Structural racism and COVID-19 response: higher risk of exposure drives disparate COVID-19 deaths among Black and Hispanic/Latinx residents of Illinois, USA

Long-term exposure to wildland fire smoke PM2.5 and mortality in the contiguous United States

Despite the substantial evidence on the health effects of short-term exposure to ambient fine particles (PM2.5), including increasing studies focusing on those from wildland fire smoke, the impacts of long-term wildland fire smoke PM2.5 exposure remain unclear. We investigated the association between long-term exposure to wildland fire smoke PM2.5 and non-accidental mortality and mortality from a wide range of specific causes in all 3,108 counties in the contiguous U.S., 2007-2020. Controlling for non-smoke PM2.5, air temperature, and unmeasured spatial and temporal confounders, we found a non-linear association between 12-month moving average concentration of smoke PM2.5 and monthly non-accidental mortality rate. Relative to a month with the long-term smoke PM2.5 exposure below 0.1 μg/m3, non-accidental mortality increased by 0.16-0.63 and 2.11 deaths per 100,000 people per month when the 12-month moving average of PM2.5 concentration was of 0.1-5 and 5+ μg/m3, respectively. Cardiovascular, ischemic heart disease, digestive, endocrine, diabetes, mental, and chronic kidney disease mortality were all found to be associated with long-term wildland fire smoke PM2.5 exposure. Smoke PM2.5 contributed to approximately 11,415 non-accidental deaths/year (95% CI: 6,754, 16,075) in the contiguous U.S. Higher smoke PM2.5-related increases in mortality rates were found for people aged 65 above. Positive interaction effects with extreme heat (monthly number of days with daily mean air temperature higher than the county's 90th percentile warm season air temperature) were also observed. Our study identified the detrimental effects of long-term exposure to wildland fire smoke PM2.5 on a wide range of mortality outcomes, underscoring the need for public health actions and communications that span the health risks of both short- and long-term exposure.

Racial and Ethnic Disparities in Primary Prevention of Cardiovascular Disease

Cardiovascular disease (CVD) disproportionately affects ethnic-minority groups globally. Ethnic-minority groups face particularly high CVD burden and mortality, exacerbated by disparities across modifiable risk factors, wider determinants of health, and limited access to preventative interventions. This narrative review summarizes evidence on modifiable risk factors, such as physical activity, hypertension, diet, smoking, alcohol consumption, diabetes, and the polypill for the primary prevention of CVD in ethnic minorities. Across these factors, we find inequities in risk factor prevalence. The evidence underscores that inequalities in accessibility to interventions and treatments impede progress in reducing CVD risk using primary prevention interventions for ethnic-minority people. Although culturally tailored interventions show promise, further research is required across the different risk factors. Social determinants of health and structural inequities also exacerbate CVD risk for ethnic-minority people and warrant greater attention. Additionally, we find that only limited ethnicity-specific data and guidelines are available on CVD primary prevention interventions for most risk factors. To address these gaps in research, we provide recommendations that include the following: investigating the sustainability and real-world effectiveness of culturally sensitive interventions; ensuring that ethnic-minority peoples' perspectives are considered in research; longitudinal tracking of risk factors; interventions and outcomes in ethnic-minority people; and ensuring that data collection and reporting of ethnicity data are standardized.

Continuum of Trauma: Fear and Mistrust of Institutions in Communities of Color During the COVID-19 Pandemic

Historical, cultural, and social trauma, along with social determinants of health (SDOH), shape health outcomes, attitudes toward medicine, government, and health behaviors among communities of color in the United States (U.S.). This study explores how trauma and fear influence COVID-19 testing and vaccination among Black/African American, Latinx/Indigenous Latin American, and Native American/Indigenous communities. Leveraging community-based participatory research methods, we conducted 11 virtual focus groups from January to March of 2021 with Black/African American (n = 4), Latinx/Indigenous Latin American (n = 4), and Native American/Indigenous (n = 3) identifying community members in Inland Southern California. Our team employed rapid analytic approaches (e.g., template and matrix analysis) to summarize data and identify themes across focus groups and used theories of intersectionality and trauma to meaningfully interpret study findings. Historical, cultural, and social trauma induce fear and mistrust in public health and medical institutions influencing COVID-19 testing and vaccination decisions in communities of color in Inland Southern California. This work showcases the need for culturally and structurally sensitive community-based health interventions that attend to the historical, cultural, and social traumas unique to racial/ethnic minority populations in the U.S. that underlie fear and mistrust of medical, scientific, and governmental institutions.

Cost of SARS-CoV-2 self-test distribution programmes by different modalities: a micro-costing study in five countries (Brazil, Georgia, Malaysia, Ethiopia and the Philippines)

OBJECTIVE

Diagnostic testing is an important tool to combat the COVID-19 pandemic, yet access to and uptake of testing vary widely 3 years into the pandemic. The WHO recommends the use of COVID-19 self-testing as an option to help expand testing access. We aimed to calculate the cost of providing COVID-19 self-testing across countries and distribution modalities.

DESIGN

We estimated economic costs from the provider perspective to calculate the total cost and the cost per self-test kit distributed for three scenarios that differed by costing period (pilot, annual), the number of tests distributed (actual, planned, scaled assuming an epidemic peak) and self-test kit costs (pilot purchase price, 50% reduction).

SETTING

We used data collected between August and December 2022 in Brazil, Georgia, Malaysia, Ethiopia and the Philippines from pilot implementation studies designed to provide COVID-19 self-tests in a variety of settings-namely, workplace and healthcare facilities.

RESULTS

Across all five countries, 173 000 kits were distributed during pilot implementation with the cost/test distributed ranging from $2.44 to $12.78. The cost/self-test kit distributed was lowest in the scenario that assumed implementation over a longer period (year), with higher test demand (peak) and a test kit price reduction of 50% ($1.04-3.07). Across all countries and scenarios, test procurement occupied the greatest proportion of costs: 58-87% for countries with off-site self-testing (outside the workplace, for example, home) and 15-50% for countries with on-site self-testing (at the workplace). Staffing was the next key cost driver, particularly for distribution modalities that had on-site self-testing (29-35%) versus off-site self-testing (7-27%).

CONCLUSIONS

Our results indicate that it is likely to cost between $2.44 and $12.78 per test to distribute COVID-19 self-tests across common settings in five heterogeneous countries. Cost-effectiveness analyses using these results will allow policymakers to make informed decisions on optimally scaling up COVID-19 self-test distribution programmes across diverse settings and evolving needs.

COVID-Related Stressors and Psychological Distress Among Chicago Residents: the Moderating Role of Race

BACKGROUND

Racial and ethnic minorities have been disproportionately affected by the COVID-19 pandemic and have experienced greater financial loss, housing instability, and food insecurity due to COVID-related restrictions. As a result, Black and Hispanic communities may be at greater risk of experiencing psychological distress (PD).

METHODS

Using data collected between October 2020 and January 2021from 906 Black (39%), White (50%), and Hispanic (11%) adults, we assessed racial/ethnic differences in the effect of three COVID-related stressors-employment stress, housing instability, and food insecurity-on PD using ordinary least square regression.

RESULTS

Black adults reported lower PD levels compared to White adults (β =  - 0.23, P < 0.001), but Hispanic adults did not differ significantly from White adults. COVID-related housing instability (β = 0.46, P < 0.001), food insecurity (β = 0.27, P < 0.001), and employment stress (β = 0.29, P < 0.001) were associated with higher PD. Employment stress was the only stressor to differentially affect PD by race/ethnicity. Among those that reported employment stress, Black adults had lower levels of distress compared to Whites (β =  - 0.54, P < 0.001) and Hispanics (β =  - 0.04, P = 0.85).

CONCLUSION

Despite relatively high exposure to COVID-related stressors, Black respondents had lower levels of PD compared to Whites and Hispanics which may reflect differences in race-specific coping mechanisms. Future research is needed to elucidate the nuances of these relationships and identify policies and interventions that prevent and minimize the impact of employment, food, and housing-related stressors and support coping mechanisms that promote mental health among minority populations, such as policies that support easier access to mental health and financial and housing assistance.

Making sense of COVID-19: manifestations of health capital during the pandemic

BACKGROUND

Grounded in Bourdieu's theory of human practice, this study aims to examine how individuals as social agents made sense of and acted upon their COVID-19 experiences. A recent conceptualization of health capital is utilized to explain the practices of patients in the pandemic, in relation to their biographical background.

METHODS

This is a qualitative research in which the data were collected by biographical narrative interviews through a theoretical sampling approach. Eighteen interviews with COVID-19 patients were conducted and 8 of them were analyzed by the Documentary Method.

RESULTS

The informants made sense of their illness experiences through their health capital, which is manifested in their self-perception of health, their attitudes towards the healthcare system, their conception of terms such as luck, their work status, and the gendered division of labour at home in the COVID-19 pandemic. All the manifestations are mediated by the social, cultural, and economic capital of the informants, and their habitual practices are based on their symbolic capital.

