Perceptions of Racial-Ethnic Inequities in COVID-19 Healthcare and Willingness to Receive the COVID-19 Vaccine.

BACKGROUND: Perceptions of the US healthcare system can impact individuals' healthcare utilization, including vaccination intentions. This study examined the association between perceived racial-ethnic inequities in COVID-19 healthcare and willingness to receive the COVID-19 vaccine. METHODS: This study used data from REACH-US, a nationally representative online survey of a large, diverse sample of U.S. adults (N=5145 January 26, 2021-March 3, 2021). Confirmatory factor and regression analyses examined a latent factor of perceived racial-ethnic inequities in COVID-19 healthcare, whether the factor was associated with willingness to receive the COVID-19 vaccine, and whether associations varied across racial-ethnic groups reported as probit estimates (B) and 95% confidence intervals (CIs). RESULTS: Perceived racial-ethnic inequities in COVID-19 healthcare were highest among Black/African American adults (mean latent factor score: 0.65 ± 0.43) and lowest among White adults (mean latent factor score: 0.04 ± 0.67). Black/African American (B = -0.08; 95% CI = -0.19, 0.03) and Native Hawaiian/Pacific Islander (B = -0.08; 95% CI = -0.23, 0.07) adults who perceived greater racial-ethnic inequities in COVID-19 healthcare were less willing than participants who perceived lower inequities. In contrast, American Indian/Alaska Native (B = 0.15; 95% CI = -0.01, 0.30), Asian (B = 0.20; 95% CI = 0.08, 0.31), Hispanic/Latino (English language preference) (B = 0.22; 95% CI = 0.01, 0.43), Multiracial (B = 0.23; 95% CI = 0.09, 0.36), and White (B = 0.31; 95% CI = 0.19, 0.43) adults who perceived greater racial-ethnic inequities in COVID-19 healthcare were more willing to receive the COVID-19 vaccine than participants perceiving higher inequities. CONCLUSIONS: Greater perceived racial-ethnic inequities in COVID-19 healthcare were associated with less willingness to receive the COVID-19 vaccine among Black/African American and Native Hawaiian/Pacific Islander adults.

Racial/ethnic differences in the associations between trust in the U.S. healthcare system and willingness to test for and vaccinate against COVID-19.

BACKGROUND: Trust in the healthcare system may impact adherence to recommended healthcare practices, including willingness to test for and vaccinate against COVID-19. This study examined racial/ethnic differences in the associations between trust in the U.S. healthcare system and willingness to test for and vaccinate against COVID-19 during the first year of the pandemic. METHODS: This cross-sectional study used data from the REACH-US study, a nationally representative online survey conducted among a diverse sample of U.S. adults from January 26, 2021-March 3, 2021 (N = 5,121). Multivariable logistic regression estimated the associations between trust in the U.S. healthcare system (measured as "Always", "Most of the time", "Sometimes/Almost Never", and "Never") and willingness to test for COVID-19, and willingness to receive the COVID-19 vaccine. Racial/ethnic differences in these associations were examined using interaction terms and multigroup analyses. RESULTS: Always trusting the U.S. healthcare system was highest among Hispanic/Latino Spanish Language Preference (24.9%) and Asian (16.7%) adults and lowest among Multiracial (8.7%) and Black/African American (10.7%) adults. Always trusting the U.S. healthcare system, compared to never, was associated with greater willingness to test for COVID-19 (AOR: 3.20, 95% CI: 2.38-4.30) and greater willingness to receive the COVID-19 vaccine (AOR: 2.68, 95% CI: 1.97-3.65). CONCLUSIONS: Trust in the U.S. healthcare system was associated with greater willingness to test for COVID-19 and receive the COVID-19 vaccine, however, trust in the U.S. healthcare system was lower among most marginalized racial/ethnic groups. Efforts to establish a more equitable healthcare system that increases trust may encourage COVID-19 preventive behaviors.

Perceived COVID-19 threat, perceived healthcare system inequities, personal experiences of healthcare discrimination and their associations with COVID-19 preventive behavioral intentions among college students in the U.S.

