Confirming—and testing—bonds of trust: A mixed methods study exploring community health workers' experiences during the COVID-19 pandemic in Bangladesh, Haiti and Kenya

Amidst the COVID-19 pandemic and national responses, trust (one's belief that a system acts in one's best interest) is important to consider. In community health systems, trust is embedded in relationships between clients, CHWs, and health system stakeholders. This mixed-methods study explores trust through the evolving COVID-19 crisis in Bangladesh, Haiti, and Kenya, where multi-country community health research was underway. We investigate the extent and ways trust between communities, community health workers (CHWs), and health system actors shift, including its relation to community fear and hostility, through self-reported positive and negative experiences of CHWs and policy/program stakeholders on a phone-based survey with 2,025 CHWs and 72 key informant interviews, including CHWs, in late 2020. On surveys, CHWs reported high levels of community trust (8/10 in Bangladesh and Kenya;6/10 in Haiti) with over 60% reporting client relief in seeing their CHWs. About one-third of CHWs across countries reported experiencing instances of hostility from community members during the pandemic in the form of refused home-entry, ignored advice, or being shouted at. Multivariate analyses revealed that CHWs reporting more positive and fewer negative experiences is consistently associated with continuing routine work, doing COVID-19-related work, and greater community trust. Qualitative interviews showed that existing pre-pandemic trusting relationships withstood the early phase of COVID-19, mitigating negative community reactions toward CHWs and stigma towards COVID-positive individuals, maintaining routine health services, and sustaining appreciation for CHW-provided prevention information and emotional support. CHW-community and CHW-health system actor trust is strengthened when CHWs are well-resourced;CHW-community trust is strained by public frustration at the pandemic, associated restrictions, and sociopolitical stressors. Our study suggests that with adequate institutional support, bonds of trust can promote resilient community health systems during extended public health crises, through CHWs' commitment to mitigating misinformation, reducing stigma, maintaining routine service provision, and promoting COVID-19 prevention.

Impact of Public Health and Social Measures on the COVID-19 Pandemic in the United States and Other Countries: Descriptive Analysis.

BACKGROUND: The United States of America has the highest global number of COVID-19 cases and deaths, which may be due in part to delays and inconsistencies in implementing public health and social measures (PHSMs). OBJECTIVE: In this descriptive analysis, we analyzed the epidemiological evidence for the impact of PHSMs on COVID-19 transmission in the United States and compared these data to those for 10 other countries of varying income levels, population sizes, and geographies. METHODS: We compared PHSM implementation timing and stringency against COVID-19 daily case counts in the United States and against those in Canada, China, Ethiopia, Japan, Kazakhstan, New Zealand, Singapore, South Korea, Vietnam, and Zimbabwe from January 1 to November 25, 2020. We descriptively analyzed the impact of border closures, contact tracing, household confinement, mandated face masks, quarantine and isolation, school closures, limited gatherings, and states of emergency on COVID-19 case counts. We also compared the relationship between global socioeconomic indicators and national pandemic trajectories across the 11 countries. PHSMs and case count data were derived from various surveillance systems, including the Health Intervention Tracking for COVID-19 database, the World Health Organization PHSM database, and the European Centre for Disease Prevention and Control. RESULTS: Implementing a specific package of 4 PHSMs (quarantine and isolation, school closures, household confinement, and the limiting of social gatherings) early and stringently was observed to coincide with lower case counts and transmission durations in Vietnam, Zimbabwe, New Zealand, South Korea, Ethiopia, and Kazakhstan. In contrast, the United States implemented few PHSMs stringently or early and did not use this successful package. Across the 11 countries, national income positively correlated (r=0.624) with cumulative COVID-19 incidence. CONCLUSIONS: Our findings suggest that early implementation, consistent execution, adequate duration, and high adherence to PHSMs represent key factors of reducing the spread of COVID-19. Although national income may be related to COVID-19 progression, a country's wealth appears to be less important in controlling the pandemic and more important in taking rapid, centralized, and consistent public health action.

