Relative importance of selected predictors of health-related quality-of-life (HRQOL) among U.S. adults.

PURPOSE: Many factors have been associated with health-related quality of life (HRQOL), and researchers often have tried to rank these contributing factors. Variable importance quantifies the net independent contribution of each individual predictor in a set of predictors to the prediction accuracy of the outcome. This study assessed relative importance (RI) of selected contributing factors to respondents' physically unhealthy days (PUD), mentally unhealthy days (MUD), activity limitation days (ALD), and EuroQol EQ-5D index derived from the Healthy Days measures (dEQ-5D). METHODS: Using data from the 2021 Behavioral Risk Factor Surveillance Systems (BRFSS), we estimated the RI of seven socio-demographics and seventeen chronic conditions and risk behaviors. A variable's importance was measured as the average increase in the coefficient of determination after adding the variable to all possible sub-models. RESULTS: After controlling for socio-demographics, arthritis and no physical activity were the most important variables for PUD with a RI of 10.5 and 10.4, respectively, followed by depression (RI = 8.5) and COPD (RI = 8.3). Depression was the most important variable for MUD with RI = 23.0 while all other 16 predictors had a RI < 7.0. Similar results were observed for ALD and dEQ-5D: depression was the most important predictor (RI = 16.3 and 15.2, respectively), followed by no physical activity, arthritis, and COPD (RI ranging from 7.1 to 9.2). CONCLUSION: This study quantified and ranked selected contributing factors of HRQOL. Results of this analysis also can be used to validate HRQOL measures based on domain knowledge of HRQOL.

The relationship between healthcare access and change in health-related quality-of-life among the general population of five countries during the COVID-19 pandemic.

PURPOSE: To determine whether (1) healthcare access at onset of the pandemic and (2) age, gender, socioeconomic status (SES), and pre-existing health status were associated with change in health-related quality-of-life (HRQoL) during the COVID-19 pandemic. The study includes a general population sample of five countries. METHODS: An online questionnaire was administered to respondents from Greece, Italy, the Netherlands, the UK, and the US at the onset of the COVID-19 pandemic between April 22nd and May 5th of 2020, and 1 year later between May 23rd and June 29th of 2021. The questionnaire included questions on demographic background, health status, and HRQoL. The primary outcome was change in HRQoL as measured by the EQ-5D-5L instrument. Specifically, the EQ-5D-5L index and EQ VAS were used. Healthcare access was quantified with regard to the respondent's ease of getting an appointment, waiting time, and opportunity to contact the provider and during analysis dichotomized into "sufficient" versus "insufficient". Linear regression analysis was performed with change in HRQoL as dependent variable and background variables as independent variables. RESULTS: In total, 6,765 respondents completed the second questionnaire. 19.8% of total respondents reported insufficient healthcare access. Respondents with insufficient healthcare had both more improved and deteriorated HRQoL compared to respondents with sufficient healthcare, whose HRQoL remained unchanged. We did not find significant interactions between age, gender, SES and/or chronic disease status with healthcare access at onset of the COVID-19 pandemic. CONCLUSION: Healthcare access was not associated with cumulative differences in change in HRQoL over a 1-year period in strata of age, gender, SES, and chronic disease status.

An Intersectional Approach to Quantifying the Impact of Geographic Remoteness and Health Disparities on Quality-Adjusted Life Expectancy: Application to Australia.

