Supplementary Figure from The Timing, the Treatment, the Question: Comparison of Epidemiologic Approaches to Minimize Immortal Time Bias in Real-World Data Using a Surgical Oncology Example

The alarming rising incidence of colorectal cancer (CRC) among individuals younger than 50 years (early-onset CRC) underscores the need to identify the genetic drivers to improve personalized clinical management and outcomes. The objective of this study was to characterize the somatic mutation profile of early-onset tumors from Hispanics living in Puerto Rico (HPR), a U.S. Hispanic subpopulation with a high CRC burden. Whole exome sequencing was performed using the HiSeq4000 System (Illumina) on colorectal adenocarcinoma and corresponding mucosa samples from 62 individuals with non-familial, sporadic early-onset CRC and 25 diagnosed with average-onset CRC ( >60 years old). Somatic variant calling and annotation/visualization were performed with Strelka and Ingenuity Variant Analysis software, respectively. Mutational frequency in APC, TP53, KRAS, and SMAD4 was compared to data in TCGA and AACR Project GENIE. The mutational burden in early-onset CRC tumors from HPR was comparable to average-onset tumors. However, mutations in APC (p = 0.015), PIK3CA (p = 0.03), TP53BP1 (p = 0.03), and MUC16 (p = 0.02) were more common in average-onset tumors. The aflatoxin exposure signature (SBS24) was only identified in early-onset tumors, with 22.4% showing a signature fraction >10%. When compared to data on tumors in the TCGA and GENIE datasets, early-onset CRC tumors from HPR showed a distinct somatic mutational frequency in key driver genes. Early-onset CRC tumors display distinct somatic mutational profile compared to average-onset tumors. Additional studies with larger, diverse samples are crucial for understanding the population-specific underlying mechanisms leading to early-onset disease. Maria Gonzalez-Pons, Julie Dutil, Ingrid Montes-Rodríguez Montes-Rodríguez, Luis D. Borrero-Garcia, Lenis Rovira-Torres, Leslie Casiano, Anna M. Napoles, Jung S. Byun, Eliseo Perez-Stable, Kevin L. Gardner, Marcia Cruz-Correa. Somatic mutations in early-onset colorectal cancer: insights from a U.S. Hispanic cohort [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: The Rise in Early-Onset Cancers—Knowledge Gaps and Research Opportunities; 2025 Dec 10-13; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(23_Suppl):Abstract nr C024.

OBJECTIVE Diabetes is a leading cause of death in the U.S. Previous studies have found substantial racial, ethnic, and geographical disparities in diabetes mortality; however, research considering racial, ethnic, and geographical disparities simultaneously has been limited. To fill this gap, we estimated trends in diabetes mortality rates from 2000 to 2019 at the county level for five racial and ethnic populations.RESEARCH DESIGN AND METHODS We applied small-area estimation methods to death registration data from the U.S. National Vital Statistics System and population data from the U.S. National Center for Health Statistics and corrected for misclassification of race and ethnicity on death certificates.RESULTS Age-standardized diabetes mortality rates decreased in the U.S. from 28.1 deaths per 100,000 (95% uncertainty interval 27.9-28.2) in 2000 to 19.1 deaths per 100,000 (19.0-19.2) in 2019. In 2019, national-level rates were highest for the American Indian or Alaska Native (AIAN) population (35.6 [32.1-39.4]), followed by the Black (31.9 [31.5-32.3]), Latino (19.7 [19.3-20.2]), White (17.6 [17.5-17.8]), and Asian (12.6 [12.1-13.1]) populations. There was substantial heterogeneity in diabetes mortality rates across counties within each racial and ethnic population, with the AIAN population experiencing the greatest heterogeneity in 2019 (interquartile range 18.7-50.3 [median 31.9]). For each racial and ethnic population, mortality rates declined in most counties from 2000 to 2019.CONCLUSIONS Since 2000, progress has been made in reducing diabetes mortality rates. Nonetheless, diabetes mortality remains too high for many Americans. Interventions focusing on communities at highest risk are vital to resolving persistent health inequities.

