key: cord-1011649-inspc6gy authors: Mercadante, Amanda R.; Chu, Vivian; Chen, Aleda M. H.; Wong, Jason C.; Khare, Manorama M.; Law, Anandi V. title: COVID‐19 behavioral questionnaire (CoBQ): Comparing the pandemic's impact on health behavior in three US states date: 2022-04-30 journal: J Am Coll Clin Pharm DOI: 10.1002/jac5.1625 sha: bb4d1aa41c59337aa6bf734dc8015c2e09794dc3 doc_id: 1011649 cord_uid: inspc6gy BACKGROUND: The COVID‐19 pandemic impacted daily routines for a majority of the population, with implications for their health behaviors. Racial and ethnic minorities have been disproportionately impacted by COVID‐19. The novel COVID‐19 Behavioral Questionnaire (CoBQ) was developed in Fall 2020 to provide a means to measure the impact of the COVID‐19 pandemic on the United States population. The study utilized behavioral domains to determine which demographic groups reported that they were made the most vulnerable during Fall‐Winter 2020–2021 of the pandemic. OBJECTIVES: The study aimed to further validate and test the CoBQ in varied US regions and compare the scores obtained from three states, California, Ohio, and Illinois. METHODS: A prospective, multi‐site survey‐based study was designed to further validate and test the 17‐item CoBQ in varied populations. Respondents included patients on routine visits at each pharmacy or clinical site who agreed to complete the survey online via Qualtrics. Data analyses included descriptive statistics, psychometric testing, and comparison of groups using Analysis of Variance. RESULTS: Completed surveys (n = 507) between October 2021 and March 2021 were analyzed. Respondents were mostly female, white, and had some college education. The CoBQ showed improved reliability compared with previous testing and strong construct validity through factor analysis. Overall scores were similar between three states. The most impacted groups included those who reported within the 18–49 age group, a yearly household income <$50 000, or education up to high school. CONCLUSIONS: The CoBQ is the first validated tool to measure the negative impact of the COVID‐19 pandemic on health behaviors. Results could serve as a baseline to address the most vulnerable patient groups and support identified behavioral needs during a similar pandemic situation. As of January 2022, the coronavirus 2019 (COVID-19) pandemic has affected more than 72 million people and caused more than 870 000 deaths in the United States (US). 1 The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) recommended preventative measures such as mask mandates, hand hygiene, and social distancing to curb the spread of this virus. Additional public health recommendations to prevent COVID-19 spread and infection included avoiding crowds, self-isolation, and getting vaccinated when eligible. 2, 3 These measures had a positive impact, reducing infection rates, subsequent hospitalizations, and deaths. [4] [5] [6] However, these measures also resulted in people staying at home, working from home, and subsequently facing isolation. [7] [8] [9] Routines for many people, especially families with children, shifted due to the sudden closure of schools, daycares, recreational services, and workplaces during the COVID-19 pandemic. 10, 11 In addition, the COVID-19 pandemic altered the availability and delivery of outpatient medical care services and affected the health-seeking behaviors of patients. [12] [13] [14] [15] Health care systems were overwhelmed during the pandemic with the demand on the health care workers to handle high volumes of COVID-19 related emergencies and hospitalizations. Resources such as hospital beds, personal protective equipment (PPE), life-support devices, and medications were redirected toward these services. 16 Many health care institutions reduced or stopped nonurgent procedures and care during this time. 17 Patients with chronic conditions delayed regular healthcare visits; about 41% of US adults missed planned medical visits from March to July 2020, primarily due to medical practice closure, financial repercussions of the pandemic, and fear of COVID-19 infection. 18 During the second quarter of 2020, primary care visits decreased by 21.4% in the US. 19 According to WHO, health behavior is defined as any action taken by an individual who affects health maintenance. 20 Health behaviors are determined by a blend of factors such as income, education, health beliefs, access to healthcare, and physical environment. 21 Examples of health behaviors include physical activity, dietary habits, substance use, sleep, health-seeking behavior, and adherence to medical recommendations. 22 Much of these health behaviors, as well as access to care, were adversely impacted during the COVID-19 pandemic. For example, adults under the age of 50, women, and those with moderate to severe depression were more likely to exhibit less than optimal health behaviors in the US. 23 One poll published in April 2021 by the Kaiser Family Foundation reported younger adults and women (especially mothers) were affected the most by the current pandemic in terms of negative mental health impact. 24 When examining ethnicity, communities of color have been disproportionately affected by COVID-19 and generally are noted to have barriers to accessing health care. 25, 26 There were reports during the COVID-19 pandemic of unexpected health care behaviors (eg, increase in alcohol consumption, smoking, decreased exercise, increased eating). 