COVID‐19: The Time for Collaboration Between Long‐Term Services and Supports,Health Care Systems,and Public Health Is Now

Policy Points

• To address systemic problems amplified by COVID‐19, we need to restructure US long‐term services and supports (LTSS) as they relate to both the health care systems and public health systems. We present both near‐term and long‐term policy solutions.
• Seven near‐term policy recommendations include requiring the uniform public reporting of COVID‐19 cases in all LTSS settings; identifying and supporting unpaid caregivers; bolstering protections for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing barriers to telehealth in LTSS; and providing incentives to care for vulnerable populations.
• Long‐term reform should focus on comprehensive workforce development, comprehensive LTSS financing reform, and the creation of an age‐friendly public health system.

ContextThe heavy toll of COVID‐19 brings the failings of the long‐term services and supports (LTSS) system in the United States into sharp focus. Although these are not new problems, the pandemic has exacerbated and amplified their impact to a point that they are impossible to ignore. The primary blame for the high rates of COVID‐19 infections and deaths has been assigned to formal LTSS care settings, specifically nursing homes. Yet other systemic problems have been unearthed during this pandemic: the failure to coordinate the US public health system at the federal level and the effects of long‐term disinvestment and neglect of state‐ and local‐level public health programs. Together these failures have contributed to an inability to coordinate with the LTSS system and to act early to protect residents and staff in the LTSS care settings that are hotspots for infection, spread, and serious negative health outcomes.MethodsWe analyze several impacts of the COVID‐19 pandemic on the US LTSS system and policy arrangements. The economic toll on state budgets has been multifaceted, and the pandemic has had a direct impact on Medicaid, the primary funder of LTSS, which in turn has further exacerbated the states’ fiscal problems. Both the inequalities across race, ethnicity, and socioeconomic status as well as the increased burden on unpaid caregivers are clear. So too is the need to better integrate LTSS with the health, social care, and public health systems.FindingsWe propose seven near‐term actions that US policymakers could take: implementing a uniform public reporting of COVID‐19 cases in LTSS settings; identifying and supporting unpaid caregivers; bolstering support for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing the barriers to telehealth in LTSS; and providing incentives to care for our most vulnerable populations. Our analysis also demonstrates that our nation requires comprehensive reform to build the LTSS system we need through comprehensive workforce development, universal coverage through comprehensive financing reform, and the creation of an age‐friendly public health system.ConclusionsCOVID‐19 has exposed the many deficits of the US LTSS system and made clear the interdependence of LTSS with public health. Policymakers have an opportunity to address these failings through a substantive reform of the LTSS system and increased collaboration with public health agencies and leaders. The opportunity for reform is now.     

The Structure and Financing of Health Care Systems Affected How Providers Coped With COVID‐19

Policy Points

• We compared the structure of health care systems and the financial effects of the COVID‐19 pandemic on health care providers in the United States, England, Germany, and Israel: systems incorporating both public and private insurers and providers.
• The negative financial effects on health care providers have been more severe in the United States than elsewhere, owing to the prevalence of activity‐based payment systems, limited direct governmental control over available provider capacity, and the structure of governmental financial relief.
• In a pandemic, activity‐based payment reverses the conventional financial positions of payers and providers and may prevent providers from prioritizing public health because of the desire to avoid revenue loss caused by declines in patient visits.

Financial distress in the health care sector is a nonintuitive consequence of a pandemic. Yet, in the United States, the budgets of health care providers are under considerable strain as the COVID‐19 pandemic continues.Analysts anticipate that these continuing financial challenges will generate a wave of consolidation among hospitals and physician practices through 2021. ¹ Critical access hospitals, hospitals serving vulnerable populations, and independent primary care practices are particularly threatened. ² , ³ These dire financial outcomes arose through the interaction of the public health measures taken in response to the COVID‐19 epidemic, particularly the shutdown of elective procedures, along with the underlying structure of US health care financing and the US government''s emergency response.But COVID‐19 is a global epidemic. The twin effects of COVID‐19 treatment and reduced non‐COVID treatment have dramatically changed the number and case mix of patients treated in similar ways across high‐income countries. In all countries, the number of acutely ill patients with COVID rose while the number of patients with other conditions fell. The effects of these changes on health care providers’ finances have varied, however, depending on how health care systems are ordinarily structured and financed and to what extent government actions protected health care providers. By comparing the financial effects of the COVID‐19 pandemic in the United States and three other health care systems (England, Germany, and Israel) that incorporate both public and private insurers and providers, we can identify the governmental and policy factors that contributed to the severity and distribution of the effects of COVID‐19 on US providers.In all four countries, the impacts of COVID on the utilization of health care were similar. During infection surges, the number of COVID patients stressed hospitals, and as a result, nonurgent services for non‐COVID patients were postponed or forgone. The governments of all four countries directly supported health care providers with funding for increased COVID‐related expenditures (such as for personal protective equipment). The governments of all four countries also protected and compensated health care providers for their financial losses, but they did so in different ways, reflecting the structure of their health systems. In Israel, which uses relatively little activity‐based financing, the government saw less need for dedicated financial assistance. The governments of Germany and England shifted the form of payment away from activity‐based financing toward budgets to provide financial protection to health care providers, particularly in hospitals. Finally, in the United States, where activity‐based payment is prevalent and the health care–financing system is far too fragmented to permit a rapid switch in the method of payment, the government directly compensated providers for lost revenue.     

