Emergency Department Visits for Pedestrians Injured in Motor Vehicle Traffic Crashes - United States, January 2021-December 2023.

Traffic-related pedestrian deaths in the United States reached a 40-year high in 2021. Each year, pedestrians also suffer nonfatal traffic-related injuries requiring medical treatment. Near real-time emergency department visit data from CDC's National Syndromic Surveillance Program during January 2021-December 2023 indicated that among approximately 301 million visits identified, 137,325 involved a pedestrian injury (overall visit proportion = 45.62 per 100,000 visits). The proportions of visits for pedestrian injury were 1.53-2.47 times as high among six racial and ethnic minority groups as that among non-Hispanic White persons. Compared with persons aged ≥65 years, proportions among those aged 15-24 and 25-34 years were 2.83 and 2.61 times as high, respectively. The visit proportion was 1.93 times as high among males as among females, and 1.21 times as high during September-November as during June-August. Timely pedestrian injury data can help collaborating federal, state, and local partners rapidly monitor trends, identify disparities, and implement strategies supporting the Safe System approach, a framework for preventing traffic injuries among all road users.

Meeting the Aerobic and Muscle-Strengthening Physical Activity Guidelines Among Older US Adults, National Health Interview Survey 1998-2018.

The Physical Activity Guidelines for Americans, second edition, recommends older adults participate in ≥150 minutes per week of moderate-intensity equivalent aerobic activity and ≥2 days per week of muscle-strengthening activity. We estimated prevalence and trends of meeting the guidelines among US adults aged ≥65 years from 1998 to 2018. Using the 1998-2018 National Health Interview Survey, we estimated the prevalence of meeting aerobic, muscle-strengthening, and combined physical activity guidelines stratified by age group, sex, race and ethnicity, and education level. Within age groups, we calculated prevalence differences by sociodemographic categories. Prevalence of meeting each guideline increased for all age groups and most sociodemographic subgroups. The increased magnitude of meeting the combined guideline from 1998-2000 to 2016-2018 differed across levels of educational attainment for most age groups. Despite increasing over time, the prevalence among older adults of meeting physical activity guidelines remains low (range for combined guideline: 7.2%-17.2%).

Association Between Leisure-Time Physical Activity and Occupation Activity Level, National Health Interview Survey-United States, 2020.

BACKGROUND: Physical activity for any purpose counts toward meeting Physical Activity Guidelines (PAG). However, national surveillance systems traditionally focus on leisure-time physical activity. There is an incomplete understanding of the association between meeting PAG in leisure time and occupation activity level among US workers. METHODS: We used cross-sectional 2020 National Health Interview Survey data to examine US adults aged 18-64 years who worked the week before the survey (n = 14,814). We estimated the proportion meeting aerobic and muscle-strengthening PAG in leisure time by occupation activity level (low, intermediate, and high). Using logistic regression, we examined the association between meeting PAG in leisure time and occupation activity level, adjusted for sociodemographic characteristics and stratified by hours worked. We compared the sociodemographic characteristics of adults working ≥40 hours (the previous week) in high-activity occupations to those in low- or intermediate-activity occupations. RESULTS: Adults working in high-activity occupations were less likely to meet PAG in leisure time (26.1% [24.3-28.1]) versus those in low-activity (30.6% [29.1-32.2], P < .01) or intermediate-activity (32.4% [30.8-34.2]) occupations. In stratified, adjusted models, adults working ≥40 hours in low- and intermediate-activity occupations were 13% and 20%, respectively, more likely to meet PAG in leisure time versus those in high-activity occupations. Among those working ≥40 hours, adults in high-activity occupations were more likely to be Hispanic or Latino, male, younger, and have a high school education or lower compared with those in less active occupations. CONCLUSION: Traditional surveillance may underestimate meeting PAG among people working in high-activity occupations, potentially disproportionately affecting certain groups.

Prevalence of vision zero action plans or strategies: USA, 2021.

