WE DIDN'T HAVE THAT PRIVILEGE LIKE OTHER PEOPLE: LOW-INCOME MICHIGAN RESIDENTS' EXPERIENCES OF COVID-19 PANDEMIC HEALTH POLICIES

BACKGROUND: Low-income individuals, particularly ethnic/racial minorities, are at higher risk of contracting and dying from coronavirus disease 2019 (COVID-19) but little is known about their experiences with public health policies. Here we report findings related to health equity of a study exploring experiences of low-income Michigan residents during the pandemic. METHODS: We conducted semi-structured phone interviews with Michigan residents ages 18-65. with annual income below 200% of the federal poverty level (FPL). Interviewees were selected to achieve balance in geographic residence, age, gender, and race/ethnicity. Interviews, conducted in English or Spanish, asked about: sources of COVID19 information, perceived risk of infection, protective behaviors, and experiences with COVID-19 policies. Five team members independently performed thematic analyses using Dedoose version 8.3.45, with 2-3 analysts per interview. Analysts tagged excerpts with themes and subthemes, drafted a codebook with inclusion and exclusion criteria and examples, and compared coding until reaching consensus. RESULTS: 24 people (11 men and 13 women), aged 20-65 years (mean=39) participated. 9 participants were non-Hispanic white, 6 were Hispanic (4 interviewed in Spanish), 8 were African American, and 1 was Native American. 7 participants lived in rural areas. 3 of 21 themes with 9 subthemes illustrated health equity implications. Interviewees described difficulty protecting themselves and their family from COVID-19 (housing density, multi-generational household, working in person), for instance “it's a very reduced space. we're all like sharing the same environment and breathing the same air . infected people are separated, but we didn't have that privilege.” They talked about financial hardship (unreliable work, limiting expenses due to financial stress, job loss due to pandemic, the need to work). A waiter said “So first thing, they had to reduce the number of people who visit the restaurant .You wouldn't be getting that much income as you got during the pre-COVID-19 period .” A man moved into his travel trailer “because I can't afford to rent a house anymore, you know? You've got to bring water in . In the winter, you don't have electricity. So you've gotta use a a ventless heater and then buying extra gas to cook on and, you know, just wondering if you're gonna make it.” Interviewees also described resiliency (social unity, feeling of security due to having health insurance), for instance “I make sure that we do fun stuff even still with things shutting down.” CONCLUSIONS: This diverse group of low-income Michiganders described difficulty protecting themselves from COVID-19 along with detrimental impacts from the pandemic on housing and finances. To counter health disparities exacerbated by the pandemic, policy needs to address overcrowded housing, economic hardship, and risk accompanying in-person employment.

SETTING PRIORITIES FOR CONNECTIONS AND ACTIVITIES DURING A PANDEMIC

This paper will describe and analyze restrictions on connection and interaction (i.e., social distancing) during the first pandemic in a century. During a pandemic, decision makers are required to make difficult decisions with incomplete information, under high levels of uncertainty, public scrutiny and urgency. Many critical and far-reaching priority setting decisions have occurred outside the health sector, for instance the closing of schools or restrictions on businesses or transportation. These decisions, like decisions about allocating vaccine or hospital care, involve the allocation of some budgetary and human resources. However, more so than in healthcare, they also explicitly involve the allocation of burdens or costs, from both limits on movement and, for instance for service workers, greater exposure to infection. These decisions, like those about allocating healthcare resources, have critical consequences for health. Households suffer job losses and reduced income;children miss school;many, especially those residing in institutions, suffer social isolation- outcomes which have been associated with declines in physical and mental health. These burdens of restrictions on movement and connection and consequent health outcomes may be unevenly distributed and exacerbate existing health inequities. Fair decision making about priorities for connection and interaction is as crucial as fair decision making about allocating intensive care and vaccine. The application of priority setting methods and principles, however, has focused on healthcare and not on other policy actions that can profoundly influence health. This paper presents an analysis of restrictive measures introduced during the COVID-19 pandemic, what we have learned, so far, about the consequences of those restrictions, and makes recommendations for the development and application of priority setting frameworks in this arena to inform future research and practice.

