Preventive Medicine Reports

BackgroundVaccination against COVID-19 will likely involve children in order to mitigate transmission risks in community settings. Successful implementation of COVID-19 immunization in the United States may hinge on factors associated with parents likelihood of immunizing their children and themselves. MethodsWe fielded a national household survey in English and Spanish from June 5-10, 2020 (n=1,008). Parents were asked about their likelihood of immunizing their children and themselves against COVID-19. We fit separate regression models of parents likelihood to vaccinate themselves and their children against COVID-19, using bivariate and multivariable approaches in analyses weighted to be nationally representative. ResultsOverall, 63% of parents (95% CI: 59%, 66%) were likely to vaccinate their children against COVID-19, and 60% (57%, 64%) were likely to get a vaccine themselves. These responses were highly correlated (Pearsons r=0.89). Parent age, sex, marital status, education level, and income were all associated with parents likelihood to vaccinate their children and themselves in bivariate analyses; race/ethnicity was significantly associated with parents likelihood to vaccinate their children. In multivariable analyses, younger parents were significantly less likely than older parents to vaccinate their children and themselves against COVID-19, as were parents with high school or less education compared with parents with bachelors degrees and non-Hispanic White parents compared with Hispanic parents (all p<.05). ConclusionIn this national survey, only approximately 60% of U.S. parents stated that they are likely to vaccinate their children or themselves against COVID-19. Addressing parents hesitancy to vaccinate themselves and their children against COVID-19 will be instrumental to achieving herd immunity in the US.

BackgroundCOVID-19 vaccines have been approved for use in Canada since December 2020. However, data about factors associated with vaccine hesitancy and the impact of mental health and/or substance use (MHSU) issues on vaccine uptake are currently not available. The goal of this study was to explore factors, particularly MHSU factors, that impact COVID-19 vaccination intentions in Ontario, Canada. MethodsA community-based cross-sectional survey with recruitment based on age, gender, and geographical location (to ensure a representative population of Ontario), was conducted in February 2021. Multinomial logistic regression was used to test the relationship between COVID-19 vaccination status and plans and sociodemographic background, social support, anxiety about contracting COVID-19, and MHSU concerns. ResultsOf the total sample of 2528 respondents, 1932 (76.4%) were vaccine ready, 381 (15.1%) were hesitant, and 181 (7.1%) were resistant. Significant independent predictors of vaccine hesitancy compared with vaccine readiness included younger age (OR=2.11, 95%CI=1.62-2.74), female gender (OR=1.36, 95%CI=1.06-1.74), Black ethnicity (OR=2.11, 95%CI=1.19-3.75), lower education (OR=1.69, 95%CI=1.30-2.20), lower SES status (OR=.88, 95%CI=.84-.93), lower anxiety about self or someone close contracting COVID-19 (OR=2.06, 95%CI=1.50-2.82), and lower depression score (OR=.90, 95%CI=.82-.98). Significant independent predictors of vaccine resistance compared with readiness included younger age (OR=1.72, 95%CI=1.19-2.50), female gender (OR=1.57, 95%CI=1.10-2.24), being married (OR=1.50, 95%CI=1.04-2.16), lower SES (OR=.80, 95%CI=.74-.86), lower satisfaction with social support (OR=.78, 95%CI=.70-.88), lower anxiety about contracting COVID-19 (OR=7.51, 95%CI=5.18-10.91), and lower depression score (OR=.85, 95%CI=.76-.96). InterpretationCOVID-19 vaccination intention is affected by sociodemographic factors, anxiety about contracting COVID-19, and select mental health issues.

BackgroundCOVID-19 vaccination rates among children have stalled, while new coronavirus strains continue to emerge. To improve child vaccination rates, policymakers must better understand parental preferences and reasons for COVID-19 vaccination among their children. Methods and FindingsCross-sectional surveys were administered online to 30,174 US parents with at least one child of COVID-19 vaccine eligible age (5-17 years) between January 1 and May 9, 2022. Participants self-reported willingness to vaccinate their child and reasons for hesitancy, and answered additional questions about demographics, pandemic related behavior, and vaccination status. Willingness to vaccinate a child for COVID-19 was strongly associated with parental vaccination status (multivariate odds ratio 97.9, 95% confidence interval 86.9-111.0). The majority of fully vaccinated (86%) and unvaccinated (84%) parents reported concordant vaccination preferences for their eligible child. Age and education had differing relationships by vaccination status, with higher age and education positively associated with willingness among vaccinated parents. Among all parents hesitant to vaccinate their children, the two most frequently reported reasons were possible side effects (47%) and that vaccines are too new (44%). Among hesitant parents, parental vaccination status was inversely associated with reported lack of trust in government (p<.001) and scientists (p<.001). Cluster analysis identified three groups of hesitant parents based on their reasons for hesitance to vaccinate, with distinct concerns that may be obscured when analyzed in aggregate. ConclusionFactors associated with willingness to vaccinate children and reasons for hesitancy may inform targeted approaches to increase vaccination.