BACKGROUND: Vision Zero is a strategy to eliminate traffic fatalities and to promote equitable mobility options for all road users. Using a nationally representative survey, we aimed to estimate the prevalence of Vision Zero action plans or strategies in the USA. METHODS: Municipal officials were surveyed in 2021. In this cross-sectional study, we calculated the prevalence of Vision Zero plans or strategies and compared municipalities with adjusted prevalence ratios (PR) to account for region and sociodemographic characteristics. RESULTS: Among 1955 municipalities participating in the survey (question-specific response rate: 44.3%), the prevalence of a Vision Zero action plan or strategy was 7.7%; 70.5% responded no and 21.8% don't know. Prevalence was 4.8% in small municipalities (1000-2499 residents), 20.3% in medium-large municipalities (50 000-124 999 residents; PR=4.1), and 37.8% in large municipalities (≥125 000 residents; PR=7.6). CONCLUSION: The prevalence of Vision Zero plans and strategies across the USA is low. Additional adoption of Vision Zero plans and strategies could help address traffic fatalities.

Time Playing Outdoors Among Children Aged 3-5 Years: National Survey of Children's Health, 2021.

INTRODUCTION: Federal guidelines recommend physical activity throughout the day for preschool-aged children. Time playing outdoors can support physical activity participation, health, and development. Estimates of time playing outdoors among U.S. children aged 3-5 years have not been published. METHODS: Parent/caregiver-reported data on children aged 3-5 years from the 2021 National Survey of Children's Health were analyzed in 2022-23. Chi-square tests were used to identify differences in time playing outdoors by sociodemographic and neighborhood characteristics. Multiple logistic regression analyses were conducted with significant characteristics for weekdays and weekend days. RESULTS: Among 11,743 children aged 3-5 years, 37% played outdoors for ≤1 hour on weekdays, and 24% played outdoors for ≤1 hour on weekend days. In 9 states, ≥40% of children played outdoors for ≤1 hour on weekdays. Adjusted models for weekdays and weekend days showed a greater likelihood of ≤1 hour playing outdoors among those in all racial/ethnic groups compared to non-Hispanic White, those who lived in metropolitan statistical areas, those who did not participate in child care, and those whose adult proxy disagreed with "we watch out for each other's children in this neighborhood." The weekday model showed additional differences by sex, with girls more likely to have ≤1 hour of time playing outdoors. CONCLUSIONS: Nearly 40% of preschool-aged children play outdoors for ≤1 hour per day on weekdays, with differences by sociodemographic and neighborhood characteristics. Further study and interventions focused on building supportive, equitable communities might increase the amount of time preschool-aged children spend playing outdoors.

Changes in Perceptions of the Near-Home Walking Environment Among US Adults-2015 and 2020 National Health Interview Survey.

BACKGROUND: The built environments in which we work, live, and play can influence physical activity behaviors, and perceptions of these environments are associated with walking behavior. This study's objective is to compare national-level data on perceptions of the near-home walking environment from the 2015 and 2020 National Health Interview Survey. METHODS: Adults in 2015 (n = 30,811) and 2020 (n = 29,636) reported perceptions of walkable supports (roads, sidewalks, paths, or trails; sidewalks on most streets), destinations (shops, stores, or markets; bus or transit stops; movies, libraries, or churches; places that help you relax, clear your mind, and reduce stress), and barriers to walking (traffic; crime; animals). Age-adjusted prevalence estimates, prevalence differences, and 95% confidence intervals were calculated overall and by demographic characteristics. RESULTS: The reported prevalence of roads, sidewalks, paths, or trails for walking increased overall (85.3% in 2015 to 88.0% in 2020) and for many subgroups. Perceived places to walk to for relaxation, to clear your mind, and to reduce stress increased overall (72.1% in 2015 to 77.1% in 2020) and for all subgroups. Perceptions of crime as a barrier to walking decreased overall (12.5% in 2015 to 11.2% in 2020) and for some subgroups. From 2015 to 2020, the proportion of adults perceiving roads, sidewalks, paths, or trails; places to relax; and crime as a barrier to walking improved. CONCLUSIONS: Continuing to monitor perceptions of the walking environment could contribute to progress toward national walking and walkability goals in the United States.

Physical Activity-Friendly Policies and Community Design Features in the US, 2014 and 2021.

