Do social determinants of health explain racial/ethnic disparities in COVID-19 infection?

Nonalcoholic Fatty Liver Disease and Ethnicity: Lessons Learned from the Arab Population in Israel

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease. We aimed to investigate the potential similarities and differences regarding the disease among Arabs and Jews. Retrospective study included all patients older than 18 years with NAFLD diagnosis according to ICD-10 codes. Data regarding demographics, comorbidities, and outcomes were retrieved using the MdClone platform from "Clalit" in Israel. Data concerning 34,090 Arab patients and 173,500 Jewish patients with NAFLD were included. Arab patients were significantly younger at diagnosis (35.0 ± 13 years vs. 43.6 ± 15 years, p < 0.001) and had higher rates of obesity and diabetes mellitus (69.5% vs. 56.5% and 27.0% vs. 22.7%, p < 0.001, respectively). Arab patients had higher rates of cirrhosis and portal hypertension-related complications (2.5% vs. 2.0%, p < 0.001), esophageal varices (0.9% vs. 0.5%, p < 0.001), spontaneous bacterial peritonitis (0.3% vs. 0.1%, p < 0.001), and hepatorenal syndrome (0.3% vs. 0.1%, p < 0.001). There was no significant difference in the prevalence of hepatocellular carcinoma between study groups (0.4% vs. 0.5%, p = 0.156). Liver transplantation was performed in 0.2% of Arab NAFLD patients compared to 0.07% of Jewish NAFLD patients (p < 0.001). Lower rates of all-cause mortality were found among the Arab NAFLD patients versus Jewish NAFLD patients (7.7% versus 11.5%, p < 0.001). According to the Cox regression model, Arab ethnicity is a risk factor for death with OR of 1.36. Significant differences regarding comorbidities, complications, liver transplantations rates, and all-cause mortality were found among NAFLD patients of different ethnicities, hence specific population need specific consideration in prevention, early diagnosis and follow up.

Substandard housing and the risk of COVID-19 infection and disease severity: A retrospective cohort study

In this study we examine associations between substandard housing and the risk of COVID-19 infection and severity during the first year of the pandemic by linking individual-level housing and clinical datasets. Residents of Chelsea, Massachusetts who were tested for COVID-19 at any Mass General Brigham testing site and who lived at a property that had received a city housing inspection were included (N = 2873). Chelsea is a densely populated city with a high prevalence of substandard housing. Inspected properties with housing code violations were considered substandard; inspected properties without violations were considered adequate. COVID-19 infection was defined as any positive PCR test, and severe disease defined as hospitalization with COVID-19. We used a propensity score design to match individuals on variables including age, race, sex, and income. In the severity model, we also matched on ten comorbidities. We estimated the risk of COVID-19 infection and severity associated with substandard housing using Cox Proportional Hazards models for lockdown, the first phase of reopening, and the full study period. In our sample, 32% (919/2873) of individuals tested positive for COVID-19 and 5.9% (135/2297) had severe disease. During lockdown, substandard housing was associated with a 48% increased risk of COVID-19 infection (95%CI 1.1-2.0, p = 0.006). Through Phase 1 reopening, substandard housing was associated with a 39% increased infection risk (95%CI 1.1-1.8, p = 0.020). The difference in risk attenuated over the full study period. There was no difference in severe disease risk between the two groups. The increased risk, observed only during lockdown and early reopening - when residents were most exposed to their housing - strengthens claims that substandard housing conveys higher infection risk. The results demonstrate the value of combining cross-sector datasets. Existing city housing data can be leveraged 1) to identify and prioritize high-risk areas for future pandemic response, and 2) for longer-term housing solutions.

