Health equity and COVID-19: global perspectives

Funding the pandemic response for Indigenous Peoples: an equity-based analysis of COVID-19 using a Health Equity Impact Assessment (HEIA) Indigenous lens tool

This study examines the allocation of COVID-19 funding for Indigenous Peoples in Canada, Australia, New Zealand, and the United States during the pandemic's first wave. Indigenous communities, already facing health disparities, systemic discrimination, and historical forces of colonisation, found themselves further vulnerable to the virus. Analysing the funding policies of these countries, we employed a Health Equity Impact Assessment (HEIA) tool and an Indigenous Lens Tool supplement to evaluate potential impacts. Our results identify three major funding equity issues: unique health and service needs, socioeconomic disparities, and limited access to community and culturally safe health services. Despite efforts for equitable funding, a lack of meaningful consultation led to shortcomings, as seen in Canada's state of emergency declaration and legal disputes in the United States. New Zealand stood out for integrating Māori perspectives, showcasing the importance of consultation. The study calls for a reconciliation-minded path, aligning with Truth and Reconciliation principles, the UN Declaration on the Rights of Indigenous Peoples, and evolving government support. The paper concludes that co-creating equitable funding policies grounded in Indigenous knowledge requires partnership, meaningful consultation, and organisational cultural humility. Even in emergencies, these measures ensure responsiveness and respect for Indigenous self-determination.

Access to healthcare services during the COVID-19 pandemic: a cross-sectional analysis of income and user-access across 16 economically diverse countries

BACKGROUND

National health systems have different strengths and resilience levels. During the COVID-19 pandemic, resources often had to be reallocated and this impacted the availability of healthcare services in many countries. To date there have been few quantitative contemporary studies of inequalities in access to healthcare within and between countries. In this study, we aim to compare inequality within and between 16 economically diverse countries.

METHODS

Online surveys were conducted on 22 150 adults in 16 countries across six continents in 2022. Quota sampling and post-stratification weighting was used to obtain an age, gender, geographically, and educationally representative sample. The study assesses the differences in challenges in access to healthcare during the pandemic (for GP, surgical/clinical and digital GP services) using country-specific expanded health-needs-adjusted Erreygers' concentration indices and compares these values between countries using a Spearman's rank correlation coefficient.

RESULTS

Results show wide variation in income-related challenges in access within countries for different types of care. For example, Erreygers' concentration index for digital services in Colombia exhibited highly regressive inequality at 0·17, compared to Japan with an index of -0·15. Inequalities between countries were also evident, with Spearman rank coefficients of -0·69 and -0·65 (p-values of 0·003 and 0·006) for digital and surgical access, indicating that lower income countries had greater inequality in healthcare access challenges.

CONCLUSION

During the pandemic, inequalities in challenges to accessing healthcare were greatest in low and middle-income countries. Digital technologies offer a reasonable means to address some of this inequality if adequate support is provided and accessible digital infrastructure exists.

Austerity Measures and the Resilience of Zimbabwe's Healthcare System: Challenges and Solutions

Austerity measures have become a contentious topic, shaping the landscape of health care systems around the world. As governments grapple with economic challenges, the impact of austerity on health care has emerged as a critical concern. This study focuses on the consequences of austerity actions adopted by the Zimbabwean government under the Transitional Stabilization Program (TSP) from August 2018 to December 2025. This research examines the impact of austerity measures on Zimbabwe's health care sector, exploring its connections with health infrastructure and resources, accessibility and affordability of health care, health funding, health care inequalities, and the health care workforce. Using a quantitative approach and data from 970 participants, including the general populace, health care providers, and government officials, significant positive correlations between austerity measures and these health care variables were identified. The findings indicated a noteworthy positive correlation between the independent variable "austerity measures" and five dependent variables: health care accessibility and affordability, health care inequalities, infrastructure and resources, health care funding, and health care workforce. The t-statistics values exceeded the threshold of 1.96, with values of 5.085, 3.120, 6.459, 8.517, and 3.830, respectively. These findings highlight the importance of considering the effects of austerity on health care access, health funding, health care inequalities, health workforce, health infrastructure and resources development. Policymakers should prioritize equitable resource allocation and targeted investments to strengthen the resilience of the health care system during economic challenges. Understanding these associations is crucial for evidence-based policy decisions and fostering a more equitable and resilient health care system in Zimbabwe.

Conceptualizing Patient as an Organization With the Adoption of Digital Health

The concept of viewing a patient as an organization within the context of digital healthcare is an innovative and evolving concept. Traditionally, the patient-doctor relationship has been centered around the individual patient and their interactions with healthcare providers. However, with the advent of technology and digital healthcare solutions, the dynamics of this relationship are changing. Digital healthcare platforms and technologies enable patients to have more control and active participation in managing their health and healthcare processes. This shift empowers patients to take on a more proactive role, similar to how an organization functions with various stakeholders, goals, and strategies. The prevalence of mobile phones and wearables is regarded as an important factor in the acceptance of digital health.

Objective

This study aimed to identify the factors affecting adoption intention using the TAM (Technology Acceptance Model), HB (Health Belief model), and the UTAUT (Unified Theory of Acceptance and Use of Technology). The argument is made that the adoption of the technology enables patients to create resources (ie, data), transforming patients from mere consumers to producers as well.

Results

PLS analysis showed that health beliefs and perceived ease of use had positive effects on the perceived usefulness of digital healthcare, and system capabilities positively impacted perceived ease of use. Furthermore, perceived service, the customer's willingness to change and reference group influence significantly impacted adoption intention (b > 0.1, t > 1.96, P < .05). However, privacy protection and data security, online healthcare resources, and user guidance were not positively associated with perceived usefulness.

Conclusions

Perceived usefulness, the customer's willingness to change, and the influence of the reference group are decisive variables affecting adoption intention among the general population, whereas privacy protection and data security are indecisive variables. Online resources and user guides do not support adoption intentions.

Telemedicine and Pediatric Care in Rural and Remote Areas of Middle-and-Low-Income Countries: Narrative Review

OBJECTIVES

Caring for children in low- and middle-income countries (LMIC) can be challenging. This review article aims to explore role of telemedicine in supporting pediatric care in LMIC.

METHODOLOGY

A narrative review of existing English and Spanish literature was conducted to assess role of telemedicine to support pediatric care in LMIC.

RESULTS

Beside medical education and direct pediatric care, telemedicine can provide sub-specialties consultations without extra burden on families. Additionally, telemedicine can help in lowering under-5 mortality by supporting neonatal care, infectious illnesses, and non-communicable diseases (NCDs). Telemedicine can be a gate for universal coverage for all children at a lower cost. For over a decade, it has been implemented successfully and sustained in a few LMIC. However, challenges in implementing telemedicine are enormous. Still, opportunities arise by using simpler technology, low-width band internet, smartphones, instant messaging applications and solar energy. COVID-19 pandemic facilitated acceptance and applicability of telemedicine worldwide including LMIC. Nevertheless, governments must regulate telemedicine by issuing policies and ensuring employment of local experts when possible to meet local resources and cultural competency.

CONCLUSION

Telemedicine has proven successful in improving pediatrics care. Many LMIC should take advantage of this innovation to promote equity and access to high quality pediatric care.

Advancing equity, diversity, inclusivity, and accessibility in primary care: The development of an integrated educational experience model

This article presents the development of the Equity, Diversity, Inclusivity, and Accessibility (EDIA) Cross-Cutting Theme Project within the Team Primary Care (TPC) initiative, aimed at addressing systemic inequities through innovative educational strategies. Grounded in the social accountability of health professions framework, this project aims to equip primary care teams with the knowledge, skills, and attitudes necessary to promote health equity. The EDIA Integrated Educational Experience (IEE) model includes a self-assessment tool, digital learning space, and national mentorship network, providing a comprehensive approach for primary care teams to promote health equity. The IEE model utilizes a layered micro, meso, and macro approach to support cultural transformation within highly complex healthcare environments. Key lessons learned involve trust- and relationship-building processes to help dismantle historical silos and encourage open dialogue. Future efforts focus on implementation, ensuring adaptability, scalability, and sustainability, positioning the model as a catalyst for equitable primary care delivery.

Social inequalities in self-reported SARS-CoV-2 infection in Brazilian adults: PNAD COVID-19

OBJECTIVE

To investigate inequalities related to race/ethnicity and socioeconomic status in self-reported positive diagnosis for COVID-19 in Brazilian adults.

METHODS

Data available from the National Household Sample Survey COVID-19 (PNAD COVID 19) (July/September/November, 2020) were used in this retrospective investigation. The analyses considered the sampling design, primary sampling units, strata and sample weights. Poisson regression with robust variance was used to estimate prevalence ratio (PR) and the 95% confidence interval (95%CI) of the associations.

RESULTS

In July, September and November 2020, with regard to the rapid test, indigenous people were 2.45 (95%CI 1.48-4.08), 2.53 (95%CI 1.74-4.41) and 1.23 (95%CI 1.11-1.86) times more likely to report a positive history of SARS-CoV-2 infection, respectively. With regard to the RT-PCR test in November, indigenous people were more likely to test positive for COVID-19 (PR: 1.90; 95%CI 1.07-3.38). It was observed that the indigenous group was 1.86 (95%CI 1.05-3.29) and 2.11 (95%CI 1.12-3.59) times more likely to test positive for COVID-19 in September and November (2020). Income was associated with testing positive for COVID-19: in November, individuals whose income ranged from R$0.00-R$1.044 were more likely (PR: 1.69; 95%CI 1.16-23.06) to test positive using the RT-PCR test; participants whose income was in this range were also more likely to be diagnosed with COVID-19 using blood tests (PR: 1.72; 95%CI 1.43-2.07).

