Population confidence in the health system in 15 countries: results from the first round of the People's Voice Survey.

Population confidence is essential to a well functioning health system. Using data from the People's Voice Survey-a novel population survey conducted in 15 low-income, middle-income, and high-income countries-we report health system confidence among the general population and analyse its associated factors. Across the 15 countries, fewer than half of respondents were health secure and reported being somewhat or very confident that they could get and afford good-quality care if very sick. Only a quarter of respondents endorsed their current health system, deeming it to work well with no need for major reform. The lowest support was in Peru, the UK, and Greece-countries experiencing substantial health system challenges. Wealthy, more educated, young, and female respondents were less likely to endorse the health system in many countries, portending future challenges for maintaining social solidarity for publicly financed health systems. In pooled analyses, the perceived quality of the public health system and government responsiveness to public input were strongly associated with all confidence measures. These results provide a post-COVID-19 pandemic baseline of public confidence in the health system. The survey should be repeated regularly to inform policy and improve health system accountability.

Health system quality and COVID-19 vaccination: a cross-sectional analysis in 14 countries.

The social and behavioural determinants of COVID-19 vaccination have been described previously. However, little is known about how vaccinated people use and rate their health system. We used surveys conducted in 14 countries to study the health system correlates of COVID-19 vaccination. Country-specific logistic regression models were adjusted for respondent age, education, income, chronic illness, history of COVID-19, urban residence, and minority ethnic, racial, or linguistic group. Estimates were summarised across countries using random effects meta-analysis. Vaccination coverage with at least two or three doses ranged from 29% in India to 85% in Peru. Greater health-care use, having a regular and high-quality provider, and receiving other preventive health services were positively associated with vaccination. Confidence in the health system and government also increased the odds of vaccination. By contrast, having unmet health-care needs or experiencing discrimination or a medical mistake decreased the odds of vaccination. Associations between health system predictors and vaccination tended to be stronger in high-income countries and in countries with the most COVID-19-related deaths. Access to quality health systems might affect vaccine decisions. Building strong primary care systems and ensuring a baseline level of quality that is affordable for all should be central to pandemic preparedness strategies.

Divergent Attitudes Toward COVID-19 Vaccine vs Influenza Vaccine.

This survey study examines attitudes toward COVID-19 and influenza vaccines among US adults.

Communications for US Populations With Limited English Proficiency During Infectious Disease Outbreaks: A Scoping Review.

The COVID-19 pandemic has highlighted the need for research about communicating with populations who have limited English proficiency in the United States during infectious disease outbreaks. These populations have experienced significantly worse health outcomes during emergencies, including the COVID-19 pandemic, and evidence-based risk communications are critical to protecting their health. To support improved development of emergency communications for these communities, we conducted a scoping review that examined the extent of research available, with an intent to identify which communications topics are covered in the literature and where research gaps exist. Following the JBI framework, with reporting guided by the PRISMA extension for scoping reviews, 6 electronic databases were systematically searched in October 2022. The inclusion criteria for articles selected were: data collected between 2009 and 2022, published in English, and focused on communications pertaining to emergency infectious disease outbreaks (eg, H1N1 influenza, Zika virus, COVID-19) for populations with limited English proficiency. Of 2,049 articles identified through the search, 31 met the inclusion criteria and were selected for review. We identified major limitations in the evidence base: a majority of studies were conducted only among Spanish speakers or during the COVID-19 pandemic, and most used qualitative or nonrandom samples. Most studies documented basic language barriers in communications, but there was little exploration of more nuanced barriers, such as cultural relevance or social context. Ahead of future outbreaks, more research is urgently needed to examine the information landscapes of populations with limited English proficiency, to inform the development of more effective communications strategies from public health institutions and others.

Telemedicine Visits in US Skilled Nursing Facilities.

