Category: Social Determinants

COVID-19 Vaccination Disparities and Social Determinants

Posted on by justincrow

The Social Determinants of Health (SDOH) are a major determinant of population health outcomes. Depending on how they are measured and defined, the SDOH may account for up to 90% of the variation in health outcomes between communities. COVID-19 is no exception. Previous analysis examined how factors such as race and ethnicity, occupation, poverty and rurality, and housing are playing a role in COVID-19 outcomes in Virginia and elsewhere. Access to health resources is often a factor underlying health disparities, while increasing access can help alleviate disparities created by other factors. In the case of COVID-19, access to vaccines by at-risk populations is essential to addressing disparities. The post examines vaccine disparities by poverty, rurality, and SDOH at the census tract level in Virginia as of August 26, 2021.

Poverty Level Disparities

First Dose vaccination coverage varied widely by poverty level, with the highest coverage in those census tracts with less than 10% of the population living below 100% federal poverty level. However, the lowest coverage is found in census tracts with over 39.9% of the population living below 100% federal poverty level. One of the largest disparities in vaccination rates in Virginia is found among high and low census tract poverty levels.

 

 

Health Opportunity Index Disparities

The Virginia Department of Health provides the Virginia Health Opportunity Index (HOI) which is a composite measure of the social determinants of health – the social, economic, educational and environmental factors that relate to a community’s well-being – at the census tract level. The index is divided into 5 levels – very high, high, moderate, low, and very low – and census tracts can be grouped into these 5 levels. Vaccination coverage was higher in high health opportunity census tracts than in low health opportunity census tracts. Persons living in the very high health opportunity census tracts were 37% more likely to be vaccinated as those in very low health opportunity census tracts.

 

 

Rurality Disparities

Rural and urban census tracts were classified by the Rural-Urban Commuting Area (RUCA) taxonomy and then further classified into groups – metropolitan, micropolitan, small town and rural. Based on the chart, it can be seen that, people living in metropolitan areas have a higher rate of COVID-19 first dose vaccination than those living in rural areas.  People living in metropolitan areas are 16% more likely to have received their first vaccination than those in the rural areas.

 

 

 

COVID-19 Death Disparities by Census Tract Poverty Level, Health Opportunity Index and Rurality

Posted on by justincrow

by Michael Landen & Rexford Anson-Dwamena

COVID-19 Death Disparities by Census Tract Poverty Level, Health Opportunity Index and Rurality

Disparities for key COVID-19 indicators by race/ethnicity in Virginia and the United States have been well documented (see March 8, 2021 COVID-19 Health and Disease Disparities by Race and Ethnicity in Virginia blog post). This report focuses on COVID-19 death rate disparities for adults 35-54 years of age in Virginia by census tract level poverty, health opportunity index and rurality. The entire age range was not used for this analysis because subpopulations, such as those with different poverty levels, have different age structures and therefore can’t be fairly compared for an outcome that is associated with age such as COVID-19 death. The 35-54 year age group was chosen for these comparisons because it is the youngest age group with sufficient numbers of deaths to allow for reasonable death rate comparisons at the census tract level.

Poverty Level Disparities

A person’s income is not included in their death records, however, the percentage of persons living below the federal poverty level by census tract is available. COVID-19 deaths among persons 35-54 years of age can be grouped by this percentage. The largest disparity in the COVID-19 death rate was found between those living in census tracts with the greatest percentage of persons living in poverty, >= 40%, and those living in census tracts with the lowest percentage of persons living in poverty, < 10%. Persons living in census tracts with the highest percentage of people in poverty were 2.3 times more likely to die of COVID-19 than those from the lowest poverty census tracts (Figure 1).

Figure 1.  COVID-19 Death Rates per 100,000 persons aged 35-54 years by Census Tract Percentage of Persons Living below the Federal Poverty Level, Virginia, March 2020 – April 2021

 

Health Opportunity Index Disparities

The Virginia Department of Health provides the Virginia Health Opportunity Index (HOI) which is a composite measure of the social determinants of health – the social, economic, educational and environmental factors that relate to a community’s well-being – at the census tract level. The index is divided into 5 levels – very high, high, moderate, low, and very low – and census tracts can be grouped into these 5 levels. In general, persons living in census tracts with a higher HOI tend to have lower disease and death rates.  COVID-19 deaths among persons 35-54 years of age can be grouped by the level of HOI for the census tract in which they reside. The largest disparity in the COVID-19 death rate for this age group was found between those living in census tracts with the lowest HOI and those living in census tracts with the highest HOI. Persons living in census tracts with the lowest HOI were 1.9 times more likely to die of COVID-19 than those from census tracts with the highest HOI (Figure 2).

