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Several studies on COVID-19 have revealed gaping disparities in the U.S. that negatively affect the health of people who aren’t white, especially nonwhite women. A deep dive from researchers at Washington University School of Medicine in St. Louis and the university’s Brown School shows that in St. Louis County, Black women suffered at disproportionately higher rates than men and people of other racial and ethnic backgrounds during the height of the pandemic.

In a study published recently by the Centers for Disease Control and Prevention, researchers found that from August 2020 through October 2020, Black women in St. Louis County were at the highest risk for employment loss and food insecurity compared with Black men, white women and white men. Previous studies of COVID-19 mostly have focused on comparisons between different racial identities or between males and females.

Focusing on more than one social identity — in this study, race and sex — is known as an intersectional analysis. Taking that approach provided researchers a more complete analysis of who has been most impacted by the pandemic, “and we found that Black women have been affected profoundly more than other groups,” said Kia Davis, ScD, an assistant professor in the School of Medicine’s Division of Public Health Sciences, and senior author of the study published in the CDC journal Preventing Chronic Disease. “This study is not only recognition of significant inequities, but may help us better defend those who are most harmed should similar scenarios occur in the future.”

Davis said the research team sought to “dig deeper than just saying women experienced more job loss than men, or Blacks suffered more food insecurities than whites. Disaggregating the data allows us to use the results to guide health-care and social services programs, interventions and policy to mitigate the disproportionate effects of COVID-19 and related social harms on Black women.”

Employment loss and food insecurity are recognized as major social determinants of health, defined as social and economic circumstances influencing individual health. Examples of employment loss include job furloughs, layoffs and reduced wages; food insecurity refers to the quality and quantity of food eaten, worrying about food, and receiving free meals or groceries.

Over the years, multiple studies have documented the link between employment loss and job insecurity as both separate and combined factors contributing to adverse health outcomes, including an increased risk of death and diseases such as substance abuse, suicide, depression and anxiety, substandard physical health, and chronic diseases.

“Historically, African-Americans and women are most harmed by social determinants of health due to systemic racism and sexism,” Davis said. “Our study shows that COVID-19 has widened existing sex and racial disparities that can affect health.”

The researchers analyzed de-identified data of 2,146 adults ages 18 or older who resided in St. Louis County, Missouri. People were contacted via phone by county public health officials through a collaboration between St. Louis County and Washington University’s Institute for Public Health. Participants were asked a series of questions about their experiences with employment and food during the pandemic.

Overall, the researchers found that Black women suffered more employment loss and food insecurity than Black men, white women and white men, with the largest gaps occurring between Black women and white men.

Among the study’s participants who had been laid off due to the COVID-19 pandemic, 16% were Black women compared with 7.1% of Black men, 8.6% of white women, and 6.1% of white men.

Regarding food insecurity, 79.6% of white men never worried their food would run out compared with 75.8% of white women, 72.6% of Black men and 57.6% of Black women.

“I wasn’t surprised that Black women faced higher harms, but I was surprised by the magnitude,” said the study’s first author, Jacquelyn Coats, a doctoral student at the Brown School. “These results emphasize the need for increased community outreach programs and for bigger structural changes, such as labor laws offering better worker protection.”

Coats JV, Humble S, Johnson KJ, Pedamallu H, Drake BF, Geng E, Goss CW, Davis KL. Employment Loss and Food Insecurity — Race and Sex Disparities in the Context of COVID-19. Preventing Chronic Disease. Published online in August 2022 issue.

This work was supported by the St. Louis County Department of Public Health through the 2020 Coronavirus Aid, Relief, and Economic Security Act.

A network of community partners in St. Louis, coordinated and funded through the Brown School’s Prevention Research Center, has helped people in low-resource neighborhoods combat the social isolation, lack of physical activity, and food insecurity that intensified during the COVID-19 pandemic. Now, the network is hoping to strengthen its efforts to sustain its impact. 

“Every month when the partners meet and I hear what they’re doing, the people who have benefited, and the ideas they’re coming up with, I feel great that we were able to support what they are doing,” said Diana Parra Perez, research assistant professor at the PRC, who has led the effort.