Life Expectancy Changes During the COVID-19 Pandemic, 2019-2021: Highly Racialized Deaths in Young and Middle Adulthood in the United States as Compared With Other High-Income Countries

We estimated changes in life expectancy between 2019 and 2021 in the United States (in the total population and separately for 5 racial/ethnic groups) and 20 high-income peer countries. For each country's total population, we decomposed the 2019-2020 and 2020-2021 changes in life expectancy by age. For US populations, we also decomposed the life expectancy changes by age and number of coronavirus disease 2019 (COVID-19) deaths. Decreases in US life expectancy in 2020 (1.86 years) and 2021 (0.55 years) exceeded mean changes in peer countries (a 0.39-year decrease and a 0.23-year increase, respectively) and disproportionately involved COVID-19 deaths in midlife. In 2020, Native American, Hispanic, Black, and Asian-American populations experienced larger decreases in life expectancy and greater losses in midlife than did the White population. In 2021, the White population experienced the largest decrease in US life expectancy, although life expectancy in the Native American and Black populations remained much lower. US losses during the pandemic were more severe than in peer countries and disproportionately involved young and middle-aged adults, especially adults of this age in racialized populations. The mortality consequences of the COVID-19 pandemic deepened a US disadvantage in longevity that has been growing for decades and exacerbated long-standing racial inequities in US mortality.

The impact of COVID-19 on life expectancy among four Asian American subgroups

Background and objective

To date, the impact of the COVID-19 pandemic on life expectancy for the Asian American (AA) population has been reported in aggregate. This study provides estimates of life expectancy at birth before and during the pandemic, with a set of demographic, health, and socioeconomic risk factors for the four largest subgroups: Asian Indians, Chinese, Filipinos, and Vietnamese. These estimates are placed in context of the broader U.S. population.

Methods

This study uses age-specific all-cause mortality from CDC WONDER and population counts from the American Community Surveys. We apply methodologies to address variability in population sizes over time (smoothing) and data quality issues at older ages (Brass relational model life table system) to produce three sets of sex-specific life expectancy estimates by subgroup for 2019, 2020, and 2021.

Results

Almost all estimates show that the four AA subgroups experienced greater losses between 2019 and 2020 than Whites. These losses ranged from 1.1 to 3.9 years, with the largest drops among Chinese women (2.0-2.4) and Filipino men (3.5-3.9). Under all scenarios, losses in life expectancy were considerably smaller in 2021 than in 2020 among the four subgroups - with several subgroups experiencing a modest rebound - but these improvements did not compensate for the large increases in death rates in 2020. Filipino men had the largest decline in life expectancy from 2019 to 2021 among the four subgroups (3.4-4.2 years), and Vietnamese men and women experienced large losses which continued into the second year of the pandemic.

Conclusions

Despite high pre-pandemic life expectancies, AAs suffered a large, and rarely acknowledged, increase in mortality during the pandemic, with substantial heterogeneity across subgroups and between women and men. This variability is due in part to the pronounced differences in risk factors for infection and severity which have been documented within the AA population.

The relationship between health and housing in low-income older adults: A secondary analysis of survey data

OBJECTIVE

To examine the health-housing relationship in low-income older adults, and differences by income and receipt of housing assistance.

DESIGN

Secondary analysis of longitudinal survey data.

SAMPLE

About 10,858 adults aged 62+ who completed at least one wave of the 2014 Survey of Income and Program Participation (SIPP) (n = 37,333 observations).

MEASUREMENTS

SIPP variables representing demographics and housing quality, affordability, stability, and neighborhood were analyzed. Low-income and higher-income participants were differentiated by the household income-to-poverty ratio.

RESULTS

Low-income participants were significantly more likely to be in poor health and report problems with housing quality, affordability, and neighborhood safety compared to higher-income participants (p < .001). Increased household size and problems with housing quality and neighborhood safety were associated with poor health in both groups (p < .05). Low-income participants who received housing assistance were significantly poorer, less healthy, and food insecure than participants not receiving assistance (p < .001); however, the health-housing relationship was not different in the two groups.

CONCLUSIONS

Results provide additional support for housing as a social determinant of older adult health. Though housing assistance programs reached a subset of low-income older adults, the results suggest a housing assistance shortfall. Implications for public health nurses and researchers are explored.

Cumulative exposure to extreme heat and trajectories of cognitive decline among older adults in the USA

BACKGROUND

The projected increase in extreme heat days is a growing public health concern. While exposure to extreme heat has been shown to negatively affect mortality and physical health, very little is known about its long-term consequences for late-life cognitive function. We examined whether extreme heat exposure is associated with cognitive decline among older adults and whether this association differs by race/ethnicity and neighbourhood socioeconomic status.

