US Pharm. 2023;48(4):46-50.
ABSTRACT: Certain risk factors, such as coexisting comorbidities, have been shown to influence COVID-19 outcomes. Additionally, disparities in COVID-19 outcomes, including higher rates of cases, hospitalizations, and mortality, were noted early in the pandemic among U.S. minority populations compared with the white population. These results rekindled discussions about health inequities in minority groups and other vulnerable populations. Although rates of COVID-19 cases and mortality have declined, the fact that notable differences existed initially indicates the need to further evaluate potential reasons for these disparities and prevent future recurrence. Awareness of possible contributors to differences in COVID-19 outcomes in minority populations and solutions for minimizing or mitigating them can improve healthcare access and healthcare quality in these patient populations.
As of January 2023, more than 102 million people in the United States have been infected with COVID-19, and more than 1.1 million COVID-19–associated deaths have resulted.1 Although certain underlying comorbidities have been identified as risk factors for more severe COVID-19 outcomes, it has also been suggested that racial or ethnic minority groups have been disproportionately affected.2-12
What the Numbers Say
At the beginning of the COVID-19 pandemic, higher rates of cases, hospitalizations, and mortality were noted specifically in the African American and Hispanic populations, as well as the Native American and Asian American populations to some degree, compared with the white population. These differences in outcomes were seen regardless of geographic location. In April 2020, African American persons had higher rates of COVID-19–related deaths in Louisiana (56.25%), Alabama (47.4%), and Michigan (40%) despite comprising only 32.7%, 26.8%, and 14%, respectively, of the population of these states.4 In May 2020, mortality from COVID-19 in New York City was higher in Hispanic persons (187 per 100,000 residents) and African American persons (184 per 100,000 residents) compared with white persons (93 per 100,000 residents).3 In Chicago, higher mortality rates were reported in Hispanic persons (36 per 100,000 residents) and African American persons (73 per 100,000 residents) compared with white persons (22 per 100,000 residents). On December 28, 2022, the CDC reported that rate ratios for COVID-19 cases, hospitalizations, and deaths were higher in non-Hispanic American Indian/Alaska Native persons, non-Hispanic black/African American persons, and Hispanic/Latino persons (TABLE 1); this suggests that race and ethnicity could be risk markers for other conditions that affect health, such as socioeconomic status, healthcare access, and occupation-related viral exposure.13
Current (January 2023) rates of COVID-19 cases for which race or ethnicity was reported are as follows: 53.6% in the non-Hispanic white population; 24.5% in the Hispanic/Latino population; 12.4% in the non-Hispanic black population; 4.4% in the non-Hispanic Asian population; 3.8% in the non-Hispanic/Other population; 1% in the non-Hispanic American Indian/Alaska Native population; and 0.3% in the non-Hispanic Native Hawaiian/Other Pacific Islander population.14 Current rates of COVID-19 deaths are as follows: 63.6% in the non-Hispanic white population; 16.8% in the Hispanic/Latino population; 13% in the non-Hispanic black population; 3.2% in the non-Hispanic Asian population; 1.1% in the non-Hispanic American Indian/Alaska Native population; 2.1% in the non-Hispanic Multiple/Other population; and 0.2% in the non-Hispanic Native Hawaiian/Other Pacific Islander population.14
These numbers can be compared with U.S. population statistics. Non-Hispanic white persons represent 59.3% of the population; Hispanic/Latino persons, 18.9%; non-Hispanic black persons, 13.6%; non-Hispanic Asian persons, 6.1%; non-Hispanic American Indian/Alaska Native persons, 1.3%; and non-Hispanic Native Hawaiian/Other Pacific Islander, 0.3%.15
Although the rates of cases and mortality have decreased throughout the COVID-19 pandemic, the fact that notable differences existed initially indicates the need to further evaluate potential reasons for these disparities and prevent their recurrence in the future.
Recognizing Long-Standing Health Disparities
The U.S. has a long-standing history of health disparities, especially involving comorbid conditions, healthcare access, and likelihood of having a primary care provider (PCP).4,6,7 The COVID-19 pandemic has demonstrated that a number of health inequities remain present among minority and underserved populations. It is therefore prudent to investigate the explanations for these imbalances to improve outcomes in these patient populations while avoiding perpetuation of racial or ethnic stereotypes. Studies have suggested possible explanations including a mix of social and structural determinants of health, racism and discrimination, economic and educational disadvantages, healthcare access and quality, and individual behaviors and biology.3,8,9 Awareness of the risk factors for and contributors to these inequities not only could guide clinicians in identifying risk factors for poorer COVID-19 outcomes and performing risk stratification for their patients but could also enhance public-health efforts to better serve vulnerable groups. This article will explore contributors to the varied COVID-19 outcomes among minority populations and summarize current thinking on possible remedies for these disparities.