CONCLUSION

The study depicts how social agents' health capital manifested in the pandemic, relying on their symbolic capital, and shaping their practices. Further research across diverse contexts is needed to fully understand extra dimensions of health capital as a descriptor of the social determinants of health.

Changing COVID-19 cases and deaths detection in Florida

Epidemic data are often difficult to interpret due to inconsistent detection and reporting. As these data are critically relied upon to inform policy and epidemic projections, understanding reporting trends is similarly important. Early reporting of the COVID-19 pandemic in particular is complicated, due to changing diagnostic and testing protocols. An internal audit by the State of Florida, USA found numerous specific examples of irregularities in COVID-19 case and death reports. Using case, hospitalization, and death data from the the first year of the COVID-19 pandemic in Florida, we present approaches that can be used to identify the timing, direction, and magnitude of some reporting changes. Specifically, by establishing a baseline of detection probabilities from the first (spring) wave, we show that transmission trends among all age groups were similar, with the exception of the second summer wave, when younger people became infected earlier than seniors, by approximately 2 weeks. We also found a substantial drop in case-fatality risk (CFR) among all age groups over the three waves during the first year of the pandemic, with the most drastic changes seen in the 0 to 39 age group. The CFR trends provide useful insights into infection detection that would not be possible by relying on the number of tests alone. During the third wave, for which we have reliable hospitalization data, the CFR was remarkably stable across all age groups. In contrast, the hospitalization-to-case ratio varied inversely with cases while the death-to-hospitalization ratio varied proportionally. Although specific trends are likely to vary between locales, the approaches we present here offer a generic way to understand the substantial changes that occurred in the relationships among the key epidemic indicators.

Racial and Ethnic Identity and Vulnerability to Upper Respiratory Viral Infections Among US Children

BACKGROUND

It is unclear whether there are racial/ethnic disparities in the risk of upper respiratory viral infection acquisition and/or lower respiratory manifestations.

METHODS

We studied all children and children with asthma aged 6 to 17 years in the National Health and Nutrition Examination Survey (2007-2012) to evaluate (1) the association between race/ethnicity and upper respiratory infection (URI) and (2) whether race/ethnicity is a risk factor for URI-associated pulmonary eosinophilic inflammation or decreased lung function.

RESULTS

Children who identified as Black (adjusted odds ratio [aOR], 1.38; 95% CI, 1.10-1.75) and Mexican American (aOR, 1.50; 95% CI, 1.16-1.94) were more likely to report a URI than those who identified as White. Among those with asthma, Black children were more than twice as likely to report a URI than White children (aOR, 2.28; 95% CI, 1.31-3.95). Associations between URI and pulmonary eosinophilic inflammation or lung function did not differ by race/ethnicity.

CONCLUSIONS

Findings suggest that there may be racial and ethnic disparities in acquiring a URI but not in the severity of infection. Given that upper respiratory viral infection is tightly linked to asthma exacerbations in children, differences in the risk of infection among children with asthma may contribute to disparities in asthma exacerbations.

Learning from the COVID-19 pandemic: a systematic review of mathematical vaccine prioritization models

As the world becomes ever more connected, the chance of pandemics increases as well. The recent COVID-19 pandemic and the concurrent global mass vaccine roll-out provides an ideal setting to learn from and refine our understanding of infectious disease models for better future preparedness. In this review, we systematically analyze and categorize mathematical models that have been developed to design optimal vaccine prioritization strategies of an initially limited vaccine. As older individuals are disproportionately affected by COVID-19, the focus is on models that take age explicitly into account. The lower mobility and activity level of older individuals gives rise to non-trivial trade-offs. Secondary research questions concern the optimal time interval between vaccine doses and spatial vaccine distribution. This review showcases the effect of various modeling assumptions on model outcomes. A solid understanding of these relationships yields better infectious disease models and thus public health decisions during the next pandemic.

Spatial and Temporal Drug Usage Patterns in Wastewater Correlate with Socioeconomic and Demographic Indicators in Southern Nevada

Evaluating drug use within populations in the United States poses significant challenges due to various social, ethical, and legal constraints, often impeding the collection of accurate and timely data. Here, we aimed to overcome these barriers by conducting a comprehensive analysis of drug consumption trends and measuring their association with socioeconomic and demographic factors. From May 2022 to April 2023, we analyzed 208 wastewater samples from eight sampling locations across six wastewater treatment plants in Southern Nevada, covering a population of 2.4 million residents with 50 million annual tourists. Using bi-weekly influent wastewater samples, we employed mass spectrometry to detect 39 analytes, including pharmaceuticals and personal care products (PPCPs) and high risk substances (HRS). Our results revealed a significant increase over time in the level of stimulants such as cocaine (pFDR=1.40×10-10) and opioids, particularly norfentanyl (pFDR =1.66×10-12), while PPCPs exhibited seasonal variation such as peak usage of DEET, an active ingredient in insect repellents, during the summer (pFDR =0.05). Wastewater from socioeconomically disadvantaged or rural areas, as determined by Area Deprivation Index (ADI) and Rural-Urban Commuting Area Codes (RUCA) scores, demonstrated distinct overall usage patterns, such as higher usage/concentration of HRS, including cocaine (p=0.05) and norfentanyl (p=1.64×10-5). Our approach offers a near real-time, comprehensive tool to assess drug consumption and personal care product usage at a community level, linking wastewater patterns to socioeconomic and demographic factors. This approach has the potential to significantly enhance public health monitoring strategies in the United States.

Validity of a Common Measure of Intimate Partner Violence Perpetration: Impact on Study Inference in Trials in Low- and Middle-Income Countries

Background

In lower-and middle-income countries (LMICs), studies of interventions to reduce intimate partner violence (IPV) perpetration are expanding, yet measurement equivalence of the IPV perpetration construct that is the primary outcome in these investigations has not been established. We assessed the measurement equivalence of physical and sexual IPV perpetration item sets used in recent trials in LMICs and tested the impact of non-invariance on trial inference.

Methods

With data from three intervention trials among men (sample size 505-1537 across studies) completed in 2019, we calculated tetrachoric correlations among items and used multiple-group confirmatory factor analysis to assess invariance across arms and over time. We also assessed treatment effects adjusting for covariate imbalance and using inverse probability to treatment weights to assess concordance of invariant measures with published results, where warranted.

Findings

The average correlation among items measuring IPV perpetration was high and increased by 0.03 to 0.15 for physical IPV and 0.07 to 0.17 for sexual IPV over time with several items in two studies showing correlations ≥ 0.85 at endline. Increases in the degree of correlation for physical IPV were concentrated in the treatment arm in two of the studies. The increase in correlation in sexual IPV differed by arm across studies. Across all studies, a correlated two-factor solution was the best fitting model according to the EFAs and CFAs. One study demonstrated measurement invariance across arms and over time. In two of the studies, longitudinal measurement non-invariance was detected in the intervention arms. In post hoc testing, one study attained invariance with a one-factor model and study inference was concordant with published findings. The other study did not attain even partial invariance.

Conclusion

Common measures of physical and sexual IPV perpetration cannot be used validly for comparisons across treatment versus control groups over time without further refinement. The study highlights the need for an expanded item set, content validity assessments, further measurement invariance testing, and then consistent use of the item sets in future intervention trials to ensure valid inferences regarding the effectiveness of IPV perpetration prevention interventions within and across trials.

Evaluating the impact of 'Ask the Specialist Plus': a training program for improving cultural safety and communication in hospital-based healthcare

BACKGROUND

First Nations peoples in colonised countries often feel culturally unsafe in hospitals, leading to high self-discharge rates, psychological distress and premature death. To address racism in healthcare, institutions have promised to deliver cultural safety training but there is limited evidence on how to teach cultural safety. To that end, we created Ask the Specialist Plus: a training program that focuses on improving healthcare providers intercultural communication skills to improve cultural safety. Our aim is to describe training implementation and to evaluate the training according to participants.

METHODS

Inspired by cultural safety, Critical Race Theory and Freirean pedagogy, Ask the Specialist Plus was piloted at Royal Darwin Hospital in Australia's Northern Territory in 2021. The format combined listening to an episode of a podcast called Ask the Specialist with weekly, one-hour face-to-face discussions with First Nations Specialists outside the clinical environment over 7 to 8 weeks. Weekly surveys evaluated teaching domains using five-point Likert scales and via free text comments. Quantitative data were collated in Excel and comments were collated in NVivo12. Results were presented following Kirkpatrick's evaluation model.

RESULTS

Fifteen sessions of Ask the Specialist Plus training were delivered. 90% of participants found the training valuable. Attendees enjoyed the unique format including use of the podcast as a catalyst for discussions. Delivery over two months allowed for flexibility to accommodate clinical demands and shift work. Students through to senior staff learnt new skills, discussed institutionally racist systems and committed to behaviour change. Considering racism is commonly denied in healthcare, the receptiveness of staff to discussing racism was noteworthy. The pilot also contributed to evidence that cultural safety should be co-taught by educators who represent racial and gender differences.

