Racial Disparities-Associated COVID-19 Mortality among Minority Populations in the US

Influence of Medical Mistrust on Prevention Behavior and Decision-Making Among Minoritized Youth and Young Adults During the COVID-19 Pandemic

BACKGROUND

Medical mistrust (MM) is seen as a barrier to assessing healthcare needs and addressing health disparities; however, limited literature has focused on assessing MM for vulnerable populations, especially racial/ethnic minority and sexual/gender minority youth and young adults (YYA).

METHODS

Between February 2021 and March 2022, we conducted the Youth and Young Adults COVID-19 Study, a prospective cohort of minoritized YYA aged 14 to 24 years (n = 1027), within the United States and its territories. Participants were recruited through a combination of paid social media ads, outreach with organizations serving marginalized youth, and an existing registry, targeting racial and ethnic minority and LGBTQ + youth for a study on COVID-19 health behaviors. Multiple multinomial logistic regression models were developed to examine associations between demographics and three dimensions of MM including healthcare experience, government information, and scientific information.

RESULTS

Most participants were between the ages of 18 and 21 years (48.3%), identified as Hispanic (33.3%) or white (22.5%), and bisexual or pansexual (34.3%). Queer YYA had higher odds of reporting worse personal healthcare experiences than their straight peers. The odds of gay/lesbian YYA that reported somewhat or extreme trust in doctor's sources were two times higher than their straight peers. Except for those who identified as Asian, racial/ethnic minority YYA were less likely to report somewhat or extreme trust in the CDC's general information or its COVID-19 data than white YYA. Transgender and gender diverse YYA were more than twice as likely to report being very or extremely influenced by statistics of the dangers of COVID-19 than cisgender YYA.

CONCLUSIONS

Our study indicated the importance of incorporating marginalized identities into the assessment of medical mistrust to better understand YYA's health prevention and treatment behaviors and to develop public health prevention and treatment strategies, especially for minoritized communities.

Health Equity and Access to COVID-19 Treatments Available through Emergency Use Authorizations

Understanding and evaluating equity in access to care is a critical component to ensuring health equity for all individuals. During the COVID-19 pandemic, the U.S. Food and Drug Administration made unprecedented use of its regulatory authority by authorizing the use of unapproved products through Emergency Use Authorizations (EUAs). We use data from the U.S. National COVID Cohort Collaborative (N3C) to understand how access to therapeutic products authorized under EUAs has varied across COVID-19 patients and over time. We find that Black patients were more likely to receive early EUA drugs while White patients were more likely to receive monoclonal antibodies. Male patients were more likely to receive any EUA drug than Female patients. Patients in Metropolitan areas were more likely to receive EUA drugs than patients in other regions. Additionally, differences in the rates of exposure to EUA drugs by gender, rural-urban classification, and length of stay decreased over time while differences by race and ethnicity have generally persisted. Our project identifies inequities in the rate of access to EUA drugs across patient groups that can inform policy makers in future planning and decision making.

Anxiety sensitivity and COVID-19 mental health, fatigue, and well-being: a longitudinal examination among adults from the United States during March-October 2020

There is widespread empirical evidence that the COVID-19 pandemic contributed to elevated risk of mental and physical health symptoms and decreased quality of life. The present investigation sought to examine if individual differences in anxiety sensitivity was associated with mental health, psychosomatic, and well-being among a sample of US adults during a 6-month period early in the COVID-19 pandemic. Employing longitudinal research methodology, we tested the hypothesis that the anxiety sensitivity global factor would be related to increased risk of anxiety, depression, fatigue, and lower well-being. Secondary analyses evaluated the lower order anxiety sensitivity factors for the same criterion variables. The sample consisted of 778 participants with an average age of 37.96 (SD = 11.81; range 18-73). Results indicated that, as hypothesized, anxiety sensitivity was associated with increased risk for more severe anxiety, depression, fatigue, and lesser well-being; the observed effects of anxiety sensitivity were relatively robust and evident in adjusted models that controlled for numerous theoretically and clinically relevant factors (e.g. perceived health status). Overall, these results suggest that pandemic functioning could likely be improved via interventions that target elevated anxiety sensitivity as a vulnerability factor for a broad range of aversive psychosomatic symptoms and personal well-being.

COVID-19 Pandemic as an Equalizer of the Health Returns of Educational Attainment for Black and White Americans

BACKGROUND

COVID-19 pandemic has immensely impacted the social and personal lives of individuals around the globe. Marginalized-related diminished returns (MDRs) theory suggests that educational attainment shows a weaker protective effect for health and behavioral outcomes for Black individuals compared to White individuals. Previous studies conducted before the COVID-19 pandemic demonstrated diminished returns of educational attainment for Black individuals compared to White individuals.

OBJECTIVES

The study has three objectives: First, to test the association between educational attainment and cigarette smoking, e-cigarette vaping, presence of chronic medical conditions (CMC), self-rated health (SRH), depressive symptoms, and obesity; second, to explore racial differences in these associations in the USA during the COVID-19 pandemic; and third, to compare the interaction of race and return of educational attainment pre- and post-COVID-19 pandemic.

METHODS

This study utilized data from the Health Information National Trends Survey (HINTS) 2020. Total sample included 1313 adult American; among them, 77.4% (n = 1017) were non-Hispanic White, and 22.6% (n = 296) were non-Hispanic Black. Educational attainment was the independent variable operationalized as years of education. The main outcomes were cigarette smoking, e-cigarette vaping, CMC, SRH, depressive symptoms, and obesity. Age, gender, and baseline physical health were covariates. Race/ethnicity was an effect modifier.

RESULTS

Educational attainment was significantly associated with lower CMC, SRH, depressive symptoms, obesity, cigarette smoking, and e-cigarette vaping. Educational attainment did not show a significant interaction with race on any of our outcomes, suggesting that the health returns of education is similar between non-Hispanic White and non-Hispanic Black individuals.

CONCLUSION

COVID-19 may have operated as an equalizer of the returns of educational attainment. This observation may be because White may have more to lose; Black communities may be more resilient or have economic and social policies that buffered unemployment and poverty regardless of historical anti-Black oppression.

Effects of Covid-19-related anxiety on overeating and weight gain in a diverse college sample

The outbreak of the Covid-19 pandemic has been linked with caloric overeating and weight gain. We employed a mediation analysis to determine whether pandemic-associated overeating was a direct effect of Covid-19-related anxiety (affect regulation theory) or mediated by a coping mechanism of escape eating (escape theory). A diverse pool of college students participated in a repeated cross-sectional study during three separate waves: May 2021 (wave 1, n = 349), December 2021 (wave 2, n = 253), and March 2022 (wave 3, n = 132). The results revealed a significant indirect effect of Covid-19-related anxiety on high-caloric overeating mediated by escape eating, but no direct path between Covid-19-related anxiety and caloric overeating. Analysis of racial/ethnic status uncovered significantly greater Covid-weight gain in Hispanic participants compared with White, Black, and Asian participants. Our results suggest that Covid-19 weight gain is a byproduct of a mediated escape mechanism differentially affecting racial/ethnic groups.

One size doesn't fit all: methodological reflections in conducting community-based behavioural science research to tailor COVID-19 vaccination initiatives for public health priority populations

BACKGROUND

Promoting the uptake of vaccination for infectious diseases such as COVID-19 remains a global challenge, necessitating collaborative efforts between public health units (PHUs) and communities. Applied behavioural science can play a crucial role in supporting PHUs' response by providing insights into human behaviour and informing tailored strategies to enhance vaccination uptake. Community engagement can help broaden the reach of behavioural science research by involving a more diverse range of populations and ensuring that strategies better represent the needs of specific communities. We developed and applied an approach to conducting community-based behavioural science research with ethnically and socioeconomically diverse populations to guide PHUs in tailoring their strategies to promote COVID-19 vaccination. This paper presents the community engagement methodology and the lessons learned in applying the methodology.

METHODS

The community engagement methodology was developed based on integrated knowledge translation (iKT) and community-based participatory research (CBPR) principles. The study involved collaboration with PHUs and local communities in Ontario, Canada to identify priority groups for COVID-19 vaccination, understand factors influencing vaccine uptake and co-design strategies tailored to each community to promote vaccination. Community engagement was conducted across three large urban regions with individuals from Eastern European communities, African, Black, and Caribbean communities and low socioeconomic neighbourhoods.

