Associations of the COVID-19 pandemic with quality of life: A cross-sectional study of older-age people with and without HIV in rural Uganda.

Background: COVID-19-related lockdowns and other public health measures may have differentially affected the quality of life (QOL) of older people with and without human immunodeficiency virus (HIV) in rural Uganda. Methods: The Quality of Life and Aging with HIV in Rural Uganda study enrolled people with and without HIV aged over 49 from October 2020 to October 2021. We collected data on COVID-19-related stressors (behavior changes, concerns, interruptions in health care, income, and food) and the participants' QOL. We used linear regression to estimate the associations between COVID-19-related stressors and QOL, adjusting for demographic characteristics, mental and physical health, and time before vs after the lockdown during the second COVID-19 wave in Uganda. Interaction between HIV and COVID-19-related stressors evaluated effect modification. Results: We analyzed complete data from 562 participants. Mean age was 58 (standard deviation (SD) = 7); 265 (47%) participants were female, 386 (69%) were married, 279 (50%) had HIV, and 400 (71%) were farmers. Those making ≥5 COVID-19-related behavior changes compared to those making ≤2 had worse general QOL (estimated linear regression coefficient (b) = - 4.77; 95% confidence interval (CI) = -6.61, -2.94) and health-related QOL (b = -4.60; 95% CI = -8.69, -0.51). Having access to sufficient food after the start of the COVID-19 pandemic (b = 3.10, 95% CI = 1.54, 4.66) and being interviewed after the start of the second lockdown (b = 2.79, 95% CI = 1.30, 4.28) were associated with better general QOL. Having HIV was associated with better health-related QOL (b = 5.67, 95% CI = 2.91,8.42). HIV was not associated with, nor did it modify the association of COVID-19-related stressors with general QOL. Conclusions: In the context of the COVID-19 pandemic in an HIV-endemic, low-resource setting, there was reduced QOL among older Ugandans making multiple COVID-19 related behavioral changes. Nonetheless, good QOL during the second COVID-19 wave may suggest resilience among older Ugandans.

The association between non-English primary language and COVID-19 clinical trial eligibility and enrollment: A retrospective cohort study.

BACKGROUND: Establishing equitable access to COVID-19 clinical trials is an important step in mitigating outcomes disparities. Historically, language has served as a barrier to equitable clinical trial participation. METHODS: A centralized research infrastructure was established at our institution to screen potential trial participants and to promote efficient and equitable access to COVID-19 clinical trials. Rates of eligibility and enrollment in COVID-19 clinical trials by primary language between April 9 and July 31, 2020 (during the first regional COVID-19 surge) were evaluated using logistic regression. Estimates were adjusted for potential confounders including age, sex, and time. RESULTS: A total of 1245 patients were admitted to the hospital with COVID-19 during the study period and screened for clinical trial eligibility. Among all screened patients, 487 (39%) had a non-English primary language. After adjustment, patients with a non-English primary language had 1.98 times higher odds (CI 1.51 to 2.59) of being eligible for 1 or more COVID-19 clinical trials. Among eligible patients, those with a non-English primary language had 1.83 times higher odds (CI 1.36 to 2.47) of enrolling in COVID-19 clinical trials than patients with English as the primary language. CONCULSION: These findings suggest that there are modifiable barriers that can be addressed to lessen the impact of language discordance on access to clinical trials and provide an opportunity to further investigate factors associated with clinical trial participation for patients whose primary language is not English.

The role of informational support from women's social networks on antenatal care initiation: qualitative evidence from pregnant women in Uganda.

