Racial and ethnic disparities in the association between financial hardship and self-reported weight change during the first year of the pandemic in the U.S.

Studies have shown that financial hardship can impact weight change; however, it is unclear what the economic impact of the COVID-19 pandemic has had on weight change in U.S. adults, or whether racial-ethnic groups were impacted differentially. We estimated the association between financial hardship and self-reported weight change using data from the cross-sectional COVID-19's Unequal Racial Burden (CURB) survey, a nationally representative online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Latino (English- and Spanish-speaking), Native Hawaiian/Pacific Islander, White, and multiracial adults conducted from 12/2020 to 2/2021. Financial hardship was measured over six domains (lost income, debt, unmet general expenses, unmet healthcare expenses, housing insecurity, and food insecurity). The association between each financial hardship domain and self-reported 3-level weight change variable were estimated using multinomial logistic regression, adjusting for sociodemographic and self-reported health. After adjustment, food insecurity was strongly associated with weight loss among American Indian/Alaska Native (aOR = 2.18, 95% CI = 1.05-4.77), Black/African American (aOR = 1.77, 95% CI = 1.02-3.11), and Spanish-speaking Latino adults (aOR = 2.32, 95% CI = 1.01-5.35). Unmet healthcare expenses were also strongly associated with weight loss among Black/African American, English-speaking Latino, Spanish-speaking Latino, and Native Hawaiian/Pacific Islander adults (aORs = 2.00-2.14). Other domains were associated with weight loss and/or weight gain, but associations were not as strong and less consistent across race-ethnicity. In conclusion, food insecurity and unmet healthcare expenses during the pandemic were strongly associated with weight loss among racial-ethnic minority groups. Using multi-dimensional measures of financial hardship provides a comprehensive assessment of the effects of specific financial hardship domains on weight change among diverse racial-ethnic groups.

Racial and Ethnic Disparities in Excess Deaths During the COVID-19 Pandemic, March to December 2020.

BACKGROUND: Although racial/ethnic disparities in U.S. COVID-19 death rates are striking, focusing on COVID-19 deaths alone may underestimate the true effect of the pandemic on disparities. Excess death estimates capture deaths both directly and indirectly caused by COVID-19. OBJECTIVE: To estimate U.S. excess deaths by racial/ethnic group. DESIGN: Surveillance study. SETTING: United States. PARTICIPANTS: All decedents. MEASUREMENTS: Excess deaths and excess deaths per 100 000 persons from March to December 2020 were estimated by race/ethnicity, sex, age group, and cause of death, using provisional death certificate data from the Centers for Disease Control and Prevention (CDC) and U.S. Census Bureau population estimates. RESULTS: An estimated 2.88 million deaths occurred between March and December 2020. Compared with the number of expected deaths based on 2019 data, 477 200 excess deaths occurred during this period, with 74% attributed to COVID-19. Age-standardized excess deaths per 100 000 persons among Black, American Indian/Alaska Native (AI/AN), and Latino males and females were more than double those in White and Asian males and females. Non-COVID-19 excess deaths also disproportionately affected Black, AI/AN, and Latino persons. Compared with White males and females, non-COVID-19 excess deaths per 100 000 persons were 2 to 4 times higher in Black, AI/AN, and Latino males and females, including deaths due to diabetes, heart disease, cerebrovascular disease, and Alzheimer disease. Excess deaths in 2020 resulted in substantial widening of racial/ethnic disparities in all-cause mortality from 2019 to 2020. LIMITATIONS: Completeness and availability of provisional CDC data; no estimates of precision around results. CONCLUSION: There were profound racial/ethnic disparities in excess deaths in the United States in 2020 during the COVID-19 pandemic, resulting in rapid increases in racial/ethnic disparities in all-cause mortality between 2019 and 2020. PRIMARY FUNDING SOURCE: National Institutes of Health Intramural Research Program.

Leading cancers contributing to educational disparities in cancer mortality in the US, 2017.