Importance: Telemedicine in skilled nursing facilities (SNFs) has the potential to improve access and timeliness of care. During the COVID-19 pandemic in 2020 to 2022, telemedicine coverage expanded, but little is known about patterns of use in SNFs. Objective: To describe patterns of telemedicine use in SNFs. Design, Setting, and Participants: This cohort study used 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records to identify short- and long-term care SNF residents. Clinician visits were grouped into routine SNF visits (ie, regular primary care within SNF) and other outpatient visits (ie, with non-SNF affiliated primary and specialty care clinicians). Using a difference-in-differences approach, assessments included whether off-hours visits (measured as weekend visits), new specialist visits, psychiatrist visits, or visits for residents with limited mobility changed differentially between 2018 to 2019 and 2020 to 2021 for SNFs with high compared with low telemedicine use in 2020. Exposure: Telemedicine adoption at SNF after 2020. Main Outcomes and Measures: Number and proportion of telemedicine SNF and outpatient visits. Results: Across 15 434 SNFs and 4 463 591 residents from the period January 2019 through June 2022 (mean [SD] age, 79.7 [11.6] years; 61% female in 2020), telemedicine visits increased from 0.15% in January 2019 to February 2020 to 15% SNF visits and 25% outpatient visits in May 2020. By 2022, telemedicine dropped to 2% of SNF visits and 8% of outpatient visits. The proportion of SNFs with any telemedicine visits annually dropped from 91% in 2020 to 61% in 2022. The facilities with high telemedicine use were more likely to be rural (adjusted odds ratio vs urban, 2.06; 95% CI, 1.77 to 2.40). Psychiatry visits differentially increased in high vs low telemedicine-use SNFs (20.2% relative increase; 95% CI, 1.2% to 39.2%). In contrast, there was little change in outpatient visits for residents with limited mobility (7.2%; 95% CI, -0.1% to 14.6%) or new specialist visits (-0.7%; 95% CI, -2.5% to 1.2%). Conclusions and Relevance: In this cohort study of SNF residents, telemedicine was rapidly adopted in early 2020 but subsequently stabilized at a low use rate that was nonetheless higher than before 2020. Higher telemedicine use in SNFs was associated with improved access to psychiatry visits in SNFs. A policy to encourage continued telemedicine use may facilitate further access to important services as the technology matures.

Video Telemedicine Experiences In COVID-19 Were Positive, But Physicians And Patients Prefer In-Person Care For The Future.

To help inform policy discussions about postpandemic telemedicine reimbursement and regulations, we conducted dual nationally representative surveys among primary care physicians and patients. Although majorities of both populations reported satisfaction with video visits during the pandemic, 80 percent of physicians would prefer to provide only a small share of care or no care via telemedicine in the future, and only 36 percent of patients would prefer to seek care by video or phone. Most physicians (60 percent) felt that the quality of video telemedicine care was generally inferior to the quality of in-person care, and both patients and physicians cited the lack of physical exam as a key reason (90 percent and 92 percent, respectively). Patients who were older, had less education, or were Asian were less likely to want to use video for future care. Although improvements to home-based diagnostic tools could improve both the quality of and the desire to use telemedicine, virtual primary care will likely be limited in the immediate future. Policies to enhance quality, sustain virtual care, and address inequities in the online setting may be needed.

Trust In US Federal, State, And Local Public Health Agencies During COVID-19: Responses And Policy Implications.

Public health agencies' ability to protect health in the wake of COVID-19 largely depends on public trust. In February 2022 we conducted a first-of-its-kind nationally representative survey of 4,208 US adults to learn the public's reported reasons for trust in federal, state, and local public health agencies. Among respondents who expressed a "great deal" of trust, that trust was not related primarily to agencies' ability to control the spread of COVID-19 but, rather, to beliefs that those agencies made clear, science-based recommendations and provided protective resources. Scientific expertise was a more commonly reported reason for "a great deal" of trust at the federal level, whereas perceptions of hard work, compassionate policy, and direct services were emphasized more at the state and local levels. Although trust in public health agencies was not especially high, few respondents indicated that they had no trust. Lower trust was related primarily to respondents' beliefs that health recommendations were politically influenced and inconsistent. The least trusting respondents also endorsed concerns about private-sector influence and excessive restrictions and had low trust in government overall. Our findings suggest the need to support a robust federal, state, and local public health communications infrastructure; ensure agencies' authority to make science-based recommendations; and develop strategies for engaging different segments of the public.

Getting Critical Information During the COVID-19 Pandemic: Experiences of Spanish and Chinese Speakers With Limited English Proficiency.

People with limited English proficiency in the United States have suffered disproportionate negative health outcomes during the COVID-19 pandemic. Effective communications are critical tools in addressing inequities insofar as they can motivate adoption of protective behaviors and reduce incidence of disease; however, little is known about experiences of communities with limited English proficiency receiving relevant information during COVID-19 or other outbreaks. To address this gap and provide inputs for communication strategies, we completed a study based on 2 novel and nationally representative surveys conducted between June and August 2020 among Spanish and Chinese speakers with limited English proficiency (n = 764 and n = 355, respectively). Results first showed that Spanish and Chinese speakers did not consistently receive information about protective behaviors from key public health and government institutions early in the pandemic. Second, for such information, Spanish and Chinese speakers used a diverse set of information resources that included family and friends, social media, and traditional media from both inside and outside the United States. Third, Spanish and Chinese speakers faced challenges getting COVID-19 information, including receiving media messages that felt discriminatory toward Latinx or Chinese people. Together, these findings suggest gaps in effectively reaching Spanish and Chinese speakers. Data highlight the important role of bilingual materials to support sharing of information between Spanish or Chinese speakers and English speakers within their social networks, and the need for digital news content for traditional and social media. Finally, efforts are needed to address discriminatory messaging in media and to actively counter it in public health communications.

