Self-Reported Unmet Healthcare Needs Due to the COVID-19 Pandemic and Emergency Services Use and Hospitalization Among Cancer Survivors

Introduction

The COVID-19 pandemic has significantly disrupted the entire healthcare system, resulting in unmet needs for medical care (e.g., delayed or forgone care) among patients with cancer.

Methods

Using 2020 National Health Interview Survey data, we examined the prevalence of unmet healthcare needs and whether the self-reported experience of having delayed or forgone healthcare is associated with increased emergency services use and hospitalizations. A multivariable logistic regression model was used to assess the associations between unmet healthcare needs because of COVID-19 and emergency services use and hospitalization, controlling for potential confounding. All analysis was conducted in March and April 2022.

Results

Among 2,386 study participants living with cancer (representing 25.6 million U.S. adults), 33.7% reported having unmet healthcare needs because of the COVID-19 pandemic. The prevalence of unmet healthcare needs was higher among younger cancer survivors and those with higher education. In the adjusted analysis, cancer survivors with unmet healthcare needs were 31% more likely to report any emergency services use (adjusted OR=1.31, 95% CI=1.05, 1.65) than those without. Having unmet healthcare needs was not significantly associated with hospitalization (p=0.465).

Conclusions

Our findings highlight the unmet need for cancer care because of the pandemic and potential adverse health outcomes.

Understanding the effect of new U.S. cervical cancer screening guidelines and modalities on patients' comprehension and reporting of their cervical cancer screening behavior

With recent shifts in guideline-recommended cervical cancer screening in the U.S., it is important to accurately measure screening behavior. Previous studies have indicated the U.S. National Health Interview Survey (NHIS), a resource for measuring self-reported screening adherence, has lower validity among non-White racial/ethnic groups and non-English speakers. Further, measuring diverse population groups' comprehension of items and attitudes toward HPV self-sampling merits investigation as it is a modality likely to be recommended in the U.S. soon. This study cognitively tested NHIS items assessing recency of and reasons for receiving cervical cancer screening and attitudes toward HPV self-sampling. We conducted cognitive interviews between April 2021 - April 2022 in English and Spanish with individuals screened in the past two years by either a medical center in metropolitan Seattle, Washington or a safety-net healthcare system in Dallas, Texas. Interviews probed understanding of reasons for screening, experiences with abnormal results, and interest in HPV self-sampling. We completed 32 interviews in Seattle and 42 interviews in Dallas. A majority of participants were unaware that two different tests for cervical cancer screening exist (Pap and HPV). Many did not know which type(s) of test they received. Dallas participants had more limited and inaccurate knowledge of HPV compared to Seattle participants, and fewer responded favorably toward HPV self-sampling (32% vs. 55%). To improve comprehension and accurate reporting of cervical cancer screening, we suggest specific refinements to currently used survey questions. Attitudes toward self-sampling should be explored further as differences may exist by region and/or sociodemographic factors.

Changes in electronic cigarette use among U.S. Adults by cigarette smoking status, socciodemographics, and subjective depression, 2019-2020

E-cigarette use increased from 2017 to 2019 and then declined in 2020 among U.S. adults. It is important to understand whether the decline differed by smoking status and sociodemographic groups and whether daily e-cigarette use has subsequently changed. This study estimated e-cigarette use prevalence in 2019 and 2020 by analyzing the pooled National Health Interview Survey (n = 63,565) in 2022. Multivariable logistics regressions were performed to examine biannual change in current and daily e-cigarette use, overall and stratified by cigarette smoking status, sociodemographic factors, and subjective depression frequency. Among US adults, change in current e-cigarette use during 2019-2020 differed by smoking status (cigarette smoking status × year, p =.01) and race/ethnicity (race/ethnicity × year, p =.03). Current e-cigarette use prevalence decreased among current cigarette smokers (11.7 % to 8.0 %, p = 0.0001) but not among former or never smokers, and among Non-Hispanic White adults (5.1 % to 4.2 %, p = 0.04) and Non-Hispanic Black adults (3.4 % to 1.6 %, p = 0.0003) but not among other racial and ethnic groups. Current e-cigarette use also declined among those 25-64 years old but not among young adults 18-24 years old. Daily e-cigarette use did not significantly change during 2019-2020 in the overall sample (2.3 % to 2.0 %, p = 0.10), but declined among adults who were Non-Hispanic Black (2.4 % to 0.9 %, p = 0.0007), aged 35-44 years, and lived below the federal poverty level. Adults with monthly depressive episodes (vs without) continued to have a higher prevalence of current (7.0 % vs 3.0 %) and daily e-cigarette use (3.6 % vs 1.6 %) in 2020. Continuous monitoring of cross-population differences in adult e-cigarette use is warranted.