PURPOSE: To inform prevention efforts, we sought to determine which cancer types contribute the most to cancer mortality disparities by individual-level education using national death certificate data for 2017. METHODS: Information on all US deaths occurring in 2017 among 25-84-year-olds was ascertained from national death certificate data, which include cause of death and educational attainment. Education was classified as high school or less (≤ 12 years), some college or diploma (13-15 years), and Bachelor's degree or higher (≥ 16 years). Cancer mortality rate differences (RD) were calculated by subtracting age-adjusted mortality rates (AMR) among those with ≥ 16 years of education from AMR among those with ≤ 12 years. RESULTS: The cancer mortality rate difference between those with a Bachelor's degree or more vs. high school or less education was 72 deaths per 100,000 person-years. Lung cancer deaths account for over half (53%) of the RD for cancer mortality by education in the US. CONCLUSION: Efforts to reduce smoking, particularly among persons with less education, would contribute substantially to reducing educational disparities in lung cancer and overall cancer mortality.

Multi-cultural perspectives on group singing among diverse older adults.

Group choir singing has been shown to have health benefits for older adults. However, because most studies have included predominantly white participants, it is unknown whether findings generalize to older adults from more diverse backgrounds. This multi-site qualitative study assessed perceived benefits of group singing for socioeconomically and racially/ethnically diverse older adults. We interviewed 31 choir participants, 6 music professionals and 6 administrators involved in a large, cluster-randomized trial. We used content analysis to identify themes. Psychosocial engagement was most commonly reported, with six components: emotional well-being, self-esteem, self-confidence, social connection and support, decreased loneliness, and cultural identity and multi-cultural appreciation. A few reported cognitive and physical benefits. They also suggest that group singing among ethnically diverse older adults can have multiple psychosocial benefits and enhance a sense of cultural identity and appreciation of other cultures. These findings can help in selecting structured outcome measures for choir interventions.

Allostatic Load: Importance, Markers, and Score Determination in Minority and Disparity Populations.

Allostatic load is a physiological measure of the cumulative burden of stress on the body assessed by markers of physiological dysregulation. It is a multisystem construct that quantifies biological risk which leads to poor health and maladaptive trajectories. In this overview, which is based on a presentation made at the Flip the Script: Understanding African American Women's Resilience in the Face of Allostatic Load meeting at Ohio State University in August 2018, we build upon previous reviews by discussing four key aspects of allostatic load, specifically its: (1) importance, (2) operationalization, (3) use in minority health and health disparities research, and (4) value in such research. Operationalized in various ways, allostatic load is composed of 10 original markers and additional markers deriving from research among minority and disparity populations. The markers represent four biological systems: (1) cardiovascular, (2) metabolic, (3) inflammatory, and (4) neuroendocrine. System-specific racial/ethnic and sex-based differences have been observed. An overall score can be determined using sample-generated or empirically derived clinically relevant cut points. In summary, allostatic load provides an overall and a body system-specific mechanistic link between exposures to stressors and health outcomes that may help explain health disparities among minority populations.

Relationships between allostatic load, unhealthy behaviors, and depressive disorder in U.S. adults, 2005-2012 NHANES.

Unhealthy behaviors may modify relationships between chronic stress and depression among diverse older adults. We analyzed nationally representative cross-sectional data from participants aged 40-79 years of the 2005-2012 National Health and Nutrition Examination Survey. Unhealthy behaviors included current smoking, excessive/binge drinking, insufficient physical activity, and fair/poor diet. Allostatic load was defined by 10 biomarkers indicating the cumulative physiologic burden of stress. Depressive disorder was assessed using the Patient Health Questionnaire. Multivariable logistic regression examined whether current smoking, excessive/binge drinking, insufficient physical activitiy, and fair/poor diet modified relationships between allostatic load and depressive disorder. Mean age of 12,272 participants was 55.6 years (standard error = 0.19), 51.9% were women, and most had at least a high school education (81.8%). Latinos (11.3%) and African Americans (10.4%) were more likely than Whites (7.1%; p < 0.001) to meet depressive disorder criteria. Allostatic load was not associated independently with depressive disorder in any racial/ethnic group and this lack of a relationship did not differ by the extent of unhealthy behaviors. Although Latinos and African Americans report higher levels of depression than Whites, physiological markers of stress do not appear to explain these differences.

A Randomized Controlled Trial of a Cervical Cancer Education Intervention for Latinas Delivered Through Interactive, Multimedia Kiosks.

