Rapid deployment of a community engagement study and educational trial via social media: implementation of the UC-COVID study

Bolstering agreement with scarce resource allocation policy using education: a post hoc analysis of a randomized controlled trial

BACKGROUND

The COVID- 19 pandemic prompted rapid development of scarce resource allocation policies (SRAP) in case demand for critical health services eclipsed capacity. We sought to test whether a brief, educational video could improve alignment of participant values and preferences with the tenets of the University of California Health's SRAP in a post hoc analysis of a randomized controlled trial (RCT) conducted during the pandemic.

METHODS

An RCT of an educational video intervention embedded in a longitudinal web-based survey conducted from May to December 2020, analyzed in August 2024. The "explainer" video intervention was approximately 6 min long and provided an overview of the mechanics and ethical principles underpinning the UC Health SRAP, subtitled in six languages. California residents were randomized to view the intervention or not, stratified by age, sex, education, racial identity, and self-reported health care worker status. Non-California residents were assigned to the control group. 1,971 adult participants were enrolled at baseline, and 939 completed follow-up. 770 participants with matched baseline and follow-up responses were analyzed. Self-reported survey assessments of values regarding components of SRAP were scored as the percentage of agreement with the UC Health SRAP as written. Participants responded to items at baseline and follow-up (approximately 10 weeks after baseline), with randomization occurring between administrations.

RESULTS

After the intervention, overall agreement improved by a substantial margin of 5.2% (from 3.8% to 6.6%, P <.001) for the intervention group compared to the control group. Significant changes in agreement with SRAP logistics and health factors were also observed in the intervention group relative to the control, while no significant changes were noted for social factors. Differential intervention effects were observed for certain demographic subgroups.

CONCLUSIONS

A brief educational video effectively explains the complex ethical principles and mechanisms of the SRAP, as well as how to improve the alignment of participant values with the foundational principles of UC Health SRAP. This directly informs practice by providing a framework for educating individuals about the use of these policies during future situations that require crisis standards of care, which can, in turn, enhance agreement and buy-in from affected parties.

TRIAL REGISTRATION

ClinicalTrials.gov registration NCT04373135 (registered 4 May 2020).

Tobacco consumption behavior change during the COVID-19 pandemic is associated with perceived COVID threat

RATIONALE

Tobacco use is a risk factor for COVID-19 adverse outcomes. Despite health implications, data conflict regarding COVID-19 and tobacco consumption. We present results from a survey of health behaviors during the pandemic to identify how COVID-19 influenced tobacco behaviors.

METHODS

A nationally administered, internet-based survey was deployed between May-September 2020. Of respondents, we analyzed participants who reported current smoking and/or vaping. Our primary outcome of interest was change in tobacco or vape use using measures from the Behavioral Risk Factor Surveillance System, as well as whether participants reported that these changes were related to COVID-19. Our principal exposures were previously psychometrically evaluated measures of anxiety, depression, and novel perceived COVID-19 threat scale with additional adjustment for age. We employed multinomial logistic regression to determine associations between these factors and tobacco consumption.

RESULTS

We identified 500 respondents who reported ever smoking in their lifetime, 150 of which reported currently smoking at the time of the survey. Of 220 participants who reported any use of vapes, 110 reported currently vaping. Increased perceived threat of COVID-19 was associated with both increased (aRRincrease 1.75, 95% CI [1.07-2.86], P = 0.03) and decreased (aRRdecrease 1.72 [1.04-2.85], P = 0.03) tobacco consumption relative to no change. There were no significant relationships found between perceived threat of COVID-19 and vaping behavior.

CONCLUSIONS

As perceived COVID-19 threat increased, people were more likely to increase or decrease their smoking as opposed to continue at the same amount of use, even after controlling for anxiety and depression, both of which are known to affect smoking in either direction. Further study into motivators of changing tobacco consumption behaviors, and how barriers to care from safer-at-home policies and changes in care delivery moderate change in tobacco use will aid planning tobacco reduction interventions during the ongoing and future respiratory viral pandemics.

