The Magnification of Health Disparities During the COVID-19 Pandemic

The patient perspective on diversity-sensitive care: a systematic review

BACKGROUND

The provision of diversity-sensitive care is a promising approach towards reducing health disparities. Recent criticism and a scientific gap demonstrate the need for the patient perspective on diversity-sensitive care. This systematic review aims to describe the patient perspective, including patient experiences, expectations, and satisfaction with diversity-sensitive care provided by healthcare providers.

METHODS

In December 2022 the Medline ALL, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO and additionally Google Scholar were searched for original studies that described or measured patient expectations, experiences, and/or satisfaction, specifically focusing on cultural or diversity competence of healthcare providers. Analysis of the collected data was performed using a convergent mixed-methods design based on thematic synthesis.

RESULTS

From initially 5,387 articles, 117 were selected for full-text screening, and ultimately, 34 articles were included in this study. The concept of diversity-sensitive care was observed to comprise three components. The first component is focused on patient-centered care and includes competencies such as clear and direct communication, shared decision-making, individualized care, empathy, and consideration. The second component centers on providing culturally tailored information, adjusting care to cultural needs, working with interpreters, allyship, community partnerships, self-awareness, and cultural knowledge, and builds upon the first component. Across the first two components of diversity-sensitive care, patients have reported experiencing dissatisfaction and encountering shortcomings in their healthcare providers, sometimes resulting in the third and final component pertaining to provider care. This component underscores the importance of linguistic, ethnic, cultural, and gender concordance in delivering quality care.

CONCLUSION

In conclusion, the patient perspective on diversity-sensitive care encompasses multiple components, from patient-centered care to concordant care. The components incorporate various competencies as communication skills, empathy, self-awareness and adjusting care to cultural needs. Patients reported experiencing dissatisfaction and shortcomings across all components of diversity-sensitive care provided by healthcare providers.

From art to health action: lessons from a community-based, culturally tailored arts-meets-health educational campaign in Hispanic communities

Introduction

Robust digital and community-led approaches are needed to combat health misinformation, as highlighted by the COVID-19 pandemic. Such gaps in public health outreach, compounded by systemic health barriers, contributed to higher rates of COVID-19 infection, mortality, and mental health effects among Hispanics during the peak of the pandemic. Thus, we conducted a community-based art-meets-health intervention [Stay Connected Los Angeles (SCLA)] to address the impacts of the COVID-19 pandemic in Hispanic communities.

Methods

Led by local artists in collaboration with public health specialists and community members, SCLA used multimedia to promote infection mitigation behaviors and psychological well-being among the 120,000 residents of Eastern Los Angeles. Campaign materials were designed with input from community representatives and included digital media, large-scale murals, and comic-book style pieces. Two semi-structured focus groups (one in English and another in Spanish) were conducted to solicit participants' views on attributes of the campaign. Independent coders analyzed transcripts and applied thematic analysis to summarize key learnings regarding central health and mitigation messages, media modalities, how health information would be communicated, and the ideal spokespersons for delivering health-related messages.

Results

Focus group participants emphasized the effectiveness of social media, GIFs, and references to popular media. Further, youth involvement in the creative process was deemed to be important. Participants highlighted the need for clarity in public health messaging and adaptation of visual campaigns to the preferences of diverse age groups through different art styles. Finally, community leaders were found to be critical health information sources.

Discussion

As a model of a culturally tailored arts-meets health public education campaign, SCLA yielded valuable information on how to structure future public health messaging and media to create a meaningful improvement in health knowledge, mental well-being, and compliance with mitigation behaviors in communities that are often overlooked. Contributions from local artists can heighten appeal and acceptability of messages.

Association Between Changes in Racial Residential and School Segregation and Trends in Racial Health Disparities, 2000-2020: A Life Course Perspective

INTRODUCTION

Most studies of the relationship between racial segregation and racial health disparities have focused on residential segregation. School-based racial segregation is an additional form of segregation that may be associated with racial disparities in health. This study examines the relationship between both residential segregation and school segregation and racial health disparities among non-Hispanic Black compared to non-Hispanic White persons at the county level in the United States. It also examines the relationship between changes in residential and school segregation and subsequent trajectories in a variety of racial health disparities across the life course.

