Public Health Data of the People, by the People, for the People: A Public Health of Consequence, June 2023

The author discusses a study by Krieger and colleagues, published within the issue which presents information on the alarming decreases in response rates across six national U.S. surveys in 2020 compared with those in 2019. Topics include people who were more likely to complete surveys than those who did, importance of the application of an equity-focused lens to data collection, and the impact of the COVID-19 pandemic on response rates.

The Other Side of the Balance Sheet: Work as a Fundamental Determinant of Health

The article discusses a study from Gaffney and colleagues, published within the issue which provides evidence for the fundamental role that workplace transmission played in differences in the risk of COVID-19 infection. Topics include the impact of occupational transmission of COVID-19;reasons for the denial on the role of work in the risk of disease, injury and death;and means by which work as a fundamental determinant of health can be targeted.

Community seroprevalence of SARS-CoV-2 in children and adolescents in England, 2019-2021.

OBJECTIVE: To understand community seroprevalence of SARS-CoV-2 in children and adolescents. This is vital to understanding the susceptibility of this cohort to COVID-19 and to inform public health policy for disease control such as immunisation. DESIGN: We conducted a community-based cross-sectional seroprevalence study in participants aged 0-18 years old recruiting from seven regions in England between October 2019 and June 2021 and collecting extensive demographic and symptom data. Serum samples were tested for antibodies against SARS-CoV-2 spike and nucleocapsid proteins using Roche assays processed at UK Health Security Agency laboratories. Prevalence estimates were calculated for six time periods and were standardised by age group, ethnicity and National Health Service region. RESULTS: Post-first wave (June-August 2020), the (anti-spike IgG) adjusted seroprevalence was 5.2%, varying from 0.9% (participants 10-14 years old) to 9.5% (participants 5-9 years old). By April-June 2021, this had increased to 19.9%, varying from 13.9% (participants 0-4 years old) to 32.7% (participants 15-18 years old). Minority ethnic groups had higher risk of SARS-CoV-2 seropositivity than white participants (OR 1.4, 95% CI 1.0 to 2.0), after adjusting for sex, age, region, time period, deprivation and urban/rural geography. In children <10 years, there were no symptoms or symptom clusters that reliably predicted seropositivity. Overall, 48% of seropositive participants with complete questionnaire data recalled no symptoms between February 2020 and their study visit. CONCLUSIONS: Approximately one-third of participants aged 15-18 years old had evidence of antibodies against SARS-CoV-2 prior to the introduction of widespread vaccination. These data demonstrate that ethnic background is independently associated with risk of SARS-CoV-2 infection in children. TRIAL REGISTRATION NUMBER: NCT04061382.

Risk of partial school closure for COVID-19 by socio-economic level in the period 2020-22.

BACKGROUND: The objective was to analyse the risk of partial school closure by economic level in Barcelona city. METHODS: In this ecological study, the risk of partial school closure for the academic years 2020-21 and 2021-22 was estimated by dividing the total number of days that each child was in quarantine or isolation by the total number of days that each child was at risk to be in quarantine or isolation in the academic year. The association between partial school closure risk and mean income by district was estimated with the Spearman rho. RESULTS: The lower the mean income, the higher the risk of partial closure (Spearman rho = 0.83; P-value = 0.003) during the academic year 2020-21. Specifically, the children from the district with the lowest income had a six times greater risk of partial school closure compared with those from the highest-income district. This risk did not show a significant socioeconomic gradient in the academic year 2021-22. CONCLUSIONS: The risk of partial school closure presented an inverse socioeconomic gradient in the city of Barcelona according to average income by district in the academic year 2020-21. This distribution was not observed in the academic year 2021-22.

Increasing ethnicity reporting to better understand cultural needs accessing a primary care talking therapy service.

