Variation in Covid-19 vaccination rates is mediated by poverty and race and not by access to care: A case study in Chicago

doi:10.21203/rs.3.rs-3204162/v1

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Variation in Covid-19 vaccination rates is mediated by poverty and race and not by access to care: A case study in Chicago

https://doi.org/10.21203/rs.3.rs-3204162/v1

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published 25 Mar, 2024

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Introduction: Chicago’s deeply-rooted racial and socioeconomic residential segregation is a pattern mirrored in other major cities, making it a prototype for studying the uptake of public health interventions across the US. Residential segregation is related to availability of primary care, sense of community, and trust in the healthcare system, components which are essential in the response to crises like Covid-19. We aimed to evaluate the association between rates of access to primary care and community-belonging with Covid-19 vaccination within Chicago’s neighborhoods.

Methods: Data from Chicago Department of Public Health (12/2020-6/2022) on Covid-19 vaccination rates, race/ethnicity (% Black and % Hispanic/Latinx residents), age (% >65), gender (% female), socioeconomic status (% below the federal poverty line), access to needed care rate, rate of households with a primary care physician, and rate of self-reported sense of community-belonging on the neighborhood level were analyzed. Linear mixed models (LMMs) were used to study the impact of variables on vaccination; each neighborhood was added as a random effect to adjust for between-community variation.

Results: The average Covid-19 vaccination rates across Chicago’s neighborhoods was 79%, ranging from 37 to 100%, with median 81%. We found that Covid-19 vaccination rates were positively correlated with access to needed care (p < 0.001) and community-belonging (p < 0.001). Community areas that had lower vaccination rates had greater percentage of Black residents (p < 0.0001) and greater poverty rates (p < 0.0001). After adjusting for poverty, race, gender and age in the models, the association between vaccination rates and access to care or community-belonging were no longer significant, but % Black residents and poverty remained significant.

Conclusions: Though access to needed primary care and community-belonging are correlated with vaccination rates, this association was not significant when controlling for demographic factors. The association between poverty, race and vaccination status remained significant, indicating that socioeconomic and racial disparities across Chicago drive Covid-19 vaccine recommendation adherence regardless of care access. Understanding how poverty, and its intersectional relation to race and primary care access, affects vaccination should be a priority for public health efforts broadly.

COVID-19

Vaccination

Vaccine Hesitancy

Health Disparities

Primary Care

Chicago is home to diverse residents living in 77 community areas (CAs). Like other cities, historical residential segregation structures have led to neighborhoods with high concentrations of people of color. Data from Chicago’s neighborhoods may be useful for understanding patterns of vaccination related to race, socioeconomic status, and access to care in other US cities with geographic segregation.

Previous studies have highlighted that metropolitan neighborhoods experiencing more segregation have less access to primary care physicians (PCPs)¹. Historical exploitation and marginalization of minority communities by the healthcare system has contributed to the barrier of trust between communities and healthcare providers, impacting acceptance of public health recommendations between neighborhoods².

Racial disparities in vaccination rates have been noted across the US³. Survey data show that 60% of respondents trusted their PCP most to provide information about the vaccine, implicating the important role of primary care in promoting vaccine adherence⁴. Perceived community-belonging also contributes to health seeking behavior and preventative health care⁵. Given the tight relationship between racial and socioeconomic segregation and access to or uptake of health care, and their independent associations with vaccination rates, it is important to investigate the relationship between these elements¹. In this study, we aimed to evaluate the association between neighborhood levels of adult Covid-19 vaccinations to neighborhood rates of access to care, having a primary care provider, and community-belonging, and neighborhood demographics including race and socioeconomic status.

Data were accessed on the Chicago Health Atlas and by requesting publicly accessible CA-level information on Covid-19 vaccination collected by the Chicago Department of Public Health from December 2020-June 2022. Chicago Health Atlas data were derived from the Healthy Chicago survey and census data; methodologies are available online^6,7.

