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Ethno-cultural disparities in mental health during the COVID-19 pandemic: a cross-sectional study on the impact of exposure to the virus and COVID-19-related discrimination and stigma on mental health across ethno-cultural groups in Quebec (Canada)

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Ethno-cultural disparities in mental health during the COVID-19 pandemic: a cross-sectional study on the impact of exposure to the virus and COVID-19-related discrimination and stigma on mental health across ethno-cultural groups in Quebec (Canada)

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Background Although social and structural inequalities associated with COVID-19 have been documented since the start of the pandemic, few studies have explored the association between pandemic-specific risk factors and the mental health of minority populations. Aims We investigated the association of exposure to the virus, COVID-19-related discrimination and stigma with mental health during the COVID-19 pandemic, in a culturally diverse sample of adults in Quebec (Canada). Method A total of 3273 residents of the province of Quebec (49% aged 18–39 years, 57% women, 51% belonging to a minority ethno-cultural group) completed an online survey. We used linear and ordinal logistic regression to identify the relationship between COVID-19 experiences and mental health, and the moderating role of ethno-cultural identity. Results Mental health varied significantly based on socioeconomic status and ethno-cultural group, with those with lower incomes and Arab participants reporting higher psychological distress. Exposure to the virus, COVID-19-related discrimination, and stigma were associated with poorer mental health. Associations with mental health varied across ethno-cultural groups, with exposed and discriminated Black participants reporting higher mental distress. Conclusions Findings indicate sociocultural inequalities in mental health related to COVID-19 in the Canadian context. COVID-19-related risk factors, including exposure, discrimination and stigma, jeopardise mental health. This burden is most noteworthy for the Black community. There is an urgent need for public health authorities and health professionals to advocate against the discrimination of racialised minorities, and ensure that mental health services are accessible and culturally sensitive during and in the aftermath of the pandemic.
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Ethno-cultural disparities in mental health
during the COVID-19 pandemic: a cross-sectional
study on the impact of exposure to the virus and
COVID-19-related discrimination and stigma on
mental health across ethno-cultural groups in
Quebec (Canada)
Diana Miconi, Zhi Yin Li, Rochelle L. Frounfelker, Tara Santavicca, Jude Mary Cénat, Vivek Venkatesh and
Cécile Rousseau
Background
Although social and structural inequalities associated with
COVID-19 have been documented since the start of the pan-
demic, few studies have explored the association between
pandemic-specific risk factors and the mental health of minority
populations.
Aims
We investigated the association of exposure to the virus, COVID-
19-related discrimination and stigma with mental health during
the COVID-19 pandemic, in a culturally diverse sample of adults
in Quebec (Canada).
Method
A total of 3273 residents of the province of Quebec (49% aged
1839 years, 57% women, 51% belonging to a minority ethno-
cultural group) completed an online survey. We used linear and
ordinal logistic regression to identify the relationship between
COVID-19 experiences and mental health, and the moderating
role of ethno-cultural identity.
Results
Mental health varied significantly based on socioeconomic sta-
tus and ethno-cultural group, with those with lower incomes and
Arab participants reporting higher psychological distress.
Exposure to the virus, COVID-19-related discrimination, and
stigma were associated with poorer mental health. Associations
with mental health varied across ethno-cultural groups, with
exposed and discriminated Black participants reporting higher
mental distress.
Conclusions
Findings indicate sociocultural inequalities in mental health
related to COVID-19 in the Canadian context. COVID-19-related
risk factors, including exposure, discrimination and stigma,
jeopardise mental health. This burden is most noteworthy for the
Black community. There is an urgent need for public health
authorities and health professionals to advocate against the
discrimination of racialised minorities, and ensure that mental
health services are accessible and culturally sensitive during and
in the aftermath of the pandemic.
Keywords
Pandemic; mental health; sociocultural factors; discrimination
and stigma; exposure to virus.
Copyright and usage
© The Authors, 2020. Published by Cambridge University Press
on behalf of the Royal College of Psychiatrists. This is an Open
Access article, distributed under the terms of the Creative
Commons Attribution licence (http://creativecommons.org/
licenses/by/4.0/), which permits unrestricted re-use, distribu-
tion, and reproduction in any medium, provided the original work
is properly cited.
The COVID-19 pandemic is affecting social, cultural and economic
systems around the world, and mounting evidence suggests pro-
found and concerning negative effects of COVID-19 on mental
health, with long-lasting consequences on society.
13
Preliminary
reports from the USA and the UK have denounced how individuals
that experience structural and social inequities, such as ethnic and
racial minorities,
4,5
are disproportionately exposed to the virus
and affected by the pandemic. This is because of systemic social
and economic disparities,
68
including poverty, poor housing and
inadequate healthcare, and has prompted a call to identify and
address sociocultural health disparities in the COVID-19 crisis.
