistaxis were retrospectively followed for 7 days. Spanish-speaking patients were propensity score matched to English-speaking patients by demographics and medical history. Outcomes included use of nasal decongestant, nasal packing or cautery, diagnostic nasal endoscopy, endoscopic control of hemorrhage, hospital admission, and mortality. The analysis was also performed with stratification by race and ethnicity.

RESULTS

Spanish-speaking patients were less likely to receive nasal packing or cautery [odds ratio, OR: 0.78; 95% confidence interval, CI: (0.68; 0.90)] or diagnostic nasal endoscopy [OR: 0.72; 95% CI: (0.52; 0.98)] compared to English-speaking patients. Black patients were more likely to receive treatment with a nasal decongestant spray [OR: 1.31; 95% CI: (1.27, 1.36)], but less likely to receive any other treatment compared to White patients. Asian patients were less likely to undergo nasal packing or cautery [OR: 0.90; 95% CI: (0.82; 0.99)], but had more ED visits [(1.37; 1.32) P < .01] compared to White patients. Hispanic patients were less likely to be admitted [OR: 0.93; 95% CI: (0.87; 0.98)], and averaged fewer ED visits [(1.27; 1.30) P = <.0001] compared to non-Hispanic patients.

CONCLUSION

While demographic trends in ED epistaxis management are nuanced, our results suggest that Spanish-speaking, Black, Asian, and Hispanic patients are less likely to receive diagnostic and epistaxis control procedures. Additional research is needed to determine the etiology of these differences.

Informing Vaccine Messaging and Community Outreach: Experience in Chicago with a Community-Based Participatory Approach

PURPOSE

In response to disparities in COVID-19 vaccine uptake in urban environments, we ascertained whether a community-engaged evaluation could rapidly determine why unvaccinated Chicago residents were hesitant to receive the COVID-19 vaccine.

APPROACH

The assessment used a mixed-methods approach, grounded in community-based participatory research (CBPR) principles.

SETTING

Interviews were conducted by community partners between April and May 2022 in Chicago, in-person and via phone.

PARTICIPANTS

A purposive sample of Chicagoans (n = 456), who were: (1) adults (≥18 years); (2) living in priority areas in Chicago heavily impacted by COVID-19; (3) who spoke English or Spanish; and (4) had not received the COVID-19 vaccine.

METHOD

A transdisciplinary academic-community team co-developed an assessment tool. Members of Chicago's Community Health Response Corps (CHRC) (N = 115) interviewed participants, using a 46-item survey in Qualtrics. Interviews were analyzed using qualitative and quantitative software, including Dedoose for coding and SAS for descriptive statistics.

RESULTS

Over half of all respondents were not concerned about getting COVID-19. Respondents voiced concerns about side effects (36%), vaccine safety (27%), and trust in governmental institutions, given historical events involving unethical research. Participants also reported other social needs (e.g., food or housing insecurity) that made COVID-19 a lower priority.

CONCLUSION

The collaborative research approach highlighted issues of trust, concerns about side effects and vaccine safety, issues that have informed vaccine messaging.

The impact of targeted local outreach clinics to improve COVID-19 vaccine uptake: controlled interrupted time series in South West England

BACKGROUND

Outreach clinics were part of efforts to maximise uptake in COVID-19 vaccination.

METHODS

We used controlled interrupted time series, matching on age, sex, deprivation and vaccination eligibility date, to determine the effect of outreach clinics on time to first COVID-19 vaccine, using a population-based electronic health record database of 914,478 people, from December 2020 to December 2021; people living within 1 mile of each outreach clinics were exposed.

RESULTS

50% of 288,473 exposed citizens were white British, and 71% were aged 0-49 years. There was no evidence for an overall statistically significant increase in cumulative percentage vaccinated due to the outreach clinic at 6 weeks, with an overall pooled effect estimate of -0.07% (95% CI: -1.15%, 1.02%). The pooled estimate for increased cumulative vaccine uptake varied slightly depending on how the analysis was stratified; by ethnic group it was - 0.12% (95% CI: -0.90%, 0.66%); by age group it was - 0.06% (95% CI: -0.41%, 0.28%); and by deprivation it was 0.03% (95% CI: -0.74%, 0.79%).

CONCLUSIONS

Living within a mile of an outreach clinic was not associated with higher vaccine uptake. Evaluation of future outreach clinics should consider the relative importance of travel amongst other barriers to accessing vaccines.

