key: cord-0813054-xj0p00l5
authors: Moore, Karen S.
title: The Impact of COVID‐19 on the Latinx Population: A Scoping Literature Review
date: 2021-04-20
journal: Public Health Nurs
DOI: 10.1111/phn.12912
sha: 5fc754f37be478ef4ce2ea81326f9fbf5f085e54
doc_id: 813054
cord_uid: xj0p00l5

OBJECTIVES: To explore factors associated with the impact of COVID‐19 on the Latinx population, a Scoping Review of literature was undertaken. DESIGN: A systematic review was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis Scoping Review (PRISMA ScR) guidelines. A search of databases PubMed, CINAHL, and APA PsycINFO was conducted and included studies through November 23, 2020. SAMPLE: Selected articles were limited to English language, included population data from the US, were specific to the topic of COVID‐19, Latinx community findings significantly addressed, and added significant information to the developing narrative not covered elsewhere. RESULTS: Sixteen studies in the final selection included meta‐analyses, community‐based assessments, and electronic health records reviews of hospital systems and local/state/national public databases. This review describes the prevalence of COVID‐19 in the Latinx population, social factors related to disease burden, and the economic implications and disproportionality of COVID‐19. CONCLUSIONS: The impact of COVID‐19 on the Latinx population is multi‐factorial. More research is needed to examine each of these factors in greater detail.

The havoc visited upon the global community by COVID-19 has brought the impact of infectious disease to the fore. The pandemic swiftly sickened over 125 million people and claimed the lives of 2.7 million worldwide (JHU, 2020) . In the United States (US) alone over 30 million people have been sickened and more than 546,000 people have died (JHU, 2020) . The increased impact of COVID-19 on communities of color in the United States is of particular concern (Carethers, 2020; Chamie et al., 2020; Figueroa et al., 2020; Tai et al., 2020; Tirupathi et al., 2020) . 

Health disparities and inequity are foundational components to the discussion of disease distribution, morbidity, and mortality in populations, and this is especially true for U.S. Latinx. The impact of socioeconomic position (SEP) (Meier et al., 2016) , poverty (Trepka et al., 2016) , lack of availability of fresh, affordable, healthy food options termed "greengrocery deserts" (Carethers, 2020) , insufficient housing (Velasco-Mondragon et al., 2016) , and lack of access to adequate healthcare (Soyemi et al., 2014; Truman et al., 2020) has long been associated with increased levels of infectious and non-communicable disease (Meier et al., 2016; Soyemi et al., 2014; Sullivan et al., 2018; Trepka et al., 2016; Truman et al., 2020; Velasco-Mondragon et al., 2016) . Delays in treatment and lack of preventive care increase the risk of serious sequelae and disease burden for infections: for example, hepatitis, cancer, tuberculosis (Gudenkauf & Thrift, 2020; Pan et al., 2020; Velasco-Mondragon et al., 2016) , HIV (Sullivan et al., 2018; Trepka et al., 2016) , and syphilis (Sullivan et al., 2018) .

For diseases of a communicable nature, delay can increase community spread and disease impact.

While Latinx persons are interwoven into communities across the United States, there are significant differences between their experiences compared to their NHW counterparts. On average, Latinx within the United States are four times less likely to have completed high school, twice as likely to live in poverty, with 9.6% of Latinx living in deep poverty defined as less than half of the poverty line when compared to NHW (Velasco-Mondragon et al., 2016) . Latinx are less likely to engage in preventive health care and less likely to report access to care for the prevention or treatment of health conditions (Carethers, 2020; Clarke et al., 2020; Cuellar et al., 2020; Velasco-Mondragon et al., 2016) .