Less is known about how such systemic social and economic
inequalities, and associated experiences during the pandemic,
affect the mental health of vulnerable communities. Indeed, the
pandemic has highlighted social, economic and political fractures
and injustices within communities and societies, fuelling fear and
xenophobic discourses in the general population. As a result, minor-
ities and marginalised groups, who have already been severely
affected by the pandemic, have also increasingly become the
target of COVID-19-related racialised and discriminatory
actions.
5,913
Although conspiracy theories and otheringprocesses
targeting minorities and at-risk groups are common in pan-
demics,
12
empirical evidence on the impact of sociocultural
factors and COVID-19-related experiences of exposure, stigma
and discrimination on mental health are scarce.
Discrimination, stigma, exposure and mental health
during a pandemic
Discrimination and stigma refer to complex and diverse social pro-
cesses that exist at the individual, interpersonal and structural levels
of society, and represent significant public health concerns.
14
Stigma refers to the process of unfair treatment of others, and pre-
vents opportunities for equal participation in society for stigmatised
groups, fuelling social inequalities.
15
In the current study, we focus
on individualstigma, referring to the internalisation of discrimin-
ating beliefs and associated feelings of shame, leading to
BJPsych Open (2021)
7, e14, 110. doi: 10.1192/bjo.2020.146
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concealment, and on experiences of discrimination as a form of
enactedstigma.
16
Prior research documented the overall negative
impact of stigma
1719
and discrimination
20,21
on mental health.
With regards to exposure, a recent meta-analysis showed that
direct exposure to the Ebola virus is linked with more mental dis-
tress, although the magnitude of this association may vary according
to personal and sociocultural experiences and characteristics.
22
However, empirical evidence on the relationship of exposure to
the virus, pandemic-specific stigma and discrimination with mental
health during the COVID-19 pandemic is still limited. The few
available empirical studies from the USA indicate that gender, occu-
pation, age, socioeconomic status, being a member of a racial/ethnic
minority, being foreign-born and experiencing discrimination are
associated with COVID-19-related mental health.
23,24
Direct expos-
ure to COVID-19 was a risk factor for mental health in a study con-
ducted on the Chinese general population,
25
and among healthcare
workers in China.
2
Much less is known about the Canadian context
or among culturally diverse samples. Given that experiences of
exposure to COVID-19 and COVID-19-related stigma and discrim-
ination may play a detrimental role on ones mental health during
the present pandemic, empirical studies aimed at shedding light
on the contributions of such factors to ones mental health in cultur-
ally diverse samples are warranted.
The Quebec context
In Canada, the first case of COVID-19 was confirmed at the end of
January 2020. Although representing just 22.57% of the national
population, with >52% of confirmed cases and >64% of deaths,
the province of Quebec became the epicentre of the pandemic in
Canada.
26
More than one-third of confirmed cases in Quebec
were identified in the city of Montreal, with a disproportionately
higher number of individuals diagnosed with COVID-19 residing
in diverse, multiracial areas of the city, suggesting cultural and
social disparities in rates of COVID-19 infections and deaths.
27
Specific concerns have been expressed over issues of systemic dis-
crimination and unsafe work conditions, given that healthcare
attendants in seniorsresidences and hospitals are mostly racialised
(e.g. Black, Asian, Latino and Arab).
27
Since March 2020, there has
been an increase in reported discrimination and xenophobic inci-
dents directed at members of Asian communities in the province,
including hate speech, vandalism and physical intimidation on
streets and in stores.
27
It is important to note that Quebec society
is demographically and culturally diverse, and 21.9% of its popula-
tion is foreign-born;
28
this highlights the importance of investigat-
ing social and ethnic disparities during the current health
emergency. Information on sociocultural correlates of mental
health during the pandemic is critical to inform public health inter-
ventions and programmes for at-risk populations at the institu-
tional, community and individual level.
The current study
This study investigates the association of sociocultural characteris-
tics and pandemic-specific risk factors (i.e. exposure to the virus,
COVID-19-related discrimination and stigma) with mental health
during the COVID-19 pandemic in a culturally diverse sample of
adults in Quebec (Canada). Specifically, we investigate the follow-
ing: (a) whether sociocultural characteristics (i.e. ethno-cultural
group, immigrant generation, income) are associated with mental
health; (b) whether exposure to the virus and COVID-19-related
discrimination and stigma are associated with mental health,
when controlling for relevant sociodemographic variables, includ-
ing prior mental health and discrimination not related to the pan-
demic; and (c) whether the association between risk factors and
mental health varies across ethno-cultural groups. Based on the
limited evidence on sociocultural vulnerabilities during the
COVID-19 pandemic, we expected participants with lower eco-
nomic resources, an immigrant background and/or those who are
members of a racialised minority to be at higher risk of mental dis-
tress. We expected that exposure to the virus and experiencing
COVID-19-related discrimination and stigma would be negatively
associated with mental health, and that the magnitude of these rela-
tionships would be stronger among those racialised minority groups
most affected by the pandemic.