Building Resilient Inclusive Communities (BRIC) is a nationwide program established in 2021 by the Centers for Disease Control and Prevention and the National Association of Chronic Disease Directors as part of COVID relief efforts. They asked the Brown School’s center to organize Missouri’s efforts when state health authorities were unable to take it on. PRC Director Ross Brownson, asked Parra Perez to coordinate the project, and the results have been positive, helping to fund projects like community gardens, safer streets, and reconnecting seniors with their communities. Parra Perez has also worked statewide with the Missouri Department of Health and Senior Services to provide feedback on the state’s aging plan and the state health plan. That includes feedback like partnering with libraries so homebound seniors can get books and internet access.

“COVID amplified the health and social inequities in our region and BRIC is making a difference in our communities due to the outstanding leadership of Dr. Parra Perez and our many partners,” said Brownson, the Steven H. and Susan U. Lipstein Distinguished Professor at the Brown School.

Community partners, too, are enthusiastic about the results, and said Parra Perez’s leadership was key.

“Our project could not have taken place without her,” said John Saunders, executive director of Wesley House, a nonprofit in North St. Louis that used funding from BRIC for a community garden where neighborhood seniors and youth worked together, and for computer training for isolated seniors that allowed them to reconnect with family and friends. The extension to the Wesley House garden produced tomatoes, cabbage, and green beans for its food pantry, which benefited the neighborhood by bringing fresh food to the area, located in a food desert. The intergenerational work also helped bridge the gap between youth and seniors in the neighborhood. “It made a difference,” Saunders said. “It eased the seniors’ anxiety level interacting with young people.”

As COVID limited interpersonal contact, Wesley House used funds from the BRIC grant to train seniors on computer use. The seniors participated in Zoom calls about exercise and healthy eating and were able to interact with friends and family. “It helped cut down those barriers of isolation, especially from COVID,” Saunders said. “It was amazing when seniors opened up a laptop and saw what they could do.” As the area returns to in-person contact, he hopes to resume gardening in the spring.

Another project that benefited from BRIC was Calm Streets, an effort to make streets safer for pedestrians and bicyclists. The project was created by Trailnet, a local nonprofit that used BRIC funding to partner with the Hyde Park Farmer’s market on Salisbury Street, just off a busy interstate highway where cars frequently drive at high speeds off the exit. After assessing the needs for calming on the street, Trailnet proposed removable “bumpouts” to remove parking near crosswalks, and other measures.

“What’s great about BRIC is it has helped us establish new relationships with other nonprofits,” said Cindy Mense, the chief executive officer of Trailnet. “And the funding really helps bring other funding to the table.”

Part of the grant was also used for Trailnet’s work in Spanish Lake, a community in St. Louis County outside of the city. “This grant has helped introduce people in the city and county and find ways they can help one another,” she said. As BRIC funding winds down, Mense is working with Parra Perez to maintain financial support for the efforts. “Collaboration is really brewing, and these things wouldn’t have happened without BRIC,” said Mense, who added that internships with Trailnet are available to Washington University students.

Parra Perez said she hopes BRIC funding will be renewed. “It is a wonderful network, reaching out to sustain community projects and uplift communities,” she said. The Brown School has lent expertise to grant writing for community partners, as well to connect them with the school’s resources like the Evaluation Center to measure the impact of their work. The learning has been a two-way street, she said. “I’ve learned so much from these community-based organizations,” she said. “They know their communities better than anyone.”

The COVID-19 pandemic created challenges that spanned the boundaries of public health, social needs, and communication while magnifying already-existing health disparities in St. Louis and across the nation. The Health Communication Research Laboratory (HCRL), based at the Brown School, has taken quick action on all those fronts, partnering with local organizations to secure millions of dollars in federal grants to address immediate issues like vaccination and community impact while conducting longer-term research that can make a difference when the next pandemic hits.

The lab’s team began soon after COVID arrived in the U.S. by publishing reports correlating the pandemic’s progress with growing social-needs across the nation, using information the lab was already collecting from 2-1-1 helplines in 43 states. Twelve COVID-related projects followed with missions that included addressing vaccine hesitancy and disparities in St. Louis, boosting COVID testing in underserved communities, and understanding how the pandemic was affecting the nation’s most vulnerable. The surge in work increased the lab’s team from 23 to 64 faculty, staff and students, the largest workforce in the HCRL’s 26-year history, involved in 18 active projects.

“Our team was already deeply involved in health disparities and social needs research when the pandemic hit, and we were well-positioned,” said Matthew W. Kreuter, the Kahn Family Professor of Public Health at the Brown School, the founder and senior scientist of the HCRL, and a leading expert in health communication. “If you’re going to be in our field and you have a pandemic like this, you have to rise to the occasion,” he said.