RESULTS

We developed and applied a seven-step methodology for conducting community-based behavioural science research: (1) aligning goals with system-level partners; (2) engaging with PHUs to understand priorities; (3) understanding community strengths and dynamics; (4) building relationships with each community; (5) establishing partnerships (community advisory groups); (6) involving community members in the research process; and (7) feeding back and interpreting research findings. Research partnerships were successfully established with members of prioritized communities, enabling recruitment of participants for theory-informed behavioural science interviews, interpretation of findings, and co-design of targeted recommendations for each PHU to improve COVID-19 vaccination uptake. Lessons learned include the importance of cultural sensitivity and awareness of sociopolitical context in tailoring community engagement, being agile to address the diverse and evolving priorities of PHUs, and building trust to achieve effective community engagement.

CONCLUSION

Effective community engagement in behavioural science research can lead to more inclusive and representative research. The community engagement approach developed and applied in this study acknowledges the diversity of communities, recognizes the central role of PHUs, and can help in addressing complex public health challenges.

Mobilizing faith-based COVID-19 health ambassadors to address COVID-19 health disparities among African American older adults in under-resourced communities: A hybrid, community-based participatory intervention

INTRODUCTION

The COVID-19 pandemic disproportionately affected older adults, particularly those with pre-existing chronic health conditions. To address the health disparity and challenges faced by under-resourced African American older adults in South Los Angeles during this period, we implemented a hybrid (virtual/in-person), pre-post, community-based participatory intervention research project utilizing a faith-based lay health advisor model (COVID-19 Health Ambassador Program (CHAP)). We recruited COVID-19 Health Ambassadors (CHAs) and African American older adults (participants) from faith-based organizations who partook in CHA-led meetings and follow-ups that educated and supported the participants. This paper seeks to evaluate this intervention's implementation using the Consolidated Framework for Implementation Research (CFIR) as a reporting tool with an emphasis on fidelity, challenges, and adaptations based on data collected via stakeholder interviews and surveys.

RESULTS

CHAP was delivered to 152 participants by 19 CHAs from 17 faith-based organizations. CHAs assisted with chronic disease management, resolved medication-related challenges, encouraged COVID-19 vaccination, reduced psychological stress and addressed healthcare avoidance behaviors such as COVID-19 vaccine hesitancy among the participants. Challenges encountered include ensuring participant engagement and retention in the virtual format and addressing technological barriers for CHAs and participants. Adaptations made to better suit the needs of participants included providing communication tools and additional training to CHAs to improve their proficiency in using virtual platforms in addition to adapting scientific/educational materials to suit our participants' diverse cultural and linguistic needs.

CONCLUSION

The community-centered hybrid approach in addition to our partnership with faith-based organizations and their respective COVID-19 health ambassadors proved to be essential in assisting underserved African American older adults manage chronic health conditions and address community-wide health disparities during the COVID-19 pandemic. Adaptability, cultural sensitivity, and teamwork are key to implementing health interventions especially in underserved populations.

The next generation of developmental psychopathology research: Including broader perspectives and becoming more precise

The current Special Issue marks a major milestone in the history of developmental psychopathology; as the final issue edited by Cicchetti, we have an opportunity to reflect on the remarkable progress of the discipline across the last four decades, as well as challenges and future directions for the field. With contemporary issues in mind, including rising rates of psychopathology, health disparities, and international conflict, as well as rapid growth and accessibility of digital and mobile technologies, the discipline of developmental psychopathology is poised to advance multidisciplinary, developmentally- and contextually- informed research, and to make substantial progress in supporting the healthy development of individuals around the world. We highlight key future directions and challenges for the next generation of developmental psychopathology research including further investigation of culture at multiple levels of analysis, incorporation of macro-level influences into developmental psychopathology research, methods advances to address heterogeneity in translational research, precision mental health, and the extension of developmental psychopathology research across the lifespan.

The impact of COVID-19 on hospitalizations that underwent endoscopic retrograde cholangiopancreatography in the United States

BACKGROUND/OBJECTIVES

COVID-19 impacts technical success of endoscopic retrograde cholangiopancreatography (ERCP). In this study, we aimed to assess the influence of COVID-19 on hospitalizations that underwent ERCP.

METHODS

We identified all adult COVID-19 and non-COVID-19 hospitalizations that underwent ERCP in the United States using the National Inpatient Sample for 2020. Hospitalization characteristics, clinical outcomes, and complications were compared between the two groups.

RESULTS

In 2020, 2015 COVID-19 and 203,094 non-COVID-19 hospitalizations underwent ERCP. The COVID-19 cohort had a higher mean age (60.3 vs 55.6 years, p < 0.001) and a higher proportion of Blacks and Hispanics compared to the non-COVID-19 cohort. After adjusting for confounders, the COVID-19 cohort had higher all-cause inpatient mortality (4.77 vs 1.45%, aOR 4.09, 95% CI 2.50-6.69, p < 0.001), mean length of stay (LOS) [10.19 vs 5.94 days, mean difference: 3.88, 95% CI 2.68-5.07, p < 0.001] and mean total hospital charges (THC) [$152,933 vs $96,398, mean difference: 46,367, 95% CI 21,776-70,957, p < 0.001] compared to the non-COVID-19 cohort. Increasing age, higher Charlson Comorbidity Index, and post-ERCP pancreatitis were identified to be independent predictors of inpatient mortality for COVID-19 hospitalizations that underwent ERCP. Furthermore, the COVID-19 cohort had higher odds of developing post-ERCP pancreatitis (PEP) (11.55 vs 7.05%, aOR 1.64, 95% CI 1.19-2.25, p = 0.002) compared to the non-COVID-19 cohort, after adjusting for confounders. However, there was no statistical difference in the rates of bowel perforations and post-ERCP hemorrhage between the two groups.

CONCLUSION

COVID-19 hospitalizations that underwent ERCP had higher inpatient mortality, mean LOS, mean THC, and odds of developing PEP compared to the non-COVID-19 cohort.

CLINICAL TRIAL REGISTRATION

This study is not a part of a clinical trial.

The Role of Place in Person- and Family-Oriented Long-Term Services and Supports

Policy Points Little attention to date has been directed at examining how the long-term services and supports (LTSS) environmental context affects the health and well-being of older adults with disabilities. We develop a conceptual framework identifying environmental domains that contribute to LTSS use, care quality, and care experiences. We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain; increased neighborhood social and economic deprivation are highly associated with experiencing adverse consequences due to unmet need, whereas availability and generosity of the health care and social services delivery environment are inversely associated with participation restrictions in valued activities. Policies targeting local and state-level LTSS-relevant environmental characteristics stand to improve the health and well-being of older adults with disabilities, particularly as it relates to adverse consequences due to unmet need and participation restrictions.

CONTEXT

Long-term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person-reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them.

METHODS

We advance a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. We assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status.

FINDINGS

We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well-being. Observed relationships between measures of LTSS-relevant environmental characteristics and care experiences were generally held in directionality but were attenuated for key subpopulations.

CONCLUSIONS

We present a framework and analyses describing the variable relationships between LTSS-relevant environmental factors and person-reported care experiences. LTSS-relevant environmental characteristics are differentially relevant to the care experiences of older adults with disabilities. Greater attention should be devoted to strengthening state- and community-based policies and practices that support aging in place.

The impact of air pollution on neurocognitive development: Adverse effects and health disparities

Air pollution is recognized as a major public health concern. The number of deaths related to ambient air pollution has increased in recent years and is projected to continue rising. Additionally, both short- and long-term air pollution exposure has been linked with deleterious effects on neurocognitive function and development. While air pollution poses as a threat to everyone, people of color and individuals of lower socioeconomic status are often exposed to elevated levels of air pollution as a function of systemic racism and classism. Further, given additional disparities in access to healthcare and other compounding stressors, adverse effects of air pollution on neurocognitive health are exacerbated among individuals who hold marginalized identities-making effects both less likely to be detected and treated. This review examines evidence of the effects of air pollution on neurocognitive development across the lifespan and incorporates an environmental justice perspective to highlight disparities in air pollution exposure across race and socioeconomic status. Last, upon the reviewed evidence, limitations of past research and recommendations for policy are discussed.