To estimate overall and racial/ethnic-specific associations between COVID-19 infection status and sleep health. We analyzed online survey data collected from December 2020 to February 2021 among Asian, Black, Latino (English- and Spanish-speaking), and White adults (n = 1,000 each), along with American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and multiracial adults (n = 500). COVID-19 infection (confirmed, probable, suspected), based on self-reported data on symptoms and infected contacts, was classified using World Health Organization definitions. Sleep disturbances were categorized as “yes” (mild/moderate/severe) vs “no” (normal). Weighted analyses were used to generate nationally representative estimates within each racial/ethnic group. Adjusting for sociodemographic and health behaviors, Poisson regression with robust variance estimated prevalence ratios and confidence intervals for sleep disturbances among individuals with vs without a COVID-19 infection in the overall population and by gender, ability to get health care, and race/ethnicity. Among 5,359 eligible participants, 24

Background Understanding how specific populations are affected by liver cancer is important for identifying priorities, policies, and interventions to mitigate health risks and reduce disparities. This study aims to provide comprehensive analysis of rates and trends in liver cancer mortality for different racial and ethnic populations in the USA nationally and at the county level from 2000 to 2019. Methods We applied small-area estimation methods to death registration data from the US National Vital Statistics System and population data from the US National Center for Health Statistics to estimate liver cancer mortality rates by county, racial and ethnic population, and year (2000-19) in the USA. Race and ethnicity were categorised as nonLatino and non-Hispanic American Indian or Alaska Native (AIAN), non-Latino and non-Hispanic Asian or Pacific Islander (Asian), non-Latino and non-Hispanic Black (Black), Latino or Hispanic (Latino), and non-Latino and nonHispanic White (White). Estimates were adjusted using published misclassification ratios to correct for inaccuracies in race or ethnicity as recorded on death certificates, and then age-standardised. Mortality rate estimates are presented for all county and racial and ethnic population combinations with a mean annual population greater than 1000. Findings Nationally, the age-standardised liver cancer mortality rate increased between the years 2000 (42 deaths per 100 000 population [95% uncertainty interval 41-43]) and 2016 (60 per 100 000 [59-61]), followed by a stabilisation in rates from 2016 to 2019 (61 per 100 000 [60-62]). Similar trends were observed across the AIAN, Black, Latino, and White populations, whereas the Asian population showed an overall decrease across the 20-year study period. Qualitatively similar trends were observed in most counties; however, the mortality rate and the rate of change varied substantially across counties, both within and across racial and ethnic populations. For the 2016-19 period, mortality continued to increase at a substantial rate in some counties even while it stabilised nationally. Nationally, the White population had the lowest mortality rate in all years, while the racial and ethnic population with the highest rate changed from the Asian population in 2000 to the AIAN population in 2019. Racial and ethnic disparities were substantial: in 2019, mortality was highest in the AIAN population (105 deaths per 100 000 [91-120]), notably lower for the Asian (75 per 100 000 [71-79]), Black (76 per 100 000 [73-78]), and Latino (77 per 100 000 [75-80]) populations, and lowest for the White population (55 [54-56]). These racial and ethnic disparities in mortality were prevalent throughout the country: in 2019, mortality was higher in minoritised racial and ethnic populations than in the White population living in the same county in 408 (877%) of 465 counties with unmasked estimates for the AIAN population, 604 (906%) of 667 counties for the Asian population, 1207 (812%) of 1486 counties for the Black population, and 1073 (730%) of 1469 counties for the Latino population. Interpretation Although the plateau in liver cancer mortality rates in recent years is encouraging, mortality remains too high in many locations throughout the USA, particularly for minoritised racial and ethnic populations. Addressing population-specific risk factors and differences in access to quality health care is essential for decreasing the burden and disparities in liver cancer mortality across racial and ethnic populations and locations. Funding US National Institutes of Health (Intramural Research Program, National Institute on Minority Health and Health Disparities; National Heart, Lung, and Blood Institute; Intramural Research Program, National Cancer Institute; National Institute on Aging; National Institute of Arthritis and Musculoskeletal and Skin Diseases; Office of Disease Prevention; and Office of Behavioral and Social Sciences Research). Copyright (c) 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

In the United States, COVID-related discrimination towards racial and ethnic minority populations is well documented; however, its impact on healthcare access during the pandemic has not been assessed. We used data from our nationally representative, online survey of 5,500 American Indian/Alaska Native (AIAN), Asian, Black, Native Hawaiian/Pacific Islander, Latino, White, and multiracial adults conducted between 12/2020–2/2021 (baseline) and 8/2021–9/2021 (6-month follow-up; 35.1