US Latina women experience disproportionately high cervical cancer incidence and mortality rates. These health disparities are largely preventable with routine pap tests and human papillomavirus (HPV) screening. This study tested the efficacy of a cervical cancer education intervention to improve risk factor knowledge, attitudes, self-efficacy, and self-reported behavior related to cervical cancer screening among low-income Latinas who had not been screened in the past 2 years, compared to a usual care control group. Low-income Latinas who had not had a pap test in the prior 2 years were recruited from three Federally Qualified Health Centers and randomly assigned to intervention and control groups, with in-person assessment at baseline and 6-month follow-up. Women in the intervention group received a one-time low-literacy cervical cancer education program through an interactive, multimedia kiosk in either English or Spanish based on their language preference. Compared to the control group, the intervention group demonstrated greater knowledge (p < 0.0001) and more favorable attitudes at follow-up; fewer intervention group women never thought of getting a pap test (46 vs. 54 %, p = 0.050) or agreed that it is fate whether a woman gets cervical cancer or not (24 vs. 31 %, p = 0.043). The groups did not differ significantly on the proportion who had obtained or made an appointment for a pap test at follow-up (51 vs. 48 %, p = 0.35). Both groups reported high levels of self-efficacy regarding pap screening at post-intervention. A one-time interactive, multimedia educational intervention improved cervical cancer knowledge and attitudes among low-income Latinas but had no effect on cervical cancer-screening behavior. Exposure of the control group to the pre-test conducted on the multimedia kiosk may have influenced their screening behavior.

Inaccurate Language Interpretation and Its Clinical Significance in the Medical Encounters of Spanish-speaking Latinos.

BACKGROUND: Limited English-proficient patients suffer poorer quality of care and outcomes. Interpreters can ameliorate these disparities; however, evidence is lacking on the quality of different interpretation modes. OBJECTIVE: Compare accuracy of interpretation for in-person (IP) professional, professional videoconferencing (VC), and ad hoc (AH) interpretation. DESIGN: A cross-sectional study of transcribed audiotaped primary care visits. SUBJECTS: Subjects included 32 Spanish-speaking Latino patients and 14 clinicians. MEASURES: Independent coding of transcripts by 4 coders (2 were internists) for accurate and inaccurate interpretation instances. Unit of analysis was a segment of continuous speech or text unit (TU). Two internists independently verified inaccurate interpretation instances and rated their clinical significance as clinically insignificant, mildly, moderately, or highly clinically significant. RESULTS: Accurate interpretation made up 70% of total coded TUs and inaccurate interpretation (errors) made up 30%. Inaccurate interpretation occurred at twice the rate for AH (54% of coded TUs) versus IP (25%) and VC (23%) interpretation, due to more errors of omission (P<0.001) and answers for patient or clinician (P<0.001). Mean number of errors per visit was 27, with 7.1% of errors rated as moderately/highly clinically significant. In adjusted models, the odds of inaccurate interpretation were lower for IP (OR=0.25, 95% CI, 0.19, 0.33) and VC (OR=0.31; 95% CI, 0.17, 0.56) than for AH interpreted visits; the odds of a moderately/highly clinically significant error were lower for IP (OR=0.25; 95% CI, 0.06, 0.99) than for AH interpreted visits. CONCLUSIONS: Inaccurate language interpretation in medical encounters is common and more frequent when untrained interpreters are used compared with professional IP or through VC. Professional VC interpretation may increase access to higher quality medical interpretation services.

Physician counseling on colorectal cancer screening and receipt of screening among Latino patients.

