Abstract
An accurate understanding of the distributional implications of public health policies is critical for ensuring equitable responses to the COVID-19 pandemic and future public health threats. To identify and quantify the association of race/ethnicity-based, sex-based, and income-based inequities of state-specific lockdowns with 6 well-being dimensions in the United States. This pooled, repeated cross-sectional study used data from 14 187 762 households who participated in phase 1 of the population-representative US 2020 Household Pulse Survey (HPS). Households were invited to participate by email, text message, and/or telephone as many as 3 times. Data were collected via an online questionnaire from April 23 to July 21, 2020, and participants lived in all 50 US states and the District of Columbia. Indicators of race/ethnicity, sex, and income and their intersections. Unemployment; food insufficiency; mental health problems; no medical care received for health problems; default on last month's rent or mortgage; and class cancellations with no distance learning. Race/ethnicity, sex, income, and their intersections were used to measure distributional implications across historically marginalized populations; state-specific, time-varying population mobility was used to measure lockdown intensity. Logistic regression models with pooled repeated cross-sections were used to estimate risk of dichotomous outcomes by social group, adjusted for confounding variables. The 1 088 314 respondents (561 570 [51.6%; 95% CI, 51.4%-51.9%] women) were aged 18 to 88 years (mean [SD], 51.55 [15.74] years), and 826 039 (62.8%; 95% CI, 62.5%-63.1%) were non-Hispanic White individuals; 86 958 (12.5%; 95% CI, 12.4%-12.7%), African American individuals; 86 062 (15.2%; 95% CI, 15.0%-15.4%), Hispanic individuals; and 50 227 (5.6%; 95% CI, 5.5%-5.7%), Asian individuals. On average, every 10% reduction in mobility was associated with higher odds of unemployment (odds ratio [OR], 1.3; 95% CI, 1.2-1.4), food insufficiency (OR, 1.1; 95% CI, 1.1-1.2), mental health problems (OR, 1.04; 95% CI, 1.0-1.1), and class cancellations (OR, 1.1; 95% CI, 1.1-1.2). Across most dimensions compared with White men with high income, African American individuals with low income experienced the highest risks (eg, food insufficiency, men: OR, 3.3; 95% CI, 2.8-3.7; mental health problems, women: OR, 1.9; 95% CI, 1.8-2.1; medical care inaccessibility, women: OR, 1.7; 95% CI, 1.6-1.9; unemployment, men: OR, 2.8; 95% CI, 2.5-3.2; rent/mortgage defaults, men: OR, 5.7; 95% CI, 4.7-7.1). Other high-risk groups were Hispanic individuals (eg, unemployment, Hispanic men with low income: OR, 2.9; 95% CI, 2.5-3.4) and women with low income across all races/ethnicities (eg, medical care inaccessibility, non-Hispanic White women: OR, 1.8; 95% CI, 1.7-2.0). In this cross-sectional study, African American and Hispanic individuals, women, and households with low income had higher odds of experiencing adverse outcomes associated with the COVID-19 pandemic and stay-at-home orders. Blanket public health policies ignoring existing distributions of risk to well-being may be associated with increased race/ethnicity-based, sex-based, and income-based inequities.
Highlights
Since the COVID-19 outbreak was declared a global pandemic, the threat of the virus has been evolving and unpredictable
Every 10% reduction in mobility was associated with higher odds of unemployment, food insufficiency (OR, 1.1; 95% CI, 1.1-1.2), mental health problems (OR, 1.04; 95% CI, 1.0-1.1), and class cancellations (OR, 1.1; 95% CI, 1.1-1.2)
Across most dimensions compared with White men with high income, African American individuals with low income experienced the highest risks
Summary
Since the COVID-19 outbreak was declared a global pandemic, the threat of the virus has been evolving and unpredictable. During the early months of COVID-19 in the United States, stay-at-home orders were implemented in most states The goal of these orders was to reduce the potential for personal contact, which can contribute to the spread of COVID-19.5 Statewide mandates, while varying in strictness, were blanket strategies that restricted movement by requiring citizens to stay home except to conduct essential tasks or business. These policies have been associated with important reductions in cases and deaths,[6] the benefits have been unequally distributed across the population. Quantifying the heterogeneity of risks across the population can aid decision-makers in predicting and balancing consequences prior to policy implementation for more equitable COVID-19 pandemic outcomes
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