INTRODUCTION: The 2014 Community-Based Survey of Supports for Healthy Eating and Active Living documented the prevalence of US municipal policy and community design supports for physical activity. The survey was repeated in 2021. Our study examined change in the prevalence of supports from 2014 to 2021, overall and by municipality characteristic. METHODS: Municipalities were sampled independently each survey year. We calculated prevalence in 2014 and 2021 and the prevalence ratio (PR) for 15 supports covering zoning codes, park policies and budgets, design standards, Complete Streets policies, and shared use agreements. We used a Bonferroni-corrected Breslow-Day test to test for interaction by municipality characteristic. RESULTS: In 2014 (2,009 municipalities) compared with 2021 (1,882 municipalities), prevalence increased for several zoning codes: block sizes of walkable distances (PR = 1.46), minimum sidewalk width (PR = 1.19), pedestrian amenities along streets (PR = 1.15), continuous sidewalk coverage (PR = 1.14), and building orientation to pedestrian scale (PR = 1.08). Prevalence also increased for design standards requiring dedicated bicycle infrastructure for roadway expansion projects or street retrofits (PR = 1.19). Prevalence declined for shared use agreements (PR = 0.87). The prevalence gap widened between the most and least populous municipalities for Complete Streets policies (from a gap of 33.6 percentage points [PP] in 2014 to 54.0 PP in 2021) and for zoning codes requiring block sizes that were walkable distances (from 11.8 PP to 41.4 PP). CONCLUSION: To continue progress, more communities could consider adopting physical activity-friendly policies and design features.

Joint Prevalence of Influenza Preventive Behaviors Among Adults-United States, 2020.

INTRODUCTION/OBJECTIVES: The Centers for Disease Control and Prevention recognizes routine vaccination, sufficient sleep, and adequate physical activity as behavioral approaches to reduce the incidence of influenza. We aimed to determine the joint national prevalence of these health behaviors among U.S. adults, which has not been reported. METHODS: We used the 2020 National Health Interview Survey to assess prevalence of receiving influenza vaccination in the past 12 months, obtaining sufficient sleep, and achieving adequate physical activity among U.S. adults (n = 30,312). We calculated the joint prevalence overall and by sociodemographic and health-related variables. RESULTS AND CONCLUSIONS: The overall joint prevalence was 8.5% (95% CI, 8.0-9.0). Prevalence was lower among older persons (vs younger); Hispanic and non-Hispanic Black persons (vs non-Hispanic White); current and former smokers (vs never smokers); postpartum women (vs neither pregnant nor postpartum); and those with a history of coronary heart disease, hypertension, stroke, diabetes, and chronic obstructive pulmonary disease (vs not having those respective condition). In addition to recommending annual vaccination, primary care providers might encourage sufficient sleep and adequate physical activity-especially among patients who have increased risk for influenza complications and are less likely to achieve these behaviors.

Changes in Physical Inactivity Among US Adults Overall and by Sociodemographic Characteristics, Behavioral Risk Factor Surveillance System, 2020 Versus 2018.

The COVID-19 pandemic may have disrupted people's work-life patterns and access to places to be physically active. Behavioral Risk Factor Surveillance System data were analyzed to assess changes in self-reported leisure-time physical inactivity. The results showed that prevalence of inactivity among US adults decreased 0.7 percentage points (95% CI: -1.2 to -0.3), from 24.5% in 2018 to 23.8% in 2020, and the greatest decreases were observed among rural-dwelling women, rural-dwelling men, and non-Hispanic White women. These findings highlight a need to understand and address factors that lead to differential changes in leisure-time physical inactivity across subpopulations during public health emergencies.

Changes in Teleworking and Physical Activity Behaviors in the United States Before and After Emergence of COVID-19.

OBJECTIVE: The aim of the study is to determine the prevalence of perceived decreases in three physical activity (PA) behaviors and meeting the PA guideline, by changes in telework. METHODS: US workers ( N = 2393) reported teleworking and PA behaviors before and after COVID-19 emergence. Those reporting more and less telework were compared with those reporting stable telework on prevalence of (1) decreasing behaviors and (2) meeting the aerobic guideline (≥150 min/wk of moderate-intensity PA). RESULTS: Compared with workers with stable telework, those with increased telework were more likely to report decreases in any PA (by 61%), active transportation (65%), and park use (52%). Workers who deceased telework were also more likely to report decreases in these behaviors. Groups were equally likely to meet the guideline. CONCLUSIONS: Changes in teleworking status-either more or less-may be associated with decreased participation in PA behaviors.

Awareness and Knowledge of the Physical Activity Guidelines for Americans, 2nd Edition.

