Racism Experience Among American Adults During COVID-19: A Mixed-Methods Study

The Association Between Black vs. White Race and 30-Day Hospitalization Among People Diagnosed with COVID-19 Within an Integrated Care Setting: a Cohort Study

BACKGROUND

Black Americans are more likely to experience hospitalization from COVID-19 compared with White Americans. Whether this excess risk differs by age, sex, obesity, or diabetes, key risk factors for COVID hospitalization, among an integrated population with uniform healthcare access, are less clear.

METHODS

We identified all adult members (≥ 18 years) of Kaiser Permanente Georgia (KPGA) diagnosed with COVID-19 between January 1, 2020, and September 30, 2021 (N = 24,564). We restricted the analysis to members of Black or White race identified from electronic medical records. Our primary outcome was first hospitalization within 30 days of COVID-19 diagnosis. To assess the association between race and 30-day hospitalization, we performed multivariable logistic regression adjusting for several member and neighborhood-level characteristics, and tested for interactions of race with age, sex, diabetes, and obesity. A regression-based decomposition method was then used to estimate how much of the observed race disparity in 30-day hospitalization could be explained by member and neighborhood-level factors.

RESULTS

Overall, 11.27% of Black KPGA members were hospitalized within 30 days of a COVID diagnosis, as compared with 9.44% of White KPGA members. Black (vs. White) KPGA members had a 34% (aOR: 1.32 [95% CI: 1.19-1.47]) higher odds of 30-day hospitalization following COVID-19 after accounting for clinical differences. The odds of 30-day hospitalization in Black vs. White KPGA members did not differ significantly by sex (men: 1.46 [1.25-1.70]; women: 1.24 [1.07-1.43]), by age (18-29 years: 1.33 [0. 841-2.10]; 30-49 years: 1.26 [1.02-1.56]; ≥ 50 years: 1.24 [1.10-1.41]); by diabetes status (with diabetes: 1.38 [1.16-1.66]; without diabetes: 1.26 [1.11-1.44]), or by obesity (with obesity: 1.31 [1.15-1.50]; without obesity: 1.28 [1.06-1.53]). Factors that, if Black and White KPGA members had the same level of exposure, would be most likely to reduce the Black-White disparity in 30-day hospitalization from COVID-19 were obesity, history of flu vaccine, and neighborhood-level income and social vulnerability.

CONCLUSIONS

Early in the pandemic, Black (vs. White) members of an integrated health system had higher odds of being hospitalized within 30 days of COVID-19 diagnosis and this excess risk was similar by sex, age, and comorbidities. Factors that explained the largest proportions of race-based disparities were obesity, receipt of flu vaccine, and neighborhood-level social determinants of health. These findings suggest that social determinants of health, or other unmeasured factors, may be drivers of racial disparities in COVID-19 outcomes.

Experienced Racism and Discrimination and Psychological Distress amid Different Phases of the COVID-19 Pandemic: Evidence from Wisconsin

The SARS-COV-2 pandemic created an unprecedented crisis and raised concerns about racial discrimination and psychological distress. We assessed trends in COVID-19-related racism and discrimination irrespective of infection status and changes in emotional health and mental well-being outcomes due to experienced racism and discrimination. Using three waves of the Wisconsin COVID-19 Community Impact Survey (2020-2021), we compared demographics of respondents categorized by two mutually exclusive groups: reporting vs. not reporting COVID-19-related racism and discrimination. Using longitudinal logistic-multivariable regressions, we modeled changes in racism and discrimination-induced stress and 4-item patient health questionnaire screening for anxiety and depression (PHQ-4) associated with experiencing racism and discrimination. Prevalence of reported experiencing COVID-19-related racism and discrimination increased among adult Wisconsinites between 2020 and 2021: 6.28% in Wave 1, 11.13% in Wave 2 (Pearson's chi-square Wave 1 vs 2=16.96, p<.001) vs. 10.87% in Wave 3 (chi-square, Wave 1 vs 3=14.99, p<.001). Experiencing COVID-19-related racism and discrimination was associated with a higher likelihood stress (OR=3.15, 95% CI 2.32-4.29) and a higher PHQ-4 score (coeff=0.63, 95% CI 0.32-0.94). Relative to White respondents, racial/ethnic minorities had a higher likelihood of feeling stress: Black OR=7.13, 95% CI 4.68-10.85; Hispanics OR=3.81, 95% CI 2.11-6.89; and other races OR=2.61, 95% CI 1.51-4.53. Estimated associations varied across racial/ethnic groups, age groups, and survey waves. Our study showed that experienced COVID-19-related racism and discrimination increased during the first 2 years of the pandemic and was associated with greater psychological distress among Wisconsinites of all racial/ethnic groups. Public health policies promoting inclusiveness should be implemented to reduce (COVID-19-related) racism and discrimination and its long-term effects on mental health and well-being.