BACKGROUND: Early and appropriate use of antenatal care services is critical for reducing maternal and neonatal mortality and morbidity. Yet most women in sub-Saharan Africa, including Uganda, do not seek antenatal care until later during pregnancy. This qualitative study explored pregnant women's reliance on social ties for information about initiation of antenatal care. METHODS: We conducted semi-structured, in-depth interviews with 30 pregnant women seeking their first antenatal care visit at Kawempe Referral Hospital in Kampala, Uganda. Recruitment was done purposively to obtain variation by parity and whether women currently had a male partner. Study recruitment occurred from August 25th 2020 - October 26th, 2020. We used thematic analysis following a two-stage coding process, with both deductive and inductive codes. Deductive codes followed the key domains of social network and social support theory. RESULTS: We found that the most important source of information about antenatal care initiation was these women's mothers. Other sources included their mothers-in-law, female elders including grandmothers, and male partners. Sisters and female friends were less influential information sources about antenatal initiation. One of the primary reasons for relying on their own mothers, mothers-in-law, and elder women was due to these women's lived experience with pregnancy and childbirth. Trust in the relationship was also an important factor. Some pregnant women were less likely to rely on their sisters or female friends, either due to lack of trust or these women's lack of experience with pregnancy and childbirth. The advice that pregnant women received from their mothers and others on the ideal timing for antenatal care initiation varied significantly, including examples of misinformation about when to initiate antenatal care. Pregnant women seemed less likely to delay care when more than one social tie encouraged early antenatal care. CONCLUSIONS: Educating women's social networks, especially their mothers, mothers-in-law, and community elders, about the importance of early antenatal care initiation is a promising avenue for encouraging pregnant women to seek care earlier in pregnancy.

Syndemics and clinical science.

The theory of syndemics has received increasing attention in clinical medicine since the onset of the COVID-19 pandemic, due to the synergistic interactions of the disease with pre-existing political, structural, social and health conditions. In simple terms, syndemics are synergistically interacting epidemics that occur in a particular context with shared drivers. When policymakers ask why some communities have higher death rates from COVID-19 compared with other communities, those working from a syndemics framework argue that multiple factors synergistically work in tandem, and populations with the highest morbidity and mortality experience the greatest impact of these interactions. In this Perspective, we use specific case examples to illustrate these concepts. We discuss the emergence of syndemics, how epidemics interact, and what scientists, clinicians and policymakers can do with this information.

Research priorities to reduce the impact of COVID-19 in low- and middle-income countries

Background The COVID-19 pandemic has caused disruptions to the functioning of societies and their health systems. Prior to the pandemic, health systems in low- and middle-income countries (LMIC) were particularly stretched and vulnerable. The International Society of Global Health (ISoGH) sought to systematically identify priorities for health research that would have the potential to reduce the impact of the COVID-19 pandemic in LMICs. Methods The Child Health and Nutrition Research Initiative (CHNRI) method was used to identify COVID-19-related research priorities. All ISoGH members were invited to participate. Seventy-nine experts in clinical, translational, and population research contributed 192 research questions for consideration. Fifty-two experts then scored those questions based on five pre-defined criteria that were selected for this exercise: 1) feasibility and answerability;2) potential for burden reduction;3) potential for a paradigm shift;4) potential for translation and implementation;and 5) impact on equity. Results Among the top 10 research priorities, research questions related to vaccination were prominent: health care system access barriers to equitable uptake of COVID-19 vaccination (ranked 1st), determinants of vaccine hesitancy (4th), development and evaluation of effective interventions to decrease vaccine hesitancy (5th), and vaccination impacts on vulnerable population/s (6th). Health care delivery questions also ranked highly, including: effective strategies to manage COVID-19 globally and in LMICs (2nd) and integrating health care for COVID-19 with other essential health services in LMICs (3rd). Additionally, the assessment of COVID-19 patients’ needs in rural areas of LMICs was ranked 7th, and studying the leading socioeconomic determinants and consequences of the COVID-19 pandemic in LMICs using multi-faceted approaches was ranked 8th. The remaining questions in the top 10 were: clarifying paediatric case-fatality rates (CFR) in LMICs and identifying effective strategies for community engagement against COVID-19 in different LMIC contexts. Interpretation Health policy and systems research to inform COVID-19 vaccine uptake and equitable access to care are urgently needed, especially for rural, vulnerable, and/or marginalised populations. This research should occur in parallel with studies that will identify approaches to minimise vaccine hesitancy and effectively integrate care for COVID-19 with other essential health services in LMICs. ISoGH calls on the funders of health research in LMICs to consider the urgency and priority of this research during the COVID-19 pandemic and support studies that could make a positive difference for the populations of LMICs.

Sociodemographic and geographic disparities in excess fatal drug overdoses during the COVID-19 pandemic in California: A population-based study.