CONCLUSION

The Ask the Specialist Plus training program provides an effective model for cultural safety training with high potential to achieve behaviour change among diverse healthcare providers. The training provided practical information on how to improve communication and fostered critical consciousness among healthcare providers. The program demonstrated that training delivered weekly over two months to clinical departments can lead to positive changes through cycles of learning, action, and reflection.

Toward standardization, harmonization, and integration of social determinants of health data: A Texas Clinical and Translational Science Award institutions collaboration

Introduction

The focus on social determinants of health (SDOH) and their impact on health outcomes is evident in U.S. federal actions by Centers for Medicare & Medicaid Services and Office of National Coordinator for Health Information Technology. The disproportionate impact of COVID-19 on minorities and communities of color heightened awareness of health inequities and the need for more robust SDOH data collection. Four Clinical and Translational Science Award (CTSA) hubs comprising the Texas Regional CTSA Consortium (TRCC) undertook an inventory to understand what contextual-level SDOH datasets are offered centrally and which individual-level SDOH are collected in structured fields in each electronic health record (EHR) system potentially for all patients.

Methods

Hub teams identified American Community Survey (ACS) datasets available via their enterprise data warehouses for research. Each hub's EHR analyst team identified structured fields available in their EHR for SDOH using a collection instrument based on a 2021 PCORnet survey and conducted an SDOH field completion rate analysis.

Results

One hub offered ACS datasets centrally. All hubs collected eleven SDOH elements in structured EHR fields. Two collected Homeless and Veteran statuses. Completeness at four hubs was 80%-98%: Ethnicity, Race; < 10%: Education, Financial Strain, Food Insecurity, Housing Security/Stability, Interpersonal Violence, Social Isolation, Stress, Transportation.

Conclusion

Completeness levels for SDOH data in EHR at TRCC hubs varied and were low for most measures. Multiple system-level discussions may be necessary to increase standardized SDOH EHR-based data collection and harmonization to drive effective value-based care, health disparities research, translational interventions, and evidence-based policy.

Adaptation of the brainwriting premortem technique to inform the co-creation of COVID-19 testing strategies in underserved communities in South San Diego

INTRODUCTION

Meaningful engagement of partners in co-creating and refining health-related programs can increase the initial uptake, sustained implementation, broad reach, and effectiveness of these programs. This is especially important for underserved communities where resources are limited and need to be prioritized. Brainwriting premortem is a novel qualitative approach to partner engagement that combines the strengths of individual idea generation with the concept of premortem exercise that addresses failure points prior to the implementation of new programs.

METHODS

An adapted form of brainwriting premortem was used to inform iterative refinements to a COVID-19 testing program at a Federally Qualified Health Center (FQHC) in San Diego. Patients and providers from the FQHC participated in interviews at two time points (early- and mid-implementation of the program). Interview data were transcribed, translated, and analyzed using a rapid qualitative approach. Key themes and sub-themes were identified and used to inform refinements to the program.

RESULTS

A total of 11 patients (7 Spanish- and 4 English-speaking) and 8 providers participated in the brainwriting premortem interviews. Key themes related to possible reasons for COVID-19 testing program failure: advertising/sharing information; access to testing; handling of test results; staff and patient safety; patient beliefs and views regarding the SARS-CoV-2 virus; and COVID-19 testing options offered. Proposed solutions were offered for the key failures except for patient beliefs and views regarding the SARS-CoV-2 virus. Additional solutions offered were related to education, physical operations, and recruitment strategies. Real-time changes to the program flow and components were made in response to 7 suggestions from patients and 11 from providers. Changes related to the process of returning results were the most common, and included sending results via email with distinct workflows based on the test result.

CONCLUSION

The implementation of the adapted brainwriting premortem technique allowed us to incorporate the perspective of key partners in the delivery and iterative refinement of the COVID-19 testing program. This was an effective tool in the context of an FQHC and can be a promising and approach to incorporate iterative input from patients and providers to ensure successful program implementation. Future studies, particularly those requiring rapid response to public health emergencies, should consider the use of this technique.

"There is nothing that can prevent me from supporting her:" Men's perspectives on their involvement and support of women's use of topical therapy for cervical precancer treatment in Kenya

Purpose

Cervical cancer disproportionately impacts women in low- and middle-income countries (LMICs). The World Health Organization's (WHO) 90/70/90 strategy aims to eliminate cervical cancer by 2030 by increasing HPV vaccination coverage to 90%, screening 70% of eligible women, and effectively treating 90% of those with abnormal results by 2030, potentially preventing 62 million deaths in LMICs. LMICs, however, struggle with limited access to cervical precancer treatment, in part due to a lack of trained professionals and weak health systems. Effective non-surgical, self-administered, which have demonstrated efficacy in high-income countries, could bridge the treatment gap in LMICs and may be more scalable and cost-effective than provider-administered therapies. To inform feasibility studies in LMICs, data are needed on the role of male partners in influencing the acceptability and uptake of self-administered topical therapies, including their support of recommended abstinence and contraception guidelines associated with these therapies.

Methods

Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with men aged 25 to 65 years in Kenya to explore their perspective and perceived support regarding their female partners using topical self-administered therapies for cervical precancer treatment. The FGDs were moderated by local qualitative research assistants and conducted in local languages, transcribed, coded, and analyzed using qualitative description.

Results

Male participants in the FGDs strongly expressed acceptance and willingness to support their wives or partners in using topical therapies for cervical precancer treatment, if available. Reported supportive behavior included permitting the use of the therapies and support of maintaining abstinence during the recommended times. Additionally, participants desired male involvement in clinic and community-based education about topical therapies to facilitate widespread support.

Conclusion

The use of self-administered topical therapies for cervical precancer treatment, if supported by efficacy studies in LMICs, may support achieving the WHO's 2030 goal of 90% treatment access. We find that with adequate education, men express overwhelming support of their female partner's use of topical therapies, including adherence to abstinence and contraception guidelines.

Racial and Ethnic Disparities in COVID-19-Related Stressor Exposure and Adverse Mental Health Outcomes Among Health Care Workers

OBJECTIVE

Racial and ethnic disparities in exposure to COVID-19-related stressors, pandemic-related distress, and adverse mental health outcomes were assessed among health care workers in the Bronx, New York, during the first wave of the pandemic.

METHODS

The authors analyzed survey data from 992 health care workers using adjusted logistic regression models to assess differential prevalence of outcomes by race/ethnicity and their interactions.

RESULTS

Compared with their White colleagues, Latinx, Black, Asian, and multiracial/other health care workers reported significantly higher exposure to multiple COVID-19-related stressors: redeployment, fear of being sick, lack of autonomy at work, and inadequate access to personal protective equipment. Endorsing a greater number of COVID-19-related stressors was associated with pandemic-related distress in all groups and with adverse mental health outcomes in some groups; it was not related to hazardous alcohol use in any of the groups. These associations were not significantly different between racial and ethnic groups. Latinx health care workers had significantly higher probabilities of pandemic-related distress and posttraumatic stress than White colleagues. Despite greater exposure to COVID-19-related stressors, Black, Asian, and multiracial/other health care workers had the same, if not lower, prevalence of adverse mental health outcomes. Conversely, White health care workers had a higher adjusted prevalence of moderate to severe anxiety compared with Asian colleagues and greater hazardous alcohol use compared with all other groups.

CONCLUSIONS

Health care workers from racial and ethnic minority groups reported increased exposure to COVID-19-related stressors, suggestive of structural racism in the health care workforce. These results underscore the need for increased support for health care workers and interventions aimed at mitigating disparities in vocational exposure to risk and stress.

MICEAL Black and Latinx Perspectives on COVID-19 Vaccination: A Mixed-Methods Examination

OBJECTIVES

To describe the differences and similarities in perceptions and attitudes regarding COVID-19 vaccination among Black and Latinx Michiganders.

METHODS

Utilizing a convergent mixed-methods approach, forty interviews were conducted with 24 Black and 16 Latinx community members between December 2020 and June 2021 across four Michigan counties disproportionately affected by COVID-19. Survey data were collected from a representative sample of 1598 individuals living in Detroit between January and March 2021.

RESULTS

Vaccine hesitancy was a more prevalent theme among Black interview participants than Latinx participants. Trust in experts and vaccine access were significantly more influential in the decision to vaccinate for Latinx residents compared to Black residents. Latinx individuals reported greater intention to receive a COVID-19 vaccine compared to Black respondents. Multinomial logit models revealed that 30% of Black participants expressed hesitancy about the COVID-19 vaccine compared to 10% of Latinx respondents.

CONCLUSIONS AND IMPLICATIONS

This study provides a deeper understanding of key differences and similarities in vaccine acceptance/hesitancy across race/ethnicity. The findings can enhance health interventions and outcomes by informing the development of culturally responsive practices tailored to specific communities.

Sociodemographic Differences in COVID-19 Pandemic Experiences Among Families in the United States

Importance

Few population-based studies in the US collected individual-level data from families during the COVID-19 pandemic.

