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Commentary

Commentary: Social Determinants of Health and Latinx Families, Risk for COVID-19 Infection

Velasco-Huerta, Fernanda MS; Ramirez, Elda G. PhD, RN, FNP-BC, ENP-C, FAAN, FAANP, FAEN; Payén, Samuel S. AAS; Alvarez, Arlene BSN, RN; Ottosen, Madelene J. PhD, MSN; Hernandez, Daphne C. PhD, MSEd, FAAHB

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doi: 10.1097/FCH.0000000000000289
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AMONG US households, a greater percentage of Latinx households have been disproportionately affected by the COVID-19 pandemic.1 Unaddressed social determinants of health (SDOH)2 contribute to the vulnerability of communities. Several potential SDOH are worth exploring to understand why Latinx communities are vulnerable to COVID-19.

FINANCIAL HARDSHIP

While the intention of stay-at-home orders was to help communities prepare for, cope with, and recover from COVID-19 infection, many Latinx individuals never had the luxury to stay at home and work remotely because they work public-facing occupations or essential jobs (eg, grocery clerks, sanitation, construction, food production, and factory workers).3 Compared with nonessential workers, essential workers are more likely to live in overcrowded housing, which increases the risk of exposure to COVID-19.4 Despite good intentions, stay-at-home orders had a negative overall economic impact on jobs in the service sector (eg, hospitality, entertainment, and retail), which employs 8 million Latinx individuals.5 Employers resorted to reducing work hours and furloughing or laying off their employees,5 with Latinx experiencing the most job loss.6 While many Latinx families were experiencing economic hardship prior to COVID-19,6 the economic instability brought on by the COVID-19 pandemic highlights social inequality.

COMORBID MEDICAL CONDITIONS

The financial hardships experienced by Latinx individuals contribute to their health inequities. The rates of underlying, or comorbid, medical conditions, such as obesity, diabetes, and hypertension,1 increase the risk of infection and severity of COVID-19 among Latinx populations. Unfortunately, a number of these comorbidities are undetected or uncontrolled because of a lack of health insurance.3 While the percentage of uninsured Latinx fell significantly after the implementation of the Affordable Care Act, 19% of Latinx individuals remained uninsured, which is higher than that for their Black (11.5%), white (7.5%), and Asian (6.8%) counterparts.7 Furthermore, the scarcity of disposable income for necessities, such as associated medical care cost (eg, costs of tests and medications) and access to medical care (ie, transportation costs), along with the inability to take time off work, jeopardizes Latinx families' ability to mobilize for COVID-19 testing and seek needed care, thus increasing their risk of experiencing COVID-19 complications.8

ANTI-IMMIGRANT SENTIMENTS

Inequities in access to health care are further impacted by anti-immigrant sentiments. Immigrants are considered to be a public charge if they are unable to care for themselves and primarily depend on government assistance, such as Medicaid. In February 2020, the US Citizenship and Immigration Services implemented the Inadmissibility on Public Charge Grounds final rule, whereby immigrants who are considered a potential public charge could be denied admission into the United States. This new public charge ruling, along with Immigration and Customs Enforcement raids and family separation at the border, has created fear and distrust in the Latinx community.8 While there are no public charge implications for testing or treatment related to COVID-19, many undocumented and mixed-status Latinx households are not getting tested or seeking medical treatment for fear of deportation and family separation.8

LANGUAGE BARRIERS AND LACK OF EDUCATIONAL MATERIALS

Aside from the underlying financial hardships, comorbid medical conditions, and anti-immigrant sentiments, language barriers and the lack of educational materials also exist.1 To reduce COVID-19 transmission, restrictions on nonpatient visitors have been implemented in many hospitals and long-term care facilities. Consequently, translators and interpreters for immigrant families, who are usually their bilingual children, are not allowed to enter clinics and hospitals with their family members.9 Spanish-speaking patients are left to rely on their limited or lacking English capabilities to communicate with medical professionals and to understand medical procedures and discharge instructions.9 Finally, limited English proficiency can also preclude the delivery of health information in a timely manner, as was the case with the Spanish flu pandemic of 1918 and the H1N1 swine flu pandemic of 2009.10 In the absence of information, individuals may believe that infection is related to fatalism and the use of prayer alone is efficient and effective treatment remedy.11 Incorrect information and the delay of accurate information reaching non–English-speaking communities magnify COVID-19–related health inequities.1