Background: The coronavirus disease 2019 (COVID-19) pandemic is co-occurring with a drug addiction and overdose crisis. Methods: We fit overdispersed Poisson models, accounting for seasonality and secular trends, to estimate the excess fatal drug overdoses (i.e., deaths greater than expected), using data on all deaths in California from 2016 to 2020. Findings: Between January 5, 2020 and December 26, 2020, there were 8605 fatal drug overdoses-a 44% increase over the same period one year prior. We estimated 2084 (95% CI: 1925 to 2243) fatal drug overdoses were excess deaths, representing 5·28 (4·88 to 5·68) excess fatal drug overdoses per 100,000 population. Excess fatal drug overdoses were driven by opioids (4·48 [95% CI: 4·18 to 4·77] per 100,000), especially synthetic opioids (2·85 [95% CI: 2·56 to 3·13] per 100,000). The non-Hispanic Black and Other non-Hispanic populations were disproportionately affected with 10·1 (95% CI: 7·6 to 12·5) and 13·26 (95% CI: 11·0 to 15·5) excess fatal drug overdoses per 100,000 population, respectively, compared to 5·99 (95% CI: 5.2 to 6.8) per 100,000 population in the non-Hispanic white population. There was a steep, nonlinear educational gradient with the highest rate among those with only a high school degree. There was a strong spatial patterning with the highest levels of excess mortality in the southernmost region and consistently lower levels at progressively more northern latitudes (7·73 vs 1·96 per 100,000). Interpretation: Fatal drug overdoses disproportionately increased in 2020 among structurally marginalized populations and showed a strong geographic gradient. Local, tailored public health interventions are urgently needed to reduce growing inequities in overdose deaths. Funding: US National Institutes of Health and Department of Veterans Affairs.

Food insufficiency and mental health service utilisation in the USA during the COVID-19 pandemic.

OBJECTIVE: To estimate the association between food insufficiency and mental health service utilisation in the USA during the COVID-19 pandemic. DESIGN: Cross-sectional study. Multiple logistic regression models were used to estimate the associations between food insufficiency and mental health service utilisation. SETTING: US Census Household Pulse Survey data collected in October 2020. PARTICIPANTS: Nationally representative sample of 68 611 US adults. RESULTS: After adjusting for sociodemographic factors, experiencing food insufficiency was associated with higher odds of unmet mental health need (adjusted OR (AOR) 2·90; 95 % CI 2·46, 3·43), receiving mental health counselling or therapy (AOR 1·51; 95 % CI 1·24, 1·83) and psychotropic medication use (AOR 1·56; 95 % CI 1·35, 1·80). Anxiety and depression symptoms mediated most of the association between food insufficiency and unmet mental health need but not the associations between food insufficiency and either receiving mental health counselling/therapy or psychotropic medication use. CONCLUSIONS: Clinicians should regularly screen patients for food insufficiency, especially in the wake of the COVID-19 pandemic. Expanding access to supplemental food programmes may help to mitigate the need for higher mental health service utilisation during the COVID-19 pandemic.

Association Between Prison Crowding and COVID-19 Incidence Rates in Massachusetts Prisons, April 2020-January 2021.

Importance: COVID-19 incidence and mortality are higher among incarcerated persons than in the general US population, but the extent to which prison crowding contributes to their COVID-19 risk is unknown. Objective: To estimate the associations between prison crowding, community COVID-19 transmission, and prison incidence rates of COVID-19. Design, Setting, and Participants: This was a longitudinal ecological study among all incarcerated persons in 14 Massachusetts state prisons between April 21, 2020, and January 11, 2021. Exposures: The primary exposure of interest was prison crowding, measured by (1) the size of the incarcerated population as a percentage of the prison's design capacity and (2) the percentage of incarcerated persons housed in single-cell units. The analysis included the weekly COVID-19 incidence in the county where each prison is located as a covariate. Main Outcomes and Measures: The primary outcome was the weekly COVID-19 incidence rate as determined by positive SARS-CoV-2 tests among incarcerated persons at each prison over discrete 1-week increments. Results: There was on average 6876 people incarcerated in 14 prisons during the study period. The median level of crowding during the observation period ranged from 25% to 155% of design capacity. COVID-19 incidence was significantly higher in prisons where the incarcerated population was a larger percentage of the prison's design capacity (incidence rate ratio [IRR] per 10-percentage-point difference, 1.14; 95% CI, 1.03-1.27). COVID-19 incidence was lower in prisons where a higher proportion of incarcerated people were housed in single-cell units (IRR for each 10-percentage-point increase in single-cell units, 0.82; 95% CI, 0.73-0.93). COVID-19 transmission in the surrounding county was consistently associated with COVID-19 incidence in prisons (IRR [for each increase of 10 cases per 100 000 person-weeks in the community], 1.06; 95% CI, 1.05-1.08). Conclusions and Relevance: This longitudinal ecological study found that within 14 Massachusetts state prisons, increased crowding was associated with increased incidence rates of COVID-19. Researchers and policy makers should explore strategies that reduce prison crowding, such as decarceration, as potential ways to mitigate COVID-19 morbidity and mortality among incarcerated persons.