CONCLUSION

The data presented show an association between race/ethnicity and economic status with a positive diagnosis of COVID-19.

Patients' and professionals' experiences with remote care during COVID-19: a qualitative study in general practices in low-income neighborhoods

AIM

To explore how patients and general practice professionals in low-income neighborhoods experienced the increase of remote care during COVID-19.

BACKGROUND

As the GP (general practitioner) is the first point of contact in Dutch health care, there are concerns about access to remote care for patients from low-income neighborhoods. Now that general practice professionals have returned to the pre-pandemic ways of healthcare delivery, this paper looks back at experiences with remote care during COVID-19. It investigates experiences of both patients and general practice professionals with the approachability and appropriateness of remote care and their satisfaction.

METHODS

In this qualitative study, 78 patients and 18 GPs, 7 nurse practitioners and 6 mental health professionals were interviewed. Interviews were held on the phone and face-to-face in the native language of the participants.

FINDINGS

Remote care, especially telephone consultation, was generally well-approachable for patients from low-income neighborhoods. Contrarily, video calling was rarely used. This was partly because patients did not know how to use it. The majority of patients thought remote care was possible for minor ailments but would also still like to see the doctor face-to-face regularly. Patients were generally satisfied with remote care at the time, but this did not necessarily reflect their willingness to continue using it in the future. Moreover, there was lack in consensus among general practice professionals on the appropriateness of remote care for certain physical and mental complaints. Nurse practitioners and mental health professionals had a negative attitude toward remote care. In conclusion, it is important to take the opinions and barriers of patients and care providers into account and to increase patient-centered care elements and care provider satisfaction in remote care. Integrating remote care is not only important in times of crisis but also for future care that is becoming increasingly digitalized.

Telehealth as a Strategy for Health Equity: A Scoping Review of Telehealth in India During and Following the COVID-19 Pandemic for People with Disabilities

Introduction: Telehealth in India is growing rapidly and represents a strategy to promote affordable, inclusive, timely and safe access to healthcare. Yet there is a risk that telehealth increases inequity due to the digital divide and existing poor health literacy. Methods: A scoping review was conducted to explore use of telehealth in India during and following the COVID-19 pandemic by people with disabilities to inform strategies to increase equity of telehealth for people with disabilities. Of 1966 studies from the initial search in four databases and three specific telehealth journals, 20 sources met the inclusion criteria, limited to a focus on physical disability in India. Results: Findings showed examples of how people with disabilities can exercise increased control in the timing of appointments, convenience of receiving services from home and not having to travel to clinics or hospitals, and platform preference through tools and applications already familiar to them. Carers and families of people with disabilities were described as highly valued stakeholders with important roles in the uptake and effectiveness of telehealth for people with disabilities. The identified benefits of telehealth resulted in high levels of user satisfaction due to increased control and convenience, however, systemic barriers for accessibility remain. Conclusion: This review suggested that if telehealth is not designed intentionally to change the status quo for people with disabilities and prioritize equity, then the benefits may not be sustainable. Recommendations for telehealth India are provided, based on both findings from the literature and analysis of results.

Emergency surgical management for ocular trauma with confirmed COVID-19 symptoms: A case report

INTRODUCTION AND IMPORTANCE

Conducting urgent eye trauma surgery amidst the COVID-19 pandemic poses distinct difficulties, as strict infection control measures are crucial to safeguard both patients and medical staff. Nonetheless, eye trauma remains a significant contributor to avoidable vision loss in developing countries.

CASE PRESENTATION

A 57-year-old man presented with redness, bleeding, and injury in the left eye after a motorcycle accident 9 h prior to hospital admission, along with a torn wound on his left cheek. The visual acuity in the left eye showed no light perception. Limited eye movement in all directions, eyelid hematoma, conjunctival injection, hyphema, and tissue protrusion from the limbus at 6 to 8 o'clock positions were observed. The patient had a history of cataract surgery (+) in both eyes and was diagnosed with an open globe injury with zone II penetrating trauma, accompanied by full hyphema, vitreous and choroid prolapse in the left eye, and a confirmed case of COVID-19. Evisceration of the left eye was performed following the basic guidelines for ocular trauma surgery during the COVID-19 pandemic. Postoperative follow-up was conducted as usual by the operator in isolation for confirmed COVID-19 patients with no significant complaints.

CLINICAL DISCUSSION

Urgent surgical intervention is necessary to prevent visual impairment, following guidelines recommending surgery within 4-72 h. Ocular tissue may facilitate COVID-19 transmission via the nasolacrimal system, posing risks to healthcare workers, particularly during surgery. Preoperative measures, including obtaining COVID-19 status and providing appropriate personal protective equipment (PPE), are crucial. Minimizing aerosol-generating procedures and employing virucidal disinfection further mitigates the transmission risks. This case underscores the need to balance immediate intervention for eye injuries with safety protocols for COVID-19, emphasizing standardized PPE and surgical procedures to safeguard healthcare professionals.

CONCLUSION

Incorporating insights gained during the COVID-19 pandemic will fortify healthcare systems against future pandemics. In particular, it enables effective surgical emergency response while mitigating infectious disease risks.

COVID-19 ethics: unique aspects and a review as of early 2024

COVID-19 presents a variety of ethical challenges in a set of arenas, arenas not always considered in past pandemics. These challenges include issues related to autonomy, distributive ethics, and the establishment of policies of equity and justice. Methods are a literature review based on regular editing of an online textbook during the COVID-19 outbreak and a literature review using key ethical terms. Patients are confronted with new issues related to autonomy. Providers need to expand their concepts of ethical issues to include decisions based on proportionality and public health ethics. The public health sector needs to assess the beneficence of alternative modes of disease control. The research community needs to redefine the concept of informed consent in emergent conditions. All elements of the medical spectrum-physicians, scientists, and the community-at-large including the pharmaceutical industry-need to consider the multifaceted methods for preventing future pandemics. This will require giving particular emphasis to public health funding and ending the documented discrimination that exists in the provision of proven therapies. The developing world is especially at risk for most of the ethical issues, especially those related to equity and justice. The ethical issues associated with the COVID-19 outbreak are not unique but provide a diverse set of issues that apply to patients, providers, social groups, and investigators. The further study of such issues can help with preventing future outbreaks.

Pandemic preparedness and response: a new mechanism for expanding access to essential countermeasures

As the world comes together through the WHO design and consultation process on a new medical counter-measures platform, we propose an enhanced APT-A (Access to Pandemic Tools Accelerator) that builds on the previous architecture but includes two new pillars - one for economic assistance and another to combat structural inequalities for future pandemic preparedness and response. As part of the APT-A, and in light of the Independent Panel on Pandemic Preparation & Response's call for an enhanced end-to-end platform for access to essential health technologies, we propose a new mechanism that we call the Pandemic Open Technology Access Accelerator (POTAX) that can be implemented through the medical countermeasures platform and the pandemic accord currently under negotiation through the World Health Assembly and supported by the High-Level Meeting review on Pandemic Prevention, Preparedness, and Response at the United Nations. This mechanism will provide (1) conditional financing for new vaccines and other essential health technologies requiring companies to vest licenses in POTAX and pool intellectual property and other data necessary to allow equitable access to the resulting technologies. It will also (2) support collective procurement as well as measures to ensure equitable distribution and uptake of these technologies.

SARS-CoV-2 Positivity in Foreign-Born Adults: A Retrospective Study in Verona, Northeast Italy

We compared SARS-CoV-2 positivity between the foreign-born adult working population and Italians living in the Verona area to investigate whether being a foreign-born adult could confer an increased risk of infection or lead to a diagnostic delay. The present study included 105,774 subjects, aged 18-65 years, tested for SARS-CoV-2 by nasopharyngeal swabs and analyzed at the University Hospital of Verona between January 2020 and September 2022. A logistic regression model was used, controlling for gender, age, time of sampling, and source of referral. A higher proportion of SARS-CoV-2 positivity in Italian (30.09%) than in foreign-born (25.61%) adults was reported, with a higher proportion of SARS-CoV-2 positivity in men than women in both cohorts analyzed. The difference in swab positivity among Italian and foreign-born adults was the highest in people aged 18-29 years (31.5% vs. 23.3%) and tended to disappear thereafter. Swab positivity became comparable between Italian and foreign-born adults during the vaccination campaign. Multivariable analysis confirmed the lower risk of swab positivity among foreign-born adults (OR = 0.85, 95% CI 0.82-0.89). In the Verona area, foreign-born adults showed a lower rate of SARS-CoV-2 positivity than the native population, likely because of underdiagnosis. Hence, public health should increase attention toward these particularly vulnerable populations.

Equity Lens on Canada's COVID-19 Response: Review of the Literature

BACKGROUND

A growing literature has documented how the secondary effects of the COVID-19 pandemic have compounded socioeconomic vulnerabilities already present in society, particularly across social categories such as gender, race, class, and socioeconomic status. Such effects demonstrate how pandemic response policies act as structural determinants of health to influence not only direct health outcomes but also intermediary outcomes, such as access to education or income.