Our dependent outcome variable was vaccination completion rate, defined as the percent of responding households per CA reporting at least two doses of a two-shot series. Our independent predictor variables were the community adult rates reported of “received needed care”, “primary care rate”, and “community-belonging”. Covariates included community rates of race/ethnicity, age, gender, and poverty (% below the federal poverty line (≤ FPL)).

Linear mixed models (LMMs) were used to assess the association between the predictors and vaccination completion rates. Each neighborhood was added as a random effect to adjust for between-community variation. A univariate analysis was conducted before multivariate analysis controlling for demographic factors.

The mean poverty rate across Chicago was 17.1% (Range = 3.3%-50.9%) and the average percent Non-Hispanic (NH) Black was 28.8% (Range-0.39%-96.81%). The far south Riverdale neighborhood had the highest poverty rate (50.94%) and third largest percent NH Black (95.2%) population, while north Forest Glen had the lowest poverty rate (17.1%) and the second lowest percent NH Black population (0.5%). The association between vaccine completion and race and poverty are demonstrated in Fig. 1.

The average Covid-19 vaccination rate across Chicago’s neighborhoods was 79%, ranging from 25.3–86.1%. The lowest vaccination rates were in Riverdale, far south (25.3%), O’Hare, northwest, (31.1%), and West Pullman, far south (47.3%). The highest vaccination rates were seen in the West Lawn, southwest side (86.1%) and Forest Glen, north (81.5%) neighborhoods.

The average percentage of neighborhood respondents reporting having a PCP was 81.9% (CA rates range 62.8% − 98.5%). PCP rates were highest in the southside CAs of Mount Greenwood (98.5%) and Calumet Heights (95.8%), while the lowest rate was in West Pullman, far south (62.8%).

On average, 77.6% of respondents received needed care (range 53.1% − 95%). The highest received needed care rate was 95% in near south Oakland, and second greatest received needed care rate was in Forest Glen (93.9%). Washington Park, southside, had the lowest rate for this indicator (56.4%) and far south Riverdale with the fourth lowest rate (65.2%).

The average community-belonging rate was 43.1% (range23.5% − 70.5%). The highest rates of community-belonging were in Beverly, southside (70.5%), Kenwood, near south (65.4%), with Forest Glen, north (63.4%). The neighborhoods of South Deering, southside (23.5%) and East Side, southeast side (25.9%) had the lowest rates of community-belonging. Riverdale had a community-belonging rate in the third quartile (36.7%).

CAs that had lower vaccination rates had greater percentage of Black residents (p < 0.0001). Additionally, areas with a greater percentage of households living ≤ FPL were associated with lower vaccination rates (p < 0.0001). We also found in univariate analysis that Covid-19 vaccination rates were positively correlated with having access to needed care (p < 0.001) and sense of community-belonging (p < 0.001) but not with access to primary care.

In multivariate models including poverty, race, gender and age, the association between vaccination rates and access to needed care or community-belonging were no longer significant (p = 0.08 and 0.82, respectively). Race (p < 0.05) and poverty (p < 0.002) remained significantly associated with community-level vaccination rates in multivariable models.

In this study, we found that areas with the greatest percentage of households living ≤ FPL and with greater percentage of NH Black residents had lower vaccination completion rates. Higher Covid-19 vaccination rates were associated with greater sense of community-belonging and better access to care when needed but not with access to primary care. In multivariable models, the rates of community-belonging and access to needed care were not significant, but the percentage of NH Black residents and percentage living in poverty were significantly associated with Covid-19 vaccination rates. It should be noted that between April 2021 and July 2022, the national gap in vaccination rates between white and Black Americans decreased from 14–5%; we noted that that over a similar time-period, Chicago maintained an appreciable gap in vaccination rates by CA³.