BackgroundWell-child visits (WCVs) are critical for preventive counseling but often constrained by limited time and variability in delivery. This study systematically reviews U.S.-based research published between 2014 and 2025 to examine the duration and content of preventive counseling provided during WCVs for children aged 6-12 years, with a particular focus on practitioner communication related to overweight and obesity. MethodsWe conducted a systematic review of U.S.-based studies that was reported in accordance with the PRISMA 2020 guidelines. Comprehensive searches were conducted in MEDLINE (Ovid), Embase (Ovid), and CENTRAL. Two reviewers independently screened titles, abstracts, and full texts, with discrepancies resolved by discussion or a third reviewer. Data was extracted using Covidence with a standardized form, and analyses were conducted in Microsoft Excel. Key variables included counseling content, duration, and delivery approach. ResultAfter screening 2,588 references, seven studies met inclusion criteria. Preventive counseling addressed nutrition, weight management, physical activity, behavioral health, cardiovascular risk, and injury prevention, but coverage was inconsistent, with most studies reporting only a subset. Missed opportunities were common, particularly for cardiovascular risk, injury prevention, and follow-up counseling. No study quantified the duration of individual topics; however, one study reported that visits lasting [&ge;]15-20 minutes were associated with higher odds of counseling on injury prevention (OR = 2.8), nutrition (OR = 3.0), and physical activity (OR = 6.5). Language-concordant care was limited, with interpreters used in only 25% of applicable visits. Two studies described engagement strategies such as motivational interviewing or structured follow-up, and only one reported transdisciplinary care. Notably, one large cohort study linked electronic health record (EHR) documentation of weight management counseling with improvements in child BMI, suggesting that documentation may reflect outcomes despite validity concerns. ConclusionPreventive counseling during pediatric WCV remains inconsistent, often lacking depth and Preventive counseling during pediatric WCVs remains inconsistent, often lacking depth and standardized reporting. Future research should prioritize culturally responsive approaches, team-based care models, and development of standardized metrics for counseling time and content. Addressing language barriers and integrating transdisciplinary teams are essential steps toward delivering equitable, high-quality preventive care, particularly for underserved populations. Trial registrationNot applicable. Systematic review registrationPROSPERO CRD42025064475.

BackgroundRecent evidence suggests that willingness to vaccinate against COVID-19 has been declining throughout the pandemic and is low among ethnic minority groups. MethodsObservational study using a nationally representative longitudinal sample (N =7,840) from the Understanding America Study (UAS). Changes in the percentage of respondents willing to vaccinate, undecided, or intending to refuse a COVID-19 vaccine were examined over 20 survey waves from April 1 2020 to February 15 2021. ResultsAfter a sharp decline in willingness to vaccinate against COVID-19 between April and October 2020 (from 74.0% to 52.7%), willingness to vaccinate increased by 8.1% (p <.001) to 60.8% between October 2020 and February 2021. A significant increase in willingness to vaccinate was observed across all demographic groups examined and Black (15.6% increase) and Hispanic participants (12.1% increase) showed particularly large changes. ConclusionsWillingness to vaccinate against COVID-19 increased in the US from October 2020 to February 2021. Funding statementN/A