OBJECTIVES: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) is a novel method for exploring the interaction between sociodemographic characteristics that affect health outcomes. This study explores the interaction between geographic remoteness and socioeconomic status on health outcomes in Australia from an intersectional perspective. METHODS: Data from a cross-sectional survey were matched with data from the Australian Bureau of Statistics and the Australian Institute of Health and Welfare. To explore the effect of health-related quality of life on life expectancy, quality-adjusted life expectancy (QALE) was estimated through applying utility values derived from the EQ-5D-5L to life table data from the Australian Bureau of Statistics. The effect of geographic remoteness on QALE was quantified using multivariable linear regression. An intersectional MAIHDA was performed to explore differences in mean QALE across strata formed by intersections of age, sex, and Socioeconomic Indexes for Areas score. RESULTS: Based on multivariable linear modeling, QALE declined significantly with increasing remoteness (inner regional, -1.0 years [undiscounted]; remote/very remote, -3.3 years [undiscounted]) (P < .001). In contrast, life expectancy was only significantly different between participants in remote/very remote areas and major cities (ß-coefficient, -2.4; 95% CI -4.4 to -0.4; P = .016). No intersectional interaction effects between strata on QALE were found in the MAIHDA. CONCLUSIONS: QALE has considerable value as a metric for exploring disparities in health outcomes. Given that no intersectional interactions were identified, our findings support broad interventions that target the underlying social determinants of health appropriately reduce disparities versus interventions targeting intersectional interactions.

Construct validity and responsiveness of a health-related symptom index for persons either treated or monitored for anal high-grade squamous intraepithelial lesions (HSIL): AMC-A01/-A03.

PURPOSE: To determine whether treatment of anal high-grade squamous intraepithelial lesions (HSIL), vs active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV, the US National Cancer Institute funded the Phase III ANal Cancer/HSIL Outcomes Research (ANCHOR) clinical trial. As no established patient-reported outcomes (PRO) tool exists for persons with anal HSIL, we sought to estimate the construct validity and responsiveness of the ANCHOR Health-Related Symptom Index (A-HRSI). METHODS: The construct validity phase enrolled ANCHOR participants who were within two weeks of randomization to complete A-HRSI and legacy PRO questionnaires at a single time point. The responsiveness phase enrolled a separate cohort of ANCHOR participants who were not yet randomized to complete A-HRSI at three time points: prior to randomization (T1), 14-70 (T2), and 71-112 (T3) days following randomization. RESULTS: Confirmatory factor analysis techniques established a three-factor model (i.e., physical symptoms, impact on physical functioning, impact on psychological functioning), with moderate evidence of convergent validity and strong evidence of discriminant validity in the construct validity phase (n = 303). We observed a significant moderate effect for changes in A-HRSI impact on physical functioning (standardized response mean = 0.52) and psychological symptoms (standardized response mean = 0.60) from T2 (n = 86) to T3 (n = 92), providing evidence of responsiveness. CONCLUSION: A-HRSI is a brief PRO index that captures health-related symptoms and impacts related to anal HSIL. This instrument may have broad applicability in other contexts assessing individuals with anal HSIL, which may ultimately help improve clinical care and assist providers and patients with medical decision-making.

Association between self-reported body mass index and active life expectancy in a large community-dwelling sample of older U.S. adults.

BACKGROUND: Obesity may have a protective effect (greater survival) in older adults, a finding known as the "obesity paradox." This study examined the association between self-reported body mass index (BMI) and active life expectancy (ALE) among older U.S. adults. METHODS: Using the Medicare Health Outcomes Survey Cohort 15 (2012 baseline, 2014 follow-up), we estimated life expectancy and ALE by participants' baseline BMI and age using multi-state models. A participant was classified as in an active state if this person reported having no difficulty for any of these six activities of daily living (ADLs). RESULTS: Small differences in life expectancy were noted among persons in normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25-29.9 kg/m2), and obesity ranges (BMI 30 kg/m2 and higher). However, persons with obesity had a significantly lower ALE. ALE at age 65 was 11.1 (11.0-11.2) years for persons with obesity, 1.2 (1.1-1.3) years less than that for the normal weight and overweight persons (12.3 years for both, 12.2-12.4). Persons with class III obesity had a significantly lower life expectancy and ALE than normal weight persons. Although persons with class I or II obesity had a similar life expectancy as normal weight persons, they have a shorter ALE. CONCLUSIONS: Although older adults with obesity have a similar life expectancy as normal weight persons, they have a significantly shorter ALE. Given the complex relationship of BMI and ALE, a "one size fits all" approach to weight management is not advisable.