‘They're getting a taste of our world’: A qualitative study of people with multiple sclerosis' experiences of accessing health care during the COVID‐19 pandemic in the Australian Capital Territory

BackgroundPeople with multiple sclerosis (MS), who are often immunocompromised, require complex care and engage with a variety of health‐care providers to manage their health.ObjectiveTo elucidate people with MS'' experiences of accessing health care during the COVID‐19 pandemic in Australia.DesignA qualitative study involving semi‐structured interviews and thematic analysis.Settings and participantsEight adults with a clinical diagnosis of MS participated in telephone or video call interviews between June and July 2020.ResultsParticipants were aware that having MS made them more vulnerable to contracting COVID‐19. In some cases, usual care was postponed or not sought. Some circumstances warranted the risk of a face‐to‐face consultation. Benefits of telehealth consultations included improved access, convenience and being contact‐free. In comparison with video consultations, those via telephone were considered less personal and limited capacity to read body language, and for physical examination. Most participants hoped to incorporate telehealth into their future health‐care routines.Discussion and conclusionPersonal risk assessment and trust in health‐care professionals are determinants of the mode through which people with MS accessed health care during the COVID‐19 pandemic. Telehealth has been a valuable tool to mitigate COVID‐19 transmission through enabling contact‐free consultations. People with MS may find specific value in video consultations, which enable visualization of physical function. There is a need for training and support for all clinicians to conduct remote consultations.Patient or public contributionThis study was conducted by a team comprised of four people with MS, a neurologist and four health services researchers.     

Barriers and facilitators to mobile health and active surveillance use among older adults with skin disease

BackgroundThe COVID‐19 pandemic has accelerated the adoption of telemedicine, including teledermatology. Monitoring skin lesions using teledermatology may become increasingly important for several skin diseases, including low‐risk skin cancers. The purpose of this study was to describe the key factors that could serve as barriers or facilitators to skin disease monitoring using mobile health technology (mHealth) in older adults.MethodsOlder adult dermatology patients 65 years or older and their caregivers who have seen a dermatologist in the last 18 months were interviewed and surveyed between December 2019 and July 2020. The purpose of these interviews was to better understand attitudes, beliefs and behaviours that could serve as barriers and facilitators to the use of mHealth and active surveillance to monitor low‐risk skin cancers.ResultsA total of 33 interviews leading to 6022 unique excerpts yielded 8 factors, or themes, that could serve as barriers, facilitators or both to mHealth and active surveillance. We propose an integrated conceptual framework that highlights the interaction of these themes at both the patient and provider level, including care environment, support systems and personal values.Discussion and conclusionsThese preliminary findings reveal factors influencing patient acceptance of active surveillance in dermatology, such as changes to the patient‐provider interaction and alignment with personal values. These factors were also found to influence adoption of mHealth interventions. Given such overlap, it is essential to address barriers and facilitators from both domains when designing a new dermatology active surveillance approach with novel mHealth technology.Patient or public contributionThe patients included in this study were participants during the data collection process. Members of the Stanford Healthcare and Denver Tech Dermatology health‐care teams aided in the recruitment phase of the data collection process.     

Chronic and rare disease patients' access to healthcare services during a health crisis: The example of the COVID‐19 pandemic in Turkey

ObjectiveThe restructuring of healthcare provision for the coronavirus disease 2019 (COVID‐19) pandemic caused disruptions in access for patients with chronic or rare diseases. This study explores the experiences of patients with chronic or rare diseases in access to healthcare services in Turkey during the COVID‐19 pandemic.MethodsSemi‐structured interviews were conducted with representatives (n = 10) of patient organisations (n = 9) based in Istanbul. Thematic analysis with an inductive approach was conducted to analyse the responses obtained through the interviews.ResultsThe lack of clinical information at the beginning of the pandemic caused fear among patients with chronic or rare diseases. Patients experienced obstacles in access to healthcare services because of the overcrowding of hospitals with COVID‐19 patients. Some treatment procedures were cancelled or postponed by physicians. Of these procedures, some were medically vital for those patients, leading to or exacerbating further health problems. The most positive measures that patients identified were where the Social Security Institution introduced regulations to facilitate access to prescribed medicine for chronic patients. Information exchange between the doctors and their patients was important to alleviate the uncertainty and reduce the anxiety among patients.DiscussionAccess problems experienced by patients during the COVID‐19 pandemic were a complex mix of factors including shortages and physical barriers, but also perceptions of barriers. The findings of this study show that patient organisations can provide insights on disease‐specific experiences and problems that are very valuable to improve access to healthcare services to achieve the universal health coverage target. Hence, this study emphasises the inclusion of patient organisations in decision‐making processes during times of health crises.Public ContributionRepresentatives of patient organisations participated in the interviews.     