COVID-19 Case, Death, and Vaccination Rate Disparities by Race and Ethnicity in Virginia

This paper tracks trends in COVID-19 case, death, and vaccination rate disparities by race and ethnicity in Virginia during the COVID-19 pandemic. COVID-19 case, death, and vaccination rates were obtained from electronic state health department records from March 2020 to February 2022. Rate ratios were then utilized to quantify racial and ethnic disparities for several time periods during the pandemic. The Hispanic population had the highest COVID-19 case and age-adjusted death rates, and the lowest vaccination rates at the beginning of the pandemic in Virginia. These disparities resolved later in the pandemic. COVID-19 case and death rates among the Black population were also higher than those of the White population and these disparities remained throughout the pandemic. Racial and ethnic disparities changed over time in Virginia as vaccination coverage and public health policies evolved. Year 2 of the analysis saw lower case and death rates, and higher vaccination rates for non-White populations in Virginia. Public health strategies need to be addressed during the pandemic and developed before the next pandemic to ensure that large racial and ethnic disparities are not again present at the outset.

Factors Influencing COVID-19 Vaccine Uptake among Spanish-Speaking Pregnant People

The coronavirus disease 2019 (COVID-19) pandemic exposed the vulnerability of pregnant women to excess morbidity and mortality, as well as the disproportionate disease burden in certain racial, ethnic, and sociodemographic groups. Vaccine hesitancy represents a major threat to public health, and crafting messages that reach vulnerable groups and address their intersectionality remains a weakness for pandemic preparedness. We sought to investigate factors that influenced vaccine acceptance and social media ad response in a mixed-methods study of Spanish-speaking women living in the rural Western United States who were pregnant or recently pregnant between November 2022 and June 2023. Direct interviews were translated, transcribed, and coded, while the ad ratings were analyzed using linear mixed models. Participants most favorably rated ads that featured doctors and text-heavy content describing benefits of vaccination. Qualitative data illustrated how information from trusted medical providers along with generational and cultural history of vaccine acceptance positively impacted perspectives on vaccination. Immigration status had varying influences on vaccination perspectives. Future vaccination campaigns targeting Spanish-speaking pregnant individuals in rural communities should use medical providers as ad messengers and dispel fears that vaccine acceptance may lead to problems with immigration status.

Delivery of biologics: Topical administration

Biologics are unaffordable to a large majority of the global population because of prohibitively expensive fermentation systems, purification and the requirement for cold chain for storage and transportation. Limitations of current production and delivery systems of biologics were evident during the recent pandemic when <2.5% of vaccines produced were available to low-income countries and ∼19 million doses were discarded in Africa due to lack of cold-chain infrastructure. Among FDA-approved biologics since 2015, >90% are delivered using invasive methods. While oral or topical drugs are highly preferred by patients because of their affordability and convenience, only two oral drugs have been approved by FDA since 2015. A newly launched oral biologic costs only ∼3% of the average cost of injectable biologics because of the simplified regulatory approval process by elimination of prohibitively expensive fermentation, purification, cold storage/transportation. In addition, the cost of developing a new biologic injectable product (∼$2.5 billion) has been dramatically reduced through oral or topical delivery. Topical delivery has the unique advantage of targeted delivery of high concentration protein drugs, without getting diluted in circulating blood. However, only very few topical drugs have been approved by the FDA. Therefore, this review highlights recent advances in oral or topical delivery of proteins at early or advanced stages of human clinical trials using chewing gums, patches or sprays, or nucleic acid drugs directly, or in combination with, nanoparticles and offers future directions.

Gut Microbiome and Lipidome Signatures in Irritable Bowel Syndrome Patients from a Low-Income, Food-Desert Area: A Pilot Study

Irritable bowel syndrome (IBS) is a common gastroenterological disorder with triggers such as fructose. We showed that our IBS patients suffering from socioeconomic challenges have a significantly high consumption of high-fructose corn syrup (HFCS). Here, we characterize gut microbial dysbiosis and fatty acid changes, with respect to IBS, HFCS consumption, and socioeconomic factors. Fecal samples from IBS patients and healthy controls were subjected to microbiome and lipidome analyses. We assessed phylogenetic diversity and community composition of the microbiomes, and used linear discriminant analysis effect size (LEfSe), analysis of compositions of microbiomes (ANCOM) on highly co-occurring subcommunities (modules), least absolute shrinkage and selection operator (LASSO) on phylogenetic isometric log-ratio transformed (PhILR) taxon abundances to identify differentially abundant taxa. Based on a Procrustes randomization test, the microbiome and lipidome datasets correlated significantly (p = 0.002). Alpha diversity correlated with economic factors (p < 0.001). Multiple subsets of the phylogenetic tree were associated with HFCS consumption (p < 0.001). In IBS patients, relative abundances of potentially beneficial bacteria such as Monoglobaceae, Lachnospiraceae, and Ruminococcaceae were lower (p = 0.007), and Eisenbergiella, associated with inflammatory disorders, was higher. In IBS patients, certain saturated fatty acids were higher and unsaturated fatty acids were lower (p < 0.05). Our study aims first to underscore the influence of HFCS consumption and socioeconomic factors on IBS pathophysiology, and provides new insights that inform patient care.

COVID-19-Induced Inequalities and Mental Health: Testing the Moderating Roles of Self-rated Health and Race/Ethnicity

This study examines the relationship among COVID-19-induced social, economic, and educational inequalities on mental health (i.e., anxiety and depression). This study also examines if levels of self-rated health (SRH) moderate the relationship (i.e., COVID-induced inequalities [CII] and mental health), as well as examines the racial/ethnic group differences among 567 young adults in the mid-Atlantic region. Using a moderation model, results indicate that CII were significantly related to depression (b = .221, t(554) = 4.59, p = .000) and anxiety (b = .140, t(555) = 3.23, p = .001). SRH and race/ethnicity also moderated both relationships. At above-average SRH (i.e., moderator), higher CII were also significantly related to lower anxiety (Asian young adults only) and lower depression (Asian and White young adults only). Overall, SRH and race/ethnicity are important factors in the mental health impact of COVID-19 on young adults.

Parent-reported provider recommendation of HPV vaccination among minority adolescents before and during the COVID-19 pandemic: Findings from the National Immunization Survey-Teen, 2019-2021

Provider recommendation of human papillomavirus (HPV) vaccination among adolescents has steadily improved over the years, however, limited research has been conducted to examine if the COVID-19 pandemic disrupted this positive trend in parent-reported provider recommendation among minority adolescents. Therefore, we conducted the present study to determine if there is an association between the pandemic and parent-reported provider recommendation of HPV vaccine among non-Hispanic black and Hispanic adolescents. We also examined whether any changes in parent-reported provider recommendation in the years 2019, 2020, and 2021 differed by race or ethnicity. Using a cross-sectional design to examine data from the National Immunization Survey-Teen (2019-2021), a moderation analysis and logistic regression analysis were performed to model race-specific variation in parent-reported provider recommendation (n = 50,739). We found that Hispanic parents had lower odds (aOR = 0.80 [0.71, 0.91]) of reporting receiving a recommendation compared to non-Hispanic white parents. We also found that the odds of parent-reported provider recommendation were higher in 2020 (aOR = 1.15 [1.03-1.29]) than in 2019. Other variables-age, region, sex, health insurance status, and poverty status-were all associated with parent-reported provider recommendation. These findings demonstrated that the pandemic may not have triggered any race-related gap in the recommendation of HPV vaccines, however, more pandemic-resilient public health efforts are needed to improve parent and provider communication regarding HPV vaccination of adolescents.

A national examination of discrimination, resilience, and depressive symptoms during the COVID-19 pandemic: the All of Us Research Program

Objective

To examine the impact of resilience on the association between discrimination and trajectories of depressive symptoms during the COVID-19 pandemic across racial and ethnic groups.