BACKGROUND: Assessing awareness and knowledge of the Physical Activity Guidelines for Americans, 2nd edition (Guidelines), released in 2018, is important for monitoring factors that contribute to increasing physical activity. METHODS: We estimated prevalence of awareness and knowledge of the adult aerobic guideline (≥150 min/wk of moderate-intensity equivalent aerobic physical activity preferably spread out over a week) among adults (n = 3471) and of the youth aerobic guideline (≥60 min/d of mostly moderate- to vigorous-intensity aerobic physical activity) among a subset of parents (n = 744) from a nationwide sample of US adults in the 2019 FallStyles survey. We estimated odds ratios using logistic regression, adjusting for demographic and other characteristics. RESULTS: Approximately 1 in 10 US adults and parents reported being aware of the Guidelines. Only 3% of adults knew the correct adult aerobic guideline. The most common responses were "don't know/not sure" (44%) and "30 minutes a day, 5 or more days a week" (28%). Among parents, 15% knew the youth aerobic guideline. Awareness and knowledge tended to be lower with lower education and income. CONCLUSIONS: Limited awareness and knowledge of the Guidelines suggest communication about the Guidelines could be strengthened, especially among adults with low income or education.

Leisure-time physical activity and mortality from influenza and pneumonia: a cohort study of 577 909 US adults.

OBJECTIVE: To examine the association of leisure-time physical activity with mortality from influenza and pneumonia. METHODS: A nationally representative sample of US adults (aged ≥18 years) who participated in the National Health Interview Survey from 1998 to 2018 were followed for mortality through 2019. Participants were classified as meeting both physical activity guidelines if they reported ≥150 min/week of moderate-intensity equivalent aerobic physical activity and ≥2 episodes/week of muscle-strengthening activity. Participants were also classified into five volume-based categories of self-reported aerobic and muscle-strengthening activity. Influenza and pneumonia mortality was defined as having an underlying cause of death with an International Classification of Diseases, 10th Revision code of J09-J18 recorded in the National Death Index. Mortality risk was assessed using Cox proportional hazards, adjusting for sociodemographic and lifestyle factors, health conditions and influenza and pneumococcal vaccination status. Data were analysed in 2022. RESULTS: Among 577 909 participants followed for a median of 9.23 years, 1516 influenza and pneumonia deaths were recorded. Compared with participants meeting neither guideline, those meeting both guidelines had 48% lower adjusted risk of influenza and pneumonia mortality. Relative to no aerobic activity, 10-149, 150-300, 301-600 and >600 min/week were associated with lower risk (by 21%, 41%, 50% and 41%). Relative to <2 episodes/week of muscle-strengthening activity, 2 episodes/week was associated with 47% lower risk and ≥7 episodes/week with 41% higher risk. CONCLUSIONS: Aerobic physical activity, even at quantities below the recommended level, may be associated with lower influenza and pneumonia mortality while muscle-strengthening activity demonstrated a J-shaped relationship.

Association between passively collected walking and bicycling data and purposefully collected active commuting survey data-United States, 2019.

Commercially-available location-based services (LBS) data derived primarily from mobile devices may provide an alternative to surveys for monitoring physically-active transportation. Using Spearman correlation, we compared county-level metrics of walking and bicycling from StreetLight with metrics of physically-active commuting among U.S. workers from the American Community Survey. Our strongest pair of metrics ranked counties (n = 298) similarly for walking (rho = 0.53 [95% CI: 0.44-0.61]) and bicycling (rho = 0.61 [0.53-0.67]). Correlations were higher for denser and more urban counties. LBS data may offer public health and transportation professionals timely information on walking and bicycling behavior at finer geographic scales than some existing surveys.

BMI and Physical Activity, Military-Aged U.S. Population 2015-2020.