 

Figure 2.  COVID-19 Death Rates per 100,000 persons aged 35-54 years by Census Tract HOI, Virginia, March 2020 – April 2021

 

Rurality Disparities

Persons living in rural areas, in general, tend to have higher disease and death rates than those living in metropolitan areas. Rural and urban census tracts can be classified by the Rural/Urban Community Area (RUCA) taxonomy and then further classified into groups – metropolitan, micropolitan, small town and rural.  COVID-19 deaths among persons 35-54 years of age can be grouped by these RUCA groups for the census tract in which they resided. The largest disparity in the COVID-19 death rate for this age group was found between those living in small town census tracts and those living in metropolitan census tracts. Persons living in small town census tracts were 1.5 times more likely to die of COVID-19 than those from metropolitan census tracts, and both persons from micropolitan census tracts and persons from rural census tracts were 1.4 times more likely to die of COVID-19 than those from metropolitan census tracts (Figure 3).

Figure 3.  COVID-19 Death Rates per 100,000 persons aged 35-54 years by Census Tract RUCA, Virginia, March 2020 – April 2021

COVID-19 death rates for those 35-54 years are higher in non-metropolitan communities and for persons living in communities with a higher percentage of people living in poverty in Virginia. This is not surprising since many health indicators are worse for communities with high poverty rates and for rural communities. In general, these communities may have fewer opportunities than communities with lower poverty and metropolitan communities. One approach to reducing these disparities is to increase social, economic, vocational and educational opportunities in these high poverty communities and rural communities. An “opportunity” specifically related to COVID-19 is vaccination, and these vaccinations should continue to be prioritized for persons in rural communities and those with high poverty rates or percentages.

 

Eviction Moratoriums and COVID-19

Posted on by justincrow

By Priya Pattath, Ph.D, MPH & Michael Landen, MD, MPH

Eviction Moratoriums and COVID-19

Evictions threaten to increase the spread of COVID-19 by increasing homelessness and crowding while interfering with key public health interventions such as isolation, quarantine, social distancing and contact tracing. Historically, evictions and housing displacement have been drivers of health inequity and can be particularly harmful to individual and public health during a pandemic. Populations with higher rates of COVID-19 cases, hospitalizations and death, such as African American and Hispanic populations, are more likely to face eviction which may further exacerbate COVID-19 disparities. Specifically, 80% of persons facing eviction are people of color. Reducing evictions through eviction moratoriums helps reduce COVID-19 transmission and supports public health measures.

Evictions

Many people are at risk of eviction. When the COVID-19 pandemic began in the United States, about 20.8 million renter households (47.5% of all renter households) were already rental cost-burdened. In Virginia, 499,000 households (46.1% of renter households) are rental cost-burdened, with higher percentages for Black (53.3%) and Hispanic (55.9%) households. In 2020 women and people of color were severely affected by the COVID-19 pandemic and associated economic fallout. 51.7% of individuals that were filed against for eviction since March 15, 2020 were women.

Eviction rates are not the same throughout the country. Using data from Princeton University’s Eviction Lab and the RVA,  researchers at the Federal Reserve Bank of Richmond found that localities in Virginia, North Carolina, and South Carolina rank among cities with the most evictions in the country. In Virginia in 2016, the eviction rate was 5.1% compared to 2.8% for the U.S. Richmond had the second highest eviction rate among large cities in the United States in 2016, with an eviction rate of 11.4%, while Hampton, Newport News and Chesapeake ranked 3rd, 4th and 10th, respectively with eviction rates of 10.5%, 10.2% and 7.9%, respectively. Among mid-size cities in the United States with the highest eviction rates, Petersburg, Hopewell and Portsmouth ranked 2nd, 4th and 5th, respectively with eviction rates of 17.6%, 15.7% and 15.1%, respectively. Data from the RVA Eviction Lab, also analyzed by Richmond Fed researchers, show that state and federal policies addressing the evictions were effective early in the pandemic. Compared to 2019, filings and judgments in Virginia fell significantly between January and July of 2020.  However, their effectiveness may have waned, with more than 10,500 eviction filings and 4,500 eviction judgments issued between July and September.

Evictions and COVID-19

Evictions have been shown to increase homelessness and household crowding as people lose regular housing or move into someone else’s home. Both homelessness and household crowding have been shown to increase the risk of COVID-19. Individuals experiencing homelessness are at increased risk of severe COVID-19 due to a lack of safe housing and the high prevalence of risk factors for COVID-19 in this population. In New York City among pregnant women, neighborhood socioeconomic status and household crowding were associated with the risk of COVID-19.

Recent studies have also shown that lifting eviction moratoriums was associated with increased COVID-19 incidence and mortality in various states with effects growing over time. One study pending peer review examined whether lifting eviction moratoriums was associated with COVID-19 incidence and mortality. Among 44 states that had eviction moratoriums in place during March–September 2020, twenty-seven states (61%) lifted their moratoriums during the study period. The study found that 16 weeks after eviction moratoriums were lifted, COVID-19 incidence was twice that of states that kept their moratoriums and COVID-19 mortality was 5.4 times greater translating to a total of 433,700 excess cases and 10,700 excess deaths. The study also suggested that effects grew over time, perhaps due to displacement, crowding, and homelessness as evictions proceeded.