Latinx decreased access to preventative healthcare is multifactorial and includes lack of English fluency, discomfort with social services organizations including healthcare providers, unavailable or unacceptable choice of culturally sensitive healthcare providers, and lack of adequate health insurance (Clarke et al., 2020; Cuellar et al., 2020; Velasco-Mondragon et al., 2016) . Lack of employerbased health coverage for working-age Latinx is estimated at 30%, compared to their NHW counterparts at 11% uninsured or underinsured (Velasco-Mondragon et al., 2016) . Reduced access to routine healthcare services places Latinx at greater risk for health conditions associated with COVID-19, such as hypertension, diabetes, obesity, and heart disease (Velasco-Mondragon et al., 2016) .

Issues of inequity and disproportionality were identified early in the COVID-19 pandemic. The cause of the increased rate of COVID-19 in Black, native-American, and Latinx populations when compared to NHW has been theorized but no single answer emerged (Chamie et al., 2020; Cuellar et al., 2020; Figueroa et al., 2020; Izzy et al., 2020; Macias Gil et al., 2020; Selden & Berdahl, 2020; Tai et al., 2020; Tirupathi et al., 2020) . This literature review compared only Latinx to NHW, so a focused exploration of the topics could be completed.

A systematic scoping review of literature focused on the impact of COVID-19 on the Latinx population was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Scoping Review (PRISMA ScR) guidelines with results summarized in Figure 1 (Moher et al., 2009) 

The articles selected for review were all peer-reviewed and utilized a variety of research methodologies: cross-sectional design, retrospective records reviews, systematic reviews of existing literature, community-based assessment, and representative sampling. As the selected articles were examined and synthesized, themes were identified that illuminated the impact of COVID-19 on the Latinx community: prevalence, economics, and social variables.

Infectious disease prevalence within a population provides a snapshot of community health. For COVID-19, prevalence is viewed through the prism of seroprevalence for active and prior infections, as well as over- 

In community-based convenience sampling conducted in a largely Latinx census tract, Latinx persons represented only 41% of the 3,953 samples collected, but over 95% of the positive results (Chamie et al., 2020) . Similarly, a community-based random-sampling survey of non-congregant adults found seroprevalence for the overall population was 4.0% compared to 19.9% for Hispanic/Latinx (Mahajan et al., 2020) . A Veterans Health Administration (VHA) nationwide retrospective records review of over 5 million persons found Hispanic patients had a higher likelihood of testing positive for (1.84) compared to NHW (Rentsch et al., 2020) 

COVID-19 disease disparity in the Latinx community is further borne out with increased illness and death observed regardless of age, healthcare setting, and comorbidities. (Carethers, 2020; Cates et al., 2020; Figueroa et al., 2020; Holtgrave et al., 2020; Izzy et al., 2020; Meyerowitz et al., 2020; Mithal et al., 2020; Sachdev et al., 2020; Tai et al., 2020; Tirupathi et al., 2020) . To examine disparities in morbidity and mortality, studies utilizing retrospective electronic health records reviews of public local, state, and national level databases (Holtgrave et al., 2020; Sachdev et al., 2020; Tirupathi et al., 2020) , Veterans Administration (Cates et al., 2020) , and private health institutions (Holtgrave et al., 2020; Izzy et al., 2020; Meyerowitz et al., 2020; Mithal et al., 2020) , a cross-sectional analysis (Figueroa et al., 2020) , and a meta-analysis (Tirupathi et al., 2020) were reviewed.

Although Latinx in the United States comprises approximately 18% of the total population (US Census Bureau, 2020), they account for nearly 33.8% of COVID-19 cases where race is reported (Tai et al., 2020) . Latinx patients with COVID-19 are more likely to be admitted to the hospital regardless of age, more likely to require hospitalization and intensive care unit (ICU) admission, and disproportionally more likely to die from COVID-19 than their NHW counterparts (Figueroa et al., 2020; Holtgrave et al., 2020; Izzy et al., 2020; Tirupathi et al., 2020) .

A meta-analysis of public health data from 16 states and New

York City (NYC) demonstrated that Latinx persons are at a substantially higher risk of serious illness and death from COVID-19 when compared to NHW (Tirupathi et al., 2020) . A cross-sectional analysis in Massachusetts found a similar disparity with a 10-percentage point increase in the Latinx population associated with an increased case rate of 258.2 cases per 100,000 persons (Figueroa et al., 2020) .