Preventing erosion of oral polio vaccine acceptance: A role for vaccinator visits and social norms.

BACKGROUND: With continued challenges to the timeline for polio transmission interruption in Pakistan, including COVID-19, there is a risk of oral polio vaccine campaign fatigue among caregivers of young children. Renewed efforts to minimize oral polio vaccine acceptance erosion may be needed. This study examines the possible role of social norms in protecting against acceptance erosion and the role of vaccinators in promoting these social norms. METHODS: Data were analyzed from a poll conducted by local interview teams between February 23 and April 5, 2016, among 4,070 parents and other caregivers of children under age 5 living in areas at high-risk for polio transmission in Pakistan. The sample was drawn via a stratified multistage cluster design utilizing random route methods at the household level. We calculated the prevalence of subjective and descriptive social norms around vaccine acceptance; vaccine acceptance and commitment to vaccinate in future; and experiences and views of polio vaccinators across the population. We examined the relationship between these social norms and vaccination behaviors as well as the relationship between experiences with and views of vaccinators and social norms using uncontrolled comparisons (t-tests of proportion) and logistic repressions to control for demographics. RESULTS: Both descriptive and subjective positive social norms were associated with vaccine acceptance and future commitment. Positive experiences with and views of vaccinators (trust, perceived technical knowledge, compassion, and overall pleasantness of the interaction) were associated with both descriptive and subjective positive social norms. CONCLUSIONS: These data support the idea that positive social norms could be protective against erosion of oral polio vaccine acceptance and that positive experiences with, and views of, vaccinators could help promote these positive social norms. Creative community engagement efforts may be able to leverage positive experiences with vaccinators to help foster social norms and protect against the risk of acceptance erosion.

Effect of the suspension of the J&J COVID-19 vaccine on vaccine hesitancy in the United States.

On April 13, 2021, U.S. authorities announced an investigation into potential adverse events associated with the Johnson & Johnson (Janssen, J&J) COVID-19 vaccine and recommended "a pause in the use of this vaccine out of an abundance of caution." We examined whether public attitudes toward COVID-19 vaccination shifted after this recommended suspension using an interrupted time series with data from the Census Bureau's Household Pulse Survey, which was fielded bi-weekly between January 6 and April 26, 2021. We found no significant changes in trends of the proportion of the U.S. adult population hesitant about getting a COVID-19 vaccine, but a significant increase in concerns about safety and efficacy of COVID-19 vaccines among the already hesitant population.

Experiences and Views of Domestic Summer Travelers During the COVID-19 Pandemic: Findings from a National Survey.

Domestic travel creates a serious risk of spreading COVID-19, including novel strains of the virus. Motivating potential travelers to take precautions is critical, especially for those at higher risk for severe illness. To provide an evidence base for communication efforts, we examined the experiences and views of travelers during the summer of 2020 through a telephone survey of 1,968 US adults, conducted in English and Spanish, July 2 through July 16, 2020. The survey found that more than one-quarter (28%) of adults had traveled domestically in the prior 30 days, most commonly for "vacation" (43%), and less than half wore masks (46%) or practiced social distancing (47%) "all of the time." Although high-risk adults were significantly less likely to travel than non-high-risk adults (23% vs 31%; P < .001), they were no more likely to take precautions. Many travelers did not wear a mask or practice social distancing because they felt such actions were unnecessary (eg, they were outside or with friends and family). Although a substantial share of travelers (43% to 53%) trusted public health agencies "a great deal" for information about reducing risks while traveling, more travelers (73%) trusted their own healthcare providers. Findings suggest that outreach may be improved by partnering with providers to emphasize the benefits of layering precautions and provide targeted education to high-risk individuals. Messages that are empathetic to the need to reduce stress and convey how precautions can protect loved ones may be particularly resonant after more than a year of pandemic-related restrictions.

Seasonal Influenza Vaccine in Pregnant Women: Views and Experiences of Obstetrician-Gynecologists.