Objective:To examine the association of financial hardship with weight changes in the US during the COVID-19 pandemic. Methods:We used data from the COVID-19's Unequal Racial Burden survey, a nationally representative, cross-sectional, online survey of diverse adults living in the US, 12/2020-2/2021. This study included 1000 Asian, Black, Latino (half Spanish-speaking), and White adults and 500 American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and multiracial adults (5500 total). Age-specific (18-39, 40-59, ≥60) associations between financial hardship domains and weight change were estimated using multinomial logistic regression, adjusted for demographic and health characteristics. Results:Financial hardship during the COVID-19 pandemic was prevalent across all age groups (18-39: 76.2 %; 40-59: 75.6 %; ≥60: 50.6 %). Among adults aged 18-39 and ≥ 60 years old, food insecurity was significantly associated with weight loss (18-39: aOR = 1.42, 95 % CI = 1.04, 1.95; ≥60: aOR = 3.67, 95 % CI = 1.50, 8.98). Among all age groups, unmet healthcare expenses was also associated with weight loss (18-39: aOR = 1.31, 95 % CI = 1.01, 1.70; 40-59: aOR = 1.49, 95 % CI = 1.06, 2.08; ≥60: aOR = 1.73, 95 % CI = 1.03, 2.91). Among adults aged 18-39 and ≥ 60 years old, lost income was significantly associated with weight gain (18-39: aOR = 1.36, 95 % CI = 1.09-1.69; ≥60: aOR = 1.46, 95 % CI = 1.04, 2.06), and among adults 40-59 years old, experiencing increased debt was significantly associated with weight gain (aOR = 1.50, 95 % CI = 1.13, 1.99). Conclusions:For those aged 18-39 and ≥ 60 years old experiencing financial hardship during the COVID-19 pandemic was associated with both weight loss and weight gain. Less correlation was observed among adults aged 40-59.

Background The COVID-19 pandemic had a profound social and economic impact across the United States due to the lockdowns and consequent changes to everyday activities in social spaces. Methods The COVID-19’s Unequal Racial Burden (CURB) survey was a nationally representative, online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Latino (English- and Spanish-speaking), Native Hawaiian/Pacific Islander, White, and multiracial adults living in the U.S. For this analysis, we used data from the 1,931 participants who responded to the 6-month follow-up survey conducted between 8/16/2021-9/9/2021. As part of the follow-up survey, participants were asked “What was the worst thing about the pandemic that you experienced?” and “Was there anything positive in your life that resulted from the pandemic?” Verbatim responses were coded independently by two coders using open and axial coding techniques to identify salient themes, definitions of themes, and illustrative quotes, with reconciliation across coders. Chi-square tests were used to estimate the association between sociodemographics and salient themes. Results Commonly reported negative themes among participants reflected disrupted lifestyle/routine (27.4%), not seeing family and friends (9.8%), and negative economic impacts (10.0%). Positive themes included improved relationships (16.9%), improved financial situation (10.1%), and positive employment changes (9.8%). Differences in themes were seen across race-ethnicity, gender, and age; for example, adults ≥ 65 years old, compared to adults 18–64, were more likely to report disrupted routine/lifestyle (37.6% vs. 24.2%, p < 0.001) as a negative aspect of the pandemic, and Spanish-speaking Latino adults were much more likely to report improved relationships compared to other racial-ethnic groups (31.1% vs. 14.8–18.6%, p = 0.03). Discussion Positive and negative experiences during the COVID-19 pandemic varied widely and differed across race-ethnicity, gender, and age. Future public health interventions should work to mitigate negative social and economic impacts and facilitate posttraumatic growth associated with pandemics.

Studies have shown that financial hardship can impact weight change; however, it is unclear what the economic impact of the COVID-19 pandemic has had on weight change in U.S. adults, or whether racial-ethnic groups were impacted differentially. We estimated the association between financial hardship and self-reported weight change using data from the cross-sectional COVID-19’s Unequal Racial Burden (CURB) survey, a nationally representative online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Latino (English- and Spanish-speaking), Native Hawaiian/Pacific Islander, White, and multiracial adults conducted from 12/2020 to 2/2021. Financial hardship was measured over six domains (lost income, debt, unmet general expenses, unmet healthcare expenses, housing insecurity, and food insecurity). The association between each financial hardship domain and self-reported 3-level weight change variable were estimated using multinomial logistic regression, adjusting for sociodemographic and self-reported health. After adjustment, food insecurity was strongly associated with weight loss among American Indian/Alaska Native (aOR = 2.18, 95% CI = 1.05–4.77), Black/African American (aOR = 1.77, 95% CI = 1.02–3.11), and Spanish-speaking Latino adults (aOR = 2.32, 95% CI = 1.01–5.35). Unmet healthcare expenses were also strongly associated with weight loss among Black/African American, English-speaking Latino, Spanish-speaking Latino, and Native Hawaiian/Pacific Islander adults (aORs = 2.00-2.14). Other domains were associated with weight loss and/or weight gain, but associations were not as strong and less consistent across race-ethnicity. In conclusion, food insecurity and unmet healthcare expenses during the pandemic were strongly associated with weight loss among racial-ethnic minority groups. Using multi-dimensional measures of financial hardship provides a comprehensive assessment of the effects of specific financial hardship domains on weight change among diverse racial-ethnic groups