As federal resources became available, the HCRL joined three national networks funded by the National Institutes of Health and the Centers for Disease Control and Prevention to address COVID-related disparities. “We worked with community partners to act and evaluate solutions,” Kreuter said, including hundreds of meetings with leading organizations to increase vaccination and testing in vulnerable populations, especially African Americans. The studies provided a wealth of opportunities for Brown School students, who played key roles in the lab’s work.

Vaccines, Testing, and Underserved Communities

The bulk of the HCRL’s COVID work was part of the three networks:

“Over the last 18 months we’ve captured really good information on action-oriented community responses that we’re evaluating in real time so we can share lessons learned with the larger community,” he said, particularly with the misinformation-monitoring response system. “We’re getting accurate information into the hands of trusted local messengers,” he added.

Kreuter said the lab’s work has broken new ground in rapid research in public health.

“It’s illustrated a new way that academic research centers like ours can work with community partners to address urgent needs of the community in a faster and more rigorous way than could be conducted without a partnership,” he said. The HCRL also partnered with the Sam Fox School to create the Health Communication Design Studio, led by Penina Laker, to contribute design expertise to messaging and communication. “It’s another big and lasting product of this work,” Kreuter said.

Community partners say the lab’s expertise has had an immediate impact.

“The St. Louis County Department of Public Health is pleased with the support from the HCRL that helps ensure racial equity in COVID-19 vaccination across the St. Louis region,” said Damon Broadus, a member of the regional response team to the pandemic. “Early in the project we worked hard to address challenges to vaccination, including reluctance, especially among African Americans. The survey results shared by the HCRL team helped us adjust our strategies to reach residents exactly where they are in the community. This was invaluable given the limited resources available during the height of a pandemic.” Broadus also praised the weekly misinformation monitoring, which he called “a creative strategy to build knowledge and trust about COVID-19 vaccinations.”

The HCRL also created simple instruction booklets for using COVID-19 self-tests for homebound seniors. The city liked the approach and asked the HCRL to print more in order to expand distribution through the St. Louis public schools.

Surge in rapid research creates challenges, opportunities

Founded in 1996, the Health Communication Research Laboratory seeks to eliminate health disparities by increasing the reach and effectiveness of health information to low-income and minority populations. Past projects have investigated ways to encourage immunization, cancer prevention, and healthy schools. Aside from COVID-related research, current projects include efforts to find ways to help more people stop smoking and control diabetes, led by HCRL co-director Amy McQueen, associate professor of medicine.

Charlene Caburnay, HCRL co-director and research assistant professor at the Brown School, said the expansion that these projects brought to the HCRL has more than doubled the lab’s staff and students. “All the hiring and training, space, computers, working remotely and managing field work in the community during a pandemic required a great deal of effort,” she said. “It was exciting but really required a lot of coordination and flexibility as well.”

Jennifer Wolff, the HCRL’s research director, said the short turnaround time required to make a fast impact presented obstacles unusual for the typical academic research timeline. Establishing relationships and planning with community partners added even more moving parts.

“It’s really changed how I think about research,” said Wolff, who came to the lab from the University of North Florida, where she was an assistant professor of psychology. “We’ve had to work quickly, and change as the pandemic changed. When I step back, it’s kind of amazing what we’ve been able to accomplish.”

McQueen noted that the lab also kept other big grant projects going despite COVID challenges. Those included working with multiple 211 and state tobacco quitlines to provide support for smokers interested in quitting or creating a smoke-free home; a project with a Medicaid health plan partner in Louisiana to address unmet needs among a sample of adults with type 2 diabetes; and wrapping up the main analyses and report for another project that tested novel intervention strategies for smokers who called 211 for help with unmet needs.

“Even as we added COVID projects, we still had three major trials in various stages of data collection and analysis to maintain,” McQueen said. “COVID caused some delays and declines in recruitment, as well as influenced the basic needs expressed by our participants. It has been essential to have great project managers on our study teams, as investigators get spread thin over multiple projects.”

Students gain valuable experience

Those accomplishments wouldn’t be happening were it not for the myriad of accomplished Brown School students who have played key roles.

Rachel Garg, MPH ’18, is a fifth-year doctoral student in the Brown School’s public health sciences program. The COVID project she worked on most was Focus-19, in which she led a team of grad students to analyze data from 2-1-1 help lines to find stories about the pandemic’s social and economic impact, like one report that linked an increase in requests for help with rent in Milwaukee to the upcoming lifting of a ban on evictions during the pandemic.