Methods

Data were drawn from 5 waves of the All of Us Research Program's survey on the impact of COVID-19 on the lives of American adults. Linear mixed-effects models were fitted to assess the association between discrimination exposure throughout the pandemic and depressive symptoms over time. An interaction term was introduced between resilience and discrimination exposure to assess if resilience buffered the association between discrimination and depressive symptoms over time. Race-stratified linear mixed-effects models examined racial/ethnic differences in the association between resilience, discrimination, and depressive symptoms over time.

Results

Fifty-one thousand nine hundred fifty-eight participants completed surveys between May and December of 2020. Results indicated that exposure to more discrimination was associated with increasing trajectories of depressive symptoms over time (b = 0.48, p < 0.001). However, resilience moderated the association between discrimination and well-being over time such that higher resilience mitigated the detrimental effect of experiencing discrimination on depressive symptoms across time (b = -0.02, p < 0.001).

Conclusion

Identifying protective features such as resilience can promote the development of culturally tailored interventions to address mental health in the context of discrimination.

Prevalence and Predictors of Long COVID in Patients Accessing a National Digital Mental Health Service

MindSpot is a national mental health service that provides assessments and treatment to Australian adults online or via telephone. Since the start of 2020, questions related to the mental health impacts of COVID-19 have been routinely administered. The objective of the current study is to report the prevalence and predictors of self-reported "long COVID" in patients completing an assessment at the MindSpot Clinic between 5 September 2022 and 7 May 2023 (n = 17,909). Consistent with the World Health Organization definition, we defined long COVID as the occurrence of ongoing physical or mental health symptoms three months after a COVID-19 infection. We conducted a descriptive univariate analysis of patients who reported: no COVID-19 diagnosis (n = 6151); a current or recent (within 3 months) COVID-19 infection (n = 2417); no symptoms three months post-COVID-19 infection (n = 7468); or COVID-related symptoms at least three months post-infection (n = 1873). Multivariate logistic regression was then used to compare patients with and without symptoms three months post-COVID to identify potential predictors for long COVID. The prevalence of long COVID was 10% of the total sample (1873/17909). Patients reporting symptoms associated with long COVID were older, more likely to be female, and more likely to be depressed and report a reduced ability to perform their usual tasks. Sociodemographic factors, including cultural background, education, and employment, were examined. These results provide evidence of the significant prevalence of symptoms of long COVID in people using a national digital mental health service. Reporting outcomes in an Australian context and in specific sub-populations is important for public health planning and for supporting patients.

The intersectionality-based policy analysis framework: demonstrating utility through application to the pre-vaccine U.S. COVID-19 policy response

Few guidelines exist for the development of socially responsible health policy, and frameworks that balance considerations of data, strategy, and equity are limited. The Intersectionality-Based Policy Analysis (IBPA) framework utilizes a structured questioning process to consider problems and policies, while applying guiding principles of equity, social justice, power, intersectionality, and diversity of knowledge and input. We apply the IBPA framework's guiding principles and questions to the pre-vaccine U.S. COVID-19 policy response. Results suggest the IBPA approach is a promising tool for integrating equity considerations in the development of policy solutions to urgent US public health challenges, including the COVID-19 pandemic. We found the IBPA framework particularly useful in differentiating between problems or policies and representations of problems or policies, and in considering the impacts of representations on different groups. The explicit inclusion of short-, medium- and long-term solutions is a reminder of the importance of holding a long-term vision of the equitable public health system we want while working towards immediate change.

Understanding the efficacy of wastewater surveillance for SARS-CoV-2 in two diverse communities

During the COVID-19 pandemic, wastewater-based surveillance has been shown to be a useful tool for monitoring the spread of disease in communities and the emergence of new viral variants of concern. As the pandemic enters its fourth year and clinical testing has declined, wastewater offers a consistent non-intrusive way to monitor community health in the long term. This study sought to understand how accurately wastewater monitoring represented the actual burden of disease between communities. Two communities varying in size and demographics in Michigan were monitored for SARS-CoV-2 in wastewater between March of 2020 and February of 2022. Additionally, each community was monitored for SARS-CoV-2 variants of concern from December 2020 to February 2022. Wastewater results were compared with zipcode and county level COVID-19 case data to determine which scope of clinical surveillance was most correlated with wastewater loading. Pearson r correlations were highest in the smaller of the two communities (population of 25,000) for N1 GC/person/day with zipcode level case data, and date of the onset of symptoms (r = 0.81). A clear difference was seen with more cases and virus signals in the wastewater of the larger community (population 110,000) when examined based on vaccine status, which reached only 50%. While wastewater levels of SARS-CoV-2 had a lower correlation to cases in the larger community, the information was still seen as valuable in supporting public health actions and further data including vaccination status should be examined in the future.

Addressing Racial Capitalism's Impact on Black Essential Workers During the COVID-19 Pandemic: Policy Recommendations

Black Americans are more likely to be essential workers due to racial capitalism. Because of the COVID-19 pandemic, essential workers are less able to adhere to social distancing and stay-at-home guidelines due to the nature of their work, because they are more likely to occupy crowded households, and are more likely to possess pre-existing health conditions. To assist Black essential workers in preventing infection or reducing the intensity of symptoms if contracted, vaccination against the virus is essential. Unfortunately, Black essential workers face considerable barriers to accessing vaccinations and are hesitant to receive the vaccine due to widespread misinformation and justified historical mistrust of the American medical system. The purpose of this work is to (1) describe the disproportionate impact of COVID-19 on Black essential workers due to racial capitalism, (2) outline the socioeconomic and racial barriers related to vaccination within this population, and (3) to suggest policy-related approaches to facilitate vaccination such as access to on-site vaccination opportunities, the funding of community outreach efforts, and the mandating of increased employee benefits.

Supporting Faith-Based Communities Through and Beyond the Pandemic

The COVID-19 pandemic brought widespread and notable effects to the physical and mental health of communities across New York City with disproportionate suffering Black/African American and Hispanic/Latino communities alongside additional stressors such as racism and economic hardship. This report describes the adaptation of a previously successful evidence-based community engagement health education program for the deployment of resilience promoting workshop program in faith-based organizations in BIPOC communities in New York City. From June 2021 to June 2022, nine faith-based organizations implemented 58 workshops to 1,101 non-unique workshop participants. Most of the workshops were delivered online with more women (N = 803) than men (N = 298) participating. All organizations completed the full curriculum; the workshop focused on self-care and physical fitness was repeated most frequently (N = 13). Participants in the workshops ranged from 4 to 73 per meeting and were largely female. The Building Community Resilience Project is an easy and effective way to modify an existing, evidence-based community health education program to address new and relevant health needs such as resilience and stress amidst the COVID-19 pandemic among faith communities serving BIPOC populations. More research is needed regarding the impact of the workshops as well as adaptability for other faith traditions.

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

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

On the use of aspect-based sentiment analysis of Twitter data to explore the experiences of African Americans during COVID-19

According to data from the U.S. Center for Disease Control and Prevention, as of June 2020, a significant number of African Americans had been infected with the coronavirus disease, experiencing disproportionately higher death rates compared to other demographic groups. These disparities highlight the urgent need to examine the experiences, behaviors, and opinions of the African American population in relation to the COVID-19 pandemic. By understanding their unique challenges in navigating matters of health and well-being, we can work towards promoting health equity, eliminating disparities, and addressing persistent barriers to care. Since Twitter data has shown significant promise as a representation of human behavior and for opinion mining, this study leverages Twitter data published in 2020 to characterize the pandemic-related experiences of the United States' African American population using aspect-based sentiment analysis. Sentiment analysis is a common task in natural language processing that identifies the emotional tone (i.e., positive, negative, or neutral) of a text sample. Aspect-based sentiment analysis increases the granularity of sentiment analysis by also extracting the aspect for which sentiment is expressed. We developed a machine learning pipeline consisting of image and language-based classification models to filter out tweets not related to COVID-19 and those unlikely published by African American Twitter subscribers, leading to an analysis of nearly 4 million tweets. Overall, our results show that the majority of tweets had a negative tone, and that the days with larger numbers of published tweets often coincided with major U.S. events related to the pandemic as suggested by major news headlines (e.g., vaccine rollout). We also show how word usage evolved throughout the year (e.g., outbreak to pandemic and coronavirus to covid). This work also points to important issues like food insecurity and vaccine hesitation, along with exposing semantic relationships between words, such as covid and exhausted. As such, this work furthers understanding of how the nationwide progression of the pandemic may have impacted the narratives of African American Twitter users.