METHODS

Data were drawn from seven waves of the Health and Retirement Study (2006-2018) merged with historical temperature data. We used growth curve models to assess the role of extreme heat exposure on trajectories of cognitive function among US adults aged 52 years and older.

RESULTS

We found that high exposure to extreme heat was associated with faster cognitive decline for blacks and residents of poor neighbourhoods, but not for whites, Hispanics or residents of wealthier neighbourhoods.

CONCLUSION

Extreme heat exposure can disproportionately undermine cognitive health in later life for socially vulnerable populations. Our findings underscore the need for policy actions to identify and support high-risk communities for increasingly warming temperatures.

Individual and structural determinants of COVID-19 vaccine uptake in a marginalized community in the United States

Socially and medically vulnerable groups (e.g., people 65 years or older, minoritized racial groups, non-telework essential workers, and people with comorbid conditions) experience barriers to COVID-19 prevention and treatment, increased burden of disease, and increased risk of death from COVID-19. Researchers are paying increased attention to social determinants of health (SDH) in explaining inequities in COVID-19-related health outcomes and rates of vaccine uptake. The purpose of the present manuscript is to identify clinically significant predictors of COVID-19 vaccine uptake among people who were socially and medically vulnerable to SARs-CoV-2 infection. Analysis was informed by the SDH framework and included a sample of 641 baseline surveys from participants in a clinical trial designed to increase COVID-19 testing. All participants were at high risk of developing COVID-19-related complications or dying from COVID-19. Following community-based participatory research principles, a well-established community collaborative board conducted every aspect of the study. Multiple logistic regressions were conducted to examine the relationships between individual and structural factors and COVID-19 vaccine uptake. In the final time adjusted model, we found that vaccine uptake was only predicted by specific individual-level factors: being 65 years and older, living with HIV/AIDS, and having previously received a flu vaccine or a COVID-19 test. Those reporting to believe in COVID-19-conspiracy theories were less likely to get the COVID-19 vaccine. More research is needed to identify predictors of vaccine uptake among people with comorbidities that make them more vulnerable to COVID-19 complications or death.

Racial-ethnic, gender identity, and sexual orientation disparities in COVID-19-related social and health outcomes: A decomposition analysis

Despite the growing literature on racial-ethnic disparities during the pandemic, less is known about the explanatory mechanisms of these disparities and inequalities across other axes, such as gender and sexual identities. We studied the levels and sources of racial-ethnic, gender identity, and sexual minority disparities in social (i.e., unmet resource needs) and health (i.e., hospitalization) outcomes among individuals diagnosed with COVID-19, hypothesizing differential age structure, underlying health, and work and living arrangements as contributors to inequalities. Using large-scale administrative data from Chicago and adjusting for covariates, we found substantial racial-ethnic and gender identity disparities in both outcomes, and weak evidence of sexual minority disparities in unmet needs. Subsequent decomposition analyses revealed that living in larger households, having a higher share of non-adult cases, and facing higher burdens of chronic illness, obesity, and unemployment each statistically significantly drove racial-ethnic disparities in unmet needs, but these together explained less than 15% of the disparities. Similarly, about 20% of the Black-White gap in hospitalization resulted from disparities in underlying health and unemployment, whereas a higher proportion of non-adult cases or higher unemployment rates respectively proved the only significant pathways to partially explain transgender individuals' disadvantages in unmet needs (12%) or hospitalization (6%). These findings highlight the importance of considering multiple dimensions of social differences in studying health disparities, the vulnerabilities of transgender and non-adult communities during the pandemic, and the valid yet quite limited roles of previously suggested sociodemographic factors in accounting for COVID-19-related categorical inequalities.