BackgroundTo effectively promote vaccine uptake, it is important to understand which people are most and least inclined to be vaccinated and why. PurposeTo identify predictors of COVID-19 vaccine uptake and reasons for non-vaccination. DesignA longitudinal English-language survey study. SettingOnline in December-2020, January-2021, and March-2021. Participants. 930 US respondents (63% Veterans). MeasurementsSurveys included questions about respondents behaviors, well-being, healthcare experiences, and attitudes regarding the pandemic. ResultsThe proportion of respondents who received [&ge;]1-dose of a COVID-19 vaccine increased from 18% in January to 67% in March. Older age predicted vaccine uptake in January (OR=2.02[95%CI=1.14-3.78], p<.001) and March (10.92[6.76-18.05], p<.001). In January, additional predictors of vaccine uptake were higher numeracy (1.48[1.20-1.86], p<.001), COVID-19 risk perceptions (1.35[1.03-1.78], p=.029), and believing it is important that adults get the COVID-19 vaccine (1.66[1.05-2.66], p=.033). In March, additional predictors of vaccine uptake were believing it is important that adults get the COVID-19 vaccine (1.63[1.15-2.34], p=.006), previous (January) COVID-19 vaccine intentions (1.37[1.10-1.72], p=.006), and belief in science (0.84[0.72-0.99], p=.041). Concerns about side effects and the vaccine development process were the most common reasons for non-vaccination. Unvaccinated respondents with no interest in getting a COVID-19 vaccine were younger (0.27[0.09-0.77], p=.016), held negative views about COVID-19 vaccines for adults (0.15[0.08-0.26], p<.001), had lower trust in healthcare (0.59[0.36-0.95], p=.032), and preferred to watch and wait in clinically ambiguous medical situations (0.66[0.48-0.89], p=.007). LimitationsReliance on the accuracy and consistency of self-reported data. ConclusionThese findings offer important insights regarding key predictors of vaccine uptake during the early stages of the COVID-19 vaccine rollout in the US, which can help guide health communications and public outreach. Evidence that attitudes and intentions towards COVID-19 vaccines are important predictors of uptake provides validation for studies which have used these measures and reinforces the need to develop effective strategies for addressing concerns about vaccine safety and development which continue to be at the forefront of vaccine hesitancy. RegistrationThe pre-registration document associated with this manuscript is available at: https://aspredicted.org/MKS_HRZ.

IntroductionAge-group specific disparities for dentalcare use persist in the United States. The COVID-19 led to delays in non-urgent dentalcare. We provide national estimates on dentalcare use and influencing factors for the U.S. population before and during the COVID-19. MethodsWe used nationally representative Medical Expenditure Panel Survey for over pre-COVID-19 years (2018-2019) and COVID-19 years (2020-2021) We estimated yearly survey-weighted trends in mean non-zero dental visits by age followed Poisson regression, controlling for a comprehensive set of confounders across five domains of influence. Dentalcare visits were defined as visits to any dentalcare provider. ResultsOverall analytic sample included non-institutionalized community living persons (unweighted n=6518, weighted N[~]320 million) grouped as ages 0-17, 18-44, 45-64, 65-74 and 75+ present in all four years The prevalence ratio (PR) for dental visits was slightly higher for ages 75+ in comparison to ages 65-74 across years 2018-2021 and increased from 1.73 (95% CI: 1.4, 2.1) to 1.84 (95% CI: 1.5, 2.3) to 2.13 (95% CI: 1.7, 2.7) from 2018 to 2020 but rebounding to near pre-pandemic level in 2021 to 1.66 (95% CI, 1.3, 2.0). Consistent factors during COVID-19 pandemic years 2020-2021 that increased dental visits included dental insurance, high income, and having a usual source of care (p<0.01). ConclusionsDentalcare use rebounded for older adults in 2021 but remained below pre-pandemic levels. Practical ImplicationsIncreasing dentalcare visits across ages remains a key policy priority. Continued monitoring of dentalcare use trends beyond COVID-19 among older adults is critical to improve their oral health.

ObjectivesLung cancer screening (LCS) is the only screening test incorporating behavioral risk factors into eligibility determination. However, collecting necessary smoking history data has been challenging, limiting screening uptake. In this study, we evaluated how a program coordinators detailed shared decision-making (SDM) impacted smoking data reliability. MethodsPatients who underwent a baseline screening low-dose CT between July 31, 2013, and August 25, 2023, were stratified into pre- and post-intervention cohorts. The intervention was a comprehensive pre-CT smoking history assessment with SDM by an LCS program coordinator, implemented on July 31, 2017. We compared the completeness and concordance of smoking history data between clinician and patient self-report. ResultsAmong 3795 patients, 670 (18%) were pre- and 3125 (82%) were post-intervention. Having a coordinator reduced missing smoking data (p<0.001), but did not eliminate it. Both groups showed high concordance between clinician-documented and self-reported smoking status (pre: kappa=0.84, 95% confidence interval [CI] 0.79-0.89; post: kappa=0.84, 95% CI 0.83-0.86). Correlations strengthened for smoking duration (rho=0.71 vs. 0.65, p=0.026) and years since quitting (rho=0.83 vs. 0.80, p=0.21) after involving a coordinator. Correlations for smoking intensity and pack years remained fair (rho<0.6). LCS eligibility based on self-reported smoking history increased from 46.0% (308/670) pre- to 64.1% (2003/3125) post-intervention, below the 100% eligibility using clinician-documented history. ConclusionsSmoking data reliability improved after a dedicated LCS program coordinator implemented a smoking history assessment. Meanwhile, challenges remained with the ascertainment of total pack-years. Detailed probing and patient education may be insufficient to overcome challenges in assessing smoking intensity.