Method
Participants and procedure
A total of 3273 residents of the province of Quebec, aged 18 years,
completed an online survey (see Table 1). Participants were ran-
domly selected from the Leo panel (Léger Opinion), which includes
>400 000 Canadian households. To get to a culturally diverse
sample, respondents who matched the visible minorityprofile
were targeted in the panel based on the ethnic profiling information
available in the Leo panel. The research project was presented as a
study about COVID-19 and social distancing. Participants com-
pleted the survey in either French or English, between 1 June
2020 and 23 June 2020. Participation was voluntary and confiden-
tial. All participants received from 50 cents to $2 in compensation,
depending upon length of time taken to complete the survey
(average completion time of 12 min), and provided electronic
informed consent. A total of 8825 invitation emails were sent. The
response rate was 37%. The authors assert that all procedures con-
tributing to this work comply with the ethical standards of the rele-
vant national and institutional committees on human
experimentation and with the Helsinki Declaration of 1975, as
revised in 2008. All procedures involving human participants
were approved by the McGill Faculty of Medicine Institutional
Review Board (Approval no. A05-B25-20A 20-05-005) .
Measures
Mental health
Mental health was assessed with the Hopkins Symptom Checklist-
10 (HSCL-10),
29
comprising six items measuring symptoms of
depression and four items measuring symptoms of anxiety.
Participants are asked to rate on a Likert scale from 1 (not at all)
to 4 (extremely), how much they were bothered by the reported
symptoms during the past week. Symptom severity is computed
by averaging responses on the items (range 14), with higher
scores indicating higher distress. Cronbachsαand McDonaldsω
were both 0.89 in our sample.
Perceived impact of COVID-19 on mental health is a categorical
variable (none, a little bit, a great deal), measured by participant
responses to the question, How much has the COVID-19 epidemic
affected your mental health?.
Prior exposure to COVID-19 was measured via five questions
(yes/no response format), to investigate whether the participant
had been diagnosed with COVID-19 and if they knew anyone
around them, among their neighbours, friends and/or within their
household/family, who had been diagnosed with COVID-19 in
the past month. Responses were categorised into a binary variable
(yes/no), with participants who replied yes to at least one of the
questions considered as having been exposed to COVID-19.
COVID-19-related discrimination
All participants were asked to report experiences of perceived
discrimination (if any) in the past month as a result of their pre-
sumed COVID-19 status, based on a questionnaire developed by
Miconi et al
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Table 1 Sociocultural characteristics of participants and descriptive statistics of outcomes across sociocultural variables
Total sample HSCL-10 Impact of COVID-19 on mental health
n%nMean (s.d.) P-value n
Prevalence
P- valueA great deal’‘A little bit’‘None
Age 3273 3195 <0.001 3252 <0.001
1839 years 1611 49.22 1555 1.85 (0.64) 1594 19.26% 55.21% 25.53%
4059 years 994 30.37 977 1.64 (0.56) 991 12.41% 49.65% 37.94%
60 years 668 20.41 663 1.47 (0.45) 667 6.15% 40.78% 53.07%
Gender 3273 3195 <0.001 3252 <0.001
Male 1418 43.32 1386 1.61 (0.58) 1410 11.06% 44.89% 44.04%
Female 1855 56.68 1809 1.78 (0.60) 1842 17.10% 54.89% 28.01%
Race/ethnicity 3273 3195 <0.001 3252 <0.001
White 1606 49.07 1583 1.63 (0.56) 1599 12.01% 48.72% 39.27%
East Asian 249 7.61 243 1.70 (0.59) 246 10.98% 57.32% 31.71%
South Asian 96 2.93 90 1.81 (0.64) 93 21.51% 52.69% 25.81%
Black 692 21.14 669 1.75 (0.63) 687 18.05% 47.74% 34.21%