TRIAL REGISTRATION

This manuscript is derived from baseline survey data obtained in the "Understanding Community Considerations, Opinions, Values, Impacts, and Decisions in COVID-19" study.

CLINICALTRIALS

gov registration NCT04373135, registered 04/30/2020.

Promotion of Knowledge and Trust Surrounding Scarce Resource Allocation Policies: A Randomized Clinical Trial

Importance

The COVID-19 pandemic prompted rapid development of scarce resource allocation policies (SRAPs) in case demand for critical health services eclipsed capacity.

Objective

To test whether a brief educational video could improve knowledge of how the University of California Health's SRAP would be implemented and trust in health systems to implement such policies in accordance with ethical principles during the pandemic.

Design, Setting, and Participants

This randomized clinical trial used an educational video intervention embedded in a longitudinal web-based survey and was conducted between May and December 2020 and analyzed during March 2024. A total of 1971 adult participants were enrolled, of whom 939 completed follow-up; participants with matched baseline and follow-up responses were analyzed. California residents were randomized to view the intervention (n = 345) or not (n = 353) and stratified by age, sex, education, racial identity, and self-reported health care worker status. Non-California residents were allocated to the control group (n = 241).

Interventions

A brief (6-minute) "explainer" video that provided an overview of mechanics and ethical principles underpinning the University of California Health SRAP, subtitled in 6 languages.

Main Outcomes and Measures

Self-reported survey assessment of knowledge of components of SRAP, graded as correct vs incorrect, and trust graded on a 10-point Likert scale. Anxiety about such policies was graded on a 10-point Likert scale with an a priori noninferiority margin of half of a standard deviation. Participants answered items at baseline and follow-up (approximately 10 weeks after baseline), with randomization occurring between administrations.

Results

Of 770 randomized participants with responses at both points, 566 (73.5%) were female, and the median (IQR) age was 43.5 (36-57) years. Intervention participants demonstrated improvement of 5.6 (95% CI, 4.8-6.4; P < .001) more correct knowledge items of 20 vs controls, as well as significant improvements in reported trust in fairness/consistency and honesty/transparency about SRAP implementation. There was no significant change in reported anxiety surrounding SRAP in either treatment or control groups.

Conclusions and Relevance

The trial found that a brief educational video is sufficient to explain complex ethical tenets and mechanics of SRAP and improved knowledge of such policies and trust in health systems to implement them equitably while not exacerbating anxiety about potential policy implications. This informs practice by providing a framework for educating people about the use of these policies during future situations necessitating crisis standards of care.

Trial Registration

ClinicalTrials.gov Identifier: NCT04373135.

Health Professional vs Layperson Values and Preferences on Scarce Resource Allocation

Importance

COVID-19 prompted rapid development of scarce resource allocation (SRA) policies to be implemented if demand eclipsed health systems' ability to provide critical care. While SRA policies follow general ethical frameworks, understanding priorities of those affected by policies and/or tasked with implementing them is critical.

Objective

To evaluate whether community members and health care profesionals (HCP) agree with SRA protocols at the University of California (UC).

Design, Setting, and Participants

This survey study used social media and community-partnered engagement to recruit participants to a web-based survey open to all participants aged older than 18 years who wished to enroll. This study was fielded between May and September 2020 and queried participants' values and preferences on draft SRA policy tenets. Participants were also encouraged to forward the survey to their networks for snowball sampling. Data were analyzed from July 2020 to January 2024.

Main Outcomes and Measures

Survey items assessed values and preferences, graded on Likert scales. Agreement was tabulated as difference in Likert points between expressed opinion and policy tenets. Descriptive statistics were tested for significance by HCP status. Free text responses were analyzed using applied rapid qualitative analysis.