METHODS

This review aims to scope research that analyzes pandemic response policies in Canada from an equity perspective, to identify common themes, recommendations, and gaps.

RESULTS

Fourteen studies were thematically analyzed, the majority being qualitative policy document analysis, applying critical frameworks and focused on effects on select priority populations. Analysis of economic and labour policies indicates a lack of consideration for the specific needs of priority populations, and those engaged in precarious, informal, and essential labour. Analysis of social policies illustrate the wide-ranging effects of school and service closures, particularly on women and children. Furthermore, these policies lacked consideration of populations marginalized during the pandemic, include older adults and their caregivers, as well as lack of consideration of the diversity of Indigenous communities. Recommendations proposed in this review call for developing policy responses that address persistent social and economic inequities, pandemic response policies tailored to the needs of priority populations and more meaningful consultation during policy development.

CONCLUSION

The limited number of studies suggests there is still much scope for research recognizing policies as structural determinants of health inequities, including research which takes an intersectional approach.

Pandemic Pressure: Changes in Hypertensive Management Adherence in Indonesia

PURPOSE

This study aimed to determine factors associated with changes in adherence to hypertension management (medication adherence and blood pressure control) in respondents with hypertension before and during the COVID-19 pandemic in Bogor city, Indonesia.

METHODS

An observational study was conducted using two sources of data (before and during COVID-19 pandemic). Data before the pandemic were derived from the 2019 Cohort Study of non-communicable disease risk factors. Data during the pandemic were derived from an online survey conducted in September and October 2020. Information from 880 participants were analyzed. The dependent variable was the change in adherence to hypertension management before and during the COVID-19 pandemic. Multivariate analysis was performed using logistic polynomial regression.

RESULTS

Respondents who adhered to hypertension management decreased from 82.0% in 2019 to 47.8% in 2020. The likelihood of non-adherence (respondents who did not adhere to hypertension management both before and during the pandemic) increased in respondents below 55 years old, who did not own any healthcare insurance, who were not obese, and who had no other comorbidities. In the partial adherence group (respondents who did not adhere to hypertension management either before or during the pandemic), we found that most respondents adhered before the pandemic but no longer adhered during the COVID-19 pandemic. We found an increased partial adherence in young and highly educated respondents.

CONCLUSIONS

Efforts to improve adherence to hypertension management after the COVID-19 pandemic should target those who were young, highly educated, who did not have any healthcare insurance, and who did not perceive themselves as not having comorbidities.

Relationship between social inequality perception patterns and depressive symptoms among Chinese adults: A national representative longitudinal study

BACKGROUND

The rising prevalence of depressive symptoms presents a pressing global public health concern, exacerbated by prevailing social inequality.

AIM

This study seeks to identify latent profiles of social inequality perception and explore their associations with depressive symptoms.

METHODS

Data were obtained from the China Family Panel Studies (CFPS) involving 10,529 residents aged 18 years and above. Latent profile analysis (LPA) was used to identify different patterns of social inequality perception. Multiple linear regression analysis examined the links between these patterns and depressive symptoms.

RESULTS

Three distinct patterns of social inequality perception were identified: the disappointed pattern (TDP), the neutral pattern (TNP), and the positive pattern (TPP). Perceived social inequality was significantly associated with short-term and long-term depressive symptoms (β = .51, 95% CI [0.29, 0.72] vs. β = .51, 95% CI [0.27, 0.74]). Increases in social inequality perception patterns were also related to more severe depressive symptoms (β = .55, 95% CI [0.36, 0.74]).

CONCLUSIONS

Increasing perceived social inequality is closely linked to elevated depressive symptoms in Chinese adults. This underscores the need for tailored strategies aimed at addressing heightened perceptions of social inequality to reduce the risk of depressive symptoms.

Priority setting in times of crises: an analysis of priority setting for the COVID-19 response in the Western Pacific Region

BACKGROUND

While priority setting is recognized as critical for promoting accountability and transparency in health system planning, its role in supporting rational, equitable and fair pandemic planning and responses is less well understood. This study aims to describe how priority setting was used to support planning in the initial stage of the pandemic response in a subset of countries in the Western Pacific Region (WPR).

METHODS

We purposively sampled a subset of countries from WPR and undertook a critical document review of the initial national COVID-19 pandemic response plans. A pre-specified tool guided data extraction and the analysis examined the use of quality parameters of priority setting, and equity considerations.

RESULTS

Nine plans were included in this analysis, from the following countries: Papua New Guinea, Tonga, The Philippines, Fiji, China, Australia, New Zealand, Japan, and Taiwan. Most commonly the plans described strong political will to respond swiftly, resource needs, stakeholder engagement, and defined the roles of institutions that guided COVID-19 response decision-making. The initial plans did not reflect strong evidence of public engagement or considerations of equity informing the early responses to the pandemic.

CONCLUSION

This study advances an understanding of how priority setting and equity considerations were integrated to support the development of the initial COVID-19 responses in nine countries in WPR and contributes to the literature on health system planning during emergencies. This baseline assessment reveals evidence of the common priority setting parameters that were deployed in the initial responses, the prioritized resources and equity considerations and reinforces the importance of strengthening health system capacity for priority setting to support future pandemic preparedness.

Evaluation of patient health outcomes of a student-run free clinic in East Harlem

BACKGROUND

Most United States medical schools have affiliated student-run free clinics, but the quality of services provided in such contexts compared to national metrics is unknown. This study determines whether a student-run, attending-supervised free clinic servicing a low-income and minority race patient population in New York City can meet national metrics of care.

METHODS

Through chart review from January 1, 2020 to December 31, 2020, patient outcomes and service utilization in the Healthcare Effectiveness Data and Information Set were examined and compared to national rates of patients using Medicaid HMO or Medicare. Patients are ≥ 21 years of age, residents of East Harlem, and ineligible for health insurance because of legal residency requirements. The majority identify as Hispanic and speak Spanish as their primary language. All patients who were seen in the clinic during the 2020 calendar year were included. The primary study outcome is the number of Healthcare Effectiveness Data and Information Set measures in which patients, seen in a student-run free clinic, meet or exceed national comparisons.

RESULTS

The healthcare outcomes of 238 patients, mean age 47.8 years and 54.6% female, were examined in 18 Healthcare Effectiveness Data and Information Set measures. The student-run free clinic met or exceeded national metrics in 16 out of 18 categories.

CONCLUSIONS

The student-run free clinic met or exceeded the national standard of care according to national metrics. Evidence-based priorities have been clarified for future improvement. Other student-run free clinics should similarly evaluate the quality of their services.

Assisting primary care teams and patients in a culturally diverse periphery: impact on medical students' future career choices

BACKGROUND

Medical students can assist in reducing healthcare disparities and promote health equity by engaging with rural communities and gaining insights into their unique healthcare needs. A two-arm student-delivered program was designed and implemented during COVID-19 in a social-geographic peripheral area to assist clinics with complex chronic and/or socially disadvantaged patients and improve preventive behavior in townships through home visits delivering community kits.

METHODS

We conducted a pre-post design study which included weekly structured medical student reports and monthly structured telephone interviews with clinic directors and municipal partners. Students completed pre-post program survey on their knowledge, skills, and capabilities to address chronic patients from diverse cultural backgrounds (n = 73). The Wilcoxon-Signed-Rank test for related samples was used to determine differences.

RESULTS

Following the program, the knowledge and awareness levels of students about working in the community (P < 0.001) and their knowledge of common chronic diseases were significantly improved (Mean Difference (MD) = 0.31; p < 0.001). The program significantly increased students' interest to integrate into community care alongside a hospital (P = 0.012). Thematic analysis of student reports revealed improved insight into the role of primary care. Clinic directors (90%) were highly satisfied and reported that students became an integral part of the clinics' teams.

CONCLUSIONS

Integrating medical students into the community through primary-care clinics and home visits in diverse communities, exposed students to the interwoven effect of clinical and social determinants on health and improve their knowledge of common chronic diseases. Participation in the program encouraged students to consider a career in community care.

Unraveling socioeconomic determinants of health-related behavior, reception of information, and perceptions on disease disclosure at the time of the COVID-19 pandemic: did health insurance curb the disparities in the Philippines?

BACKGROUND

The study uncovers micro and macro socioeconomic disparities in terms of health behavior, disease perception, and reception of information. Furthermore, findings shed light on the possible role of health insurance on access to information, disease perception and the adoption of preventive behaviors in the context of a public health emergency such as the COVID-19 pandemic.

METHODS

This study employed a cross-sectional design using the Philippine Demographic and Health Survey (DHS). With a total of 29,809 respondents, it evaluated the individual or household and systemwide socioeconomic determinants of four different outcomes: receipt of information, disease perception, uptake of free preventive services, and treatment-seeking behavior. In addition to logistic regression models with the socioeconomic variables as the independent variables, models for the evaluation of the moderating effect of insurance ownership were fitted. Predicted probabilities were reported for the analysis of moderating effects.

RESULTS

Findings show that individual and householdsocioeconomic determinants affected health-behavior and access to or receipt of information pertinent to the COVID-19 pandemic. Both education and wealth affected the receipt of information such that individuals in more advantaged socioeconomic positions were at least 30% more likely to have received information on COVID-19. Wealth was also associated to treatment-seeking behavior. Regional differences were seen across all dependent variables. Moreover, the study provides evidence that ownership of insurance can close education-based gaps in the uptake of free vaccination and COVID-19 testing.