Coronavirus Disease 2019 (COVID-19) Transmission in the United States Before Versus After Relaxation of Statewide Social Distancing Measures.

BACKGROUND: Weeks after issuing social distancing orders to suppress severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission and reduce growth in cases of severe coronavirus disease 2019 (COVID-19), all US states and the District of Columbia partially or fully relaxed these measures. METHODS: We identified all statewide social distancing measures that were implemented and/or relaxed in the United States between 10 March and 15 July 2020, triangulating data from state government and third-party sources. Using segmented linear regression, we estimated the extent to which relaxation of social distancing affected epidemic control, as indicated by the time-varying, state-specific effective reproduction number (Rt). RESULTS: In the 8 weeks prior to relaxation, mean Rt declined by 0.012 units per day (95% confidence interval [CI], -.013 to -.012), and 46/51 jurisdictions achieved Rt < 1.0 by the date of relaxation. After relaxation of social distancing, Rt reversed course and began increasing by 0.007 units per day (95% CI, .006-.007), reaching a mean Rt of 1.16. Eight weeks later, the mean Rt was 1.16 and only 9/51 jurisdictions were maintaining an Rt < 1.0. Parallel models showed similar reversals in the growth of COVID-19 cases and deaths. Indicators often used to motivate relaxation at the time of relaxation (eg, test positivity rate <5%) predicted greater postrelaxation epidemic growth. CONCLUSIONS: We detected an immediate and significant reversal in SARS-CoV-2 epidemic suppression after relaxation of social distancing measures across the United States. Premature relaxation of social distancing measures undermined the country's ability to control the disease burden associated with COVID-19.

Perceptions, risk and understandings of the COVID-19 pandemic in urban South Africa.

BACKGROUND: How people perceive the coronavirus disease 2019 (COVID-19) pandemic and understand their risk can influence their health, behaviours and overall livelihood. The disease's novelty and severity have elicited a range of attitudes and perspectives countrywide, which consequently influence the public's adherence to public health prevention and treatment guidelines. AIM: To investigate perceptions, experiences and knowledge on COVID-19 in a community-based cohort study. SETTING: Adults living in Soweto in South Africa's Gauteng province during the first six weeks of the national lockdown regulations (i.e. Alert Level 5 lockdown from end of March to beginning of May 2020). METHODS: Participants completed a series of surveys and answered open-ended questions through telephonic interviews (n = 391). We queried their perceptions of the origins of COVID-19, understandings of the disease, personal and communal risks and its relations with the existing disease burden. RESULTS: Findings from our sample of 391 adults show that perceptions and knowledge of COVID-19 vary across several demographic characteristics. We report moderate levels of understanding about COVID-19, prevention methods and risk, as well as exposure to major physical, psychosocial and financial stressors. Depressive symptoms, perceived infection risk and concern about COVID-19 significantly predicted COVID-19 prevention knowledge. CONCLUSION: Public health communication campaigns should focus on continuing to improve knowledge and reduce misinformation associated with the virus. Policymakers should consider the mental health- and non-health-related impact of the pandemic on their citizens in order to curb the pandemic in a manner that maximises well-being.

Prevalence and Sociodemographic Correlates of Unmet Need for Mental Health Counseling Among Adults During the COVID-19 Pandemic.