Confirming-and testing-bonds of trust: A mixed methods study exploring community health workers' experiences during the COVID-19 pandemic in Bangladesh, Haiti and Kenya.

Amidst the COVID-19 pandemic and national responses, trust (one's belief that a system acts in one's best interest) is important to consider. In community health systems, trust is embedded in relationships between clients, CHWs, and health system stakeholders. This mixed-methods study explores trust through the evolving COVID-19 crisis in Bangladesh, Haiti, and Kenya, where multi-country community health research was underway. We investigate the extent and ways trust between communities, community health workers (CHWs), and health system actors shift, including its relation to community fear and hostility, through self-reported positive and negative experiences of CHWs and policy/program stakeholders on a phone-based survey with 2,025 CHWs and 72 key informant interviews, including CHWs, in late 2020. On surveys, CHWs reported high levels of community trust (8/10 in Bangladesh and Kenya; 6/10 in Haiti) with over 60% reporting client relief in seeing their CHWs. About one-third of CHWs across countries reported experiencing instances of hostility from community members during the pandemic in the form of refused home-entry, ignored advice, or being shouted at. Multivariate analyses revealed that CHWs reporting more positive and fewer negative experiences is consistently associated with continuing routine work, doing COVID-19-related work, and greater community trust. Qualitative interviews showed that existing pre-pandemic trusting relationships withstood the early phase of COVID-19, mitigating negative community reactions toward CHWs and stigma towards COVID-positive individuals, maintaining routine health services, and sustaining appreciation for CHW-provided prevention information and emotional support. CHW-community and CHW-health system actor trust is strengthened when CHWs are well-resourced; CHW-community trust is strained by public frustration at the pandemic, associated restrictions, and sociopolitical stressors. Our study suggests that with adequate institutional support, bonds of trust can promote resilient community health systems during extended public health crises, through CHWs' commitment to mitigating misinformation, reducing stigma, maintaining routine service provision, and promoting COVID-19 prevention.

Burden of mental distress in the US associated with trust in media for COVID-19 information.

During the COVID-19 pandemic, news and social media outlets have played a major role in dissemination of information. This analysis aimed to study the association between trust in social and traditional media and experiences of mental distress among a representative sample of US adults. Data for this study came from National Pandemic Pulse, a cross-sectional, nationally representative survey that sampled participants on the Dynata platform. Participants included 6435 adults surveyed between 15-23 December 2020. Ordinal logistic regression analyses examined the associations of trust in (i) social media, (ii) print media, (iii) broadcast TV and (iv) cable TV, for COVID-19-related information with self-reported mental distress (4-item Patient Health Questionnaire), controlling for sociodemographics and census region. Compared with those who distrusted social media, those who trusted social media had 2.09 times (95% CI = 1.84-2.37) greater adjusted odds of being in a more severe category of mental distress. In contrast, compared with those who distrusted print media, those who trusted print media had 0.80 times (95% CI = 0.69-0.93) lower adjusted odds of being in a more severe category of mental distress. No significant associations were found between mental distress and trust in broadcast or cable TV for accessing news about COVID-19. Trust in different news outlets may be associated with mental distress during public health emergencies like the COVID-19 pandemic. Future studies should explore mechanisms behind these associations, including adherence to best practices for crisis reporting among different media sources and exposure of individuals to misinformation.

During the COVID-19 pandemic, both, traditional channels like print, TV and cable news, as well as social media, have been major sources to obtain news about the pandemic. In this manuscript, we study the association between trust in social and traditional media and symptoms of mental distress among a nationally representative sample of 6435 US adults surveyed in December 2020. Our findings show that those who reported trusting traditional print media were less likely to report more severe mental distress. Conversely, those who reported trusting social media were more likely to report more severe levels of mental distress. This highlights the urgent need for understanding the diffusion patterns of misinformation and rumors that circulate on social media, and consumers' reactions to them. It is important that during a public health emergency, we follow best practices for crisis communication to reduce panic, address uncertainty, promote protective behaviors and mental health.