Children's perspectives and experiences of the COVID‐19 pandemic and UK public health measures

BackgroundThe COVID‐19 pandemic has had profound impacts on how we live our lives; yet, the implications for children and the effects on children''s everyday lives have been relatively underacknowledged. Understanding children''s views on COVID‐19 and related restrictions on their lives provides an important opportunity to understand how children have responded to the pandemic, including the impacts on their social and emotional well‐being.ObjectiveThis study explored the experiences and perspectives of children in relation to the COVID‐19 pandemic and related restrictions on everyday life.MethodA qualitative study using semistructured online interviews with participatory drawings was undertaken between May and July 2020. Eighteen children from England and Wales, aged 7–11 years, participated in interviews.FindingsThemes included children''s reflections on (1) COVID‐19 as a deadly contagion; (2) fears and sadness and (3) social responsibility and opportunities to respond positively.ConclusionsYoung children offer insightful reflections on their experiences during the first wave of the COVID‐19 pandemic in the United Kingdom. Children and young people''s perspectives must be considered in future public health discourse.Patient or Public ContributionThis work was informed by conversations with my own three primary school‐aged children and the children of friends. A formal Patient and Public Involvement (PPI) group was not established due to the speed with which the project was undertaken. Any future research in this area would benefit from formal PPI in the design, methods and questions.     

International Collaboration to Ensure Equitable Access to Vaccines for COVID‐19: The ACT‐Accelerator and the COVAX Facility

Policy Points

• Equitable access to a COVID‐19 vaccine in all countries remains a key policy objective, but experience of previous pandemics suggests access will be limited in developing countries, despite the rapid development of three successful vaccine candidates.
• The COVAX Facility seeks to address this important issue, but the prevalence of vaccine nationalism threatens to limit the ability of the facility to meet both its funding targets and its ambitious goals for vaccine procurement.
• A failure to adequately address the underlying lack of infrastructure in developing countries threatens to further limit the success of the COVAX Facility.

ContextSignificant effort has been directed toward developing a COVID‐19 vaccine, which is viewed as the route out of the pandemic. Much of this effort has coalesced around COVAX, the multilateral initiative aimed at accelerating the development of COVID‐19 vaccines, and ensuring they are equitably available in low‐ and middle‐income countries (LMICs). This paper represents the first significant analysis of COVAX, and the extent to which it can be said to have successfully met these aims.MethodsThis paper draws on the publicly available policy documents made available by the COVAX initiatives, as well as position papers and public statements from governments around the world with respect to COVID‐19 vaccines and equitable access. We analyze the academic literature regarding access to vaccines during the H1N1 pandemic. Finally, we consider the WHO Global Allocation System, and its principles, which are intended to guide COVAX vaccine deployment.FindingsWe argue that the funding mechanism deployed by the COVAX Pillar appears to be effective at fostering at‐risk investments in research and development and the production of doses in advance of confirmation of clinical efficacy, but caution that this represents a win‐win situation for vaccine manufacturers, providing them with opportunity to benefit regardless of whether their vaccine candidate ever goes on to gain regulatory approval. We also argue that the success of the COVAX Facility with respect to equitable access to vaccine is likely to be limited, primarily as a result of the prevalence of vaccine nationalism, whereby countries adopt policies which heavily prioritize their own public health needs at the expense of others.ConclusionsCurrent efforts through COVAX have greatly accelerated the development of vaccines against COVID‐19, but these benefits are unlikely to flow to LMICs, largely due to the threat of vaccine nationalism.

