COVID-19-Associated Misinformation Across the South Asian Diaspora: Qualitative Study of WhatsApp Messages.

Background: South Asians, inclusive of individuals originating in India, Pakistan, Maldives, Bangladesh, Sri Lanka, Bhutan, and Nepal, comprise the largest diaspora in the world, with large South Asian communities residing in the Caribbean, Africa, Europe, and elsewhere. There is evidence that South Asian communities have disproportionately experienced COVID-19 infections and mortality. WhatsApp, a free messaging app, is widely used in transnational communication within the South Asian diaspora. Limited studies exist on COVID-19-related misinformation specific to the South Asian community on WhatsApp. Understanding communication on WhatsApp may improve public health messaging to address COVID-19 disparities among South Asian communities worldwide. Objective: We developed the COVID-19-Associated misinfoRmation On Messaging apps (CAROM) study to identify messages containing misinformation about COVID-19 shared via WhatsApp. Methods: We collected messages forwarded globally through WhatsApp from self-identified South Asian community members between March 23 and June 3, 2021. We excluded messages that were in languages other than English, did not contain misinformation, or were not relevant to COVID-19. We deidentified each message and coded them for one or more content categories, media types (eg, video, image, text, web link, or a combination of these elements), and tone (eg, fearful, well intentioned, or pleading). We then performed a qualitative content analysis to arrive at key themes of COVID-19 misinformation. Results: We received 108 messages; 55 messages met the inclusion criteria for the final analytic sample; 32 (58%) contained text, 15 (27%) contained images, and 13 (24%) contained video. Content analysis revealed the following themes: "community transmission" relating to misinformation on how COVID-19 spreads in the community; "prevention" and "treatment," including Ayurvedic and traditional remedies for how to prevent or treat COVID-19 infection; and messaging attempting to sell "products or services" to prevent or cure COVID-19. Messages varied in audience from the general public to South Asians specifically; the latter included messages alluding to South Asian pride and solidarity. Scientific jargon and references to major organizations and leaders in health care were included to provide credibility. Messages with a pleading tone encouraged users to forward them to friends or family. Conclusions: Misinformation in the South Asian community on WhatsApp spreads erroneous ideas regarding disease transmission, prevention, and treatment. Content evoking solidarity, "trustworthy" sources, and encouragement to forward messages may increase the spread of misinformation. Public health outlets and social media companies must actively combat misinformation to address health disparities among the South Asian diaspora during the COVID-19 pandemic and in future public health emergencies.

Public Figure Vaccination Rhetoric and Vaccine Hesitancy: Retrospective Twitter Analysis.

Background: Social media has emerged as a critical mass communication tool, with both health information and misinformation now spread widely on the web. Prior to the COVID-19 pandemic, some public figures promulgated anti-vaccine attitudes, which spread widely on social media platforms. Although anti-vaccine sentiment has pervaded social media throughout the COVID-19 pandemic, it is unclear to what extent interest in public figures is generating anti-vaccine discourse. Objective: We examined Twitter messages that included anti-vaccination hashtags and mentions of public figures to assess the connection between interest in these individuals and the possible spread of anti-vaccine messages. Methods: We used a data set of COVID-19-related Twitter posts collected from the public streaming application programming interface from March to October 2020 and filtered it for anti-vaccination hashtags "antivaxxing," "antivaxx," "antivaxxers," "antivax," "anti-vaxxer," "discredit," "undermine," "confidence," and "immune." Next, we applied the Biterm Topic model (BTM) to output topic clusters associated with the entire corpus. Topic clusters were manually screened by examining the top 10 posts most highly correlated in each of the 20 clusters, from which we identified 5 clusters most relevant to public figures and vaccination attitudes. We extracted all messages from these clusters and conducted inductive content analysis to characterize the discourse. Results: Our keyword search yielded 118,971 Twitter posts after duplicates were removed, and subsequently, we applied BTM to parse these data into 20 clusters. After removing retweets, we manually screened the top 10 tweets associated with each cluster (200 messages) to identify clusters associated with public figures. Extraction of these clusters yielded 768 posts for inductive analysis. Most messages were either pro-vaccination (n=329, 43%) or neutral about vaccination (n=425, 55%), with only 2% (14/768) including anti-vaccination messages. Three main themes emerged: (1) anti-vaccination accusation, in which the message accused the public figure of holding anti-vaccination beliefs; (2) using "anti-vax" as an epithet; and (3) stating or implying the negative public health impact of anti-vaccination discourse. Conclusions: Most discussions surrounding public figures in common hashtags labelled as "anti-vax" did not reflect anti-vaccination beliefs. We observed that public figures with known anti-vaccination beliefs face scorn and ridicule on Twitter. Accusing public figures of anti-vaccination attitudes is a means of insulting and discrediting the public figure rather than discrediting vaccines. The majority of posts in our sample condemned public figures expressing anti-vax beliefs by undermining their influence, insulting them, or expressing concerns over public health ramifications. This points to a complex information ecosystem, where anti-vax sentiment may not reside in common anti-vax-related keywords or hashtags, necessitating further assessment of the influence that public figures have on this discourse.