College students are often reluctant to follow U.S. preventive guidelines to lower their risk of COVID-19 infection, despite an increased risk of transmission in college settings. Prior research suggested that college students who perceived greater COVID-19 severity and susceptibility (i.e., COVID-19 threat) were more likely to engage in COVID-19 preventive behaviors, yet there is limited research examining whether perceived COVID-19 threat, perceived U.S. healthcare system inequities, and personal experiences of healthcare discrimination collectively influence college students' COVID-19 preventive behaviors. This study identified latent classes of perceived COVID-19 threat, perceived U.S. healthcare system inequities, and personal experiences of healthcare discrimination, examined whether latent classes were associated with COVID-19 preventive behavioral intentions, and assessed whether latent class membership varied across racial/ethnic groups.Students from the University of Maryland, College Park (N = 432) completed the Weighing Factors in COVID-19 Health Decisions survey (December 2020-December 2021). Latent class analysis identified latent classes based on perceived COVID-19 threat, perceived U.S. healthcare system inequities, and personal experiences of healthcare discrimination. Regression analyses examined associations between the latent classes and COVID-19 preventive behavioral intentions (i.e., social distancing, mask-wearing, COVID-19 vaccination) and whether latent class membership varied across racial/ethnic groups.Students in Latent Class 1 (27.3% of the sample) had high perceived COVID-19 threat and U.S. healthcare system inequities and medium probability of experiencing personal healthcare discrimination. Students in Latent Class 1 had higher social distancing, mask-wearing, and vaccination intentions compared to other latent classes. Compared to Latent Class 4 (reference group), students in Latent Class 1 had higher odds of identifying as Hispanic or Latino, Non-Hispanic Asian, Non-Hispanic Black or African American, and Non-Hispanic Multiracial versus Non-Hispanic White.Latent classes of higher perceived COVID-19 threat, perceived U.S. healthcare system inequities, and personal experiences of healthcare discrimination were associated with higher COVID-19 preventive behavioral intentions and latent class membership varied across racial/ethnic groups. Interventions should emphasize the importance of COVID-19 preventive behaviors among students who perceive lower COVID-19 threat.

Naïve models of dietary splurges: Beliefs about caloric compensation and weight change following non-habitual overconsumption.

The mechanisms that lead to overeating and the consumption of tempting, unhealthy foods have been studied extensively, but the compensatory actions taken afterwards have not. Here we describe the naïve models individuals hold around dietary splurges (single bouts of overeating) and associated weight changes. Across six online experiments, we found that, following a hypothetical dietary splurge, participants did not plan to adequately adjust calorie consumption to account for the additional calories consumed (Studies 1 and 2), and this pattern was worse following hypothetical splurges characterized by a large amount of food consumed in a single bout (Study 3). Participants expected weight changes to happen faster than they do in reality (Study 4) and they expected that weight gained from a dietary splurge would disappear on its own without explicit compensation attempts through diet or exercise (Study 5). Similarly, participants expected that when compensation attempts were made through calorie restriction, the rate of weight loss would be faster following a dietary splurge compared to normal eating (Study 6). This research contributes novel data demonstrating an important mechanism that likely contributes to weight gain and failed weight loss attempts.

Motivators and Barriers to COVID-19 Vaccination Intentions Across U.S. County-Level Barriers in the COVID-19 Vaccine Coverage Index.

BACKGROUND: County-level barriers (sociodemographic barriers, limited healthcare system resources, healthcare accessibility barriers, irregular healthcare seeking behaviors, low vaccination history) may impact individuals' reasons for receiving the COVID-19 vaccine. METHODS: This study linked data from REACH-US (Race-Related Experiences Associated with COVID-19 and Health in the United States), a nationally representative, online survey of 5475 adults living in the U.S (January-March 2021) to county-level barriers in the COVID-19 Vaccine Coverage Index. County-level vaccination barriers were measured using the COVID-19 Vaccine Coverage Index. Participants reported why they would or would not receive the COVID-19 vaccine in an open-ended item and their responses were coded using thematic analysis. Descriptive statistics and chi-square tests assessed whether reasons for COVID-19 vaccination intentions varied by county-level barriers and whether these distributions varied across racial/ethnic groups. RESULTS: Thematic analysis revealed twelve themes in participants' reasons why they would or would not receive the COVID-19 vaccine. Themes of societal responsibility (9.8% versus 7.7%), desire to return to normal (8.1% versus 4.7%), and trust in science/healthcare/government (7.7% versus 5.1%) were more frequently reported in counties with low/medium barriers (versus high/very high) (p-values < 0.05). Concerns of COVID-19 vaccine side effects/safety/development (25.3% versus 27.9%) and concerns of access/costs/availability/convenience (1.9% versus 3.6%) were less frequently reported in counties with low/medium barriers (versus high/very high) (p-values < 0.05). Trends in the prevalence of these themes varied across racial/ethnic groups (p-values < 0.05). CONCLUSIONS: Future pandemic responses should consider potential ways county-level barriers shape reasons for COVID-19 vaccination.

Patient Lung Cancer Screening Decisions and Environmental and Psychosocial Factors.