Association Between Racial Segregation and COVID-19 Vaccination Rates

OBJECTIVE

To examine the association between county-level Black-White residential segregation and COVID-19 vaccination rates.

DESIGN

Observational cross-sectional study using multivariable generalized linear models with state fixed effects to estimate the average marginal effects of segregation on vaccination rates.

SETTING

National analysis of county-level vaccination rates.

MAIN OUTCOME MEASURE

County-level vaccination rates across the United States.

RESULTS

We found an overall positive association between county-level segregation and the proportion population fully vaccinated, with a 6.8, 11.3, and 12.8 percentage point increase in the proportion fully vaccinated by May 3, September 27, and December 6, 2021, respectively. Effects were muted after adjustment for sociodemographic variables. Furthermore, in analyses including an interaction term between the county proportion of Black residents and the county dissimilarity index, the association between segregation and vaccination is positive in counties with a lower proportion of Black residents (ie, 5%) but negative in counties with the highest proportions of Black residents (ie, 70%).

CONCLUSIONS

Findings highlight the importance of methodological decisions when modeling disparities in COVID-19 vaccinations. Researchers should consider mediating and moderating factors and examine interaction effects and stratified analyses taking racial group distributions into account. Results can inform policies around the prioritization of vaccine distribution and outreach.

Active Medical Learner Engagement Results in the Discovery That One Size Does Not Fit All in Overcoming COVID-19 Vaccine Hesitancy

Vaccine hesitancy is an ongoing public health concern defined as the refusal of a vaccine that is readily available. Therefore, we developed a project to explore why patients in a safety net medical center were hesitant or refused the COVID-19 vaccine. The project was conducted by healthcare learners to promote "learning by doing". Responses were collected through a previously developed and ongoing survey among both hospitalized and ambulatory patients that had no previous history of COVID-19 infection, were currently infected, or had recovered from COVID-19. Results were analyzed using a priori power analysis and Chi-squared test. We discovered that different self-reported ethnic groups had different reasons for vaccine hesitancy; specifically, 69% of Black/African American respondents stated that their main reason for hesitancy was vaccine safety compared to 13.9% of non-Hispanic Whites (p = 0.005). Furthermore, our cohort was significantly more likely to disagree rather than agree with the statement: "getting vaccinated is important for the health of others in my community"(p = 0.016). The learners discovered that a more specific approach to vaccine education would be required to understand and overcome vaccine hesitancy in our cohort of socioeconomic and ethnically diverse groups.

Outcomes of COVID-19 hospitalizations in patients with sickle cell disease: A nationwide analysis

INTRODUCTION

There is a paucity of data on the outcomes of coronavirus disease 2019 (COVID-19) in patients with sickle cell disease (SCD) in the United States. We examined the outcomes of patients with COVID-19 and SCD.

METHODS

We utilized the National Inpatient Sample (NIS) to identify the data of patients diagnosed with COVID-19 and SCD in 2020 using the International Classification of Disease, Tenth Revision codes. In-hospital outcomes (invasive mechanical ventilation and mortality) were compared between SCD and non-SCD groups.

RESULTS

Of the 1 057 550 COVID-19 hospitalizations, 2870 (0.3%) had SCD. The median age of the SCD group was 42 (IQR: 31) vs. 66 (IQR: 23) in the non-SCD group (p < .0001). Patients with SCD were likely to be females (62.02% vs. 37.98%, p < .0001), Blacks (87.81% vs. 12.19%, p < .0001), and in the lowest income quartile (50.62% vs. 11.15%, p < .0001). There was no difference in the outcomes between the two groups. There were increased odds of invasive mechanical ventilation and in-hospital mortality in COVID-19 in Asians, Hispanics, Native Americans, and Blacks (except for in-hospital mortality) compared to Whites.

CONCLUSION

In-hospital mortality and invasive mechanical ventilation outcomes in SCD are comparable to that in non-SCD patients hospitalized with COVID-19.

Associations of Combustible Cigarette, Electronic Cigarette, and Dual Use With COVID Infection and Severity in the U.S.: A Cross-sectional Analysis of the 2021 National Health Information Survey

Given the potential respiratory health risks, the association of COVID infection and the use of combustible cigarettes, electronic nicotine delivery systems (ENDS), and concurrent dual use is a priority for public health. Many published reports have not accounted for known covarying factors. This study sought to calculate adjusted odds ratios for self-reported COVID infection and disease severity as a function of smoking and ENDS use, while accounting for factors known to influence COVID infection and disease severity (i.e., age, sex, race and ethnicity, socioeconomic status and educational attainment, rural or urban environment, self-reported diabetes, COPD, coronary heart disease, and obesity status). Data from the 2021 U.S. National Health Interview Survey, a cross-sectional questionnaire design, were used to calculate both unadjusted and adjusted odds ratios for self-reported COVID infection and severity of symptoms. Results indicate that combustible cigarette use is associated with a lower likelihood of self-reported COVID infection relative to non-use of tobacco products (AOR = .64; 95% CI [.55, .74]), whereas ENDS use is associated with a higher likelihood of self-reported COVID infection (AOR = 1.30; 95% CI [1.04, 1.63]). There was no significant difference in COVID infection among dual users (ENDS and combustible use) when compared with non-users. Adjusting for covarying factors did not substantially change the results. There were no significant differences in COVID disease severity between those of varying smoking status. Future research should examine the relationship between smoking status and COVID infection and disease severity utilizing longitudinal study designs and non-self-report measures of smoking status (e.g., the biomarker cotinine), COVID infection (e.g., positive tests), and disease severity (e.g., hospitalizations, ventilator assistance, mortality, and ongoing symptoms of long COVID).

Cultural Competence Guides for COVID-19 Messaging in Hispanic Communities

PURPOSE

The Rio Grande Valley in South Texas comprises 5% percent of Texas's population yet 17%of Texas's COVID-19 deaths. We aimed to address underlying mistrust and systemic racism in our Hispanic community that contributes to health inequities by developing a cultural competence guide for public health messaging.

METHODS

We employed a mixed method design (e.g., focus groups, surveys, interviews) to develop and implement a cultural competence guide in an iterative community-informed process. We created a general cultural competence guide, one for the Hispanic community and one for the hard-of-hearing community.

RESULTS

Our cultural competence guides provide an interpretation as to whether the message is culturally competent or requires revisions. The guides have the following five categories: content and clarity, emotions and values, audience and inclusivity, call to action, and gestalt.

CONCLUSIONS

The Hispanic community needs more culturally competent public health messaging to address a key root cause of health inequities surrounding COVID-19. Our novel, concise guides can help organizations and individuals seeking to create culturally sensitive and, therefore, more effective public health messaging for Hispanic or deaf and hard-of-hearing communities.

The COVID-19 pandemic and male sex workers who have sex with men: associations between age and race and advertising for work in 2019-2021

Despite government-mandated restrictions on business and social activities worldwide, some sex workers continued to see clients in person throughout the COVID-19 pandemic. To better understand this behaviour, we compiled publicly available data from Internet advertisements posted on a popular website before and during the pandemic by male sex workers providing services to men. We first collected data in March 2019 from 172 advertisements - the complete number available at that time - posted by male sex workers advertising services in the Atlanta region. We then assessed whether these same sex workers continued to advertise their availability at three subsequent points during the COVID-19 pandemic: April 2020, January 2021 and February 2021. We also determined whether age and race were associated with advertising presence at each time point. While advertising rates declined among sex workers in all race categories (Black, White and 'other'), results from our mixed effects logistic regression model show that the odds of older male sex workers continuing to advertise were greater than the odds for their younger counterparts. Further, the predicted probability of continued advertising was highest for White male sex workers. Our findings provide additional insights into male sex work during a global pandemic.