HPV vaccination initiation among white, black and Middle East North African (MENA) males

Objectives

US males initiate HPV vaccination at older ages than females and currently have low population coverage. We aim to describe the prevalence and predictors of HPV vaccination initiation among males of White, Black, and Middle-Eastern/North-African (MENA) descent in southeast Michigan.

Methods

We conducted three community-based surveys in 2019 that provided primary data via self report. Using population weights and multivariate modeling, we measured the prevalence and predictors of HPV vaccine initiation in each race/ethnicity of men (age 18–34 years) analyzed.

Results

The vaccine initiation rates were 44.5 % (95 % CI: 44.4, 44.6) for White men, 46.2 % (46.0, 46.4) for Black men, and 23.2 % (22.8, 23.6) for MENA men, (p < 0.001). Being a student, compared to unemployed or disabled, was significantly associated with HPV vaccine initiation across all three races/ethnicities. Married men of any race/ethnicity were unlikely to be vaccinated. MENA men born in the US and having some college education were also more likely to initiate HPV vaccination.

Conclusions

White, Black, and MENA men are not vaccinated in accord with Healthy (Healthy People 2030, 2022) goals. Each race/ethnicity has different predictors of vaccination.

Acculturation and depression are associated with short and long sleep duration among Mexican Americans in NHANES 2005-2018

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Length of time in the US was associated with long sleep duration.

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Individuals who speak majority English had higher odds of short sleep duration.

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Depression severity was linked to short and long sleep duration.

Acculturation and depression are linked to poor sleep quality and sleep problems that may explain ongoing health disparities for Hispanics/Latinos. We examined the associations of acculturation, depression, and sleep duration among the Mexican American population. We used a multinomial logistic regression model on cross-sectional data from the 2005–2018 National Health and Nutrition Examination Survey on 4,700 Mexican American adults aged ≥18 years old. The outcome of sleep duration was operationalized as short (≤6 h), optimal (7–8 h), and long (≥9 h). Acculturation was constructed using years living in the U.S. and language(s) spoken at home (majority Spanish, English and Spanish equally, majority English). Depression severity was assessed using the 9-item Patient Health Questionnaire. Covariates included gender, age, marital status, income, and U.S. citizenship. Speaking majority English (Adjusted Odds Ratio (AOR) = 1.23; 95% Confidence Interval (CI) = 1.00–1.52) and mild (AOR = 1.63; 95%CI = 1.32–2.01), moderate (AOR = 1.94; 95%CI = 1.43–2.63), and moderately severe/severe (AOR = 2.58; 95%CI = 1.72–3.88) levels of depression were significantly associated with short sleep duration. Living in the U.S. for ≥10 years (AOR = 1.61; 95%CI = 1.17–2.23) and moderately severe/severe depression (AOR = 2.30; 95%CI = 1.34–3.93) were significantly associated with long sleep duration. Our results provide additional evidence of a link between acculturation, depression, and short and long sleep duration among the Mexican American population. Understanding the sleep health of this population is important for informing future public health interventions and research. Additional investigation into the relationship between acculturation/depression and other sleep health measures among this population is warranted.

Development of a panel of U.S. adult tobacco users to inform tobacco regulatory science

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FDA developed the TCS Panel to field tobacco regulatory research studies.

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TCS Panel is a rigorous probability-based panel of ∼4,000 U.S. adult tobacco users.

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TCS Panel represents a spectrum of U.S. cigarette, cigar, and smokeless users.