South-East Asian 119 3.64 115 1.78 (0.67) 119 15.13% 59.66% 25.21%
Arab 450 13.75 434 1.86 (0.61) 447 17.67% 53.02% 29.31%
Other 61 1.86 61 1.93 (0.72) 61 18.03% 63.93% 18.03%
Religion 3176 3106 <0.001 3156 .003
Christianism 1626 51.20 1594 1.67 (0.58) 1616 13.37% 48.89% 37.75%
Islam 378 11.90 362 1.83 (0.59) 372 16.40% 52.69% 30.91%
Judaism 135 4.25 134 1.61 (0.59) 134 11.19% 48.51% 40.30%
Atheism 906 28.53 890 1.73 (0.61) 904 15.15% 52.77% 32.08%
Other 131 4.12 126 1.80 (0.70) 130 18.46% 51.54% 30.00%
Main language 3273 3195 <0.001 3252 <0.001
French 1984 60.62 1941 1.67 (0.57) 1973 13.38% 48.91% 37.71%
English 534 16.32 518 1.77 (0.65) 530 15.66% 52.64% 31.70%
Both 755 23.07 736 1.77 (0.63) 749 16.56% 53.40% 30.04%
Immigrant generation 3221 3155 <0.001 3208 <0.001
First 1167 36.23 1137 1.72 (0.59) 1163 14.36% 50.64% 35.00%
Second 668 20.74 655 1.82 (0.65) 665 17.14% 56.54% 26.32%
Third or more 1386 43.03 1363 1.64 (0.57) 1380 13.19% 47.75% 39.06%
Education 3229 3163 0.101 3215 0.487
High school or less 476 14.74 463 1.76 (0.61) 473 14.16% 51.59% 34.25%
Technical degree/some college or university 1218 37.72 1189 1.71 (0.62) 1212 15.59% 50.17% 34.24%
University degree or above 1535 47.54 1511 1.69 (0.58) 1530 13.73% 50.65% 35.62%
Household income 2928 2877 <0.001 2918 0.002
$19 999 293 10.01 277 1.90 (0.67) 285 18.60% 50.88% 30.53%
$20 000$39 999 447 15.27 437 1.81 (0.65) 446 18.16% 48.65% 33.18%
$40 000$59 999 604 20.63 596 1.75 (0.59) 603 15.92% 52.57% 31.51%
$60 000$79 999 492 16.80 483 1.69 (0.61) 492 12.80% 47.97% 39.23%
$80 000$99 999 382 13.05 380 1.65 (0.56) 382 13.09% 50.26% 36.65%
$100 000 710 24.25 704 1.60 (0.55) 710 11.41% 51.27% 37.32%
Employment 3219 3154 0.830 3206 <0.001
Employed, essential worker 1046 32.49 1023 1.71 (0.60) 1043 16.20% 52.64% 31.16%
Employed, non-essential worker 886 27.52 873 1.71 (0.59) 884 14.14% 52.38% 33.48%
Unemployed 1287 39.98 1258 1.70 (0.60) 1279 13.45% 47.46% 39.09%
Household size 3193 3127 <0.001 3178 0.022
One person 605 18.95 590 1.69 (0.60) 600 15.67% 49.00% 35.33%
Two people 1077 33.73 1061 1.63 (0.54) 1073 12.30% 49.58% 38.12%
Three people 594 18.60 580 1.71 (0.59) 593 14.00% 52.28% 33.73%
Four people 573 17.95 561 1.80 (0.64) 569 15.82% 52.90% 31.28%
Five or more people 344 10.77 335 1.78 (0.64) 343 18.08% 48.10% 33.82%
Geographical location 3180 3115 <0.001 3166 <0.001
Greater Montreal region 2176 68.43 2126 1.73 (0.61) 2166 15.28% 51.62% 33.10%
Outside Greater Montreal region 1004 31.57 989 1.64 (0.55) 1000 12.00% 47.50% 40.50%
Non-COVID-19-related discrimination 3199 3136 <0.001 3185 <0.001
Yes 838 26.20 808 1.98 (0.67) 832 22.60% 51.44% 25.96%
No 2361 73.80 2328 1.61 (0.54) 2353 11.27% 50.38% 38.35%
COVID-19 exposure 3231 3163 <0.001 3214 <0.001
Yes 920 28.47 908 1.83 (0.65) 917 19.30% 52.78% 27.92%
No 2311 71.53 2255 1.66 (0.57) 2297 12.45% 49.54% 38.01%
Mental health before COVID-19 3243 3182 <0.001 3237 <0.001
Excellent 1865 57.51 1840 1.49 (0.49) 1865 9.17% 41.29% 49.54%
Average 1120 34.54 1093 1.92 (0.57) 1117 17.73% 66.61% 15.67%
Poor 258 7.96 249 2.37 (0.64) 255 38.82% 47.84% 13.33%
COVID-19-related stigma (median) 3217 3157 <0.001 3208 <0.001
4 1664 51.73 1642 1.62 (0.57) 1663 13.23% 47.20% 39.57%
>4 1553 48.27 1515 1.81 (0.62) 1545 15.60% 54.56% 29.84%
COVID-19-related discrimination 3184 3124 <0.001 3169 <0.001
Yes 551 17.31 529 2.01 (0.68) 546 21.98% 53.48% 24.54%
No 2633 82.69 2595 1.64 (0.56) 2623 12.81% 49.87% 37.32%
Total 3273 3195 1.71 (0.60) 3252 14.48% 50.55% 34.96%
The Otherethno-cultural cohort grouped participants who self-identified as West Asian (n= 30), Latin American (n= 27) and who responded otherto the question on their ethno-cultural
group (n= 4). The P-value of the univariate effect of each sociocultural variable and predictor on outcomes is reported (n= 3273). HSCL-10, Hopkins Symptom Checklist-10.