27 For example, a recent study conducted in the United Kingdom suggested social lockdown led to higher rates of overeating and decreased physical activity for those with a negative mental health condition during the pandemic. 28 The combined impact of delayed regular health care visits and poor health behavior had consequences on patients' quality of life in the physical, emotional, and social domains. 29 Evidence from past outbreaks, such as severe acute respiratory syndrome (SARS) and H1N1, have emphasized important predictors of health behaviors such as public awareness, beliefs toward preventative behaviors, perceived disease severity, and perceived susceptibility to illness. 30, 31 Tools were developed to measure the impact of the COVID-19 pandemic on health behaviors, but were notably complex to administer, had not been tested for validation, or did not address COVID-19 challenges other than lifestyle-related behaviors. 32, 33 The COVID-19 Behavioral Questionnaire, also referred to as the CoBQ, is a tool that was developed by the authors (ARM and AVL) to assess the impact of the COVID-19 pandemic on the health behaviors of the US population. The initial 18-item CoBQ was devel- A prospective, multi-site survey-based study was designed to further validate and test the 17-item CoBQ in varied populations from CA, OH, and IL. The survey included the CoBQ and demographic items to determine respondent health behavior during the COVID-19 pandemic. Patientreported outcomes included the CoBQ score based on a 4-item Likert The study required a minimum of 30 respondents per state for comparative analysis and determined that a total of 377 respondents would provide a 95% confidence interval with 5% margin of error (Raosoft)." Respondents were obtained through convenience sampling at the pre- health. 33 The CoBQ has also demonstrated robustness in psychometric properties with relation to region and timing, which supports its generalizability. The utility of this tool is its ability to provide the insight needed for health care workers and policy makers to properly address vulnerable populations and predict patient needs during a COVID-19 outbreak. With communities of color and other vulnerable populations experiencing disparities along with being at greater risk of the negative consequences of COVID-19, it may be important to identify the challenges patients face and promote health equity. 35 By utilizing a questionnaire such as the CoBQ, healthcare providers could potentially connect patients with specific resources to address their needs rather than making assumptions of their needs. Through follow-up conversations and dialogue, providers could build long-term relationships with patients who further promote health equity. 36, 37 Further research could explore the utility of this tool in patient-provider encounters and include training of providers on how best to address the areas of concerns identified. While recruitment was intended to reach patients who utilized pharmacies and clinical sites, there may have been selection bias due to requirements of understanding English in OH and IL sites and technological requirements. Self-selection could also have occurred from respondents who are more engaged with their health and willing to respond to a lengthy survey. Access to the survey was limited at certain sites; most locations required their respondents to use an internet connection and mobile, tablet, or computer device to participate. All potential respondents may not have been given an equal chance to participate due to the inability to discuss the study at busier times and the prioritization of pharmacy and clinical services. The study fell short in its ability to recruit a range of ethnicities and access to medical care; this is possibly explained by convenience sampling and characteristics of the majority of respondents within each state (eg, percentage of self-reported as white: 72% in Illinois and 81% in Ohio). 38, 39 The study did, however, achieve a multi-regional diversity in education, age, and gender identity. The CoBQ is the first documented reliable and valid tool that measures the negative impact of the COVID-19 pandemic on individuals' health behavior. This tool could be used as a standard measure in the US to explore COVID-19 or similar outbreaks. It could also be adapted to examine the impact on populations outside of the US who are still experiencing high infection rates of COVID-19. The CoBQ has the ability to inform healthcare systems and policymakers to best support patients' health behaviors. Centers for Disease Control and Prevention. 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Examining patients' vaccine intention for flu and COVID-19 using the health belief model Health equity considerations and racial and ethnic minority groups What we can do to promote health equity Patient-centered care starts with patient-provider communication World Population Review. Illinois population 2021 World Population Review. Ohio population 2021 COVID-19 behavioral questionnaire (CoBQ): Comparing the pandemic's impact on health behavior in three US states The authors would like to thank all sites and respondents for participating in the completion of this questionnaire. The authors declare no conflicts of interest.