Schooling amidst a pandemic in the United States: Parents' perceptions about reopening schools and anticipated challenges during COVID-19.

INTRODUCTION: During the COVID-19 pandemic, numerous states in the United States instituted measures to close schools or shift them to virtual platforms. Understanding parents' preferences for sending their children back to school, and their experiences with distance learning is critical for informing school reopening guidelines. This study characterizes parents' plans to return their children to school, and examines the challenges associated with school closures during the 2020-2021 academic year. METHODS: A national-level cross-sectional online survey was conducted in September 2020. Focusing on a subset of 510 respondents, who were parents of school-aged children, we examined variations in parents' plans for their children to return to school by their demographic and family characteristics, and challenges they anticipated during the school-year using multivariable logistic regressions. RESULTS: Fifty percent of respondents (n = 249) said that they would send their children back to school, 18% (n = 92) stated it would depend on what the district plans for school reopening, and 32% (n = 160) would not send their children back to school. No demographic characteristics were significantly associated with parents plans to not return their children to school. Overall, parents reported high-level of access to digital technology to support their child's learning needs (84%). However, those who reported challenges with distance learning due to a lack of childcare were less likely to not return their children to school (aOR = 0.33, 95% CI: 0.17, 0.64). Parents who reported requiring supervision after school had higher odds of having plans to not return their children to school (aOR = 1.97, 95% CI: 1.03, 3.79). Parents viewed COVID-19 vaccines and face-masks important for resuming in-person classes. DISCUSSION: About one-third of parents objected to their children returning to school despite facing challenges with distance learning. Besides access to vaccines and face-masks, our findings highlight the need to better equip parents to support remote learning, and childcare.

Burden of mental distress in the United States is associated with delayed medical visits and missed prescription refills during the COVID-19 pandemic.

The COVID-19 pandemic has contributed to poor health due to a decrease in healthcare utilization and those with mental health problems may be impacted. For this analysis, data came from a cross-sectional, nationally representative December 2020 survey. Logistic regression analyses examined associations between (1) mental distress and delayed medical visits, (2) mental distress and missed prescription refills, controlling for sociodemographics, pre-existing chronic conditions, and access to health insurance. We found that, compared to those that exhibited normal levels of mental distress, those with mild (aOR = 2.83, 95% CI = 2.47-3.24), moderate (aOR = 3.43, 95% CI = 2.95-3.99), and severe (aOR = 4.96, 95% CI = 4.21-5.84) mental distress showed greater odds of delaying medical visits. Similarly, compared to those that exhibited normal levels of mental distress, those with mild (aOR =3.93, 95% CI = 3.04-5.09), moderate (aOR =6.52, 95% CI = 5.07-8.43), and severe (aOR =8.69, 95% CI = 6.71-11.32) mental distress showed greater odds of missing prescription refills. Our study shows that individuals who showed signs of mental distress had increased odds of delayed medical visits and missed prescription refills, compared to those that showed normal levels of mental distress.

Changes in prenatal care and vaccine willingness among pregnant women during the COVID-19 pandemic.