QUALITY OF PANDEMIC PRIORITY SETTING IN THE U.S

Priority setting during public health emergencies presents an enormous challenge for federal and state decision makers in the U.S. Objectives We describe the degree to which U.S. priority setting adheres to established quality indicators and explore relationships between such indicators and states' demographic characteristics. Methods Data includes the U.S. COVID-19 preparedness and response plan of January 2021 and individual state plans. Purposive sampling of 22 states from multiple geographic regions considered total population,% rural residents, income per capita, health ranking, and political leanings. State plans were sought online and using multiple contacts with state health and emergency preparedness departments. We analyzed plans using a tool based on an established framework of quality indicators to evaluate priority setting, for example principles and criteria, stakeholder and public participation, publicity and accountability. Results The national plan included 7 of 20 quality parameters, including attention to at-risk populations, a comprehensive list of resources and interventions to which priority setting would apply, publicity, and the use of (and efforts to improve) evidence for priority setting decisions. The US plan describes the importance of 'engag[ing] the American people' and various stakeholders to inform the federal response. Enforcement, accountability, incentives, and assessment of impact were not identified in the plan. We obtained pandemic plans from 4 states and documents from 6 states that, while not explicitly labelled as pandemic plans, include priority setting. Analysis is in process;we expect to present results for 4-10 states. Discussion The US plan's consideration of various scarce resources, public engagement, and equity concerns recognizes the disproportionate impact of COVID-19 among racial and ethnic minorities and low-income communities. However, its lack of accountability and assessment of impact on outcomes may hinder achievement of goals. Difficulty finding and obtaining state plans suggests a lack of publicity and transparency.

PROFILE OF PRIORITY SETTING INCORPORATED TO COVID-19 RESPONSE PLANS IN 86 COUNTRIES IN THE WORLD

Background The COVID-19 pandemic has imposed a burden on all health systems budgets and pushed policymakers to rapidly set priorities for resource allocation. This study aimed to identify quality parameters of priority setting (PS) incorporated in a sample of the national response plans. Methods We reviewed a sample of COVID-19 national response plans from 86 countries across six regions of the WHO to assess the degree to which they included twenty quality indicators of effective PS. A quantitative descriptive analysis was used to explore the profile of PS according to independent variables. Results The countries sampled represent 40% of countries in AFRO, 54,5% of EMRO, 45% of EURO, 46% of PAHO, 64% of SEARO, and 41% of WPRO. They also represent 39% of all HICs in the world, 39% of Upper-Middle, 54% of Lower-Middle, and 48% of LICs. No pattern in attention to PS quality indicators emerged by WHO region or country income levels. As per the quality PS parameters, evidence of political will, stakeholder participation, use of scientific evidence/adoption of WHO recommendations were each found in over 80% of plans. Regarding the frequency of other parameters we found, description of a specific PS process (7%);explicit criteria for PS (36,5%);inclusion of publicity strategies (65%), mention of mechanisms for enforcing decisions, either for appealing decisions or implementing strategies to improve internal accountability and reduce corruption (20%);explicit reference to public values (15%);description of means for enhancing compliance with the decisions (5%). Conclusion We found some emphasis on PS according to contextual factors. For instance, LMICs receiving international donations presented more detailed descriptions of resources required, plans for allocating resources and improving internal accountability. HICs more likely described stakeholder participation, mechanisms for public communication, and explicit PS processes. However, no country included all twenty parameters of PS.

WERE FORCIBLY DISPLACED PEOPLE PRIORITIZED IN THE COVID-19 NATIONAL RESPONSE PLANS?

Background Forcibly displaced people represent a huge humanitarian problem globally. At the end of 2020, the total number was 82,4 million;from those, 34,4 million were refugees, asylum seekers, and Venezuelan displaced abroad. Forcibly displaced people were identified as priority populations during the pandemic due to their risk of being the last served populations with healthcare. This paper aimed to identify if this population was prioritized in the COVID-19 national response plans of a sample of 86 countries. Methods This study is part of a document analysis of 86 COVID-19 national response plans, assessing the degree of comply to quality parameters of effective priority setting. One of the parameters included was the degree to which vulnerable populations such as forcibly displaced people were explicitly prioritized for receiving COVID-19 related interventions or for continuity of non-COVID healthcare services. The analysis involved assessing whether and how forcibly displaced people were prioritized in the COVID-19 national response plans. This was compared with the displaced populations identified in the host countries' UNHCR Forced Displacement 2020 report. Results Only five countries among 86 analyzed prioritized forcibly displaced people in their COVID-19 national response plans. Among the top ten forcibly displaced people hosting countries, Uganda was the only one with an explicit prioritization of this vulnerable group. Although Turkey, Colombia, and Germany account for nearly one-fifth (6,6 million) of refugees, asylum seekers and Venezuelans displaced abroad, none of the COVID-19 response plans of these countries prioritized these populations. Discussion Few countries recognized forcibly displaced people as a vulnerable population in their COVID-19 response and preparedness plans. Governments may have incorporated actions and interventions for these vulnerable groups after publishing the COVID-19 response plans. It would be essential to evaluate the impact of this lack of prioritization on the health and wellbeing of these population groups.