Objective

To examine differences in COVID-19 pandemic-related experiences in a large sociodemographically diverse sample of children and caregivers.

Design, Setting, and Participants

The Environmental influences on Child Health Outcomes (ECHO) multi-cohort consortium is an ongoing study that brings together 64 individual cohorts with participants (24 757 children and 31 700 caregivers in this study) in all 50 US states and Puerto Rico. Participants who completed the ECHO COVID-19 survey between April 2020 and March 2022 were included in this cross-sectional analysis. Data were analyzed from July 2021 to September 2022.

Main Outcomes and Measures

Exposures of interest were caregiver education level, child life stage (infant, preschool, middle childhood, and adolescent), and urban or rural (population <50 000) residence. Dependent variables included COVID-19 infection status and testing; disruptions to school, child care, and health care; financial hardships; and remote work. Outcomes were examined separately in logistic regression models mutually adjusted for exposures of interest and race, ethnicity, US Census division, sex, and survey administration date.

Results

Analyses included 14 646 children (mean [SD] age, 7.1 [4.4] years; 7120 [49%] female) and 13 644 caregivers (mean [SD] age, 37.6 [7.2] years; 13 381 [98%] female). Caregivers were racially (3% Asian; 16% Black; 12% multiple race; 63% White) and ethnically (19% Hispanic) diverse and comparable with the US population. Less than high school education (vs master's degree or more) was associated with more challenges accessing COVID-19 tests (adjusted odds ratio [aOR], 1.88; 95% CI, 1.06-1.58), lower odds of working remotely (aOR, 0.04; 95% CI, 0.03-0.07), and more food access concerns (aOR, 4.14; 95% CI, 3.20-5.36). Compared with other age groups, young children (age 1 to 5 years) were least likely to receive support from schools during school closures, and their caregivers were most likely to have challenges arranging childcare and concerns about work impacts. Rural caregivers were less likely to rank health concerns (aOR, 0.77; 95% CI, 0.69-0.86) and social distancing (aOR, 0.82; 95% CI, 0.73-0.91) as top stressors compared with urban caregivers.

Conclusions

Findings in this cohort study of US families highlighted pandemic-related burdens faced by families with lower socioeconomic status and young children. Populations more vulnerable to public health crises should be prioritized in recovery efforts and future planning.

Predictors of COVID-19 vaccine uptake among adults in South Africa: multimethod evidence from a population-based longitudinal study

BACKGROUND

COVID-19 vaccine coverage remains low in many low and middle-income countries despite widespread access. To understand the dynamic decision-making process around vaccination and provide evidence for future vaccine promotion campaigns, we identified predictors of COVID-19 vaccine uptake among South African adults, including those who did not believe in the vaccine's safety or efficacy.

METHODS

Data from two longitudinal telephone surveys in late 2021 and early 2022 of unvaccinated South African adults were used to model COVID-19 uptake. Predictors of interest informed by the theory of planned behaviour included vaccine attitudes and beliefs, social norms, perceived behavioural control and vaccine intentions. Responses to open-ended questions provided insights into key reasons for getting vaccinated.

RESULTS

Among panel participants (n=1772), 19% reported being vaccinated between Survey 1 and Survey 2. Vaccine uptake was greater among participants who reported wanting to get vaccinated 'as soon as possible' (+27 percentage points, p<0.01). Vaccine uptake was greater among participants who believed that the vaccine is effective in preventing COVID-19 infection and/or death (+12 percentage points, p<0.01) and lower among those who believed that the vaccine is unsafe (-9 percentage points, p<0.01). Among participants who did not believe the vaccine is safe, living with someone already vaccinated against COVID-19 increased vaccine uptake (+6 percentage points, p<0.05). At Survey 1, the intention to get vaccinated as soon as possible was positively associated with perceived risk of illness from COVID-19 (+9.2 percentage points, p<0.05), the belief that most people in their area had been vaccinated (+7.0 percentage points, p<0.05) and living with someone already vaccinated against COVID-19 (+6.6 percentage points, p<0.05).

CONCLUSION

Study findings underscore the predictive power of intentions and of beliefs about disease risk, vaccine safety and vaccine efficacy. Social proof interventions hold promise for increasing vaccination intentions and overcoming concerns about vaccine safety.

Filling the gaps: A community case study in using an interprofessional approach and community-academic partnerships to address COVID-19-related inequities

Public health challenges rapidly escalated during the COVID-19 pandemic. In response to a severe lack of resources and support in the near western suburbs of Chicago, the COVID Equity Response Collaborative: Loyola (CERCL) was established by an interprofessional team of Loyola University Chicago students, staff, and faculty. CERCL sought to minimize the negative impact of COVID-19 on vulnerable communities, those that are largely Black, Hispanic, or low-income. From April 2020 to the present, the collaborative utilized community-academic partnerships and interdisciplinary collaborations to conduct programming. CERCL's programming included free community-based testing, screening for and assistance with social determinants of health, dissemination of relevant and reliable COVID-related information, provision of personal protective equipment, and facilitation of access to vaccines. With partners, the collaborative conducted 1,500 COVID-19 tests, trained 80 individuals in contact tracing, provided over 100 individuals with specifically tailored resources to address social and legal needs, distributed 5,000 resource bags, held 20 community conversations, canvassed 3,735 homes, and hosted 19 vaccine clinics. Community-academic partnerships with the health system, community and governmental agencies, and the local public health department have been critical to CERCL efforts. The interdisciplinary and interprofessional successes demonstrated in this case study lends the example of a relevant, sustainable, and practical intervention to address nuanced public health issues.

Permanent, long-acting and short-acting reversible contraceptive methods use among women in Bangladesh: an analysis of Bangladesh Demographic and Health Survey 2017-2018 data

OBJECTIVES

This study aims to explore the factors associated with the permanent and long-acting reversible contraceptive (LARC) method use compared with short-acting reversible contraceptive (SARC) methods among Bangladeshi ever-married women aged 15-49 years.

DESIGN

Cross-sectional study.

SETTING

We used data from Bangladesh Demographic Health Survey (BDHS) 2017-2018.

PARTICIPANTS

A total of 9669 Bangladeshi reproductive-aged women who gave information on contraception use were the study participants. A multilevel multinomial logistic regression model was employed where the SARC method was considered as the base category and the cluster was considered as level-2 factor.

RESULTS

Among the contraceptive users in Bangladeshi women, about 83.48% used the SARC method, while 11.34%, and 5.18% used permanent and LARC methods, respectively. Compared with SARC, women with no formal education and only primary education who were non-Muslims, and had parity of ≥3 had a higher likelihood of using both permanent and LARC methods. Women from the age group of 25-34 years (adjusted relative risk ratio (aRRR): 7.03, 95% CI: 4.17 to 11.85) and 35-49 years (aRRR: 12.53, 95% CI: 7.27 to 21.58) who were employed (aRRR: 1.19, 95% CI: 1.00 to 1.40), had media access (aRRR: 1.24, 95% CI: 1.03 to 1.49), gave birth in last 5 years (aRRR: 1.40, 95% CI: 1.11 to 1.76), whose contraception decision solely made by their husband (aRRR: 7.03, 95% CI: 5.15 to 9.60) and having high decision-making power (aRRR: 2.12, 95% CI: 1.62 to 2.77) were more likely to use permanent contraceptive methods. We observed that women from households with richer (aRRR: 0.65, 95% CI: 0.45 to 0.93) and richest (aRRR: 0.38, 95% CI: 0.23 to 0.63) wealth quintiles were less likely to use LARC methods.

CONCLUSIONS

This study identified that women with no/less education, non-Muslims, and having parity of ≥3 were more likely to use both permanent and LARC methods than SARC methods. Targeted interventions could be developed and implemented to promote personalised contraceptive use.

Programme and policy perspectives towards a tobacco-free generation in India: findings from a qualitative study

OBJECTIVE

This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India's transition towards a tobacco-free generation.

DESIGN

Qualitative semi-structured interviews.

SETTING

Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically.

PARTICIPANTS

Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated.

RESULTS

The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an 'application' for 'compliance and monitoring indicators' in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation.

CONCLUSION

Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly.

Excess mortality associated with the COVID-19 pandemic during the 2020 and 2021 waves in Antananarivo, Madagascar

INTRODUCTION

COVID-19-associated mortality remains difficult to estimate in sub-Saharan Africa because of the lack of comprehensive systems of death registration. Based on death registers referring to the capital city of Madagascar, we sought to estimate the excess mortality during the COVID-19 pandemic and calculate the loss of life expectancy.

METHODS

Death records between 2016 and 2021 were used to estimate weekly excess mortality during the pandemic period. To infer its synchrony with circulation of SARS-CoV-2, a cross-wavelet analysis was performed. Life expectancy loss due to the COVID-19 pandemic was calculated by projecting mortality rates using the Lee and Carter model and extrapolating the prepandemic trends (1990-2019). Differences in life expectancy at birth were disaggregated by cause of death.