Estimated COVID-19 fatality rates for Latinx patients in New York state were 0.12% compared to 0.03% for NHW (Holtgrave et al., 2020) . Latinx patients of all ages are 3.2 times more likely to die of COVID-19 than NHW and 4.3 times higher in the 25-34-year-old age range (Carethers, 2020 (Izzy et al., 2020) .

To better understand the hospitalization path for a patient admitted with COVID-19, a review of VHA records comparing patients' hospital experience admitted for COVID-19 versus influenza was completed (Cates et al., 2020) . COVID-19 patients had a higher risk of severe multi-system complications such as respiratory failure, kidney failure, and sepsis with Latinx patients' rates of these sequelae noted to be significantly higher than NHW (Cates et al., 2020) . Mithal et al. (2020) found that although the pediatric emergency department usage for Latinx patients was 52%, Latinx infants represented 78% of positive COVID-19 results. This trend of overrepresentation of COVID-19 seropositive Latinx patients also held true for persons living with HIV (PLWH) who were co-infected (Meyerowitz et al., 2020; Sachdev et al., 2020) .

Over 70% of Latinx are estimated to have insufficient funds to cover three months of living expenses, placing their financial situation during a mandatory shelter-in-place or job loss at grave risk (Carethers, 2020) . Latinx persons are more likely to live in poverty, have a lower education level, and be uninsured or have Medicaid for their insurance (Carethers, 2020) . Identified factors associated with a recent diagnosis of COVID-19 included household income less than $50,000 per year, employment as a frontline service worker, and an inability to shelter-in-place related to potential loss of employment or income (Chamie et al., 2020) .

Of late, workplace has often meant working remotely to limit our exposure to this respiratory contagion; however, for many in the Latinx community, working from home is a luxury they cannot afford (Baquero et al., 2020; Carethers, 2020; Figueroa et al., 2020; Selden & Berdahl, 2020) . Latinx persons are more likely than NHW to fill "essential" jobs (e.g., food service, building maintenance, and housekeeping) which are more likely to be impacted by COVID-19 through a reduction in pay or unemployment (Carethers, 2020; Figueroa et al., 2020; Selden & Berdahl, 2020) . In a meta-analysis of HCWs, factors commonly associated with seropositivity included:

frontline patient care duties, healthcare-assistant role, and shortage of personal protective equipment (PPE) (Galanis et al., 2020) .

While overall compliance rates with risk mitigation efforts such as avoiding public places (73%), avoiding in-home gatherings (75%), and wearing a mask when outside the home (97%), were relatively comparable across groups (e.g., NHW, Black, Hispanic), a noticeable difference was in the ability to work from home: Hispanics/ Latinx at (11.8%) compared to all respondents (39.3%) (Mahajan et al., 2020) .

Issues of access to health insurance, access to healthcare, sick leave, childcare, and historic wage disparities are particularly consequential for the Latinx community (Carethers, 2020; Figueroa et al., 2020; Izzy et al., 2020; Macias Gil et al., 2020; Meyerowitz et al., 2020; Sachdev et al., 2020; Selden & Berdahl, 2020; Tai et al., 2020) . For an "essential worker" the prospect of missing work to care for a child who is sick or learning remotely is a precarious situation with financial consequences (Carethers, 2020; Selden & Berdahl, 2020) .

Policies that cause communities of color to experience economic disparities, including redlining of housing (Millett et al., 2020; Tai et al., 2020) , have a significant impact on overall family wealth creation and lessen the ability of those in poverty to move up into the middle class. For those Latinx who are recent immigrants, less favorable immigration policies, and fear of public institutions related to deportation risk are significant deterrents to seeking care for health-related issues (Figueroa et al., 2020; Izzy et al., 2020; Macias Gil et al., 2020) .