Abstract Background Despite evidence of the impact of breastfeeding information on breastfeeding rates, it is unknown if information sources and impact vary by race/ethnicity, thus this study assessed race/ethnicity-specific associations between breastfeeding information sources and breastfeeding. Methods We used data from the 2016–2019 Pregnancy Risk Assessment Monitoring System. Race/ethnicity-stratified multinomial logistic regression was used to estimate associations between information source (e.g., family/friends) and breastfeeding rates (0 weeks/none, < 10 weeks, or ≥ 10 weeks; < 10 weeks and ≥ 10 weeks = any breastfeeding). All analyses were weighted to be nationally representative. Results Among 5,945,018 women (weighted), 88% reported initiating breastfeeding (≥ 10 weeks = 70%). Information from family/friends (< 10 weeks: aORs = 1.58–2.14; ≥ 10 weeks: aORs = 1.63–2.64) and breastfeeding support groups (< 10 weeks: aORs = 1.31–1.76; ≥ 10 weeks: aORs = 1.42–2.77) were consistently associated with breastfeeding and duration across most racial/ethnic groups; effects were consistently smaller among Alaska Native, Black, and Hispanic women (vs White women). Over half of American Indian and one-quarter of Black women reported not breastfeeding/stopping breastfeeding due to return to school/work concerns. Conclusions Associations between breastfeeding information source and breastfeeding rates vary across race/ethnicity. Culturally tailored breastfeeding information and support from family/friends and support groups could help reduce breastfeeding disparities. Additional measures are needed to address disparities related to concerns about return to work/school.

Abstract Somatic mutational profiling is increasingly being used to identify potential targets for breast cancer. However, limited tumor-sequencing data from Hispanic/Latinas (H/L) are available to guide treatment. To address this gap, we performed whole-exome sequencing (WES) and RNA sequencing on 146 tumors and WES of matched germline DNA from 140 H/L women in California. Tumor intrinsic subtype, somatic mutations, copy-number alterations, and expression profiles of the tumors were characterized and compared with data from tumors of non-Hispanic White (White) women in The Cancer Genome Atlas (TCGA). Eight genes were significantly mutated in the H/L tumors including PIK3CA, TP53, GATA3, MAP3K1, CDH1, CBFB, PTEN, and RUNX1; the prevalence of mutations in these genes was similar to that observed in White women in TCGA. Four previously reported Catalogue of Somatic Mutations in Cancer (COSMIC) mutation signatures (1, 2, 3, 13) were found in the H/L dataset, along with signature 16 that has not been previously reported in other breast cancer datasets. Recurrent amplifications were observed in breast cancer drivers including MYC, FGFR1, CCND1, and ERBB2, as well as a recurrent amplification in 17q11.2 associated with high KIAA0100 gene expression that has been implicated in breast cancer aggressiveness. In conclusion, this study identified a higher prevalence of COSMIC signature 16 and a recurrent copy-number amplification affecting expression of KIAA0100 in breast tumors from H/L compared with White women. These results highlight the necessity of studying underrepresented populations. Significance: Comprehensive characterization of genomic and transcriptomic alterations in breast tumors from Hispanic/Latina patients reveals distinct genetic alterations and signatures, demonstrating the importance of inclusive studies to ensure equitable care for patients. See related commentary by Schmit et al., p. 2443