CONCLUSION

It is imperative that targeted efforts be maximized by utilizing existing strategies and mechanisms to reach the marginalized and disadvantaged segments of the population. Health insurance may give off added benefits that increase proficiency in navigating through the healthcare system. Further research may focus on examining pathways by which health insurance or social policies may be used to leverage responses to public health or environmental emergencies.

Exploring the needs and experiences of contact tracing staff during the COVID-19 pandemic in Ireland

BACKGROUND

Contact tracing is a key component in controlling the spread of COVID-19, however little research has focused on learning from the experiences of contact tracing staff. Harnessing learning from those in this role can provide valuable insights into the process of contact tracing and how best to support staff in this crucial role.

METHODS

Thematic analysis was used to analyse 47 semi-structured interviews conducted with contact tracing staff via telephone or Zoom at three time points in 2021: March, May and September-October.

RESULTS

Six themes related to the contact tracing role were identified, including training, workforce culture, systems issues, motivation and support. While initially nervous in the role, participants were motivated to contribute to the pandemic response and believed the role provided them with valuable transferable skills. Participants described the training as having improved over time while desiring more proactive training. Sources of frustration included a perceived lack of opportunity for feedback and involvement in process changes, feelings of low autonomy, and a perception of high staff turnover. Participants expressed a need for improved communication of formal emotional supports. Increased managerial support and provision of opportunities for career advancement may contribute to increased motivation among staff.

CONCLUSIONS

These findings identify the experiences of contact tracing staff working during the COVID-19 pandemic, and have important implications for the improvement of the contact tracing system. Recommendations based on learning from participants offer suggestions as to how best to support the needs of contact tracing staff during a pandemic response.

Digital health and health equity: How digital health can address healthcare disparities and improve access to quality care in Africa

The healthcare industry is constantly evolving to bridge the inequality gap and provide precision care to its diverse population. One of these approaches is the integration of digital health tools into healthcare delivery. Significant milestones such as reduced maternal mortality, rising and rapidly proliferating health tech start-ups, and the use of drones and smart devices for remote health service delivery, among others, have been reported. However, limited access to family planning, migration of health professionals, climate change, gender inequity, increased urbanization, and poor integration of private health firms into healthcare delivery rubrics continue to impair the attainment of universal health coverage and health equity. Health policy development for an integrated health system without stigma, addressing inequalities of all forms, should be implemented. Telehealth promotion, increased access to infrastructure, international collaborations, and investment in health interventions should be continuously advocated to upscale the current health landscape and achieve health equity.

Real-World Effectiveness of Sotrovimab for the Early Treatment of COVID-19: Evidence from the US National COVID Cohort Collaborative (N3C)

BACKGROUND AND OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has been an unprecedented healthcare crisis, one that threatened to overwhelm health systems and prompted an urgent need for early treatment options for patients with mild-to-moderate COVID-19 at high risk for progression to severe disease. Randomised clinical trials established the safety and efficacy of monoclonal antibodies (mAbs) early in the pandemic; in vitro data subsequently led to use of the mAbs being discontinued, without clear evidence on how these data were linked to outcomes. In this study, we describe and compare real-world outcomes for patients with mild-to-moderate COVID-19 at high risk for progression to severe COVID-19 treated with sotrovimab versus untreated patients.

METHODS

Electronic health records from the National COVID Cohort Collaborative (N3C) were used to identify US patients (aged ≥ 12 years) diagnosed with COVID-19 (positive test or ICD-10: U07.1) in an ambulatory setting (27 September 2021-30 April 2022) who met Emergency Use Authorization (EUA) high-risk criteria. Patients receiving the mAb sotrovimab within 10 days of diagnosis were assigned to the sotrovimab cohort, with the day of infusion as the index date. Untreated patients (no evidence of early mAb treatment, prophylactic mAb or oral antiviral treatment) were assigned to the untreated cohort, with an imputed index date based on the time distribution between diagnosis and sotrovimab infusion in the sotrovimab cohort. The primary endpoint was hospitalisation or death (both all-cause) within 29 days of index, reported as descriptive rate and adjusted [via inverse probability of treatment weighting (IPTW)] odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Of nearly 2.9 million patients diagnosed with COVID-19 during the analysis period, 4992 met the criteria for the sotrovimab cohort, and 541,325 were included in the untreated cohort. Before weighting, significant differences were noted between the cohorts; for example, patients in the sotrovimab cohort were older (60 years versus 54 years), were more likely to be white (85% versus 75%) and met more EUA criteria (mean 3.1 versus 2.2) versus the untreated cohort. The proportions of patients with 29-day hospitalisation or death were 3.5% (176/4992) and 4.5% (24,163/541,325) in the sotrovimab and untreated cohorts, respectively (unadjusted OR: 0.78; 95% CI: 0.67, 0.91; p = 0.001). In adjusted analysis, sotrovimab was associated with a 25% reduction in the odds of hospitalisation or death compared with the untreated cohort (IPTW-adjusted OR: 0.75; 95% CI: 0.61, 0.92; p = 0.005).

CONCLUSIONS

Sotrovimab demonstrated clinical effectiveness in preventing severe outcomes (hospitalisation, mortality) in the period 27 September 2021-30 April 2022, which included Delta and Omicron BA.1 variants and an early surge of Omicron BA.2 variant.

Sexual and Reproductive Health Outcomes Among Adolescent Females During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Coronavirus disease 2019 (COVID-19) posed a significant threat to adolescents' sexual and reproductive health. In this study, we examined population-level pregnancy and sexual health-related care utilization among adolescent females in Ontario, Canada during the pandemic and evaluated relationships between these outcomes and key sociodemographic characteristics.

METHODS

This was a population-based, repeated cross-sectional study of >630 000 female adolescents (12-19 years) during the prepandemic (January 1, 2018-February 29, 2020) and COVID-19 pandemic (March 1, 2020-December 31, 2022) periods. Primary outcome was pregnancy; secondary outcomes were contraceptive management visits, contraception prescription uptake, and sexually transmitted infection (STI) management visits. Poisson models with generalized estimating equations for clustered count data were used to model pre-COVID-19 trends and forecast expected rates during the COVID-19 period. Absolute rate differences between observed and expected outcome rates for each pandemic month were calculated overall and by urbanicity, neighborhood income, immigration status, and region.

RESULTS

During the pandemic, lower-than-expected population-level rates of adolescent pregnancy (rate ratio 0.87; 95% confidence interval [CI]:0.85-0.88), and encounters for contraceptive (rate ratio 0.82; 95% CI:0.77-0.88) and STI management (rate ratio 0.52; 95% CI:0.51-0.53) were observed. Encounter rates did not return to pre-pandemic rates by study period end, despite health system reopening. Pregnancy rates among adolescent subpopulations with the highest pre-pandemic pregnancy rates changed least during the pandemic.

CONCLUSIONS

Population-level rates of adolescent pregnancy and sexual health-related care utilization were lower than expected during the COVID-19 pandemic, and below-expected care utilization rates persist. Pregnancy rates among more structurally vulnerable adolescents demonstrated less decline, suggesting exacerbation of preexisting inequities.

Moral Injury Post-COVID-19: More Than Military? A Theological Perspective

The author of this article considers moral distress theologically, as a potential shattering of core sustaining belief systems, hope, securities, self-identities, and organizing principles of one's existence. Shattering of individual moral expectations can occur in both medical and military moral injury.

Psychometric evaluation of the Chinese version of new fear of the coronavirus questionnaire

The fear of COVID-19 significantly impacting the health of people globally. This study translated newly developed measurement tool New Fear of the Coronavirus Questionnaire (New_FCQ) into Chinese language and evaluated the psychometric properties of the Chinese version of New_FCQ among Chinese population. A total of 522 participants were included in the study. Internal consistency, construct validity, criterion validity, and concurrent validity of the Chinese version of New_FCQ were assessed in this study. The Chinese version of New_FCQ had excellent internal consistency (α = 0.97) and exploratory factor analysis demonstrated one-dimensional structure of the Chinese version of New_FCQ. The preliminary criterion validity revealed statistically significant differences in the fear of COVID-19 scores based on age and education level (P = .002 and P = .03, respectively). The good concurrent validity also established with the Chinese version Fear of COVID-19 Scale(P < .001). Psychometric proportions of the Chinese version of New_FCQ were established, which exhibited sufficient validity and reliability among Chinese population.

Economic and social determinants of health care utilization during the first wave of COVID-19 pandemic among adults in Ghana: a population-based cross-sectional study

BACKGROUND

The COVID-19 pandemic had socioeconomic effects in Africa. This study assessed the social and economic determinants of healthcare utilization during the first wave of COVID-19 among adults in Ghana.

METHODS

Information about individuals residing in Ghana was derived from a survey conducted across multiple countries, aiming to evaluate the impact of the COVID-19 pandemic on the mental health and overall well-being of adults aged 18 and above. The dependent variable for the study was healthcare utilization (categorized as low or high). The independent variables were economic (such as financial loss, job loss, diminished wages, investment/retirement setbacks, and non-refunded travel cancellations) and social (including food scarcity, loss of financial support sources, housing instability, challenges affording food, clothing, shelter, electricity, utilities, and increased caregiving responsibilities for partners) determinants of health. A multinomial logistic regression was conducted to identify factors associated with healthcare utilization after adjusting for confounders (age, gender, access to medical insurance, COVID-19 status, educational background, employment, and marital status of the participants).