Prevalence, risk factors, and burden of disease for falls and balance or walking problems among older adults in the U.S.

This study assesses the prevalence of falls, factors predicting future falls, and health impacts of falls and balance or walking problems for U.S. older adults. Data were from participants ≥65 years in the Medicare Health Outcomes Survey Cohort 15 (baseline survey in 2012; follow-up survey in 2014; n = 164,597). We examined baseline factors predicting falls at follow-up and estimated the impact of falls and balance/walking problems on health-related quality of life (HRQOL), mortality, and quality-adjusted life years (QALYs). About 23% reported falls and 34% reported balance/walking problems in the past 12 months. The strongest predictors of falls were previous falls [adjusted odds ratio (OR) = 2.9] and balance/walking problems (OR = 1.7). Many self-reported chronic conditions (e.g., depression, stroke, and diabetes), geriatric symptoms (e.g., urine leakage), and limitations of activities of daily living (e.g., transferring and walking) also predicted falls, but at a smaller magnitude (ORs = 1.1-1.3). Having balance/walking problems was associated with a greater decrease in HRQOL scores (0.195 points) than falls (0.077 points), while falls were associated with a greater increase in mortality [adjusted hazard ratio (HR) = 1.5] than balance/walking problems (HR = 1.1). Falls were associated with a 4.6-year (48%) decrease in QALYs, while balance/walking problems was associated with a 7.3-year (62%) decrease in QALYs. Falls are a major problem for U.S. elderly and will continue to have an even greater impact as the population ages. The nearly 50% decrease in QALYs for falls and >60% decrease for balance or walking problems demonstrates the substantial burden associated with these problems among older Americans.

Quality-adjusted Life Years (QALY) for 15 Chronic Conditions and Combinations of Conditions Among US Adults Aged 65 and Older.

BACKGROUND: Although the life expectancy for the US population has increased, a high proportion of this population has lived with ≥1 chronic conditions. We have quantified the burden of disease associated with 15 chronic conditions and combinations of conditions by estimating quality-adjusted life years (QALYs) for older US adults. RESEARCH DESIGN: Data were from the Medicare Health Outcomes Survey Cohort 15 (baseline survey in 2012, follow-up survey 2014, with mortality follow-up through January 31, 2015). We included individuals aged 65 years and older (n=96,481). We estimated mean QALY throughout the remainder of the lifetime according to the occurrence of these conditions. RESULTS: The age-adjusted QALY was 5.8 years for men and 7.8 years for women. Over 90% respondents reported at least 1 condition and 72% reported multiple conditions. Respondents with depression and congestive heart failure had the lowest age-adjusted QALY (1.1-1.5 y for men and 1.5-2.2 y for women), whereas those with hypertension, arthritis, and sciatica had higher QALY (4.2-5.4 and 6.4-7.2 y, respectively). Having either depression or congestive heart failure and any 1 or 2 of the other 13 conditions was associated with the lowest QALY among the possible dyads and triads of chronic conditions. Dyads and triads with hypertension or arthritis were more prevalent, but had higher QALY. CONCLUSIONS: Understanding the burden of disease for common chronic conditions and for combinations of these conditions is useful for delivering high-quality primary care that could be tailored for individuals with combinations of chronic conditions.

Examining transdiagnostic vulnerabilities among HIV positive smokers seen at three inner city community based organizations.