Abstract Introduction Poor sleep is associated with adverse cardiometabolic health outcomes and increased risk of mortality. Although primary care providers recognize the importance of sleep, they report low comfort levels in diagnosing, treating, and managing sleep disorders; lack of clinical knowledge and skills is the most common barrier to recognizing insomnia in family practice. Furthermore, minoritized racial/ethnic groups are disproportionately affected by poor sleep health, likely due in part to structural and other forms of racism that result in limited access to sleep healthcare. Health Resources & Services Administration (HRSA) has a variety of awards that support scholarships and loan repayment programs at colleges and universities to meet critical workforce shortages and diversify the health professions. We assessed the distribution of sleep specialists among clinicians who participated in a HRSA grant program because they tend to work for health care organizations that serve persons from lower socioeconomic and diverse racial-ethnic backgrounds. Methods Publicly available data were obtained from the HRSA data warehouse. Data were available for 44,199 clinicians (49% MD/DO and 16% Nurse Practitioner) who participated in a HRSA grant program between 2011 and 2021. We report data for those clinicians who endorsed sleep medicine as their subspecialty. Results Of the 44,199 clinicians, 27 (0.06%) physicians trained in a medical subspecialty of sleep medicine, and the majority (52%) were in Michigan. The remainder of sleep medicine specialists completed their program in Pennsylvania (33%), Ohio (7%), Minnesota (4%), and California (4%). Only the participants in the Children's Hospital Graduate Medical Education program designated their subspecialty as sleep medicine. None of the sleep medicine specialists currently practice in Health Professional Shortage Areas (HPSAs) or Medically Underserved Areas/Populations (MUA/P), and 1 physician currently practices in a rural area. Conclusion A marked paucity of trained sleep specialists in HRSA grant programs and an absence of such practitioners in HSPAs underscores the disparities in access to sleep specialty care. Initiatives are needed to incentivize sleep specialists to serve in under-resourced communities as well as to implement programs training primary care practitioners working in these areas to deliver sleep health care, supported by sleep specialists. Support (if any) Divisions of Intramural Research: NIMHD/NIEHS, NIH

Background: Patients with language barriers suffer significant health disparities, including adverse events and poor health outcomes. While remote language services can help improve language access, these modalities remain persistently underused. The objective of this study was to understand clinician experiences and challenges using dual-handset interpreter telephones and to inform recommendations for future language access interventions.Methods: We conducted four focus groups with nurses (N=14) and resident physicians (N=20) to understand attitudes toward dual-handset interpreter telephones in the hospital, including general impressions, effects on communication, situations in which they did and did not use them, and impact on clinical care. Three researchers independently coded all transcripts using a constant comparative approach, meeting repeatedly to discuss coding and to reconcile differences to reach consensus.Results: We identified five salient themes, including increased language access (improved convenience, flexibility, and versatility of phones over in-person or ad hoc interpreters); effects on interpersonal processes of care (improved ability to communicate directly with patients); effects on clinical processes of care (improvements in critical patient care functions, including pain and medication management); impact on time (needing extra time for interpreted encounters and perceived delays impacting future use); and patients for whom, and circumstances in which, the dual-handset interpreter telephone is inadequate (e.g., complex discussions, hands-on instruction, or multiple speakers are present).Conclusions: Our findings indicate that clinicians value dual-handset interpretation in bridging communication barriers and highlight recommendations to guide future implementation interventions to increase the uptake of remote language services in hospital settings.

This editorial presents: 1) a review of Perinatal Psychiatry Access Programs as an integrated care model with potential for promoting perinatal mental health equity; and 2) a summary of how the model has been and can be further adapted to help achieve perinatal mental health equity in geographically diverse settings. Within the editorial, we highlight Access Programs as a promising model for promoting perinatal mental health equity. This editorial is supported by original descriptive data on the Lifeline for Moms National Network of Perinatal Psychiatric Access Programs. Descriptive data is additionally provided on three statewide Access Programs. The Access Program model, and the accompanying Network of Access Programs, is a multi-level approach demonstrating promise in reducing perinatal mental health inequities. Access Programs demonstrate potential to implement interventions to address well-documented inequities in perinatal mental healthcare access at the patient-, clinician-, practice-, community-, and policy-levels. For Access Programs to leverage their potential to advance perinatal mental health equity, systematic efforts are needed that include partnership with impacted communities and implementation teams.

