key: cord-0817695-ouvzrsmd
authors: Carroll, Jennifer K.; Arias Hernandez, Paulina; Brooks-Greisena, Alicia; Carlos Cardet, Juan; Cui, Jing; Ericson, Brianna; Fagan, Maureen; Fajt, Merritt L.; Forth, Victoria E.; Fuhlbrigge, Anne L.; Lorenzi, Margie; Rodriguez-Louis, Jacqueline; Maher, Nancy E.; Manning, Brian K.; Pace, Wilson D.; Shields, Joel B.; Israel, Elliot
title: Socioeconomic impact of COVID-19 and willingness to be vaccinated in African American/Black and Hispanic/Latinx adults
date: 2022-01-26
journal: J Natl Med Assoc
DOI: 10.1016/j.jnma.2021.12.010
sha: 807cee8620326bb817805224b37bd1dbdfac3a94
doc_id: 817695
cord_uid: ouvzrsmd

PURPOSE: To describe the socioeconomic and healthcare-related effects of the COVID-19 pandemic, and willingness to receive a free COVID-19 vaccine, among African American/Black (AA/B) and Hispanic/Latinx (H/L) adults with asthma currently enrolled in a large trial. METHODS: The present analysis is a sub-study of the PeRson EmPowered Asthma RElief (PREPARE) study, a pragmatic study of 1201 AA/B and H/L adults with asthma. A monthly questionnaire was completed by a subset of PREPARE participants (n = 325) during May–August, 2020. The 5-item questionnaire assessed self-reported impact of COVID-19 on respondents’ ability to obtain asthma medications, medical care quality, employment, income and ability to pay bills; and willingness to get a free COVID-19 vaccine. Bivariate analysis and multivariate logistic regression were performed to investigate factors associated with vaccine hesitancy. RESULTS: Of 325 survey respondents (25% AA/B, 75% H/L), the majority reported no impact of COVID-19 on medical care or ability to get asthma medications. Approximately half of employed respondents experienced a lower level of employment or job loss, and approximately half reported having difficulty paying bills during the pandemic. Thirty-five percent of respondents reported unwillingness and 31% reported being somewhat likely to receive a free COVID-19 vaccine. AA/B race/ethnicity and poorer reported physical health were associated with a higher likelihood of COVID-19 vaccine hesitancy. CONCLUSION: AA/B and H/L adults with asthma may experience changes in the quality of their asthma care and increased socioeconomic stressors as a result of the COVID-19 pandemic and may be hesitant or unwilling to receive a COVID-19 vaccine.

A frican American/Black (AA/B) and Hispanic/Latinx (H/L) individuals in the United States experience disproportionate morbidity and mortality due to coronavirus disease 2019 . According to the Centers for Disease Control and Prevention (CDC), rate ratios for COVID-19 cases, hospitalizations and deaths are higher in both AA/B (1.1, 2.9, and 1.9, respectively) and H/L individuals (1.3, 3.2, and 2.3, respectively) when compared to White, non-Hispanic persons. 1 While COVID-19 has disproportionately burdened the AA/B and H/L communities, strategies to slow the spread of the virus (e.g., quarantine, work from home) may cause additional harm, such as lost wages, reduced access to services, and increased stress, for some individuals. 2 There has been a growing literature describing the importance of addressing health equity in the national and global response to COVID-19. 3 , 4 With the recent emergency use authorization of several COVID-19 vaccines by the US Food and Drug Administration (FDA), it is important to understand the willingness of individuals to receive a COVID-19 vaccine, particularly among the racial and ethnic groups most heavily impacted by the pandemic. Previous studies have reported lower rates of vaccine uptake for influenza, [5] [6] [7] Human Papilloma Virus (HPV), 8 and tetanus/diphtheria/acellular pertussis (Tdap) 9 among AA/B individuals compared to non-Hispanic Whites. Information about vaccine uptake and hesitancy are more limited among H/L individuals and show mixed results, with some reports indicating a higher proportion of influenza vaccine uptake, 10 and others demonstrating lower rates of vaccine uptake and higher rates of hesitancy. 5 , 11 Limited data suggest increased COVID-19 vaccine hesitancy in AA/B versus white individuals. 12 The objectives of this study are to describe the socioeconomic and healthcare-related effects of the COVID-19 pandemic on AA/B and H/L adults with asthma currently enrolled in a large trial, and to describe their willingness to receive a free COVID-19 vaccine. This knowledge can help inform optimal strategies to maximize vaccine uptake and reduce morbidity and mortality among AA/B and H/L individuals, who are highly impacted by the COVID pandemic.