Investigators have proposed a "transdiagnostic vulnerability framework" that examines the relationship between smoking and broader emotional factors, including anhedonia, anxiety sensitivity, and distress tolerance. Because smoking and depression are more common in persons living with HIV and AIDS (PLWHA) than in the general population, understanding the relationship between smoking and mental health is critical. The following study aims to characterize levels of clinically significant depressive symptoms and these broader emotional factors as well as the relationship between these factors and smoking-related variables in a sample of PLWHA. This cross-sectional study employed convenience sampling to survey adult clients who attended one of three AIDS service organizations in New York City. The questionnaires assessed sociodemographic and HIV health care variables, tobacco use, and anxiety - and depression-related constructs. 150 PLWHA completed surveys. Among the 118 smokers, the prevalence of clinically depressive symptoms was 53%. Participants with clinically significant depressive symptoms had significantly higher mean anhedonia scores and anxiety sensitivity scores and lower mean distress tolerance total scores compared to participants without clinically significant depressive symptoms (p < 0.001). Smoking cessation treatment for persons with co-morbid psychiatric disorders has been suboptimal and treatment for co-morbid mental health conditions tends to align with disorder-specific treatment. Given that PLWHA are a priority population, further research should address how to best tailor interventions to a group with multiple obstacles to successful tobacco cessation.

Incremental decreases in quality-adjusted life years (QALY) associated with higher levels of depressive symptoms for U.S. Adults aged 65 years and older.

BACKGROUND: Quality-adjusted life years (QALY) is a single value index that quantifies the overall burden of disease. It reflects all aspects of heath, including nonfatal illness and mortality outcomes by weighting life-years lived with health-related quality of life (HRQOL) scores. This study examine the burden of disease due to increasing levels of depressive symptoms by examining the association between the 9-item Patient Health Questionnaire (PHQ-9) scores and QALY for U.S. adults aged 65 years and older. METHODS: We ascertained respondents' HRQOL scores and mortality status from the 2005-2006, 2007-2008, and 2009-2010 cohorts of the National Health and Nutrition Examination Survey (NHANES) with mortality follow-up data through December 31, 2011. This analysis included respondents aged 65 years and older (n = 3,680). We estimated the mean QALY throughout the remaining lifetime according to participants' depression severity categories: none or minimal (PHQ-9 score 0-4), mild (5-9), moderate (10-14), and moderately severs and severe (15 or higher). We estimated QALY loss due to major depressive disorder (PHQ-9 score 10 or higher) and to mild depression (5-9). RESULTS: The QALY for persons with none/minimal, mild, moderate, and moderately severe/severe depression were 14.0, 7.8, 4.7, and 3.3 years, respectively. Compared to persons without major depressive disorder, persons with major depressive disorder had 8.3 fewer QALY (12.7 vs. 4.4), or a 65% loss. Compared to persons who reported "none" or minimal depressive symptoms, persons who reported mild depressive symptoms had 6.2 fewer QALY (14.0 vs. 7.8), or a 44% loss. The same patterns were noted in demographic and socioeconomic subgroups and according to number of comorbidities. CONCLUSIONS: This study not only confirmed the significant burden of disease for major depressive disorder among the U.S. elderly, but also showed an incremental decrease in QALY with an increasing severity of depressive symptoms as well as significant QALY loss due to mild depression. Specifically, individuals with higher (or more impaired) PHQ-9 scores had significantly fewer QALYs and our findings of fewer years of QALY for persons with major depressive disorder and mild depression were not only statistically significant but also clinically important.

Dose-response effect of smoking status on quality-adjusted life years among U.S. adults aged 65 years and older.

Background: To estimate the impact of smoking on quality-adjusted life years (QALY) for US adults aged 65 years and older. Methods: Using the 2003-08 National Health and Nutrition Examination Survey Linked Mortality File, we estimated the mean QALY throughout the remaining lifetime by participants' smoking status as well as smoking intensity and time since cessation. Results: Never, former and current smokers had a mean QALY of 16.1, 12.7 and 7.3 years, respectively. Among current smokers, those who started smoking before age 18 had fewer QALYs than those who started at or after age 18 (6.0 and 8.5 years, respectively) and those smoking ≥20 cigarettes per day had fewer QALYs than those smoking <20 cigarettes per day (6.6 and 8.1 years, respectively). QALYs also declined with a longer duration of smoking and a shorter time since cessation. The potential gains if a person quit smoking would be 5.4 QALYs, and the gains would increase with a longer time since quitting as well as quitting at a younger age. Conclusions: This study demonstrated the dose-response effect of smoking status on QALY. The results indicate the health benefits of tobacco cessation at any age and sizeable losses for former or current smokers.