Training the next generation of learning health system scientists.

Introduction: The learning health system (LHS) aligns science, informatics, incentives, stakeholders, and culture for continuous improvement and innovation. The Agency for Healthcare Research and Quality and the Patient-Centered Outcomes Research Institute designed a K12 initiative to grow the number of LHS scientists. We describe approaches developed by 11 funded centers of excellence (COEs) to promote partnerships between scholars and health system leaders and to provide mentored research training. Methods: Since 2018, the COEs have enlisted faculty, secured institutional resources, partnered with health systems, developed and implemented curricula, recruited scholars, and provided mentored training. Program directors for each COE provided descriptive data on program context, scholar characteristics, stakeholder engagement, scholar experiences with health system partnerships, roles following program completion, and key training challenges. Results: To date, the 11 COEs have partnered with health systems to train 110 scholars. Nine (82%) programs partner with a Veterans Affairs health system and 9 (82%) partner with safety net providers. Clinically trained scholars (n = 87; 79%) include 70 physicians and 17 scholars in other clinical disciplines. Non-clinicians (n = 29; 26%) represent diverse fields, dominated by population health sciences. Stakeholder engagement helps scholars understand health system and patient/family needs and priorities, enabling opportunities to conduct embedded research, improve outcomes, and grow skills in translating research methods and findings into practice. Challenges include supporting scholars through roadblocks that threaten to derail projects during their limited program time, ranging from delays in access to data to COVID-19-related impediments and shifts in organizational priorities. Conclusions: Four years into this novel training program, there is evidence of scholars' accomplishments, both in traditional academic terms and in terms of moving along career trajectories that hold the potential to lead and accelerate transformational health system change. Future LHS training efforts should focus on sustainability, including organizational support for scholar activities.

The Impact of the COVID-19 Pandemic on Internet Use and the Use of Digital Health Tools: Secondary Analysis of the 2020 Health Information National Trends Survey.