BACKGROUND: The COVID-19 pandemic highlighted the under-utilisation of statutory mental health care services by minority ethnic groups in the United Kingdom (UK). AIM: To improve ethnicity reporting to better understand the needs of patients accessing a primary care talking therapies service. METHOD: We conducted a clinical audit to observe outcomes from pre-COVID (2019), first wave of COVID-19 (2020) and 2021 for three broad ethnic categories: black African/Caribbean, Asian and white British. Intervention was conducted on staff to improve data recording of ethnicity. A patient survey was sent to those identified as dropped out from treatment from May 2020 to April 2021. A total of 229 patients responded to the survey. The survey asked for reasons that impacted on not continuing with sessions. RESULTS: Quantitative analysis showed a statistically significant difference on discharge outcome between white British and black African/Caribbean (p=<0.0001), with black African/Caribbean patients most likely to drop out of treatment, and in 2020 the Asian population was below the recovery target of 50%. Qualitative analysis revealed therapist factors included lack of confidence in therapist and not being listened to, patient factors included neurodiversity, being unsure whether it would be helpful and confidentiality concerns, and service factors included being notified of discharge from the service, remote delivery of therapy, treatment options, and treatment materials. DISCUSSIONS: Services must work towards improving service provision by capturing hidden disparities and socialising treatment to meet the needs of minority ethnic groups in the UK. The present study recommends culturally adapted treatment and co-producing therapy materials.

Patient Characteristics Associated with Telehealth Scheduling and Completion in Primary Care at a Large, Urban Public Healthcare System.

Understanding patient characteristics associated with scheduling and completing telehealth visits can identify potential biases or latent preferences related to telehealth usage. We describe patient characteristics associated with being scheduled for and completing audio and video visits. We used data from patients at 17 adult primary care departments in a large, urban public healthcare system from August 1, 2020 to July 31, 2021. We used hierarchical multivariable logistic regression to generate adjusted odds ratios (aOR) for patient characteristics associated with having been scheduled for and completed telehealth (vs in-person) visits and for video (vs audio) scheduling and completion during two time periods: a telehealth transition period (N = 190,949) and a telehealth elective period (N = 181,808). Patient characteristics were significantly associated with scheduling and completion of telehealth visits. Many associations were similar across time periods, but others changed over time. Patients who were older (≥ 65 years old vs 18-44 years old: aOR for scheduling 0.53/completion 0.48), Black (0.86/0.71), Hispanic (0.76/0.62), or had Medicaid (0.93/0.84) were among those less likely to be scheduled for or complete video (vs audio) visits. Patients with activated patient portals (1.97/3.34) or more visits (≥ 3 scheduled visits vs 1 visit: 2.40/1.52) were more likely to be scheduled for or complete video visits. Variation in scheduling/completion explained by patient characteristics was 7.2%/7.5%, clustering by provider 37.2%/34.9%, and clustering by facility 43.1%/37.4%. Stable and dynamic associations suggest persistent gaps in access and evolving preferences/biases. Variation explained by patient characteristics was relatively low compared with that explained by provider and facility clustering.

Impact of healthcare strain on access to mechanical ventilation and mortality of hospitalized COVID-19 patients: a retrospective cohort study.

OBJECTIVE: Healthcare saturation has been a prominent worry during the COVID-19 pandemic. Increase of hospital beds with mechanical ventilators has been central in Mexico's approach, but it is not known whether this actually improves access to care and the resulting quality of it. This study aimed to determine the impact of healthcare strain and other pre-specified variables on dying from coronavirus disease 2019 (COVID-19) without receiving invasive mechanical ventilation (IMV). METHODS: A retrospective cohort study was conducted using open data from Mexico City between 8 May 2020 and 5 January 2021. We performed Cox proportional hazards models to identify the strength of the association between proposed variables and the outcomes. RESULTS: Of 33 797 hospitalized patients with suspected or confirmed COVID-19, 19 820 (58.6%) did not require IMV and survived, 5414 (16.1%) required IMV and were intubated and 8563 (25.3%) required IMV but died without receiving it. A greater occupation of IMV-capable beds increased the hazard of death without receiving IMV (hazard ratio [HR] 1.56, comparing 90% with 50% occupation). Private healthcare was the most protective factor for death without IMV (HR 0.14). CONCLUSIONS: Higher hospital bed saturation increased the hazard of dying without being intubated and worsened the outcomes among mechanically ventilated patients. Older age also increased the hazard of the outcomes, while private healthcare dramatically decreased them.