The use of combination therapies*, as well as FDA-approved drugs for off-label indications, to treat advanced cancer, is widespread. While much is known about their clinical effectiveness, there exists no examination of the relative cost of novel multidrug combinations vs. traditional available therapy options, or study as to how knowledge about comparative therapy costs at the point-of-care can be leveraged by doctors, health systems, and payers. We found that: O_LIcombination multidrug cancer regimens may be less costly than monotherapies or other standard options; C_LIO_LInovel, multidrug combinations are often better financial values than monotherapies or other standard options; C_LIO_LIhaving treatment cost and value data, at the point of care, enables the prompt selection of more cost-effective medications and the avoidance of expensive low-value therapies that are financially wasteful. C_LI We conclude that the effectiveness of value-based purchasing initiatives may be amplified if physicians and payers use comparative treatment cost/value data to enhance their cancer drug-selection decision making. * Including combinations of immunotherapies, chemotherapies, targeted drugs with distinct mechanisms of action, etc. SO_SCPLOWTUDYC_SCPLOW HO_SCPLOWIGHLIGHTSC_SCPLOWWhat Is The Current Knowledge On The Topic? {ballotcheck}The effectiveness of molecularly targeted multidrug therapies used to treat advanced cancer is well established; 1-4 that few clinicians are aware of the cost of the medications they prescribe, or which are more cost-effective, deliver a better return-on-investment or represent a financial value; 8 and, that it is intuitive to believe that a combination of multiple high-cost medications is more expensive than a single-drug or other standard therapy options. What Question Did This Study Address? {ballotcheck}Although studies on the clinical impact of multidrug cancer treatments abound, 1-4 there are no examinations of the relative cost or value of combination therapies vs. that of traditional monotherapies, or how knowledge of how this data can be used in practice. A systematic method to calculate, evaluate and compare the relative cost of mono-therapies, 2- and 3-drug combination cancer therapy options is presented for use by physicians, health systems and payers to better manage their oncology specialty pharmacy spend and drive better medical outcomes. 3 What Does This Study Add To Our Knowledge? {ballotcheck}We show that multidrug cancer therapies are not necessarily more costly than single-drug or other standard therapy options; and that furnishing physicians and payers with comparative treatment cost and value data to augment their complex medication selection decision making enables them to identify drugs that are a value, avoid those that are wasteful, and create better targeted novel combination cancer therapies that represent a value, which incorporates both clinical and financial aspects. How Might This Change Combination Therapy Drug Selection Or Value-Based Oncology Management? {ballotcheck}Clinicians have the tools, information, and data with which to confidently prescribe novel drug combinations that customize molecular targeting, and lower treatment costs. Payers now have a framework within which to drive value-based purchasing to gain control of their oncology specialty drug risk. Patients will benefit from more personalized, efficient and effective therapies and less financial toxicity (i.e., distress).

BackgroundThe HPV vaccine provides parents with an opportunity to significantly decrease their childrens future cancer risk. Unfortunately, children face considerable barriers, including stigma and hesitancy, to completing the HPV vaccine schedule. These barriers have contributed to lower HPV vaccination completion rates in rural communities. Although general vaccine hesitancy grew during the pandemic, whether rising vaccine hesitancy further widened rural HPV vaccination gaps remains unknown. Focusing on Iowa, a state with the fastest rising incidence of HPV-associated cancer, we evaluated if county-level COVID-19 vaccination rates corresponded to county-level changes in rural-urban HPV vaccination completion trends. MethodsWith data from the Iowa Department of Health and Human Services (2017-2024), we analyzed annual, county-level sex-stratified HPV vaccination completion rates. Rates were reported as a proportion of the 13-15-year-old population. In addition to evaluating overall trends, we grouped counties by rural/urban status and above/below median COVID-19 vaccination rates. We then constructed population-weighted, two-way fixed effect panel regression models testing if HPV vaccination completion rates changed after year 2020; and whether these changes varied by rurality and COVID-19 vaccination rates. ResultsOverall, HPV vaccination completion rates increased 5.5%-points (CI = 4.5, 6.5) after 2020 in females and 7.1%-points (CI = 6.0, 8.1) in males. In females, there was no increase after 2020 in HPV vaccine completion in counties with below median COVID-19 vaccine rates (Urban = -0.2%-points, CI = -3.3, 3.3; Rural = 2.9, CI = -0.8, 6.7). In males, the increase after 2020 in HPV vaccine completion rates were consistent across all counties, but lowest in rural counties regardless of COVID-19 vaccine uptake (Above Median = 0.025, CI = 0.010, 0.042; Below Median = 0.027; CI = 0.011, 0.043). ConclusionsIn Iowa, the dynamic post-pandemic HPV vaccination completion trends warrant interventions that address multiple factors driving unique contributors to incomplete HPV vaccination adherence.