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Comparisons with NHIS suggest lack of systematic bias in estimates from TCS Panel.

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Panels can be a feasible method for conducting tobacco regulatory science research.

The National Panel of Tobacco Consumer Studies (TCS Panel) is a probability-based panel of about 4,000 U.S. adult cigarette, cigar, and smokeless tobacco users developed by the U.S. Food and Drug Administration’s Center for Tobacco Products to conduct observational and experimental studies to inform tobacco regulatory activities. This paper describes the methods and characteristics of the current panel. The TCS Panel employed a stratified 4-stage sample design and in-person screening of U.S. sampled households. Selected eligible adults participated in an enrollment interview and completed a baseline survey assessing tobacco use behaviors to enroll in the Panel; 3,893 individuals were enrolled from September 2016–August 2017. Replenishment occurred from July 2019–December 2019 with 2,260 new members, for a current panel of 3,929 members. Demographic and tobacco use characteristics of the current panel were analyzed in 2020. Most demographic characteristics of the TCS Panel are similar to those of U.S. tobacco users in the 2018 National Health Interview Survey, suggesting a lack of systematic bias in the Panel. Small, but statistically significant, differences were observed in the proportion of 18- to 25-year-olds; high school diploma and bachelor’s degree/higher; never married and married (p < 0.05 for all). The TCS Panel appears to be representative of U.S. cigarette, cigar, and smokeless tobacco users; such panels can be a feasible method for conducting tobacco regulatory science research. The TCS Panel has been used to field studies examining purchasing behaviors, receipt and use of free samples/coupons, and the impact of a hypothetical tobacco product standard.

Cardiovascular risk profile of Middle Eastern immigrants living in the United States-the National Health Interview Survey

BACKGROUND

Middle Eastern (ME) immigrants are one of the fastest-growing groups in the US. Although ME countries have a high burden of atherosclerotic cardiovascular disease (ASCVD), the cardiovascular health status among ME immigrants in the US has not been studied in detail. This study aims to characterize the cardiovascular health status (CVD risk factors and ASCVD burden) among ME immigrants in the US.

METHODS

We used 2012-2018 data from the National Health Interview Survey, a US nationally representative survey. ME origin, CVD risk factors, and ASCVD status were self-reported. We compared these to US-born non-Hispanic white (NHW) individuals in the US.

RESULTS

Among 139,778 adults included, 886 (representing 1.3 million individuals, mean age 46.8) were of ME origin, and 138,892 were US-born NHWs (representing 150 million US adults, mean age 49.3). ME participants were more likely to have higher education, lower income and be uninsured. The age-adjusted prevalence of hypertension (22.4% vs 27.4%) and obesity (21.4% vs 31.4%) were significantly lower in ME vs NHW participants, respectively. There were no significant differences between the groups in the age-adjusted prevalence of ASCVD, diabetes, hyperlipidemia, and smoking. Only insufficient physical activity was higher among ME individuals. ME immigrants living in the US for 10 years or more reported higher age-adjusted prevalence of hypertension, hyperlipidemia, and ASCVD.

CONCLUSIONS

ME immigrants in the US have lower odds of hypertension and obesity, and of having a suboptimal CRF profile compared to US-born NHWs. Further studies are needed to determine whether these findings are related to lower risk, selection of a healthier ME subgroup in NHIS, or possible under-detection of cardiovascular risk factors in ME immigrants living in the US.

Heterogeneity in cardio-metabolic risk factors and atherosclerotic cardiovascular disease among Asian groups in the United States

OBJECTIVE

The Asian American population in the U.S. comprises various, ethnically diverse subgroups. Traditionally, this population has been studied as a single, aggregated group, potentially masking differences in risk among subgroups. Analyses using disaggregated data can help better characterize the health needs of different Asian subpopulations and inform targeted, effective public health interventions. We assessed the prevalence of cardiovascular disease (CVD) risk factors and atherosclerotic CVD (ASCVD) and their associations with socioeconomic factors among Chinese, Asian Indian, Filipino and Other Asian subjects, compared with non-Hispanic White (NHW) subjects in the U.S.