Impact of COVID-19 lockdowns on hospital presentations and admissions in the context of low community transmission: evidence from time series analysis in Melbourne, Australia.

BACKGROUND: Melbourne, Australia, successfully halted exponential transmission of COVID-19 via two strict lockdowns during 2020. The impact of such restrictions on healthcare-seeking behaviour is not comprehensively understood, but is of global importance. We explore the impact of the COVID-19 pandemic on acute, subacute and emergency department (ED) presentations/admissions within a tertiary, metropolitan health service in Melbourne, Australia, over two waves of community transmission (1 March to 20 September 2020). METHODS: We used 4 years of historical data and novel forecasting methods to predict counterfactual hospital activity for 2020, assuming absence of COVID-19. Observed activity was compared with forecasts overall, by age, triage category and for myocardial infarction and stroke. Data were analysed for all patients residing in the health service catchment area presenting between 4 January 2016 and 20 September 2020. RESULTS: ED presentations (n=401 805), acute admissions (n=371 723) and subacute admissions (n=15 676) were analysed. Substantial departures from forecasted presentation levels were observed during both waves in the ED and acute settings, and during the second wave in subacute. Reductions were most marked among those aged >80 and <18 years. Presentations persisted at expected levels for urgent conditions, and ED triage categories 1 and 5, with clear reductions in categories 2-4. CONCLUSIONS: Our analyses suggest citizens were willing and able to present with life-threatening conditions during Melbourne's lockdowns, and that switching to telemedicine did not cause widespread spill-over from primary care into ED. During a pandemic, lockdowns may not inhibit appropriate hospital attendance where rates of infectious disease are low.

News Focus

This section offers medical-related news briefs for the year 2023 in the United Kingdom (UK) which includes funding allocated by the Department for Health and Social Care for women's health hubs in England, plan for the spring Covid-19 booster campaign, and areas with highest emergency admissions and death rates for lung conditions.

Visualization Analysis of Primary Healthcare Research during the COVID-19 Pandemic

Background Primary healthcare is the first line of defense for the containment of COVID-19 pandemic. Primary healthcare has been studied extensively by academic circles in various countries during the pandemic，but the focuses vary across these studies due to differences in primary healthcare systems in different countries. Objective To understand the advances，hotspots，trends and differences of primary care-related research at home and abroad during the COVID-19 epidemic，and to provide a reference for further research in this field. Methods Primary healthcare-related studies published during the COVID-19 pandemic（between January 1，2020 and June 30，2022）were searched in databases of CNKI and Web of Science Core Collection on July 5，2022，and 282 from the former database and 1 755 from the latter were included. CiteSpace was used for visualization analysis to provide a graphic visualization of co-occurrence networks of authors，keywords and keywords clusters，to perform a timeline analysis，and to detect keywords with bursts. Results The number of publications in China grew fast at the beginning of the pandemic，then the growth gradually decreased，and tended to level off at the late stage. In contrast，relevant research started later in foreign countries，but the number of relevant publications maintained high-speed growth as of the study time. The major author cooperation forms were inter-small teams cooperation and inter-individual cooperation，and no large-scale inter-team cooperation was found. The hotspots of domestic research focus on the systems，the exploration of mechanisms and management practices related to pandemic prevention and control，while international research focuses on changes in healthcare-seeking patterns and the satisfaction of patients' medical needs under the influence of the pandemic. Psychological problems related to the pandemic were concerned by both domestic and international research. Conclusion Domestic and foreign studies have similarities and different focuses. To continuous refine and diversify domestic research，it is suggested to learn international experience，pay attention to the construction of relevant research forces，improve the knowledge system in this field，and actively use information technology to improve the primary care system amid the pandemic. © 2023 Chinese General Practice. All rights reserved.

