COVID-19 and Adverse Social Determinants of Health

Abstract

This introduction to the Special Issue (SI) on COVID-19 and adverse social determinants of health (SDoH) provides theoretical and empirical context for featured articles. Existing disparities and inequities are highlighted and emerging research on disparities resulting from these and the COVID-19 pandemic are briefly reviewed. General disparities and inequities resulting from the COVID-19 pandemic are briefly conceptualized through the SDoH. Critical factors outlined by the SDoH framework parallel those discussed by the Centers for Disease Control and Prevention as well as those in a conceptual framework article also feature in this SI. Some of these consist of racism, exclusion, blocked opportunity, and socioeconomic status (SES), among others. Furthermore, we discuss broader social inequities, namely growing income and wealth inequality that undermine the health and wellbeing of the general population and ethnic minority groups in particular. Big Event theory is offered as an additional conceptual framework that can illuminate potential downstream negative impacts of the pandemic. Having provided summaries of featured articles in this SI, we make a call for researchers to engage in further theoretical and empirical work to identify the most critical SDOH to further the field of public health as well as related fields and inform policy.

Keywords:

• disparities
• inequality
• adverse social determinants of health
• COVID-19

Introduction

Significant health disparities persist, and many have increased over time despite great advances in medicine and public health.^1–5 Disparities are found across the life course—for instance, birth weight, infant mortality, education, income, obesity, diabetes, substance use, heart disease, and life expectancy.^5,6 A variety of (mostly) cross-sectional surveys indicate that ethnic minority groups are disproportionately bearing the brunt of COVID-19, which appears to be the result of long-standing disparities.^7–11 For instance, 72% of Latino/a Americans, 60% of African Americans, and 53% of Native Americans reported facing serious financial problems during the COVID-19 pandemic versus 37% of Asian Americans and 36% of non-Latino/a Whites.¹¹ Disparities also exist in other marginalized populations such as sexual and gender minorities, and within these SGM population the burdens also evident among those who hold multiple minority identities.^12–14 A recent report on the Delta variant is consistent with these earlier reports on the unique issues faced by ethnic/racial minorities but also documents the generalized hardship experienced by many American households.¹⁵ However, as far as negative economic impacts are concerned, an analysis using data from the Current Population Survey (CPS, Bureau of Labor Statistics, BLS) indicated that many of the differential race/ethnicity impacts associated with the COVID-19 pandemic have diminished—though have not been completely erased for all groups.¹⁶ Additionally, geography or environmental context play a critical role,^4,17,18 as many of the articles in this Special Issue (SI) highlight. For instance, the South, and minorities within it, are particularly vulnerable to COVID-19 and its psychosocial consequences.^9,10,19 Unfortunately, disparities linked to this pandemic are not purely psychosocial. Disparities exist for infection rates, morbidity, and mortality rates.²⁰ Because research is cross-sectional and the pandemic is ongoing, the full adverse psychosocial, behavioral, and economic consequences of COVID-19 on disadvantaged minority groups will not be known for years to come, and its effects are likely to be long-term as it is associated with several key determinants of health (e.g., education, employment, income, wealth).²¹ Yet this SI identifies some of the critical psychosocial dimensions of COVID-19 disparities and inequities as well as social determinants of health (SDOH) and, as such, sets the stage for rigorous empirical and theoretically-driven investigations that will positively impact lives, further the field, and impact policy.

Health disparities associated with the COVID-19 pandemic, and perhaps others (public health) crises before it, can be best understood with the SDOH framework. This framework outlines how various social factors such as the context, socioeconomic status (SES), poverty, health equity, among others shape health.^2,5,22–25 Although some SDOH may be health-enhancing, it is critical to call attention to those that disproportionately negatively affect ethnic minorities. Indeed, many ethnic minority communities have access to a variety of protective of health-enhancing factors such as social capital and social cohesion that have provided them resilience in the face of socioeconomic and racial adversity in U.S. society.^23–26 As such, the ability of these communities to weather the crisis over the long-term might be a testament to such protective and resilience factors. Nevertheless, compared to non-Latino/a Whites, several life opportunities and upward social mobility are limited for nonwhite ethnic minorities given racism, societal exclusion, and blocked opportunity.^25,30,31 Troubling ethnic disparities and inequities exist in education, a critical SDOH because it affords better employment opportunities, increased life chances, healthier neighborhoods and lifestyles, and life expectancy.^{5,6,15,32–34} Further, socioeconomic status (SES) is one of the strongest predictors of health outcomes, and greater returns to education can be expected compared to medical advances.³⁵ Emerging evidence indicates that declining SES and related despair are driving mortality-rate increases in the U.S.^23,24,36 Further, income and wealth inequality are growing,^37–40 and not only is this resulting in declining life-expectancy^23,24,36 but it is also associated with a variety of psychological and social problems, which have direct and indirect implications for individual and population health.^28,41–44 Indeed, life-expectancy in the U.S. for several groups, which had already been declining due to the so-called diseases and deaths of despair,^23,24,36 has been reduced further, primarily for ethnic minorities, because of the pandemic.^45,46 Not only do these social and public health challenges/problems reinforce and influence one another but they may, individually and synergistically, translate into other public health as well as social problems.