A vaccine is viewed as the key to bringing about the end of the COVID‐19 pandemic. The sooner a vaccine is available, the sooner the world can begin to escape the acute phase of the pandemic, suppressing mortality and morbidity caused by infection and restoring a degree of normality to social life and the global economy. Not only is global equitable access to a COVID‐19 vaccine an important public health tool, but it is also necessary to ensure that all countries can discharge their human rights obligations. ¹ In an attempt to accelerate the availability of vaccines and other tools to combat COVID‐19, the World Health Organization (WHO) established the Access to COVID‐19 Tools (ACT) Accelerator, a global initiative designed to harbor international cooperation and knowledge regarding the pandemic. Specifically, the ACT‐Accelerator is focused on accelerating development in four areas, or pillars: diagnostics, therapeutics, vaccines (called COVAX), and health systems strengthening.Although efforts to develop a vaccine are starting to prove successful, with the development of successful candidates from Pfizer, Moderna, and AstraZenica/University of Oxford all receiving emergency regulatory approval in late 2020, key questions remain about which countries will have access to these vaccines, when they will get access, and in what quantities. During the 2009 H1N1 influenza pandemic, procurement of pandemic vaccines was dominated by developed countries, which used advance purchase agreements to reserve doses ahead of production. This severely limited the number of doses available in developing countries. ² In addition to accelerating research and development (R&D) through the ACT‐Accelerator, and in an attempt to ensure more equitable access to vaccines for COVID‐19, the Coalition for Epidemic Preparedness Innovations (CEPI); Gavi, the Vaccine Alliance; and the WHO formed the COVAX Facility in early 2020. The COVAX Facility is designed to address the issues encountered by developing countries during the 2009 H1N1 pandemic by using significant advance market commitments to secure access to vaccines on their behalf. It also encourages multilateral cooperation to increase access to vaccines in all participating countries.This paper argues that the funding mechanism deployed by the COVAX pillar appears to be effective at fostering at‐risk investments in R&D and the production of doses in advance of confirmation of clinical efficacy. Indeed, the development of two vaccine candidates funded by the ACT‐Accelerator is testament to this fact. However, this comes with a caution that the mechanism heavily favors pharmaceutical companies, for which up‐front investment from the COVAX pillar represents a win‐win situation and an opportunity to benefit regardless of whether their vaccine candidate ever goes on to gain regulatory approval. The paper then discusses the COVAX Facility, arguing that, like any multilateral purchasing system, securing a sufficient degree of interest and participation is essential to its success. It argues that the COVAX Facility has so far failed to do this, primarily as a result of the prevalence of vaccine nationalism, whereby countries adopt policies that heavily prioritize their own public health needs at the expense of others, and that its success is therefore likely to be limited. The paper concludes by arguing that the Global Allocation System, designed by the WHO, fails to address the issues experienced by the Vaccine Deployment Initiative during the 2009 H1N1 pandemic, specifically the delays in deploying vaccine in developing countries owing to a lack of preparedness and vaccine utilization infrastructure. It argues that, if these issues are not addressed, the COVAX Facility will fail to secure equitable access to vaccines in developing countries, despite the rapid development of successful vaccine candidates, because the allocation framework will be unable to operate as intended.     

Understanding COVID‐19 misinformation and vaccine hesitancy in context: Findings from a qualitative study involving citizens in Bradford,UK

BackgroundCOVID‐19 vaccines can offer a route out of the pandemic, yet initial research suggests that many are unwilling to be vaccinated. A rise in the spread of misinformation is thought to have played a significant role in vaccine hesitancy. To maximize uptake, it is important to understand why misinformation has been able to take hold at this time and why it may pose a more significant problem within certain contexts.ObjectiveTo understand people''s COVID‐19 beliefs, their interactions with (mis)information during COVID‐19 and attitudes towards a COVID‐19 vaccine.Design and ParticipantsBradford, UK, was chosen as the study site to provide evidence to local decision makers. In‐depth phone interviews were carried out with 20 people from different ethnic groups and areas of Bradford during Autumn 2020. Reflexive thematic analysis was conducted.ResultsParticipants discussed a wide range of COVID‐19 misinformation they had encountered, resulting in confusion, distress and mistrust. Vaccine hesitancy could be attributed to three prominent factors: safety concerns, negative stories and personal knowledge. The more confused, distressed and mistrusting participants felt about their social worlds during the pandemic, the less positive they were about a vaccine.ConclusionsCOVID‐19 vaccine hesitancy needs to be understood in the context of the relationship between the spread of misinformation and associated emotional reactions. Vaccine programmes should provide a focused, localized and empathetic response to counter misinformation.Patient or Public ContributionA rapid community and stakeholder engagement process was undertaken to identify COVID‐19 priority topics important to Bradford citizens and decision makers.     

High‐deductible health plans and low‐value imaging in the emergency department

ObjectiveTo examine the effect of an employer‐mandated switch to high‐deductible health plans (HDHP) on emergency department (ED) low‐value imaging.Data SourcesClaims data of a large national insurer between 2003 and 2014.Study DesignDifference‐in‐differences analysis with matched control groups.Data Collection/Extraction MethodsThe primary outcome is low‐value imaging during ED visits for syncope, headache, or low back pain. We included members aged 19‐63 years whose employers offered only low‐deductible (≤$500) plans for one (baseline) year and, in the next (follow‐up) year, offered only HDHPs (≥$1000). Contemporaneous members whose employers offered only low‐deductible plans for two consecutive years served as controls. The groups were matched by person and employer propensity for HDHP switch, employer size, baseline calendar year, and baseline year quarterly number of total and imaged ED visits for each condition. We modeled the visit‐level probability of low‐value imaging using multivariable logistic regression with member‐clustered standard errors. We also calculated population level monthly cumulative ED visit rates and modeled their trends using generalized linear regression adjusting for serial autocorrelation.Principal FindingsAfter matching, we included 524 998 members in the HDHP group and 5 448 803 in the control group with a mean age of approximately 42 years and 48% female in both groups. On visit‐level analyses, there were no significant differential changes in the probability of low‐value imaging use in the HDHP and control groups. In population‐level analyses, compared with control group members, members who switched to HDHPs experienced a relative decrease of 5.9% (95% CI − 10.3, −1.6) in ED visits for the study conditions and a relative decrease of 5.1% (95%CI −9.6, −0.6) in the subset of ED visits with low‐value imaging.ConclusionThough HDHP switches decreased ED utilization, they had no significant effect on low‐value imaging use after patients have decided to seek ED care.     