Importance: Screening for lung cancer using low-dose computed tomography is associated with reduced lung cancer-specific mortality, but uptake is low in the US; understanding how patients make decisions to engage with lung cancer screening is critical for increasing uptake. Prior research has focused on individual-level psychosocial factors, but environmental factors (eg, historical contexts that include experiencing racism) and modifying factors-those that can be changed to make it easier or harder to undergo screening-also likely affect screening decisions. Objective: To investigate environmental, psychosocial, and modifying factors influencing lung cancer screening decision-making and develop a conceptual framework depicting relationships between these factors. Design, Setting, and Participants: This multimethod qualitative study was conducted from December 2021 to June 2022 using virtual semistructured interviews and 4 focus groups (3-4 participants per group). All participants met US Preventive Services Task Force eligibility criteria for lung cancer screening (ie, age 50-80 years, at least a 20 pack-year smoking history, and either currently smoke or quit within the past 15 years). Screening-eligible US participants were recruited using an online panel. Main Outcomes and Measures: Key factors influencing screening decisions (eg, knowledge, beliefs, barriers, and facilitators) were the main outcome. A theory-informed, iterative inductive-deductive approach was applied to analyze data and develop a conceptual framework summarizing results. Results: Among 34 total participants (interviews, 20 [59%]; focus groups, 14 [41%]), mean (SD) age was 59.1 (4.8) years and 20 (59%) identified as female. Half had a household income below $20 000 (17 [50%]). Participants emphasized historical and present-day racism as critical factors contributing to mistrust of health care practitioners and avoidance of medical procedures like screening. Participants reported that other factors, such as public transportation availability, also influenced decisions. Additionally, participants described psychosocial processes involved in decisions, such as perceived screening benefits, lung cancer risk appraisal, and fear of a cancer diagnosis or harmful encounters with practitioners. In addition, participants identified modifying factors (eg, insurance coverage) that could make receiving screening easier or harder. Conclusions and Relevance: In this qualitative study of patient lung cancer screening decisions, environmental, psychosocial, and modifying factors influenced screening decisions. The findings suggest that systems-level interventions, such as those that help practitioners understand and discuss patients' prior negative health care experiences, are needed to promote effective screening decision-making.

County-level barriers in the COVID-19 vaccine coverage index and their associations with willingness to receive the COVID-19 vaccine across racial/ethnic groups in the U.S.

Background: County-level vaccination barriers (sociodemographic barriers, limited healthcare system resources, healthcare accessibility barriers, irregular healthcare seeking behaviors, history of low vaccination) may partially explain COVID-19 vaccination intentions among U.S. adults. This study examined whether county-level vaccination barriers varied across racial/ethnic groups in the U.S. and were associated with willingness to receive the COVID-19 vaccine. In addition, this study assessed whether these associations differed across racial/ethnic groups. Methods: This study used data from the REACH-US study, a large online survey of U.S. adults (N = 5,475) completed from January 2021-March 2021. County-level vaccination barriers were measured using the COVID-19 Vaccine Coverage Index. Ordinal logistic regression estimated associations between race/ethnicity and county-level vaccination barriers and between county-level vaccination barriers and willingness to receive the COVID-19 vaccine. Models adjusted for covariates (age, gender, income, education, political ideology, health insurance, high-risk chronic health condition). Multigroup analysis estimated whether associations between barriers and willingness to receive the COVID-19 vaccine differed across racial/ethnic groups. Results: American Indian/Alaska Native, Black/African American, Hispanic/Latino ELP [English Language Preference (ELP); Spanish Language Preference (SLP)], and Multiracial adults were more likely than White adults to live in counties with higher overall county-level vaccination barriers [Adjusted Odd Ratios (AORs):1.63-3.81]. Higher county-level vaccination barriers were generally associated with less willingness to receive the COVID-19 vaccine, yet associations were attenuated after adjusting for covariates. Trends differed across barriers and racial/ethnic groups. Higher sociodemographic barriers were associated with less willingness to receive the COVID-19 vaccine (AOR:0.78, 95% CI:0.64-0.94), whereas higher irregular care-seeking behavior was associated with greater willingness to receive the vaccine (AOR:1.20, 95% CI:1.04-1.39). Greater history of low vaccination was associated with less willingness to receive the COVID-19 vaccine among Black/African American adults (AOR:0.55, 95% CI:0.37-0.84), but greater willingness to receive the vaccine among American Indian/Alaska Native and Hispanic/Latino ELP adults (AOR:1.90, 95% CI:1.10-3.28; AOR:1.85, 95% CI:1.14-3.01). Discussion: Future public health emergency vaccination programs should include planning and coverage efforts that account for structural barriers to preventive healthcare and their intersection with sociodemographic factors. Addressing structural barriers to COVID-19 treatment and preventive services is essential for reducing morbidity and mortality in future infectious disease outbreaks.