ImportanceEfficient distribution and administration of vaccines are critical to preventing unnecessary morbidity and mortality. We assess the distribution, uptake, and wastage of COVID-19 vaccine doses across the U.S., providing insights for optimizing future vaccination distribution strategies. ObjectiveWe evaluate the distribution, uptake, and wastage of COVID-19 vaccine doses in the U.S. Specifically, we quantify the impact of limiting vaccine wastage and illustrate incidence and deaths averted under two targets set by the Global Alliance for Vaccines and Immunization (GAVI). Design and SettingWe obtained COVID-19 vaccine doses administered by location and wastage data from jurisdictions, pharmacies, and federal entities from the Centers for Disease Control and Prevention through a Freedom of Information Act. From this data, a retrospective analysis covering the period from December 2020 to October 2022 involving 761 million vaccine doses distributed across all counties and states in the U.S. We estimate the proportion of vaccines wasted, and then incidence and deaths averted had adherence to GAVI waste targets occurred to inform on the quality of the national vaccination effort and identify potential regions for improvement. ExposureVaccine uptake and waste vary substantially across states, as measured by doses administered per capita. GAVI targets of 25% and 15% vaccine waste serve as benchmarks for assessing the impact of potential improvements in vaccine distribution and acceptance. Main outcomes and measuresThe identification of within and across-state variation in COVID-19 vaccine waste relative to GAVI targets and their implications on morbidity and mortality. ResultsAmong the 761 million distributed doses, only 600 million were administered, resulting in a national average of 1.8 doses per capita. Substantial regional disparities were observed, with the District of Columbia reaching 2.5 doses per capita and Alabama lagging at 1.3 doses per capita. Thirty states exceeded the GAVI 15% vaccine waste target, corresponding to 64.2 million unused doses. Meeting the 15% target would have averted 29,669,318 incidences and 6,468 deaths. Conclusion and relevanceAddressing the causes of county-level variations and targeting states with below-average vaccine hesitancy and above-target vaccine waste would likely maximize future vaccine distribution efforts and minimize wastage-related losses. This strategy highlights an avenue for improving future vaccine distribution policy. KEY POINTS QuestionIn what areas of domestic vaccine allocation could improvements be made to reduce vaccine waste? What impact could reducing vaccine waste have had on lowering both COVID-19 incidence rates and mortality rates? FindingsBetween December 2020 and October 2022, the U.S. wasted approximately 25.4 million COVID-19 vaccine doses. Reducing waste to under 25% could have averted 1.3 million COVID-19 cases and an estimated 1,570 deaths over that period. Waste was associated with hesitancy, rurality, and prevalent political affiliation. MeaningThis counterfactual exercise underscores the importance of addressing vaccine wastage to mitigate COVID-19 incidence and its associated fatalities.

IntroductionAmong adults who test positive for COVID-19, some develop long COVID (symptoms lasting [&ge;]3 months), and some do not. We compared 3 groups on selected measures to help determine strategies to reduce COVID impact. MethodsUsing Stata and data for 385,617 adults from the 2022 Behavioral Risk Factor Surveillance System, we compared adults reporting long COVID, those with just a positive test, and those who never tested positive, on several health status and risk factor measures plus vaccination rates (data for 178,949 adults in 29 states). ResultsPrevalence of just COVID was 26.5% (95% CI 26.2-26.8) and long COVID was 7.4% (7.3-7.6). Compared with adults with just COVID those with long COVID had worse rates for 13 of 17 measures of chronic disease, disability, and poor health status, while those with just COVID had the best results for 15 of the 17 measures among all 3 groups. The 5 risk factors (obesity, diabetes, asthma, cardiovascular disease, and COPD) previously associated with COVID deaths, increased long COVID but not just COVID rates, which were highest among younger and higher income adults. Adults with long COVID had the highest rate among the 3 groups for any COVID risk factors and data from 29 states showed they had the lowest rates for [&ge;]3 vaccine doses of 35.6%, vs. 42.7% and 50.3% for those with just a positive test, and neither, respectively. Vaccination with [&ge;]3 vaccines vs. <3 reduced long COVID rates by 38%, and just COVID rates by 16%. ConclusionsResults show the seriousness of long COVID vs. just a positive test and that increasing vaccine coverage by targeting adults with risk factors shows promise for reducing COVID impact.