PRIORITY-SETTING FOR EFFECTIVE PANDEMIC PREPAREDNESS: A CASE STUDY OF PRIORITY SETTING FOR COVID-19 IN THE WESTERN PACIFIC REGION

Background There have been divergent approaches used by countries to curb and control the spread, impact and burden of COVID-19. While priority setting - defined as decision- making about the allocation of resources between competing claims of different services, populations and elements of care - is recognized as critical for promoting accountability and transparency in health system planning, its role in supporting rational, equitable and fair pandemic preparedness planning is less well understood. Our multicountry project investigates the effectiveness of priority setting for pandemic preparedness planning. This study aims to describe how priority setting guided the COVID-19 responses implemented in the sub-set of countries in the Western Pacific Region. Methods Guided by the adapted Kapiriri and Martin Framework, we purposively sampled a subset of countries in the WHO Western Pacific Region (WPRO) and undertook a critical document review of national-level pandemic preparedness plans. A pre-specified, validated tool guided data extraction on twenty quality parameters of PS. A critical synthesis was completed. Results Nine plans were included (41% WPRO countries), including: Papua New Guinea, Tonga, Philippines, Fiji, China, Australia, New Zealand, Japan, and Taiwan. There was evidence of strong political will to quickly and effectively combat the pandemic. With 8/9 countries being islands, an emphasis on securing boarders was reflected in the plans. A limited number of quality indicators of effective priority setting were described. Most commonly, plans described resource needs (n=8), stakeholder engagement (n=8), and responsibilities of legitimate institutions (n=7). Consideration of health inequalities, fair financial burden, or public engagement/acceptance of priorities was not evident in any plans. Discussion This project advances understanding of how priority setting has been used in the WPRO region to support COVID-19 responses. It provides a basis for examining the relationship between effective priority setting for pandemic preparedness and country-level outcomes in future work.

'I'm being forced to make decisions I have never had to make before': Oncologists and the conundrums created by COVID-19

Background: The COVID-19 pandemic has created conundrums for physicians. This study examines the experiences of oncologists who engage in complex decision-making regarding the use of chemotherapy in seriously ill persons in the context of the COVID-19 pandemic. Methods: Between January 2020 and August 2020, the authors conducted semistructured, in-depth individual interviews with 22 purposefully sampled oncologists from practices enrolled in the Michigan Oncology Quality Consortium. Transcripts were double-coded and reconciled by consensus using qualitative data analysis software for thematic analysis. Results: Among the thematic clusters we identified, one was related to conundrums created by the COVID-19 pandemic. In this presentation, we report the results pertaining to three themes within this cluster: (1) the ethical dilemmas faced by oncologists due to the COVID-19 pandemic, (2) the need for both patients and oncologists to manage uncertainty and emotions, and (3) the importance and complexity of integrating technology and communication for seriously ill persons. Oncologists grappled with several conundrums including resource scarcity, resource allocation, delays in care, a duty to promote equity and non-abandonment, high levels of uncertainty and fear, and the importance of advanced care directives and end-of-life care planning. Nonabandonment featured as a coping mechanism for increased stress, and integration of communication with telemedicine was frequent and necessary. Conclusions: This study offers an indepth exploration of the conundrums faced by oncologists due to the COVID-19 pandemic and how they navigated them. Optimal decision-making for seriously ill persons with cancer during the COVID-19 pandemic must include open acknowledgement of the ethical dilemmas faced, the heightened emotions experienced by both patients and their oncologists, and the urgent need for integrating technology with compassionate communication in determining patient preferences.