Trends in HPV Vaccine Initiation and Completion among Girls in Texas: Behavioral Risk Factor Surveillance System Data, 2008-2010.

OBJECTIVE: The objective of this study was to evaluate the trend of HPV vaccine initiation and completion among girls in Texas from 2008 to 2010. METHODS: Data were obtained from the Behavioral Risk Factors Surveillance System (BRFSS) over 3 years (2008-2010). The information regarding HPV vaccination was gathered from the parents of 9- to 17-year-old daughters (choosing only 1 per household) in randomly selected households in the sample area. RESULTS: The highest prevalence of vaccine initiation and completion were detected in 2010 (20.9% and 9.7%, respectively). Over the study period, HPV vaccine initiation statistically significantly increased (2008, 14.9%; 2009, 20.7%; 2010, 24.3%; p = 0.002), corresponding to an annual increase in coverage of 33.5% (odds ratio [OR] = 1.33; 95% confidence interval [CI]: 1.11-1.60). Similarly, HPV vaccination completion increased (2008, 6.3%; 2009, 9.6%; 2010, 11.6%; p = 0.021), corresponding to an annual increase in coverage of 37.1% (OR = 1.37; 95% CI: 1.05-1.79). Increasing trends in HPV vaccination initiation and completion were observed in mothers, white, non-Hispanic parents, parents who had attended some college or were college graduates, parents who were married/partnered, and parents who lived in urban areas. CONCLUSION: Although HPV vaccination coverage in Texas is lower than recommended, there have been increases in the trends of vaccine initiation and completion. The campaigns promoting HPV vaccination should target specific population groups in which HPV immunization rates did not increase over time.

Cancer beliefs and patient activation in a diverse, multilingual primary care sample.

OBJECTIVES: Greater patient activation, defined as having the knowledge, skills, and confidence to manage one's health, is associated with cancer control behaviors. Cancer risk beliefs may be associated with patient activation, and delineating this relationship could inform cancer control interventions across diverse patient subgroups. This study examines associations between cancer risk beliefs, language preference, and patient activation within a multilingual urban primary care setting. DESIGN: Patients 18 years and older within a New York City public hospital serving a large proportion of non-native-born Americans were surveyed regarding their cancer risk beliefs and patient activation in Haitian Creole, Spanish, or English based on language preference during a health care visit. RESULTS: The sample (N = 460) included 150 Haitian Creole speakers, 159 Spanish speakers, and 151 English speakers and was primarily non-White (92%). Most participants (84%) had not been born in the United States. Cancer risk beliefs differed across language preference. Beliefs that cancer could be avoided by minimizing thoughts about cancer risk were significantly higher in Haitian Creole speakers than in others; reported negative emotion when thinking about cancer risk was higher in Spanish and English than in Haitian Creole speakers. These cancer risk beliefs were positively related to patient activation, even when controlling for language preference. CONCLUSION: Cancer risk beliefs differ across language preference and are related to patient activation, making them potentially important in cancer control. Consideration of language represents important demographic stratification for understanding the frequency and relevance of different beliefs about cancer and patient activation.

Impact of nine chronic conditions for US adults aged 65 years and older: an application of a hybrid estimator of quality-adjusted life years throughout remainder of lifetime.