BackgroundIn 1990, two risk factors that would figure prominently in the COVID-19 pandemic were on divergent paths in the US. The smoking rate was 23.5% and dropped to 13.5% in 2021, while the obesity rate was 11.5% and increased 186% to 33.0%. ObjectiveThe study objective was to compare the global impact of those risk factors on COVID deaths to help prepare the US for future pandemics. MethodsStata and Excel were used to regress global COVID deaths on obesity and smoking before and after vaccines were available, and US deaths/day were compared pre-and post-vaccines. ResultsObesity was associated with global COVID deaths, with R2 as high as 0.87 for cumulative data with slightly lower R2 and coefficients for post-vaccines. For 9 regressions of deaths on obesity, all P values (overall and coefficients) were <0.05 while for regressions on smoking, no P values were < 0.05. Of the 1.1 million US deaths, the death rate/day post-vaccines was 59% of that pre-vaccines. If the US obesity rate had remained 11.5%, estimates suggest 800,000+ lives could have been saved. US smoking rate was reduced 42% by multiple strategies using support from a 1998 multi-billion-dollar settlement between states and tobacco companies. ConclusionVaccines have limited ability to reduce total COVID deaths, with obesity remaining a key factor in death rates. Results suggest that lower obesity rates are needed to further reduce US COVID deaths, potentially saving thousands of lives in future pandemics. Lessons from reducing smoking rates might prove useful.

IntroductionTo assess vaccine acceptance among adults living in a largely rural Southern state. MethodsData were collected between October 3 and October 17, 2020 using random digit dialing. Participants included residents aged 18+, able to understand English or Spanish, and provide informed consent. The primary outcome was a multi-dimensional COVID-19 vaccine acceptance measure. Scores varied between -3 to +3. ResultsThe sample (n=1,164) was weighted to be representative of the states population. Black participants had the lowest overall vaccine acceptance (0.5) compared to White participants (1.2). Hispanic participants had the highest scores (1.4). In adjusted models, Black participants had 0.81 points lower acceptance than White participants, and Hispanic participants had 0.35 points higher acceptance. Hispanic participants had the highest scores for all five vaccine acceptance dimensions, relatively equivalent to White participants. Black participants had consistently lower scores, especially perceived vaccine safety (mean -0.2, SD 0.1). ConclusionsThe lowest vaccine acceptance rates were among Black participants particularly on perceived vaccine safety. While Black participants had the lowest acceptance scores, Hispanic participants had the highest. This variability shows the value of a multi-dimensional vaccine acceptance measure to inform COVID-19 vaccination campaign strategies.

IntroductionEarly COVID-19 vaccine acceptance rates suggest that up to one-third of HCWs may be vaccine-hesitant. However, it is unclear whether hesitancy among HCWs has improved with time and if there are temporal changes whether these differ by healthcare worker role. MethodsIn October 2020, a brief survey was sent to all participants in the Healthcare Worker Exposure Response and Outcomes (HERO) Registry with a yes/no question regarding vaccination under emergency use authorization (EUA): "If an FDA emergency use-approved vaccine to prevent coronavirus/COVID-19 was available right now at no cost, would you agree to be vaccinated?" The poll was repeated in December 2020, with the same question sent to all registry participants. Willingness was defined as a "Yes" response, and hesitancy was defined as a "No" response. Participants were stratified into clinical care roles. Baseline demographics of survey respondents at each timepoint were compared using appropriate univariate statistics (chi-squared and t-tests). Analyses were descriptive, with frequencies and percentages reported for each category. ResultsOf 4882 HERO active registry participants during September 1 - October 31, 2020, 2070 (42.4%) completed the October survey, and n=1541 (31.6%) completed the December survey. 70.2% and 67.7% who were in clinical care roles, respectively. In October, 54.2% of HCWs in clinical roles said they would take an EUA-approved vaccine, which increased to 76.2% in December. The largest gain in vaccine willingness was observed among physicians, 64.0% of whom said they would take a vaccine in October, compared with 90.5% in December. Nurses were the least likely to report that they would take a vaccine in both October (46.6%) and December (66.9%). We saw no statistically significant differences in age, race/ethnicity, gender, or medical role between time points. When restricting to the 998 participants who participated at both time points, 69% were vaccine-willing at both time points; 15% were hesitant at both time points, 13% who were hesitant in October were willing in December; and 2.9% who were willing in October were hesitant in December. ConclusionsIn a set of cross-sectional surveys of vaccine acceptance among healthcare workers, willingness improved substantially over 2 calendar months during which the US had a presidential election and two vaccine manufacturers released top-line Phase 3 trial results. While improved willingness was observed in all role categories, nurses reported the most vaccine hesitancy at both time points.