Ethnocultural disparities in mental health during COVID19
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Williams et al
30
and adapted to the present health emergency
context. Responses were categorised into a binary variable (yes/no).
COVID-19-related stigma
Participants indicated on a seven-point Likert scale how much they
agreed with the following statements: If a member of my family
became ill with COVID-19, I would want it to remain secret; If I
became ill with COVID-19, I would want it to remain secret.
Responses to the two questions were summed, with higher scores
indicating greater stigma (range 214).
Sociocultural variables
Participants provided information on their age (1839, 4059 or
60 years), gender (male, female or other), education (high
school or less, technical degree or some college/university, univer-
sity degree and above), household income ($19 999, $20 000
$39 999, $40 000$59 999, $60 000$79 999, $80 000$99 999 or
$100 000), number of people in the household (one, two, three,
four or five or more), immigrant generation (first-, second- or
third-generation immigrant and above), religion (Christianism,
Islam, Judaism, Atheism or other), race/ethnicity (White, East
Asian, South Asian, Black, South-East Asian, Arab or other), lan-
guage (French, English or both), employment (unemployed,
employed and designated as an essential worker by the Quebec gov-
ernment, or employed but not designated as an essential worker).
Perceived discrimination not related to COVID-19 in the past
month was measured as a binary variable (yes/no). Self-reported
mental health before the pandemic was assessed with one item,
on a three-point Likert scale (poor, average or excellent).
Data analysis
Descriptive information for the sample was summarised with
counts and proportions for categorical variables, and means and s.
d. for continuous variables, as well as univariate analysis to
examine differences in mental health according to sociocultural
variables. Missing values for both continuous and categorical vari-
ables were imputed with multiple imputations by chained equations
(n= 10).
31
Sensitivity analysis suggested that missing data and mul-
tiple imputations did not alter the observed patterns of associations.
As the total HSCL-10 scale was not normally distributed, we
extracted factor scores of the HSCL-10 latent function via a con-
firmatory factor analysis on the HSCL-10 items, testing a single
latent variable model, using a diagonally weighted least squares
method. Factor scores had a univariate distribution closer to
normal than raw scores, and were therefore included as the
outcome of interest in the subsequent multivariate models. Total
stigma scores were standardised to a mean of 0 and an s.d. of 1,
to facilitate interpretation, allowing for inference of the effect of a
1-s.d. increase in stigma on HSCL-10 scores. Regression analyses
were conducted in three steps: first, we tested linear and ordinal
logistic regression models to assess the relationship between socio-
cultural variables and mental health; next, we tested linear and
ordinal logistic regression models, controlling for the relevant socio-
demographic variables, to assess the impact of prior exposure to
COVID-19 and COVID-19-related discrimination and stigma on
mental health; and finally, in the same models, we included a
two-way interaction between each predictor (i.e. exposure,
COVID-19-related discrimination and stigma) and race/ethnicity,
to explore potential effect modification by ethno-cultural group.
The threshold for statistical significance was set to 0.05 (two-sided
tests). R software version 4.0.3 for Apple (R Foundation for
Statistical Computing, Vienna, Austria; see https://www.R-project.
org/) was used in all analyses.
32
Results
Descriptive statistics of the sample across sociocultural variables at
the univariate level are reported in Tables 1 and 2. In terms of
mental health, all sociocultural variables except education and
employment were significantly associated with HSCL-10 scores.
All variables except education were significantly associated with
self-reported impact of COVID-19 on mental health at the univari-
ate level (Table 1). Participants aged 1839 years, first- and second-
generation immigrants, essential workers, people living in Montreal
and in households of three or more people, and participants who
experienced discrimination not related to COVID-19 reported
higher prevalence of exposure to the virus and COVID-19-related
discrimination, and higher endorsement of COVID-19-related
stigma. Black, Arab and South Asian participants had a higher
prevalence of exposure, whereas Asian and Black participants
reported more COVID-19-related discrimination and stigma.
Muslim participants were the religious group most exposed to the
virus, followed by Christian participants. Muslim participants and
participants who identified with otherin terms of religion reported
higher COVID-19-related discrimination. Anglophone participants
were less exposed to the virus, but Francophone participants
reported less discrimination because of COVID-19. Participants
with an income >$40 000 were more exposed to the virus,
whereas participants with an income <$20 000 reported higher
stigma and more COVID-19-related discrimination. Participants
who self-reported poor mental health before the pandemic also
reported higher stigma; participants who were exposed to the
virus reported higher stigma and higher prevalence of COVID-
19-related discrimination. Participants who reported higher
stigma (above median) also reported a higher prevalence of expos-
ure and COVID-19-related discrimination. Neither education nor
gender were associated with exposure, stigma or COVID-19-
related discrimination (see Table 2).
