Racial Disparities in COVID-19 Severity are Partially Mediated by Chronic Stress– Evidence from a Large Integrated Healthcare System Restricted; Files Only

Abstract

Background: Chronic stress is disproportionally experienced by racial and ethnic minorities. Minorities have also experienced a disproportionate burden of severe COVID-19. Whether chronic stress explains the excess COVID-19 severity risk among racial minorities is unknown.

Methods: We included adults (≥18 years) enrolled in care at Kaiser Permanente Georgia (KPGA) with a confirmed COVID-19 diagnosis (defined by ICD-10 codes or positive PCR), from January 1, 2020 through September 30, 2021 (n=29,162), excluding those with incomplete biomarker data (n=18,096; 62.1%) for a final sample size of 11,066 participants. Self-reported race (Black, White, or Other) was defined using electronic medical record (EMR) data. Chronic stress, characterized as allostatic load (AL) score, was calculated based on 7 cardio-metabolic biomarkers extracted from KPGA’s EMR at least 45 days prior to COVID-19 diagnosis, and defined as high, medium, or low. Severe COVID-19 was defined as hospitalization or mortality within 30 days of COVID-19 diagnosis. To assess if AL mediated the relationship between race and severe COVID-19, we used the Baron and Kenny method of mediation, using ordinal logistic regression analyses adjusted for age, sex, comorbidities, and neighborhood-level socioeconomic factors.

Results: Among 11,066 adult KPGA members with COVID-19 and complete biomarkers, 26%, 58%, and 16%, had low, moderate, and high AL, respectively. Black (vs. White) KPGA members were 56% (OR: 1.56, 95%CI: 1.40,1.74) more likely to have moderate AL and 30% (OR: 1.30, 95%CI: 1.14,1.49) more likely to have severe COVID-19. Other (vs. White) members were 20% (OR: 1.20, 95%CI: 1.04,1.39) more likely to have moderate AL and equally likely (OR: 1.05, 95%CI: 0.86,1.28) to have severe COVID-19. Adjustment for AL risk in fully adjusted models showed that partial mediation by AL risk explained 18.0% of the disparity in severe COVID-19 among Black vs. white populations, while there was no evidence of AL mediation in Other vs. white populations.  

Conclusion: In our study, chronic stress partially mediates the relationship between race and COVID-19 severity. To mitigate excess COVID-19 risk, future interventions should target systematic and structural factors that increase stress, including racial discrimination, housing standards and accessibility, an equitable living wage, and access to affordable healthcare.

Table of Contents

Literature Review...............................................................................................1

Introduction.......................................................................................................9

Study Aims.........................................................................................................10

Methods............................................................................................................10

Results..............................................................................................................18

Baseline Characteristics......................................................................................18

Race and Severe COVID-19..................................................................................20

Race and Allostatic Load.....................................................................................20

AL as a mediator of race and severe COVID-19.....................................................21

Sensitivity Analysis of Variations in Allostatic Load Score Determination.............23

Discussion........................................................................................................24

Conclusion.........................................................................................................28

References........................................................................................................30

Supplementary Tables......................................................................................39

Appendix..........................................................................................................46

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Palabra Clave	COVID-19 Allostatic Load Racial Health Disparities Chronic Stress
Committee Chair / Thesis Advisor	Jessica Harding, Emory University
Partnering Agencies	Industrial or Commercial (for-profit) organization Emory University schools, faculty or affiliated programs

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