OBJECTIVE: This study aimed to determine the prevalence and correlates of unmet need for mental health counseling among U.S. adults during the COVID-19 pandemic. METHODS: Data from the December 9-21, 2020, cross-sectional Household Pulse Survey (N=69,944) were analyzed. RESULTS: Overall, 12.8% of adults reported an unmet need for mental health counseling in the past month, including 25.2% of adults with a positive screen for depression or anxiety. Among adults with a positive screen, risk factors associated with an unmet need for mental health counseling included female sex, younger age, income below the federal poverty line, higher education, and household job loss during the pandemic, while protective factors included Asian and Black race. CONCLUSIONS: Over one-quarter of U.S. adults with a positive screen for depression or anxiety experienced an unmet need for mental health counseling during the pandemic. Policy makers should consider increasing funding for mental health services as part of pandemic relief legislation.

Mental health among outpatient reproductive health care providers during the US COVID-19 epidemic.

INTRODUCTION: Both inpatient and outpatient providers may be at increased risk of stress, anxiety and depression from their roles as health providers during the COVID-19 epidemic. This study explores how the US COVID-19 epidemic has increased feelings of stress, anxiety and depression among outpatient reproductive health providers. METHODS: We conducted a survey with open-ended responses among outpatient reproductive health providers across the U.S. engaged in contraceptive care to collect data on their experiences with stress, anxiety and depression during the COVID-19 epidemic. The study population included physicians, nurses, social workers, and other health professions [n = 288]. Data were collected from April 21st-June 24th 2020. We used content analysis of free text responses among providers reporting increased stress, anxiety or depression. RESULTS: Two-thirds (184) of providers reported increased stress and one-third (96) reported increased anxiety or depression related to care provision during the COVID-19 epidemic. The major sources of stress, anxiety and depression were due to patient care, worry about becoming infected or infecting family members, work- and home-related concerns, experiencing provider burnout, and fear of the unknown. Concerns about quality of patient care, providers' changing responsibilities, lack of personal protective equipment, and difficulty coping with co-worker illness and absence all contributed to provider stress and anxiety. Worries about unemployment and childcare responsibilities were also highlighted. Providers attributed their stress, anxiety or depression to feeling overwhelmed, being unable to focus, lacking sleep, and worrying about the unknown. CONCLUSIONS: US outpatient providers are experiencing significant stress, anxiety, and depression during the US COVID-19 epidemic. Policy and programmatic responses are urgently needed to address the widespread adverse mental health consequences of this epidemic on outpatient providers, including reproductive health providers, across the US. Both inpatient and outpatient providers may be at increased risk of stress, anxiety and depression from their roles as health providers during the COVID-19 epidemic. This study explores how the US COVID-19 epidemic has increased feelings of stress, anxiety and depression among outpatient reproductive health providers across the US. We conducted a survey from April 21st to June 24th, 2020 among outpatient reproductive health providers, including physicians, nurses, social workers and other health professions. We asked open-ended questions to understand why providers reported increased stress, anxiety and/or depression. Two-thirds (184) of providers reported increased stress and one-third (96) reported increased anxiety or depression from care provision during the COVID-19 epidemic. Major sources of stress, anxiety and depression were due to patient care, worry about becoming infected or infecting family members, work- and home-related concerns, experiencing provider burnout, and fear of the unknown. Concerns about quality of patient care, providers' changing responsibilities, lack of personal protective equipment, and difficulty coping with co-worker illness and absence all contributed to provider stress and anxiety. Worries about unemployment and childcare responsibilities were also highlighted. Providers attributed their stress, anxiety or depression to feeling overwhelmed, being unable to focus, lacking sleep, and worrying about the unknown. This study highlights that US outpatient reproductive health providers are experiencing significant stress, anxiety, and depression during the US COVID-19 epidemic. Policy and programmatic responses are urgently needed to address the widespread adverse mental health consequences of this epidemic on outpatient providers, including reproductive health providers, across the US.

Food Insufficiency and Mental Health in the U.S. During the COVID-19 Pandemic.