INTRODUCTION: Obesity and physical inactivity are considered possible U.S. national security threats because of their impact on military recruitment. The objectives of this study were to estimate the prevalence of (1) BMI eligibility for military entrance, (2) adequate physical activity participation among the BMI-eligible population, and (3) combined BMI eligibility and adequate physical activity. METHODS: This cross-sectional study of nonpregnant, military-aged civilians (aged 17-42 years) used objectively measured weight and height data and self-reported aerobic physical activity data from the 2015-2020 National Health and Nutrition Examination Survey. BMI eligibility was defined as 19.0-27.5 kg/m2, per Department of Defense regulation. Adequate physical activity for entering initial military training was defined as ≥300 minutes/week of equivalent moderate-intensity aerobic physical activity from all domains, approximating U.S. Army guidance. Participants meeting both definitions were further classified as eligible and active. Analyses were conducted in 2021-2022. RESULTS: Of military-aged participants (unweighted n=5,964), 47.3% were eligible by BMI. Among BMI-eligible participants, 72.5% reported adequate physical activity. Taken together, 34.3% were both eligible and active. The prevalence of eligible and active status was higher among males, persons who were younger and non-Hispanic White, college graduates, and those with higher family income than among their counterparts. CONCLUSIONS: Among the military-aged U.S. population, slightly under half were eligible to enter the military on the basis of their BMI, and only 1 in 3 met BMI eligibility and were adequately physically active. Equitable promotion of healthy weight achievement and physical activity participation may improve military preparedness.

Traffic as a barrier to walking safely in the United States: Perceived reasons and potential mitigation strategies.

Motor vehicle traffic is commonly cited as a barrier to walking, but national level perceptions of traffic characteristics that negatively influence walking and potential traffic mitigation strategies remain unclear. The objectives of this study were to describe perceptions of (1) traffic characteristics that make walking unsafe in the United States and (2) potential mitigation strategies to address these concerns among those who report traffic as a barrier to walking. Data were from FallStyles, a nationwide internet panel survey conducted in October 2019 (n = 3,284 adults). Respondents reported if traffic makes walking unsafe where they live; those who answered yes were then asked about traffic characteristics that make walking unsafe (number of vehicles, speed of vehicles, distracted or impaired driving, types of vehicles, and other reasons) and potential mitigation strategies (new or improved sidewalks, crosswalks, pedestrian signals, street lighting, things that slow vehicles down, separating the sidewalk from the road, fewer vehicle lanes, and other). Prevalence of responses was assessed overall and by select sociodemographic and geographic characteristics, and by walking status. Nearly 25% of US adults reported that traffic is a barrier to walking where they live. Of these, 79% selected vehicle speed as a contributing traffic characteristic, and 57% indicated new or improved sidewalks as a potential mitigation strategy. These top responses were shared across all sociodemographic, geographic, and walking behavior subgroups. Speed reduction efforts and built environment enhancements such as sidewalks may alleviate pedestrian safety concerns. Promotion campaigns may be needed to bring awareness to such changes.

Association of Muscle-Strengthening and Aerobic Physical Activity With Mortality in US Adults Aged 65 Years or Older.

This cohort study uses national data to explore the dose-response association between guideline-recommended physical activity and mortality in older adults.

Telehealth and Public Health Practice in the United States-Before, During, and After the COVID-19 Pandemic.

Telehealth is the use of electronic information and telecommunication technologies to provide care when the patient and the provider are not in the same room at the same time. Telehealth accounted for less than 1% of all Medicare Fee-for-Service outpatient visits in the United States in 2019 but grew to account for 46% of all visits in April 2020. Changes in reimbursement and licensure policies during the COVID-19 pandemic appeared to greatly facilitate this increased use. Telehealth will continue to account for a substantial portion of care provided in the United States and globally. A better understanding of telehealth approaches and their evidence base by public health practitioners may help improve their ability to collaborate with health care organizations to improve population health. The article summarizes the Centers for Disease Control and Prevention's (CDC's) approach to understanding the evidence base for telehealth in public health practice, possible applications for telehealth in public health practice, and CDC's use of telehealth to improve population health.

Observation of and intention to use new places and changed spaces for physical activity during the COVID-19 pandemic - United States, June 2021.

The COVID-19 pandemic prompted built environment changes throughout the United States. We assessed the prevalence of new places and changed spaces for physical activity as observed by US adults and their intentions to use them. We used data from SummerStyles, a web-based survey of US adults conducted in June 2021 (n = 4073). Respondents were asked if they had discovered new places to be physically active during the past year, and if changes had been made to streets or outdoor areas to allow additional space for recreating. Those responding "yes" were asked if they intended to use the respective space. We estimated the weighted prevalence of adults who observed new places and changed spaces, and their intended use, by sociodemographic and geographic characteristics, physical activity level, and walking status. We compared subgroups with prevalence ratios (PR). Overall, 25.0% of US adults reported discovering new places for physical activity, and 25.3% reported changes to streets and outdoor spaces. Intention to use new places and changed spaces exceeded 50% among all sociodemographic and geographic subgroups. Among those reporting changes, adults who were physically inactive compared to those who were sufficiently active had similar intentions to use new places (PR = 0.83; 95% CI = 0.63, 1.10) and changed spaces (PR = 0.90; 95% CI = 0.69, 1.17). Approximately 1 in 4 adults reported discovering new places or changed spaces to support physical activity during the COVID-19 pandemic, and most intended to use these features. Expanding access to such supportive environments may help promote physical activity participation.