RESULTS

The analysis included 364 responses. Individuals who encountered a loss of financial support (AOR: 9.58; 95% CI: 3.44-26.73; p < 0.001), a decrease or loss of wages (AOR: 7.44, 95% CI: 3.05-18.16, p < 0.001), experienced investment or retirement setbacks (AOR: 10.69, 95% CI: 2.60-43.88, p = 0.001), and expressed concerns about potential food shortages (AOR: 6.85, 95% CI: 2.49-18.84, p < 0.001) exhibited significantly higher odds of low healthcare utilization during the initial phase of the pandemic. Contrastingly, participants facing challenges in paying for basic needs demonstrated lower odds of low healthcare utilization compared to those who found it easy to cover basic expenses (AOR: 0.19, 95% CI: 0.06-0.67, p = 0.001).

CONCLUSION

Economic and social factors were associated with low healthcare utilization in Ghana during the first wave of the pandemic. Investment or retirement loss and financial support loss during the pandemic had the largest effect on healthcare utilization. Further research is needed to understand the connection between concerns about food shortages, welfare losses during pandemics and healthcare utilization during pandemics in Ghana.

Impact of coronavirus disease 2019 on cancer care: How the pandemic has changed cancer utilization and expenditures

PURPOSE

Since identified in December 2019, the novel coronavirus disease 2019 (COVID-19) has had a global impact on medical resource use and costs for patients with cancer in South Korea. This study aimed to identify the medical use and costs among patients with cancer during the COVID-19 pandemic, to predict these patterns in South Korea in the future.

METHODS

We conducted a secondary claims data analysis using the National Health Insurance Service database for the calendar period of 2019-2020. Monthly relative percent changes in cancer incidence, medical use, and billing costs for medical care utilization by cancer type were calculated. Then, the medical use and costs after January 2020 were predicted using a time series model with data before the COVID-19 outbreak (2014-2019).

RESULTS

The incidence of cancer diagnoses has seen a notable decline since the outbreak of the COVID-19 in 2020 as compared to 2019. Despite the impact of COVID-19, there hasn't been a distinct decline in outpatient utilization when compared to inpatient utilization. While medical expenses for both inpatient and outpatient visits have slightly increased, the number of patients treated for cancer has decreased significantly compared to the previous year. In June 2020, overall outpatient costs experienced the highest increase (21.1%), while individual costs showed the most significant decrease (-4.9%) in June 2020. Finally, the number of hospitalisations and outpatient visits increased slightly from June-July in 2020, reducing the difference between the actual and predicted values. The decrease in the number of inpatient hospitalisations (-22~-6%) in 2020 was also high.

CONCLUSIONS

The overall use of medical services by patients with cancer decreased in 2020 compared with that in the pre-COVID-19 pandemic period. In the future, the government should consider how to recover from the COVID-19 pandemic, and establish permanent health policies for patients with cancer.

Real-world effectiveness of sotrovimab for the treatment of SARS-CoV-2 infection during Omicron BA.2 subvariant predominance: a systematic literature review

PURPOSE

Emerging SARS-CoV-2 variants have impacted the in vitro activity of sotrovimab, with variable fold changes in neutralization potency for the Omicron BA.2 sublineage and onward. The correlation between reduced in vitro activity and clinical efficacy outcomes is unknown. A systematic literature review (SLR) evaluated the effectiveness of sotrovimab on severe clinical outcomes during Omicron BA.2 predominance.

METHODS

Electronic databases were searched for peer-reviewed journals, preprint articles, and conference abstracts published from January 1-November 3, 2022.

RESULTS

Five studies were included, which displayed heterogeneity in study design and population. Two UK studies had large samples of patients during BA.2 predominance: one demonstrated clinical effectiveness vs molnupiravir during BA.1 (adjusted hazard ratio [aHR] 0.54, 95% CI 0.33-0.88; p = 0.014) and BA.2 (aHR 0.44, 95% CI 0.27-0.71; p = 0.001); the other reported no difference in the clinical outcomes of sotrovimab-treated patients when directly comparing sequencing-confirmed BA.1 and BA.2 cases (HR 1.17, 95% CI 0.74-1.86). One US study showed a lower risk of 30-day all-cause hospitalization/mortality for sotrovimab compared with no treatment during the BA.2 surge in March (adjusted relative risk [aRR] 0.41, 95% CI 0.27-0.62) and April 2022 (aRR 0.54, 95% CI 0.08-3.54). Two studies from Italy and Qatar reported low progression rates but were either single-arm descriptive or not sufficiently powered to draw conclusions on the effectiveness of sotrovimab.

CONCLUSION

This SLR showed that the effectiveness of sotrovimab was maintained against Omicron BA.2 in both ecological and sequencing-confirmed studies, by demonstrating low/comparable clinical outcomes between BA.1 and BA.2 periods or comparing against an active/untreated comparator.

Ophthalmic implications of biological threat agents according to the chemical, biological, radiological, nuclear, and explosives framework

As technology continues to evolve, the possibility for a wide range of dangers to people, organizations, and countries escalate globally. The United States federal government classifies types of threats with the capability of inflicting mass casualties and societal disruption as Chemical, Biological, Radiological, Nuclear, and Energetics/Explosives (CBRNE). Such incidents encompass accidental and intentional events ranging from weapons of mass destruction and bioterrorism to fires or spills involving hazardous or radiologic material. All of these have the capacity to inflict death or severe physical, neurological, and/or sensorial disabilities if injuries are not diagnosed and treated in a timely manner. Ophthalmic injury can provide important insight into understanding and treating patients impacted by CBRNE agents; however, improper ophthalmic management can result in suboptimal patient outcomes. This review specifically addresses the biological agents the Center for Disease Control and Prevention (CDC) deems to have the greatest capacity for bioterrorism. CBRNE biological agents, encompassing pathogens and organic toxins, are further subdivided into categories A, B, and C according to their national security threat level. In our compendium of these biological agents, we address their respective CDC category, systemic and ophthalmic manifestations, route of transmission and personal protective equipment considerations as well as pertinent vaccination and treatment guidelines.

COVID-19 vaccine equity and health equity conversations on Twitter

This study used social network analysis and trending hashtags on Twitter to identify trends related to health and vaccine equity during the Omicron wave. The analysis was conducted using consumer-friendly platforms/tools such as the Healthcare Hashtag Project and NodeXL. The study found that during the Omicron wave, there was a higher volume of tweets related to the more specific hashtag #VaccineEquity, as compared to the more general topic of #HealthEquity. The study also identified the top influencers for these hashtags and how they changed over time. The study proposes a combination of existing tools and approaches, including ontological surveillance and social network analysis, to develop proactive strategies that respond to public opinion in a timely manner. Social network analysis tools could also be useful for healthcare organizations and providers in training their staff involved in social media management to develop better social media communication strategies.

Predictions based on inflammatory cytokine profiling of Egyptian COVID-19 with 2 potential therapeutic effects of certain marine-derived compounds

BACKGROUNDS

A worldwide coronavirus pandemic has affected many healthcare systems in 2019 (COVID-19). Following viral activation, cytokines and chemokines are released, causing inflammation and tissue death, particularly in the lungs, resulting in severe COVID-19 symptoms such as pneumonia and ARDS. COVID-19 induces the release of several chemokines and cytokines in different organs, such as the cardiovascular system and lungs.

RESEARCH IDEA

COVID-19 and its more severe effects, such as an elevated risk of death, are more common in patients with metabolic syndrome and the elderly. Cytokine storm and COVID-19 severity may be mitigated by immunomodulation targeting NF-κB activation in conjunction with TNF- α -inhibition. In severe cases of COVID-19, inhibiting the NF-κB/TNF- α, the pathway may be employed as a therapeutic option.

MATERIAL AND METHODS

The study will elaborate on the Egyptian pattern for COVID-19 patients in the first part of our study. An Egyptian patient with COVID-19 inflammatory profiling will be discussed in the second part of this article using approved marine drugs selected to inhabit the significant inflammatory signals. A biomarker profiling study is currently being performed on Egyptian patients with SARS-COV-2. According to the severity of the infection, participants were divided into four groups. The First Group was non-infected with SARS-CoV-2 (Control, n = 16), the Second Group was non-intensive care patients (non-ICU, n = 16), the Third Group was intensive care patients (ICU, n = 16), and the Fourth Group was ICU with endotracheal intubation (ICU + EI, n = 16). To investigate COVID-19 inflammatory biomarkers for Egyptian patients, several inflammatory, oxidative, antioxidant, and anti-inflammatory biomarkers were measured. The following are examples of blood tests: CRP, Ferritin, D-dimer, TNF-α, IL-8, IL-6., IL-Ib, CD8, NF-κB, MDA, and total antioxidants.