The present analysis is a sub-study of the PeRson Em-Powered Asthma RElief (PREPARE) study. PREPARE is a randomized, open-label, pragmatic, real-world study which aims to assess whether a patient-guided, relievertriggered inhaled corticosteroid (ICS) strategy can improve asthma outcomes in AA/B and H/L adult patient populations. Details of the PREPARE study design and methods have been published previously. 13 PREPARE has enrolled 1201 AA/B and H/L adults with asthma from primary care and specialty clinics in 19 clinical organizations across the United States, and the study is ongoing.

The outcomes of this sub-study are the self-reported impact of COVID-19 on respondents' ability to obtain asthma medications, medical care quality, employment, income and ability to pay bills; and respondents' willingness to get a free COVID-19 vaccine.

Data for this analysis came from a monthly questionnaire completed by a subset of PREPARE participants during the months of May-August, 2020. In May, the research team added COVID-19-related questions to the usual monthly questionnaires completed by PREPARE par ticipants. All PREPARE par ticipants remaining in the study during this time block were eligible and had the option of responding to the COVID-19-specific questions. All participants who were currently enrolled in the PRE-PARE study at the time of the survey administration (May through August 2020) were therefore invited to complete the survey.

In this report, we describe respondents' answers to five questions which were adapted, with the guidance of the PREPARE Patient Partners, from a survey being conducted at the University of Pittsburgh Asthma & Environmental Lung Health Institute regarding asthma, COVID-19, and socioeconomic impact. Colleagues at the University of Pittsburgh developed the initial questions and reviewed them for internal coherence and interpretability. The PREPARE Patient Partners then reviewed the survey to ensure relevance to participant experience and appropriateness of the readability level. The Spanishspeaking Patient Partners also reviewed the translation for cultural adaptation.

Survey questions may be found in Appendix A . We did not give out any information related to vaccines as part of the survey itself. However, we did communicate with participants about other aspects of COVID-19 prevention. For example, in May 2020, due to reports of asthma patients not using their asthma medications appropriately during COVID, the study team sent a message to remind participants to take their asthma medication. In October 2020, the team sent a mask and a sanitizer to all participants.

Descriptive statistics were used to summarize respondents' baseline characteristics and answers to these questions. We further dichotomized attitudes toward the COVID-19 vaccine as "Vaccine Hesitant" (answered "not likely" to question 5) versus "Vaccine Willing" (answered JID: JNMA [mNS; January 25, 2022; 19:22 ] "very likely" or "somewhat likely" to question 5). To examine which factors may affect a respondent's attitude toward the COVID-19 vaccine, bivariate analyses were done to explore relationships between patient baseline characteristics and the dichotomized vaccine hesitancy/willingness variable. Variables found to be significant in bivariate analyses were entered into a multivariate logistic regression model to investigate factors associated with vaccine hesitancy/willingness. All analyses were done in SAS 9.4.

A total of 325 PREPARE participants (71% of the 456 participants remaining in the PREPARE study at the time) completed the monthly COVID-19 questionnaire during May-August 2020. Respondent characteristics are described in Table 1 . Although the PREPARE study enrolled approximately 50% ( n = 601) AA/B and 50% ( n = 598) H/L individuals in total, the sequence in which sites were initiated led to differential enrollment of AA/B and H/L participants over the course of the study (AA/Bs tended to be enrolled earlier, while H/Ls tended to be enrolled later). Thus, in this sub-study, which was conducted during the later stages or PREPARE enrollment, approximately 25% ( n = 82) of respondents self-identified as AA/B, while 75% ( n = 243) self-identified as H/L. On average, respondents had very poorly controlled asthma at baseline [mean Asthma Control Test (ACT) score = 14.3], and the majority were using asthma medications consistent with Global Initiative for Asthma (GINA) 14 therapy steps 3-5, indicating moderate to severe asthma. Approximately half of respondents reported being in fair or poor general health, and 71% reported at least one comorbidity.

Respondents reported a modest impact of COVID-19 on their medical care. In response to question 1, 87% ( n = 283) of respondents reported no impact on their ability to get their asthma medications, while the remaining 13% ( n = 41) experienced some impact: 8% ( n = 27) had a more difficult time paying for their medications, and 4% ( n = 14) did not want to go to the pharmacy for fear of contracting COVID-19. Medical care was unchanged for the majority (69%, n = 222) of respondents, while 6% ( n = 21) indicated that medical care changed for the better since the beginning of the outbreak and 25% ( n = 81) indicated that medical care got worse.

Approximately half of respondents (54%, n = 172) were not employed outside of the home when they completed the survey. Of the 149 respondents who were employed, 48% ( n = 72) reported they kept their same job and level of employment, 17% ( n = 26) had their hours cut back, 20% ( n = 29) were put on leave, and 15% ( n = 22) lost their job completely.