BackgroundIf access to Medicaid improves health outcomes, it may also result in lower long-term spending, however the association between Medicaid expansion and Medicare spending is unknown. In this analysis we sought to investigate the association between Medicaid expansion and per capita Medicare spending at the county level. MethodsThis is an observational analysis of all U.S. counties in the ten years from 2010 to 2019. We used a difference-in-difference event study to investigate the difference in per capita Medicare spending between counties in states that expanded Medicaid and counties in states that did not expand Medicaid. The exposure was treatment year, which characterized whether a county was in an expansion state and when expansion occurred. In non-expansion counties, treatment year was assigned 0 for all observations. In expansion counties, treatment year ranged from -3 to +6, with treatment year 1 corresponding to the first full year of expansion. The primary outcome was fee-for-service Medicare spending per capita in each county. A secondary analysis investigated subcategories of per capita spending including inpatient, outpatient, skilled nursing care, inpatient rehabilitation, home health, and hospice care. ResultsWe analyzed 1,648 expansion and 1,494 non-expansion counties, with ten observations per county, one for each year between 2010 and 2019. In the adjusted event study analysis, the difference between expansion and non-expansion counties in expansion year 5 compared to pre-expansion was -200 [95% Confidence Interval (CI): -406, 6] dollars. In the subcategory analysis, the difference in inpatient care, skilled nursing care, outpatient care, and home health spending were -46 [95% CI: -103, 12], -92 [95% CI: -194, 11], 57 [95% CI: -67, 181], and 55 [95% CI: -17, 126] dollars per capita respectively. ConclusionsMedicaid expansion is not consistently significantly associated with lower Medicare spending compared to pre-expansion. However, observed trends towards lower spending and cost-shifting from inpatient to outpatient settings in expansion counties warrant additional investigation.

ObjectivesTo examine associations between cardiometabolic conditions and health-related quality of life (HRQoL) and to evaluate whether condition-associated HRQoL changed from 2001 to 2022. MethodsWe analyzed nationally representative data from U.S. adults aged [&ge;]18 years in the Medical Expenditure Panel Survey, 2001-2022. Survey years without BMI data (2017, 2019, 2021) were excluded. EQ-5D utilities were mapped from SF-12 scores using a validated algorithm. For each survey year, survey-weighted multivariable regression models estimated associations of sociodemographic characteristics, BMI, and cardiometabolic conditions (diabetes, heart disease, high blood pressure, high cholesterol, obesity, stroke) with HRQoL measured by EQ-5D. Temporal changes in condition-associated HRQoL decrements were assessed using meta-regression across years. Associations in recent survey years were summarized using pooled estimates from 2015, 2016, 2018, and 2022. ResultsOverall HRQoL improved from 2001 to 2022 across age groups, with the largest improvement among older adults. In pooled analyses, stroke was associated with the largest adjusted HRQoL decrement (-0.0714), followed by heart disease (-0.0503), diabetes (-0.0427), high blood pressure (-0.0328), obesity (-0.0305), and high cholesterol (-0.0236). Additional adjustment for BMI attenuated condition-associated decrements, most notably for obesity (-0.0305 to -0.0183), diabetes (-0.0427 to -0.0414), and high blood pressure (-0.0328 to -0.0316). Over time, diabetes- and heart disease-associated decrements attenuated linearly (diabetes: - 0.0489 in 2001 to -0.0406 in 2022; heart disease: -0.0591 to -0.0493). High blood pressure (-0.0337 in 2001, -0.0415 in 2012, -0.0306 in 2022) and obesity (-0.0305 in 2001, -0.0283 in 2012, -0.0367 in 2022) showed nonlinear patterns. ConclusionsCondition-associated HRQoL decrements varied over time, and recent-year utility estimates are recommended for population health research. HRQoL decrements for diabetes and heart disease attenuated, consistent with improvements in treatment and survival. High blood pressure-associated were lowest around 2012, and obesity-associated became more negative after 2012, consistent with worsening blood pressure control and obesity severity.

BackgroundThe estimates of economic burden due to smoking attributed illnesses provide an opportunity to assess its overall impact on the economy and generate evidence for public health policy interventions for tobacco control. In this study, we estimated out of pocket expenditures on tobacco attributed illnesses and smoking attributable burden in Pakistan. MethodsWe used a prevalence-based disease-specific cost approach by including three major tobacco attributed illnesses i.e. lung cancer, chronic obstructive pulmonary disease, and cardiovascular diseases. Our analysis included out of pocket healthcare expenditures including direct and indirect costs which were estimated by interviewing the patients of selected illnesses. The smoking-attributable expenditure was calculated by the WHO tool kit. ResultsIn 2018, the economic burden attributed to smoking related illnesses was Rs 192 billion (USD 1.3 billion). Smoking-attributable expenditure on cardiovascular disease was Rs 123 billion (USD 0.9 billion) which was 69% of the total economic cost of tobacco attributed illnesses in Pakistan. The economic cost in males was nearly three times higher than females. ConclusionsOur study showed a significant economic burden due to tobacco attributed illnesses in Pakistan which can be prevented by implementing tobacco control policies effectively.