Patient Factors Associated With Teledermatology Visit Type and Submission of Photographs During the COVID-19 Pandemic: Cross-sectional Analysis

Background: The COVID-19 pandemic necessitated the widespread adoption of teledermatology, and this continues to account for a significant proportion of dermatology visits after clinics have reopened for in-person care. Delivery of high-quality teledermatology care requires adequate visualization of the patient's skin, with photographs being preferred over live video for remote skin examination. It remains unknown which patients face the greatest barriers to participating in a teledermatology visit with photographs. Objective: The aim of this study was to identify patient characteristics associated with type of telemedicine visit and the factors associated with participating in teledermatology visits with digital photographs versus those without photographs. Methods: We performed a cross-sectional analysis of the University of Pennsylvania Health System electronic health record data for adult patients who participated in at least 1 teledermatology appointment between March 1, 2020, and June 30, 2020. The primary outcomes were participation in a live-interactive video visit versus a telephone visit and participation in any teledermatology visit with photographs versus one without photographs. Multivariable logistic regression was performed to evaluate the associations between patient characteristics and the primary outcomes. Results: In total, 5717 unique patients completed at least 1 teledermatology visit during the study period;68.25% (n=3902) of patients participated in a video visit, and 31.75% (n=1815) participated in a telephone visit. A minority of patients (n=1815, 31.75%) submitted photographs for their video or telephone appointment. Patients who submitted photographs for their teledermatology visit were more likely to be White, have commercial insurance, and live in areas with higher income, better education, and greater access to a computer and high-speed internet (P<.001 for all). In adjusted analysis, older age (age group >75 years: odds ratio [OR] 0.60, 95% CI 0.44-0.82), male sex (OR 0.85, 95% CI 0.75-0.97), Black race (OR 0.79, 95% CI 0.65-0.96), and Medicaid insurance (OR 0.81, 95% CI 0.66-0.99) were each associated with lower odds of a patient submitting photographs for their video or telephone visit. Older age (age group >75 years: OR 0.37, 95% CI 0.27-0.50) and Black race (OR 0.82, 95% CI 0.68-0.98) were also associated with lower odds of a patient participating in a video visit versus telephone visit. Conclusions: Patients who were older, male, or Black, or who had Medicaid insurance were less likely to participate in teledermatology visits with photographs and may be particularly vulnerable to disparities in teledermatology care. Further research is necessary to identify the barriers to patients providing photographs for remote dermatology visits and to develop targeted interventions to facilitate equitable participation in teledermatology care. ©Jordan E Lamb, Robert Fitzsimmons, Anjana Sevagamoorthy, Carrie L Kovarik, Daniel B Shin, Junko Takeshita. Originally.

Client-level barriers to successful utilization of telehealth for clients with autism spectrum disorder

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication and repetitive, restricted behaviors, with a current estimated prevalence of 1:54. Individuals with ASD typically benefit from a range of medical, psychological, and other services due to impairments caused by ASD as well as high rates of comorbid conditions. Despite this increased need, individuals with ASD and their families often report significant difficulty accessing services, an issue which is compounded for some groups including minoritized racial groups and people living in rural areas. The current study sought to identify challenges faced by clients with ASD and their families when attempting to access behavioral health services via telehealth within the context of the COVID-19 pandemic. Specific research questions were: (1) What are the most common challenges faced by clients with ASD and their families when attempting to access telehealth services? (2) What are the most problematic barriers (i.e., barriers most associated with being unable to access telehealth) faced by clients with ASD and their families when attempting access telehealth services? and (3) Which demographic groups (e.g., race, age, comorbidities) are least likely to be able to access telehealth?Data were extracted from client records of a multi-site provider of developmental disability (DD) services in Ohio following Institutional Review Board (IRB) approval. Results of our analyses suggest that the most common challenges faced by clients with ASD and their families were issues related to client behavior, including client inattention, client noncompliance, and need for in-person support. In regard to ability versus inability to access telehealth services, need for in-person support was found to be related to decreased likelihood of receiving telehealth services, and client inattention was found to be related to increased likelihood of receiving telehealth services. Demographic groups most likely to experience difficulty accessing telehealth services were African American/Black clients and clients with a language disorder.Results of the current study re-iterate challenges identified in previous studies on healthcare access for clients with ASD and their families, including issues related to behavior and communication difficulties. They also highlight the effects of race on access to services, with minoritized racial groups consistently being found to experience increased challenges in accessing healthcare. While future research should further study these effects on additional samples and outside of the context of COVID-19, the current results provide information on where interventions designed to increase access to behavioral health services may be most efficiently targeted. Possible solutions to address identified issues are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Telehealth Use and Access to Care for Underserved Populations Before and During the COVID-19 Pandemic