INTRODUCTION: Concerns about SARS-CoV-2 infection risk in health care settings have resulted in changes in prenatal care and birth plans, such as shifts to in-person visits and increased Cesarean delivery. These changes may affect quality of care and limit opportunities for clinicians to counsel pregnant individuals, who are at higher risk of severe COVID-19 disease and adverse pregnancy outcomes, about prevention and vaccination. METHODS: We conducted a cross-sectional online survey of United States adults on changes in prenatal care, COVID-19 vaccine willingness, and reasons for unwillingness to receive a vaccine. We summarized changes in access to care and examined differences in vaccine willingness between pregnant and propensity-score matched non-pregnant controls using chi-squared tests and multivariable conditional logistic regression. RESULTS: Between December 15-23, 2020, 8481 participants completed the survey, of which 233 were pregnant. Three-quarters of pregnant women (n = 186) experienced a change in prenatal care, including format of care (n = 84, 35%) and reduced visits (n = 69, 24%). Two-thirds experienced a change in birth plans, from a hospital birth to home birth (n = 45, 18%) or vaginal birth to a Cesarean delivery (n = 42, 17%). Although 40% of pregnant women (n = 78) were unwilling to receive COVID-19 vaccination, they had higher, though non-significant, odds of reporting willingness to receive vaccination compared to similar non-pregnant women (aOR 1.38, 95% CI: 0.95, 2.00). CONCLUSION: To support pregnant women through the perinatal care continuum, maternity care teams should develop protocols to foster social support, patient-centered education around infection prevention that focuses on improved risk perception, expected changes in care due to COVID-19, and vaccine effectiveness and safety.

Food Insecurity and Delayed or Forgone Medical Care During the COVID-19 Pandemic.

Objectives. To describe food insecurity in the United States in December 2020 and examine associations with underuse of medical care during the COVID-19 pandemic. Methods. We fielded a nationally representative Web-based survey in December 2020 (n = 8318). Multivariable logistic regression models and predicted probabilities were used to evaluate factors associated with food insecurity and compare the likelihood of delaying or forgoing medical care because of cost concerns by food security status. Results. In December 2020, 18.8% of US adults surveyed reported experiencing food insecurity. Elevated odds of food insecurity were observed among non-Hispanic Black, Hispanic, and low-income respondents. Experiencing food insecurity was significantly associated with a greater likelihood of forgoing any type of medical care as a result of cost concerns. Conclusions. Food insecurity during the COVID-19 pandemic disproportionately affected non-White and low-income individuals. Experiencing food insecurity was a significant risk factor for delaying or forgoing medical care, an association that could have cumulative short- and long-term health effects. Public Health Implications. Comprehensive policies that target the most at-risk groups are needed to address the high rates of food insecurity in the United States and mitigate its adverse health effects. (Am J Public Health. 2022;112(5):776-785. https://doi.org/10.2105/AJPH.2022.306724).

Assessing the reliability of phone surveys to measure reproductive, maternal and child health knowledge among pregnant women in rural India: a feasibility study.

OBJECTIVES: Efforts to understand the factors influencing the uptake of reproductive, maternal, newborn, child health and nutrition (RMNCH&N) services in high disease burden low-resource settings have often focused on face-to-face surveys or direct observations of service delivery. Increasing access to mobile phones has led to growing interest in phone surveys as a rapid, low-cost alternatives to face-to-face surveys. We assess determinants of RMNCH&N knowledge among pregnant women with access to phones and examine the reliability of alternative modalities of survey delivery. PARTICIPANTS: Women 5-7 months pregnant with access to a phone. SETTING: Four districts of Madhya Pradesh, India. DESIGN: Cross-sectional surveys administered face-to-face and within 2 weeks, the same surveys were repeated among two random subsamples of the original sample: face-to-face (n=205) and caller-attended telephone interviews (n=375). Bivariate analyses, multivariable linear regression, and prevalence and bias-adjusted kappa scores are presented. RESULTS: Knowledge scores were low across domains: 52% for maternal nutrition and pregnancy danger signs, 58% for family planning, 47% for essential newborn care, 56% infant and young child feeding, and 58% for infant and young child care. Higher knowledge (≥1 composite score) was associated with older age; higher levels of education and literacy; living in a nuclear family; primary health decision-making; greater attendance in antenatal care and satisfaction with accredited social health activist services. Survey questions had low inter-rater and intermodal reliability (kappa<0.70) with a few exceptions. Questions with the lowest reliability included true/false questions and those with unprompted, multiple response options. Reliability may have been hampered by the sensitivity of the content, lack of privacy, enumerators' and respondents' profile differences, rapport, social desirability bias, and/or enumerator's ability to adequately convey concepts or probe. CONCLUSIONS: Phone surveys are a reliable modality for generating population-level estimates data about pregnant women's knowledge, however, should not be used for individual-level tracking. TRIAL REGISTRATION NUMBER: NCT03576157.