BACKGROUND: Latinos have lower rates of colorectal cancer (CRC) screening and later stage diagnosis than Whites, which may be partially explained by physician communication factors. OBJECTIVE: We assessed associations between patient-reported physician counseling regarding CRC screening and receipt of CRC screening among Latino primary care patients. DESIGN: This was a cross-sectional telephone survey. PARTICIPANTS: The participants of this study were Latino primary care patients 50 years of age or older, with one or more visits during the preceding year. MAIN MEASURES: We developed patient-reported measures to assess whether physicians provided explanations of CRC risks and tests, elicited patients' barriers to CRC screening, were responsive to patients' concerns about screening, and encouraged patients to be screened. Outcomes were patient reports of receipt of endoscopy (sigmoidoscopy or colonoscopy) and fecal occult blood test (FOBT) within recommended guidelines. KEY RESULTS: Of 817 eligible patients contacted, 505 (62 %) completed the survey; mean age was 61 years (SD 8.4), 69 % were women, and 53 % had less than high school education. Forty-six percent reported obtaining endoscopy (with or without FOBT), 13 % reported FOBT only, and 41 % reported no CRC screening. In bivariate analyses, physician explanations, elicitation of barriers, responsiveness to concerns, and greater encouragement for screening were associated with receipt of endoscopy (p < 0.001), and explanations (p < 0.05) and encouragement (p < 0.001) were associated with FOBT. Adjusting for covariates, physician explanations (OR = 1.27; 95 % CI 1.03, 1.58) and greater physician encouragement (OR = 6.74; 95 % CI 3.57, 12.72) were associated with endoscopy; patients reporting quite a bit/a lot of physician encouragement had six times higher odds of obtaining the FOBT as those reporting none/a little encouragement (OR = 6.54; 95 % CI 2.76, 15.48). CONCLUSIONS: Among primarily lower-socioeconomic status Latino patients, the degree to which patients perceived that physicians encouraged CRC screening was more strongly associated with screening than with providing risk information, eliciting barriers, and responding to their concerns about screening.

Development of a conceptually equivalent Chinese-language translation of the US Household Food Security Survey Module for Chinese immigrants to the USA.

OBJECTIVE: To develop a conceptually equivalent Chinese-language translation of the eighteen-item US Household Food Security Survey Module. DESIGN: In the current qualitative study, we (i) highlight methodological challenges which arise in developing survey instruments that will be used to make comparisons across language groups and (ii) describe the development of a Chinese-language translation of the US Household Food Security Survey Module, called the San Francisco Chinese Food Security Module. SETTING: Community sites in San Francisco, CA, USA. SUBJECTS: We conducted cognitive interviews with twenty-two community members recruited from community sites hosting food pantries and with five professionals recruited from clinical settings. RESULTS: Development of conceptually equivalent surveys can be difficult. We highlight challenges related to dialect, education, literacy (e.g. preferences for more or less formal phrasing), English words and phrases for which there is no Chinese language equivalent (e.g. 'balanced meals' and 'eat less than you felt you should') and response formats. We selected final translations to maximize: (i) consistency of the Chinese translation with the intent of the English version; (ii) clarity; and (iii) similarities in understanding across dialects and literacy levels. CONCLUSIONS: Survey translation is essential for conducting research in many communities. The challenges encountered illustrate how literal translations can affect the conceptual equivalence of survey items across languages. Cognitive interview methods should be routinely used for survey translation when such non-equivalence is suspected, such as in surveys addressing highly culturally bound behaviours such as diet and eating behaviours. Literally translated surveys lacking conceptual equivalence may magnify or obscure important health inequalities.

Study protocol for a cluster randomized trial of the Community of Voices choir intervention to promote the health and well-being of diverse older adults.

BACKGROUND: Older adults are the fastest growing segment of the United States population. There is an immediate need to identify novel, cost-effective community-based approaches that promote health and well-being for older adults, particularly those from diverse racial/ethnic and socioeconomic backgrounds. Because choral singing is multi-modal (requires cognitive, physical, and psychosocial engagement), it has the potential to improve health outcomes across several dimensions to help older adults remain active and independent. The purpose of this study is to examine the effect of a community choir program (Community of Voices) on health and well-being and to examine its costs and cost-effectiveness in a large sample of diverse, community-dwelling older adults. METHOD/DESIGN: In this cluster randomized controlled trial, diverse adults age 60 and older were enrolled at Administration on Aging-supported senior centers and completed baseline assessments. The senior centers were randomly assigned to either start the choir immediately (intervention group) or wait 6 months to start (control). Community of Voices is a culturally tailored choir program delivered at the senior centers by professional music conductors that reflects three components of engagement (cognitive, physical, and psychosocial). We describe the nature of the study including the cluster randomized trial study design, sampling frame, sample size calculation, methods of recruitment and assessment, and primary and secondary outcomes. DISCUSSION: The study involves conducting a randomized trial of an intervention as delivered in "real-world" settings. The choir program was designed using a novel translational approach that integrated evidence-based research on the benefits of singing for older adults, community best practices related to community choirs for older adults, and the perspective of the participating communities. The practicality and relatively low cost of the choir intervention means it can be incorporated into a variety of community settings and adapted to diverse cultures and languages. If successful, this program will be a practical and acceptable community-based approach for promoting health and well-being of older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT01869179 registered 9 January 2013.