While several studies have documented the rapid growth in telehealth visits during the pandemic, none have examined its relationship with greater overall access to care among vulnerable populations. We use Association of American Medical Colleges' Consumer Survey data to examine the relationship between access to care and telehealth use before and during the pandemic. The proportion of survey respondents who were always able to get medical care when needed was slightly lower in 2020 compared with prior years while telehealth use rose dramatically. Disparities in telehealth use for Medicaid beneficiaries and rural respondents disappeared during the pandemic, but remained for lower-income populations. Before the pandemic, telehealth use was associated with greater access, but not during the pandemic—when it appears to have become a substitute for in-person. After the pandemic, telehealth could once again be an opportunity to supplement access to care, if telehealth policies enacted during the pandemic are made permanent.

Digital Technology in Community Engagement: Impacts and Implications

Health professionals are increasingly using digital technology as a strategy to maximize community engagement and effectively implement health interventions, a phenomenon evidenced by the COVID-19 pandemic. While technology has improved health information dissemination, communication, and data management, it cannot replace the human-based interactions offered by traditional grassroots outreach that can influence long-term health behavior change, particularly for underserved communities. Digital community engagement can be part of the digital divide, often widening disparities by excluding those without access or limited access to technology. It may hinder the accurate collection of contextual and comprehensive data needed to analyze social determinants of health, thereby widening the equity gap. This commentary explores the challenges of using digital technology and justifies leveraging it to complement traditional community engagement rather than as a replacement.

The COVID-19 Pandemic in Hong Kong: Exploring the Gaps in COVID-19 Prevention Practices from a Social Justice Framework

Like many settings worldwide, Hong Kong has recently been combatting the COVID-19 pandemic. Ethnic minorities have reported perceived discrimination via local media outlets. They have been stereotyped as virus spreaders due to the increasing number of confirmed cases and untraceable COVID-19 clusters in Hong Kong. Using a social justice framework, this qualitative study explores gaps in COVID-19 prevention practices to eliminate systemic barriers for ethnic minorities in Hong Kong. Fifteen interviews were conducted with social service providers who worked closely with ethnic minority groups (South and Southeast Asian groups from low-income households, foreign domestic workers and asylum seekers and refugees) during the fourth wave of the COVID-19 pandemic in Hong Kong. This study yielded six themes using thematic analysis as follows: (i) lacking mental health support for diverse ethnic minority groups;(ii) lacking efforts to eliminate perceived discrimination;(iii) existing language barriers across diverse services;(iv) lacking channels to disseminate accurate information;(v) a need for advanced technology and (vi) lacking appropriate surgical mask sizes for some ethnic minority individuals. This study recommends culturally responsive practices in Hong Kong.

Adapting parent‐focused interventions for diverse caregivers of children with intellectual and developmental disabilities: Lessons learned during global crises