INTRODUCTION: During the COVID-19 pandemic, the rates of food insecurity and mental illness have been projected to increase in the U.S. owing to significant social and economic disruption. This study aims to estimate the prevalence of food insufficiency (often the most extreme form of food insecurity), the correlates of food insufficiency, and the associations between food insufficiency and symptoms of poor mental health in the U.S. during the COVID-19 pandemic. METHODS: Cross-sectional data from 63,674 participants of the U.S. Census Household Pulse Survey were collected and analyzed in 2020. Multiple Poisson regression models were used to estimate associations with food insufficiency. RESULTS: Food insufficiency rose from 8.1% to 10.0% from March to June 2020. Factors associated with food insufficiency included lower age, Black/African American or Latinx race/ethnicity, being unmarried, larger household size, recent employment loss, income below the federal poverty line, and lower education (all p<0.001). Food insufficiency was independently associated with all symptoms of poor mental health, adjusting for socioeconomic and demographic factors (adjusted RRs ranged from 1.16 to 1.42, all p<0.001). The association between food insufficiency and poor mental health was attenuated among people who received free groceries or meals. CONCLUSIONS: Food insufficiency has increased during the COVID-19 pandemic and affects vulnerable populations, placing individuals at higher risk for symptoms of poor mental health. Particularly in the current crisis, clinicians should regularly screen patients for food insufficiency and mental health outcomes as well as provide support in accessing appropriate resources.

Job Insecurity and Symptoms of Anxiety and Depression Among U.S. Young Adults During COVID-19.

PURPOSE: This study aimed to estimate the associations between job insecurity and symptoms of anxiety and depression among U.S. young adults amidst the COVID-19 pandemic. METHODS: We analyzed data on young adults aged 18-26 years from June 15 to June 30, 2020, from the weekly, cross-sectional Household Pulse Survey (n = 4,852) conducted by the U.S. Census Bureau. Two job insecurity measures and four anxiety and depression measures were analyzed using multivariable Poisson regression models adjusting for age, sex, race/ethnicity, education, and marital status. RESULTS: Fifty-nine percent of participants experienced direct or household employment loss since the start of the COVID-19 pandemic, and 38% were expected to experience direct or household employment loss in the coming 4 weeks. Recent direct or household employment loss and expected direct or household employment loss, among participants who did not experience recent employment loss, were associated with a greater risk of poor mental health on all four measures. CONCLUSIONS: U.S. young adults experience a significant mental health burden as a result of job insecurity amidst the COVID-19 pandemic.

Correction: Social distancing to slow the US COVID-19 epidemic: Longitudinal pretest-posttest comparison group study.

[This corrects the article DOI: 10.1371/journal.pmed.1003244.].

Social distancing to slow the US COVID-19 epidemic: Longitudinal pretest-posttest comparison group study.

BACKGROUND: Social distancing measures to address the US coronavirus disease 2019 (COVID-19) epidemic may have notable health and social impacts. METHODS AND FINDINGS: We conducted a longitudinal pretest-posttest comparison group study to estimate the change in COVID-19 case growth before versus after implementation of statewide social distancing measures in the US. The primary exposure was time before (14 days prior to, and through 3 days after) versus after (beginning 4 days after, to up to 21 days after) implementation of the first statewide social distancing measures. Statewide restrictions on internal movement were examined as a secondary exposure. The primary outcome was the COVID-19 case growth rate. The secondary outcome was the COVID-19-attributed mortality growth rate. All states initiated social distancing measures between March 10 and March 25, 2020. The mean daily COVID-19 case growth rate decreased beginning 4 days after implementation of the first statewide social distancing measures, by 0.9% per day (95% CI -1.4% to -0.4%; P < 0.001). We did not observe a statistically significant difference in the mean daily case growth rate before versus after implementation of statewide restrictions on internal movement (0.1% per day; 95% CI -0.04% to 0.3%; P = 0.14), but there is substantial difficulty in disentangling the unique associations with statewide restrictions on internal movement from the unique associations with the first social distancing measures. Beginning 7 days after social distancing, the COVID-19-attributed mortality growth rate decreased by 2.0% per day (95% CI -3.0% to -0.9%; P < 0.001). Our analysis is susceptible to potential bias resulting from the aggregate nature of the ecological data, potential confounding by contemporaneous changes (e.g., increases in testing), and potential underestimation of social distancing due to spillover effects from neighboring states. CONCLUSIONS: Statewide social distancing measures were associated with a decrease in the COVID-19 case growth rate that was statistically significant. Statewide social distancing measures were also associated with a decrease in the COVID-19-attributed mortality growth rate beginning 7 days after implementation, although this decrease was no longer statistically significant by 10 days.