Longitudinal disparities in social determinants of health and COVID-19 incidence and mortality in the United States from the three largest waves of the pandemic

The United States experienced at least five COVID-19 waves linked with different mutated SARS-CoV-2 variants including Alpha, Delta and Omicron. In addition to the variants, the intensity, geographical distribution, and risk factors related to those waves also vary within socio-demographic characteristics and timeframes. In this project, we have examined the spatial and temporal pattern of COVID-19 in the USA and its associations with Social Determinants of Health (SDoH) by utilizing the County Health Rankings & Roadmaps (CHRR) dataset. Our epidemiologic investigation at the county level showed that the burden of COVID-19 cases and deaths is higher in counties with high percentages of smoking, number of preventable hospital stays, primary care physician rate, the average daily density of PM_2.5 and percentages of high proportions of Hispanic residents. In addition, the analysis also demonstrated that COVID-19 incidence and mortality had distinct characteristics in their association with SDoH variables. For example, the percentages of the population 65 and older had negative associations with incidence while a significant positive association with mortality. In addition to the elderly population, median household income, unemployment, and number of drug overdose deaths showed a mixed association with COVID-19 incidence and mortality. Our findings validate several influential factors found in the existing social epidemiology literature and highlight temporal associations between SDoH variables and COVID-19 incidence and mortality not yet frequently studied.

Health disparity in the spread of COVID-19: Evidence from social distancing, risk of interactions, and access to testing

OBJECTIVE

- To identify and assess whether three major risk factors that due to differential access to flexible resources might help explain disparities in the spread of COVID-19 across communities with different socioeconomic status, including socioeconomic inequalities in social distancing, the potential risk of interpersonal interactions, and access to testing.

METHODS

Analysis uses ZIP code level weekly COVID-19 new cases, weekly population movement flows, weekly close-contact index, and weekly COVID-19 testing sites in Southern California from March 2020 to April 2021, merged with the U.S. census data to measure ZIP code level socioeconomic status and cofounders. This study first develops the measures for social distancing, the potential risk of interactions, and access to testing. Then we employ a spatial lag regression model to quantify the contributions of those factors to weekly COVID-19 case growth.

RESULTS

Results identify that, during the first COVID-19 wave, new case growth of the low-income group is two times higher than that of the high-income group. The COVID-19 case disparity widens to four times in the second COVID-19 wave. We also observed significant disparities in social distancing, the potential risk of interactions, and access to testing among communities with different socioeconomic status. In addition, all of them contribute to the disparities of COVID-19 incidences. Among them, the potential risk of interactions is the most important contributor, whereas testing accessibility contributes least. We also found that close-contact is a more effective measure of social distancing than population movements in examining the spread of COVID-19.

CONCLUSION

- This study answers critically unaddressed questions about health disparities in the spread of COVID-19 by assessing factors that might explain why the spread is different in different groups.

Spatial and racial covid-19 disparities in U.S. nursing homes

In many parts of the world nursing home residents have experienced a disproportionate risk of exposure to COVID-19 and have died at much higher rates than other groups. There is a critical need to identify the factors driving COVID-19 risk in nursing homes to better understand and address the conditions contributing to their vulnerability during public health crises. This study investigates the characteristics associated with COVID-19 cases and deaths among residents in U.S. nursing homes from 2020 to 2021, with a focus on geospatial and racial inequalities. Using data from the Centers for Medicare and Medicaid Services and LTCFocus, this paper uses zero-inflated negative binomial regression models, Kruskal-Wallis tests, and Local Moran's I to generate statistical and geospatial results. Our analysis reveals that majority Hispanic facilities have alarmingly high COVID-19 cases and deaths, suggesting that these facilities have the greatest need for policy improvements in staffing and financing to reduce racial inequalities in nursing home care. At the same time we also detect COVID-19 hot spots in rural areas with predominately White residents, indicating a need to rethink public messaging strategies in these areas. The top states with COVID-19 hot spots are Kentucky, Pennsylvania, Illinois, and Oklahoma. This research provides new insights into the socio-spatial contexts and inequities that contribute to the vulnerability of nursing home residents during a pandemic.

Racial and ethnic disparities in COVID-19 vaccine uptake: A mediation framework

BACKGROUND

Previous research suggests that racial and ethnic minority groups especially Black Americans showed stronger COVID-19 vaccine hesitancy and resistance, which may result from a lack of trust toward the government and vaccine manufacturers, among other sociodemographic and health factors.

OBJECTIVES

The current study explored potential social and economic, clinical, and psychological factors that may have mediated racial and ethnic disparities in COVID-19 vaccine uptake among US adults.