RESULTS

Peaks of excess mortality in 2020-21 were associated with waves of COVID-19. Estimates of all-cause excess mortality were 38.5 and 64.9 per 100 000 inhabitants in 2020 and 2021, respectively, with excess mortality reaching ≥50% over 6 weeks. In 2021, we quantified a drop of 0.8 and 1.0 years in the life expectancy for men and women, respectively attributable to increased risks of death beyond the age of 60 years.

CONCLUSION

We observed high excess mortality during the pandemic period, in particular around the peaks of SARS-CoV-2 circulation in Antananarivo. Our study highlights the need to implement death registration systems in low-income countries to document true toll of a pandemic.

Do polygenic indices capture "direct" effects on child externalizing behavior? Within-family analyses in two longitudinal birth cohorts

Behaviors and disorders characterized by difficulties with self-regulation, such as problematic substance use, antisocial behavior, and symptoms of attention-deficit/hyperactivity disorder (ADHD), incur high costs for individuals, families, and communities. These externalizing behaviors often appear early in the life course and can have far-reaching consequences. Researchers have long been interested in direct measurements of genetic risk for externalizing behaviors, which can be incorporated alongside other known risk factors to improve efforts at early identification and intervention. In a preregistered analysis drawing on data from the Environmental Risk (E-Risk) Longitudinal Twin Study (N = 862 twins) and the Millennium Cohort Study (MCS; N = 2,824 parent-child trios), two longitudinal cohorts from the UK, we leveraged molecular genetic data and within-family designs to test for genetic effects on externalizing behavior that are unbiased by the common sources of environmental confounding. Results are consistent with the conclusion that an externalizing polygenic index (PGI) captures causal effects of genetic variants on externalizing problems in children and adolescents, with an effect size that is comparable to those observed for other established risk factors in the research literature on externalizing behavior. Additionally, we find that polygenic associations vary across development (peaking from age 5-10 years), that parental genetics (assortment and parent-specific effects) and family-level covariates affect prediction little, and that sex differences in polygenic prediction are present but only detectable using within-family comparisons. Based on these findings, we believe that the PGI for externalizing behavior is a promising means for studying the development of disruptive behaviors across child development.

Lessons learned from implementing the Non-Communicable Diseases Kit in a humanitarian emergency: an operational evaluation in Sudan

Non-communicable diseases (NCDs) are a major global health concern, and their management is particularly challenging in humanitarian contexts where healthcare resources are limited. The WHO Non-Communicable Diseases Kit (WHO-NCDK) is a health system intervention targeted at the primary healthcare (PHC) level and designed to provide essential medicines and equipment for NCDs management in emergency settings, meeting the needs of 10 000 people for 3 months. This operational evaluation aimed to assess the effectiveness and utility of the WHO-NCDK in two PHC facilities in Sudan and identify key contextual factors that may influence its implementation and impact. Using a cross-sectional mixed-methods observational approach that combined quantitative and qualitative data, the evaluation found that the kit played a critical role in maintaining continuity of care when other supply chain solutions were disrupted. However, contextual factors such as local communities' unfamiliarity with healthcare facilities, the national integration of NCDs into PHC, and the existence of monitoring and evaluation systems were identified as important considerations for enhancing the WHO-NCDK's utility and usefulness. The evaluation suggests that the WHO-NCDK can be an effective intervention in emergency settings, provided that contextual factors such as local needs, facility capacity and healthcare worker capacity are considered before kit deployments.

Racial-ethnic disparities in psychological distress during the COVID-19 pandemic in the United States: the role of experienced discrimination and perceived racial bias

BACKGROUND

Research on mental health disparities by race-ethnicity in the United States (US) during COVID-19 is limited and has generated mixed results. Few studies have included Asian Americans as a whole or by subgroups in the analysis.

METHODS

Data came from the 2020 Health, Ethnicity, and Pandemic Study, based on a nationally representative sample of 2,709 community-dwelling adults in the US with minorities oversampled. The outcome was psychological distress. The exposure variable was race-ethnicity, including four major racial-ethnic groups and several Asian ethnic subgroups in the US. The mediators included experienced discrimination and perceived racial bias toward one's racial-ethnic group. Weighted linear regressions and mediation analyses were performed.

RESULTS

Among the four major racial-ethnic groups, Hispanics (22%) had the highest prevalence of severe distress, followed by Asians (18%) and Blacks (16%), with Whites (14%) having the lowest prevalence. Hispanics' poorer mental health was largely due to their socioeconomic disadvantages. Within Asians, Southeast Asians (29%), Koreans (27%), and South Asians (22%) exhibited the highest prevalence of severe distress. Their worse mental health was mainly mediated by experienced discrimination and perceived racial bias.

CONCLUSIONS

Purposefully tackling racial prejudice and discrimination is necessary to alleviate the disproportionate psychological distress burden in racial-ethnic minority groups.

Lessons Learned with a Triad of Stakeholder Advisory Boards: Working with Adolescents, Mothers, and Clinicians to Design the TRUST Study

Optimal care for pediatric and adolescent patients is carried out under a triadic engagement model, whereby the patient, caregiver, and clinician work in collaboration. Seeking input from all triad members in the development and implementation of clinical trials and interventions may improve health outcomes for children and adolescents. Sufficient evidence demonstrating how to effectively engage stakeholders from all branches of this triadic model is lacking. We address this gap by describing the successes and challenges our team has encountered while convening advisory groups with adolescent patients, parent stakeholders, and their clinicians to assist in the development and deployment of a technology-based intervention to promote the utilization of sexual and reproductive health services by increasing adolescent-clinician alone-time. Each stakeholder group contributed in unique and complementary ways. Working with advisors, our team aligned the priorities of each group with the goals of the research team. The results were improvements made in the content, design, and delivery of the TRUST intervention. While we were largely successful in the recruitment and engagement of adolescent patients and clinicians, we had less success with parents. Future research will need to explore additional strategies for recruitment and engagement of parents, particularly in rural, minority, and underserved communities.

The impact of anti-Asian racism on routine activities and mental health among Korean American older adults and their caregivers

Introduction

Reported anti-Asian discrimination has been on the rise since the COVID-19 pandemic. Nevertheless, limited research addresses the health impact of perceived anti-Asian racism on Asian Americans, especially among older adults, during COVID-19. To address the gap, we examined how the novel coronavirus pandemic affected Korean American older adults, one of the largest Asian subgroups. Specifically, this study addressed the magnitude of racism or discrimination related to the pandemic and impact of anti-Asian racism on negative mental health symptoms among Korean American older adults and their caregivers.

Methods

We used survey data collected from 175 Korean American older adults with probable dementia and their primary caregivers (female = 62%, mean age = 71 years) who went through eligibility screening for an ongoing randomized controlled trial involving dyads in the Baltimore-Washington and the New York Metropolitan areas (ClinicalTrials.gov Identifier: NCT03909347).

Results

Nearly a quarter of the survey sample reported they were fearful for their safety due to anti-Asian racism related to the pandemic. Additionally, 47% of the respondents indicated changes to routine activities due to anti-Asian racism or discrimination related to COVID-19. The most common changes included avoiding walking alone or physical activities outside, followed by avoiding public transportation or leaving the house to go to any public places such as grocery stores, churches, or schools, not carrying out usual social activities, and avoiding going to health care appointments. Multinomial logistic regression revealed that people who reported changes to routine activities were at least five times more likely (adjusted odds ratio = 5.017, 95% confidence interval = 1.503, 16.748) to report negative mental health symptoms than those who did not. Being fearful for their own safety was not associated with experiencing negative mental health symptoms in the survey sample.

Discussion

Study findings indicate that the increased reporting of anti-Asian racism during the COVID-19 pandemic has substantially affected Korean American older adults and their caregivers. The mechanism by which changes to routine activities is related to negative mental health symptoms is unclear, future research is needed to elucidate this pathway. Furthermore, our findings highlight the importance of identifying multi-level strategies to raise awareness of and to mitigate the reported surge of racism.

Delayed Medical Care of Underserved Middle-Aged and Older African Americans with Chronic Disease during COVID-19 Pandemic

Background: While African American middle-aged and older adults with chronic disease are particularly vulnerable during the COVID-19 pandemic, it is unknown which subgroups of this population may delay seeking care. The aim of this study was to examine demographic, socioeconomic, COVID-19-related, and health-related factors that correlate with delayed care in African American middle-aged and older adults with chronic disease. Methods: In this cross-sectional study, 150 African American middle-aged and older adults who had at least one chronic disease were recruited from faith-based organizations. We measured the following exploratory variables: demographic factors (age and gender), socioeconomic status (education), marital status, number of chronic diseases, depressive symptoms, financial strain, health literacy, COVID-19 vaccination history, COVID-19 diagnosis history, COVID-19 knowledge, and COVID-19 perceived threat. The outcome was delay in chronic disease care. Results: According to the Poisson log-linear regression, higher level of education, higher number of chronic diseases, and depressive symptoms were associated with a higher level of delayed care. Age, gender, COVID-19 vaccination history, COVID-19 diagnosis history, COVID-19 perceived threat, COVID-19 knowledge, financial strain, marital status, and health literacy were not correlated with delayed care. Discussion: Given that higher healthcare needs in terms of multiple chronic medical diseases and depressive symptomatology but not COVID-19-related constructs (i.e., vaccination history, diagnosis history, and perceived threat) were associated with delayed care, there is a need for programs and interventions that assist African American middle-aged and older adults with chronic disease to seek the care that they need. More research is needed to understand why educational attainment is associated with more delayed care of chronic disease in African American middle-aged and older adults with chronic illness.