COVID-19 risk perceptions of social interaction and essential activities and inequity in the USA: results from a nationally representative survey.

INTRODUCTION: SARS-CoV-2 has disproportionately affected disadvantaged communities across the USA. Risk perceptions for social interactions and essential activities during the COVID-19 pandemic may vary by sociodemographic factors. METHODS: We conducted a nationally representative online survey of 1592 adults in the USA to understand risk perceptions related to transmission of COVID-19 for social (eg, visiting friends) and essential activities (eg, medical visits or returning to work). We assessed relationships for activities using bivariate comparisons and multivariable logistic regression modelling, between responses of safe and unsafe, and participant characteristics. Data were collected and analysed in 2020. RESULTS: Among 1592 participants, risk perceptions of unsafe for 13 activities ranged from 29.2% to 73.5%. Large gatherings, indoor dining and visits with elderly relatives had the highest proportion of unsafe responses (>58%), while activities outdoor, accessing healthcare and going to the grocery store had the lowest (<36%). Older respondents were more likely to view social gatherings and indoor activities as unsafe but less likely for other activities, such as going to the grocery store and accessing healthcare. Compared with white/Caucasian respondents, black/African-American and Hispanic/Latino respondents were more likely to view activities such as dining and visiting friends outdoor as unsafe. Generally, men versus women, Republicans versus Democrats and independents, and individuals with higher versus lower income were more likely to view activities as safe. CONCLUSION: Evidence-based interventions should be tailored to sociodemographic differences in risk perception, access to information and health behaviours when implementing efforts to control the COVID-19 pandemic.

Rapid Real-time Tracking of Nonpharmaceutical Interventions and Their Association With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Positivity: The Coronavirus Disease 2019 (COVID-19) Pandemic Pulse Study.

BACKGROUND: Current mitigation strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rely on the population-wide adoption of nonpharmaceutical interventions (NPIs). Monitoring the adoption of NPIs and their associations with SARS-CoV-2 infection history can provide key information for public health. METHODS: We sampled 1030 individuals in Maryland from 17-28 June 2020 to capture sociodemographically and geographically resolved information about NPI adoption and access to SARS-CoV-2 testing, and examine associations with self-reported SARS-CoV-2 positivity. RESULTS: Overall, 92% reported traveling for essential services and 66% visited friends/family. Use of public transport was reported by 18%. In total, 68% reported strict social distancing indoors and 53% reported strict masking indoors; indoor social distancing was significantly associated with age, and race/ethnicity and income were associated with masking. Overall, 55 participants (5.3%) self-reported ever testing positive for SARS-CoV-2, with strong dose-response relationships between several forms of movement frequency and SARS-CoV-2 positivity. In a multivariable analysis, a history of SARS-CoV-2 infection was negatively associated with strict social distancing (adjusted odds ratio [aOR] for outdoor social distancing, 0.10; 95% confidence interval, .03-.33). Only public transport use (aOR for >7 times vs never, 4.3) and visiting a place of worship (aOR for ≥3 times vs never, 16.0) remained significantly associated with SARS-CoV-2 infection after adjusting for strict social distancing and demographics. CONCLUSIONS: These results support public health messaging that strict social distancing during most activities can reduce SARS-CoV-2 transmission. Additional considerations are needed for indoor activities with large numbers of persons (places of worship and public transportation), where even NPIs may not be possible or sufficient.

Food insecurity is adversely associated with psychological distress, anxiety and depression during the COVID-19 pandemic.

