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.     

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.     

COVAX and equitable access to COVID-19 vaccines

ObjectiveTo evaluate equity in the allocation and distribution of vaccines for coronavirus disease 2019 (COVID-19) to countries and territories participating in the COVID-19 Vaccines Global Access (COVAX) Facility.MethodsWe used publicly available data on the numbers of COVAX vaccine doses allocated and distributed to 88 countries and territories qualifying for COVAX-sponsored vaccine doses and 60 countries self-financing their vaccine doses facilitated by COVAX. We conducted a benefit–incident analysis to examine the allocation and distribution of vaccines based on countries’ gross domestic product (GDP) per capita. We plotted cumulative country-level per capita allocation and distribution of COVID-19 vaccines from COVAX against the ranked per capita GDP of the countries and territories to generate a measure of the equity of COVAX benefits.FindingsBy 23 January 2022 the COVAX Facility had allocated a total of 1 678 517 990 COVID-19 vaccine doses, of which 1 028 291 430 (61%) doses were distributed to 148 countries and territories. Taking account of COVAX subsidies, we found that countries and territories with low per capita GDP benefited more than higher-income countries in the numbers of vaccines. The benefits increased further when the analysis was adjusted by population age group (aged 65 years and older).ConclusionThe COVAX Facility is helping to balance global inequities in the allocation and distribution of COVID-19 vaccines. However, COVAX alone has not been enough to reverse the inequality of total COVID-19 vaccine distribution. Future studies could examine the equity of all COVID-19 vaccine allocation and distribution beyond the COVAX-facilitated vaccines.     

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.     

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.     

Rapid Transition to Telehealth and the Digital Divide: Implications for Primary Care Access and Equity in a Post‐COVID Era

Policy Points

• Telehealth has many potential advantages during an infectious disease outbreak such as the COVID‐19 pandemic, and the COVID‐19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode.
• Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID‐19 pandemic.
• Without proactive efforts to address both patient‐ and provider‐related digital barriers associated with socioeconomic status, the wide‐scale implementation of telehealth amid COVID‐19 may reinforce disparities in health access in already marginalized and underserved communities.
• To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.

ContextThe COVID‐19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth. Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus. However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID‐19 pandemic.MethodsThe study analyzed data about small primary care practices’ telehealth use and barriers to telehealth use collected from rapid‐response surveys administered by the New York City Department of Health and Mental Hygiene''s Bureau of Equitable Health Systems and New York University from mid‐April through mid‐June 2020 as part of the city''s efforts to understand how primary care practices were responding to the COVID‐19 pandemic following New York State''s stay‐at‐home order on March 22. We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low‐income, minority or immigrant areas that were more severely impacted by COVID‐19. To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high‐SVI or low‐SVI areas. We then characterized respondents’ telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals. In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only.FindingsWhile all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers. Providers in high‐SVI areas were almost twice as likely as providers in low‐SVI areas to use telephones as their primary telehealth modality (41.7% vs 23.8%; P <.001). The opposite was true for video, which was used as the primary telehealth modality by 18.7% of providers in high‐SVI areas and 33.7% of providers in low‐SVI areas (P <0.001). Providers in high‐SVI areas also faced more patient‐related barriers and fewer provider‐related barriers than those in low‐SVI areas.ConclusionsBetween April and June 2020, telehealth became a prominent mode of primary care delivery in New York City. However, the transition to telehealth did not unfold in the same manner across communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.     

COVID‐19‐related Medicaid enrollment in Medicaid expansion and non‐expansion states