Randomized controlled trial of Nuevo Amanecer: a peer-delivered stress management intervention for Spanish-speaking Latinas with breast cancer.

BACKGROUND: Latinas with breast cancer suffer symptom and psychosocial health disparities. Effective interventions have not been developed for or tested in this population. PURPOSE: We describe community-based participatory research methods used to develop and implement the Nuevo Amanecer program, a culturally tailored, peer-delivered cognitive-behavioral stress management intervention for low-income Spanish-speaking Latinas with breast cancer, and unique considerations in implementing a randomized controlled trial to test the program in community settings. METHODS: We applied an implementation science framework to delineate the methodological phases used to develop and implement the Nuevo Amanecer program and trial, emphasizing community engagement processes. RESULTS: In phase 1, we established project infrastructure: academic and community co-principal investigators, community partners, community advisory board, steering committee, and funding. In phase 2, we identified three program inputs: formative research, a community best-practices model, and an evidence-based intervention tested in non-Latinas. In phase 3, we created the new program by integrating and adapting intervention components from the three sources, making adaptations to accommodate low literacy, Spanish language, cultural factors, community context, and population needs. In phase 4, we built community capacity for the program and trial by training field staff (recruiters and interventionists embedded in community sites), compensating field staff, and creating a system for identifying potential participants. In phase 5, we implemented and monitored the program and trial. Engaging community partners in all phases has resulted in a new, culturally tailored program that is suitable for newly diagnosed Latinas with breast cancer and a trial that is acceptable and supported by community and clinical partners. Lessons learned Engagement of community-based organizations and cancer survivors as research partners and hiring recruiters and interventionists from the community were critical to successful implementation in community settings. Having culturally and linguistically competent research staff with excellent interpersonal skills facilitated implementation. Facilitating and maintaining excellent communication among community partners was imperative to troubleshoot implementation issues. Randomization was challenging due to community concerns about assigning women to a control group. Patient privacy regulations and the need for extensive outreach to establish relationships between community partners and clinical sites hampered initial recruitment. LIMITATIONS: These were resource-intensive processes to develop and implement the program that need to be compared to less-intensive alternatives. CONCLUSION: Engaging community members in design and implementation of community-based programs and trials enhances cultural appropriateness and congruence with the community context. If the randomized trial demonstrates that the intervention is effective, it will fill a gap in evidence-based programs to address ethnic disparities in quality of life among Spanish-speaking Latinas with breast cancer.

Age-related differences in the association between financial hardship and weight change during the COVID-19 pandemic.

Objective: To examine the association of financial hardship with weight changes in the US during the COVID-19 pandemic. Methods: We used data from the COVID-19's Unequal Racial Burden survey, a nationally representative, cross-sectional, online survey of diverse adults living in the US, 12/2020-2/2021. This study included 1000 Asian, Black, Latino (half Spanish-speaking), and White adults and 500 American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and multiracial adults (5500 total). Age-specific (18-39, 40-59, ≥60) associations between financial hardship domains and weight change were estimated using multinomial logistic regression, adjusted for demographic and health characteristics. Results: Financial hardship during the COVID-19 pandemic was prevalent across all age groups (18-39: 76.2 %; 40-59: 75.6 %; ≥60: 50.6 %). Among adults aged 18-39 and ≥ 60 years old, food insecurity was significantly associated with weight loss (18-39: aOR = 1.42, 95 % CI = 1.04, 1.95; ≥60: aOR = 3.67, 95 % CI = 1.50, 8.98). Among all age groups, unmet healthcare expenses was also associated with weight loss (18-39: aOR = 1.31, 95 % CI = 1.01, 1.70; 40-59: aOR = 1.49, 95 % CI = 1.06, 2.08; ≥60: aOR = 1.73, 95 % CI = 1.03, 2.91). Among adults aged 18-39 and ≥ 60 years old, lost income was significantly associated with weight gain (18-39: aOR = 1.36, 95 % CI = 1.09-1.69; ≥60: aOR = 1.46, 95 % CI = 1.04, 2.06), and among adults 40-59 years old, experiencing increased debt was significantly associated with weight gain (aOR = 1.50, 95 % CI = 1.13, 1.99). Conclusions: For those aged 18-39 and ≥ 60 years old experiencing financial hardship during the COVID-19 pandemic was associated with both weight loss and weight gain. Less correlation was observed among adults aged 40-59.