BackgroundDespite their potential to serve as a reduced-harm alternative to combustible tobacco, e-cigarette take-up remains low among older (45+) adult smokers, especially in the U.S. While social media is a known driver of vaping attitudes and behaviors in younger populations, its influence on older smokers is poorly understood. This paper provides the first focused analysis of e-cigarette-related social media exposure in this population, documenting its prevalence, characteristics, and attitudinal correlates. MethodsData come from an opt-in survey of U.S. adults (N = 974) recruited via Prolific, comprising three groups: (i) non-vaping smokers aged 45+ (N = 484), (ii) former-smoking vapers aged 45+ (N = 149), and (iii) any-vaping-status smokers aged 18-35 (N = 341). Descriptive statistics, weighted to U.S. population benchmarks, characterize self-reported exposure to e-cigarette-related content on social media. Logistic regressions estimate associations between exposure and intentions for future e-cigarette use, e-cigarette harm perceptions, and related attitudes. ResultsOlder smokers (35.3%) reported exposure to e-cigarette-related content on social media less frequently than both older vapers (44.0%) and younger smokers (72.0%). For older smokers, e-cigarette health risks were the most frequently reported topic of content viewed, followed by youth vaping and e-cigarette addiction. Among this group, exposure was positively associated with stated intentions for future e-cigarette use. Exposure was not significantly associated with perceived e-cigarette harms for any group. ConclusionsFindings provide suggestive evidence that social media exposure may promote e-cigarette adoption among older smokers. However, the cross-sectional design limits causal inference, and the observed associations may reflect selection bias or reverse causality. If a causal relationship exists, the patterns observed suggest that exposure influences e-cigarette adoption through mechanisms other than updating beliefs about e-cigarette risks. While these results tentatively support the potential of social media as a channel for older-smoker harm reduction, any policy applications must carefully weigh privacy concerns and risks to youth. Rigorous experimental studies are needed to confirm these findings and clarify how social media might be leveraged to improve public health outcomes among older smokers.

ImportanceAlthough widespread vaccination will be the most important cornerstone of the public health response to the COVID-19 pandemic, a critical question remains as to how much of the United States population will accept it. ObjectiveDetermine: 1) rate of COVID-19 vaccine hesitancy in the United States public, 2) patient characteristics associated with hesitancy, 3) reasons for hesitancy, 4) healthcare sites where vaccine acceptors would prefer to be vaccinated. Design43-question cross-sectional survey conducted November 17-18, 2020, distributed on Amazon Mechanical Turk, an online labor marketplace where individuals receive a nominal fee (here, $1.80) for anonymously completing tasks. Eligible ParticipantsUnited States residents 18-88 years of age, excluding healthcare workers. A total 1,756 volunteer respondents completed the survey (median age 38 years, 53% female). Main Outcome MeasureMultivariable logistic regression modeled the primary outcome of COVID-19 vaccine hesitancy (defined as non-acceptance or being unsure about acceptance of the COVID-19 vaccine) with respondent characteristics. ResultsA total 663 respondents (37.8%) were COVID-19 vaccine hesitant (374 [21.3%] non-acceptors and 289 [16.5%] unsure about accepting). Vaccine hesitancy was associated with not receiving influenza vaccination in the past 5 years (odds ratio [OR] 4.07, 95% confidence interval [CI] 3.26-5.07, p<0.01), female gender (OR 2.12, 95%CI 1.70-2.65, p<0.01), Black race (OR 1.54, 95%CI 1.05-2.26, p=0.03), having a high school education or less (OR 1.46, 95%CI 1.03-2.07, p=0.03), and Republican party affiliation (OR 2.41, 95%CI 1.88-3.10, p<0.01). Primary reasons for hesitancy were concerns about side effects, need for more information, and doubts about vaccine efficacy. Preferred sites for vaccination for acceptors were primary doctors offices/clinics, pharmacies, and dedicated vaccination locations. ConclusionsIn this recent national survey, over one-third of respondents were COVID-19 vaccine hesitant. To increase vaccine acceptance, public health interventions should target vaccine hesitant populations with messaging that addresses their concerns about safety and efficacy.