BACKGROUND: The COVID-19 pandemic increased the use of digital tools in health care (eg, patient portal, telemedicine, and web-based scheduling). Studies have shown that older individuals, racial/ethnic minority groups, or populations with lower educational attainment or income have lower rates of using digital health tools. Digitalization of health care may exacerbate already existing access barriers in these populations. OBJECTIVE: This study evaluated how use of digital tools to asynchronously communicate with clinicians, schedule appointments, and view medical records changed near the beginning of the pandemic. METHODS: Using 2020 Health Information National Trends Survey (HINTS) data, we examined internet use and 7 digital health technology use outcomes (electronic communication with a provider, electronic appointment scheduling, electronic test result viewing, patient portal access, portal use to download health records, portal use for patient-provider communication, and portal use to view test results). The HINTS surveyors designated surveys received after March 11, 2020, as postpandemic responses. Using weighted logistic regression, we investigated the impact of the pandemic after adjusting for sociodemographic traits (age, race/ethnicity, income, education, and gender), digital access (having ever used the internet and smartphone/tablet ownership), and health-related factors (insurance coverage, caregiver status, having a regular provider, and chronic diseases). To explore differences in changes in outcomes among key sociodemographic groups, we tested for significant interaction terms between the pandemic variable and race/ethnicity, age, income, and educational attainment. RESULTS: There were 3865 respondents (1437 prepandemic and 2428 postpandemic). Of the 8 outcomes investigated, the pandemic was only significantly associated with higher odds (adjusted odds ratio 1.99, 95% CI 1.18-3.35) of using electronic communication with a provider. There were significant interactions between the pandemic variable and 2 key sociodemographic traits. Relative to the lowest income group (

Centering Health Equity in Telemedicine.

In the wake of the racial injustices laid bare in 2020, on top of centuries of systemic racism, it is clear we need actionable strategies to fundamentally restructure health care systems to achieve racial/ethnic health equity. This paper outlines the pillars of a health equity framework from the Institute for Healthcare Improvement, overlaying a concrete example of telemedicine equity. Telemedicine is a particularly relevant and important topic, given the growing evidence of disparities in uptake by racial/ethnic, linguistic, and socioeconomic groups in the United States during the COVID-19 pandemic, as well as the new standard of care that telemedicine represents post-pandemic. We present approaches for telemedicine equity across the domains of: (1) strategic priorities of a health care organization, (2) structures and processes to advance equity, (3) strategies to address multiple determinants of health, (4) elimination of institutional racism and oppression, and (5) meaningful partnerships with patients and communities.

System-Level Factors Associated With Telephone and Video Visit Use: Survey of Safety-Net Clinicians During the Early Phase of the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic prompted safety-net health care systems to rapidly implement telemedicine services with little prior experience, causing disparities in access to virtual visits. While much attention has been given to patient barriers, less is known regarding system-level factors influencing telephone versus video-visit adoption. As telemedicine remains a preferred service for patients and providers, and reimbursement parity will not continue for audio visits, health systems must evaluate how to support higher-quality video visit access. OBJECTIVE: This study aimed to assess health system-level factors and their impact on telephone and video visit adoption to inform sustainability of telemedicine for ambulatory safety-net sites. METHODS: We conducted a cross-sectional survey among ambulatory care clinicians at a hospital-linked ambulatory clinic network serving a diverse, publicly insured patient population between May 28 and July 14, 2020. We conducted bivariate analyses assessing health care system-level factors associated with (1) high telephone adoption (4 or more visits on average per session); and (2) video visit adoption (at least 1 video visit on average per session). RESULTS: We collected 311 responses from 643 eligible clinicians, yielding a response rate of 48.4%. Clinician respondents (N=311) included 34.7% (n=108) primary or urgent care, 35.1% (n=109) medical, and 7.4% (n=23) surgical specialties. Our sample included 178 (57.2%) high telephone adopters and 81 (26.05%) video adopters. Among high telephone adopters, 72.2% utilized personal devices for telemedicine (vs 59.0% of low telephone adopters, P=.04). Video nonadopters requested more training in technical aspects than adopters (49.6% vs 27.2%, P<.001). Primary or urgent care had the highest proportion of high telephone adoption (84.3%, compared to 50.4% of medical and 37.5% of surgical specialties, P<.001). Medical specialties had the highest proportion of video adoption (39.1%, compared to 14.8% of primary care and 12.5% of surgical specialties, P<.001). CONCLUSIONS: Personal device access and department specialty were major factors associated with high telephone and video visit adoption among safety-net clinicians. Desire for training was associated with lower video visit use. Secure device access, clinician technical trainings, and department-wide assessments are priorities for safety-net systems implementing telemedicine.