RESULTS AND DISCUSSION

The results of the current study revealed many logical findings, such as the elevation of CRP, Ferritin, D-dimer, TNF- α, CD8, IL-6, IL-, NF-κB, and MDA. Where a significant increase showed in ICU group results (23.05 ± 0.30, 2.35 ± 0.86, 433.4 ± 159.3, 26.67 ± 3.51, 7.52 ± 1.48, 7.49 ± 1.04, 5.76 ± 1.31, 7.41 ± 0.73) respectively, and also ICU group results (54.75 ± 3.44, 0.65 ± 0.13, 460.2 ± 121.42, 27.43 ± 2.52, 8.63 ± 2.68, 10.65 ± 2.75, 5.93 ± 1.4, 10.64 ± 0.86) respectively, as well as ICU + EI group results (117.63 ± 11.89, 1.22 ± 0.65, 918.8 ± 159.27, 26.68 ± 2.00, 6.68 ± 1.08, 11.68 ± 6.16, 6.23 ± 0.07, 22.41 ± 1.39),respectively.The elevation in laboratory biomarkers of cytokines storm in three infected groups with remarkable increases in the ICU + EI group was due to the elevation of oxidative stress and inflammatory storm molecules, which lead to highly inflammatory responses, specifically in severe patients of COVID-19. Another approach to be used in the current study is investigating new computational drug compounds for SARS-COV-2 protective agents from the marine environment. The results revealed that (Imatinib and Indinavir) had the highest affinity toward Inflammatory molecules and COVID-19 proteins (PDB ID: -7CZ4 and 7KJR), which may be used in the future as possible COVID-19 drug candidates.

CONCLUSION

The investigated inflammatory biomarkers in Egyptian COVID-19 patients showed a strong correlation between IL6, TNF-α, NF-κB, CRB, DHL, and ferritin as COVID-19 biomarkers and determined the severity of the infection. Also, the oxidative /antioxidant showed good biomarkers for infection recovery and progression of the patients.

Essential Oils Infused Poly-ε-Caprolactone/Gelatin Electrospun Nanofibrous Mats: Biocompatibility and Antibacterial Study

Infections caused by antibiotic-resistant pathogens result in a delayed wound-healing process. As an approach to prevent infections, alternatives in the form of natural antimicrobial products have become public interest. Essential oils derived from plants are used as antimicrobials owing to their broad-spectrum activity against pathogenic organisms. In this study, essential oil from seeds of watermelon, jackfruit, and papaya was incorporated into poly-ε-caprolactone/gelatin nanofibers using an electrospinning technique. The synthesized nanofibers were smooth, continuous, and bead-free. The nanofibers were found to be mechanically competent as confirmed by the universal tensile tester. The antibacterial activity of the various essential oil-loaded nanofibrous mats was determined by disc diffusion assay. Furthermore, they were found to be non-toxic and biocompatible by MTT and CMFDA assays on fibroblast cells. The obtained results have demonstrated that essential oil-loaded nanofiber mats are promising alternatives to conventional antibacterial wound dressings.

Inequalities in health system coverage and quality: a cross-sectional survey of four Latin American countries

The premise of health as a human right in Latin America has been challenged by health system fragmentation, quality gaps, a growing burden of chronic disease, sociopolitical upheaval, and the COVID-19 pandemic. We characterised inequities in health system quality in Colombia, Mexico, Peru, and Uruguay. We did a cross-sectional telephone survey with up to 1250 adults in each country. We created binary outcomes in coverage, user experience, system competence, and confidence in the system and calculated the slope index of inequality by income and education. Although access to care was high, only a third of respondents reported having a high-quality source of care and 25% of those with mental health needs had those needs met. Two-thirds of adults were able to access relevant preventive care and 42% of older adults were screened for cardiovascular disease. Telehealth access, communication and autonomy in most recent visit, reasonable waiting times, and receiving preventive health checks showed inequalities favouring people with a high income. In Uruguay, inequality between government and social security services explained a substantial proportion of disparities in preventive health access. In other study countries, inequalities were also substantial within government and social security subsectors. Essential health system functions are unequal in these four Latin American countries.

A collaboration to harmonize COVID-19 health messaging and fill communication gaps during initial U.S. refugee resettlement

To communicate with U.S.-bound refugees during travel to the United States during the onset of the COVID-19 pandemic, five federal and international organizations collaborated in a strategic work group to synergize COVID-19 prevention health messaging and COVID-19 considerations before, during, and after travel, as well as promote shared resources. This work group sought to establish consistent COVID-19 messaging, disseminate messages to partners, and identify message gaps as the pandemic evolved. In early Fall 2020, CDC released new communication materials, including a fact sheet, a welcome booklet, and infographics translated into 19 languages, to address refugee health partners' need for culturally and linguistically concordant educational materials for refugees. Rapidly changing health communications needs during the pandemic fostered opportunities for collaboration among federal and refugee health partners and highlighted a long-standing need among agencies to address health messaging across the continuum of care for refugees.

What drives the vaccination intention against COVID-19? Application of EPPM, TAM, and theories of risk assessment

Vaccines are widely used to fight against COVID-19. However, COVID-19 vaccine hesitancy appears as some individuals are concerned with COVID-19 vaccines. This study investigates the vaccination intention against COVID-19 in China with the Extended Parallel Process Model (EPPM), Technology Acceptance Model (TAM), and theories of risk information assessment. Results showed that the formation mechanism of vaccination intention could be considered a psychological process, as subjective knowledge was a primary influence on correspondents' weighting of both the potentially positive (usefulness) and negative effects (threat) of vaccination. This unequal consideration then resulted in different levels of fear arousal between subjects. Driven by usefulness/threat perception and fear, people conducted different decision strategies, so-called analytical assessment, and experiential assessment to make vaccination decision. In addition to the direct effects of experiential assessment on vaccination intention, two decision strategies and fear arousal also affected people's vaccination intention through the mediation role of vaccination attitude. For policymakers and stakeholders, this study provides a knowledge base for confidence-building, and emotional guidance concerning against COVID-19 vaccination.

The Effect of "Offline-to-Online" Trust Transfer on the Utilization of Online Medical Consultation Among Chinese Rural Residents: Experimental Study

BACKGROUND

Online medical consultation can serve as a valuable means for rural residents to access high-quality health care resources, thereby mitigating the geographic and economic disadvantages prevalent in rural areas. Nevertheless, due to lower cognitive abilities, rural residents often face challenges in trusting and making effective use of online medical consultations. More likely, adopting a bounded rational decision-making model that facilitates the "offline-to-online" trust transfer could prove to be a potentially effective approach. This strategy aims to encourage less technologically experienced rural residents to trust and make use of online medical consultations.

OBJECTIVE

This study aims to characterize the status of "offline-to-online" trust transfer among rural residents in the context of internet health care, and analyze its direct impact on facilitating the utilization of online medical consultation. Additionally, we investigate the family spillover effect of "offline-to-online" trust transfer in promoting the use of online medical consultation among rural family members, considering its distributional effect across various education levels of the population.

METHODS

A multistage stratified random sampling method was used to survey participants in rural areas of China from July to September 2021, encompassing a total of 2597 rural residents from 960 rural households. Propensity score values were estimated using logit regression, and the propensity score matching method, using the K-nearest neighbor matching, radius matching, and kernel matching methods, was applied to create matched treatment and control samples of rural residents based on their experience of "offline-to-online" trust transfer. Subsequently, we calculated average treatment effect scores to compare the differences in utilizing online medical consultation between the treatment and control rural samples.

RESULTS

As many as 551/960 (57.4%) rural residents experienced an "offline-to-online" trust transfer, with a higher likelihood observed in the older population with lower levels of education and higher satisfaction with local health care services. Furthermore, rural residents who underwent "offline-to-online" trust transfer were 37%-40% more likely to utilize online medical consultation compared with those who did not experience this trust transfer. Additionally, family members of householders who underwent "offline-to-online" trust transfer were 25%-28% more likely to utilize online medical consultation than those whose householders did not experience this trust transfer. Notably, when compared with populations with high-level education, the "offline-to-online" trust transfer had more significant direct and spillover effects on the utilization of online medical consultation services among rural residents with low-level education.

CONCLUSIONS

To enhance the "offline-to-online" trust transfer among rural residents and its facilitation in their utilization of online medical consultation, as well as other mobile health (mHealth) and ubiquitous health (uHealth) services, we recommend that online health care providers adopt a "patient-oriented" service model. This approach aims to elevate rural residents' satisfaction with local health care services and harness the trust-building functions inherent in physician-patient relationships and among family members.

Socioeconomic inequalities in COVID-19 incidence during the first six waves in Barcelona

BACKGROUND

The emergence of SARS-CoV-2 affected urban areas. In Barcelona, six waves of COVID-19 hit the city between March 2020 and March 2022. Inequalities in the incidence of COVID-19 have been described. However, no studies have examined the daily trends of socioeconomic inequalities and how they changed during the different phases of the pandemic. The aim of this study is to analyse the dynamic socioeconomic inequalities in the incidence of COVID-19 during the six waves in Barcelona.

METHODS

We examined the proportion of daily cases observed in the census tracts in the lower income tercile compared with the proportion of daily cases observed in the sum of the lower and higher income terciles. Daily differences in these proportions were assessed as a function of the epidemic waves, sex, age group, daily incidence and daily change in the incidence. A logistic regression model with an autoregressive term was used for statistical analysis.

RESULTS

A time-dynamic effect was found for socioeconomic inequalities in the incidence of COVID-19. In fact, belonging to a lower-income area changed from being a risk factor (Waves 1, 2, 4 and 5) to being a protective factor in the sixth wave of the pandemic. Age also had a significant effect on incidence, which also changed over the different waves of the pandemic. Finally, the lower-income areas showed a comparatively lower incidence during the ascending phase of the epidemic waves.

CONCLUSION

Socioeconomic inequalities in COVID-19 changed by wave, age group and wave phase.

