The COVID-19 pandemic disproportionately impacted racial and ethnic minorities in the US, with Black and Hispanic populations experiencing significantly higher hospitalization and death rates compared to White individuals. These disparities are multifactorial, stemming from factors such as lower insurance coverage, inadequate management of comorbidities, chronic stress from discrimination, and occupational exposure risks rooted in structural racism. While previous research indicated that racial minorities perceived a higher risk of contracting COVID-19 and often adopted better preventative practices, this study aimed to investigate the interplay between race/ethnicity, SDOH, and COVID-19-related attitudes, practices, and mental health outcomes. The study focuses on Arkansas, a state with consistently poor health outcomes and significant racial and ethnic disparities in morbidity and mortality rates for various conditions. The study utilized data from a UAMS COPH random digit pulse poll to analyze the relationship between SDOH and COVID-19-related outcomes across different racial and ethnic groups in this context of high COVID-19 transmission in Arkansas.

Existing literature reveals conflicting findings on racial differences in COVID-19-related risk perception, knowledge, attitudes, and practices. Some studies found that racial minorities perceived a greater risk and exhibited safer practices, potentially due to awareness of structural disadvantages. Others found less worry and fewer behavioral changes among Black respondents. Studies also highlight racial and ethnic disparities in mental health outcomes related to the pandemic, with minorities reporting higher rates of anxiety, depression, substance use, and suicidal ideation. This study builds on this existing body of research by examining the complex interplay of SDOH, race/ethnicity, and COVID-19-related outcomes in a specific state context.

The study used data from the Pandemic Pulse Poll conducted by UAMS COPH from May to December 2020. The poll employed random digit dialing to contact Arkansans aged 18 and older. The analysis focused on data from September to December 2020 (n=8582) after excluding participants who did not identify as White, Black, or Hispanic, or had missing data. Variables included demographic characteristics (sex, age, race/ethnicity, rurality), COVID-19 attitudes (composite score from eight binary-transformed variables), practices (composite score from three variables), and a 4-item SDOH score (composite score reflecting access to care and financial security). Mental health outcomes were assessed using the PHQ-2 (depression) and GAD-2 (anxiety). Weighted multivariable linear and logistic regressions were used to analyze the associations between SDOH scores and COVID-19 attitudes, practices, and mental health outcomes, stratified by race/ethnicity, while controlling for age, sex, and rurality.

Compared to White respondents, Black and Hispanic respondents had significantly higher attitude and practice scores (indicating safer behaviors), despite having significantly lower SDOH scores. A one-point increase in the SDOH score was associated with a 0.35-point decrease in attitude scores and a 0.09-point decrease in practice scores overall. This negative association between SDOH and safer behaviors was also observed within each racial group (White, Black, and Hispanic), although the effect was less pronounced for Black respondents' practices. Furthermore, a one-point increase in the SDOH score was associated with 76% and 85% increased odds of screening negative for anxiety and depression, respectively. However, when considering mental health outcomes, Black respondents experienced worse mental health compared to White respondents regardless of SDOH score. The 95% confidence intervals for the association between SDOH and mental health outcomes across racial groups did not indicate statistically significant differences in the strength of these associations, although there were notable differences in the actual outcomes themselves.

The findings reveal a complex relationship between SDOH, race/ethnicity, COVID-19 behaviors, and mental health. While Black and Hispanic respondents exhibited safer COVID-19 attitudes and practices, their lower SDOH scores highlight the underlying social inequities driving these behaviors. The need to adopt safer practices may be a consequence of their greater vulnerability and exposure to risks associated with lower socioeconomic status and structural racism. The association between higher SDOH scores and better mental health, but also riskier behaviors, suggests a complex interplay of factors that require further investigation. The disparity in mental health outcomes between Black and White respondents, independent of SDOH, emphasizes the enduring effects of structural racism and other social factors beyond the scope of the SDOH score.

This study underscores the critical role of SDOH in shaping COVID-19-related attitudes, practices, and mental health outcomes, especially among racial and ethnic minorities. The findings highlight the need for targeted interventions that address systemic inequities and improve access to resources for vulnerable communities. Future research should explore the interplay of additional social factors, such as discrimination and fear of deportation, and investigate the long-term mental health consequences of the pandemic on these populations.

The study's limitations include the relatively small sample size of some racial groups which limits the power of analyses comparing mental health outcomes across racial groups, the inability to examine changes over time (due to changes in the survey questions), and the potential for unmeasured SDOH variables to impact the results. The study's timeframe, ending before vaccine introduction and the discovery of new variants, also limits the generalizability of the findings.