Research ObjectiveTo explore whether expanded Medicaid helps mitigate the relationship between unemployment due to COVID and being uninsured. Unanticipated unemployment spells are generally associated with disruptions in health insurance coverage, which could also be the case for job losses during the COVID‐19 pandemic. Expanded access to Medicaid may insulate some households from long uninsurance gaps due to job loss.Data SourcePhase 1 of the Census Bureau''s Experimental Household Pulse Survey covering April 23, 2020–July 21, 2020.Study DesignWe compare differences in health insurance coverage source and status linked to recent lob losses attributable to the COVID‐19 pandemic in states that expanded Medicaid against states that did not expand Medicaid.Data Collection/Extraction MethodsOur analytical dataset was limited to 733,181 non‐elderly adults aged 20–64.Principal FindingsTwenty‐six percent of our study sample experienced an income loss between March 13, 2020, and the time leading up to the survey—16% experienced job losses (e.g., layoff, furlough) due to the COVID‐19 crisis, and 11% had other reasons they were not working. COVID‐linked job losses were associated with a 20 (p < 0.01) percentage‐point (PPT) lower likelihood of having employer‐sponsored health insurance (ESI). Relative to persons in states that did not expand Medicaid, persons in Medicaid expansion states experiencing COVID‐linked job losses were 9 PPT (p < 0.01) more likely to report having Medicaid and 7 PPT (p < 0.01) less likely to be uninsured. The largest increases in Medicaid enrollment were among people who, based on their 2019 incomes, would not have qualified for Medicaid previously.ConclusionsOur findings suggest that expanded Medicaid eligibility may allow households to stabilize health care needs and they should become detached from private health coverage due to job loss during the pandemic. Households negatively affected by the pandemic are using Medicaid to insure themselves against the potential health risks they would incur while being unemployed.     

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.     

Using a structural vulnerability framework to understand the impact of COVID‐19 on the lives of Medicaid beneficiaries receiving substance use treatment in New York City

ObjectiveTo investigate how the COVID‐19 pandemic impacted low‐income individuals with substance use disorder (SUD) in New York City (NYC) during the beginning of the pandemic, using a structural competency and structural vulnerability theoretical framework and a qualitative research approach.Data SourcesPrimary qualitative data were collected from racial/ethnic minority adults enrolled in Medicaid receiving outpatient substance use treatment (e.g., medication, counseling) in NYC.Study DesignSemi‐structured in‐depth qualitative interviews (N = 20) were conducted during “stay‐at‐home” orders in NYC, the first epicenter of the COVID‐19 pandemic in the United States. Interviews were conducted over the phone during the earlier stages of the pandemic, between April 2020 and June 2020.Data Collection/Extraction MethodsSemi‐structured in‐depth interviews were conducted and audio recorded, transcribed, and analyzed using a thematic analysis approach.Principal FindingsThree themes were yielded from our thematic analysis: (1) COVID‐19 heightened food insecurity and housing conditions increased risks of infection; (2) stay‐at‐home orders limited access to resources but had positive impacts in strengthening social relationships and reducing substance use triggers; and (3) although COVID‐19 created challenges for treatment, most described that SUD care improved during the pandemic.ConclusionsWhile COVID‐19 exacerbated numerous structural vulnerabilities among low‐income individuals with SUD, programmatic adaptations to COVID‐19 SUD care, including telehealth and loosening restrictions around medications for opioid use disorders mitigated past difficulties that patients had faced. Reducing structural vulnerabilities for Medicaid patients will require continuation of telehealth treatment delivery, retaining flexible medication regulations, and mobilizing community resources to mitigate economic disparities.     

The Commercial Determinants of Three Contemporary National Crises: How Corporate Practices Intersect With the COVID‐19 Pandemic,Economic Downturn,and Racial Inequity

Policy Points

•  The United States finds itself in the middle of an unprecedented combination of crises: a global pandemic, economic crisis, and unprecedented civic responses to structural racism.
•  While public sector responses to these crises have faced much justified criticism, the commercial determinants of these crises have not been sufficiently examined.
•  In this commentary we examine the nature of the contributions of such actors to the conditions that underpin these crises in the United States through their market and nonmarket activities.
•  On the basis of this analysis, we make recommendations on the role of governance and civil society in relation to such commercial actors in a post‐COVID‐19 world.