Background: Seasonal influenza vaccination rates among pregnant women remain well below the Healthy People 2020 target of 80%. Obstetrician-gynecologist (OB/GYN) recommendations are a critical means of encouraging pregnant women to get vaccinated, but there are limited data about their views. Materials and Methods: A nationally representative survey of 506 practicing OB/GYNs was completed between October 26, 2015, and May 8, 2016. Analyses included univariate distributions and comparisons based on age, size of practice, and academic affiliation using all-pairs, dependent t-tests. Results: A majority of OB/GYNs report they "strongly recommend" seasonal influenza vaccination for their pregnant patients in the first (79%) or second and third trimesters (81%). Among those who do not strongly recommend the flu vaccine in the first trimester, many say this is because of their own concerns (28%) or their patients' concerns (44%) about safety. Older OB/GYNs, those in smaller practices, and those without academic affiliation were less likely to recommend the vaccine and more likely to have safety concerns. For example, 72% of those age 60+ strongly recommended the vaccine in the second and third trimester, compared with 86% of those ages 30-44 and 83% of those ages 45-59 (p < 0.05 for all comparisons). Conclusions: OB/GYNs across the country largely support seasonal flu vaccination among pregnant women. Nonetheless, safety is a concern for them and their patients. Outreach to support clinician decisions and conversations with pregnant patients may be most needed among older physicians, those in smaller practices, and those without academic affiliation.

Obstetrician-Gynecologist Views of Pregnancy-Related Medication Safety.

Background: Medication use among pregnant women is widespread, despite limited evidence about the teratogenicity of most medications. Improved physician-patient communication about pregnancy-related medication safety has been identified as a strategy to address this critical issue; however, little is known about physicians' knowledge, attitudes, and practices that could inform tools for information access and sharing to support such communication. The primary objective of this study is to address gaps in what is known about obstetrician-gynecologist views, practices, and needs related to accessing and sharing pregnancy-related medication safety information with patients. Materials and Methods: The basis for this study is a nationally representative, randomized survey of 506 practicing obstetrician-gynecologists. The survey was completed by mail or online between October 26, 2015 and May 8, 2016 with a 52% response rate. Data were weighted to population parameters to reduce the risk of potential nonresponse biases. Analyses included univariate distributions and comparisons between physicians in different residency cohorts using all-pairs dependent t-tests. Results: Findings point to critical features of obstetrician-gynecologist access and sharing of medication safety information. Obstetrician-gynecologists often retrieve medication safety information during a clinical visit. There is widespread provision of potentially problematic "safe lists" to patients, particularly by younger cohorts, and limited counseling for reproductive-aged patients not actively planning a pregnancy. Conclusions: To improve clinical care, physician-patient communication may be enhanced with technical and policy solutions, including improved digital information tools for retrieving and discussing information in the clinical setting; evidence-based, written information for physicians to share with patients; and encouragement for counseling all women of reproductive age receiving teratogenic medications.

Gender discrimination in the United States: Experiences of women.

OBJECTIVE: To examine reported experiences of gender discrimination and harassment among US women. DATA SOURCE AND STUDY DESIGN: Data come from a nationally representative, probability-based telephone survey of 1596 women, conducted January-April 2017. METHODS: We calculated the percentages of women reporting gender discrimination and harassment in several domains, including health care. We used logistic regression to examine variation in experiences among women by race/ethnicity and sexual orientation/gender identity. PRINCIPAL FINDINGS: Sizable fractions of women experience discrimination and harassment, including discrimination in health care (18 percent), equal pay/promotions (41 percent), and higher education (20 percent). In adjusted models, Native American, black, and Latina women had higher odds than white women of reporting gender discrimination in several domains, including health care. Latinas' odds of health care avoidance versus whites was (OR [95% CI]) 3.69 (1.59, 8.58), while blacks' odds of discrimination in health care visits versus whites was 2.00 [1.06, 3.74]. Lesbian, gay, bisexual, transgender, and queer (LGBTQ) women had higher odds of reporting sexual harassment (2.16 [1.06, 4.40]) and violence (2.71 [1.43, 5.16]) against themselves or female family members than non-LGBTQ women. CONCLUSIONS: Results suggest that discrimination and harassment are widely experienced by women across multiple domains of their lives, particularly those who are a racial/ethnic minority or LGBTQ. Further policy and programmatic efforts beyond current legal protections for women are needed to meaningfully reduce these negative experiences, as they impact women's health care and their lives overall.