Using machine learning to improve our understanding of COVID-19 infection in children

PURPOSE

Children are at elevated risk for COVID-19 (SARS-CoV-2) infection due to their social behaviors. The purpose of this study was to determine if usage of radiological chest X-rays impressions can help predict whether a young adult has COVID-19 infection or not.

METHODS

A total of 2572 chest impressions from 721 individuals under the age of 18 years were considered for this study. An ensemble learning method, Random Forest Classifier (RFC), was used for classification of patients suffering from infection.

RESULTS

Five RFC models were implemented with incremental features and the best model achieved an F1-score of 0.79 with Area Under the ROC curve as 0.85 using all input features. Hyper parameter tuning and cross validation was performed using grid search cross validation and SHAP model was used to determine feature importance. The radiological features such as pneumonia, small airways disease, and atelectasis (confounded with catheter) were found to be highly associated with predicting the status of COVID-19 infection.

CONCLUSIONS

In this sample, radiological X-ray films can predict the status of COVID-19 infection with good accuracy. The multivariate model including symptoms presented around the time of COVID-19 test yielded good prediction score.

Comparing income-related inequality on health service utilisation between older rural-to-urban migrant workers and older rural residents in China: a cross-sectional study

OBJECTIVES

This study quantifies income-related inequalities in health service utilisation of older rural-to-urban migrant workers, by comparison with older rural residents, and identify with factors giving rise to the inequalities.

SETTING

Nationally representative survey conducted in 29 provinces, municipalities and autonomous regions of China.

PARTICIPANTS

952 older rural-to-urban migrant workers and 2676 older rural residents were identified for further analysis.

MAIN OUTCOME MEASURES

The probability of 2 weeks outpatient utilisation and inpatient utilisation.

DESIGN

Coarsened exact matching was used to control the confounding factors between older rural-to-urban migrant workers and their rural counterparts. Concentration index was used to depict the inequality in health service utilisation, and it can be decomposed proportionally into contributions.

RESULTS

The concentration indices of 2 weeks outpatient utilisation of two groups were -0.2061 (95% CI: 0.0193 to 0.1364) and -0.2041 (95% CI: 0.0594 to 0.1469), respectively. The concentration indices of inpatient of two groups were -0.0024 (95% CI: -0.0047 to 0.0639) and -0.1412 (95% CI: 0.0235 to 0.1125), respectively. The contributors of the inequality of 2 weeks outpatient utilisation of two groups were poor self-assessed health (SAH) status and richest group. The contributors of the inequality of inpatient utilisation of the rural elderly were poor SAH, fair SAH and sense of happiness. The horizontal inequality indices for 2 weeks outpatient of two groups were 0.1321 and -0.0.992, respectively. The horizontal inequality indices for the inpatient of two groups were -0.0032 and -0.0396, respectively.

CONCLUSIONS

The results illustrated the existence of a socioeconomic gradient in health service utilisation between older rural-to-urban migrant workers and older rural residents. Our studies provided evidences to take full account of the health service needs, contributing to more reliable understandings of inequalities in the health service utilisation. The results may be referential to identify policy priorities conducive to the health policy reform in the process of active ageing in China.

Factors Associated with Telehealth Utilization among Older African Americans in South Los Angeles during the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic transformed healthcare delivery with the expansive use of telemedicine. However, health disparities may result from lower adoption of telehealth among African Americans. This study examined how under-resourced, older African Americans with chronic illnesses use telehealth, including related sociodemographic and COVID-19 factors.

METHODS

Using a cross-sectional design, 150 middle-aged and older African Americans were recruited from faith-based centers from March 2021 to August 2022. Data collected included sociodemographics, comorbidities, technological device ownership, internet usage, and attitudes toward COVID-19 disease and vaccination. Descriptive statistics and multivariable regression models were conducted to identify factors associated with telehealth use.

RESULTS

Of the 150 participants, 32% had not used telehealth since the COVID-19 pandemic, with 75% reporting no home internet access and 38% having no cellular/internet network on their mobile device. Age, access to a cellular network on a mobile device, and wireless internet at home were significantly associated with the utilization of telehealth care. Higher anxiety and stress with an increased perceived threat of COVID-19 and positive attitudes toward COVID-19 vaccination were associated with telehealth utilization.

DISCUSSION

Access and integration of telehealth services were highlighted as challenges for this population of African Americans. To reduce disparities, expansion of subsidized wireless internet access in marginalized communities is necessitated. Education outreach and training by healthcare systems and community health workers to improve uptake of telehealth currently and post-COVID-19 should be considered.

Inclusion of Cultural and Linguistic Diversity in COVID-19 Public Health Research: Research Design Adaptations to Seek Different Perspectives in Victoria, Australia

Participation of people from culturally and linguistically diverse (CALD) communities in public health research is often limited by challenges with recruitment, retention and second-language data collection. Consequently, people from CALD communities are at risk of their needs being marginalised in public health interventions. This paper presents intrinsic case analyses of two studies which were adapted to increase the cultural competence of research processes. Both cases were part of the Optimise study, a major mixed methods research study in Australia which provided evidence to inform the Victorian state government's decision-making about COVID-19 public health measures. Case study 1 involved the core Optimise longitudinal cohort study and Case study 2 was the CARE Victorian representative survey, an Optimise sub-study. Both case studies engaged cultural advisors and bilingual staff to adjust the survey measures and research processes to suit target CALD communities. Reflexive processes provided insights into the strengths and weaknesses of the inclusive strategies. Selected survey results are provided, demonstrating variation across CALD communities and in comparison to participants who reported speaking English at home. While in most cases a gradient of disadvantage was evident for CALD communities, some patterns were unexpected. The case studies demonstrate the challenge and value of investing in culturally competent research processes to ensure research guiding policy captures a spectrum of experiences and perspectives.

Differential COVID-19 infection rates in children, adults, and elderly: Systematic review and meta-analysis of 38 pre-vaccination national seroprevalence studies

Background

Debate exists about whether extra protection of elderly and other vulnerable individuals is feasible in COVID-19. We aimed to assess the relative infection rates in the elderly vs the non-elderly and, secondarily, in children vs adults.

Methods

We performed a systematic review and meta-analysis of seroprevalence studies conducted in the pre-vaccination era. We identified representative national studies without high risk of bias through SeroTracker and PubMed searches (last updated May 17, 2022). We noted seroprevalence estimates for children, non-elderly adults, and elderly adults, using cut-offs of 20 and 60 years (or as close to these ages, if they were unavailable) and compared them between different age groups.

Results

We included 38 national seroprevalence studies from 36 different countries comprising 826 963 participants. Twenty-six of these studies also included pediatric populations and twenty-five were from high-income countries. The median ratio of seroprevalence in elderly vs non-elderly adults (or non-elderly in general, if pediatric and adult population data were not offered separately) was 0.90-0.95 in different analyses, with large variability across studies. In five studies (all in high-income countries), we observed significant protection of the elderly with a ratio of <0.40, with a median of 0.83 in high-income countries and 1.02 elsewhere. The median ratio of seroprevalence in children vs adults was 0.89 and only one study showed a significant ratio of <0.40. The main limitation of our study is the inaccuracies and biases in seroprevalence studies.

Conclusions

Precision shielding of elderly community-dwelling populations before the availability of vaccines was indicated in some high-income countries, but most countries failed to achieve any substantial focused protection.

Registration

Open Science Framework (available at: https://osf.io/xvupr).

Evaluation of the Community Health Worker Model for COVID-19 Response and Recovery

Community health workers (CHWs), or promotores de salud, have long played a role in health promotion, but the COVID-19 pandemic has brought renewed attention to the functions, sustainability, and financing of CHW models. ¡Andale! ¿Que Esperas? was a 12-month (June 2021-May 2022) campaign that expanded the CHW workforce to increase COVID-19 vaccination rates in structurally vulnerable, Latinx communities across California. This mixed-methods evaluation aims to elucidate (1) the role of CHWs in COVID-19 response, recovery, and rebuilding and (2) the importance, needs, and perils of CHW models in the COVID-19 era and beyond. CHWs facilitated 159,074 vaccinations and vaccine appointments by countering mis/disinformation, addressing mental health and social needs, building digital competencies, and meeting people where they are, all of which expanded access and instilled confidence in the COVID-19 vaccine. CHWs' success in engaging the community lies in their shared lived experience as well as their accessibility and recognition in the community, enabling their role in both immediate response and long-term recovery. Funding instability imperils the advances made by CHWs, and efforts are needed to institutionalize the CHW workforce with sustainable funding models. While Medicaid reimbursement models exist in some states, these models are often limited to healthcare services, overlooking a critical function of the CHW model: building community resilience and mobilizing the community for social change.