METHODS

Using the CDC WONDER Multiple Case of Death database, we derived an annual estimate of race-specific death rates and rate ratios for each county during the period 2000-2020. We then examined the relationship between baseline levels of residential and school segregation in 1991 as well as changes between 1991-2000 and the trajectories of the observed racial health disparities between 2000 and 2020. We used latent trajectory analysis to identify counties with similar patterns of residential and school segregation over time and to identify counties with similar trajectories in each racial health disparity. Outcomes included life expectancy, early mortality (prior to age 65), infant mortality, firearm homicide, total homicide, and teenage pregnancy rates.

RESULTS

During the period 1991-2020, racial residential segregation remained essentially unchanged among the 1051 counties in our sample; however, racial school segregation increased during this period. Increases in school segregation from 1991 to 2000 were associated with higher racial disparities in each of the health outcomes during the period 2000-2020 and with less progress in reducing these disparities.

CONCLUSION

This paper provides new evidence that school segregation is an independent predictor of racial health disparities and that reducing school segregation-even in the face of high residential segregation-could have a long-term impact on reducing racial health disparities. Furthermore, it suggests that the health consequences of residential segregation have not been eliminated from our society but are now being exacerbated by a new factor: school-based segregation. Throughout this paper, changes in school-based segregation not only show up as a consistent significant predictor of greater racial disparities throughout the life course, but at times, an even stronger predictor of health inequity than residential segregation.

An Opportunity for Change: Principles for Reforming Internal Medicine Inpatient Conferences

Inpatient educational conferences are a key part of internal medicine residency training. Many residencies made conferences virtual during the COVID-19 pandemic, and are now returning to in-person sessions. As we navigate this change, we can seize this opportunity to re-evaluate the role that inpatient conferences serve in resident education. In this paper, we briefly review the history of inpatient educational conferences before offering five recommendations for improvement. Our recommendations include grounding conference formats in educational theory, leveraging the expertise of all potential educators, broadening content to include health equity and justice throughout all curricula, and explicitly focusing on cultivating community among participants. Recognizing that each residency program is different, we anticipate that these recommendations may be implemented differently based on program size, available resources, and current institutional practices. We also include examples of prior successful curricular reforms aligned with our principles. We hope these recommendations ensure inpatient conferences continue to be a central part of residency education for future generations of internal medicine residents.

Evaluation of concordance in estimation of excess mortality due to COVID-19 pandemic

BACKGROUND

The World Health Organization (WHO) kept track of COVID-19 data at country level daily during the pandemic that included the number of tests, infected cases and fatalities. This daily record was susceptible to change depending on the time and place and impacted by underreporting. In addition to reporting cases of excess COVID-19-related deaths, the WHO also provided estimates of excess mortality based on mathematical models.

OBJECTIVE

To evaluate the WHO reported and model-based estimate of excess deaths to determine the degree of agreement and universality.

METHODOLOGY

Epidemiological data gathered from nine different countries between April 2020 and December 2021 are used in this study. These countries are India, Indonesia, Italy, Russia, United Kingdom, Mexico, the United States, Brazil and Peru and each of them recorded more than 1.5 million deaths from COVID-19 during these months. Statistical tools including correlation, linear regression, intraclass correlation and Bland-Altman plots are used to assess the degree of agreement between reported and model-based estimates of excess deaths.

RESULTS

The WHO-derived mathematical model for estimating excess deaths due to COVID-19 was found to be appropriate for only four of the nine chosen countries, namely Italy, United Kingdom, the United States and Brazil. The other countries showed proportional biases and significantly high regression coefficients.

CONCLUSION

The study revealed that, for some of the chosen nations, the mathematical model proposed by the WHO is practical and capable of estimating the number of excess deaths brought on by COVID-19. However, the derived approach cannot be applied globally.

