High-risk, disadvantaged groups face barriers to preventing spread of COVID-19

Social factors such as education, financial stability, food security and the neighborhood where someone resides were strongly correlated with whether or not individuals with heart disease adopted measures to prevent the spread of COVID-19, including wearing masks and working from home, according to a study presented at the American College of Cardiology's 70th Annual Scientific Session. The researchers say the findings draw attention to longstanding challenges related to social determinants of health.

"Unless we look at COVID-19 through the lens of social determinants of health, we may not optimize our yield from interventions, and we might not be reaching the group of individuals who need these interventions the most," said Kobina Hagan, MD, a postdoctoral fellow at Houston Methodist Research Institute and the study's lead author.

The research is based on data from the COVID-19 Household Impact Survey, which assessed COVID-19 preventive strategies along with health and sociodemographic factors among more than 25,000 U.S. adults. The researchers analyzed responses from just over 2,000 survey respondents who reported a history of heart disease, heart attack or stroke. According to the U.S. Centers for Disease Control and Prevention, heart disease increases the risk of severe illness from COVID-19. The researchers grouped survey respondents into quartiles reflecting social risk factors based on income and financial security, employment, education, health insurance status, food insecurity and neighborhood quality.

The largest gap was seen in the degree to which respondents reported having flexibility in their work arrangements—defined as being able to work from home or cancel or postpone work activities. Compared to those with the most favorable social risk profile, those with the greatest social adversity were 46% less likely to report flexibility at work. Individuals with the greatest social adversity were also 31% less likely to engage in all social distancing measures (canceling or postponing social activities and avoiding crowded public places, restaurants and contact with high-risk people) and 17% less likely to engage in all personal protective measures (wearing a face mask, washing hands and keeping a 6-foot distance from those outside their household) compared to those with the most favorable social risk profile. These differences remained significant even after accounting for demographics and comorbidities.

The study was conducted before COVID-19 vaccines were available, at a time when public health experts primarily recommended social distancing and other measures to slow the disease's spread. However, similar trends are likely at play in the context of vaccine access, researchers said.

"I think we are repeating the same mistakes and expecting better results," Hagan said. "I hope we can come to a point where we as a society take social disparities into account in our decision making. We have to prioritize these socially disadvantaged individuals in our public policy programs, including vaccine delivery, to reduce the disparities in COVID-19 risk and outcomes."

Although the survey did not assess the reasons why respondents did or did not adopt COVID-19 mitigation measures, Hagan said many of the factors reflect circumstances that are often outside of a person's control, such as their ability to work from home. For measures that involve more personal choice, he suggested that low health literacy may play a role in the lower uptake of mitigation measures among disadvantaged groups.

"We as a society have ignored all the disparities and inequities that were happening during calmer times, even in cardiovascular disease," Hagan said. "2020 was a time when we could no longer ignore the disparities. We need to focus on holistic strategies to effectively fight this pandemic and ensure those not afforded the privilege of personal protection, social distancing and work flexibilities are prioritized with vaccine outreach to avoid further compounding existing health inequalities."

This study will be simultaneously published in Circulation: Cardiovascular Quality & Outcomes.