Parent‐focused interventions have been designed to provide training and support to caregivers who are essential in achieving positive outcomes for children with intellectual and developmental disabilities (IDD). In 2020, significant crises, including the COVID‐19 pandemic and continued racial tensions, profoundly impacted the livelihood of children with IDD and their families. Many ongoing efforts to address disparities among this population were halted temporarily and required further adaptations. Researchers adapted interventions and support to address the disparities impacting children with IDD and their families with limited guidance. We provide a descriptive case analysis of four parent‐focused interventions that responded to the global crises to continue serving children with IDD and their families. The four distinct programs were based on applied behavior analysis and naturalistic, developmental‐behavioral paradigms that were culturally adapted for families of young children with IDD from diverse cultural and socioeconomic backgrounds. We present the qualitative reports on the challenges and benefits that arose with adapting the four parent‐focused interventions for telehealth implementation. We focused specifically on adaptations made in recruitment and retention, instrumentation and measurement, research staff training, and intervention delivery. We synthesize our experience with challenges and solutions in adapting parent‐focused interventions for racially/ethnically and socioeconomically diverse children with IDD and their families. We conclude with recommendations for researchers and practitioners on methods for adapting parent‐focused interventions to address the significant health disparities that impact racially, ethnically, and socioeconomically diverse children with IDD and their families.

Social Accountability and Legal Empowerment Initiatives: Improving the Health of Underserved Roma Communities in Eastern Europe

Improving the protection of the right to health of ethnic Roma people is one of the most pressing public health challenges in contemporary Europe, as their life expectancy and health status remain significantly lower than their non-Roma counterparts. This paper analyzes Roma-led accountability initiatives that embrace social accountability and legal empowerment approaches to advocate for equitable fulfillment of the right to health. While these initiatives have led to the elimination of some harmful health practices (such as illegal cash bribes and violent and abusive treatment by medical professionals) and to improvements in health care, and some Roma communities have become driving forces for local and national health system reforms for advancing the fulfillment of health rights, the health inequalities affecting Roma communities remain significant. This issue also remains largely overlooked by European health research and policy experts, who are mostly reluctant to incorporate analyses of ethnicity and racialization into their research on health inequalities in Europe. The COVID-19 pandemic has further exacerbated these health inequalities.

The COVID-19 outbreak and the HIV pandemic

The global outbreak of COVID-19 has imposed considerable stress on healthcare systems throughout the world, further complicating treatment of HIV and access to care for HIV patients. The many challenges that persons living with HIV must negotiate daily are now accentuated by COVID-19 imposed constraints. This includes the repetition and magnification of stigma, loss, isolation, psychological trauma complicated by healthcare disparities, additional barriers to accessing care, and depletion of already strained healthcare resources. The COVID-19 outbreak also introduces a new and perilous threat of COVID-19 and HIV comorbidity. Numerous challenges that arise with the COVID-19 pandemic also provide opportunities for persons with HIV to strengthen their individual coping skills, build resilience, and become a resource for their communities. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Vaccine perceptions among Black adults with long COVID.

OBJECTIVES: Low uptake of COVID vaccines within Black communities is a concern given the stark racial inequities associated with the pandemic. Prior research details COVID vaccine perceptions within the general population and Black communities specifically. However, Black individuals with long COVID may be more or less receptive to future COVID vaccination than their peers without long COVID. The impact of COVID vaccination on long COVID symptoms is still controversial, since some studies suggest that vaccination can improve long COVID symptoms, whereas other studies report no significant change in symptoms or a worsening of symptoms. In this study, we aimed to characterize the factors influencing perceptions of COVID vaccines among Black adults with long COVID to inform future vaccine-related policies and interventions. DESIGN: We conducted 15 semi-structured, race-concordant interviews over Zoom with adults who reported physical or mental health symptoms that lingered for a month or more after acute COVID infection. We transcribed and anonymized the interviews and implemented inductive, thematic analysis to identify factors influencing COVID vaccine perceptions and the vaccine decision-making process. RESULTS: We identified five themes that influenced vaccine perceptions: (1) Vaccine safety and efficacy; (2) Social implications of vaccination status; (3) Navigating and interpreting vaccine-related information; (4) Possibility of abuse and exploitation by the government and scientific community; and (5) Long COVID status. Safety concerns were amplified by long COVID status and mistrust in social systems due to mistreatment of the Black community. CONCLUSIONS: Among the factors influencing COVID vaccine perceptions, participants reported a desire to avoid reinfection and a negative immune response. As COVID reinfection and long COVID become more common, achieving adequate uptake of COVID vaccines and boosters may require approaches that are tailored in partnership with the long COVID patient community.