Opportunities, challenges, and future directions for simulation modeling the effects of structural racism on cancer mortality in the United States: a scoping review.

PURPOSE: Structural racism could contribute to racial and ethnic disparities in cancer mortality via its broad effects on housing, economic opportunities, and health care. However, there has been limited focus on incorporating structural racism into simulation models designed to identify practice and policy strategies to support health equity. We reviewed studies evaluating structural racism and cancer mortality disparities to highlight opportunities, challenges, and future directions to capture this broad concept in simulation modeling research. METHODS: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension guidelines. Articles published between 2018 and 2023 were searched including terms related to race, ethnicity, cancer-specific and all-cause mortality, and structural racism. We included studies evaluating the effects of structural racism on racial and ethnic disparities in cancer mortality in the United States. RESULTS: A total of 8345 articles were identified, and 183 articles were included. Studies used different measures, data sources, and methods. For example, in 20 studies, racial residential segregation, one component of structural racism, was measured by indices of dissimilarity, concentration at the extremes, redlining, or isolation. Data sources included cancer registries, claims, or institutional data linked to area-level metrics from the US census or historical mortgage data. Segregation was associated with worse survival. Nine studies were location specific, and the segregation measures were developed for Black, Hispanic, and White residents. CONCLUSIONS: A range of measures and data sources are available to capture the effects of structural racism. We provide a set of recommendations for best practices for modelers to consider when incorporating the effects of structural racism into simulation models.

Hypertension and Diabetes Status by Patterns of Stress in Older Adults From the US Health and Retirement Study: A Latent Class Analysis.

Background Hypertension and diabetes disproportionately affect older non-Hispanic Black and Hispanic adults in the United States. Chronic stress may partially explain these disparities. This study identified underlying stress profiles of older US adults, analyzed stress profiles in relation to hypertension and diabetes, examined the distribution of stress profiles by race and ethnicity, and assessed patterns of change in latent classes of stress over time. Methods and Results Latent class analysis was conducted with a nationally representative sample of older US adults who completed 3 waves of the HRS (Health and Retirement Study) (ie, 2010 [n=6863], 2014 [n=4995], and 2018 [n=3089]). Latent classes of stress in 2010 (ie, stress profiles) were identified using 15 indicators of unmet needs within 5 categories (ie, physiological, safety/security, belonging, esteem, and self-fulfillment). Hypertension and diabetes status were examined as outcomes of latent class membership at 3 time points, and race and ethnicity were examined in association with class membership, adjusting for sociodemographic covariates. Finally, a latent transition analysis examined the stability of latent class membership and racial and ethnic differences in the patterns of stress profiles experienced from 2010 to 2018. Five classes were identified: Generally Unmet Needs (13% of sample), Generally Met Needs (42% of sample), Unmet Self-Efficacy/Goal Needs (12% of sample), Unmet Financial Needs (20% of sample), and Unmet Social Belonging Needs (13% of sample). Compared with the Generally Met Needs class, the Generally Unmet Needs class had higher odds of hypertension (odds ratio [OR], 1.80; [95% CI, 1.35-2.39]) and diabetes (OR, 1.94; [95% CI, 1.45-2.59]), and the Unmet Financial Needs class had higher odds of diabetes (OR, 1.50; [95% CI, 1.10-2.05]). Non-Hispanic Black participants compared with non-Hispanic White participants had higher odds of being members of the Generally Unmet Needs, Unmet Self-Efficacy/Goal Needs, and Unmet Financial Needs classes (OR, 2.70; [95% CI, 1.59-4.58]; OR, 1.99; [95% CI, 1.15-3.43]; and OR, 4.74; [95% CI, 3.32-6.76], respectively). Class membership remained relatively stable over time, with 93% of participants remaining in Generally Met Needs and 78% of participants remaining in Generally Unmet Needs across time points. Compared with non-Hispanic White participants, non-Hispanic Black participants had lower odds of Generally Met Needs class membership at any time point (OR, 0.60; [95% CI, 0.42-0.84]) and had lower odds of moving into the Generally Met Needs class and higher odds of moving into the Unmet Financial Needs class from 2010 to 2014 (OR, 0.33; [95% CI, 0.13-0.86]; and OR, 3.02; [95% CI, 1.16-7.87], respectively). Conclusions Underlying classes of stress based on unmet needs were associated with hypertension and diabetes status. Racial and ethnic differences were observed for both latent class membership and transitions between classes over time. Latent classes of stress associated with unmet needs, hypertension, and diabetes and the ability to transition between classes may explain the perpetuation of racial and ethnic disparities in cardiovascular health. Interventions targeting unmet needs may be used to confront these disparities.