Discrimination in the United States: Experiences of black Americans.

OBJECTIVE: To examine experiences of racial discrimination among black adults in the United States, which broadly contribute to their poor health outcomes. DATA SOURCE AND STUDY DESIGN: Data come from a nationally representative, probability-based telephone survey including 802 non-Hispanic black and a comparison group of 902 non-Hispanic white US adults, conducted January-April 2017. METHODS: We calculated the percent of blacks reporting discrimination in several domains, including health care. We used logistic regression to compare the black-white difference in odds of discrimination, and among blacks only to examine variation by socioeconomic status, gender, and neighborhood racial composition. PRINCIPAL FINDINGS: About one-third of blacks (32 percent) reported experiencing discrimination in clinical encounters, while 22 percent avoided seeking health care for themselves or family members due to anticipated discrimination. A majority of black adults reported experiencing discrimination in employment (57 percent in obtaining equal pay/promotions; 56 percent in applying for jobs), police interactions (60 percent reported being stopped/unfairly treated by police), and hearing microaggressions (52 percent) and racial slurs (51 percent). In adjusted models, blacks had significantly higher odds than whites of reporting discrimination in every domain. Among blacks, having a college degree was associated with higher odds of experiencing overall institutional discrimination. CONCLUSIONS: The extent of reported discrimination across several areas of life suggests a broad pattern of discrimination against blacks in America, beyond isolated experiences. Black-white disparities exist on nearly all dimensions of experiences with public and private institutions, including health care and the police. Evidence of systemic discrimination suggests a need for more active institutional interventions to address racism in policy and practice.

Views and Experiences of Travelers from US States to Zika-Affected Areas.

Travelers to areas with Zika virus transmission are at risk of infection and of transmitting the virus after returning home. While protective behaviors during and after travel can reduce these risks, information about traveler practices or underlying views is limited. We examined these issues using data from the first representative poll of travelers from US states to Zika-affected areas, including US territories and Miami, Florida, conducted December 1 to 23, 2016. We analyzed results among all travelers (n = 1,285) and 2 subgroups at risk for pregnancy-related complications: (1) travelers in households where someone was pregnant or considering pregnancy (n = 72), and (2) other travelers of reproductive age (n = 631). We also examined results among those with different levels of awareness and knowledge about Zika virus. Results show that in households where someone was pregnant or considering pregnancy, awareness of Zika in the destination, concern about infection, and adoption of protective behaviors was relatively high. That said, sizable shares of travelers as a whole did not know information about asymptomatic and sexual transmission or post-travel behaviors. Further, concern about getting infected during travel was low among travelers as a whole, including other travelers of reproductive age. Few travelers consistently adopted protective behaviors during or after travel. Even among travelers who were aware of Zika in their destination and knew how to protect themselves, adoption of protective behaviors was only slightly higher. Findings from this poll suggest communications may be more effective if tailored to different levels of true and perceived risk. To address gaps in knowledge about transmission and post-travel protective behaviors, messaging should include facts and acknowledge the complexities of novel information and social context. Consideration should also be given to emphasizing other benefits of Zika protective behaviors or prioritizing behaviors that are most feasible.

Parents' Perceptions of the Challenges to Helping Their Children Maintain or Achieve a Healthy Weight.

Introduction: Parents play a critical role in their children's weight. This paper examines parents' perceptions about the challenges to helping their kids maintain or achieve a healthy weight. Methods: We analyzed data in 2017 from a U.S. telephone poll conducted during October-November 2012 among parents or caregivers of children aged 2-17 years using a nationally representative sample of households. It included 667 White, 123 Black, and 167 Hispanic parents. Multiple logistic regressions were used to examine parent perceptions about the individual- and environmental-level challenges to helping their children maintain or achieve a healthy weight. Results: Overall, 45% of children have parents who reported challenges helping the child eat to maintain or achieve a healthy weight, and 35% have parents who reported challenges for exercise. According to parents, most children consumed snacks between 3 pm and bedtime during the school week (83%), and 63% of those children had an unhealthy snack. Parents did not express much concern about unhealthy snacks; 80% of children had parents who said that they did not mind since their child generally ate healthy food. Children with Hispanic and Black parents were more likely than those with White parents to have parents reporting environment challenges, such as unhealthy foods in schools. Conclusions: Helping children maintain a healthy weight through diet is a problem for many parents, regardless of their race or ethnicity. Differences by race/ethnicity in parent perceptions of food environment challenges to helping their child maintain or achieve a healthy weight suggest possible areas for future interventions.