In multivariate models, women and participants aged between
18 and 39 years reported worse mental health across both outcomes.
Arab participants had higher HSCL-10 scores and reported a greater
impact of the pandemic on their mental health than other racial/cul-
tural groups. East Asian participants reported lower HSCL-10
scores compared with other ethno-cultural groups. Participants
who reported poorer mental health before COVID-19 scored
higher on the HSCL-10 scale and reported a stronger impact of
the pandemic on mental health. Non-COVID-19-related discrimin-
ation was also associated with both mental health outcomes.
Individuals with a lower household income (<$100,000), and
those living with three people in the same household, had higher
HSCL-10 scores, but not more perceived impact of COVID-19 on
mental health, than those living alone. Participants living in the
Greater Montreal area reported greater impact of the pandemic
on their mental health than those living in other parts of Quebec.
Employment, education, generation, language and religion were
not associated with either mental health outcome at the multivariate
level (see Table 3). Differences in the associations of sociocultural
variables with mental health outcomes at the univariate and multi-
variate levels may be partially explained by issues of collinearity
among variables (see Supplementary material available at https://
doi.org/10.1192/bjo.2020.146).
Prior exposure to the virus was associated with HSCL-10 scores
and self-reported impact of COVID-19 on mental health. Both
COVID-19-related discrimination and stigma were associated
with higher scores on the HSCL-10. Neither COVID-19-related dis-
crimination nor reported stigma were associated with perceived
impact of COVID-19 on mental health (Table 4). The magnitude
of the relationship between exposure to the virus, experiencing
Miconi et al
4
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Table 2 Descriptive statistics of study variables across sociocultural variables
Exposure to COVID-19 COVID-19-related stigma COVID-19-related discrimination
nPrevalence P-value nMean (s.d.) P-value nPrevalence P-value
Age 3231 <0.001 3217 <0.001 3184 <0.001
1839 years 1589 34.11% 1576 6.45 (3.97) 1551 24.37%
4059 years 978 25.66% 982 5.29 (3.65) 974 10.88%
60 years 664 19.13% 659 4.16 (3.15) 659 10.17%
Gender 3231 0.059 3217 0.533 3184 0.924
Male 1401 26.77% 1392 5.68 (3.81) 1381 17.38%
Female 1830 29.78% 1825 5.59 (3.83) 1803 17.25%
Race/ethnicity 3231 <0.001 3217 <0.001 3184 <0.001
White 1597 23.79% 1586 4.77 (3.40) 1575 10.03%
East Asian 247 21.86% 244 6.54 (3.79) 245 31.43%
South Asian 94 28.72% 89 6.29 (4.00) 93 30.11%
Black 674 38.72% 678 6.60 (4.11) 666 24.32%
South-East Asian 116 30.17% 118 6.24 (4.14) 117 25.64%
Arab 444 33.56% 444 6.41 (4.01) 427 19.20%
Other 59 23.73% 58 5.50 (3.90) 61 22.95%
Religion 3137 0.024 3125 <0.001 3097 <0.001
Christianism 1598 29.79% 1606 5.43 (3.78) 1595 16.30%
Islam 372 33.87% 368 6.99 (4.05) 353 24.36%
Judaism 135 24.44% 132 4.78 (3.45) 133 5.26%
Atheism 902 25.72% 891 5.31 (3.60) 886 14.67%
Other 130 26.15% 128 6.59 (4.27) 130 39.23%
Main language 3231 <0.001 3217 0.065 3184 <0.001
French 1958 29.01% 1953 5.50 (3.82) 1921 14.37%
English 527 22.20% 520 5.87 (3.87) 524 22.71%
Both 746 31.50% 744 5.79 (3.78) 739 21.11%
Immigrant generation 3182 <0.001 3173 <0.001 3142 <0.001
First 1147 28.51% 1145 6.07 (3.99) 1132 20.58%
Second 660 38.18% 661 6.34 (3.93) 651 23.35%
Third or more 1375 24.36% 1367 4.88 (3.47) 1359 11.41%
Education 3190 0.943 3184 0.231 3151 0.117
High school or less 468 28.85% 469 5.89 (3.97) 462 19.91%
Technical degree/some college or university 1201 28.81% 1191 5.55 (3.75) 1182 17.94%
University degree or above 1521 28.27% 1524 5.57 (3.82) 1507 15.99%
Household income 2895 0.012 2889 <0.001 2859 <0.001
$19 999 290 23.10% 282 6.41 (4.00) 278 27.34%
$20 000$39 999 438 24.43% 440 5.74 (3.98) 439 23.46%
$40 000$59 999 594 28.79% 595 5.61 (3.72) 585 18.63%
$60 000$79 999 489 30.67% 487 5.88 (3.94) 482 16.80%
$80 000$99 999 378 33.86% 380 5.61 (3.84) 374 12.57%
