Race, ethnicity, community-level socioeconomic factors, and risk of COVID-19 in the United States and the United Kingdom

Chun-Han Lo, Long H Nguyen, David A Drew, Erica T Warner, Amit D Joshi, Mark S Graham, Adjoa Anyane-Yeboa, Fatma M Shebl, Christina M Astley, Jane C Figueiredo, Chuan-Guo Guo, Wenjie Ma, Raaj S Mehta, Sohee Kwon, Mingyang Song, Richard Davies, Joan Capdevila, Carole H Sudre, Jonathan Wolf, Yvette C Cozier, Lynn Rosenberg, Lynne R Wilkens, Christopher A Haiman, Loïc Le Marchand, Julie R Palmer, Tim D Spector, Sebastien Ourselin, Claire J Steves, Andrew T Chan, COPE Consortium, Chun-Han Lo, Long H Nguyen, David A Drew, Erica T Warner, Amit D Joshi, Mark S Graham, Adjoa Anyane-Yeboa, Fatma M Shebl, Christina M Astley, Jane C Figueiredo, Chuan-Guo Guo, Wenjie Ma, Raaj S Mehta, Sohee Kwon, Mingyang Song, Richard Davies, Joan Capdevila, Carole H Sudre, Jonathan Wolf, Yvette C Cozier, Lynn Rosenberg, Lynne R Wilkens, Christopher A Haiman, Loïc Le Marchand, Julie R Palmer, Tim D Spector, Sebastien Ourselin, Claire J Steves, Andrew T Chan, COPE Consortium

Abstract

Background: There is limited prior investigation of the combined influence of personal and community-level socioeconomic factors on racial/ethnic disparities in individual risk of coronavirus disease 2019 (COVID-19).

Methods: We performed a cross-sectional analysis nested within a prospective cohort of 2,102,364 participants from March 29, 2020 in the United States (US) and March 24, 2020 in the United Kingdom (UK) through December 02, 2020 via the COVID Symptom Study smartphone application. We examined the contribution of community-level deprivation using the Neighborhood Deprivation Index (NDI) and the Index of Multiple Deprivation (IMD) to observe racial/ethnic disparities in COVID-19 incidence. ClinicalTrials.gov registration: NCT04331509.

Findings: Compared with non-Hispanic White participants, the risk for a positive COVID-19 test was increased in the US for non-Hispanic Black (multivariable-adjusted odds ratio [OR], 1.32; 95% confidence interval [CI], 1.18-1.47) and Hispanic participants (OR, 1.42; 95% CI, 1.33-1.52) and in the UK for Black (OR, 1.17; 95% CI, 1.02-1.34), South Asian (OR, 1.39; 95% CI, 1.30-1.49), and Middle Eastern participants (OR, 1.38; 95% CI, 1.18-1.61). This elevated risk was associated with living in more deprived communities according to the NDI/IMD. After accounting for downstream mediators of COVID-19 risk, community-level deprivation still mediated 16.6% and 7.7% of the excess risk in Black compared to White participants in the US and the UK, respectively.

Interpretation: Our results illustrate the critical role of social determinants of health in the disproportionate COVID-19 risk experienced by racial and ethnic minorities.

Keywords: COVID-19; Epidemiology; Ethnicity; Inequity; Race; Socioeconomic factor.

Conflict of interest statement

JC reports personal fees from Zoe Ltd. during the conduct of the study and outside the submitted work and is an employee of Zoe Ltd. TDS is a consultant to Zoe Ltd. LLM reports grants from National Cancer Institute during the conduct of the study. SO reports grants from Wellcome Trust, grants from Innovate UK (UKRI), grants from Chronic Disease Research Foundation (CDRF) outside the submitted work. DAD reports grants from National Institutes of Health, grants from American Gastroenterological Association during the conduct of the study and that he previously served as an investigator for a clinical trial of diet and lifestyle using a separate mobile application that was supported by Zoe Ltd. RD reports grants from Department of Health and Social Care (UK), personal fees from Zoe Ltd. during the conduct of the study and outside the submitted work and is an employee of Zoe Ltd. CJS reports grants from Chronic Disease Research Foundation during the conduct of the study. CHS reports grants from Alzheimer's Society during the conduct of the study. CMA reports grants from National Institutes of Health K23 DK120899 and Boston Children's Hospital Office of Faculty Development Career Development Award during the conduct of the study. ATC reports personal fees from Bayer Pharma AG, Pfizer Inc., Boehringer Ingelheim, and grants from Zoe Ltd. outside the submitted work and that he previously served as an investigator for a clinical trial of diet and lifestyle using a separate mobile application that was supported by Zoe Ltd. JW is the CEO of Zoe Ltd. Other authors have no conflict of interest to declare.