In our study, the socioeconomic and racial distribution by CA remained correlated with vaccination rate distribution after controlling for healthcare access variables. This indicates that poverty and race play the larger role in influencing disparities in vaccination rates in Chicago. This contrasts to findings in a study conducted across US counties which found an association between PCP rate and Covid-19 vaccination rates⁸. Previous studies have also shown that sense of community-belonging can be a powerful driver in promoting preventive health behavior change such as vaccination⁹. While we did find associations between community-belonging and vaccination rates, our findings indicate the socioeconomic and racial disparities across Chicago may drive Covid-19 vaccine recommendation adherence regardless of care-access and community-belonging. The Chicago CAs with the lowest vaccination rates and lowest rates of received needed care also had the highest rates of death due to Covid-19 in the city, a further reflection of disparities in care leading to Covid disparities⁶.

This study is limited by the use of community-level and not individual-level data, which may obscure some of the patterns we describe. However, the purpose of this study was to draw conclusions from broader community-based patterns, so these limitations do not preclude the associations described.

It is often assumed that improving access to primary care among communities with low uptake of public health interventions may improve health outcomes. However, our study finds that poverty and race are more significant determining factors behind community-level adherence to public health recommendations in a city with evident racial/ethnic clustering by CA. Understanding how socioeconomic deprivation within communities and how its intersectional relation to racial segregation and primary care access affect vaccination should be a priority for public health efforts to improve the response to future public health crises.

Ethics approval and consent to participate: Not applicable. This study was IRB exempt.

Consent for publication: Not applicable.

Availability of data and materials: The datasets generated and/or analysed during the current study are available in the Chicago Health Atlas repository, linked HERE.

Competing Interests: The authors declare that they have no competing interests.

Funding: The authors report no sources of funding.

Author’s contributions: GK, MP, and AB contributed to the initial concept and design. GK and AP contributed to data collection. MZ and HK contributed to data analysis. GK, MZ, and AB contributed to the drafting of the manuscript. All authors participated in the editing and final approval of the manuscript.

Acknowledgements: Not applicable.

Gaskin DJ, Dinwiddie GY, Chan KS, McCleary R. Residential Segregation and Disparities in Healthcare Services Utilization. Med Care Res Rev. 2012;69(2):158-175. doi:10.1177/1077558711420263
Morgan KM, Maglalang DD, Monnig MA, Ahluwalia JS, Avila JC, Sokolovsky AW. Medical Mistrust, Perceived Discrimination, and Race: a Longitudinal Analysis of Predictors of COVID-19 Vaccine Hesitancy in US Adults. J Racial Ethn Health Disparities. Published online August 1, 2022:1-10. doi:10.1007/s40615-022-01368-6
Jul 14 SHP, 2022. Latest Data on COVID-19 Vaccinations by Race/Ethnicity. KFF. Published July 14, 2022. Accessed December 23, 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-by-race-ethnicity/
American COVID-19 Vaccine Poll. Accessed March 23, 2023. https://covidvaccinepoll.com/app/aarc/covid-19-vaccine-messaging/#/
Holt-Lunstad J. Social Connection as a Public Health Issue: The Evidence and a Systemic Framework for Prioritizing the “Social” in Social Determinants of Health. Annu Rev Public Health. 2022;43(1):193-213. doi:10.1146/annurev-publhealth-052020-110732
Chicago Health Atlas. Chicago Health Atlas. Accessed December 23, 2022. https://chicagohealthatlas.org/chicagohealthatlas.org/
HCS Resources. Accessed June 2, 2023. https://www.chicago.gov/content/city/en/depts/cdph/supp_info/healthy-communities/resources.html
Lo CH, Chiu L, Qian A, et al. Association of Primary Care Physicians Per Capita With COVID-19 Vaccination Rates Among US Counties. JAMA Netw Open. 2022;5(2):e2147920. doi:10.1001/jamanetworkopen.2021.47920
Hystad P, Carpiano RM. Sense of community-belonging and health-behaviour change in Canada. J Epidemiol Community Health. 2012;66(3):277-283. doi:10.1136/jech.2009.103556

No competing interests reported.

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You are reading this latest preprint version

Variation in Covid-19 vaccination rates is mediated by poverty and race and not by access to care: A case study in Chicago

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