PURPOSE: To estimate quality-adjusted life years (QALY) loss due to each of the following nine chronic conditions-depression, diabetes mellitus, hypertension, heart disease, stroke, emphysema, asthma, arthritis, and cancer. METHODS: We ascertained respondents' health-related quality of life scores and mortality status from the 2005 to 2008 National Health and Nutrition Examination Survey (NHANES) with mortality follow-up data through December 31, 2011. We included respondents aged 65 years and older (n = 2380). A hybrid estimator was used to calculate QALY from two parts: QALY during the follow-up period and QALY beyond the follow-up period. We calculated QALY by each of the nine chronic conditions. RESULTS: For persons aged 65 and older, QALY throughout the reminder of lifetime was 12.3 years. After adjusting for age- and sex-related differences, depression had an associated 8.2 years of QALY loss; diabetes, 5.6 years; hypertension, 2.5 years; heart disease, 5.4 years; stroke, 6.4 years; emphysema, 8.0 years; asthma, 4.8 years; arthritis, 0.3 years; and cancer, 2.5 years. Compared to persons without any chronic conditions, persons with one condition had an associated 4.7 years of QALY loss; persons with two conditions, 7.9 years; and persons with three or more conditions, 10.8 years. CONCLUSIONS: This study presents a QALY estimator for respondents in the NHANES-Linked Mortality File and demonstrates the utility of this method to other follow-up data. Continued application of our method would enable the burden of disease to be compared for a range of health conditions and risk factors in the ongoing effort to improve population health.

Incorporating Spirituality in Primary Care.

Addressing cultural competency in health care involves recognizing the diverse characteristics of the patient population and understanding how they impact patient care. Spirituality is an aspect of cultural identity that has become increasingly recognized for its potential to impact health behaviors and healthcare decision-making. We consider the complex relationship between spirituality and health, exploring the role of spirituality in primary care, and consider the inclusion of spirituality in existing models of health promotion. We discuss the feasibility of incorporating spirituality into clinical practice, offering suggestions for physicians.

Beyond demographics: differences in patient activation across new immigrant, diverse language subgroups.

The federal government promotes "patient-centered medical homes" to plan care with respect to patients' cultures and values and support patients' self-care efforts. To promote self-care, the medical home would be best utilized by activated, engaged patients. The objective of this study was to measure and compare patient activation scores in English-, Spanish-, and Haitian Creole-speaking patients seen at an inner-city hospital ambulatory care practice. Patient activation was measured using the patient activation measure (PAM). Mean PAM scores and activation levels differed according to survey language (p < 0.001). US-born participants had higher mean PAM scores than persons born outside of the US. Participants living in the US longer had higher mean PAM scores than participants newer to the US. Levels of activation and mean PAM scores increased with greater comfort reading, speaking, and thinking in English. The mean PAM (SD) score of 61.5 (16.5) for Haitian Creole-speaking Caribbean Blacks was significantly lower than the mean PAM score of 68.8 (15.6) for English-speaking Caribbean Blacks (p value = 0.006). Although mean PAM scores did not significantly differ between Haitian Creole and Spanish speakers, PAM stages differed according to language of survey completion (p < 0.001), with a greater percentage of Haitian Creole speakers being categorized as stage 1 (least activated) as well as stage 4 (most activated). Spanish and Haitian Creole speakers have lower mean PAM scores than English speakers. Mean PAM scores did not differ between Hispanics and non-Hispanics or according to race, illustrating the need to examine the role of language and culture on patient activation.

Ranking the Ten Adverse Childhood Experiences: Long-Term Consequences to Health-Related Quality of Life.

INTRODUCTION: This study compared the long-term harmful consequences of individual adverse childhood experiences (ACEs) to subsequent health-related quality of life (HRQOL) among U.S. adults. METHODS: Respondents were from the eleven U.S. states that included the optional ACE module questionnaire in the 2021 Behavioral Risk Factor Surveillance Systems (BRFSS). Relative importance (RI) was estimated for ten ACEs to respondents' self-rated general health (SRGH), physically unhealthy days (PUD), mentally unhealthy days (MUD), and activity limitation days (ALD). A variable's importance was measured as the average gains in R-squared after adding the variable to all sub-models. Statistical analysis was performed in 2023. RESULTS: After controlling for demographics, household mental illness was the most important ACE for SRGH, MUD, and ALD, with RIs of 16.4, 28.4 and 23.4, respectively. This ACE was ranked second for PUD (RI=17.8). Sexual abuse was ranked first for PUD (18.7), second for MUD (16.6) and ALD (20.9), and fifth for SRGH (10.4). Parental separation (RI ≤2.4) and incarcerated household member (2.8-5.4) were the least important ACEs for all 4 outcomes. Sexual abuse, parental separation, emotional abuse, and basic needs were not met were considerably more important among females while household mental illness and household substance abuse were more important among males. CONCLUSIONS: This study highlight that certain ACEs play a greater role than others for HRQOL with certain ACEs having a greater relative importance according to sex. Additionally, a significant proportion of the long-term impacts of ACE to HRQOL was indirectly through the mediation effect of other explanatory variables.