In addition to the aforementioned issues experienced by Latinx persons in the United States, the lack of insurance and lack of access to culturally sensitive healthcare providers is a significant barrier to care which can exacerbate underlying health conditions seen in COVID-19 (Carethers, 2020; Izzy et al., 2020; Macias Gil et al., 2020; Selden & Berdahl, 2020) . Latinx have the lowest rate of medical health insurance in the United States, with 19.8% of Latinx uninsured compared to 5.4% of NHW (Macias Gil et al., 2020) . Lack of insurance leads to a reticence to seek care for fear of additional financial burden (Izzy et al., 2020; Macias Gil et al., 2020) , leading to a delayed presentation for health concerns and more advanced disease at the time of presentation (Carethers, 2020; Izzy et al., 2020; Macias Gil et al., 2020; Selden & Berdahl, 2020) . Reduced access to routine healthcare services places Latinx at greater risk for health conditions associated with COVID-19, such as hypertension, diabetes, obesity, and heart disease (Carethers, 2020) .

Complex social factors compound the already troubling landscape of COVID-19 in the Latinx community. Greengrocery deserts (Carethers, 2020; Selden & Berdahl, 2020) and household overcrowding (Figueroa et al., 2020; Izzy et al., 2020; Selden & Berdahl, 2020) significantly impact U.S. Latinx and increase their risk of contracting COVID-19.

Ready access to adequate food, water, housing, and sanitary needs are the basic requirements of a developed society, but for the U.S. Latinx community too often these basic needs go unmet. Latinx households in the United States are less likely to possess functional indoor plumbing, access to basic sanitation, and electricity than NHW (Tirupathi et al., 2020) . The time, energy, and percentage of income spent to acquire basic needs are substantial for Latinx and unlike the experience of their NHW counterparts (Carethers, 2020; Tai et al., 2020) . In the United States, socioeconomic inequities place Latinx at a distinct disadvantage, with an estimated 19% living below the poverty line compared to 9% for NHW (Tai et al., 2020) .

With shelter-in-place orders requiring children to be out of public schools, the loss of subsidized daytime meals worsens food insecurity (Carethers, 2020) .

Living in a community with a high concentration of foreign-born non-citizens, high levels of food service workers, and larger mean household sizes were independent predictors for increased rates of COVID-19 (Figueroa et al., 2020) . Multigenerational households are common in the Latinx community, which further increases the risk of experiencing a household contact who is positive for COVID-19 (Carethers, 2020; Figueroa et al., 2020; Galanis et al., 2020; Selden & Berdahl, 2020; Tai et al., 2020; Tirupathi et al., 2020) . In the Medical Expenditure Panel Survey (MEPS) database, Latinx average household size is 3.8 people compared to NHW of 2.8 people (Selden & Berdahl, 2020) . For PLWH who are Latinx, the issue of insufficient housing is even more significant, with greater than 50% reporting being unhoused or experiencing congregant living (Meyerowitz et al., 2020; Sachdev et al., 2020) . The risks associated with these social factors do not end with contracting COVID-19; rather, they extend into higher death rates as well. Higher rates of mortality attributed to are seen in areas with greengrocery deserts (Carethers, 2020; Selden & Berdahl, 2020) , higher levels of poverty (Izzy et al., 2020; Macias Gil et al., 2020; Selden & Berdahl, 2020) , and lower levels of education (Izzy et al., 2020; Macias Gil et al., 2020; Selden & Berdahl, 2020) .

Prevalence of COVID-19 in the Latinx community is seen in communitybased sampling of antigen and antibody testing, retrospective reviews, and morbidity and mortality data regardless of study type or geographic location (Chamie et al., 2020; Galanis et al., 2020; Mahajan et al., 2020; Rentsch et al., 2020) . The disparity of COVID-19 disease distribution in the Latinx community is borne out with increased illness and death observed regardless of age, healthcare setting, and comorbidities. (Carethers, 2020; Cates et al., 2020; Figueroa et al., 2020; Holtgrave et al., 2020; Izzy et al., 2020; Meyerowitz et al., 2020; Mithal et al., 2020; Sachdev et al., 2020; Tai et al., 2020; Tirupathi et al., 2020) .