METHODS

A sample of 6078 US individuals was selected from a national longitudinal survey administered in 2020-2021. Baseline characteristics were collected in December 2020, and respondents were followed up to July 2021. Racial and ethnic disparities in time to vaccine initiation and completion (based on a 2-dose regimen) were first assessed with the Kaplan-Meier Curve and log-rank test, and then explored with the Cox proportional hazards model adjusting for potential time-varying mediators, such as education, income, marital status, chronic health conditions, trust in vaccine development and approval processes, and perceived risk of infection.

RESULTS

Prior to mediator adjustment, Black and Hispanic Americans had slower vaccine initiation and completion than Asian Americans and Pacific Islanders and White Americans (p's < 0.0001). After accounting for the mediators, there were no significant differences in vaccine initiation or completion between each minoritized group as compared to White Americans. Education, household income, marital status, chronic health conditions, trust, and perceived infection risk were potential mediators.

CONCLUSION

Racial and ethnic disparities in COVID-19 vaccine uptake were mediated through social and economic conditions, psychological influences, and chronic health conditions. To address the racial and ethnic inequity in vaccination, it is important to target the social, economic, and psychological forces behind it.

Social Determinants of COVID-19 Vaccination Rates: A Time-Constrained Multiple Mediation Analysis

Objective To estimate the multiple direct/indirect effects of social, environmental, and economic factors on COVID-19 vaccination rates (series complete) in the 3109 continental counties in the United States (U.S.). Study design  The dependent variable was the COVID-19 vaccination rates in the U.S. (April 15, 2022). Independent variables were collected from reliable secondary data sources, including the Census and CDC. Independent variables measured at two different time frames were utilized to predict vaccination rates. The number of vaccination sites in a given county was calculated using the geographic information system (GIS) packages as of April 9, 2022. The Internet Archive (Way Back Machine) was used to look up data for historical dates. Methods  A chain of temporally-constrained least absolute shrinkage and selection operator (LASSO) regressions was used to identify direct and indirect effects on vaccination rates. The first regression identified direct predictors of vaccination rates. Next, the direct predictors were set as response variables in subsequent regressions and regressed on variables that occurred before them. These regressions identified additional indirect predictors of vaccination. Finally, both direct and indirect variables were included in a network model. Results  Fifteen variables directly predicted vaccination rates and explained 43% of the variation in vaccination rates in April 2022. In addition, 11 variables indirectly affected vaccination rates, and their influence on vaccination was mediated by direct factors. For example, children in poverty rate mediated the effect of (a) median household income, (b) children in single-parent homes, and (c) income inequality. For another example, median household income mediated the effect of (a) the percentage of residents under the age of 18, (b) the percentage of residents who are Asian, (c) home ownership, and (d) traffic volume in the prior year. Our findings describe not only the direct but also the indirect effect of variables. Conclusions  A diverse set of demographics, social determinants, public health status, and provider characteristics predicted vaccination rates. Vaccination rates change systematically and are affected by the demographic composition and social determinants of illness within the county. One of the merits of our study is that it shows how the direct predictors of vaccination rates could be mediators of the effects of other variables.

COVID-19 vaccine equity and the right to health for displaced Venezuelans in Latin America

Given the magnitude of Venezuelan displacement in Latin America, there is a need to assess how migrants were, and will continue to be, addressed in COVID-19 vaccination policies. To explore migration status as a dimension of vaccine equity in Latin America and in relation to international human rights, we assessed national vaccination plans, peer-reviewed, and gray literature published between January 2020 and June 2021. Three key rights-related concerns were found to restrict the health rights of migrants in the region: 1) lack of prioritization of migrants in vaccine distribution; 2) onerous documentation requirements to be eligible for COVID-19 vaccination; and (3) how pervasive anti-migrant discrimination limited equitable health care access. While international human rights law prohibits against discrimination based on migration status, few countries analyzed realized their obligations to provide equal access to COVID-19 vaccines to non-citizens, including displaced Venezuelans. Especially for migrants and displaced people, effective and sustainable vaccination strategies for COVID-19 and future pandemics in Latin America must be guided not only by epidemiological risk but also seek to align with human rights obligations. To achieve this, States must also take special measures to facilitate vaccine access for communities facing systemic discrimination, exclusion, and marginalization.