Effect of the COVID-19 pandemic on meaningful activity engagement in racially and ethnically diverse older adults

BACKGROUND

Participation and active engagement in meaningful activities support the emotional and physical well-being of older adults. In 2020, the onset of the COVID-19 pandemic altered lives, including the ability to participate in meaningful activities. This study compared meaningful activity engagement before and at the beginning of the COVID-19 pandemic in a nationally representative, diverse sample >65 years between 2015 and 2020.

METHODS

We described the proportions and characteristics of National Health and Aging Trends Study participants and their engagement in four activities: visiting friends or family, attending religious services, participating in clubs/classes/other organized activities, and going out for enjoyment. We used mixed effects logistic regressions to compare probabilities of activity engagement before 2020 and in 2020, adjusting for age, sex, functional status, income, geographic region, anxiety-depression, and transportation issues.

RESULTS

Of 6815 participants in 2015, the mean age was 77.7 (7.6) years; 57% of participants were female; 22% were Black, 5% Hispanic, 2% were American Indian, and 1% were Asian; 20% had disability; and median income was $33,000. Participation in all four activities remained consistent between 2015 and 2019 and declined in 2020. Significant differences existed in attending religious services (p < 0.01) and going out for enjoyment (p < 0.001) by race and ethnicity, before and after the start of COVID-19. Black and Hispanic participants experienced the largest decline in attending religious services (-32%, -28%) while Asian and White participants experienced the largest decline in going out for enjoyment (-49%, -56%).

CONCLUSIONS

Potential quality of life tradeoffs should be considered to a greater extent in future pandemic emergencies.

Experience of Racial Discrimination was Associated with Psychological Distress and Worsening Sex Life Among Adult Americans During COVID-19

The recent escalation of racism in the U.S. during the COVID-19 pandemic points to the importance of examining the association between experienced racism and sexual health. Based on data from a nationally representative survey conducted in the U.S. in October 2020 (n = 1,915), Chi-square tests and multivariable logistic regressions were estimated to examine the association between experience of racism and changes in sex life during the pandemic. We further performed a causal mediation analysis using the bootstrap technique to assess the mediating role of psychological distress in the observed association between the experience of racism and changes in sex life. Among the respondents, the proportions reporting better, worse, or no change in sex life were, respectively, 15%, 21%, and 64%. Experiencing racial discrimination during COVID-19 was significantly associated with worsening sex life (adjusted odd ratio [AOR] = 1.53; 95% confidence interval [CI] = 1.04, 2.25). Respondents with experienced racism were also more likely to report psychological distress (AOR = 1.68; 95% CI = 1.09, 2.59). About one-third (32.66%) of the observed association between experienced racism and worsening sex life was mediated through psychological distress. Addressing racism and its association with psychological distress has the potential to improve sexual health and reduce related racial and ethnic disparities.

Racial-ethnic disparities in psychological distress during the COVID-19 pandemic in the United States: the role of experienced discrimination and perceived racial bias

BACKGROUND

Research on mental health disparities by race-ethnicity in the United States (US) during COVID-19 is limited and has generated mixed results. Few studies have included Asian Americans as a whole or by subgroups in the analysis.

METHODS

Data came from the 2020 Health, Ethnicity, and Pandemic Study, based on a nationally representative sample of 2,709 community-dwelling adults in the US with minorities oversampled. The outcome was psychological distress. The exposure variable was race-ethnicity, including four major racial-ethnic groups and several Asian ethnic subgroups in the US. The mediators included experienced discrimination and perceived racial bias toward one's racial-ethnic group. Weighted linear regressions and mediation analyses were performed.

RESULTS

Among the four major racial-ethnic groups, Hispanics (22%) had the highest prevalence of severe distress, followed by Asians (18%) and Blacks (16%), with Whites (14%) having the lowest prevalence. Hispanics' poorer mental health was largely due to their socioeconomic disadvantages. Within Asians, Southeast Asians (29%), Koreans (27%), and South Asians (22%) exhibited the highest prevalence of severe distress. Their worse mental health was mainly mediated by experienced discrimination and perceived racial bias.

CONCLUSIONS

Purposefully tackling racial prejudice and discrimination is necessary to alleviate the disproportionate psychological distress burden in racial-ethnic minority groups.

Pandemic distress associated with segregation and social stressors

Background

Racial/ethnic minorities are disproportionately impacted by the COVID-19 pandemic, as they are more likely to experience structural and interpersonal racial discrimination, and thus social marginalization. Based on this, we tested for associations between pandemic distress outcomes and four exposures: racial segregation, coronavirus-related racial bias, social status, and social support.

Methods

Data were collected as part of a larger longitudinal national study on mental health during the pandemic (n = 1,309). We tested if county-level segregation and individual-level social status, social support, and coronavirus racial bias were associated with pandemic distress using cumulative ordinal regression models, both unadjusted and adjusted for covariates (gender, age, education, and income).