Experiences of self‐care during the COVID‐19 pandemic among individuals with rheumatoid arthritis: A qualitative study

ObjectivesThis study aimed to explore the impact of the coronavirus disease 2019 (COVID‐19) pandemic on self‐care of individuals living with rheumatoid arthritis (RA).MethodsGuided by a constructivist, qualitative design, we conducted one‐to‐one in‐depth telephone interviews between March and October 2020 with participants with RA purposively sampled for maximum variation in age, sex and education, who were participating in one of two ongoing randomized‐controlled trials. An inductive, reflexive thematic analysis approach was used.ResultsTwenty‐six participants (aged 27–73 years; 23 females) in British Columbia, Canada were interviewed. We identified three themes: (1) Adapting to maintain self‐care describes how participants took measures to continue self‐care activities while preventing virus transmissions. While spending more time at home, some participants reported improved self‐care. (2) Managing emotions describes resilience‐building strategies such as keeping perspective, positive reframing and avoiding negative thoughts. Participants described both letting go and maintaining a sense of control to accommodate difficulties and emotional responses. (3) Changing communication with health professionals outlined positive experiences of remote consultations with health professionals, particularly if good relationships had been established prepandemic.ConclusionThe insights gained may inform clinicians and researchers on ways to support the self‐care strategies of individuals with RA and other chronic illnesses during and after the COVID‐19 pandemic. The findings reveal opportunities to further examine remote consultations to optimize patient engagement and care.Patient or Public ContributionThis project is jointly designed and conducted with patient partners in British Columbia, Canada. Patient partners across the United Kingdom also played in a key role in providing interpretations of themes during data analysis.     

Effects of the COVID‐19 Emergency and National Lockdown on Italian Citizens’ Economic Concerns,Government Trust,and Health Engagement: Evidence From a Two‐Wave Panel Study

Policy Points

• Preventive measures such as the national lockdown in Italy have been effective in slowing the spread of COVID‐19. However, they also had psychological and economic impacts on people’s lives, which should not be neglected as they may reduce citizens’ trust and compliance with future health mandates.
• Engaging citizens in their own health management and in the collaboration with health care professionals and authorities via the adoption of a collaborative approach to health policy development is fundamental to fostering such measures’ effectiveness.
• Psychosocial analysis of citizens’ concerns and emotional reactions to preventive policies is important in order to plan personalized health communication campaigns.

ContextBecause of the COVID‐19 pandemic, between February 23 and March 8, 2020, some areas of Italy were declared “red zones,” with citizens asked to stay home and avoid unnecessary interpersonal contacts. Such measures were then extended, between March 10 and May 4, 2020, to the whole country. However, compliance with such behaviors had an important impact on citizens’ personal, psychological, and economic well‐being. This could result in reduced trust in authorities and lowered compliance. Keeping citizens engaged in their own health and in preventive behaviors is thus a key strategy for the success of such measures. This paper presents the results from a study conducted in Italy to monitor levels of people’s health engagement, sentiment, trust in authorities, and perception of risk at two different time points.MethodsTwo independent samples (n = 968 and n = 1,004), weighted to be representative of the adult Italian population, were recruited in two waves corresponding to crucial moments of the Italian COVID‐19 epidemic: between February 28 and March 4 (beginning of “phase 1,” after the first regional lockdowns), and between May 12 and May 18 (beginning of “phase 2,” after the national lockdown was partially dismissed). Respondents were asked to complete an online survey with a series of both validated measures and ad hoc items. A series of t‐tests, general linear models, and contingency tables were carried out to assess if and how our measures changed over time in different social groups.FindingsAlthough sense of self and social responsibility increased between the two waves, and trust toward authorities remained substantially the same, trust in science, consumer sentiment, and health engagement decreased. Our results showed that while both the level of general concern for the emergency and the perceived risk of infection increased between the two waves, in the second wave our participants reported being more concerned for the economic consequences of the pandemic than the health risk.ConclusionsThe potentially disruptive psychological impact of lockdown may hamper citizens’ compliance with, and hence the effectiveness of, behavioral preventive measures. This suggests that preventive measures should be accompanied by collaborative educational plans aimed at promoting people’s health engagement by making citizens feel they are partners in the health preventive endeavor and involved in the development of health policies.     