Advancing health equity in the aftermath of COVID-19: Confronting intensifying racial disparities

The COVID-19 pandemic has exposed and exacerbated the persistent racial and ethnic health disparities in the United States. The pandemic has also had profound spillover effects on other aspects of health and wellbeing, such as mental health, chronic diseases, education, and income, for marginalized groups. In this article, we provide a thorough analysis of the pandemic's impact on racial and ethnic health disproportionalities, highlighting the multifaceted and interrelated factors that contribute to these inequities. We also argue for a renewed focus on health equity in healthcare policy and practice, emphasizing the need for systemic changes that address both the immediate and long-term consequences of these imbalances. We propose a framework for achieving health equity that involves creating equitable systems, care, and outcomes for all individuals, regardless of their race or ethnicity.

Understanding Low Vaccine Uptake in the Context of Public Health in High-Income Countries: A Scoping Review

Although the COVID-19 pandemic has caused the need for the largest mass vaccination campaign ever undertaken to date, African, Caribbean, and Black (ACB) populations have shown both a disproportionately high degree of negative impacts from the pandemic and the lowest willingness to become vaccinated. This scoping review aims to investigate low vaccine uptake in ACB populations relative to public health in high-income countries. A search was conducted in MEDLINE(R) ALL (OvidSP), Embase (OvidSP), CINAHL (EBSCOHost), APA PsycInfo (OvidSP), the Cochrane Central Register of Controlled Trials (OvidSP), the Cochrane Database of Systematic Reviews (OvidSP), the Allied and Complimentary Medicine Database (Ovid SP), and the Web of Science following the Joanna Briggs Institute (JBI) framework for scoping reviews, supplemented by PRISMA-ScR. Theoretical underpinnings of the intersectionality approach were also used to help interpret the complexities of health inequities in the ACB population. The eligibility criteria were based on the population, concept, context (PCC) framework, and publications from 2020-19 July 2022 which discussed vaccine uptake amongst ACB people in high-income countries were included. Analysis was carried out through thematic mapping and produced four main themes: (1) racism and inequities, (2) sentiments and behaviors, (3) knowledge and communication, and (4) engagement and influence. This study has contributed to the identification and definition of the issue of low vaccine uptake in ACB populations and has illustrated the complexity of the problems, as vaccine access is hampered by knowledge, psychological, socioeconomic, and organizational barriers at the individual, organizational, and systemic levels, leading to structural inequities that have manifested as low vaccine uptake.

Reasons for COVID-19 vaccine hesitancy in ethnic minority groups: A systematic review and thematic synthesis of initial attitudes in qualitative research

Despite being disproportionately affected by the COVID-19 pandemic, ethnic and racial minority groups show widespread vaccine hesitancy. Adherence to ongoing booster vaccine campaigns is required to contain future spread of the virus and protect health systems. This review aims to appraise and synthesise qualitative studies published from December 2021 to February 2022 addressing the issue for an in-depth exploration of initial COVID-19 vaccine hesitancy in minorities, including refugee, asylum seeker and migrant populations. A systematic literature search of five databases identified 15 eligible studies. Thematic synthesis identified three main themes of "institutional mistrust", "lack of confidence in vaccine and vaccine development process", and "lack of reliable information or messengers". Two minor themes included "complacency/perceived lack of need" and "structural barriers to vaccine access". "Institutional mistrust" permeated several other themes, demonstrating the need for culturally sensitive approaches. Applying our findings to the World Health Organisation's Three C Model of vaccine hesitancy, the "confidence" dimension appears to represent a disproportionately large barrier to vaccine uptake in ethnic minority groups. Indeed, nuanced adaptations of the model may be necessary to explain vaccine hesitancy in those groups. Further research is required to explore factors facilitating vaccine uptake to monitor changes in hesitancy over time.