Cross-sectional and longitudinal comparison of health-related quality of life and mental well-being between persons with and without post COVID-19 condition.

Background: Still little is known about the impact of post COVID-19 condition (PC) on health-related quality of life (HRQOL) and mental well-being. We compared participants with PC with three groups: an acute COVID-19 infection (AC) only, at least one chronic condition (CC) but no COVID-19, or no condition at all, healthy (PH). Between these disease groups, we also estimated and compared HRQOL and mental well-being change over time. Methods: Participants from six countries (Greece, Italy, Netherlands, Sweden, United Kingdom and United States) completed two web-based questionnaires (T1 = April-May 2020 and T2 = April-June 2022). Primary outcomes were HRQOL, measured by EQ-5D-5L and EQ VAS, and mental well-being (measured by World Health Organisation-Five (WHO-5) Well-Being Index, Patient Health Questionnaire (PHQ)-9 and General Anxiety Disorder (GAD)-7). All analyses were stratified by the disease groups. Results: In total, 4,999 participants filled out both surveys: 240 were in PC, 107 in AC, 1798 in CC and 2,854 in PH. At T2, the mean EQ-5D-5L index values for the PC, AC, CC and PH groups were 0.70, 0.73, 0.75 and 0.92 (p < .001), respectively. Mean EQ VAS scores were 66, 65, 68 and 81 (p < .001), respectively. Poor mental well-being, depression and anxiety mean values were highest in the PC group (47.7; 9.1; 7.4), followed by the AC group (51.1; 7.7; 5.7), CC group (56.1; 5.2; 4.2) and the PH group (65.6; 2.8; 2.5), respectively (p < .001 between groups). Over time, HRQOL deteriorated in all groups, apart from the PH group. We observed the largest deterioration in the CC (EQ-5D-5L index: Δ0.03, p < .001) and AC group (EQ VAS: Δ6.3, p < .001). For the mental well-being outcomes, deterioration for WHO-5 and PHQ-9 were largest in the AC group (Δ4.8, p = .016; Δ-1.3, p = .012). Rates for GAD-7 improved for the PH and CC groups (PH: Δ1.27, CC: Δ0.56, p < .001). Conclusions: In the cross-sectional analysis, participants with PC had the worst HRQOL and mental well-being compared to the other groups. In terms of change since the start of the COVID-19 pandemic, HRQOL and mental well-being deterioration was highest among AC participants and had a lower impact among PC participants, most likely due to pre-existing chronic disease.

Anxiety, depression, and social connectedness among the general population of eight countries during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic affected the mental health of the general population through multiple pathways. The aim of this study was to examine anxiety, depression, self-confidence, and social connectedness among the general population of eight countries during the COVID-19 pandemic, their underlying factors, and vulnerable groups. METHODS: A web-based survey was administered to persons from the general population of China, Greece, Italy, Netherlands, Russia, Sweden, the United Kingdom, and the United States. The survey included the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9) and items on self-confidence, social connectedness, and socio-demographics. Data were analyzed with descriptive statistics, exploratory factor analysis and regression analysis. RESULTS: Twenty-three thousand six hundred twenty-two respondents completed the survey. Overall, 42% of the total sample had mild to severe anxiety symptoms and 43% had mild to severe depression symptoms. 14% to 38% reported suboptimal ratings in self-confidence, social participation, contact with family and friends, and feeling connected to others. In the exploratory factor analyses, in most countries, one dominant factor had a high influence on GAD-7, PHQ-9 sum scores and self-confidence with eigenvalue (% variance) above 3.2 (53.9%). One less dominant factor had a high influence on social connectedness scores with eigenvalue (% variance) ranging above 0.8 (12.8%). Being younger, female, having chronic conditions, perceived as risky to COVID-19 infection, and feeling not very well protected against COVID-19 were significantly associated with the two underlying factors. CONCLUSIONS: Anxiety, depression, and problems with self-confidence and social connectedness were highly prevalent in the general population of eight countries during the early phase of the COVID-19 pandemic. This highlights the importance of the allocation of additional resources to implement policies to mitigate the impact of the pandemic on mental health.