The Abrupt Expansion of Ambulatory Telemedicine: Implications for Patient Safety.

The exponential growth of telemedicine in ambulatory care triggered by the COVID-19 public health emergency has undoubtedly impacted the quality of care and patient safety. In particular, the increased adoption of remote care has impacted communication, care teams, and patient engagement, which are key factors that impact patient safety in ambulatory care. In this perspective, we draw on a scoping review of the literature, our own clinical experiences, and conversations with patient safety experts to describe how changes in communication, care teams, and patient engagement have impacted two high priority areas in ambulatory safety: diagnostic errors and medication safety. We then provide recommendations for research funders, researchers, healthcare systems, policy makers, and healthcare payors for how to improve patient safety in telemedicine based on what is currently known as well as next steps for how to advance understanding of the safety implications of telemedicine utilization.

Barriers and Facilitators to the Implementation of Virtual Reality as a Pain Management Modality in Academic, Community, and Safety-Net Settings: Qualitative Analysis.

BACKGROUND: Prior studies have shown that virtual reality (VR) is an efficacious treatment modality for opioid-sparing pain management. However, the majority of these studies were conducted among primarily White, relatively advantaged populations and in well-resourced settings. OBJECTIVE: We conducted a qualitative, theory-informed implementation science study to assess the readiness for VR in safety-net settings. METHODS: Using the theoretical lens of the Consolidated Framework for Implementation Research (CFIR) framework, we conducted semistructured interviews with current VR users and nonusers based in safety-net health systems (n=15). We investigated barriers and facilitators to a commercially available, previously validated VR technology platform AppliedVR (Los Angeles, CA, USA). We used deductive qualitative analysis using the overarching domains of the CFIR framework and performed open, inductive coding to identify specific themes within each domain. RESULTS: Interviewees deemed the VR intervention to be useful, scalable, and an appealing alternative to existing pain management approaches. Both users and nonusers identified a lack of reimbursement for VR as a significant challenge for adoption. Current users cited positive patient feedback, but safety-net stakeholders voiced concern that existing VR content may not be relevant or appealing to diverse patients. All respondents acknowledged the challenge of integrating and maintaining VR in current pain management workflows across a range of clinical settings, and this adoption challenge was particularly acute, given resource and staffing constraints in safety-net settings. CONCLUSIONS: VR for pain management holds interest for frontline pain management clinicians and leadership in safety-net health settings but will require significant tailoring and adaption to address the needs of diverse populations. Integration into complex workflows for pain management is a significant barrier to adoption, and participants cited structural cost and reimbursement concerns as impediments to initial implementation and scaling of VR use.

Usability, inclusivity, and content evaluation of COVID-19 contact tracing apps in the United States.

We evaluated the usability of mobile COVID-19 contact tracing apps, especially for individuals with barriers to communication and limited digital literacy skills. We searched the Apple App Store, Google Play, peer-reviewed literature, and lay press to find contact tracing apps in the United States. We evaluated apps with a framework focused on user characteristics and user interface. Of the final 26 apps, 77% were on both iPhone and Android. 69% exceeded 9th grade readability, and 65% were available only in English. Only 12% had inclusive illustrations (different genders, skin tones, physical abilities). 92% alerted users of an exposure, 42% linked to a testing site, and 62% linked to a public health website within 3 clicks. Most apps alert users of COVID-19 exposure but require high English reading levels and are not fully inclusive of the U.S. population, which may limit their reach as public health tools.

