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The COVID-19 pandemic laid bare profound inequalities in our world and their consequences for the well-being and survival of those that are most disenfranchised, including the poor, racial minorities, and LGBT+ people. Unfortunately, global responses to the pandemic replicated public health tendencies to focus on individual behaviors and cultural differences promoting a discourse claiming these were the explanations for disproportionate infection and death among marginalized populations. Inadequate attention was given to structural determinants of pandemic risk, like inadequate shelter, unsafe living and work conditions, and low or unstable income. This paper uses baseline survey data from the #SafeHandsSafeHearts study to characterize participants who volunteered for the intervention and structural vulnerabilities amid the pandemic, and to examine the relevance of structural violence theory in explaining higher COVID-19 risk due to social, political, and economic oppression.
Methods:
#SafehandsSafeHearts, a community-based peer-delivered eHealth intervention, recruited sexual and gender minority, predominantly racialized, people online through community-based organization and health-center listservs and LGBTQ+ media. An online, self-administered 60-minute baseline survey assessed COVID-19 pandemic impacts and associated stressors. We use descriptive statistics to characterize the sample and social-structural and mental health impacts of the pandemic, and ANOVA with gender-based analysis to identify subgroup differences.
Results:
Participants (n=202) (mean age=29.7 years, SD=10.3) identified as African/Caribbean/Black (29.2%), South/East/Southeast Asian (27.7%), Latinx/Hispanic (8.9%), white (20.3%), and other (13.9%). Over half (54.4%) identified as cisgender lesbian/bisexual/women who have sex with women (LBWSW), 26.2% cisgender gay/bisexual/men who have sex with men (GBMSM), and 19.3% transgender/gender-nonbinary people. Overall, 44.1% reported losing their job, 16.3% becoming homeless or moving in with friends, 30.2% being unable to buy food, and 26.7% being unable to financially support their family “because of COVID-19”. Participants reported decreased access to primary healthcare (21.3%), HIV testing (29.0%), STI testing (37.6%), PrEP (19.0%), condoms (25.0%), other reproductive health products (29.4% [40.7%, significantly higher for LBWSW]), and gender-affirming hormones (15.4%) among transgender people. LBWSW (73.6%) and transgender/gender-nonbinary people (71.8%) were more likely to screen in for depression than GBMSM (54.7%; p<.05). Similarly, LBWSW (62.7%) and transgender/gender-nonbinary people (66.7%) were more likely to screen in for anxiety than GBMSM (43.4%; p<.05). Of the 150 participants who received healthcare in the past 12 months, 38.0% rated the quality as poor/fair, with a mean of 2.93 on the 5-point scale.
Conclusions and Implications:
Pervasive challenges in employment, housing and food insecurity, stress on family resources, and healthcare access reported by participants are known indicators of structural violence that places marginalized populations at risk of poorer health outcomes. We also identified gender differences in constraints on healthcare access and in mental health risks. Assessment of indicators of structural violence and its role in COVID-19 and other health risks is essential to creating appropriate, community-based outreach and public health interventions tailored for gender minority, sexual minority and racial minority people who exist in intersecting marginalized identities and intersecting vectors of social, institutional, and political oppression.