Health Care During COVID-19 Among Underserved, Older Adults [Internet]

Excerpt

Background: Older (ie, people aged 50-80 years), medically underserved adults are disproportionately burdened by tobacco use in the United States. These same individuals are at particularly high risk of poor health outcomes from COVID-19 because of their age and lack of access to care and the prevalence of tobacco-associated lung diseases. As such, preventive health care services such as lung cancer screening and tobacco treatment are fundamentally important to their long-term health. These individuals' willingness and ability to engage in these preventive health services, however, were substantially threatened by the COVID-19 pandemic. Clinicians and health systems similarly grappled with when and how to motivate in-person preventive health services and were seeking guidance on how to make patients feel safe receiving in-person health care or seeking alternatives such as mobile health (mHealth) applications. We sought to identify methods to surmount the impacts of COVID-19 and systemic barriers to health care on the willingness and ability of older, underserved individuals to engage with preventive health care services.

Objectives: We aimed to (1) identify the impacts of the COVID-19 pandemic on tobacco use and preparedness for smoking cessation among underserved older individuals who smoke; (2) pinpoint the strongest barriers to and most effective facilitators of delivering tobacco treatment programs through mHealth applications to such individuals; and (3) elucidate the mechanisms that prevent older, underserved patients from reengaging with preventive health services that cannot be delivered remotely, such as lung cancer screening.

Methods: We conducted semistructured telephone interviews with patients identifying as part of 1 or more of the following groups: populations that experience health disparities, caregivers, or outpatient clinicians. Participants were recruited from the University of Pennsylvania Health System. Community members were also reached via the Latino Connection COVID-19 Mobile Response Unit in select Pennsylvania counties. Eligible patients were 50 to 80 years old; smoked tobacco daily; and identified as Black or Hispanic, living in a rural area, or of low income or formal educational attainment. Interviews were offered in both Spanish and English. We inductively developed a codebook based on emerging themes for each group of respondents. Data were initially coded by multiple team members to ensure consistency, and conflicts were resolved through consensus. Four project staff trained in qualitative methods coded all interviews in NVivo, version 12, software (QSR International), and thematic analysis was conducted for each aim and response group. Twenty percent of all data were coded by at least 2 coders to ensure interrater reliability. Concurrent with coding, we identified key themes and patterns.

Results: Between November 2020 and September 2021, we conducted 150 interviews with 55 patients, 15 caregivers, and 18 clinicians. Participating patients had a median age of 62 years, with 49.1% identifying as women, 43.6% as Black or African American, 38.2% as White, 16.4% as other race, and 1.8% as Native American. Of the participating patients, 18.2% identified as Hispanic or Latino. Participating caregivers included 66.7% identifying as women, 60% as Black or African American, 40% as White, and none as Hispanic or Latino. Participating clinicians included 61.1% identifying as women, 5.6% identifying as Black or African American, 94.4% identifying as White, and 5.6% identifying as Hispanic or Latino. Most respondents experienced intersectionality of their identities and experiences, which may include belonging to multiple health disparity populations. The results reflect their experiences with smoking and the health care system, as described by them. First, participants' smoking behaviors during the COVID-19 pandemic varied. Some respondents increased tobacco use because of anxiety, boredom, and more time at home. Others reduced their smoking based on fear of severe COVID-19 outcomes and symptomology. Among those who successfully quit in the past, then relapsed, many reported preceding triggers such as anxiety, stress, and grief. Many participants remained motivated to quit for social, health, and financial reasons. Most reported that personal willpower and motivation to quit were the most important facilitators of smoking cessation. Second, participants described challenges with unfamiliar technology and discomfort with using mobile applications beyond texting and Facebook as barriers to mHealth use. Respondents identified tutorial videos, instruction manuals, and direct guidance from a support person as potential facilitators of mHealth use. Most respondents believed that mHealth tools would facilitate tobacco cessation only among individuals committed to quitting tobacco. Third, although some preventive health services were postponed, most patients reported following through with clinician-recommended preventive care once such services resumed. Clinicians frequently postponed preventive care services early in the pandemic to reduce viral spread and because of their inpatient clinical roles. Mitigation strategies (eg, social distancing, masking, hand sanitizing, and vaccination against COVID-19) improved patients' and caregivers' perceptions of safety during in-person preventive care, as did trust in the clinician.

Conclusions: The COVID-19 pandemic resulted in changes in consumption of tobacco, experiences with mHealth tools, and use of preventive health care. Although the threat of severe COVID-19 was a motivator for tobacco treatment for some individuals, increased anxiety and boredom may have prevented more individuals from making quit attempts during this period. Further, adults who smoke tobacco may benefit from mHealth tools developed with careful attention to reducing barriers to use and incorporating stakeholder guidance. This population experiences barriers to accessing health care and disparities in the quality and extent of the health care they receive. They may benefit from the accessibility of mHealth tools for smoking cessation. Finally, although many preventive health care services were postponed during the early days of the pandemic, implementation of additional safety measures and clinicians' recommendations improved patients' and caregivers' comfort with reengaging in preventive care. These results may assist in addressing smoking cessation through the remainder of the COVID-19 pandemic and future pandemics by integrating tools new tools into cessation methods.

Limitations: Our study fills important gaps in the literature, but we acknowledge limitations of this work. We conducted broad recruitment of participants within a single state. Given the regional variation of the pandemic in the United States, our results may lack generalizability to all US locations. In addition, the impact of COVID-19 on policy and procedures was highly time dependent. Participants' experiences may have dramatically varied over time, and although we conducted the interviews over a 12-month period, we did not capture longitudinal experiences of individual participants. We also relied on participant recall in describing changes in tobacco use, mHealth experiences, and clinical decisions, which may have introduced bias.