“Focus-19 was really intense when we started,” Garg said. “I loved it, it felt really meaningful. Sometimes research takes so long, but this didn’t, and it felt really impactful.”

For her dissertation, she’s using data from the lab’s Life During COVID study, which tracks 60 low-income women with children, and surveys their needs via mobile phone every three days for more than a year. All are current or former smokers, and Garg is analyzing data to examine the relationship between social needs, stress, sleep, depression and smoking behavior.

Now in her sixth year at the HCRL, Garg said her experience there has altered her career path. “I chose the MPH because I thought it would be very practical and that I would find a job rather than start a PhD program,” she said. “But once I started at the HCRL, I got so engaged in the research process it completely changed my mind. I feel lucky I’ve been able to stay in the lab and see these research project through from start to finish.”

Mikayla Johnson, MSW/MPH ’22, worked on COVID projects including the Vaccine Ambassadors project; another getting feedback from youth about COVID; and message testing to share with St. Louis city and county public health departments. She especially enjoyed interviewing people about their COVID experiences. “It was really exciting to be able to see the process of planning projects and attacking COVID health disparities in different ways,” she said. “I really enjoyed being out in the community and hearing first hand how they were dealing with the pandemic and the different ways they think about it. It continues to be a really traumatic experience for a lot of people, and it’s valuable to hear from them so policymakers can know and do things differently in the future.”

“When I started, I had never interviewed people before. I thought it would be really hard to get them to open up. But a lot of people came with a story they wanted to share, and felt it was an important perspective for others to hear, like the recently married woman who talked about losing her husband to COVID and what that was like.”

As she applies for jobs, Johnson said she wants to build a career that would align with her values in social justice and eliminating health disparities. The HCRL was a perfect place for that. “I’ve been really grateful for my experience, where I’ve been given opportunities to contribute and use my skills.”

Like Garg, Victoria De La Vega, MPH ’22, hadn’t considered going into research before working at the HCRL. A former Peace Corps volunteer in Albania, she was attracted to the Brown School by its focus on diversity and health equity, and to the HCRL for its emphasis on the practical impact of research. “I think it’s super important to have skills and knowledge to turn data into useful information,” she said. “The HCRL does a great job at that.”

“Working for the HCRL exceeded my expectations,” she added. “The staff is great, and they gave me the flexibility to work on different projects.” One of her first projects as a research assistant was interviewing 211 staff and callers about the impact of COVID. “It was my first time conducting research interviews,” she said. “It was challenging but also extremely interesting. People got emotional, and that could be really hard. I had to be an empathetic listener while making sure we were getting relevant responses. Giving people a chance to share what they’ve been through has been hard but very rewarding, a very important learning experience for me.”

While having a child attend a private school or school with above-average instructional quality was associated with better mental health of parents during the COVID-19 pandemic, hybrid school was associated with worse parental mental health, as was working from home, finds a new study from the Brown School at Washington University in St. Louis.

The study is among the first to present the interaction of school and workplace policies and other environmental and economic effects on the mental health, hopelessness, anxiety and worry of working parents in the U.S.

“This is a piece of my research in which I genuinely connected,” said Sarah Moreland-Russell, associate professor of practice and first author of the study, “At Home and on the Brink: U.S. Parents’ Mental Health during COVID-19,” published this month in the International Journal of Environmental Research and Public Health.

“I cared for two children during the COVID-19 pandemic and definitely experienced the challenges and stress similar to many other parents across the U.S.,” she said. “This study also brings to light the gaps in family support, inequities in school quality and learning, and breaks in our system that existed prior to COVID-19 and were further exacerbated by the event.

“If there is a ‘good’ that results from the pandemic, I hope that it is in the form of policies that provide supports (financial, health, education, etc.) to families and children and that are designed to actually address and eliminate inequities in education, mental health, health and access.”

Moreland-Russell and her co-authors analyzed results of the Socio-Economic Impacts of COVID-19 Survey: United States, which was administered by Washington University’s Social Policy Institute (SPI). The survey captures a diverse array of household experiences during the pandemic through a detailed set of questions concerning both adults and children in the household.

