Racial Disparities in COVID-19 Severity Are Partially Mediated by Chronic Stress-Evidence from a Large Integrated Healthcare System

Overview

Journal J Racial Ethn Health Disparities

Specialties Public Health
Social Sciences

Date 2024 Jan 31

PMID 38294635

Authors

Miranda M Montoya

Jennifer C Gander

Shakira F Suglia

Bennett McDonald

Shivani A Patel

Teaniese Davis

Rachel E Patzer

Ram Jagannathan

Larissa Teunis

Jessica L Harding

Affiliations

Soon will be listed here.

Abstract

Background: Racial and ethnic minorities have experienced a disproportionate burden of severe COVID-19. Whether chronic stress, also disproportionately experienced by racial and ethnic minorities, explains this excess risk is unknown.

Methods: We identified 9577 adults (≥ 18 years) diagnosed with COVID-19 from January 1, 2020, through September 30, 2021, enrolled in Kaiser Permanente Georgia (KPGA) with complete biomarker data. Self-reported race (Black or White) was defined from electronic medical records. Chronic stress, defined as allostatic load (AL), a composite score (scale 0-7) based on seven cardio-metabolic biomarkers, was categorized as below (low AL) or above (high AL) the median. Severe COVID-19 was defined as hospitalization or mortality within 30 days of COVID-19 diagnosis. The association between race, AL, and severe COVID-19 was assessed using multivariable Poisson regression. The mediating effect of AL was assessed using the Valeri and VanderWeele method. All results were expressed as risk ratios (RRs) with 95% confidence intervals.

Results: Overall, Black (vs. White) KPGA members had an 18% excess risk of AL (RR: 1.18, 95%CI: 1.14-1.23) and a 24% excess risk of severe COVID-19 (RR: 1.24, 95%CI: 1.12, 1.37). AL explained 23% of the Black-White disparities in severe COVID-19.

Conclusions: In our study, chronic stress, characterized by AL, partially mediated Black-White disparities in severe COVID-19 outcomes.

References

Hooper M, Marshall V, Perez-Stable E . COVID-19 Health Disparities and Adverse Social Determinants of Health. Behav Med. 2022; 48(2):133-140. DOI: 10.1080/08964289.2021.1990007. View

Forde A, Crookes D, Suglia S, Demmer R . The weathering hypothesis as an explanation for racial disparities in health: a systematic review. Ann Epidemiol. 2019; 33:1-18.e3. PMC: 10676285. DOI: 10.1016/j.annepidem.2019.02.011. View

Epel E, Crosswell A, Mayer S, Prather A, Slavich G, Puterman E . More than a feeling: A unified view of stress measurement for population science. Front Neuroendocrinol. 2018; 49:146-169. PMC: 6345505. DOI: 10.1016/j.yfrne.2018.03.001. View

Robertson T, Beveridge G, Bromley C . Allostatic load as a predictor of all-cause and cause-specific mortality in the general population: Evidence from the Scottish Health Survey. PLoS One. 2017; 12(8):e0183297. PMC: 5559080. DOI: 10.1371/journal.pone.0183297. View

Kenrik Duru O, Harawa N, Kermah D, Norris K . Allostatic load burden and racial disparities in mortality. J Natl Med Assoc. 2012; 104(1-2):89-95. PMC: 3417124. DOI: 10.1016/s0027-9684(15)30120-6. View

Cohen S, Murphy M, Prather A . Ten Surprising Facts About Stressful Life Events and Disease Risk. Annu Rev Psychol. 2018; 70:577-597. PMC: 6996482. DOI: 10.1146/annurev-psych-010418-102857. View

Cundiff J, Bennett A, Carson A, Judd S, Howard V . Socioeconomic status and psychological stress: Examining intersection with race, sex and US geographic region in the REasons for Geographic and Racial Differences in Stroke study. Stress Health. 2021; 38(2):340-349. DOI: 10.1002/smi.3095. View

Lamontagne S, Pizzagalli D, Olmstead M . Does inflammation link stress to poor COVID-19 outcome?. Stress Health. 2020; 37(3):401-414. DOI: 10.1002/smi.3017. View

Cohen S, Tyrrell D, Smith A . Negative life events, perceived stress, negative affect, and susceptibility to the common cold. J Pers Soc Psychol. 1993; 64(1):131-40. DOI: 10.1037//0022-3514.64.1.131. View

10.

Cohen S . Psychosocial Vulnerabilities to Upper Respiratory Infectious Illness: Implications for Susceptibility to Coronavirus Disease 2019 (COVID-19). Perspect Psychol Sci. 2020; 16(1):161-174. PMC: 7345443. DOI: 10.1177/1745691620942516. View

11.

Liu S, Juster R, Dams-OConnor K, Spicer J . Allostatic load scoring using item response theory. Compr Psychoneuroendocrinol. 2022; 5:100025. PMC: 9216382. DOI: 10.1016/j.cpnec.2020.100025. View

12.

Read S, Grundy E . Allostatic load and health in the older population of England: a crossed-lagged analysis. Psychosom Med. 2014; 76(7):490-6. PMC: 4418773. DOI: 10.1097/PSY.0000000000000083. View

13.

Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi J . Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005; 43(11):1130-9. DOI: 10.1097/01.mlr.0000182534.19832.83. View

14.

Glasheen W, Cordier T, Gumpina R, Haugh G, Davis J, Renda A . Charlson Comorbidity Index: Update and Translation. Am Health Drug Benefits. 2019; 12(4):188-197. PMC: 6684052. View

15.

McNutt L, Wu C, Xue X, Hafner J . Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol. 2003; 157(10):940-3. DOI: 10.1093/aje/kwg074. View

16.

Valeri L, VanderWeele T . Mediation analysis allowing for exposure-mediator interactions and causal interpretation: theoretical assumptions and implementation with SAS and SPSS macros. Psychol Methods. 2013; 18(2):137-50. PMC: 3659198. DOI: 10.1037/a0031034. View

17.

Richiardi L, Bellocco R, Zugna D . Mediation analysis in epidemiology: methods, interpretation and bias. Int J Epidemiol. 2013; 42(5):1511-9. DOI: 10.1093/ije/dyt127. View

18.

Al-Sabah S, Al-Haddad M, Al-Youha S, Jamal M, Almazeedi S . COVID-19: Impact of obesity and diabetes on disease severity. Clin Obes. 2020; 10(6):e12414. PMC: 7645952. DOI: 10.1111/cob.12414. View

19.

Akrivos J, Zhu C, Haroutunian V . Role of cumulative biological risk in mediating socioeconomic disparities in cognitive function in the elderly: a mediation analysis. BMJ Open. 2020; 10(9):e035847. PMC: 7511641. DOI: 10.1136/bmjopen-2019-035847. View

20.

Rosemberg M, Granner J, Li Y, Seng J . A scoping review of interventions targeting allostatic load. Stress. 2020; 23(5):519-528. PMC: 7841966. DOI: 10.1080/10253890.2020.1784136. View