The Institute of Medicine's call to action revisited: assuring access to public health education for U.S. college students

The Educated Citizen and Public Health initiative promotes that an understanding of public health issues is a principal component of an educated population and is necessary to develop social responsibility and promote civic dialog. This initiative supports the Institute of Medicine's (now the National Academy of Medicine) recommendation that "all undergraduates should have access to education in public health." The purpose of our work is to examine the extent to which 2- and 4-year U.S. state colleges and universities offer and/or require a public health course. Select indicators identified include the presence and type of public health curriculum, public health course requirement, presence of public health graduate program offering, pathways to public health, Community Health Worker training, as well as demographic information for each institution. An analysis was also conducted for the historically Black colleges and universities (HBCUs), and the same select indicators were examined. The data suggest that there is an imperative need for a public health curriculum across the nation's collegiate institutions with 26% of 4-year state institutions lacking a full undergraduate public health curriculum; 54% of 2-year colleges not offering a pathway to public health education; and 74% of HBCUs not offering a public health course or degree. In the age of COVID-19, syndemics, and considering the post-pandemic phase, we argue that expanding public health literacy at the associate and baccalaureate level can help prepare an educated citizenry who is both public health literate and one that can demonstrate resilience in the face of public health challenges.

Addressing racism in the workplace through simulation: So much to unlearn

Introduction

Racism exists in the healthcare system and is a root cause of health inequities among Indigenous Peoples. When microaggressions of racism are carried out by healthcare providers, therapeutic trust may be broken and quality of care may be impacted. Anti-racism response training is considered best practice in recognizing and addressing racism. The objective of this study was to evaluate the impact of a virtual (synchronous) anti-racism response training workshop among a group of rehabilitation therapists from across Canada.

Methods

A 90-minute virtual anti-racism simulation workshop for rehabilitation therapists was developed and delivered virtually four times across Canada between 2020 and 2021. Following an introduction and pre-briefing, role-playing among participants was used to address microaggressive Indigenous-specific racism, followed by an in-depth debriefing with trained facilitators. A post-workshop survey was conducted to evaluate this anti-racism simulation workshop and assess the impact on participating occupational therapists (OTs) and physiotherapists (PTs). Following each simulation workshop, participants were invited to complete an anonymous post-activity survey (n = 20; 50% OTs, 45% PTs). Open text responses were analyzed thematically from the perspective of critical race theory.

Results

The majority of the participants self-identified as women (95%); white (90%); mid-career (52%); and had never personally experienced racism (70%). All participants agreed that the workshop gave them ideas on how to start dismantling racism in their workplace. Thematic analysis resulted in four themes: so much to unlearn, remain humble, resist the silence, and discomfort is okay.

Discussion

Despite feelings of discomfort, OTs and PTs appreciated anti-racism skills-based training and recognized the importance of taking action on racism in the workplace. Findings from this study support online (synchronous) anti-racism training as a viable and effective means of creating space for rehabilitation professionals to lean into brave conversations that are necessary for developing strategies to address racial microaggressions impacting Indigenous persons in the workplace. We believe that these small steps of preparing and practicing anti-racism strategies among rehabilitation therapists are essential to achieving a collective goal of dismantling racism in the health system.

Incidence and outcomes of intrapartum-related neonatal encephalopathy in low-income and middle-income countries: a systematic review and meta-analysis

AIM

To examine the incidence of intrapartum-related neonatal encephalopathy, and neonatal mortality and neurodevelopmental outcomes associated with it in low-income and middle-income countries.

METHODS

Reports were included when neonatal encephalopathy diagnosed clinically within 24 hours of birth in term or near-term infants born after intrapartum hypoxia-ischaemia defined as any of the following: (1) pH≤7.1 or base excess ≤-12 or lactate ≥6, (2) Apgar score ≤5 at 5 or 10 min, (3) continuing resuscitation at 5 or 10 min or (4) no cry from baby at 5 or 10 min. Peer-reviewed articles were searched from Ovid MEDLINE, Cochrane, Web of Science and WHO Global Index Medicus with date limits 1 November 2009 to 17 November 2021. Risk of bias was assessed using modified Newcastle Ottawa Scale. Inverse variance of heterogenicity was used for meta-analyses.

RESULTS

There were 53 reports from 51 studies presenting data on 4181 children with intrapartum-related neonatal encephalopathy included in the review. Only five studies had data on incidence, which ranged from 1.5 to 20.3 per 1000 live births. Neonatal mortality was examined in 45 studies and in total 636 of the 3307 (19.2%) infants died. Combined outcome of death or moderate to severe neurodevelopmental disability was reported in 19 studies and occurred in 712 out of 1595 children (44.6%) with follow-up 1 to 3.5 years.

CONCLUSION

Though there has been progress in some regions, incidence, case mortality and morbidity in intrapartum-related neonatal encephalopathy has been static in the last 10 years.

PROSPERO REGISTRATION NUMBER

CRD42020177928.

Changes in all-cause and cause-specific mortality during the first year of the COVID-19 pandemic in Minnesota: population-based study

BACKGROUND

The COVID-19 pandemic resulted in unprecedented increases in mortality in the U.S. and worldwide. To better understand the impact of the COVID-19 pandemic on mortality in the state of Minnesota, U.S.A., we characterize the changes in the causes of death during 2020 (COVID-19 period), compared to 2018-2019 (baseline period), assessing for differences across ages, races, ethnicities, sexes, and geographic characteristics.

METHODS

Longitudinal population-based study using Minnesota death certificate data, 2018-2020. Using Poisson regression models adjusted for age and sex, we calculated all-cause and cause-specific (by underlying causes of death) mortality rates per 100,000 Minnesotans, the demographics of the deceased, and years of life lost (YLL) using the Chiang's life table method in 2020 relative to 2018-2019.

RESULTS

We identified 89,910 deaths in 2018-2019 and 52,030 deaths in 2020. The mean daily mortality rate increased from 123.1 (SD 11.7) in 2018-2019 to 144.2 (SD 22.1) in 2020. COVID-19 comprised 9.9% of deaths in 2020. Other categories of causes of death with significant increases in 2020 compared to 2018-2019 included assault by firearms (RR 1.68, 95% CI 1.34-2.11), accidental poisonings (RR 1.49, 95% CI 1.37-1.61), malnutrition (RR 1.48, 95% CI 1.17-1.87), alcoholic liver disease (RR, 95% CI 1.14-1.40), and cirrhosis and other chronic liver diseases (RR 1.28, 95% CI 1.09-1.50). Mortality rates due to COVID-19 and non-COVID-19 causes were higher among racial and ethnic minority groups, older adults, and non-rural residents.

CONCLUSIONS

The COVID-19 pandemic was associated with a 17% increase in the death rate in Minnesota relative to 2018-2019, driven by both COVID-19 and non-COVID-19 causes. As the COVID-19 pandemic enters its third year, it is imperative to examine and address the factors contributing to excess mortality in the short-term and monitor for additional morbidity and mortality in the years to come.

Neurodevelopment in infants with antenatal or early neonatal exposure to SARS-CoV-2

BACKGROUND

Antenatal and neonatal viral exposure may put the developing brain at risk for abnormal neurodevelopment. A clinical program at Children's National Hospital provides detailed follow-up of infants with in utero or neonatal SARS-CoV-2 exposure.

AIMS

To determine impact of early SARS-CoV-2 exposure on neurodevelopment.

STUDY DESIGN

We performed a prospective observational study of infant evaluations between 3/2020 and 11/2021. Demographics, pregnancy and birth details, SARS-CoV-2 data, specialty consultations, and NICU records were extracted from infants' medical records. Infants had neurologic exams and developmental screening with Ages and Stages Questionnaire (ASQ). Correlations between SARS-CoV-2 exposure type and neurodevelopmental outcomes were analyzed.

SUBJECTS

Thirty-four infants evaluated in the SARS-CoV-2 follow-up program.

OUTCOME MEASURES

Abnormal neurologic exams or ASQ scores near or below suggested cut-offs.

RESULTS

Infants received up to three evaluations. Most (28/34; 82 %) were exposed in utero - 16 to symptomatic mothers (IU-S) and 12 to asymptomatic mothers (IU-A). Six were exposed only as a neonate. IU-S had abnormal neurologic exams at mean (SD) age 112 (24) days and ASQ scores near or below cut-offs for all domains more frequently than IU-A or neonatally exposed infants. IU-S were more likely to score below any ASQ cutoff compared to IU-A (P = .04); differences were significant for Fine Motor (P = .01) and Personal-Social (P = .02) domains.