$100 000 706 29.46% 705 5.12 (3.59) 701 12.98%
Employment 3181 <0.001 3172 <0.001 3140 <0.001
Employed, essential worker 1031 37.73% 1038 6.07 (4.01) 1027 22.30%
Employed, non-essential worker 878 24.26% 869 5.51 (3.63) 864 13.08%
Unemployed 1272 24.06% 1265 5.26 (3.73) 1249 16.01%
Household size 3154 <0.001 3145 <0.001 3118 0.013
One person 596 21.31% 586 5.38 (3.70) 587 15.16%
Two people 1070 25.61% 1063 5.20 (3.69) 1058 14.56%
Three people 584 33.90% 588 5.91 (4.00) 582 19.24%
Four people 563 29.66% 565 5.80 (3.83) 557 18.13%
Five or more people 341 38.12% 343 6.14 (3.83) 334 21.26%
Geographical location 3144 <0.001 3133 0.002 3102 0.002
Greater Montreal region 2150 32.88% 2142 5.71 (3.87) 2126 18.34%
Outside Greater Montreal region 994 18.71% 991 5.26 (3.63) 976 13.93%
Non-COVID-19-related discrimination 3163 <0.001 3155 <0.001 3151 <0.001
Yes 819 40.78% 824 6.70 (4.06) 816 50.86%
No 2344 24.53% 2331 5.21 (3.65) 2335 5.52%
COVID-19 exposure 3181 <0.001 3145 <0.001
Yes 914 6.00 (4.00) 900 27.33%
No 2267 5.46 (3.73) 2245 12.92%
Mental health before COVID-19 3207 0.131 3200 <0.001 3162 <0.001
Excellent 1846 27.63% 1841 5.31 (3.81) 1820 13.85%
Average 1106 28.84% 1106 5.89 (3.75) 1092 19.41%
Poor 255 33.73% 253 6.58 (3.96) 250 31.60%
COVID-19-related stigma (median) 3181 0.002 3141 <0.001
4 1649 26.38% 1645 11.19%
>4 1532 31.27% 1496 23.80%
COVID-19-related discrimination 3145 <0.001 3141 <0.001
Yes 536 45.90% 540 7.29 (4.11)
No 2609 25.07% 2601 5.22 (3.65)
Total 3231 28.47% 3217 5.63 (3.82) 3184 17.31%
P-value of the univariate effect of each sociocultural variable on predictors is reported (n= 3273).
Ethnocultural disparities in mental health during COVID19
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COVID-19-related discrimination and HSCL-10 scores was stron-
gest among participants who self-identified as Black and White.
Although the interaction effect between COVID-19-related stigma
and HSCL-10 scores was not statistically significant, higher per-
ceived stigma was associated with worse mental health among
South Asian and Black participants. The effect of exposure to the
Table 3 Results of multivariate linear and ordered logistic regression models on HSCL-10 total scores and impact of COVID-19 on mental health (n = 3273)
Variables
HSCL-10 total (factor scores) Impact of COVID-19 on mental health
B95% CI
Omnibus
F(d.f.) η2
p
Proportional
odds ratio 95% CI Likelihood ratio χ
2
(d.f.)
Gender 37.896 (1, 17 245.327)*** 0.012 44.477 (1, 41 745.532)***
Male Reference 1
Female 0.172*** 0.1170.227 1.621*** 1.4041.871
Age, years 23.513 (2, 2172.733)*** 0.015 45.230 (2, 13 7981.981)***
1839 Reference 1
4059 0.150*** 0.217 to 0.084 0.745** 0.6300.883
60 0.307*** 0.400 to 0.214 0.451*** 0.3560.573
Race/ethnicity 5.298 (6, 1191.333)** 13.598 (6, 2667.706)*
White Reference 1
East Asian 0.164* 0.292 to 0.036 0.785 0.5641.094
South Asian 0.004 0.194 to 0.201 1.372 0.8222.289
Black 0.080 0.183 to 0.024 0.965 0.7391.261
South-East Asian 0.044 0.214 to 0.126 1.097 0.7121.689
Arab 0.191** 0.0690.313 1.391* 1.0141.908
Other 0.093 0.114 to 0.299 1.370 0.8082.323
Religion 0.236 (4, 1725.438) <0.001 2.071 (4, 1519.545)
Christianism Reference 1
Islam 0.042 0.154 to 0.070 0.833 0.6241.112
Judaism 0.046 0.198 to 0.105 0.962 0.6491.426
Atheism 0.019 0.085 to 0.047 1.010 0.8501.200
Other 0.035 0.196 to 0.125 0.928 0.6071.419
Main language 1.746 (2, 8159.802) 0.001 0.974 (2, 22 662.688)
French Reference 1
English 0.074 0.012 to 0.160 1.115 0.8931.391
Both 0.007 0.076 to 0.062 1.024 0.8551.227
Immigrant generation 0.392 (2, 1985.614) <0.001 2.126 (2, 9562.608)
First Reference 1
Second 0.029 0.049 to 0.108 1.096 0.8991.336
Third or more 0.038 0.057 to 0.133 1.188 0.9261.523
Education 0.737 ( 2, 3631.138) <0.001 0.705 (2, 7634.225)
High school or less Reference 1
Technical degree/some college
or university
0.023 0.108 to 0.062 1.098 0.8851.362
University degree or above 0.016 0.070 to 0.102 1.052 0.8451.309
Household income 6.256 (5, 753.312)*** 0.011 8.164 (5, 3334.008)
$19 999 Reference 1
$20 000$39 999 0.059 0.062 to 0.179 1.107 0.8151.503