PurposeThe purpose of this study was to assess differences in COVID-19 vaccine willingness and uptake between rural and nonrural adults, and within rural racial-ethnic groups. MethodsWe utilized data from the COVID-19's Unequal Racial Burden online survey, which included 1,500 Black/African American, Latino, and White rural adults (n = 500 each). Baseline (12/2020-2/2021) and 6-month follow-up (8/2021-9/2021) surveys were administered. A cohort of nonrural Black/African American, Latino, and White adults (n = 2,277) was created to compare differences between rural and nonrural communities. Multinomial logistic regression was used to assess associations between rurality, race-ethnicity, and vaccine willingness and uptake. FindingsAt baseline, only 24.9% of rural adults were extremely willing to be vaccinated and 28.4% were not at all willing. Rural White adults were least willing to be vaccinated, compared to nonrural White adults (extremely willing: aOR = 0.44, 95% CI = 0.30-0.64). At follow-up, 69.3% of rural adults were vaccinated; however, only 25.3% of rural adults who reported being unwilling to vaccinate were vaccinated at follow-up, compared to 95.6% of adults who were extremely willing to be vaccinated and 76.3% who were unsure. Among those unwilling to vaccinate at follow-up, almost half reported distrust in the government (52.3%) and drug companies (46.2%); 80% reported that nothing would change their minds regarding vaccination. ConclusionsBy August 2021, almost 70% of rural adults were vaccinated. However, distrust and misinformation were prevalent among those unwilling to vaccinate at follow-up. To continue to effectively combat COVID-19 in rural communities, we need to address misinformation to increase COVID-19 vaccination rates.

Introduction:The economic impact of the COVID-19 pandemic has been substantial, yet little is known about the financial effects resulting from lost employment or financial hardship racial-ethnic disparities.Methods:We conducted a nationally representative, online survey of 5500 English- and Spanish-speaking American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, Latino, White, and multiracial adults, from December 2020 to February 2021. Six financial hardship domains were measured (lost income, debt, unmet expenses, unmet health care expenses, housing insecurity, and food insecurity). Prevalence of financial hardship among each racial-ethnic group was estimated using multivariable Poisson regression.Results:Overall, 70.3% reported experiencing financial hardship; debt (57.6%), lost income (44.5%), and unmet expenses (33.7%) were most common. American Indian/Alaska Native (adjusted prevalence ratio [aPR]=1.19, 95% confidence interval [CI]=1.04 to 1.35), Black/African American (aPR=1.18, 95% CI=1.06 to 1.32), Latino (English-speaking: aPR=1.15, 95% CI=1.01 to 1.31; Spanish-speaking: aPR=1.27, 95% CI=1.12 to 1.45), and Native Hawaiian/Pacific Islander (aPR=1.21, 95% CI=1.06 to 1.38) adults were more likely to experience financial hardship, compared with White adults. American Indian/Alaska Native, Black/African American, Spanish-speaking Latino, and Native Hawaiian/Pacific Islander adults were also more likely to report hardship in almost all hardship domains (e.g., housing insecurity: aPRs=1.37-1.91).Conclusions:Racial/ethnic minorities were more likely to experience financial hardship during the pandemic. The prevalence of lost income was similar across most racial/ethnic groups, suggesting that preexisting wealth disparities led to some groups being less able to handle the economic shocks caused by the COVID-19 pandemic. Financial hardship may be underestimated for communities without English or Spanish fluency. Without intervention, financial hardship will likely exacerbate wealth disparities in the United States.

Introduction:Studies have reported increases in psychological distress during the COVID-19 pandemic. This study aimed to estimate associations between race-ethnicity and psychological distress during the COVID-19 pandemic among nationally representative samples of all major racial-ethnic groups in the United States.Methods:We conducted a nationally representative cross-sectional survey between December 2020 and February 2021 of Asian, black/African American, Latino (English and Spanish speaking), American Indian/Alaska Native, Native Hawaiian/Pacific Islander, white, and multiracial adults (n=5500). Distress measures included: anxiety-depression (Patient Health Questionnaire-4 [PHQ-4]), stress (modified Perceived Stress Scale), and loneliness-isolation (frequency felt lonely and isolated). Multinomial logistic regression models estimated associations between race-ethnicity and psychological distress, adjusting for demographic and health characteristics.Results:Overall, 23.7% reported moderate/severe anxiety-depression symptoms, 34.3% reported moderate/severe stress, and 21.3% reported feeling lonely-isolated fairly/very often. Compared with white adults and adjusting for covariates, the prevalence of moderate/severe anxiety-depression was significantly lower among Asian (adjusted odds ratio [aOR]=0.44, 95% confidence interval [CI]=0.34-0.58), black (aOR=0.49, 95% CI=0.38-0.63), English-speaking Latino (aOR=0.62, 95% CI=0.45-0.85), Spanish-speaking Latino (aOR=0.31, 95% CI=0.22-0.44), and Native Hawaiian/Pacific Islander (aOR=0.66, 95% CI=0.49-0.90) adults. Similar trends were seen for moderate/severe stress and feeling lonely-isolated fairly/very often. Worse distress profiles of American Indian/Alaska Native and multiracial adults were attenuated after adjustment.Conclusions:Minoritized groups tended to have less distress than white adults. Collective experiences of cumulative disadvantage could engender shared resiliency/normalization among these groups.