CONCLUSIONS

Early SARS-CoV-2 exposure may impact neurodevelopment, especially among infants exposed in utero to symptomatic gestational parents. Vaccination and other precautions to reduce early-in-life infection may protect against neurodevelopmental delays. Children with early SARS-CoV-2 exposure should have additional longitudinal screening for neurodevelopmental delays.

Trends in Risk Factors and Symptoms Associated With SARS-CoV-2 and Rhinovirus Test Positivity in King County, Washington, June 2020 to July 2022

IMPORTANCE

Few US studies have reexamined risk factors for SARS-CoV-2 positivity in the context of widespread vaccination and new variants or considered risk factors for cocirculating endemic viruses, such as rhinovirus.

OBJECTIVES

To evaluate how risk factors and symptoms associated with SARS-CoV-2 test positivity changed over the course of the pandemic and to compare these with the risk factors associated with rhinovirus test positivity.

DESIGN, SETTING, AND PARTICIPANTS

This case-control study used a test-negative design with multivariable logistic regression to assess associations between SARS-CoV-2 and rhinovirus test positivity and self-reported demographic and symptom variables over a 25-month period. The study was conducted among symptomatic individuals of all ages enrolled in a cross-sectional community surveillance study in King County, Washington, from June 2020 to July 2022.

EXPOSURES

Self-reported data for 15 demographic and health behavior variables and 16 symptoms.

MAIN OUTCOMES AND MEASURES

Reverse transcription-polymerase chain reaction-confirmed SARS-CoV-2 or rhinovirus infection.

RESULTS

Analyses included data from 23 498 individuals. The median (IQR) age of participants was 34.33 (22.42-45.08) years, 13 878 (59.06%) were female, 4018 (17.10%) identified as Asian, 654 (2.78%) identified as Black, and 2193 (9.33%) identified as Hispanic. Close contact with an individual with SARS-CoV-2 (adjusted odds ratio [aOR], 3.89; 95% CI, 3.34-4.57) and loss of smell or taste (aOR, 3.49; 95% CI, 2.77-4.41) were the variables most associated with SARS-CoV-2 test positivity, but both attenuated during the Omicron period. Contact with a vaccinated individual with SARS-CoV-2 (aOR, 2.03; 95% CI, 1.56-2.79) was associated with lower odds of testing positive than contact with an unvaccinated individual with SARS-CoV-2 (aOR, 4.04; 95% CI, 2.39-7.23). Sore throat was associated with Omicron infection (aOR, 2.27; 95% CI, 1.68-3.20) but not Delta infection. Vaccine effectiveness for participants fully vaccinated with a booster dose was 93% (95% CI, 73%-100%) for Delta, but not significant for Omicron. Variables associated with rhinovirus test positivity included being younger than 12 years (aOR, 3.92; 95% CI, 3.42-4.51) and experiencing a runny or stuffy nose (aOR, 4.58; 95% CI, 4.07-5.21). Black race, residing in south King County, and households with 5 or more people were significantly associated with both SARS-CoV-2 and rhinovirus test positivity.

CONCLUSIONS AND RELEVANCE

In this case-control study of 23 498 symptomatic individuals, estimated risk factors and symptoms associated with SARS-CoV-2 infection changed over time. There was a shift in reported symptoms between the Delta and Omicron variants as well as reductions in the protection provided by vaccines. Racial and sociodemographic disparities persisted in the third year of SARS-CoV-2 circulation and were also present in rhinovirus infection. Trends in testing behavior and availability may influence these results.

An initiative for a more inclusive working life and its effect on return-to-work after sickness absence: a multistate longitudinal cohort study

OBJECTIVES

To reduce sickness absence (SA) and increase work participation, the tripartite Agreement for a More Inclusive Working Life (IA) was established in Norway in 2001. IA companies have had access to several measures to prevent and reduce SA. Our aim in this paper was to estimate the average effect of having access to IA at the time of entering a first SA on later return-to-work (RTW) and on time spent in other work-related states. A secondary objective was to study how effects varied between women and men, and individuals with SA due to either musculoskeletal or psychological diagnoses.

DESIGN

Population-based observational multistate longitudinal cohort study.

SETTING

Individual characteristics and detailed longitudinal records of SA, work and education between 1997-2011 were obtained from population-wide registries.

PARTICIPANTS

Each individual born in Norway 1967-1976 who entered full-time SA during 2004-2011, with limited earlier SA, was included (n=187 930).

PRIMARY AND SECONDARY OUTCOME MEASURES

Individual multistate histories containing dated periods of work, graded SA, full-time SA, non-employment and education.

METHODS

Data were analysed in a multistate model with 500 days of follow-up. The effect of IA was assessed by estimating differences in state probabilities over time, adjusted for confounders, using inverse probability weighting.

RESULTS

IA increased the probability of work after SA, with the largest difference between groups after 29 days (3.4 percentage points higher (95% CI 2.5 to 4.3)). Differences in 1-year expected length of stay were 8.4 additional days (4.9 to 11.9) in work, 7.6 (4.8 to 10.3) fewer days in full-time SA and 1.6 (-0.2 to 3.4) fewer days in non-employment. Similar trends were found within subgroups by sex, musculoskeletal and psychological diagnoses. The robustness of the findings was studied in sensitivity analyses.

CONCLUSION

Measures to prevent and reduce SA, as given through IA, were found to improve individuals' RTW after entering SA.

Tracking changes in SARS-CoV-2 transmission with a novel outpatient sentinel surveillance system in Chicago, USA

Public health indicators typically used for COVID-19 surveillance can be biased or lag changing community transmission patterns. In this study, we investigate whether sentinel surveillance of recently symptomatic individuals receiving outpatient diagnostic testing for SARS-CoV-2 could accurately assess the instantaneous reproductive number R(t) and provide early warning of changes in transmission. We use data from community-based diagnostic testing sites in the United States city of Chicago. Patients tested at community-based diagnostic testing sites between September 2020 and June 2021, and reporting symptom onset within four days preceding their test, formed the sentinel population. R(t) calculated from sentinel cases agreed well with R(t) from other indicators. Retrospectively, trends in sentinel cases did not precede trends in COVID-19 hospital admissions by any identifiable lead time. In deployment, sentinel surveillance held an operational recency advantage of nine days over hospital admissions. The promising performance of opportunistic sentinel surveillance suggests that deliberately designed outpatient sentinel surveillance would provide robust early warning of increasing transmission.

Coding Long COVID: Characterizing a new disease through an ICD-10 lens

Background

Naming a newly discovered disease is a difficult process; in the context of the COVID-19 pandemic and the existence of post-acute sequelae of SARS-CoV-2 infection (PASC), which includes Long COVID, it has proven especially challenging. Disease definitions and assignment of a diagnosis code are often asynchronous and iterative. The clinical definition and our understanding of the underlying mechanisms of Long COVID are still in flux, and the deployment of an ICD-10-CM code for Long COVID in the US took nearly two years after patients had begun to describe their condition. Here we leverage the largest publicly available HIPAA-limited dataset about patients with COVID-19 in the US to examine the heterogeneity of adoption and use of U09.9, the ICD-10-CM code for "Post COVID-19 condition, unspecified."

Methods

We undertook a number of analyses to characterize the N3C population with a U09.9 diagnosis code ( n = 21,072), including assessing person-level demographics and a number of area-level social determinants of health; diagnoses commonly co-occurring with U09.9, clustered using the Louvain algorithm; and quantifying medications and procedures recorded within 60 days of U09.9 diagnosis. We stratified all analyses by age group in order to discern differing patterns of care across the lifespan.

Results

We established the diagnoses most commonly co-occurring with U09.9, and algorithmically clustered them into four major categories: cardiopulmonary, neurological, gastrointestinal, and comorbid conditions. Importantly, we discovered that the population of patients diagnosed with U09.9 is demographically skewed toward female, White, non-Hispanic individuals, as well as individuals living in areas with low poverty, high education, and high access to medical care. Our results also include a characterization of common procedures and medications associated with U09.9-coded patients.

Conclusions

This work offers insight into potential subtypes and current practice patterns around Long COVID, and speaks to the existence of disparities in the diagnosis of patients with Long COVID. This latter finding in particular requires further research and urgent remediation.

A Socio-Ecological Approach to Addressing Digital Redlining in the United States: A Call to Action for Health Equity

Physical distancing requirements due to the coronavirus (COVID-19) pandemic has increased the need for broadband internet access. The World Health Organization defines social determinants of health as non-medical factors that impact health outcomes by affecting the conditions in which people are born, grow, work, live, and age. By this definition broadband internet access is a social determinant of health. Digital redlining-the systematic process by which specific groups are deprived of equal access to digital tools such as the internet-creates inequities in access to educational and employment opportunities, as well as healthcare and health information. Although it is known that internet service providers systematically exclude low-income communities from broadband service, little has been done to stop this discriminatory practice. In this paper, we seek to amplify the call to action against the practice of digital redlining in the United States, describe how it contributes to health disparities broadly and within the context of the COVID-19 pandemic, and use a socio-ecological framework to propose short- and long-term actions to address this inequity.