Causes of Disparities in Minority Populations
Experiences from previous pandemics and research from the beginning of the COVID-19 pandemic suggest that inequalities continue to exist for minority populations. The risk of COVID-19 exposure and the number of hospitalizations, severity, and mortality were higher among minority populations across several studies.16-30 In response to these results, a multitude of possibilities for the disparities in outcomes have been proposed. Accordingly, discussions have arisen regarding what the contributors to these results may be and how they can be controlled to address the root cause of the poorer outcomes noted in minority populations. Host and environmental factors as well as social determinants of health can provide insight into the differences in outcomes between minority populations and the white population.16
Studies have found a correlation between poorer COVID-19 outcomes and certain comorbid conditions.16,17,23,26 One study demonstrated a strong association between severe COVID-19 infection and obesity, pneumonia history, and diabetes mellitus as well as a moderate association for hypertension and renal disease.23 The fact that comorbid conditions could lead to increased COVID-19 severity and possibly poorer outcomes highlights the need to better manage these conditions in minority populations. African American persons have disproportionately more comorbid conditions, such as hypertension, diabetes mellitus, obesity, and coronary artery disease, compared with white persons.16 Additionally, not only are healthful groceries often less accessible but marketing campaigns for unhealthful products such as alcohol, cigarettes, and fast food tend to target minority populations. Difficulty obtaining healthful foods and exposure to advertising that leads to indulgence in unhealthful products can result in or worsen comorbidities. Additionally, although having a PCP appears to lower the risk of hospitalization for COVID-19, some patients may not have a PCP to manage their medical conditions because of healthcare cost or lack of access.18,28 Lack of healthcare insurance and access is higher in minority populations, with reported rates of 12% in African American, 19% in Hispanic, and 22% in Native American populations compared with 8% of the white population.16 The inability to follow up and actively manage existing medical conditions can lead to their worsening or to the development of other chronic diseases.
Such difficulties point to another possible overarching contributor to the disparities in COVID-19 outcomes noted in minority populations: barriers to healthcare access and information. Compared with the white population, minority populations have higher rates of poverty, which imposes financial limitations on health-related decision making.16 A lack of health insurance is an additional barrier because of the higher costs for healthcare services and medical treatment.20,22,24 When the COVID-19 pandemic started, the shrinking of the workforce impacted sectors in which many minority populations worked, leading to the loss of health insurance.20 Minority populations also tended to live in areas where COVID-19 testing sites were limited or where site access was restricted, leading to fewer individuals being tested. One study reported that only 6.7% and 19.1% of participants who completed COVID-19 testing were black or Hispanic, respectively, compared with 48.3% of white participants.20 Another study concluded that outpatient treatment for COVID-19 was 35.8% lower in African American persons and 29.9% lower in Hispanic persons compared with non-Hispanic persons.31
Another reason for barriers to healthcare access could be challenges related to transportation to healthcare sites. For example, 19.7% of black households, 12% of Latino households, and 13.6% of Native American households do not own a car, compared with 6.5% of white households.18 Other explanations for limited access include communication gaps due to socioeconomic disadvantages, decreased healthcare literacy, and low English proficiency.20 Many residents of Hispanic communities acquire information through their church, but amid the pandemic and stay-at-home orders, the dissemination of information was impacted drastically and necessitated the acquisition of information by other means.18
Although health information is available in many different languages, it may be limited to certain modalities that can be challenging to access, especially for those without Internet service. Therefore the language barrier remains, and persons with low English proficiency or literacy continue to have reduced access to accurate information regarding COVID-19 symptom identification, testing, and treatment.20 Delays in the provision of information can lead to delays in care. These factors could provide an explanation for delayed medical therapies or inequitable medical treatment in ethnic or racial minority patients.