Experience of patients hospitalized with COVID‐19: A qualitative study of a pandemic disease in Iran

BackgroundThe spread of COVID‐19 as an infectious disease brings about many newly arrived challenges, which call for further research on the scope of its effect on life due to the special conditions of this disease. The present study is, therefore, an attempt to understand the lived experience of inpatients hospitalized with COVID‐19.MethodIn this phenomenological study, among patients with COVID‐19 who were hospitalized in COVID‐19 referral hospitals, 17 people were selected by random sampling method. Data were gathered by interviews and analysed using MAXQDA10 software.FindingsAnalysis revealed 4 main themes and 16 subthemes. Main themes included the (1) denial of the disease, (2) negative emotions upon arrival, (3) perception of social and psychological supports and (4) post‐discharge concerns and problems.ConclusionPatients with COVID‐19 experience a different world of stresses, concerns and feelings in the course of their disease. Gaining a deeper insight into patients’ experiences with this disease can help handle this disease more effectively and provide better post‐corona nursing and psychological care and services.     

Telehealth for Contraceptive Services During the COVID-19 Pandemic: Provider Perspectives

BackgroundTelehealth use rapidly increased during the COVID-19 pandemic, including for contraceptive care (e.g., counseling and method provision). This study explored providers’ experiences with contraceptive care via telehealth.MethodsWe conducted a survey with open-ended responses among contraceptive providers across the United States. The study population included physicians, nurse practitioners, health educators, and other health professionals (n = 546). Data were collected from April 10, 2020, to January 29, 2021. We conducted qualitative content analysis of the open-ended responses.ResultsProviders highlighted the benefits of telehealth, including continuing access to contraceptive services and accommodating patients who faced challenges attending in-person contraceptive visits. Providers at school-based health centers reported telehealth allowed them to reach young people while schools were closed. However, many providers noted a lack of patient awareness about the availability of telehealth services and disparities in access to technology. Providers felt there was less personal connection in virtual contraceptive counseling, noted challenges with confidentiality, and expressed concern about the inability to provide the full range of contraceptive methods through telehealth alone.ConclusionsThe pandemic significantly impacted contraceptive health care delivery. Telehealth has sustained access to contraception in important ways, but has been accompanied by various challenges, including technological access and confidentiality. As hybrid models of care evolve, it is important to assess how telehealth can play a role in providing contraceptive care while addressing its barriers.     

Proposals for person‐centred care in the COVID‐19 era. Delphi study

BackgroundIn this COVID‐19 era, we need to rethink the criteria used to measure the results of person‐centred care strategies.ObjectiveTo identify priorities, and criteria that health services can use to pursue actually the goal of achieving person‐centred care.DesignThree‐phase online qualitative study performed during May–July of 2020 using the Delphi technique.Setting and ParticipantsAn online platform was used for a consensus meeting of 114 participants, including health planning experts, health‐care institution managers, clinicians and patients.Main Outcome MeasuresCriteria and indicators for the achievement of person‐centred care.Main ResultsThe first round began with 125 proposals and 11 dimensions. After the second round, 28 ideas reached a high level of consensus among the participants. Ultimately, the workgroup agreed on 20 criteria for goals in the implementation of person‐centred care during the COVID‐19 era and 21 related indicators to measure goal achievement.DiscussionNine dimensions and 28 priorities were identified. These priorities are also in accordance with the quadruple aim approach, which emphasizes the need for care for health‐care professionals, without whom it is impossible to achieve a better quality of care.ConclusionsPerson‐centred care continues to be a key objective. However, new metrics are needed to ensure its continued development during the restoration of public health services beyond the control of COVID‐19.Patient or Public ContributionTwelve professionals and patient representatives participated voluntarily in the construction of the baseline questionnaire and in the selection of the criteria and indicators using an online platform for consensus meetings.     

Public preference for COVID‐19 vaccines in China: A discrete choice experiment

BackgroundAs the coronavirus disease 2019 (COVID‐19) pandemic is sweeping across the globe, there is an urgent need to develop effective vaccines as the most powerful strategy to end the pandemic. This study aimed to examine how factors related to vaccine characteristics, their social normative influence and convenience of vaccination can affect the public''s preference for the uptake of the COVID‐19 vaccine in China.MethodsAn online discrete choice experiment (DCE) survey was administered to a sample of China''s general population. Participants were asked to make a series of hypothetical choices and estimate their preference for different attributes of the vaccine. A mixed logit regression model was used to analyse the DCE data. Willingness to pay for each attribute was also calculated.ResultsData of 1236 participants who provided valid responses were included in the analysis. There was strong public preference for high effectiveness of the vaccine, followed by long protective duration, very few adverse events and being manufactured overseas. Price was the least important attribute affecting the public preference in selecting the COVID‐19 vaccine.ConclusionsThe strong public preferences detected in this study should be considered when developing COVID‐19 vaccination programme in China. The results provide useful information for policymakers to identify the individual and social values for a good vaccination strategy.Patient or Public ContributionThe design of the experimental choices was fully based on interviews and focus group discussions participated by 26 Chinese people with diverse socio‐economic backgrounds. Without their participation, the study would not be possible.     