Conditions for health system resilience in the response to the COVID-19 pandemic in Mauritania

INTRODUCTION

A country's ability to manage a crisis depends on its level of resilience. Efforts are made to clarify the concept of health system resilience, but its operationalisation remains little studied. In the present research, we described the capacity of the local healthcare system in the Islamic Republic of Mauritania, in West Africa, to cope with the COVID-19 pandemic.

METHODS

We used a single case study with two health districts as units of analysis. A context analysis, a literature review and 33 semi-structured interviews were conducted. The data were analysed using a resilience conceptual framework.

RESULTS

The analysis indicates a certain capacity to manage the crisis, but significant gaps and challenges remain. The management of many uncertainties is largely dependent on the quality of the alignment of decision-makers at district level with the national level. Local management of COVID-19 in the context of Mauritania's fragile healthcare system has been skewed to awareness-raising and a surveillance system. Three other elements appear to be particularly important in building a resilient healthcare system: leadership capacity, community dynamics and the existence of a learning culture.

CONCLUSION

The COVID-19 pandemic has put a great deal of pressure on healthcare systems. Our study has shown the relevance of an in-depth contextual analysis to better identify the enabling environment and the capacities required to develop a certain level of resilience. The translation into practice of the skills required to build a resilient healthcare system remains to be further developed.

COVID-19, SDGs and public health systems: Linkages in Brazil

Background

The global 2030 Agenda covers a range of interconnected issues which need interdisciplinary and holistic approaches to improve human well-being and protect the natural environment. The COVID-19 pandemic has brought to light critical inequities in society and policy gaps in health services. As highlighted through analyses of the interlinkages among the Sustainable Development Goals (SDGs), connections between human health and well-being and the environment, can help support new policy needs in addressing systemic health crises, including widespread pandemics.

Method

We identify links between the COVID-19 crisis and multiple SDGs in the context of Brazil based on a review of the current literature in the health sector.Findings: We identify synergistic connections between 88 out of 169 SDG targets and COVID-19, notably around themes such as City Environment, Contextual Policies and the value created by improved Information and Technology. Using the context of the Brazilian National Health Service (SUS) highlights recurrent interconnections from the focal point of target 3.8. This includes topics such as challenges for universal healthcare coverage, budget allocation, and universalisation.

Conclusions

The framework developed for supporting policy-making decisions and the design of toolkits for dealing with future health-related emergency scenarios offers a practical solution in the health sector. It is worth noting that progress and action on public health systems and policies must go hand in hand with addressing existing socio-economic vulnerabilities in society. This is vital for tackling future pandemics and simultaneously addressing the SDGs.

Effects of COVID-19 on sexual and reproductive health services access in the Asia-Pacific region: a qualitative study of expert and policymaker perspectives

The COVID-19 pandemic has strained health systems globally, with governments imposing strict distancing and movement restrictions. Little is known about the effects of the COVID-19 pandemic on sexual and reproductive health (SRH). This study examined perceived effects of COVID-19 on SRH service provision and use in the Asia-Pacific region. We conducted a qualitative study using semi-structured interviews with 28 purposively sampled SRH experts in 12 Asia-Pacific countries (e.g. United Nations, international and national non-governmental organisations, ministries of health, academia) between November 2020 and January 2021. We analysed data using the six-stage thematic analysis approach proposed by Braun and Clarke (2019). Interviewees reported that COVID-19 mitigation measures, such as transport restrictions and those that decreased the availability of personal protective equipment (PPE), reduced SRH service provision and use in most countries. SRH needs related to service barriers and gender-based violence increased. Systemic challenges included fragmented COVID-19 response plans and insufficient communication and collaboration, particularly between public and private sectors. SRH service-delivery challenges included COVID-19 response prioritisation, e.g. SRH staff task-shifting to COVID-19 screening and contact tracing, and lack of necessary supplies and equipment. Innovative SRH delivery responses included door-to-door antenatal care and family planning provision in the Philippines, online platforms for SRH education and outreach in Viet Nam, and increasing SRH service engagement through social media in Myanmar and Indonesia. To ensure continuation of SRH services during health emergencies, governments should earmark human and financial resources and prioritise frontline health-worker safety; work with communities and the private sector; and develop effective risk communications.

Impact of Climate Change, Food Insecurity, and COVID-19 on the Health of Neonates and Children: A Narrative Review

Climate change, food insecurity, and epidemics affect all population sub-groups. This article reviews the current evidence on the relationships between climate change, food insecurity, and the COVID-19 pandemic in the context of newborn and child health. The authors searched Medline, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases using a structured approach. Food insecurity, particularly from the lack of food access and affordability, increased amidst the COVID-19 pandemic. Factors such as nationwide lockdowns, increased unemployment and financial instability, and school closures precipitated food insecurity. Children born to immigrant parents, belonging to racial and ethnic minority groupsor low-income families, and those who were Autistic were highly vulnerable. Climate change also contributes to food insecurity, with increased susceptibility among neonates and children compared to adults. There is a need for further research on the relationships between climate-linked exposures and COVID-19 transmission. Multisectoral collaborations and multilevel interventions are necessary to mobilize local and national resources for mitigating and preventing the synergistic effects of the three concurrent crises. The evidence-informed discourse on this topic can help in improved preparedness and response for future outbreaks and epidemics. The policy interventions for newborn and child survival need to factor in climate change, food insecurity, and emerging diseases.

A comparison of anxiety levels before and during the COVID-19 pandemic

The COVID-19 Pandemic upended the lives of nearly everyone worldwide, and recent studies have reported higher rates of anxiety, depression, and other mental health problems. Using a repeated crosssectional design, the current study compares anxiety levels from a representative sample of college students prior-to and during the COVID-19 Pandemic. Additionally, differences in anxiety prior to and following U.S. approval for use of the Pfizer-BioNTtech COVID-19 vaccine were also compared. Findings indicate that state-anxiety levels did not differ significantly prior to and during the Pandemic as well as before the vaccine and during and after the vaccine (M = 43.01, 44.10, 44.77, respectively). Surprisingly, trait anxiety levels were significantly higher during the Pandemic than before (p = .003), and anxiety levels trend down after the approval of the vaccine, but not significantly (M = 45.10, 48.85, 47.58, respectively). Future research should continue to investigate and compare anxiety levels during the COVID-19 Pandemic.

Ethnoracial Disparities in Rates of Non-Natural Causes of Death After the 2020 COVID-19 Outbreak in New York State

Introduction

COVID-19 was associated with increases in non-natural cause mortality in the U.S., including deaths due to drug overdose, homicide, and motor vehicle crashes. Initial reports indicated higher rates of non-natural mortality among ethnoracial minority groups. This report aims to clarify these disparities by documenting trends in non-natural mortality across ethnoracial groups during the 2020 COVID-19 surge in New York State.

Methods

We report monthly trends in non-natural cause mortality (overall and stratified by ethnoracial status) in New York State from January 2019 through December 2020, which included the COVID-19 onset in March 2020.

Results

Total mean monthly unintentional overdose rates per 100,000 increased from 17.45 (before surge: January 2019-February 2020) to 23.19 (after surge: March 2020-December 2020) (mean difference=5.73, 95% CI=3.82, 7.65; p<0.001). Mean monthly homicide death rates increased from 2.34 before surge to 3.55 after surge (mean difference=1.20, 95% CI=0.60, 1.81; p<0.001), with the increase seen primarily in the non-Latinx Black population. Although increasing unintentional overdose death rates before surge equally affected non-Latinx White, Latinx, and non-Latinx Black persons, they remained high for non-Latinx Black persons but dropped for the other 2 groups after the pandemic onset. None of the ethnoracial subgroups showed significant increases in suicide or motor vehicle crash death rates.

Conclusions

Non-Latinx Black persons showed disproportionately high and sustained increased rates of unintentional overdose and homicide death rates after the 2020 COVID-19 surge in New York State. Fatality review and death scene investigation research is needed to better understand these disparities.

Nirmatrelvir combined with ritonavir for preventing and treating COVID-19

BACKGROUND

Oral nirmatrelvir/ritonavir (Paxlovid) aims to avoid severe COVID-19 in asymptomatic people or those with mild symptoms, thereby decreasing hospitalization and death. It remains to be evaluated for which indications and patient populations the drug is suitable.

OBJECTIVES

To assess the efficacy and safety of nirmatrelvir/ritonavir plus standard of care (SoC) compared to SoC with or without placebo, or any other intervention for treating COVID-19 or preventing SARS-CoV-2 infection. To explore equity aspects in subgroup analyses. To keep up to date with the evolving evidence base using a living systematic review (LSR) approach and make new relevant studies available to readers in-between publication of review updates.

SEARCH METHODS

We searched the Cochrane COVID-19 Study Register, Scopus, and World Health Organization COVID-19 Research Database, identifying completed and ongoing studies without language restrictions and incorporating studies up to 15 May 2023. This is a LSR. We conduct update searches every two months and make them publicly available on the open science framework (OSF) platform.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo, or any other intervention for treatment of people with confirmed COVID-19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS-CoV-2 infection. We screened all studies for research integrity. Studies were ineligible if they had been retracted, or if they were not prospectively registered including appropriate ethics approval.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology and used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the following outcomes: 1. to treat outpatients with mild COVID-19; 2. to treat inpatients with moderate to severe COVID-19: mortality, clinical worsening or improvement, quality of life, (serious) adverse events, and viral clearance; 3. to prevent SARS-CoV-2 infection in postexposure prophylaxis (PEP); and 4. pre-exposure prophylaxis (PrEP) scenarios: SARS-CoV-2 infection, development of COVID-19 symptoms, mortality, admission to hospital, quality of life, and (serious) adverse events. We explored inequity by subgroup analysis for elderly people, socially-disadvantaged people with comorbidities, populations from low-income countries and low- to middle-income countries, and people from different ethnic and racial backgrounds.