Health inequities as measured by the EQ-5D-5L during COVID-19: Results from New York in healthy and diseased persons.

INTRODUCTION: The effects of the COVID-19 pandemic caused considerable psychological and physical effects in healthy and diseased New Yorkers aside from the effects in those who were infected. We investigated the relationship between known risk-enhancing and health-promoting factors (social and medical), comorbidity indicators, and, as the primary outcome, health-related quality of life (HRQoL). METHODS: Between April 22 and May 5, 2020, a market research agency (Dynata) administered a digital survey including the EQ-5D-5L and items related to individual characteristics, social position, occupational and insurance status, living situation, exposures (smoking and COVID-19), detailed chronic conditions, and experienced access to care to an existing internet panel representative of New Yorkers. RESULTS: 2684 persons completed the questionnaire. The median age was 48 years old, and most respondents were non-Hispanic white (74%) and reported at least higher vocational training or a university education (83%). During COVID-19, mean HRQoL scores were 0.82 for the EQ-5D-5L index and 79.3 for the EQ VAS. Scores varied for healthy and diseased respondents differently by the above determinants. Lower age, impaired occupational status, loss of health insurance, and limited access to care exerted more influence on EQ-5D-5L scores of diseased persons compared to healthy persons. Among diseased persons, the number of chronic conditions and limited access to health care had the strongest association with EQ-5D-5L scores. While EQ-5D-5L scores improved with increasing age, gender had no noticeable effect. Deprivation factors showed moderate effects, which largely disappeared in (stratified) multivariable analysis, suggesting mediation through excess chronic morbidity and poor healthcare access. Generally, modifying effects were larger in the EQ-5D-5L as compared to the EQ VAS. CONCLUSIONS: Almost all factors relating to a disadvantaged position showed a negative association with HRQoL. In diseased respondents, pre-existing chronic comorbidity and experienced access to health care are key factors.

Examining the Impact of COVID-19 on Upper Manhattan Community-Based Organizations: A Qualitative Analysis of Employee Focus Groups.

Community-based organizations (CBOs) play a key role in assisting local communities, especially those in under-resourced areas, through their deep knowledge of the community's needs and available resources. We examined perceptions of COVID-19's impact on health-related services in CBOs located in Upper Manhattan, New York City (serving East Harlem, Central Harlem, Morningside Heights and Hamilton Heights, and Washington Heights and Inwood). Three focus groups were conducted on Zoom in November 2020; focus groups were composed of participants employed at CBOs in this catchment area. Deidentified interview transcripts were evaluated using an iterative process of thematic content analysis. We identified five major themes related to the impact of COVID-19 on community needs: 1) increased mistrust and decreased service utilization, 2) breakdowns in communication, 3) shift in need, 4) increased risk factors for negative health outcomes among staff and community, and 5) decreased funding and an uncertain future. Because of the pandemic, CBOs have pivoted to cater to the immediate and changing needs of the community and, in doing so, revised their menu of services as well as their service delivery model. In trying to maintain connectivity with and the trust of community members, participants had to construct novel strategies and develop new outreach strategies; participants also recognized the role strain of trying to balance community needs with home responsibilities. Given these findings, concern arises around the long-term health and well-being of community members and participants. The government must provide the necessary resources to ensure the viability of CBOs and create a stronger infrastructure for future emergencies.