Municipal Ethnic Composition and Disparities in COVID-19 Infections in New Jersey: A Blinder-Oaxaca Decomposition Analysis

COVID-19 has disproportionally impacted Latinx and Black communities in the US. Our study aimed to extend the understanding of ethnic disparities in COVID-19 case rates by using a unique dataset of municipal case rates across New Jersey (NJ) during the first 17 months of the pandemic. We examined the extent to which there were municipal-level ethnic disparities in COVID-19 infection rates during three distinct spikes in case rates over this period. Furthermore, we used the Blinder-Oaxaca decomposition analysis to identify municipal-level exposure and vulnerability factors that contributed to ethnic disparities and how the contributions of these factors changed across the three initial waves of infection. Two clear results emerged. First, in NJ, the COVID-19 infection risk disproportionally affected Latinx communities across all three waves during the first 17 months of the pandemic. Second, the exposure and vulnerability factors that most strongly contributed to higher rates of infection in Latinx and Black communities changed over time as the virus, alongside medical and societal responses to it, also changed. These findings suggest that understanding and addressing ethnicity-based COVID-19 disparities will require sustained attention to the systemic and structural factors that disproportionately place historically marginalized ethnic communities at greater risk of contracting COVID-19.

Reductions in US life expectancy during the COVID-19 pandemic by race and ethnicity: Is 2021 a repetition of 2020?

COVID-19 had a huge mortality impact in the US in 2020 and accounted for most of the overall reduction in 2020 life expectancy at birth. There were also extensive racial/ethnic disparities in the mortality impact of COVID-19 in 2020, with the Black and Latino populations experiencing reductions in life expectancy at birth over twice as large as that of the White population. Despite continued vulnerability of these populations, the hope was that widespread distribution of effective vaccines would mitigate the overall mortality impact and reduce racial/ethnic disparities in 2021. In this study, we quantify the mortality impact of the COVID-19 pandemic on 2021 US period life expectancy by race and ethnicity and compare these impacts to those estimated for 2020. Our estimates indicate that racial/ethnic disparities have persisted, and that the US population experienced a decline in life expectancy at birth in 2021 of 2.2 years from 2019, 0.6 years more than estimated for 2020. The corresponding reductions estimated for the Black and Latino populations are slightly below twice that for Whites, suggesting smaller disparities than those in 2020. However, all groups experienced additional reductions in life expectancy at birth relative to 2020, and this apparent narrowing of disparities is primarily the result of Whites experiencing proportionately greater increases in mortality in 2021 compared with the corresponding increases in mortality for the Black and Latino populations in 2021. Estimated declines in life expectancy at age 65 increased slightly for Whites between 2020 and 2021 but decreased for both the Black and Latino populations, resulting in the same overall reduction (0.8 years) estimated for 2020 and 2021.

Reductions in US life expectancy during the COVID-19 pandemic by race and ethnicity: Is 2021 a repetition of 2020?

COVID-19 had a huge mortality impact in the US in 2020 and accounted for most of the overall reduction in 2020 life expectancy at birth. There were also extensive racial/ethnic disparities in the mortality impact of COVID-19 in 2020, with the Black and Latino populations experiencing reductions in life expectancy at birth over twice as large as that of the White population. Despite continued vulnerability of these populations, the hope was that widespread distribution of effective vaccines would mitigate the overall impact and reduce racial/ethnic disparities in 2021. In this study, we quantify the mortality impact of the COVID-19 pandemic on 2021 US period life expectancy by race and ethnicity and compare these impacts to those estimated for 2020. Our estimates indicate that racial/ethnic disparities have persisted, and that the US population experienced a decline in life expectancy at birth in 2021 of 2.2 years from 2019, 0.6 years more than estimated for 2020. The corresponding reductions estimated for the Black and Latino populations are slightly below twice that for Whites, suggesting smaller disparities than those in 2020. However, all groups experienced additional reductions in life expectancy relative to 2020, and this apparent narrowing of disparities is primarily the result of Whites experiencing proportionately greater increases in mortality in 2021 compared with the corresponding increases in mortality for the Black and Latino populations in 2021. Estimated declines in life expectancy at age 65 increased slightly for Whites between 2020 and 2021 but decreased for both the Black and Latino populations, resulting in the same overall reduction (0.8 years) estimated for 2020 and 2021.