Approximately half of respondents experienced more difficulty paying bills due to the pandemic, with 31% ( n = 99) reporting a little difficulty, 9% ( n = 30) reporting a lot of difficulty, and 10% ( n = 34) reporting very much more difficulty. When looking at responses stratified by race/ethnicity, 27% of AA/B respondents versus 17% of H/L respondents reported a lot or very much more difficulty.

Finally, approximately one-third of respondents reported unwillingness to receive a free COVID-19 vaccine, and 31% reported being somewhat likely to receive a free vaccine. Responses to this question also varied by race/ethnicity, as shown in Fig. 1 .

Bivariate analyses ( Table 2 ) indicated that race/ethnicity, geographic region, and number of days physical health was reported as "not good" had statistically significant differences among a "Vaccine Willing" g roup ("ver y likely" or "somewhat likely" to take a free COVID-19 vaccine) and a "Vaccine Hesitant" group ("not likely" to take a free COVID-19 vaccine).

Logistic regression analyses showed that AA/B race/ethnicity and more days per month of one's physical health reported as "not good" were associated with a higher likelihood of unwillingness to receive the COVID-19 vaccine. AA/B participants were about 2.6 times more likely to be vaccine hesitant than H/L participants [OR 2.649 (95% CI 1.396-5.023), p = 0.0029], adjusting for region and days physical health not good. For every 1 day increase in days physical health was "not good", participants were 1.03 times (3%) more likely to be vaccine hesitant [OR 1.03 (95% CI 1.006-1.053), p = 0.0118], adjusting for region and race/ethnicity. This study adds to the growing literature documenting the importance of addressing racial and ethnic disparities in COVID-19 treatment and prevention. Additionally, this study examines socioeconomic impacts and factors associated with vaccine hesitancy or unwillingness in a sample of 325 AA/B and H/L individuals with moderate to severe asthma and a high burden of comorbidities.

Although the majority of respondents reported minimal change in their access to asthma medications and medical care, 13% reported some impact on their ability to get their asthma medications, and 25% indicated that their medical care had gotten worse. From a health equity perspective, it is important to align care and services for higher-risk and/or more vulnerable individuals, and future research should seek to understand and address such issues. For January 25, 2022; 19:22 ] contributing to health disparities, for example, through loss of employer-provided health care coverage and financial stress. Individuals experiencing significant financial pressures and employment instability might need to focus on immediate needs for survival before prioritizing prevention activities, such as vaccination. 25 Vaccine hesitancy and unwillingness

Our study, in which approximately one-third of respondents reported being unwilling to receive vaccination, is consistent with other published reports of AA/Bs and H/Ls reporting relatively high levels of vaccine unwillingness. 5 -9 , 11 , 12 In our study, AA/B respondents reported statistically significantly higher levels of unwillingness (50%) to receive a free COVID-19 vaccine than H/L individuals (31%). The level of vaccine unwillingness among AA/Bs in our study is higher than in another recent publication which reported vaccine hesitancy or mistrust among 32-35% of AA/Bs. 26 Medical mistrust, safety concerns, and/or past or current experiences with racism may all be reasons for this finding, and have been described in other reports. For example, a recent publication examining levels of COVID-related medical mistrust among 101 HIVpositive AA/B individuals also found high levels of medical mistrust around COVID-19, including vaccine and treatment hesitancy. 26 There is a robust literature documenting the current and historical systemic racism and mistreatment which has contributed to medical mistrust among communities of color in the United States. 25 , 27 , 28 It may also be possible that our study participants were influenced by the larger climate of uncertainty and polarization around the vaccine during the survey time period of May-August, 2020, which may have resulted in higher levels of vaccine hesitancy. Indeed, recent national polls indicate that vaccine hesitancy among African Americans has decreased in recent months to be lower than many other groups, illustrating the dynamic shifting nature of this issue. 29 Another novel finding is that individuals reporting poor health ( > 13 days per month, among our respondents) were more likely to report higher levels of vaccine hesitancy or unwillingness. Although this finding was modest, it is clinically relevant as it speaks to the fact that individuals with a high burden of illness may be a group with whom it is important to address concerns about side effects or the effort required to access the vaccine.