Trends in Clinical Severity of Hospitalized Patients With Coronavirus Disease 2019-Premier Hospital Dataset, April 2020-April 2021.

BACKGROUND: Clinical severity of coronavirus disease 2019 (COVID-19) may vary over time; trends in clinical severity at admission during the pandemic among hospitalized patients in the United States have been incompletely described, so a historical record of severity over time is lacking. METHODS: We classified 466677 hospital admissions for COVID-19 from April 2020 to April 2021 into 4 mutually exclusive severity grades based on indicators present on admission (from most to least severe): Grade 4 included intensive care unit (ICU) admission and invasive mechanical ventilation (IMV); grade 3 included non-IMV ICU and/or noninvasive positive pressure ventilation; grade 2 included diagnosis of acute respiratory failure; and grade 1 included none of the above indicators. Trends were stratified by sex, age, race/ethnicity, and comorbid conditions. We also examined severity in states with high vs low Alpha (B.1.1.7) variant burden. RESULTS: Severity tended to be lower among women, younger adults, and those with fewer comorbidities compared to their counterparts. The proportion of admissions classified as grade 1 or 2 fluctuated over time, but these less-severe grades comprised a majority (75%-85%) of admissions every month. Grades 3 and 4 consistently made up a minority of admissions (15%-25%), and grade 4 showed consistent decreases in all subgroups, including states with high Alpha variant burden. CONCLUSIONS: Clinical severity among hospitalized patients with COVID-19 has varied over time but has not consistently or markedly worsened over time. The proportion of admissions classified as grade 4 decreased in all subgroups. There was no consistent evidence of worsening severity in states with higher vs lower Alpha prevalence.

Long-Term Symptoms Among Adults Tested for SARS-CoV-2 - United States, January 2020-April 2021.

Long-term symptoms often associated with COVID-19 (post-COVID conditions or long COVID) are an emerging public health concern that is not well understood. Prevalence of post-COVID conditions has been reported among persons who have had COVID-19 (range = 5%-80%), with differences possibly related to different study populations, case definitions, and data sources (1). Few studies of post-COVID conditions have comparisons with the general population of adults with negative test results for SARS-CoV-2, the virus that causes COVID-19, limiting ability to assess background symptom prevalence (1). CDC used a nonprobability-based Internet panel established by Porter Novelli Public Services* to administer a survey to a nationwide sample of U.S. adults aged ≥18 years to compare the prevalence of long-term symptoms (those lasting >4 weeks since onset) among persons who self-reported ever receiving a positive SARS-CoV-2 test result with the prevalence of similar symptoms among persons who reported always receiving a negative test result. The weighted prevalence of ever testing positive for SARS-CoV-2 was 22.2% (95% confidence interval [CI] = 20.6%-23.8%). Approximately two thirds of respondents who had received a positive test result experienced long-term symptoms often associated with SARS-CoV-2 infection. Compared with respondents who received a negative test result, those who received a positive test result reported a significantly higher prevalence of any long-term symptom (65.9% versus 42.9%), fatigue (22.5% versus 12.0%), change in sense of smell or taste (17.3% versus 1.7%), shortness of breath (15.5% versus 5.2%), cough (14.5% versus 4.9%), headache (13.8% versus 9.9%), and persistence (>4 weeks) of at least one initially occurring symptom (76.2% versus 69.6%). Compared with respondents who received a negative test result, a larger proportion of those who received a positive test result reported believing that receiving a COVID-19 vaccine made their long-term symptoms better (28.7% versus 15.7%). Efforts to address post-COVID conditions should include helping health care professionals recognize the most common post-COVID conditions and optimize care for patients with persisting symptoms, including messaging on potential benefits of COVID-19 vaccination.