Clinician Experience with Telemedicine at a Safety-net Hospital Network during COVID-19: A Cross-sectional Survey

Objective. The COVID-19 pandemic prompted unprecedented expansion of telemedicine services. We sought to describe clinician experiences providing telemedicine to publiclyinsured, lowincome patients during COVID-19. Methods. Online survey of ambulatory clinicians in an urban safetynet hospital system, conducted May 28, 2020–July 14, 2020. Results. Among 311 participants (response rate 48.3%), 34.7% (n=108/311) practiced in primary/urgent care, 37.0% (n=115/311) medical specialty, and 7.7% (n=24/311) surgical clinics. A large majority (87.8%, 273/311) had conducted telephone visits, 26.0% (81/311) video. Participants reported observing both technical and nontechnical patient barriers. Clinicians reported concerns about the diagnostic safety of telephone (58.9%, 129/219) vs. video (35.3%, 24/68). However, clinician comfort with telemedicine was high for telephone (89.3%, 216/242) and for video (91.0%, 61/67), with many clinicians (92.1%, 220/239 telephone;90.9%, 60/66 video) planning to continue telemedicine after COVID-19. Conclusions. Clinicians in a safetynet health care system report great comfort with and intention to continue telemedicine after the pandemic, despite safety concerns and patient challenges.

The Intersection of Work and Home Challenges Faced by Physician Mothers During the Coronavirus Disease 2019 Pandemic: A Mixed-Methods Analysis.

Objectives: The coronavirus disease 2019 (COVID-19) pandemic has presented extreme challenges for health care workers. This study sought to characterize challenges faced by physician mothers, compare differences in challenges by home and work characteristics, and elicit specific needs and potential solutions. Methods: We conducted a mixed-methods online survey of the Physician Moms Group (PMG) and PMG COVID19 Subgroup on Facebook from April 18th to 29th, 2020. We collected structured data on personal and professional characteristics and qualitative data on home and work concerns. We analyzed qualitative data thematically and used bivariate analyses to evaluate variation in themes by frontline status and children's ages. Results: We included 1,806 participants in analysis and identified 10 key themes. The most frequently identified need/solution was for Community and Government Support (n = 545, 47.1%). When comparing frontline and nonfrontline physicians, those on the frontline more frequently raised concerns about Personal Health and Safety (67.8% vs. 48.4%, p < 0.001), Organizational Communication and Relationships (31.8% vs. 23.8%, p < 0.001), and Family Health and Safety (27.2 vs. 16.6, p < 0.001), while nonfrontline physicians more frequently addressed Patient Care and Safety (56.4% vs. 48.2%, p < 0.001) and Financial/Job Security (33.8% vs. 46.9%, p < 0.001). Participants with an elementary school-aged child more frequently raised concerns about Parenting/Homeschooling (44.0% vs. 31.1%, p < 0.001) and Work/Life Balance (28.4 vs. 13.7, p < 0.001), and participants with a preschool-aged child more frequently addressed Access to Childcare (24.0 vs. 7.7, p < 0.001) and Spouse/Partner Relationships (15.8 vs. 9.5, p < 0.001), when compared to those without children in these age groups. Conclusions: The physician workforce is not homogenous. Health care and government leaders need to understand these diverse challenges in order to meet physicians' professional and family needs during the pandemic.

Real-world insights from launching remote peer-to-peer mentoring in a safety net healthcare delivery setting.

Peer mentors have been proven to improve diabetes outcomes, especially among diverse patients. Delivering peer mentoring via remote strategies (phone, text, mobile applications) is critical, especially in light of the recent pandemic. We conducted a real-world evaluation of a remote diabetes intervention in a safety-net delivery system in New York. We summarized the uptake, content, and pre-post clinical effectiveness for English- and Spanish-speaking participants. Of patients who could be reached, 71% (n = 690/974) were enrolled, and 90% of those (n = 618/690) participated in coaching. Patients and mentors had a mean of 32 check-ins, and each patient set an average of 10 goals. 29% of the participants accessed the program via the smartphone application. Among participants with complete hemoglobin A1c data (n = 179), there was an absolute 1.71% reduction (P < .01). There are multiple lessons for successful implementation of remote peer coaching into settings serving diverse patients, including meaningful patient-mentor matching and addressing social determinants.