METHODS

: Cross-sectional study using data from 298,286 adults from the National Health Interview Survey (NHIS) from 2007 to 2018. We utilized chi-squared tests to compare characteristics across subgroups. Weighted proportions and unadjusted and adjusted logistic regression models were utilized to examine the associations between Asian subgroups, self-reported CVD risk factors and self-reported ASCVD, as well as between socioeconomic factors within each Asian subgroup.

RESULTS

: Asian Indian subjects had the highest prevalence of diabetes (12.5%), while Filipino subjects had the highest prevalence of hyperlipidemia (27.7%), hypertension (29.8%) and obesity (19.8%). Despite this, the prevalence of self-reported ASCVD was lower in all Asian groups compared with NHWs. Chinese subjects had the lowest odds of having each of the CVD risk factors assessed.

CONCLUSION

: We found considerable heterogeneity in the distribution of risk factors as well as ASCVD among Asian subgroups in the US. Compared with health system or community-based reports, the prevalence of risk factors and ASCVD may be underestimated in some Asian NHIS subgroups. There is an urgent need for efforts to improve recruitment of Asian participants of heterogeneous socioeconomic backgrounds in national surveys, as well as to perform a thorough assessment of risk factors and disease in this population, not relying solely on self-report.

Prevalence of cardiovascular risk factors in a nationally representative adult population with inflammatory bowel disease without atherosclerotic cardiovascular disease

Background and aims

Chronic inflammation is associated with premature atherosclerotic cardiovascular disease (ASCVD). We studied the prevalence of cardiovascular risk factors (CRFs) amongst individuals with IBD who have not developed ASCVD.

Methods

Our study population was derived from the 2015 – 2016 National Health Interview Survey. Those with ASCVD (defined as myocardial infarction, angina or stroke) were excluded. The prevalence of CRFs among individuals with IBD was compared with those without IBD. The odds CRFs among adults with IBD was assessed using logistic regression models.

Results

In our study population of 60,155 individuals, 786 (1.3%) had IBD. IBD was associated with increased odds hypertension (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.39–2.09), diabetes (OR 1.68, 95% CI 1.22–2.32), hypercholesterolemia (OR 1.62, 95% CI 1.32–2.99) and insufficient physical activity (OR 1.38, 95% CI 1.16–1.66).

Conclusion

IBD is associated with higher prevalence of CRFs. Early screening and risk mitigation strategies are warranted.

Can we determine whether physical limitations are more prevalent in the US than in countries with comparable life expectancy?

We evaluate the variability in estimates of self-reported physical limitations by age across four nationally representative surveys in the US. We consider its implications for determining whether, as previous literature suggests, the US estimates reveal limitations at an earlier age than in three countries with similar life expectancy: England, Taiwan, and Costa Rica. Based on cross-sectional data from seven population-based surveys, we use local mean smoothing to plot self-reported limitations by age for each of four physical tasks for each survey, stratified by sex. We find substantial variation in the estimates in the US across four nationally-representative surveys. For example, one US survey suggests that American women experience a walking limitation 15 years earlier than their Costa Rican counterparts, while another US survey implies that Americans have a 4-year advantage. Differences in mode of survey may account for higher prevalence of limitations in the one survey that used a self-administered mail-in questionnaire than in the other surveys that used in-person or telephone interviews. Yet, even among US surveys that used the same mode, there is still so much variability in estimates that we cannot conclude whether Americans have better or worse function than their counterparts in the other countries. Seemingly minor differences in question wording and response categories may account for the remaining inconsistency. If minor differences in question wording can result in such extensive variation in the estimates within a given population, then lack of comparability is likely to be an even greater problem when examining results across countries that do not share the same language or culture. Despite the potential utility of self-reported physical function within a survey sample, our findings imply that absolute estimates of population-level prevalence of self-reported physical limitations are unlikely to be strictly comparable across countries—or even across surveys within the same population.

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Self-reported physical limitation estimates vary widely across US national surveys.

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Thus, we cannot determine whether Americans have worse function than others.

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Differences in mode of survey may account for some of the variability.

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Minor differences in question wording and response categories may also play a role.