Latinx patients with COVID-19 are more likely to require hospitalization and ICU admission, and disproportionally more likely to die from COVID-19 than their NHW counterparts (Figueroa et al., 2020; Holtgrave et al., 2020; Izzy et al., 2020; Tirupathi et al., 2020) .

Economic frailty and social disparities are also disproportionately seen in the Latinx community and contribute to this complex disease state. Latinx persons are more likely to live in poverty, experience insufficient housing and green-grocery deserts, have lower education levels, and be uninsured or underinsured (Carethers, 2020; Izzy et al., 2020; Macias Gil et al., 2020; Selden & Berdahl, 2020) .

For Latinx workers, an inability to shelter-in-place, and employment as a frontline service-worker or healthcare assistant, places them at increased risk of exposure to COVID-19 outside the home (Carethers, 2020; Figueroa et al., 2020; Galanis et al., 2020; Selden & Berdahl, 2020) . Policies that may contribute to the experience of COVID-19 in the Latinx community and influence the ability to seek care include issues of immigration, access to health insurance, access to culturally competent healthcare, childcare, and paid sick leave for workers (Carethers, 2020; Figueroa et al., 2020; Izzy et al., 2020; Macias Gil et al., 2020; Meyerowitz et al., 2020; Sachdev et al., 2020; Selden & Berdahl, 2020; Tai et al., 2020) .

States is concerning. This potentially fatal, highly contagious infectious disease is causing infection, and death at a disproportionate rate within the Latinx community. The suffering caused by loss of income, instability in education, and childcare for Latinx children, and increased fragility of this community's socioeconomic fabric caused by increased morbidity and mortality of wage earners is significant.

The most significant limitation of this review is COVID-19 itself. The disease has been recognized for one year, yet we are still learning about transmission, prevention, treatment, and future impact of the disease. The long-term sequela for patients who survived COVID-19

infection is still unknown (Mahase, 2020) . For some survivors, ongoing severe health issues have been identified, while others appear to have few sequelae. The degree to which disparities are borne out in the later phase of COVID-19 remains to be studied.

Other unknowns that may impact the Latinx community will be shaped by the policies of our political leaders and their global counterparts. The inauguration of a new U.S. President is anticipated to change policies on issues of immigration, the economy, healthcare, and global engagement from the previous administration's approach (Alvarez, 2020; Frumkin & Myers, 2020; McInturff & Lewis, 2020; Ries, 2020) . The rate and overall degree of financial recovery for United States and global economies remain uncertain (Atkeson, 2020; Bartsch et al., 2020 , McKibbin & Fernando, 2020 . The long-term economic consequences of COVID-19 on changes in the job sector with business closures, movement from an in-person economy to one that is more heavily reliant on technology, resumption of travel, and its effect on the hospitality industry, all are quite impactful for the Latinx community. Some businesses and industries may permanently close, precipitating increased unemployment, which could lead to a worsening financial situation for marginalized communities.

Access to healthcare resources may also be altered by the closure of some primary care institutions but conversely aided by the potential expansion of public options for healthcare insurance and access to care (King, 2020) . Additionally, the global consequences to our relationships abroad and impact on international trade may be significant (Baldwin & Tomiura, 2020; Fernandes, 2020) .

Future studies on the impact of these policies on the Latinx community will be warranted.

In the near future, events will occur that can potentially reshape the battle against COVID-19. Immunizations that are estimated to have a high rate of effectiveness in the prevention of COVID-19

infection are slated for widespread release (Centers for Disease

Control & Prevention, 2020b). The overall uptake of the U.S. immunization campaign, especially within the Latinx community, will require an individualized, culturally sensitive approach (Hughes et al., 2018; Salgado de Snyder et al., 2020) . It is unclear what percentage of the population will agree to receive the immunizations or barriers to vaccination acceptance, but the issues raised and barriers presented will require further study.