PURPOSE:Although telehealth access and utilization have increased during the pandemic, rural and low-income disparities persist. We sought to assess whether access or willingness to use telehealth differed between rural and non-rural and low-income and non-low-income adults and measure the prevalence of perceived barriers.METHODS:We conducted a cross-sectional study using COVID-19's Unequal Racial Burden (CURB) online survey (December 17, 2020-February 17, 2021), which included 2 nationally representative cohorts of rural and low-income Black/African American, Latino, and White adults. Non-rural and non-low-income participants from the main, nationally representative sample were matched for rural versus non-rural and low-income versus non-low-income comparisons. We measured perceived telehealth access, willingness to use telehealth, and perceived telehealth barriers.FINDINGS:Rural (38.6% vs 44.9%) and low-income adults (42.0% vs 47.4%) were less likely to report telehealth access, compared to non-rural and non-low-income counterparts. After adjustment, rural adults were still less likely to report telehealth access (adjusted prevalence ratio [aPR] = 0.89, 95% CI = 0.79-0.99); no differences were seen between low-income and non-low-income adults (aPR = 1.02, 95% CI = 0.88-1.17). The majority of adults reported willingness to use telehealth (rural = 78.4%; low-income = 79.0%), with no differences between rural and non-rural (aPR = 0.99, 95% CI = 0.92-1.08) or low-income versus non-low-income (aPR = 1.01, 95% CI = 0.91-1.13). No racial/ethnic differences were observed in willingness to use telehealth. The prevalence of perceived telehealth barriers was low, with the majority reporting no barriers (rural = 57.4%; low-income = 56.9%).CONCLUSIONS:Lack of access (and awareness of access) is likely a primary driver of disparities in rural telehealth use. Race/ethnicity was not associated with telehealth willingness, suggesting that equal utilization is possible once granted access.

Purpose Among Latina breast cancer survivors, explore associations between rural/urban residence and health-related quality of life (HRQL), and whether associations are moderated by financial strain and low neighborhood cohesion. Methods We combined baseline data from two randomized controlled trials of a stress management intervention conducted among 151 urban and 153 rural dwelling Latinas with nonmetastatic breast cancer. Generalized linear models estimated associations between rural/urban status and HRQL (overall, emotional, social-family, physical, and functional well-being), and we examined moderation effects of financial strain and low neighborhood cohesion, controlling for age, marital status, and breast cancer characteristics. Results Rural women reported better emotional (β = 1.85; 95% CI = 0.37, 3.33), functional (β = 2.23; 95% CI = 0.69, 3.77), and overall (β = 5.68; 95% CI = 1.12, 10.25) well-being than urban women, regardless of degree of financial strain or neighborhood cohesion; moderation effects were not statistically significant. Financial strain was inversely associated with emotional (β = -2.34; 95% CI = 3.63, -1.05), physical (β = -2.56; 95% CI = -4.12, -1.01), functional (β = -1.61; 95% CI = -2.96, -0.26), and overall (β = -6.67; 95% CI = -10.96, -2.98) well-being. Low neighborhood cohesion was inversely associated with emotional (β = -1.27; 95% CI = -2.50, -0.04), social-family (β = -1.72; 95% CI = -3.02, -0.42), functional (β = -1.63; 95% CI = -2.92, -0.34), and overall (β = -5.95; 95% CI = 9.76, -2.14) well-being. Conclusions Rural Latina breast cancer survivors reported better emotional, functional and overall well-being than their urban counterparts. Greater financial strain and less neighborhood cohesion were associated with worse HRQL on most domains regardless of rural/urban context. Implications for Cancer Survivors Interventions that focus on increasing perceived neighborhood cohesion and reducing or better managing financial strain, could help improve Latina cancer survivors’ well-being.