Research and conceptual work on Big Events theory describes this complex process and potential downstream public health problems.^43,44 To illustrate briefly, Big Events such as profound social as well as political-economic system change (cf. dissolution of the Soviet Union⁴⁷) have been associated with injection drug use as well as HIV/AIDS epidemics in various countries.^43,44,48 Big Events (e.g., social, economic, political, environmental upheavals) intersect with preexisting social structures and conditions and both individually and synergistically influence a variety of aspects of daily and social life.⁴³,⁴⁹ These, in turn, may lead to intergenerational change in values and norms, involvement with networks or subgroups engaged in risky health behaviors, as well as immediate and downstream epidemics (cf. syndemics⁵⁰) The COVID-19 pandemic coincides with numerous social as well as existential challenges and threats: public health, social (e.g., social isolation), economic, racism, and the burden of climate change—all of which disproportionately impact ethnic as well as racial, cultural, sexual, gender, and other minority groups subjected to social and structural inequities.^27,28 In addition to being disproportionately impacted by COVID-19, ethnic minority groups are also confronted with multiple social and environmental challenges and problems that further undermine their socioeconomic progress and wellbeing. In this era—marked by COVID-19 and the aforementioned challenges—further theoretical and empirical work is needed to identify the most critical SDOH to further the field of public health as well as related fields and inform policy.

In this SI, empirical articles as well as an empirically grounded commentary on the unfolding adverse medical, psychosocial, behavioral, mental health, and social effects of the COVID-19 pandemic among ethnic minority groups are presented. In particular, articles primarily address the psychosocial dimensions of COVID-19 disparities, inequities, and their SDOH. Lee and Ramirez examined various contextual factors associated with COVID-19 infection rates in Colorado neighborhoods, extending work on the role of ecology, syndemic theory,⁵⁰ SDOH, and COVID-19 infection rates. Their findings are consistent with the literature on neighborhoods (e.g., SES) disadvantage/disparities and wellbeing. These authors examined the spatial distribution/clustering of COVID-19 incidence rates in Colorado and mapped these onto several SDOH such as education, income, ethnic density, among others. Using novel and exploratory methods, they found that neighborhood disadvantage was associated with increased vulnerability to COVID-19 infection rates. These results and methods require further work as well as replication.

A recurrent theme in multiple articles of the SI are the health consequences of the COVID-19 pandemic amid a “pandemic” of racism/ethnic discrimination.⁵¹ Zhou and colleagues highlight that stressors related to COVID-19 intersected with a heightened awareness of racism/ethnic discrimination in the U.S. In turn, the combined exposure to COVID-19 stressors and the direct and indirect exposure to racism/ethnic discrimination help advance our understanding of posttraumatic stress symptoms among racial/ethnic minorities. Similarly, the study by Thomas-Hawkins demonstrated that stressors related to COVID-19 compounded sociocultural stressors that are often experienced by racial/ethnic minorities. Specifically, worrying about contracting COVID-19 exacerbated adverse associations among indicators of workplace discrimination in relation to emotional well-being among nurses. In their study, Wong-Padoongpatt, Barrita, and King captured the manner in which COVID-19 may have increased perceptions/experiences of ethnic discrimination among people of Asian heritage. Their findings indicate that compared to Latinos/as Asians reported higher levels of perceived ethnic discrimination, and in turn, higher levels of internalized racism, which may have significant implications for the development of poor mental health. Lastly, Romero and colleagues focused on a vulnerable population—pregnant women. They found that compared to non-Hispanic Whites, Black and Latina women were more likely to report negative prenatal and postpartum experiences. These differences were partly explained by SDOH that included indicators of lower socioeconomic resources and having an occupation that places them as essential workers.

Although their samples and methods differ, the studies in this SI show that context matters in ways consistent with the SDOH as well as the literature outlined above on the effects of place/space, SES (e.g., education, income), ethnic/racial density as well as segregation, among others.^2,5,19–22 Another point of convergence between studies is on the significance of mental health during the COVID-19 pandemic, though the exact relationship between mental health and COVID-19 outcomes are still not well-understood. Because all studies were conducted in the U.S. or developed countries, further studies should be conducted in both non-Western and low-resource societies to illustrate how SDOH potentially operate in these contexts. Replicated with different samples, various measures, and methods, cross-culturally informed work may uncover interesting and perhaps culturally influenced relationships on the SDOH. Collectively, all studies serve as empirical examples that support the conceptual framework developed by Webb Hooper and colleagues. In their timely commentary, they propose an exploratory model to better understand the effects of multiple SDOH on COVID-19 cases and COVID-19 disparities that are influenced by longstanding inequities stemming from structural racism and discrimination.

In summary, all articles in this SI have a theoretical grounding in the SDOH, social epidemiology, and/or contextualize current COVID-19-related adversities with long-standing inequities. It is our hope that the articles presented in this SI will stimulate ongoing collaborative, interdisciplinary research on the adverse and unanticipated outcomes associated with the COVID-19 pandemic—and that will further our understanding of the various protective and risk factors for various groups. Such research is critical to help communities, especially vulnerable ones, to weather further affronts to their health and wellbeing.

Disclosure statement

The authors have no conflicts of interest to disclose.

Funding

The author(s) reported there is no funding associated with the work featured in this article.