Identity and COVID-19 in Canada: Gender, ethnicity, and minority status

BACKGROUND

During the COVID-19 pandemic, growing evidence from the United States, the United Kingdom, and China has demonstrated the unequal social and economic burden of this health crisis. Yet, in Canada, studies assessing the socioeconomic and demographic determinants of COVID-19, and how these determinants vary by gender and ethnic minority status, remain scarce. As new strains of COVID-19 emerge, it is important to understand the disparities to be able to initiate policies and interventions that target and prioritise the most at-risk sub-populations.

AIM

The objective of this study is to assess the socioeconomic and demographic factors associated with COVID-19-related symptoms in Canada, and how these determinants vary by identity factors including gender and visible minority status.

METHODS

We implemented an online survey and collected a nationally representative sample of 2,829 individual responses. The original data collected via the SurveyMonkey platform were analysed using a cross-sectional study. The outcome variables were COVID-19-related symptoms among respondents and their household members. The exposure variables were socioeconomic and demographic factors including gender and ethnicity as well as age, province, minority status, level of education, total annual income in 2019, and number of household members. Descriptive statistics, chi-square tests, and multivariable logistic regression analyses were performed to test the associations. The results were presented as adjusted odds ratios (aORs) at p < 0.05 and a 95% confidence interval.

RESULTS

We found that the odds of having COVID-19-related symptoms were higher among respondents who belong to mixed race [aOR = 2.77; CI = 1.18-6.48] and among those who lived in provinces other than Ontario and Quebec [aOR = 1.88; CI = 1.08-3.28]. There were no significant differences in COVID-19 symptoms between males and females, however, we did find a significant association between the province, ethnicity, and reported COVID-19 symptoms for female respondents but not for males. The likelihood of having COVID-19-related symptoms was also lower among respondents whose total income was $100,000 or more in 2019 [aOR = 0.18; CI = 0.07-0.45], and among those aged 45-64 [aOR = 0.63; CI = 0.41-0.98] and 65-84 [aOR = 0.42; CI = 0.28-0.64]. These latter associations were stronger among non-visible minorities. Among visible minorities, being black or of the mixed race and living in Alberta were associated with higher odds of COVID-19-related symptoms.

CONCLUSION

We conclude that ethnicity, age, total income in 2019, and province were significantly associated with experiencing COVID-19 symptoms in Canada. The significance of these determinants varied by gender and minority status. Considering our findings, it will be prudent to have COVID-19 mitigation strategies including screening, testing, and other prevention policies targeted toward the vulnerable populations. These strategies should also be designed to be specific to each gender category and ethnic group, and to account for minority status.

Lasting Declines in Couples' Social Network Interactions in the First Years of COVID

Since the onset of COVID-19, a rise in loneliness has raised concerns about the social impact of lockdowns and distancing mandates. Yet, to date, the effects of the pandemic on social networks have been studied only indirectly. To evaluate how the pandemic affected social networks, the current analyses analyzed five waves of detailed social network interviews conducted before and during the first 18 months of the pandemic in a sample especially vulnerable to contracting the virus: mostly non-White couples (243 husbands and 250 wives) recruited from lower income neighborhoods. Pre-COVID interviews asked spouses to name 24 individuals with whom they interact regularly. Post-COVID interviews indicated a nearly 50% decline in face-to-face interactions and a nearly 40% decline in virtual interactions, with little recovery over the first 18 months of the pandemic. Compared with less affluent couples, those with higher incomes maintained more of their network relationships, especially when virtual interactions were taken into account.

Politics, policies, and patient care: Rehabilitation therapists' experiences during the COVID-19 Pandemic

The year 2020 represents a historically turbulent period for the United States marked by the COVID-19 pandemic, a contentious political season, and heightened awareness of racism among citizens. This intersection of medicine, politics, and social unrest generated a demanding clinical environment for healthcare workers, including understudied groups such as physical therapists, occupational therapists, and speech-language pathologists. This descriptive qualitative study focused on experiences and perspectives of clinical rehabilitation therapists working in inpatient rehabilitation and acute-care units from September to November, 2020. Thirteen participants completed individual, semi-structured interviews focused on clinical practice and coping strategies. The analysis included a multi-step, inductive process. Four interconnecting factors chronicling participants' experiences emerged: sociopolitical, institutional, hospital unit, and personal. Stressors and buffers were noted that further shaped individual experiences. Utilization of an ecological framework provided a way to recognize the impact of a complex range of social and environmental factors affecting participants' experiences on personal and professional levels. Awareness of rehabilitation therapists' experiences enriches understanding of the pandemic's effect on healthcare workers and presents clinical implications for healthcare systems to promote therapist well-being.

How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review

BACKGROUND

Advance care planning (ACP) is the process supporting individuals with life-limiting illness to make informed decisions about their future healthcare. Ethnic disparities in ACP have been widely highlighted, but interpretation is challenging due to methodological heterogeneity. This review aims to examine differences in the presence of documented ACP in individuals' care records for people with advanced disease by ethnic group, and identify patient and clinician related factors contributing to this.

METHODS

Mixed-methods systematic review. Keyword searches on six electronic databases were conducted (01/2000-04/2022). The primary outcome measure was statistically significant differences in the presence of ACP in patients' care records by ethnicity: quantitative data was summarised and tabulated. The secondary outcome measures were patient and clinician-based factors affecting ACP. Data was analysed qualitatively through thematic analysis; themes were developed and presented in a narrative synthesis. Feedback on themes was gained from Patient and Public Involvement (PPI) representatives. Study quality was assessed through Joanna Briggs Institute Critical Appraisal tools and Gough's Weight of Evidence.

RESULTS

N=35 papers were included in total; all had Medium/High Weight of Evidence. Fifteen papers (comparing two or more ethnic groups) addressed the primary outcome measure. Twelve of the fifteen papers reported White patients had statistically higher rates of formally documented ACP in their care records than patients from other ethnic groups. There were no significant differences in the presence of informal ACP between ethnic groups. Nineteen papers addressed the secondary outcome measure; thirteen discussed patient-based factors impacting ACP presence with four key themes: poor awareness and understanding of ACP; financial constraints; faith and religion; and family involvement. Eight papers discussed clinician-based factors with three key themes: poor clinician confidence around cultural values and ideals; exacerbation of institutional constraints; and pre-conceived ideas of patients' wishes.

CONCLUSIONS

This review found differences in the presence of legal ACP across ethnic groups despite similar presence of informal end of life conversations. Factors including low clinician confidence to deliver culturally sensitive, individualised conversations around ACP, and patients reasons for not wishing to engage in ACP (including, faith, religion or family preferences) may begin to explain some documented differences.

TRIAL REGISTRATION

PROSPERO-CRD42022315252.

Pregnant in a Pandemic: Mental Wellbeing and Associated Healthy Behaviors Among Pregnant People in California During COVID-19

INTRODUCTION

Pregnancy is a time of increased vulnerability to mental health disorders. Additionally, the COVID-19 pandemic has increased the incidence of depression and anxiety. Thus, we aimed to assess mental health and associated healthy behaviors of pregnant people in California during the pandemic in order to contextualize prenatal well-being during the first pandemic of the twenty-first century.

METHODS

We conducted an online cross-sectional study of 433 pregnant people from June 6 through July 29, 2020. We explored 3 hypotheses: (1) mental health would be worse during the pandemic than in general pregnant samples to date; (2) first-time pregnant people would have worse mental health; and (3) healthy behaviors would be positively related to mental health.

RESULTS

Many of our participants (22%) reported clinically significant depressive symptoms and 31% reported clinically significant anxiety symptoms. Multiparous pregnant people were more likely to express worries about their own health and wellbeing and the process of childbirth than were primiparous pregnant people. Additionally, as pregnancy advanced, sleep and nutrition worsened, while physical activity increased. Lastly, anxious-depressive symptomology was significantly predictive of participant sleep behaviors, nutrition, and physical activity during the past week.

DISCUSSION

Pregnant people had worse mental health during the pandemic, and this was associated with worse health-promoting behaviors. Given that the COVID-19 pandemic and associated risks are likely to persist due to low vaccination rates and the emergence of variants with high infection rates, care that promotes mental and physical well-being for the pregnant population should be a public health priority.