© 2021 The Author(s).

Figures

Fig. 1
Fig. 1
Risk of living in a community within the highest quintile of community-level deprivation according to race and ethnicity. Data points represent the odds ratios with 95% confidence intervals. In both countries, White participants were used as the reference group. “Hispanic” in the United States was defined as any race of Hispanic or Latino ancestry, while other racial categories were defined as each respective race not of Hispanic or Latino ancestry. Community-level deprivation was represented by the Neighborhood Deprivation Index in the United States and the Index of Multiple Deprivation in the United Kingdom. Higher scores represented more deprived communities.
Fig. 2
Fig. 2
Risk of living in community with specific measures of deprivation according to race and ethnicity in the United States. Data points represent the odds ratios with 95% confidence intervals. White participants were used as the reference group. “Hispanic” was defined as any race of Hispanic or Latino ancestry, while other racial categories were defined as each respective race not of Hispanic or Latino ancestry. Census data from the US Census Bureau were assigned to each participant based on ZIP Code Tabulation Areas. Each domain categorized based on these cutoffs was associated with an increased risk of personal contact with COVID-19 and testing positive for COVID-19 in Supplementary Fig. 1.
Fig. 3
Fig. 3
Risk of living in community with specific measures of deprivation according to race and ethnicity in the United Kingdom. Data points represent the odds ratios with 95% confidence intervals. White participants were used as the reference group. Data from the Office for National Statistics (England), the Welsh Government (Wales), the Scottish Government (Scotland), and the Northern Ireland Statistics and Research Agency (Northern Ireland) were assigned to each participant based on Lower Layer Super Output Areas. Each domain except for housing categorized based on these cutoffs was associated with an increased risk of personal contact with COVID-19 and testing positive for COVID-19 in Supplementary Fig. 2.
Fig. 4
Fig. 4
Connections and consequences of social determinants of health in the context of COVID-19 risk. We propose that social determinants of health are the root causes of health disparities at the population level. Upstream social determinants contribute to midstream factors, such as environmental conditions and occupational factors, which in turn mediate the effects of social determinants of health on downstream health outcomes, including obesity and diabetes, among others. Finally, excess downstream COVID-19 risk is proposed to result from the upstream and midstream factors. Examples of each determinant and their contribution to COVID-19 risk are presented.