Early COVID-19 pandemic data showed a spike in both food insecurity and poor mental health. The purpose of this study was to examine the relationship between food insecurity and mental health outcomes nine months after the start of the COVID-19 pandemic. A national survey of adults 18 years and older was administered in December 2020 (N = 8,355). Multivariable logistic models and post-estimation margins commands were used to show the predicted probability of mental health outcomes (psychological distress, anxiety, and depression) by food security status. The majority of participants (68.5%) reported high/marginal food security, 15.5% had low food security, and 16.0% had very low food security. There was a strong dose response relationship between food insecurity and higher psychological distress, anxiety and depression. Fewer than one in five adults with high/marginal food security screened positive for all three mental health outcomes, while more than two in five adults with low food security screened positive for psychological distress (39.9%), depression (41.7%) and anxiety (41.3%). Among adults with very low food security, nearly half screened positive for psychological distress (47.7%), depression (48.1%) and anxiety (49.4%). Younger adults had higher prevalence of psychological distress compared to older adults regardless of food security status. Food insecure adults, particularly young adults, have higher rates of psychological distress, anxiety, and depression than their food secure counterparts. Facilitating opportunities to connect at risk populations with food assistance and affordable mental healthcare should be prioritized as the pandemic continues and beyond.

LB-10. Rapid Assessments of Non-Pharmaceutical Intervention Uptake and Population Mobility Patterns Elucidate SARS-Cov-2 Transmission Dynamics

Background. Current mitigation strategies for SARS-CoV-2 rely on population- wide adoption of non-pharmaceutical interventions (NPIs). Monitoring NPI adoption, mobility patterns and their association with SARS-CoV-2 infection can provide key information for public health agencies and be used to calibrate transmission models. Methods. We used an online panel to accrue representative samples from Florida, Illinois, and Maryland (n=3,009, approximately 1,000 per state) from July 15-31, 2020 and capture socio-demographically and geographically resolved information about NPI adoption and mobility in the prior 2 weeks. Logistic regression was used to identify correlates of self-reported SARS-CoV-2 infection in the prior 2 weeks. Results. Overall, 96% reported traveling outside their home in the prior 2 weeks, the most common reason being to visit a grocery store/pharmacy (92%), followed by visiting friends/family (61%), and visiting a place of worship (23%);22% reporting public transportation use. In total, 44% of respondents reported always practicing social distancing and 40% reported always using a mask indoors and outdoors. Overall, 74 (2.5%) reported testing positive for SARS-CoV-2 in the prior 2 weeks, with strong dose-response relationships between several forms of movement frequency and SARS-CoV-2 positivity. Variables capturing mobility were all highly correlated with one another, suggesting there are clusters of individuals who engage in multiple activities (Figure);41% of positive cases engaged in all forms of mobility captured compared to 1% of those who did not test positive within the prior 2 weeks. Patterns of mobility and NPI uptake did not significantly differ by state;however, there were significant relationships with age, race/ethnicity, and gender. In multivariable models including adjustment for NPIs, significant relationships remained with public transportation, visiting a place of worship, and participating in outdoor group fitness activities. Conclusion. NPI adoption and mobility did not vary across these three states with variable policies and SARS-CoV-2 positivity rates. Rather, associations with recent positivity appear to be driven largely by mobility patterns and engagement in activities where NPI use may be challenging or inconsistent. (Figure Presented).

WHO Digital Health Guidelines: a milestone for global health.

In 2019, the World Health Organization (WHO) released the first-ever evidence-based guidelines for digital health. The guideline provides nine recommendations on select digital health interventions that involve the use of a mobile phone or device. It also provides information on implementation considerations, quality and certainty of extant evidence, factors related to acceptability and feasibility of the intervention, and gaps in the evidence that can inform future research. Given the pivotal role digital health can play in supporting health systems, seen especially in light of the COVID-19 pandemic, these guidelines can help provide a roadmap for governments and policymakers in introducing and scaling up digital health interventions to support population health outcomes.