Comparing the impact on COVID‐19 mortality of self‐imposed behavior change and of government regulations across 13 countries

ObjectiveCountries have adopted different approaches, at different times, to reduce the transmission of coronavirus disease 2019 (COVID‐19). Cross‐country comparison could indicate the relative efficacy of these approaches. We assess various nonpharmaceutical interventions (NPIs), comparing the effects of voluntary behavior change and of changes enforced via official regulations, by examining their impacts on subsequent death rates.Data SourcesSecondary data on COVID‐19 deaths from 13 European countries, over March–May 2020.Study DesignWe examine two types of NPI: the introduction of government‐enforced closure policies and self‐imposed alteration of individual behaviors in the period prior to regulations. Our proxy for the latter is Google mobility data, which captures voluntary behavior change when disease salience is sufficiently high. The primary outcome variable is the rate of change in COVID‐19 fatalities per day, 16–20 days after interventions take place. Linear multivariate regression analysis is used to evaluate impacts.Data collection/extraction methods: publicly available.Principal FindingsVoluntarily reduced mobility, occurring prior to government policies, decreases the percent change in deaths per day by 9.2 percentage points (pp) (95% confidence interval [CI] 4.5–14.0 pp). Government closure policies decrease the percent change in deaths per day by 14.0 pp (95% CI 10.8–17.2 pp). Disaggregating government policies, the most beneficial for reducing fatality, are intercity travel restrictions, canceling public events, requiring face masks in some situations, and closing nonessential workplaces. Other sub‐components, such as closing schools and imposing stay‐at‐home rules, show smaller and statistically insignificant impacts.ConclusionsNPIs have substantially reduced fatalities arising from COVID‐19. Importantly, the effect of voluntary behavior change is of the same order of magnitude as government‐mandated regulations. These findings, including the substantial variation across dimensions of closure, have implications for the optimal targeted mix of government policies as the pandemic waxes and wanes, especially given the economic and human welfare consequences of strict regulations.     

Allocating a COVID‐19 Vaccine: Balancing National and International Responsibilities

Policy Points

• In this paper we propose a middle‐ground policy for the distribution of an effective COVID‐19 vaccine, between a cosmopolitan approach that rejects entirely nation‐state priority and unbridled vaccine nationalism that disregards obligations to promote an equitable global allocation of an effective vaccine over time.
• Features of the COVAX partnership, a collaboration among the Global Alliance for Vaccines and Immunizations (GAVI), the Coalition for Epidemic Preparedness Innovations (CEPI), and the World Health Organization (WHO) to develop and distribute COVID‐19 vaccines make it an appropriate framework for a middle‐ground policy.

More than 100 vaccine candidates are now in development to prevent infection from SARS‐CoV2 or serious disease from COVID‐19; many have entered clinical trials; and several are in or ready for Phase III efficacy testing. Two mRNA vaccines have been found to be more than 90% effective based on interim data analysis. The identification and development of vaccine candidates has been an extremely fast process, because of the urgent need for a vaccine to control the pandemic. In addition, when effective vaccines are identified, logistical challenges must be faced, as it will take time to produce enough to cover the world''s population. At least for the first couple of years, the demand will be much higher than the supply, and not everyone who needs a vaccine will get one. Because low‐income countries are likely to lose out in the scramble to get access to the vaccine, there have been calls for global solidarity. For example, the Group of 20 (G20), consisting of countries with the largest economies, issued the following statement: “We will expand manufacturing capacity to meet the increasing needs for medical supplies and ensure these are made widely available, at an affordable price, on an equitable basis, where they are most needed and as quickly as possible.” ¹ But there are worries that these are only empty promises. Even though the G20 statement emphasizes an equitable distribution of medical supplies, it does not actually commit funds to the poorest countries for supplies, including a global distribution of an effective vaccine; it recommends only capacity building and technical assistance and commits only to “mobilize” funds.

We are gravely concerned with the serious risks posed to all countries, particularly developing and least developed countries, and notably in Africa and small island states, where health systems and economies may be less able to cope with the challenge, as well as the particular risk faced by refugees and displaced persons. We consider that consolidating Africa''s health defense is a key for the resilience of global health. We will strengthen capacity building and technical assistance, especially to at‐risk communities. We stand ready to mobilize development and humanitarian financing. ¹