They found several key takeaways:

“While a significant amount of school policy decision-making was advanced based on public health guidance, in many cases those decisions were made without acknowledging the large strain being put on working parents, who had to act as teachers and child care workers, while navigating a rapidly changing pandemic and still trying to make ends meet,” Moreland-Russell said.

She said, based on this research, that in the future, schools should focus on providing high-quality education and student supports within one learning modality, rather than trying to handle multiple modalities, like in-person and remote learning, simultaneously.

Co-authors on the study were Dan Ferris, assistant professor of practice; Jason Jabbari, research assistant professor; and Stephen Roll, research assistant professor, all members of the Brown School and the SPI.

The COVID-19 pandemic has exacerbated risks of violence for refugee and migrant girls and women, finds a new report from the Brown School at Washington University in St. Louis and UNICEF.

Due to multiple intersecting dimensions of identity, including gender, migrant status, religion, age and others, migrant and refugee women and girls faced unique barriers and risks as a result of lockdown measures and gaps in education, finds the report, “I was not safe in his house.”

The report, which focused on migrant women and children in Italy, was written by Ilana Seff, research assistant professor at the Brown School; Lindsay Stark, associate professor at the Brown School; and researchers at UNICEF (the United Nations Children’s Fund).

They found that physical distancing measures increased feelings of loneliness for girls and women who, due to their migration status, already faced limited support networks. Many migrant women lost their jobs in the wake of the pandemic; for single mothers in particular, financial insecurity meant not being able to provide for the needs of their family. These challenges were further aggravated by the closure of educational services and the interruption of learning paths, which are fundamental for socioeconomic inclusion.

“Migrant and refugee women and girls faced unique socioeconomic challenges and experiences of violence as a result of the pandemic,” Seff said. “At the same time, migrant and refugee women in Italy exhibited tremendous resilience, working together to create and maintain social support networks over virtual platforms.”

The study explores the impacts of the pandemic on risks of exposure to gender-based violence among refugee and migrant girls and women in Italy. It draws on findings from focus group discussions and semi-structured interviews with approximately 35 refugee and migrant women and 50 key informants in three Italian regions: Latium, Lombardy and Sicily.

It is part of a broader global study investigating the impact of the COVID-19 pandemic on the safety and well-being of girls and women and their access to gender-based violence services in Italy, Brazil, Guatemala and Iraq.

“As countries that have previously taken a hardline stance toward refugees stand ready to receive the thousands of Ukrainians fleeing their homeland, our findings point to the multidimensional and overlapping vulnerabilities of migrant women and girls that may require nuanced policy and programmatic action,” Stark said.

Fathers older than age 34 were more open to having their child vaccinated against COVID-19, while younger Black and white mothers were the least open to it, finds a new survey of Medicaid recipients from the Brown School at Washington University in St. Louis.

“Helping younger parents in all ways should be a priority,” said Matthew Kreuter, the Kahn Family Professor of Public Health. “They were the most negatively affected by all aspects of the pandemic and worried more about financial needs than avoiding COVID-19. They also had the most negative views of COVID-19 vaccinations for their children.”

Kreuter is first author of the paper “Intention to vaccinate children for COVID-19: A segmentation analysis among Medicaid parents in Florida,” being published online in the journal Preventative Medicine.

To understand how racially and ethnically diverse parents of young children enrolled in Medicaid feel about getting a COVID-19 vaccine for their children, Kreuter and his co-authors administered an online survey to a statewide sample in Florida.

They found that the youngest Black and white mothers (those ages 30 and under) were least likely to intend to vaccinate their child (24%), followed by Black and white mothers in their early 30s (36%), younger Hispanic and mixed-race or other race parents (45%), older mothers (48%) and older fathers (71%).

“Fathers appear to be more favorable than mothers toward vaccinating their children, but our study did not consider who makes health-related decisions in the family,” Kreuter said.

The youngest Black and white mothers were more likely to report their lives being worse during the COVID-19 pandemic, were far more negative and less positive about a COVID-19 vaccine, and were more concerned about paying bills than preventing COVID-19, Kreuter noted.

Younger Hispanic and mixed-race parents were less negative about getting their children vaccinated, but more likely to use emotional language (e.g., scared, nervous, worried) talking about a COVID-19 vaccine, and more likely to report that protecting their child’s health was their top concern.

The researchers determined that parents’ intentions to vaccinate a child declined as financial strain and harm from COVID grew.

“The findings suggest the importance of bundling vaccination information and services with other forms of help for parents struggling during the pandemic,” Kreuter said.