The increased risk of exposure to COVID-19 has also been cited as a contributor to the differences in outcomes in minority groups.16-18,20,21,24 Minority populations tend to work in essential and service industries (e.g., in New York City, African American persons constitute approximately 40% of transit workers), have fewer opportunities to work from home, and rely on one income.16-18,21 In addition to these limitations is the fact that only 55% of persons working in the food and service industries have sick leave.16 In these settings, protective equipment is not always available and staying home from work is typically not feasible, increasing the risks of exposure and transmission. In one report, only 13% of persons who reported working from home were Hispanic and 18% were African American; 26% were white, and 32% were Asian.20
Compounding these problems is the fact that minority populations tend to use public transportation.16 Social-distancing practices pose challenges for the increased use of public transportation and create other difficulties because of the tendency for minority populations to live in more densely populated neighborhoods, have more crowded living conditions, and live in multigenerational homes.16,17 This issue is multifold in that multigenerational housing also increases the risk of COVID-19 transmission to elderly persons, who constitute another vulnerable population. One other important aspect is that rates of incarceration are higher among black, indigenous, and Hispanic persons, especially those with low socioeconomic status or mental illness, compared with their white counterparts.20 Close contact is nearly impossible to avoid in the overcrowded conditions in prisons. Finally, the poorer air quality in many neighborhoods where minority populations live may contribute to COVID-19 severity as well. These various challenges can influence minority populations’ COVID-19 exposure and outcomes.
Advocacy for Minority Populations
The abovementioned health outcomes and contributing factors to COVID-19 outcomes in minority populations have gained much attention throughout the pandemic. Discussions on addressing these disparities have led to some general recommendations designed to generate ideas on what can be done. To ensure the provision of equal COVID-19 treatment and management, standardized treatment protocols should be followed for all patients who present for management regardless of their demographics.16,29 Communication barriers can be addressed by using integrated support services such as professional interpretive services in healthcare clinics and systems that could help resolve previous miscommunications and delays in care.16 Different methods of communication can be employed, including telephone calls, flyers, signs, and tests appropriately tailored to the target audience, to provide education on COVID-19 prevention.4 These communication methods can also be used to encourage scientific transparency and actively involve community members in managing their own care.
Educating PCPs and other healthcare providers about implicit bias can help improve cultural competency and minimize mistrust of providers, thereby enhancing the equality as well as quality of care delivered to these patients.16 The development of mobile outreach programs and telehealth opportunities and the involvement of community-based organizations that serve vulnerable populations can increase access to resources that otherwise are unattainable and can provide consistent efforts to foster trustful relationships with minority populations and enable follow-up and access to appropriate care.9,32 Navigator programs can also be used to ensure that adequate testing sites are available as both walk-up and drive-through sites to accommodate varying degrees of transportation available to minority populations.
Supporting community programs that enhance neighborhood stability, incorporating community health workers, implementing policies to empower minority communities economically, and providing access to healthcare via community health centers or safety-net hospitals can increase awareness about COVID-19 as well as repair the mistrust of the healthcare system and decrease the burden that minority populations may experience when healthcare resources are not available to them. Ensuring that minority populations are adequately represented in research studies can help clarify where differences in outcomes may lie so that solutions can be better tailored to tackling the contributing factors and helping prevent poor outcomes. Other possible solutions that have been suggested include addressing unemployment insurance, supplying home delivery of meals and groceries, and providing temporary financial assistance through the community or government.10,32
As more results from scientific studies on COVID-19–associated health disparities in minority populations are published, guidance on healthcare policies, preventive care, and impactful interventions can be refined. COVID-19 itself is evolving, and with the development of vaccines and adoption of other preventive practices, changes in the disparities seen in minority populations may occur as well. Some studies have shown variations in COVID-19 outcomes between races or ethnicities.22,33,34 However, other factors could be responsible for the differences in these studies, such as the time course of therapy, the disease timeline, or the treatment setting (i.e., inpatient care may yield improved outcomes depending on available resources and whether implicit bias or racism is present). If the reasons for health inequities can be identified, clinicians will ultimately be able to make better-informed decisions that could mitigate the challenges that these patient populations face and possibly improve their COVID-19 outcome measures.
Healthcare disparities have been a long-standing issue in the U.S., and the COVID-19 pandemic has shed light on the existing challenges that minority populations face in healthcare. Minority populations have been shown to experience increased risk of exposure to COVID because many individuals work in service jobs, have limited access to protective equipment, and have living conditions such as crowded housing and poorer air quality. Limited healthcare access likely also has contributed to the disparities in COVID-19 outcomes seen in minority populations, including limited access to financial support, health insurance, testing resources, transportation, and healthcare information. With further awareness of these possible factors, it is to be hoped that the lessons taken from the COVID-19 pandemic continue to emphasize how crucial it is for healthcare institutions and clinicians to advocate for their patients, with special attention to minority populations, and to provide the necessary resources to ensure their patients’ physical, mental, and emotional well-being.
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