Quality of life of Latina and Euro-American women with ductal carcinoma in situ.

BACKGROUND: Risk factors for psychosocial distress following a breast cancer diagnosis include younger age, history of depression, inadequate social support, and serious comorbid conditions. Although these quality of life (QOL) concerns have been studied in women with ductal carcinoma in situ (DCIS), Latina women have been understudied. METHODS: Data were from a cross-sectional telephone survey of Latina and Euro-American women with DCIS recruited through a population-based cancer registry. The sample included 396 Euro-American women and 349 Latina women; 156 were interviewed in English and 193 in Spanish, with a median of 2 years after diagnosis. Regression models were created for measures in each of the following four QOL domains: physical, psychological, social, and spiritual. RESULTS: Younger age, no partner, and lower income were related to lower QOL in various domains. Physical comorbidities were associated with lower physical, psychological, and social QOL; lingering effects of surgery and prior depression were associated with lower QOL in all domains. English-speaking and Spanish-speaking Latinas (SSLs) reported higher spiritual QOL, and SSLs reported lower social QOL than Euro-American women. CONCLUSIONS: Despite having lower mortality, women with DCIS are treated with surgery and radiation therapy as if they have invasive cancer, and the aftereffects of treatment can impact their QOL. SSLs are at risk for lower QOL partly because of poverty. However, Latinas' greater spiritual QOL may mitigate some of the psychological and social effects of treatment. IMPLICATIONS: It is important to incorporate these findings into treatment decision making (choice of surgical treatment) and survivorship care (monitoring women with a history of depression or physical comorbidity).

COVID-19 vaccination willingness and uptake among low-income Black/African American, Latino, and White adults living in the U.S.

The purpose of this study was to assess differences in COVID-19 vaccine willingness and uptake between low-income and non-low-income adults and across race-ethnicity. We utilized data from the COVID-19's Unequal Racial Burden online survey, which included baseline (12/17/2020-2/11/2021) and 6-month follow-up (8/13/2021-9/9/2021) surveys. The sample included 1,500 Black/African American, Latino, and White low-income adults living in the U.S. (N = 500 each). A non-low-income cohort was created for comparison (n = 1,188). Multinomial logistic regression was used to assess differences in vaccine willingness and uptake between low-income and non-low-income adults, as well as across race-ethnicity (low-income adults only). Only low-income White adults were less likely to be vaccinated compared to their non-low-income counterparts (extremely willing vs. not at all: OR = 0.58, 95% CI = 0.39-0.86); low-income Black/African American and Latino adults were just as willing or more willing to vaccinate. At follow-up, only 30.2% of low-income adults who reported being unwilling at baseline were vaccinated at follow-up. White low-income adults (63.6%) appeared less likely to be vaccinated, compared to non-low-income White adults (80.9%), low-income Black/African American (70.7%), and low-income Latino adults (72.4%). Distrust in the government (46.6), drug companies (44.5%), and vaccine contents (52.1%) were common among those unwilling to vaccinate. This prospective study among a diverse sample of low-income adults found that low-income White adults were less willing and less likely to vaccinate than their non-low-income counterparts, but this difference was not observed for Black/African American or Latino adults. Distrust and misinformation were prevalent among those who remained unvaccinated at follow-up.

COVID-19 vaccination willingness and uptake among rural Black/African American, Latino, and White adults.