Issues of healthcare access and increased rates of disease have been raised when discussing the prevalence of other infectious diseases in the Latinx community (Soyemi et al., 2014; Trepka et al., 2016; Truman et al., 2020) ; however, COVID-19 illuminated the factors associated with the disproportionality of disease burden within the Latinx population. The disparities, social injustice, and suffering we have seen during the COVID-19 pandemic should give us pause and force us to face the consequence of continuing down this path of inequity without attempting to change the factors that contributed to its rise. Only through the deliberate, contemplative, and steadfast actions of a motivated populace will we become "a more perfect union" (U.S. Const.,pmbl).

No datasets were generated during the current study.

Karen S. Moore https://orcid.org/0000-0002-0964-7420

This is how President-elect Biden's policies could affect Hispanics in America

What will be the economic impact of covid-19 in the US? Rough estimates of disease scenarios

Thinking ahead about the trade impact of COVID-19

Understanding and addressing Latinx COVID-19 disparities in Washington State

The potential health care costs and resource use associated with COVID-19 in The United States

Insights into disparities observed with COVID-19

Risk for in-hospital complications associated with COVID-19 and influenza-Veterans Health Administration, United States

Older adults at greater risk of requiring hospitalization or dying if diagnosed with COVID-19

SARS-CoV-2 community transmission disproportionately affects Latinx population during shelter-in-place in San Francisco

Potential impact of COVID-19 on Recently resettled refugee populations in the United States and Canada: Perspectives of Refugee Healthcare Providers

Culturally Congruent Health Care of COVID-19 in minorities in the United States: A clinical practice paper from the National Coalition of Ethnic Minority Nurse Associations

Economic effects of coronavirus outbreak (COVID-19) on the world economy

Community-level factors associated with racial and ethnic disparities in COVID-19 rates in Massachusetts

Planetary health and the 2020 US election

Seroprevalence of SARS-CoV-2 antibodies and associated factors in health care workers: A systematic review and meta-analysis

Racial/Ethnic differences in cancers attributable to preventable infectious agents in Texas

Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State

Local-level adult influenza and pneumococcal vaccination disparities

Characteristics and outcomes of Latinx patients with COVID-19 in comparison with other ethnic and racial groups

COVID-19 Dashboard by the

COVID-19 and the need for healthcare reform

Pandemic: Disparate health impact on the Hispanic/Latinx population in the United States

Seroprevalence of SARS-CoV-2-specific IgG antibodies among adults living in Connecticut: Post-Infection Prevalence (PIP) Study

Covid-19: What do we know about "long covid

What COVID-19 and the nomination of Joe Biden mean for health care in the 2020 presidential election

The economic impact of COVID-19

Early life socioeconomic position and immune response to persistent infections among elderly Latinos

White Counties stand apart: The primacy of residential segregation in COVID-19 and HIV diagnoses

SARS-CoV-2 infection in infants less than 90 days old

Preferred reporting items for systematic reviews and metaanalyses: The PRISMA statement

Late presenters among minority patients with chronic hepatitis C infection in the USA

Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study

President Trump and Joe Biden: Comparing Immigration Policies. The Heritage Foundation

COVID-19 susceptibility and outcomes among people living with HIV in San Francisco

Exploring why adult Mexican males do not get vaccinated: Implications for COVID-19 preventive actions

COVID-19 and racial/ethnic disparities in health risk, employment, and household composition

Disparities among 2009 pandemic influenza A (H1N1) hospital admissions: A mixed methods analysis-Illinois

Patterns of racial/ethnic disparities and prevalence in HIV and Syphilis diagnoses among men who have sex with men, 2016: A Novel data visualization

The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States

COVID-19 disparity among racial and ethnic minorities in the US: A cross sectional analysis

Racial-ethnic differences in all-cause and HIV mortality

Differential association of HIV funding with HIV mortality by race/ethnicity, United States

Quick Facts United States

Hispanic health in the USA: A scoping review of the literature

How to cite this article: Moore KS. The Impact of COVID-19 on the Latinx Population: A Scoping Literature Review