The united states finds itself amid three concurrent and interrelated crises. First, at the time of writing, the United States has reported more than 27 million confirmed COVID‐19 cases and more than 500,000 Americans have lost their lives. ¹ Second, in part as a consequence of the physical distancing measures enacted to slow the spread of the pandemic, the United States has faced record unemployment, a rise in the number of Americans unable to afford medical insurance, an end to federal support measures, and an uncertain economic outlook. According to the US Department of Labor, more than 50 million Americans have filed for unemployment benefits since the COVID‐19 pandemic started; more than 10 million Americans remain on state unemployment benefits. ² Third, the country is still contending with how to respond to mass civil protests in 2020 unlike any seen in half a century, triggered by the killing of George Floyd at the hands of police in Minneapolis. This civil unrest reflects centuries of structural racism and has brought unprecedented attention to this problem. ³ , ⁴ , ⁵ In each of these three concurrent crises, the pandemic, ongoing large‐scale unemployment, and civil protests, ⁶ the US federal response has been criticized as being delayed and poorly coordinated, involving downplaying the threat posed by the pandemic and building on longer‐term failures by previous administrations to make investments in public goods that may have facilitated a more robust and effective collective response.By contrast, it would appear that some of the largest entities in corporate America have responded more rapidly to each of the ongoing crises than the federal government has. A number of large companies have engaged in activities that responded to needs emerging from the pandemic, such as producing hand sanitizer, ⁷ setting up COVID‐19 testing sites, ⁸ and partnering on contact tracing. ⁹ Most notably, the pharmaceutical sector has contributed to an unexpectedly and unquestionably successful vaccine development process for SARS‐CoV‐2, with almost 200 million shots already distributed. ¹⁰ In response to the economic downturn, many companies have been adapting their business practices to supply essential services in a time of great disruption. For example, food and other essential businesses have largely kept supply chains for essential goods open, ¹¹ through extending working hours, hiring additional staff, and implementing new means of operating. Several large employers have responded to changing circumstance, aiming to keep as many employees working as possible, often through an embrace of remote working and implementing more permanent shifts into patterns of working. ¹² In response to the global protests around structural racism that erupted in 2020, a number of large companies, including Nike, Reebok, Twitter, and Citigroup, have publicly aligned themselves with the Black Lives Matter movement, ¹³ including committing more than a billion dollars in pledged donations. ¹⁴ In a moment of great national turmoil, when government seems not up to the task, private sector actors have appeared, by contrast, to be better positioned to address the three crises of the moment. This plays neatly into a private sector–centric narrative, and there is little question that much good has come from elements of the private sector during this time.It is certainly true that these visible private sector efforts have contributed to helping populations deal with the consequences of an unprecedented global pandemic. But, given the emerging evidence about the populations at risk for COVID‐19, and why that risk exists to begin with, it is legitimate to ask: in the case of COVID‐19, what was the contribution of the private sector in creating the conditions that made us vulnerable to the pandemic and its consequences to begin with? And, by extension, how can private sector actions align with a durable set of solutions to the crises that characterize this moment?We already know that large, consolidated corporate entities, particularly those that manufacture harmful products, can have profound effects on population health. ¹⁵ , ¹⁶ , ¹⁷ The most obvious way in which this manifests is through “market activity,” that is, the direct consequences of manufacturing and marketing particular products. For example, it is easy to recognize that marketing of cigarettes harms health. However, such actors also influence population health through a range of “nonmarket” activities that shape the political, social, and cultural environments that they operate in. ¹⁸ Examples of this activity include political donations, lobbying, corporate social responsibility initiatives, and legal activity. These activities, often seen as intrinsic to corporate practice, support and protect commercial interests, yet do not necessarily promote population health or structures of governance. Bearing this in mind, it is worth understanding how such activities, both market and nonmarket, have contributed to the vulnerability of the United States to the three crises we now face.     

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.     

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.     