Results

Both the segregation index (PR = 1.19; 95% CI 1.03, 1.36) and the coronavirus racial bias scale (PR = 1.17; 95% CI 1.06, 1.29) were significantly associated with pandemic distress. Estimates were similar, after adjusting for covariates, for both segregation (aPR = 1.15; 95% CI 1.01, 1.31) and coronavirus racial bias (PR = 1.12; 95% CI 1.02, 1.24). Higher social status (aPR = 0.74; 95% CI 0.64, 0.86) and social support (aPR = 0.81; 95% CI 0.73, 0.90) were associated with lower pandemic distress after adjustment.

Conclusion

Segregation and coronavirus racial bias are relevant pandemic stressors, and thus have implications for minority health. Future research exploring potential mechanisms of this relationship, including specific forms of racial discrimination related to pandemic distress and implications for social justice efforts, are recommended.

Associations of COVID-19 Related Work Stressors with Psychological Distress: Racial and Ethnic Disparities in Californian Workers

The COVID-19 pandemic continues to exert immense societal impacts, with recent data showing inequitable distribution of consequences among racial and ethnic groups. The objective of this study was to assess associations between COVID-related work stressors and psychological distress, with special emphasis on differences by race and ethnicity. Data were from the population-based California Health Interview Survey (CHIS) 2020. Associations of individual and cumulative work stressors, including job loss, reduced work hours, and working from home, with psychological distress in 12,113 workers were examined via multivariable linear regression, and stratified analyses were conducted for racial and ethnic subgroups. After adjustment for covariates, compared to workers with no work stressors, those who experienced either one or two/more work stressors had higher psychological distress (βs and 95% CIs were 0.80 [0.51, 1.09] and 1.98 [1.41, 2.56], respectively). Notably, experiencing cumulative (two/more) work stressors had much stronger effects on psychological distress among participants who were Black (β and 95% CI were 3.51 [1.09, 5.93]) or racial minorities (β and 95% CI were 3.57 [1.10, 6.05]). Occupational consequences of the COVID-19 pandemic were associated with increased psychological distress in Californian workers and inequitably distributed, with racial and ethnic minorities suffering the greatest burden.

Study Protocol: A Mixed-Methods Study for Understanding Racial Disparities in COVID-19-Related Complications

Background

In the United States, the COVID-19 pandemic has magnified the disproportionate and long-standing health disparities experienced by Black communities. Although it is acknowledged that social determinants of health (SDOH) rather than biological factors likely contribute to this disparity, few studies using rigorous analytic approaches in large, information-rich community-based data sets are dedicated to understanding the underlying drivers of these racial disparities.

Objective

The overall aim of our study is to elucidate the mechanisms by which racial disparities in severe COVID-19 outcomes arise, using both quantitative and qualitative methods.

Methods

In this protocol, we outline a convergent parallel mixed methods approach to identifying, quantifying, and contextualizing factors that contribute to the dramatic disparity in COVID-19 severity (ie, hospitalization, mortality) in Black versus white COVID-19 patients within the integrated health care system of Kaiser Permanente Georgia (KPGA). Toward this end, we will generate two quantitative cohorts of KPGA members with a confirmed COVID-19 diagnosis between January 1, 2020, and September 30, 2021: (1) an electronic medical record (EMR) cohort including routinely captured data on diagnoses, medications, and laboratory values, and a subset of patients hospitalized at Emory Healthcare to capture additional in-hospital data; and (2) a survey cohort, where participants will answer a range of questions related to demographics (eg, race, education), usual health behaviors (eg, physical activity, smoking), impact of COVID-19 (eg, job loss, caregiving responsibilities), and medical mistrust. Key outcomes of interest for these two cohorts include hospitalization, mortality, intensive care unit admission, hospital readmission, and long COVID-19. Finally, we will conduct qualitative semistructured interviews to capture perceptions of and experiences of being hospitalized with COVID-19 as well as related interactions with KPGA health care providers. We will analyze and interpret the quantitative and qualitative data separately, and then integrate the qualitative and quantitative findings using a triangulation design approach.

Results

This study has been funded by a Woodruff Health Sciences grant from December 2020 to December 2022. As of August 31, 2022, 31,500 KPGA members diagnosed with COVID-19 have been included in the EMR cohort, including 3028 who were hospitalized at Emory Healthcare, and 482 KPGA members completed the survey. In addition, 20 KPGA members (10 Black and 10 white) have been interviewed about their experiences navigating care with COVID-19. Quantitative and qualitative data cleaning and coding have been completed. Data analysis is underway with results anticipated to be published in December 2022.

Conclusions

Results from this mixed methods pilot study in a diverse integrated care setting in the southeastern United States will provide insights into the mechanisms underpinning racial disparities in COVID-19 complications. The quantitative and qualitative data will provide important context to generate hypotheses around the mechanisms for racial disparities in COVID-19, and may help to inform the development of multilevel strategies to reduce the burden of racial disparities in COVID-19 and its ongoing sequelae. Incorporating contextual information, elucidated from qualitative interviews, will increase the efficacy, adoption, and sustainability of such strategies.

International Registered Report Identifier (IRRID)

RR1-10.2196/38914