PURPOSE: The purpose of this study was to assess differences in COVID-19 vaccine willingness and uptake between rural and nonrural adults, and within rural racial-ethnic groups. METHODS: We utilized data from the COVID-19's Unequal Racial Burden online survey, which included 1,500 Black/African American, Latino, and White rural adults (n = 500 each). Baseline (12/2020-2/2021) and 6-month follow-up (8/2021-9/2021) surveys were administered. A cohort of nonrural Black/African American, Latino, and White adults (n = 2,277) was created to compare differences between rural and nonrural communities. Multinomial logistic regression was used to assess associations between rurality, race-ethnicity, and vaccine willingness and uptake. FINDINGS: At baseline, only 24.9% of rural adults were extremely willing to be vaccinated and 28.4% were not at all willing. Rural White adults were least willing to be vaccinated, compared to nonrural White adults (extremely willing: aOR = 0.44, 95% CI = 0.30-0.64). At follow-up, 69.3% of rural adults were vaccinated; however, only 25.3% of rural adults who reported being unwilling to vaccinate were vaccinated at follow-up, compared to 95.6% of adults who were extremely willing to be vaccinated and 76.3% who were unsure. Among those unwilling to vaccinate at follow-up, almost half reported distrust in the government (52.3%) and drug companies (46.2%); 80% reported that nothing would change their minds regarding vaccination. CONCLUSIONS: By August 2021, almost 70% of rural adults were vaccinated. However, distrust and misinformation were prevalent among those unwilling to vaccinate at follow-up. To continue to effectively combat COVID-19 in rural communities, we need to address misinformation to increase COVID-19 vaccination rates.

"Long Overdue": Nurse and Resident Physician Perspectives on Implementation of Dual-Handset Interpreter Phones in the Inpatient Setting.

Background: Patients with language barriers suffer significant health disparities, including adverse events and poor health outcomes. While remote language services can help improve language access, these modalities remain persistently underused. The objective of this study was to understand clinician experiences and challenges using dual-handset interpreter telephones and to inform recommendations for future language access interventions. Methods: We conducted four focus groups with nurses (N=14) and resident physicians (N=20) to understand attitudes toward dual-handset interpreter telephones in the hospital, including general impressions, effects on communication, situations in which they did and did not use them, and impact on clinical care. Three researchers independently coded all transcripts using a constant comparative approach, meeting repeatedly to discuss coding and to reconcile differences to reach consensus. Results: We identified five salient themes, including increased language access (improved convenience, flexibility, and versatility of phones over in-person or ad hoc interpreters); effects on interpersonal processes of care (improved ability to communicate directly with patients); effects on clinical processes of care (improvements in critical patient care functions, including pain and medication management); impact on time (needing extra time for interpreted encounters and perceived delays impacting future use); and patients for whom, and circumstances in which, the dual-handset interpreter telephone is inadequate (e.g., complex discussions, hands-on instruction, or multiple speakers are present). Conclusions: Our findings indicate that clinicians value dual-handset interpretation in bridging communication barriers and highlight recommendations to guide future implementation interventions to increase the uptake of remote language services in hospital settings.

Financial Hardship and Psychological Distress During the Pandemic: A Nationally Representative Survey of Major Racial-Ethnic Groups in the United States.

Introduction: While financial hardship has been consistently linked to psychological distress, little research exists on associations between financial hardship experienced during the pandemic and mental health. Methods: We conducted a nationally representative, online survey of American Indian/Alaska Native, Asian, Black/African American, Latino (English and Spanish speaking), Native Hawaiian/Pacific Islander, White, and multiracial adults, 12/2020-2/2021 (n=5500). Six financial hardship domains were measured (lost income, debt, unmet expenses, unmet health care expenses, housing insecurity, and food insecurity). Psychological distress measures included anxiety-depression symptoms (Patient Health Questionnaire-4), perceived stress (modified Perceived Stress Scale), and loneliness-isolation ("In the past month, how often have you felt lonely and isolated?"). Associations between financial hardship and psychological distress were estimated using multinomial logistic regression. Results: Overall, 70.3% of participants reported experiencing financial hardship (substantial hardship: 21.3%; some hardship: 27.4%; and a little hardship: 21.6%), with Spanish-speaking Latino (87.3%) and Native Hawaiian/Pacific Islander (79.2%) adults being most likely. Debt (57.6%), lost income (44.5%), and unmet expenses (33.7%) were the most common. There was a dose-response association between financial hardship and moderate/severe anxiety-depression symptoms (a little hardship: adjusted odds ratio [aOR]=1.42, 95% confidence interval [CI]=1.12-1.80; some hardship: aOR=3.21, 95% CI=2.58-3.98; and substantial hardship: aOR=8.15, 95% CI=6.45-10.29). Similar dose-response trends were observed with perceived stress and loneliness-isolation. No racial-ethnic difference in the association between financial hardship during the pandemic and psychological distress was seen. Discussion: Financial hardship has had a major impact on psychological distress during the pandemic; moreover, while no racial-ethnic difference in the effect of financial hardship was observed, because racial-ethnic minorities experienced greater hardship, financial hardship may exacerbate psychological distress disparities.