FAMILISM

While the various unaddressed SDOH render Latinx families and their communities at great risk for infection and severity of COVID-19, cultural values conflict with recommended COVID-19 preventive behaviors. Familism in the Latinx culture is deeply rooted in family solidarity and closeness.12 For example, 27% of Latinx families live in multigenerational homes compared with 16% of white families.13 Although these values are generally beneficial in caring for elderly family members and reducing financial hardship,12 they can also have negative consequences in the spread of COVID-19. For example, multigenerational homes place vulnerable family members (eg, elderly in-laws and immunocomprised adults) at greater risk of infection.14

SOCIAL GATHERINGS

In addition, other strongly held Latinx cultural values may be contributing factors to the high rates of COVID-19 among Latinx families. Latinx are well known for their vibrant festivities, love for dancing, and big gatherings such as Quinceañeras (celebration of a girl's 15th birthday). While other large social gatherings, including weddings, COVID parties, and college parties, have been documented by the media, Latinx cultural festivities may still be taking place indoors or in people's backyards, thereby increasing the risk of exposure in Latinx communities. Contact tracers have raised concerns about individuals' unwillingness to disclose names and locations of these types of large gatherings, consequently weakening contact tracing data and undermining public health.15 COVID-infected individuals are hesitant to collaborate with contact tracers out of concern for negative consequences to their families.15

RECOMMENDATIONS FOR BUILDING TRUST AMONG LATINX COMMUNITIES

Understanding how the aforementioned SDOH contributed to COVID-19 infection among the Latinx community is fundamental to creating the interventions to reduce the spread of infection. Before developing interventions, health leaders must establish trust among the Latinx community; otherwise, strategies to lower COVID-19 inflections within the community will not be effective. The involvement of community and faith-based leaders, who are often gatekeepers to the community, can assist in building trust. They have the means to reach numerous community members to let them know that education, testing, and contact tracing will be made available to them. The use of these leaders' facilities, such as a community center or church, to deliver COVID-19 education or testing can help reduce fear among community members and help them feel at ease.

Once trust is established, community health workers (CHWs), or promotoras, must be included in the strategies outlined later. Having CHWs or promotoras who look like those in the community, speak the same language as most of the community members, and either are from the community or have lived similar experiences is needed to create rapport. Rapport is needed to ensure that the community is receptive to COVID-19 education and responds to questions asked by contact tracers and to increase the likelihood of early testing if COVID-19 symptoms develop.

STRATEGIES TO LOWER COVID-19 INFECTION IN LATINX COMMUNITIES

To lower the number of COVID-19 infections in Latinx communities, COVID-19 education, COVID-19 testing and treatment, and contact tracing all need to be increased. Educational materials that focus on COVID-19 preventive health behaviors and the recognition of symptoms must be culturally relevant. Educational materials need to be tangible, such as a one-page infographic with concise information written in Spanish. This will help draw attention to the materials, along with making the materials easier to understand among family members with low literacy. While the educational materials could be disseminated through local food distributions and schools, a more operative strategy may be a boots-on-the-ground approach that involves educators attending places commonly frequented by community members (eg, pulga [flea market],16carnicería [butcher shops], panadería [bakeries], iglesias [churches]). Similarly, door-to-door education at a proper social distance that includes information placed on door hangers is another boots-on-the-ground strategy that could be effective.

The educational materials that are disseminated must also include information on how to seek testing if symptoms develop. To make testing feasible and accessible, a strategy that considers the daily complexities of the Latinx community is necessary. Testing in low-income Latinx neighborhoods should also be conducted via a boots-on-the-ground approach that includes mobile testing facilities and door-to-door testing. Likewise, having the same individuals who conduct the education and testing within these communities should be involved in the contact tracing may help increase participation in disclosing the names of individuals and locations of gatherings.

Finally, to lower COVID-19 inflection in Latinx communities, community-based research is needed to understand which SDOH is more prominent in contributing to a rampant transmission of COVID-19. Using research methods, such as photo elicitation, can assist with making difficult topics easier to discuss. It also has the potential to empower the research participant. Empowering Latinx to use their voice in a research study could potentially spill over to other domains, such as assisting in the mobilization of COVID-19 testing and participating in contact tracing.

CONCLUSION

The COVID-19 pandemic has highlighted how social inequities contribute to health inequities among the Latinx community. Constructing effective interventions involves recognizing the unique issues plaguing vulnerable populations and adapting solutions respective of their values and culture. To reduce health inequities, it is time to meet the needs of the Latinx community, rather than expecting the Latinx community to address their needs on limited resources and hope.

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