Taken together, these findings point to the importance of addressing COVID vaccine hesitancy or unwillingness in the context of a person's other concerns, especially if they report poor health, socioeconomic stressors, mistrust, anxiety, and/or other signs of ambivalence or uncertainty about vaccination. Previous reports have shown that, for AA/Bs, knowledge about the vaccine in and of itself is not associated with a higher receipt of vaccination. Making an informed choice about vaccination may be based on assessment of the degree of trust in the source of information, rather than on specific content. 30 It is therefore likely to be important to build upon a foundation of trust and rapport, and also focus on addressing concerns and highlighting safety. 11 There is consensus across the literature that AA/Bs and H/Ls value their physician(s) and other health care team members as trusted sources of information (especially relative to other sources such as the media, government, or industr y/phar maceutical companies). Studies have shown that a strong provider recommendation is one of the most potent factors associated with vaccine uptake. 31 Distrust of doctors generally decreases willingness to vaccinate, and this effect is largest among AA/Bs. 11 In addition, high levels of distrust among AA/Bs towards the government, FDA, CDC, and pharmaceutical companies 6 , 32 impacts decision-making about vaccination. 33 In addition to a recommendation from a trusted provider/source, 34 a collaborative communication style has also been shown to help close the gap on disparities in vaccination. 35 , 36 Strategies to optimize collaborative communication at the level of the patient-clinician interaction 35 include making a clear recommendation while engaging with the person's concerns, having a collaborative non-judgmental style, anticipating and responding to ambivalence, and addressing safety and side effect concerns in the context of the individual's health goals and motivations.

It is crucial to consider culturally cong r uent communication and relationship-building approaches. For example, promoting personalismo (valuing and building interpersonal relationships, relational warmth), confianza (trust and familiarity), and simpatía (maintaining politeness and kindness) may be important factors to consider when engaging H/L communities through interventions and interpersonal communications to address COVID-19 vaccine hesitancy and unwillingness. 37 Results from this study also contribute to the recent growing literature emphasizing that strategies to optimize health equity will likely need to be multi-pronged, and will need to intensify community engagement and communitybased interventions as a means for optimizing equitable access to vaccines. 38 , 39 As the National Medical Association's COVID-19 Task Force on Vaccines and Therapeutics states, "Building equity in plans to distribute the vaccines including culturally sensitive, multi-lingual outreach tailored for local communities will be essential for closing gaps in health outcomes." 40 JID: JNMA [mNS; January 25, 2022; 19:22 ] Limitations Study limitations include that this was a cross-sectional survey conducted during a rapidly changing situation; it is possible that the same questionnaire would produce different results at different time points in the course of the pandemic. While 71% of PREPARE participants chose to complete the COVID-19 questionnaire, the respondents represent a convenience sample for this sub-study rather than a random sample of participants in the PREPARE trial. The generalizability of the results of this sub-study may be limited to the characteristics of the PREPARE study participants, though a strength of PREPARE is that it has broad eligibility criteria which allow for the inclusion of many patients typically excluded from asthma studies (e.g., smokers), and has few exclusions for comorbidities. Finally, we lack qualitative data for this sub-study which would have provided a richer understanding for the reasons that participants answered the questions as they did.

During the four-month period in which this survey was administered (May-August, 2020) there was escalating polarization, tension, and ongoing demonstrations around racial injustice in the US and globally, galvanized by increasing national attention to the deaths of many AA/B men and women over the preceding year such as George Floyd, Ahmaud Arbery, Breonna Taylor, and Elijah Mc-Clain. It was also a time of uncertainty and national anxiety about many aspects of COVID, social distancing, economic and unemployment crises, and the vaccine development distribution process. While our survey questions did not explicitly ask about our respondents' views or experiences related to these issues, it is possible that the events that were (and are) ongoing influenced respondents' answers in ways we were unable to fully explore for this substudy.

AA/B and H/L adults with asthma may experience changes in the quality of their asthma care and increased socioeconomic stressors as a result of the COVID-19 pandemic and may be hesitant or unwilling to receive a COVID-19 vaccine. Future studies should explore associations between socioeconomic stressors and asthma outcomes over time and seek to understand and optimize COVID-19 vaccine receptivity in this population.

Research Institute (PCORI) Project Program Award (PCS-1504-30283). All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee. Juan Carlos Cardet's contribution to the manuscript was funded by grant #K23AI125785 from the National Institute of Allergy and Infectious Diseases (NIAID).

Dr. Cardet reports honoraria from Genentech and As-traZeneca for work on their advisory boards, unrelated to this manuscript, Dr. Israel reports personal fees from AB Science, Allergy and Asthma Network, Biometry, Equillium, Merck, NHLBI, 4D Pharma, Pneuma Respiratory, PPS Health, Regeneron, Sanofi Genzyme, and Sienna Biophar maceutical; g rants and personal fees from Amgen, AstraZeneca, Avillion, and Novartis; personal fees and non-financial support from Genentech, GlaxoSmithKline, and TEVA; grants from Gossamer Bio; grants and nonfinancial support from Circassia; non-financial support from Boehringer Ingelheim; and other from Vorso Corp, outside the submitted work. 

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