Differences in the Perceived Likelihood of Receiving COVID-19 Vaccine

There are limited studies on the perceived likelihood of receiving a COVID-19 vaccine among the general US population and its subpopulations. We examined the association between the perceived likelihood of receiving a COVID-19 vaccine with the self-reported likelihood of contracting COVID-19, social-distancing stress, COVID-19 diagnosis status, mental health disorders, and sociodemographic characteristics. The data were collected using a national cross-sectional survey (N = 5404) between 13 May 2021 and 9 January 2022. A multivariable logistic regression analysis was performed. Setting: United States. Participants: Adults aged ≥ 18 years. The majority of US adults (67.34%) indicated they intended to receive a COVID-19 vaccine. There was a decreased perceived likelihood of getting vaccinated associated with those aged 18-49 years (Adjusted Odds Ratio (AOR) = 0.29-59; 95% Confidence Interval (CI) = 0.20-0.85); with a less than college education (AOR = 0.37-58; 95% CI = 0.28-0.68); with no health insurance (AOR = 0.48; 95% CI = 0.40, 0.58); with no perceived likelihood of contracting COVID-19 (AOR = 0.78; 95% CI = 0.68, 0.89); and with anxiety/depression (AOR = 0.67; 95% CI = 0.59, 0.76). Black/African Americans had a lower perceived likelihood of receiving a COVID-19 vaccine (AOR = 0.84; 95% CI = 0.71, 0.98), while Asians (AOR = 1.92; 95% CI = 1.35, 2.74) and Hispanics/Latinos (AOR = 1.34; 95% CI = 1.03, 1.74) had a higher perceived likelihood compared with Whites. Individuals reporting social distancing as stressful (AOR = 1.21; 95% CI = 1.01, 1.45) were associated with an increased perceive likelihood of receiving a COVID-19 vaccine. Our study showed that younger adults, Black/African Americans, and those with a less than college education, no health insurance, or anxiety/depression may be less likely to receive vaccination. Future research should examine the explanatory mechanisms contributing to the lower perceived likelihood of vaccination among these groups, such as barriers to vaccine education or vaccine access. Public health interventions should prioritize these populations to improve vaccination rates.

Racial and ethnic and income disparities in COVID-19 vaccination among Medicare beneficiaries

BACKGROUND

Older adults have been disproportionately affected by the COVID-19 pandemic. Despite the widespread availability and proved effectiveness of COVID-19 vaccines, the issue of inequity in vaccine uptake in the United States is a potential concern among different populations. This study examined racial and ethnic and income disparities in COVID-19 vaccination rate among Medicare beneficiaries.

METHODS

Data from the Medicare Current Beneficiary Survey (MCBS) COVID-19 Winter 2021 Community Supplement were employed (n = 9606 Medicare beneficiaries, weighted N = 50,512,963). We fitted a logistic regression model to determine the association of vaccination status with beneficiary race and ethnicity and income, after controlled for a set of beneficiary characteristics.

RESULTS

Compared with non-Hispanic White respondents, Hispanic respondents (OR = 0.72, 95% CI: 0.54-0.96, p = 0.02) and Black respondents (OR = 0.84, 95% CI: 0.67-1.04, p = 0.11) were less likely to receive COVID-19 vaccine. In addition, the likelihood of COVID-19 vaccine uptake for beneficiaries who earn less than $25,000 per year was more than 50% lower than that for those whose annual income was $25,000 or more (OR = 0.44, 95% CI: 0.37-0.53, p < 0.0001).

CONCLUSIONS

Racial and ethnic and income disparities exist in COVID-19 vaccination rate among Medicare beneficiaries nationally. Community-based strategies to boost vaccine uptake may target racial and ethnic minorities and socioeconomically disadvantaged groups to reduce such disparities.

Evidence-Based Medicine in Otolaryngology, Part XIII: Health Disparities Research and Advancing Health Equity

OBJECTIVE

To provide a contemporary resource for clinicians and researchers on health equity research and implementation strategies to mitigate or eliminate disparities in health care.

DATA SOURCES

Published studies and literature on health disparities, applicable research methodologies, and social determinants of health in otolaryngology.

REVIEW METHODS

Literature through October 2021 was reviewed, including consensus statements, guidelines, and scientific publications related to health care equity research. This research focus provides insights into existing disparities, why they occur, and the outcomes of interventions designed to resolve them. Progress toward equity requires intentionality in implementing quality improvement initiatives, tracking data, and fostering culturally competent care. Priority areas include improving access, removing barriers to care, and ensuring appropriate and effective treatment. Although research into health care disparities has advanced significantly in recent years, persistent knowledge gaps remain. Applying the lens of equity to data science can promote evidence-based practices and optimal strategies to reduce health inequities.

CONCLUSIONS

Health disparities research has a critical role in advancing equity in otolaryngology-head and neck surgery. The phases of disparities research include detection, understanding, and reduction of disparities. A multilevel approach is necessary for understanding disparities, and health equity extensions can improve the rigor of evidence-based data synthesis. Finally, applying an equity lens is essential when designing and evaluating health care interventions, to minimize bias.

IMPLICATIONS FOR PRACTICE

Understanding the data and practices related to disparities research may help promote an evidence-based approach to care of individual patients and populations, with the potential to eventually surmount the negative effects of health care disparities.