Modelling the impact of a high-uptake bivalent booster scenario on the COVID-19 burden and healthcare costs in New York City

Background

Uptake of the COVID-19 bivalent booster vaccine (targeting the original SARS-CoV-2 strain and subvariants BA.4 and BA.5 of the Omicron variant) among eligible residents of New York City (NYC) has been modest and declining. Assessing the impact of improved population-level booster coverage with bivalent vaccines in NYC can help inform investment towards vaccination and potential cost-savings.

Methods

We calibrated an agent-based model of disease transmission to confirmed and probable cases of COVID-19 in NYC and simulated it to project outcomes under two scenarios. In the base case scenario, we assumed that vaccination continued with the average daily rate of 92 vaccine doses per 100,000 administered during December 2022. In the counterfactual scenario, we modeled a high-uptake scenario between January 1, 2023 and March 31, 2023, with an average daily rate of 296 vaccine doses per 100,000 population that increased bivalent coverage in NYC to match the age-specific influenza vaccine coverage of the 2020-2021 season. Vaccination rate outside the campaign duration remained the same as the base case scenario.

Findings

Compared to the base case, the high-uptake scenario averted 88,274 (95% Confidence Interval [CI]: 77,097-100,342) cases, and prevented 2,917 (95% CI: 2,557-3,267) hospitalizations between January 1 through the end of June 2023. Averted outcomes resulted in net savings of $217.2 (95% CI: 190.0-242.2) million in direct healthcare costs. We estimated that the high-uptake scenario would avert 72,879 (95% CI: 63,894-82,228) days of student absenteeism from schools due to COVID-19 illness.

Interpretation

Our results illustrate the continued benefits of COVID-19 vaccines in preventing severe health outcomes, averting healthcare costs, and maintaining educational continuity in NYC.

Funding

The Canadian Institutes of Health Research, The Natural Sciences and Engineering Research Council of Canada, NIH, Centers for Disease Control and Prevention (CDC), NSF, The Commonwealth Fund, and The Notsew Orm Sands Foundation.

Impact of comorbidities on people with and without cancer early in the COVID-19 pandemic: An observational study

BACKGROUND

The present study sought to investigate how comorbidity burden influences cancer survivors' quality of life (QoL) and the challenges/adaptations during the coronavirus disease 2019 (COVID) pandemic, and to examine how appraisal processes are related to this impact.

METHODS

This cross-sectional study, administered in spring/summer 2020, compared cancer survivors to a general-population comparison sample. QoL was assessed with standardized tools. COVID-specific questions included selected items compiled by the US National Institutes of Health, and cognitive appraisal processes were assessed using the QoL Appraisal Profilev2 Short-Form. Principal components analysis reduced the number of comparisons. Multivariate analysis of covariance investigated group differences in QoL, COVID-specific variables, and cognitive-appraisal processes. Linear regression investigated group differences in COVID-specific variables as a function of cognitive-appraisal processes, QoL, demographic covariates, and their interactions.

RESULTS

Cancer survivors fared substantially better than non-cancer participants in QoL and cognitive functioning when they had no other comorbidities, but substantially worse on QoL when they had three or more comorbidities. Cancer survivors with no comorbidities were less likely to feel worried about COVID, less likely to engage in self-protection, and prioritized engaging in problem-focused and prosocial actions compared to non-cancer participants. Conversely, cancer survivors confronted with multiple comorbidities exhibited more proactive self-protection and experienced more anxiety about the pandemic.

CONCLUSION

The impact of having multiple comorbidities in the context of cancer is associated with notable differences in social determinants of health, QoL outcomes, COVID-specific challenges/adaptations, and appraisal of QoL. These findings provide an empirical basis for implementing appraisal-based coping interventions.