In the race to develop an effective vaccine, many experts have called for a more coordinated global approach, in which individual countries agree to abandon their national interest in securing vaccines for their own populations and hand over the responsibility to distribute the vaccine globally based on need. A group of bioethicists proposed what they term the “Fair Priority Model,” advocating vaccine distribution in three phases. ² The first phase would be devoted to reducing premature deaths and irreversible direct and indirect health impacts; the second to reducing serious economic and social deprivations; and the third to reducing community transmission. They argue that all countries should go through the three phases “approximately simultaneously.” In this model, the distribution principles are based strictly on medical and economic criteria that identify the effects of the vaccine and wealthy countries would not receive the vaccine earlier just because they have the resources to buy it.Another influential approach, proposed by the World Health Organization (WHO), similarly envisages a distribution scheme in which the vaccines are distributed to countries based on the number of high‐risk groups in each country. A country should first obtain enough vaccine to cover frontline health care workers, covering 3% of the highest‐risk individuals first and then continue with other high‐risk groups such as the elderly and people with comorbidities, until 20% of each country''s population has been covered.Both the Fair Priority Model and the WHO proposal seem to disregard the relevance of national borders; that is, all countries should receive a supply of vaccines simultaneously in accordance with country‐independent criteria. Here we argue that both these approaches are untenable and that national governments have both a right and a duty to secure access to a COVID‐19 vaccine for their citizens first. Accordingly, we propose a middle‐ground policy perspective based on two premises: (1) a “cosmopolitan” approach that rejects entirely nation‐state priority is not only unrealistic but also fails to recognize that countries have a legitimate responsibility to give priority to their own citizens and residents; and (2) unbridled vaccine nationalism, without an adequately funded effort to ensure the equitable global allocation of an effective vaccine over time, is unethical and likely to be counterproductive.We present three interdependent arguments for our position. First, we believe that a prioritization framework should include a distribution scheme that can be implemented, rather than one that simply proposes general principles of distribution. Second, any viable prioritization scheme needs to start with nation‐states’ responsibility to secure the health of their populations. Third, appropriate weight needs to be given to national obligations of international assistance for low‐income countries to mobilize resources for health. We argue that the COVAX partnership provides a framework that approximates the right balance between national responsibilities for health and international commitments to global justice.     

Socioeconomic status and the effectiveness of treatment for first‐episode psychosis

ObjectiveTo assess whether patient socioeconomic status (SES) moderates the effectiveness of coordinated specialty care for first‐episode psychosis and to investigate possible mechanisms.Data SourcesA secondary analysis of data from the RAISE‐ETP Trial, which was conducted from 2010‐2014.Study DesignRAISE‐ETP was a cluster‐randomized trial comparing a coordinated specialty care (CSC) intervention called NAVIGATE with usual community care. We constructed a patient SES index based on parental education, parental occupational prestige, and race/ethnicity. After identifying correlates of SES, we used OLS regression analysis to estimate treatment effects on the major study outcomes across quartiles of the index. We also examined whether correlates of SES including the duration of untreated psychosis (DUP), and participation in NAVIGATE might account for the observed difference in effectiveness of CSC by SES.Principal FindingsThe trial sample had a similar SES distribution to the US population, and SES was positively correlated with all mental health outcomes and several potential moderators at baseline. CSC substantially improved the main trial outcomes compared to community care for patients in the highest SES quartile but had small and statistically insignificant benefits for the remaining 75% of patients. Intervention participation rates and several potential moderators did not explain this disparity.ConclusionsCSC may be more effective for high‐SES patients with early psychosis than low‐SES patients. Additional research is needed to understand why CSC is less effective for low‐SES patients and to develop methods to increase effectiveness for this subgroup.     

Identifying Opportunities to Strengthen the Public Health Informatics Infrastructure: Exploring Hospitals’ Challenges with Data Exchange

Policy Points

• Even though most hospitals have the technological ability to exchange data with public health agencies, the majority continue to experience challenges.
• Most challenges are attributable to the general resources of public health agencies, although workforce limitations, technology issues such as a lack of data standards, and policy uncertainty around reporting requirements also remain prominent issues.
• Ongoing funding to support the adoption of technology and strengthen the development of the health informatics workforce, combined with revising the promotion of the interoperability scoring approach, will likely help improve the exchange of electronic data between hospitals and public health agencies.

ContextThe novel coronavirus 2019 (COVID‐19) pandemic has highlighted significant barriers in the exchange of essential information between hospitals and local public health agencies. Thus it remains important to clarify the specific issues that hospitals may face in reporting to public health agencies to inform focused approaches to improve the information exchange for the current pandemic as well as ongoing public health activities and population health management.MethodsThis study uses cross‐sectional data of acute‐care, nonfederal hospitals from the 2017 American Hospital Association Annual Survey and Information Technology supplement. Guided by the technology‐organization‐environment framework, we coded the responses to a question regarding the challenges that hospitals face in submitting data to public health agencies by using content analysis according to the type of challenge (i.e., technology, organization, or environment), responsible entity (i.e., hospital, public health agency, vendor, multiple), and the specific issue described. We used multivariable logistic and multinomial regression to identify characteristics of hospitals associated with experiencing the types of challenges.FindingsOur findings show that of the 2,794 hospitals in our analysis, 1,696 (61%) reported experiencing at least one challenge in reporting health data to a public health agency. Organizational issues were the most frequently reported type of challenge, noted by 1,455 hospitals. The most common specific issue, reported by 1,117 hospitals, was the general resources of public health agencies. An advanced EHR system and participation in a health information exchange both decreased the likelihood of not reporting experiencing a challenge and increased the likelihood of reporting an organizational challenge.ConclusionsOur findings inform policy recommendations such as improving data standards, increasing funding for public health agencies to improve their technological capabilities, offering workforce training programs, and increasing clarity of policy specifications and reporting. These approaches can improve the exchange of information between hospitals and public health agencies.