References

    1. Sze S., Pan D., Nevill C.R., Gray L.J., Martin C.A., Nazareth J. Ethnicity and clinical outcomes in COVID-19: a systematic review and meta-analysis. EClinicalMedicine. 2020;29–30
    1. Iceland J., Mateos P., Sharp G. Ethnic residential segregation by nativity in Great Britain and the United States. J Urban Aff. 2011;33(4):409–429.
    1. U.S. Census Bureau. Multigenerational households: 2009-2011 Internet. 2012 Oct 1. Available from:
    1. Caldwell J.T., Ford C.L., Wallace S.P., Wang M.C., Takahashi LM. Intersection of living in a rural versus urban area and race/ethnicity in explaining access to health care in the United States. Am J Public Health. 2016;106(8):1463–1469.
    1. U.S. Bureau of Labor Statistics. Workers who could work at home, did work at home, and were paid for work at home, by selected characteristics, averages for the period 2017-2018 Internet. 2019 Sep 24. Available from:
    1. U.S. Bureau of Labor Statistics. Employed persons by detailed occupation, sex, race, and Hispanic or Latino ethnicity Internet. 2021 Jan 22. Available from:
    1. Lymperopoulou K., Finney N. Socio-spatial factors associated with ethnic inequalities in districts of England and Wales, 2001–2011. Urban Stud. 2017;54(11):2540–2560.
    1. Figueroa J.F., Wadhera R.K., Lee D., Yeh R.W., Sommers B.D. Community-level factors associated with racial and ethnic disparities in COVID-19 rates in Massachusetts. Health Aff. 2020;39(11):1984–1992.
    1. Seligman B., Ferranna M., Bloom D.E. Social determinants of mortality from COVID-19: a simulation study using NHANES. PLoS Med. 2021;18(1)
    1. Hatef E., Chang H.Y., Kitchen C., Weiner J.P., Kharrazi H. Assessing the impact of neighborhood socioeconomic characteristics on COVID-19 prevalence across seven states in the United States. Front Public Health. 2020;8
    1. Figueroa J.F., Wadhera R.K., Mehtsun W.T., Riley K., Phelan J., Jha A.K. Association of race, ethnicity, and community-level factors with COVID-19 cases and deaths across U.S. counties. Healthcare. 2021;9(1)
    1. Price-Haywood E.G., Burton J., Fort D., Seoane L. Hospitalization and mortality among black patients and white patients with Covid-19. N Engl J Med. 2020;382(26):2534–2543.
    1. Azar K.M.J., Shen Z., Romanelli R.J., Lockhart S.H., Smits K., Robinson S. Disparities in outcomes among COVID-19 patients in a large health care system in California. Health Aff. 2020;39(7):1253–1262.
    1. Drew D.A., Nguyen L.H., Steves C.J., Menni C., Freydin M., Varsavsky T. Rapid implementation of mobile technology for real-time epidemiology of COVID-19. Science. 2020;368(6497):1362–1367.
    1. Chan A.T., Drew D.A., Nguyen L.H., Joshi A.D., Ma W., Guo C.G. The COronavirus Pandemic Epidemiology (COPE) consortium: a call to action. Cancer Epidemiol Biomark Prev. 2020;29(7):1283–1289.
    1. National Institutes of Health. Racial and ethnic categories and definitions for NIH diversity programs and for other reporting purposes [Internet]. 2015 Apr 8. Available from:
    1. Office for National Statistics. Ethnic group, national identity and religion [Internet]. Available from:
    1. U.S. Census Bureau. Quick Facts in the United States [Internet]. 2019 Jul 1. Available from:
    1. Office for National Statistics. Population of England and Wales [Internet]. 2018 Aug 1. Available from:
    1. U.S. Census Bureau. Explore Census Data [Internet]. Available from:
    1. Messer L.C., Laraia B.A., Kaufman J.S., Eyster J., Holzman C., Culhane J. The development of a standardized neighborhood deprivation index. J Urban Health. 2006;83(6):1041–1062.
    1. Ministry of Housing, Communities & Local Government. English indices of deprivation 2019 [Internet]. . 2019 Sep 26. Available from:
    1. Welsh Government. Welsh Index of Multiple Deprivation [Internet]. 2019 Nov 27. Available from:
    1. Scottish Government. Scottish Index of Multiple Deprivation [Internet]. 2020. Available from:
    1. Northern Ireland Statistics and Research Agency. Northern Ireland Multiple Deprivation Measure [Internet]. 2017 Nov 23. Available from:
    1. Nguyen L.H., Drew D.A., Graham M.S., Joshi A.D., Guo C.G., Ma W. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Health. 2020;5(9):e475–e483.
    1. Lee S.F., Nikšić M., Rachet B., Sanchez M.J., MA L.F. Socioeconomic inequalities and ethnicity are associated with a positive COVID-19 test among cancer patients in the UK Biobank cohort. Cancers. 2021;13(7):1514.
    1. Yancy CW. COVID-19 and African Americans. JAMA. 2020;323(19):1891.
    1. Thakur N., Lovinsky-Desir S., Bime C., Wisnivesky J.P., Celedón J.C. The structural and social determinants of the racial/ethnic disparities in the U.S. COVID-19 pandemic. what's our role? Am J Respir Crit Care Med. 2020;202(7):943–949.
    1. Bunyavanich S., Grant C., Vicencio A. Racial/ethnic variation in nasal gene expression of transmembrane serine protease 2 (TMPRSS2) JAMA. 2020;324(15):1567.
    1. Gravlee C.C. How race becomes biology: embodiment of social inequality. Am J Phys Anthropol. 2009;139(1):47–57.
    1. Hernán M.A., Hernández-Díaz S., Robins J.M. A structural approach to selection bias. Epidemiology. 2004;15(5):615–625.
    1. Griffith G.J., Morris T.T., Tudball M.J., Herbert A., Mancano G., Pike L. Collider bias undermines our understanding of COVID-19 disease risk and severity. Nat Commun. 2020;11(1):5749.
    1. Jones J., Sullivan P.S., Sanchez T.H., Guest J.L., Hall E.W., Luisi N. Similarities and differences in COVID-19 awareness, concern, and symptoms by race and ethnicity in the United States: cross-sectional survey. J Med Internet Res. 2020;22(7):e20001.
    1. Chambers L. Data show COVID-19 is hitting essential workers and people of color hardest [Internet]. ACLU of Massachusetts Data for Justice. 2020. Available from:

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