New considerations of health disparities within allergy and immunology

The pandemic, political upheavals, and social justice efforts in our society have resulted in attention to persistent health disparities and the urgent need to address them. Using a scoping review, we describe published updates to address disparities and targets for interventions to improve gaps in care within allergy and immunology. These disparities-related studies provide a broad view of our current understanding of how social determinants of health threaten patient outcomes and our ability to advance health equity efforts in our field. We outline next steps to improve access to care and advance health equity for patients with allergic/immunologic diseases through actions taken at the individual, community, and policy levels, which could be applied outside of our field. Key among these are efforts to increase the diversity among our trainees, providers, and scientific teams and enhancing efforts to participate in advocacy work and public health interventions. Addressing health disparities requires advancing our understanding of the interplay between social and structural barriers to care and enacting the needed interventions in various key areas to effect change.

Diversity, Equity, and Inclusion: A Decade of Progress?

The concepts of diversity, equity, and inclusion are fundamental and more recently heavily discussed within medicine, research, and the larger society. There is increasing awareness that diversity of thoughts, perspectives, and backgrounds yields stronger teams and more effective results. There is also increasing awareness that stark inequities from systemic, institutional, and individual levels exist that limit the baseline opportunities for many populations. To close disparity gaps, broad aspects of diversity and promoting equity are required and efforts must be inclusive of those most marginalized. In this Clinical Commentary, we discuss, "How and If progress has been made in Diversity, Equity, Inclusion within the field of Allergy/Asthma/Immunology in the past decade?" We discuss the current state of clinical practice and what has been revealed over the past 10 years; describe our current workforce and what progress has or has not occurred there; and finally, review the state of scientific and medical research.

Socioeconomic Deprivation, Sleep Duration, and Mental Health during the First Year of the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) has had a rapid and sustained negative impact on sleep and mental health in the United States with disproportionate morbidity and mortality among socioeconomically deprived populations. We used multivariable and logistic regression to evaluate the associations among sleep duration, mental health, and socioeconomic deprivation (social deprivation index) in 14,676 Ohio residents from 1101 zip code tabulation areas from the 2020 Behavioral Risk Factor Surveillance System (BRFSS) survey. Higher socioeconomic deprivation was associated with shorter sleep and poorer mental health after adjusting for covariates (age, sex, race, education, income, and body mass index) in the multivariable linear regression models. Those in the highest socioeconomically deprived areas had 1.6 and 1.5 times higher odds of short sleep (duration < 6 h) and poor mental health (>14 poor mental health days), respectively, in the logistic regression models. Previous researchers have focused on limited socio-environmental factors such as crowding and income. We examined the role of a composite area based measure of socioeconomic deprivation in sleep duration and mental health during the first year of COVID-19. Our results suggest the need for a broader framework to understand the associations among socioeconomic deprivation, sleep duration, and mental health during a catastrophic event.

Syndemic aspects between COVID-19 pandemic and social inequalities

Although the coronavirus disease 2019 (COVID-19) pandemic has reached all over the world population, it has demonstrated a heterogeneous impact on different populations. The most vulnerable communities which coexist daily with the social inequalities like low access to hygiene and personal protection products, crowded residences, and higher levels of chronic diseases have a higher risk of contact and the spread of infection, beyond unfavorable clinical outcomes. The elevation of the risk of infection exposure can be related to gender due to the presence of a larger contingent of women in essential services, as well as frontline and cleaning professionals who regardless of gender have the greatest exposure to the virus. Such exposures can contribute to the development of fear of contaminating themselves or their family members associated also with the work stress, both of which are related to the emergence of mental disturbances in these populations. Furthermore, conditions of unsanitary living and low socioeconomic status, populations at war, pre-existing social barriers, and ethnicity have contributed to more impact of the pandemic both in the exposure to the virus and access to health services, COVID-19 management, and management of other pathologies. At the same time, factors such as the closing of non-essential services, the loss of jobs, and the increase in household spending aggravated the social vulnerabilities and impacted the family economy. Lastly, the COVID-19 pandemic contributed still more to the impact on women's health since it propitiated a favorable environment for increasing domestic violence rates, through the segregation of women from social life, and increasing the time of the victims with their aggressors.