Differential Effects of Race/Ethnicity and Social Vulnerability on COVID-19 Positivity, Hospitalization, and Death in the San Francisco Bay Area

BACKGROUND

Higher COVID-19 incidence and morbidity have been documented for US Black and Hispanic populations but not as clearly for other racial and ethnic groups. Efforts to elucidate the mechanisms underlying racial health disparities can be confounded by the relationship between race/ethnicity and socioeconomic status.

OBJECTIVE

Examine race/ethnicity and social vulnerability effects on COVID-19 outcomes in the San Francisco Bay Area, an ethnically and socioeconomically diverse region, using geocoded patient records from 2020 in the University of California, San Francisco Health system.

KEY RESULTS

Higher social vulnerability, but not race/ethnicity, was associated with less frequent testing yet a higher likelihood of testing positive. Asian hospitalization rates (11.5%) were double that of White patients (5.4%) and exceeded the rates for Black (9.3%) and Hispanic patients (6.9%). A modest relationship between higher hospitalization rates and increasing social vulnerability was evident only for White patients. Hispanic patients had the highest years of expected life lost due to COVID-19.

CONCLUSIONS

COVID-19 outcomes were not consistently explained by greater social vulnerability. Asian individuals showed disproportionately high rates of hospitalization regardless of social vulnerability status. Study of the San Francisco Bay Area population not only provides valuable insights into the differential contributions of race/ethnicity and social determinants of health to COVID-19 outcomes but also emphasizes that all racial groups have experienced the toll of the pandemic, albeit in different ways and to varying degrees.

"Beyond just the four walls of the clinic": The roles of health systems caring for refugee, immigrant and migrant communities in the United States

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'.

Introduction

Refugee, immigrant and migrant (hereafter referred to as "immigrant") communities have been inequitably affected by the COVID-19 pandemic. There is little data to help us understand the perspectives of health systems on their role, in collaboration with public health and community-based organizations, in addressing inequities for immigrant populations. This study will address that knowledge gap.

Methods

This qualitative study used semi-structured video interviews of 20 leaders and providers from health systems who cared for immigrant communities during the pandemic. Interviewees were from across the US with interviews conducted between November 2020-March 2021. Data was analyzed using thematic analysis methods.

Results

Twenty individuals representing health systems participated with 14 (70%) community health centers, three (15%) county hospitals and three (15%) academic systems represented. The majority [16 health systems (80%)] cared specifically for immigrant communities while 14 (70%) partnered with refugee communities, and two (10%) partnered with migrant farm workers. We identified six themes (with subthemes) that represent roles health systems performed with clinical and public health implications. Two foundational themes were the roles health systems had building and maintaining trust and establishing intentionality in working with communities. On the patient-facing side, health systems played a role in developing communication strategies and reducing barriers to care and support. On the organizational side, health systems collaborated with public health and community-based organizations, in optimizing pre-existing systems and adapting roles to evolving needs throughout the pandemic.

Conclusion

Health systems should focus on building trusting relationships, acting intentionally, and partnering with community-based organizations and public health to handle COVID-19 and future pandemics in effective and impactful ways that center disparately affected communities. These findings have implications to mitigate disparities in current and future infectious disease outbreaks for immigrant communities who remain an essential and growing population in the US.

Building Trust: Strategies for Recruiting Underrepresented Populations in Research during the COVID-19 Pandemic

The COVID-19 pandemic disproportionately affected racial and ethnic populations within the United States, creating a distinct set of circumstances that exacerbated barriers to research participation for underrepresented communities. This article aims to provide a rationale that validates the impact of the COVID-19 pandemic on these groups and suggests strategies for participant recruitment while sharing lessons learned from our own laboratory. By understanding the barriers that limit the recruitment of intended populations, researchers can implement culturally sensitive strategies and work towards a more inclusive body of literature with improved participation from underrepresented racial and ethnic populations.

Nationwide Analysis of Cardiac Arrest Outcomes During the COVID-19 Pandemic

Introduction

The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on the chain of survival following cardiac arrest. However, large population-based reports of COVID-19 in patients hospitalized after cardiac arrest are limited.

Methods

The National Inpatient Sample database was queried for cardiac arrest admissions during 2020 in the United States (US). Propensity score matching was used to match patients with and without concurrent COVID-19 according to age, race, sex, and comorbidities. Multivariate logistic regression analysis was used to identify predictors of mortality.

Results

A weighted total of 267,845 hospitalizations for cardiac arrest were identified, among which 44,105 patients (16.5%) had a concomitant diagnosis of COVID-19. After propensity matching, cardiac arrest patients with concomitant COVID-19 had higher rate of acute kidney injury requiring dialysis (64.9% vs. 54.8%) mechanical ventilation > 24 hours (53.6% vs. 44.6%) and sepsis (59.4% vs. 40.4%) compared to cardiac arrest patients without COVID-19. In contrast, cardiac arrest patients with COVID-19 had lower rates of cardiogenic shock (3.2% vs. 5.4%, p < 0.001), ventricular tachycardia (9.6% vs. 11.7%, p < 0.001), and ventricular fibrillation (6.7% vs. 10.8%, p < 0.001), and a lower utilization of cardiac procedures. In-hospital mortality was higher in patients with COVID-19 (86.9% vs. 65.5%, p <0.001) and, on multivariate analysis, a diagnosis of COVID-19 was an independent predictor of mortality.

Conclusion

Among patients hospitalized following a cardiac arrest during 2020, concomitant COVID-19 infection was associated with significantly worse outcomes characterized by an increased risk of sepsis, pulmonary and renal dysfunction, and death.

Changes in caregiver mental health and pediatric asthma control during COVID-19

OBJECTIVE

This study evaluated caregivers' stress and depressive symptoms, and children's asthma control, before COVID-19 began and after its onset among families in the RVA Breathes program.

METHODS

The RVA Breathes intervention, which took place in an urban city in the United States, includes asthma education delivered by a community health worker (CHW), a home assessment, and school nurse components. Participants included 125 children (5-11 years) with asthma and their caregivers (48% household income <$25,000) enrolled prior to the pandemic. Families were randomized to an active intervention arm (full intervention or intervention without school nurse component) or the control group. Caregivers completed the Center for Epidemiological Studies Depression Scale (CES-D) and the Perceived Stress Scale (PSS); children and caregivers completed the Childhood Asthma Control Test (cACT). Assessments pre-COVID-19 were compared to those completed after the pandemic's onset.

RESULTS

Children in both intervention groups had better cACT scores after the start of COVID-19 compared to before (t(55) = -2.131, p = .019; t(28) = -2.893, p = .004). Caregivers in the intervention groups had lower PSS scores after the start of COVID-19 compared to pre-COVID-19 (t(53) = 3.928, p < .001; t(28) = 2.568, p = .008). Furthermore, CES-D scores improved among caregivers in the full intervention (t(48) = 1.789, p = .040). Caregivers in the control condition did not report significant changes in stress or depressive symptoms.

CONCLUSIONS

Findings suggest that support from interventionists, including CHWs, might have alleviated stress and depressive symptoms during COVID-19, as well as improved asthma control during the pandemic.

A Systematic Review and Meta-analysis of the Initial Literature Regarding COVID-19 Symptoms in Children in the United States

INTRODUCTION

COVID-19 symptom presentation among adults is mostly understood. However, understanding COVID-19 symptom presentation in children lags.

METHOD

A literature search was conducted in three electronic databases. Twenty-three initial publications addressing COVID-19 symptom presentation among hospitalized children in the United States met the criteria for review and meta-analysis.

RESULTS

Fever, the most common symptom, was present in nearly all cases. Gastrointestinal, respiratory, oral symptoms, and rash occurred in over half of the cases. Disease severity assessment showed that comorbidities were present in one-third of patients; intensive care was needed for half of the patients, and supplemental oxygen and mechanical ventilation were needed by 13.3% and 7.1%, respectively.

DISCUSSION

The magnitude and significance of COVID-19 symptoms in children compared with those in adults and three common childhood viral illnesses: influenza, respiratory syncytial virus, and gastroenteritis, are discussed. Important clinical differences were found that may help clinicians distinguish COVID-19 from other illnesses.