Everyday discrimination and cancer metaphor preferences: The mediating effects of needs for personal significance and cognitive closure.

Metaphors are often used to describe cancer experiences (e.g., battle, journey). Few studies explore how social threats (e.g., discrimination) shape metaphor preferences. We examined the relationship between discrimination and preferences for cancer battle metaphors (i.e., concrete, action-based) versus journey metaphors (i.e., open-ended, reflective) and mediating effects of needs for personal significance and cognitive closure. We also stratified the analysis when discrimination was/was not attributed to race and by racial/ethnic group. Four-hundred twenty-seven U.S. participants completed an online survey. Items included everyday discrimination, need for personal significance, need for cognitive closure, and preference for cancer scenarios using battle or journey metaphors. Multigroup structural equation modeling examined: serial mediation (i.e., discrimination predicting metaphor preference via needs for personal significance and cognitive closure) stratified by discrimination attribution; and single mediation (i.e., discrimination predicting need for cognitive closure via need for personal significance) stratified by racial/ethnic group. Discrimination was associated with battle metaphor preferences through serial mediation when discrimination was not attributed to race (ß = 0.02, 95% CI [0.01,0.05]). Discrimination was directly associated with journey metaphor preferences (ß = -0.20, 95% CI [-0.37,-0.06]) and the serial mediation was nonsignificant when discrimination was attributed to race. The single mediation model varied across racial/ethnic groups and was strongest for Non-Hispanic White participants (ß = 0.17, 95% CI [0.07,0.30]). Discrimination may shape cancer metaphor preferences through needs for personal significance and cognitive closure, yet these relationships differ based on whether discrimination is attributed to race and racial/ethnic group. Given that the U.S. health system often focuses on battle metaphors when framing cancer treatment and screenings, individuals who prefer journey metaphors (i.e., those who experienced more frequent racial discrimination in the present study) may experience a systematic disadvantage in cancer communication. A more careful consideration of cultural, racial, and ethnic differences in metaphor use may be a crucial step towards reducing cancer disparities.

College students' underlying perceptions of COVID-19 threat, healthcare discrimination, and healthcare system inequities associated with self-rated health across racial/ethnic groups in the U.S.

Background: COVID-19-related health perceptions may differentially impact college students' stress, and in turn, their mental and physical health. This study examined racial/ethnic differences in college students' underlying perceptions of COVID-19 threat, healthcare discrimination, and U.S. healthcare system inequities and their associations with self-rated mental and physical health. Methods: Four-hundred-thirty-two university students completed an online survey (December 2020-December 2021). Latent class analyses identified classes of perceived COVID-19 threat (i.e., severity, susceptibility), healthcare discrimination, and U.S. healthcare system inequities. Regression analyses examined whether class membership varied by race/ethnicity and was associated with self-rated mental and physical health. Results: Class 1 members (27.3% of the sample) were more likely to identify as Hispanic or Latino, Non-Hispanic Asian, Non-Hispanic Black or African American, and Non-Hispanic Multiracial vs. Non-Hispanic White (vs. Class 4). Class 1 had high perceived COVID-19 threat, medium perceived healthcare discrimination, and high perceived U.S. healthcare system inequities, as well as higher odds of poorer mental and physical health (vs. Class 4). Conclusions: College students' underlying perceptions of COVID-19 threat, healthcare discrimination, and U.S. healthcare system inequities were associated with poorer health. Given that students with these perceptions were more likely to belong to minoritized racial/ethnic groups, concerns over COVID-19 risk and healthcare may partially explain racial/ethnic disparities in college students' health. This study contributes to a limited body of evidence on college students' perceptions of the U.S. healthcare system and suggests important ways that structural inequalities and racial/ethnic disparities in COVID-19 risk, healthcare discrimination, and concerns over U.S. healthcare system inequity may affect college students' health.

Cognitive mechanisms in violent extremism.

This paper considers the cognitive underpinnings of violent extremism. We conceptualize extremism as stemming from a motivational imbalance in which a given need "crowds out" other needs and liberates behavior from their constraints. In the case of violent extremism, the dominant need in question is the quest for personal significance and the liberated behavior is aggression employed as means to the attainment of significance. The cognitive mechanisms that enable this process are ones of learning and inference, knowledge activation, selective attention, and inhibition. These are discussed via examples from relevant research.