A recent simulation study pending peer review demonstrated that, by forcing households to merge, evictions can alter the shape of COVID-19 epidemic curves in U.S. cities. The study modeled the effect of evictions on SARS-CoV-2 epidemics, simulating viral transmission within and among households in a theoretical metropolitan area. By applying the model to Philadelphia using locally specific parameters, the researchers showed that infections particularly increase in heterogeneous cities where both evictions and contacts occur more frequently in poorer neighborhoods.

Evictions may interfere with key public health measures for reducing COVID-19. Evictions may interrupt COVID-19 quarantine and isolation. Because of an acute change of address, both case investigation and contact tracing may be harder to complete.  Evictions may also lead to lower access to COVID-19 testing and access to care by driving families to poorer, under resourced neighborhoods and medically underserved geographic areas.

 Interventions

For these reasons, the Centers for Disease Control and Prevention issued an order to temporarily halt residential evictions nationwide effective September 4, 2021 to prevent the spread of COVID-19 by facilitating self-isolation, supporting stay-at-home and social distancing, and thus reducing the risk of overcrowded living environments. The order has been renewed to continue until January 31, 2021.

The initial financial stimulus from the Coronavirus Aid, Relief, and Economic Security (CARES) Act included both direct payments and enhanced unemployment benefits. Additional COVID financial relief through additional direct payments, extended unemployment benefits and rental assistance was provided at the end of December 2020 through another COVID relief package.

During the pandemic, many states have issued additional eviction bans and provided financial assistance programs. The District of Columbia offers the most comprehensive assistance by suspending all eviction proceedings. Virginia has a rent and mortgage relief program to assist households facing evictions due to COVID-19. Administered by the Virginia Department of Housing and Community Development, the Virginia Rent and Mortgage Relief Program may provide one-time payments, with an opportunity for renewal, to persons with financial need for past due rent or mortgage payments beginning April 2020.

Conclusions

Evidence strongly supports the use of eviction moratoriums and other eviction prevention efforts to reduce COVID-19 and its complications. Evictions are more common among those groups that already are experiencing a greater burden from COVID-19. Evictions increase homelessness and household crowding. Homelessness and household crowding are associated with an increased risk of COVID-19. And evictions interfere with key public health measures such as isolation, quarantine, social distancing and contact tracing. Therefore, eviction moratoriums and related policies should be effective at reducing COVID-19 cases until transmission has declined substantially, which may not occur until the summer of 2021.

References

Benfer EA, Vlahov D, Long M et al. (in press). Eviction, Health Inequity, and the Spread of COVID-19: Housing Policy as a Primary Pandemic Mitigation Strategy. Journal of Urban Health (in press).

CDC (2020). Federal Register Notice: Temporary Halt in Residential Evictions to Prevent the Further Spread of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/downloads/eviction-moratoria-order-faqs.pdf

Dolkart P & Norris S (2020). Is a Wave of Evictions Coming? Regional Matters. Federal Reserve Bank of Richmond. 

Emeruwa UN, Ona S, Shaman JL et al. (2020). Association between Built Environment, Neighborhood Socioeconomic Status, and SARS-CoV-2 Infection among Pregnant Women in New York City. JAMA. 2020;324(4):390-392.

Eviction Lab (2020). Princeton University. 

Greenberg D, Gershenson C & Desmond M (2016). Discrimination in Evictions: Empirical Evidence and Legal Challenges. Harvard Civil Rights-Civil Liberties Law Review. 2016;51(1):115-158.

Harvard Joint Center for Housing Studies (2020). America’s Rental Housing 2020 Report. 

Leifheit KM, Linton SL, Raifman J et al. (2020). Expiring Eviction Moratoriums and COVID-19 Incidence and Mortality November 30, 2020.

Lemmerman E, Louis R & Hepburn P (2020).  Preliminary Analysis: Who is being filed against during the pandemic? Eviction Lab. Princeton University.

Perri M, Dosani N & Hwang SW (2020). COVID-19 and People experiencing Homelessness: Challenges and Mitigation Strategies. 2020;192:E716-E719.

Sheen J, Nande A, Walters EL et al. (2020). The effect of eviction moratoriums on the transmission of SARS-CoV-2. medRxiv. Published online November 1, 2020:2020.10.27.20220897.

Streeter RA, Snyder JE, Kepley H et al. (2020). The geographic alignment of primary care Health Professional Shortage Areas with markers for social determinants of health. PLOS ONE 15(4): e0231443.