MAIN RESULTS

As of 15 May 2023, we included two RCTs with 2510 participants with mild and mild to moderate symptomatic COVID-19 in outpatient and inpatient settings comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo. All trial participants were without previous confirmed SARS-CoV-2 infection and at high risk for progression to severe disease. Randomization coincided with the Delta wave for outpatients and Omicron wave for inpatients. Outpatient trial participants and 73% of inpatients were unvaccinated. Symptom onset in outpatients was no more than five days before randomisation and prior or concomitant therapies including medications highly dependent on CYP3A4 were not allowed. We excluded two studies due to concerns with research integrity. We identified 13 ongoing studies. Three studies are currently awaiting classification. Nirmatrelvir/ritonavir for treating people with asymptomatic or mild COVID-19 in outpatient settings Nirmatrelvir/ritonavir plus SoC compared to SoC plus placebo may reduce all-cause mortality at 28 days (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.68; 1 study, 2224 participants; low-certainty evidence) and admission to hospital or death within 28 days (RR 0.13, 95% CI 0.07 to 0.27; 1 study, 2224 participants; low-certainty evidence). Nirmatrelvir/ritonavir plus SoC may reduce serious adverse events during the study period compared to SoC plus placebo (RR 0.24, 95% CI 0.15 to 0.41; 1 study, 2224 participants; low-certainty evidence). Nirmatrelvir/ritonavir plus SoC probably has little or no effect on treatment-emergent adverse events (RR 0.95, 95% CI 0.82 to 1.10; 1 study, 2224 participants; moderate-certainty evidence), and probably increases treatment-related adverse events such as dysgeusia and diarrhoea during the study period compared to SoC plus placebo (RR 2.06, 95% CI 1.44 to 2.95; 1 study, 2224 participants; moderate-certainty evidence). Nirmatrelvir/ritonavir plus SoC probably decreases discontinuation of study drug due to adverse events compared to SoC plus placebo (RR 0.49, 95% CI 0.30 to 0.80; 1 study, 2224 participants; moderate-certainty evidence). No studies reported improvement of clinical status, quality of life, or viral clearance. Nirmatrelvir/ritonavir for treating people with moderate to severe COVID-19 in inpatient settings We are uncertain whether nirmatrelvir/ritonavir plus SoC compared to SoC reduces all-cause mortality at 28 days (RR 0.63, 95% CI 0.21 to 1.86; 1 study, 264 participants; very low-certainty evidence), or increases viral clearance at seven days (RR 1.06, 95% CI 0.71 to 1.58; 1 study, 264 participants; very low-certainty evidence) and 14 days (RR 1.05, 95% CI 0.92 to 1.20; 1 study, 264 participants; very low-certainty evidence). No studies reported improvement or worsening of clinical status and quality of life. We did not include data for safety outcomes due to insufficient and inconsistent information. Subgroup analyses for equity For outpatients, the outcome 'admission to hospital or death' was investigated for equity regarding age (less than 65 years versus 65 years or greater) and ethnicity. There were no subgroup differences for age or ethnicity. For inpatients, the outcome 'all-cause mortality' was investigated for equity regarding age (65 years or less versus greater than 65 years). There was no difference between subgroups of age. No further equity-related subgroups were reported, and no subgroups were reported for other outcomes. Nirmatrelvir/ritonavir for preventing SARS-CoV-2 infection (PrEP and PEP) No studies available.

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests nirmatrelvir/ritonavir reduces the risk of all-cause mortality and hospital admission or death in high-risk, unvaccinated COVID-19 outpatients infected with the Delta variant of SARS-CoV-2. There is low- to moderate-certainty evidence of the safety of nirmatrelvir/ritonavir. Very low-certainty evidence exists regarding the effects of nirmatrelvir/ritonavir on all-cause mortality and viral clearance in mildly to moderately affected, mostly unvaccinated COVID-19 inpatients infected with the Omicron variant of SARS-CoV-2. Insufficient and inconsistent information prevents the assessment of safety outcomes. No reliable differences in effect size and direction were found regarding equity aspects. There is no available evidence supporting the use of nirmatrelvir/ritonavir for preventing SARS-CoV-2 infection. We are continually updating our search and making search results available on the OSF platform.

COVID-19 and migrants: lessons for pandemic preparedness from the Malaysian experience

BACKGROUND

Aligning with global evidence related to migrants and COVID-19, the pandemic highlighted and exposed long-standing structural inequities in the context of migrant populations in Malaysia who experienced a disproportionate level of exposure to SARS-CoV-2 and COVID-19 morbidity, as well as exacerbated precarity during COVID-19 owing to disruptions to their livelihoods, health, and life.

MAIN BODY

Focusing on COVID-19 and migrant workers in Malaysia, this review addresses two research queries: (i) what are the policy responses of the government toward migrants with regard to COVID-19? (ii) what are the lessons learned from the Malaysian experience of COVID-19 and migrants that can inform pandemic preparedness, especially regarding migrant health policy? The review used Arksey and O'Malley's methodological framework refined by Levac, Colquhoun, and O'Brien. In addition to the PubMed, Web of Science, Scopus, and EBSCO databases, and Malaysian English language newspapers, including the Malay Mail, Malaysiakini, and the New Straits Times, the search also included reports from the websites of government ministries and departments, such as the Immigration Department, Ministry of Human Resources, Ministry of Health, and the International Trade and Industry Ministry.

CONCLUSION

Using the case example of Malaysia and the policy approach toward migrant populations in Malaysia during the height of the COVID pandemic in 2020 and 2021, this paper unravels complex pathways and inter-linkages between the contexts of migration and health which coalesced to engender and exacerbate vulnerability to disease and ill-health for the migrant workers. The lack of coordination and coherence in policies addressing migrant workers during the pandemic, the normalization of cheap and disposable labor in neoliberal economic regimes, and the securitization of migration were key factors contributing to the failure of migration policies to provide protection to migrant workers during COVID-19. The review suggests that policy approaches embodying the principles of Health in All Policies, a whole-of-society approach, and the promotion of safe, just, and regular migration, predicated on equity and inclusion, are integral to a comprehensive and effective response to pandemics such as COVID-19.

Maternal, newborn, and children under-five health surveillance system: a scoping review protocol

BACKGROUND

Public health surveillance is crucial in monitoring the progress of maternal, newborn, and children under-five health outcomes (MNCH). Consequently, mapping the existing surveillance system from countries with different income and development levels is needed to learn and compare the effectiveness of surveillance. However, the current COVID-19 pandemic has disrupted the health system, including the healthcare services for pregnant women, neonates, infants, and children under five, as well as the recording, reporting, and surveillance system. The need to adapt to the new normal during the pandemic has stimulated innovation while incorporating new COVID-19-related indicators into the existing public health system. Therefore, this review aims to describe the existing implementation and the COVID-19 pandemic's influence on the MNCH surveillance system.

METHODS

We will search published literature (from MEDLINE, Embase, and Portal Garuda), manually search from all reference lists of included studies, and conduct a targeted search of relevant gray literature. This review will include studies of surveillance systems or describe COVID-19 surveillance or routine reports involving MNCH (morbidity and mortality). The studies included will be in English or Indonesian language, observational study designs, and published or documented from 2010 to 2023. Two investigators will independently screen the title and abstract, including each full article to determine the eligibility of studies. The data will be assessed using a narrative approach. Data will be reported in simple descriptive tables.

DISCUSSION

Our findings are expected to map the existing implementation of MNCH surveillance systems before and during the pandemic, including the influence of the COVID-19 pandemic on MNCH surveillance across countries with different income levels. This may contribute to existing knowledge on the MNCH health surveillance system that could be integrated into the surveillance of emerging diseases, such as COVID-19.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered on the Open Science Framework ( https://osf.io/bc6t4 ).

COVID-19 epidemiology and rural healthcare: a survey in a Spanish village

We used primary care data to retrospectively describe the entry, spread, and impact of COVID-19 in a remote rural community and the associated risk factors and challenges faced by the healthcare team. Generalized linear models were fitted to assess the relationship between age, sex, period, risk group status, symptom duration, post-COVID illness, and disease severity. Social network and cluster analyses were also used. The first six cases, including travel events and a social event in town, contributed to early infection spread. About 351 positive cases were recorded and 6% of patients experienced two COVID-19 episodes in the 2.5-year study period. Five space-time case clusters were identified. One case, linked with the social event, was particularly central in its contact network. The duration of disease symptoms was driven by gender, age, and risk factors. The probability of suffering severe disease increased with symptom duration and decreased over time. About 27% and 23% of individuals presented with residual symptoms and post-COVID illness, respectively. The probability of developing a post-COVID illness increased with age and the duration of COVID-associated symptoms. Carefully registered primary care data may help optimize infection prevention and control efforts and upscale local healthcare capacities in vulnerable rural communities.