Results

A total of 1545 participants aged older than 18 years (mean [SD] age 49 [16] years; 1149 female participants [74%], 478 health care practitioners [30%]) provided data on SRA values and preferences. Agreement with UC SRA policy as drafted was moderately high among respondents, ranging from 67% to 83% across domains. Higher agreement with the interim policy was observed for laypersons across all domains except health-related factors. HCPs agreed more strongly on average that resources should not be allocated to those less likely to survive (HCP mean, 3.70; 95% CI, 3.16-3.59; vs layperson mean, 3.38; 95% CI, 3.17-3.59; P = .002), and were more in favor of reallocating life support from patients less likely to those more likely to survive (HCP mean, 6.41; 95% CI, 6.15-6.67; vs layperson mean, 5.40; 95% CI, 5.23-5.58; P < .001). Transparency and trust building themes were common in free text responses and highly rated on scaled items.

Conclusions and Relevance

This survey of SRA policy values found moderate agreement with fundamental principles of such policies. Engagement with communities affected by SRA policy should continue in iterative refinement in preparation for future crises.

Assessing the early influence of COVID-19 in an analysis of the immediate implementation of Minimum Pricing for Alcohol on drinkers in Wales

Background: The Welsh Government has commissioned a number of projects to consider the influence their implementation of Minimum Pricing for Alcohol (MPA) legislation in March 2020 had on the alcohol consumption and related behaviours of drinkers. Given the MPA's overlap with the COVID-19 pandemic and its related lockdown measures and restrictions, this rapidly became a story about the early impact of COVID-19 as it did MPA. This paper captures the core thematic messages from this specific strand of work, and in doing so reflects on (1) how early experiences of COVID-19 and the first lockdown influenced consumption and purchasing of alcohol behaviours and, in turn, (2) how relevant the introduction of MPA was for any of these. Methods: Semi-structured interviews were conducted by telephone with 32 drinkers 9 months after the implementation of the legislation in March 2020. The sample was recruited from three sources: the National Survey for Wales; a third sector organisation offering housing support to the homeless; and through an online survey on MPA. Results: COVID-19 had more relevance than MPA to drinkers. Furthermore, when MPA did have an influence on their behaviour, it was felt most keenly by the harmful drinkers in the study. These drinkers described spending more on alcohol, switching to other potentially more harmful substances, such as crack cocaine and synthetic cannabinoids, and more involvement in acquisitive crime and begging after the price increase. While our results might be an early indication of the influence of MPA on harmful drinkers, the small sample of this group in our study limits the generalisability of the findings. Conclusion: To date, the implementation of MPA has had little influence on the drinking patterns or lives of the drinkers in our sample. It is important that future research examines the longer-term influences of MPA before any conclusions on its effectiveness can be drawn.

Tobacco consumption behavior change during the COVID-19 pandemic is associated with perceived COVID threat

Rationale

Tobacco use is a risk factor for COVID-19 adverse outcomes. Despite health implications, data conflict regarding COVID-19 and tobacco consumption. We present results from a survey of health behaviors during the pandemic to identify how COVID-19 influenced tobacco use.

Methods

A national internet-based survey was deployed between May-September 2020. We analyzed participants who reported current or former smoking. We tabulated change in tobacco use, whether changes related to COVID-19, and measures of anxiety, depression, and novel perceived COVID-19 threat scale. We employed multinomial logistic regression to determine associations between these items and tobacco consumption.

Results

We identified 500 respondents who reported ever smoking previously, 150 of which were currently smoking. Of 220 participants who reported any use of vapes, 110 were currently vaping. Increased perceived threat of COVID-19 was associated with both increased (aRRincrease 1.75, 95% CI [1.07-2.86], P = 0.03) and decreased (aRRdecrease 1.72 [1.04-2.85], P = 0.03) tobacco consumption relative to no change. There were no significant relationships found between perceived threat of COVID-19 and vaping behavior.

Conclusions

As perceived COVID-19 threat increased, people were more likely to increase or decrease their smoking than stay the same, even after controlling for anxiety and depression, both of which can affect smoking in either direction. Further study into motivators of increasing or decreasing affected tobacco consumption, and how barriers to care from safer-at-home policies and changes in care delivery moderate change in tobacco use will aid planning tobacco reduction interventions during the ongoing and future respiratory viral pandemics.