Patient and public involvement in the build‐up of COVID‐19 testing in Sweden

BackgroundPatient and public involvement in healthcare can be particularly challenging during crises such as the COVID‐19 pandemic.ObjectiveThe aims of the study, which focuses on COVID‐19 testing in Sweden, were to explore (1) how, or to what extent, patients and members of the public were involved in decisions about the organization of COVID‐19 testing during the first year of pandemic and (2) whether this was seen as feasible or desirable by regional and national stakeholders.MethodsA qualitative interview study was conducted with key organizational stakeholders at three national agencies and within three Swedish regions (n = 16).ResultsThere had been no patient and public involvement activities in the area of COVID‐19 testing. The regions had, however, tried to respond to demands or critiques from patients and the public along the way and to adapt the services to respond to their preferences. The need for rapid decision‐making, the uncertainty about whom to involve, as well as a hesitation about the appropriateness of involving patients and the public contributed to the lack of involvement.ConclusionFuture studies on patient and public involvement during crises should address what structures need to be in place to carry out involvement successfully during crises and when to use activities with varying degrees of power or decision‐making authority for patients and members of the public.Patient or Public ContributionFifteen members of the public contributed with short reflections on the study findings.     

‘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.     

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.     

Public attitudes towards COVID‐19 contact tracing apps: A UK‐based focus group study

BackgroundDuring the 2020 COVID‐19 pandemic, one of the key components of many countries’ strategies to reduce the spread of the virus is contact tracing.ObjectiveTo explore public attitudes to a COVID‐19 contact tracing app in the United Kingdom.SettingOnline video‐conferencing.Participants27 participants, UK residents aged 18 years and older.MethodsQualitative study consisting of six focus groups carried out between 1st‐12th May, 2020 (39‐50 days into the UK ‘lockdown’).ResultsParticipants were divided as to whether or not they felt they would use the app. Analysis revealed five themes: (1) lack of information and misconceptions surrounding COVID‐19 contact tracing apps; (2) concerns over privacy; (3) concerns over stigma; (4)concerns over uptake; and (5) contact tracing as the ‘greater good’. Concerns over privacy, uptake and stigma were particularly significant amongst those stated they will not be using the app, and the view that the app is for the ‘greater good’ was particularly significant amongst those who stated they will be using the app. One of the most common misconceptions about the app was that it could allow users to specifically identify and map COVID‐19 cases amongst their contacts and in their vicinity.ConclusionsOur participants were torn over whether digital contact tracing is a good idea or not, and views were heavily influenced by moral reasoning.Patient or Public ContributionNo patients were involved in this study. The public were not involved in the development of the research questions, research design or outcome measures. A pilot focus group with participants not included in the present paper was used to help test and refine the focus group questions. Summary results were disseminated via email to participants prior to publication for feedback and comment.     

Rapid development of a COVID‐19 care planning decision‐aid for family carers of people living with dementia

IntroductionCOVID‐19 has disproportionately affected people living with dementia and their carers. Its effects on health and social care systems necessitated a rapid‐response approach to care planning and decision‐making in this population, with reflexivity and responsiveness to changing individual and system needs at its core. Considering this, a decision‐aid to help families of persons with dementia was developed.ObjectivesTo coproduce with people living with dementia, and the people who care for them, a decision‐aid for family carers of people living with dementia, to support decisions during the COVID‐19 pandemic and beyond.MethodsSemi‐structured interviews were undertaken in 2020 with: (1) staff from two English national end‐of‐life and supportive care organizations; and (2) people living with dementia and family carers. Simultaneously, a rapid review of current evidence on making decisions with older people at the end of life was undertaken. Evidence from these inputs was combined to shape the decision‐aid through a series of workshops with key stakeholders, including our patient and public involvement group, which consisted of a person living with dementia and family carers; a group of clinical and academic experts and a group of policy and charity leads.ResultsThe rapid review of existing evidence highlighted the need to consider both process and outcome elements of decision‐making and their effects on people living with dementia and their families. The qualitative interviews discussed a wide range of topics, including trust, agency and confusion in making decisions in the context of COVID‐19. The decision‐aid primarily focussed on care moves, legal matters, carer wellbeing and help‐seeking.ConclusionsCombining different sources and forms of evidence was a robust and systematic process that proved efficient and valuable in creating a novel decision‐aid for family carers within the context of COVID‐19. The output from this process is an evidence‐based practical decision‐aid coproduced with people living with dementia, family carers, clinical and academic experts and leading national dementia and palliative care organizations.Patient or Public ContributionWe worked with people living with dementia and family carers and other key stakeholders throughout this study, from study development and design to inclusion in stakeholder workshops and dissemination.     

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.