Online Grocery Shopping and the Supplemental Nutrition Assistance Program (SNAP) Electronic Benefit Transfer Card (EBT): Perceptions of Head Start Caregivers

The objective of this study was to explore perceptions of online grocery shopping and the online United States Department of Agriculture's (USDA) Supplemental Nutrition Assistance Program (SNAP) Electronic Benefit Transfer card (EBT) program among Head Start caregivers. Three focus groups were conducted between December 2019 and January 2020. Most participants hadn't tried online grocery shopping. Concerns included others choosing perishables, receiving wrong items, and inappropriate substitutes. Perceived benefits included saving time, preventing impulse buys, and eating healthier. Results have broad applicability in the current COVID-19 pandemic where online grocery shopping and the online SNAP EBT program have rapidly expanded across the United States.

Addressing Social Context in Adverse Childhood Experience Screening Policy: Implications for Children With Special Health Care Needs

Adverse childhood experiences (ACEs) disproportionately affect children with special health care needs, especially racial and ethnic minority children whose ACEs may be less likely to be identified. As awareness and understanding of the health impacts of ACEs have increased, heightened by the COVID-19 pandemic, several areas of the United States have initiated policy efforts to screen for and address ACEs. However, these policies do not always include mechanisms to account for context-specific adversity or contemporary stressors in the lives of children. Stressors most significant in a child's life may include adversities beyond those included in common ACE screening instruments. ACE policy in California will be discussed relative to addressing the social context in ACEs screening. By taking a holistic view of ACEs and thinking beyond deriving ACE scores alone, clinicians can ensure that ACE-related policies are implemented with maximum benefit to diverse children with special health care needs.

The COVID-19 pandemic: asthma control, tobacco use, and mental health among African American and Latinx college students

OBJECTIVE

This study investigated the impact of COVID-19 on tobacco use and mental health in US African American and Latinx college students with asthma. Associations among asthma control, tobacco use, and mental health were also examined.

METHODS

105 African American and Latinx college students with asthma (18-23 years) completed two online questionnaires (June 2019-March 2020 for Time 1; August 2020-October 2020 for Time 2). Participants completed the Epidemic-Pandemic Impacts Inventory (measure of COVID-19 impact), Asthma Control Test, Generalized Anxiety Disorder scale, Patient Health Questionnaire (measure of depression), Perceived Stress Scale, and items related to tobacco use.

RESULTS

Asthma control improved (t = -3.326, p = 0.001) from Time 1 to 2, and e-vapor product use decreased (χ²₁₀₄ = 6.572, p = 0.010). COVID-19 impact was positively associated with students' symptoms of anxiety, depression, and perceived stress (B = 0.201, p < 0.001; B = 0.179, p < 0.001; and B = 0.199, p = 0.001, respectively) at Time 2. These results remained significant with the Benjamini-Hochberg correction. Asthma control at Time 1 was negatively associated with anxiety symptoms at Time 2 (B = -0.418, p = 0.023); however, associations with perceived stress (B = -0.514, p = 0.019) and all other tobacco product use (B = -0.233, p = 0.030) did not remain significant with the Benjamini-Hochberg correction.

CONCLUSIONS

As hypothesized, a higher COVID-19 impact score was associated with students endorsing more mental health symptoms. Better control of asthma symptoms before the pandemic predicted fewer anxiety symptoms during the pandemic.

Social Safety Theory: Conceptual foundation, underlying mechanisms, and future directions

Classic theories of stress and health are largely based on assumptions regarding how different psychosocial stressors influence biological processes that, in turn, affect human health and behavior. Although theoretically rich, this work has yielded little consensus and led to numerous conceptual, measurement, and reproducibility issues. Social Safety Theory aims to address these issues by using the primary goal and regulatory logic of the human brain and immune system as the basis for specifying the social-environmental situations to which these systems should respond most strongly to maximize reproductive success and survival. This analysis gave rise to the integrated, multi-level formulation described herein, which transforms thinking about stress biology and provides a biologically based, evolutionary account for how and why experiences of social safety and social threat are strongly related to health, well-being, aging, and longevity. In doing so, the theory advances a testable framework for investigating the biopsychosocial roots of health disparities as well as how health-relevant biopsychosocial processes crystalize over time and how perceptions of the social environment interact with childhood microbial environment, birth cohort, culture, air pollution, genetics, sleep, diet, personality, and self-harm to affect health. The theory also highlights several interventions for reducing social threat and promoting resilience.

Managing the unexpected: Bicultural identity integration during the COVID-19 emergency

Unexpected and sudden emergency situations such as COVID-19 may render ethnic minorities particularly vulnerable to experiencing negative outcomes. Yet, we put forward that Bicultural Identity Integration (BII) - the degree to which bicultural individuals perceive their cultural identities as compatible and overlapping - may represent a resource in times of emergencies, since it may positively influence, through enhancement of psychological well-being, how bicultural individuals respond in terms of distress and coping strategies. Based on this assumption, the present study aimed at examining the relationship between BII and responses to COVID-19. N = 370 bicultural individuals (mean age = 26.83, SD = 8.74) from different cultural backgrounds were recruited online and completed measures of BII, psychological well-being, COVID-19 distress and coping strategies (positive attitudes, avoidance, social support seeking) during the second wave of the COVID-19 pandemic in Italy. We tested a model in which BII was the predictor, psychological well-being was the mediator and reactions to the COVID-19 emergency (distress, use of coping) were the outcomes. This model was tested against two alternative models. The proposed model showed a better fit to the data compared to the alternative models. In this model, psychological well-being mediated the relationship between BII (harmony) and coping strategies, except social support seeking. These findings highlight the important role played by BII in emergency situations, as it may indirectly, through enhancement of psychological well-being, contribute to enhance biculturals' adaptive reactions in terms of distress as well as affect coping strategies during highly stressful events.

Resources availability and COVID-19 mortality among US counties

The COVID-19 was declared a pandemic by WHO on 03/2020 has claimed millions of lives worldwide. The US leads all countries in COVID-19-related deaths. Individual level (preexisting conditions and demographics) and county-level (availability of resources) factors have been attributed to increased risk of COVID-19-related deaths. This study builds on previous studies to assess the relationship between county-level resources and COVID-19 mortality among 2,438 US counties. We merged 2019 data from AHA, AHRF, and USA FACTS. The dependent variable was the total number of COVID-19-related deaths. Independent variables included county-level resources: (1) hospital staffing levels (FTE RNs, hospitalists, and intensivists) per 10,000 population; (2) hospital capacity (occupancy rate, proportion of teaching hospitals, and number of airborne infection control rooms per 10,000 population); and (3) macroeconomic resources [per capita income and location (urban/rural)]. We controlled for population 65+, racial/ethnic minority, and COVID-19 deaths per 1,000 population. A negative binomial regression was used. Hospital staffing per 10,000 population {FTE RN [IRR = 0.997; CI (0.995-0.999)], FTE hospitalists [IRR = 0.936; CI (0.897-0.978)], and FTE intensivists [IRR = 0.606; CI (0.516-0.712)]} was associated with lower COVID-19-related deaths. Hospital occupancy rate, proportion of teaching hospitals, and total number of airborne infection control rooms per 10,000 population were positively associated with COVID-19-related deaths. Per capita income and being in an urban county were positively associated with COVID-19-related deaths. Finally, the proportion of 65+, racial/ethnic minorities, and the number of cases were positively associated with COVID-19-related deaths. Our findings suggest that focusing on maintaining adequate hospital staffing could improve COVID-19 mortality.

Men's and women's endorsement of hegemonic masculinity and responses to COVID-19

Using a gendered psychology of health approach, we examine the effects of the culturally idealized form of masculinity-hegemonic masculinity-for both men and women's health attitudes and behaviors. Using data collected across four studies (N = 805) during the COVID-19 pandemic, we found that stronger endorsement of hegemonic masculinity related to health attitudes antithetical to mitigation strategies (e.g. more engagement in risky behaviors, less support for federal mandates) and evaluations of how political leaders have responded to COVID-19. These effects did not differ by gender suggesting that hegemonic masculinity has implications for both men and women's health.