Telehealth access, willingness, and barriers during the COVID-19 pandemic among a nationally representative diverse sample of U.S. adults with and without chronic health conditions.

INTRODUCTION: During the COVID-19 pandemic, telehealth services represented a critical tool in maintaining continuity and access to care for adults in the USA. However, despite improvements in access and utilization during the pandemic, disparities in telehealth utilization have persisted. It is unclear what role access and willingness to use telehealth play in telehealth disparities. METHODS: We used data from the nationally representative COVID-19's Unequal Racial Burden (CURB) survey, an online survey conducted between December 2020 and February 2021, n = 5500. Multivariable Poisson regression was used to estimate the prevalence of perceived telehealth access and willingness to use telehealth services among adults with and without chronic conditions. RESULTS: Overall, 60.1% of adults with and 38.7% of adults without chronic conditions reported having access to telehealth. After adjustment, adults with chronic conditions were more likely to report telehealth access (adjusted prevalence ratio [aPR] = 1.35, 95% confidence interval [CI] = 1.21-1.50). Most adults with and without chronic conditions reported being willing to use telehealth services (85.1% and 79.8%, respectively), and no significant differences in willingness were observed across chronic condition status (aPR = 1.03, 95% CI = 0.95-1.13). Perceived telehealth access appeared to be a predictor of telehealth willingness in both groups (chronic conditions: aPR = 1.22, 95% CI = 0.97-1.54; no chronic conditions: aPR = 1.37, 95% CI = 1.22-1.54). The prevalence of perceived barriers to telehealth was low, with the majority reporting no barriers (chronic conditions = 51.4%; no chronic conditions = 61.4%). DISCUSSION: Perceived access to telehealth was associated with telehealth willingness. Investing in approaches that increase telehealth accessibility and awareness is needed to improve access to telehealth for adults with and without chronic conditions.

Financial hardship, sleep disturbances, and their relationship among men and women in the United States during the COVID-19 pandemic.

OBJECTIVE: In the United States (US), the health and financial consequences of COVID-19 have disproportionately impacted women and minoritized racial-ethnic groups. Yet, few US studies have investigated financial hardship during the COVID-19 pandemic and sleep health disparities. Our objective was to investigate associations between financial hardship and sleep disturbances during the COVID-19 pandemic by gender and race and ethnicity in the United States. METHODS: We used the nationally representative COVID-19's Unequal Racial Burden cross-sectional survey data collected among 5339 men and women from 12/2020 to 2/2021. Participants reported financial hardship (eg, debt, employment/work loss) since the pandemic began and completed the Patient-Reported Outcomes Management Information System Short Form 4a for sleep disturbances. Prevalence ratios (PRs) and 95% confidence intervals were estimated using adjusted, weighted Poisson regression with robust variance. RESULTS: Most (71%) participants reported financial hardship. Prevalence of moderate to severe sleep disturbances was 20% overall, higher among women (23%), and highest among American Indian/Alaska Native (29%) and multiracial adults (28%). Associations between financial hardship and moderate to severe sleep disturbances (PR = 1.52 [95% confidence interval: 1.18, 1.94]) did not differ by gender but varied by race and ethnicity: associations were strongest among Black/African American (PR = 3.52 [1.99,6.23]) adults. CONCLUSIONS: Both financial hardship and sleep disturbances were prevalent, and their relationships were strongest among certain minoritized racial-ethnic groups, particularly Black/African American adults. Interventions that alleviate financial insecurity may reduce sleep health disparities.