$40 000$59 999 0.023 0.142 to 0.096 1.186 0.8861.588
$60 000$79 999 0.062 0.185 to 0.060 0.887 0.6421.225
$80 000$99 999 0.127 0.265 to 0.012 0.946 0.6821.312
$100 000 0.193** 0.319 to 0.068 0.971 0.7111.324
Household size 2.588 (4, 3644.241)* 0.003 2.562 (4, 13 385.440)
One person Reference 1
Two people 0.003 0.079 to 0.085 0.969 0.7841.197
Three people 0.011 0.082 to 0.104 0.840 0.6611.069
Four people 0.119* 0.020 to 0.219 0.948 0.7411.214
Five or more people 0.054 0.058 to 0.166 0.899 0.6771.194
Employment 1.809 (2, 1948.613) 0.001 1.439 (2, 93 757.358)
Unemployed Reference 1
Employed, essential worker 0.062 0.135 to 0.011 1.117 0.9291.342
Employed, non-essential worker 0.006 0.083 to 0.070 1.076 0.8871.305
Geographical location 1.616 (1, 11 208.481) <0.001 5.508 (1, 15 377.989)*
Outside Greater Montreal region Reference 1
Greater Montreal region 0.041 0.022 to 0.104 1.214* 1.0301.431
Discrimination not related to
COVID-19
120.889 (1, 2806.166)*** 0.038 25.718 (1, 12 797.430)***
No Reference 1
Yes 0.362*** 0.2970.426 1.530*** 1.2951.807
Mental health before COVID-19 307.119 (2, 20 170.448)*** 0.162 284.748 (2, 8563.222)***
Excellent Reference 1
Average 0.571*** 0.5110.631 3.056*** 2.6113.575
Poor 1.065*** 0.961 to 1.168 5.895*** 4.4657.784
HSCL-10, Hopkins Symptom Checklist-10.
*P< 0.05, **P< 0.01, ***P< 0.001.
Miconi et al
6
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virus and COVID-19-related discrimination and stigma on the
impact of COVID-19 on mental health did not vary across ethno-
cultural groups (all P> 0.05). However, participants who self-iden-
tified as White and Black reported a greater impact of COVID-19 on
their mental health when exposed to the virus, compared with those
not exposed (see Table 5).
Discussion
Our study sheds light on sociocultural correlates of mental health
during the COVID-19 pandemic and highlights the contribution
of exposure to the virus and COVID-19-related discrimination
and stigma on mental health in a culturally diverse sample of
adults. In addition, the association of the hypothesized risk factors
with mental health varied across ethno-cultural groups.
As expected, socioeconomic status (in terms of income and
household size) and race/ethnicity were both associated with
mental health, beyond the contributions of prior mental health,
experiences of discrimination not related to COVID-19 and other
sociodemographic variables. Participants living in a household
with a greater number of people reported higher mental distress,
as did participants who declared a lower income. This suggests
that socioeconomic hardship represents a risk factor for ones
mental health during the present pandemic. Participants who
belonged to the Arab ethno-cultural group reported the worst
mental health outcomes, whereas participants who self-identified
as East Asian reported the best mental health across sociocultural
groups. These findings mirror results from the Quebec Cultural
Communities Survey.
33
Such results may be attributed to a combin-
ation of both variations in cultural norms around reporting mental
health issues (i.e. East Asian participants may be less likely to
express distress than other cultural groups), as well as actual differ-
ences in mental health across ethno-cultural groups, and are con-
sistent with the literature before the pandemic. Of interest,
women and younger participants reported worse mental health,
suggesting that these groups may be suffering more from the nega-
tive consequences of the pandemic. The fact that immigrant status
in terms of first-, second- or third-generation immigrant was not
associated with mental health in our study at the multivariate
level suggests that identifying as part of a minority group may be
more important to mental health than migration status. Possible
explanations for this include the immigrant paradox, whereby
first-generation immigrants have fewer mental health problems
compared with their native-born offspring,
34
and the healthy immi-
grant effect, in which recent immigrants have good mental health
relative to the host population despite higher levels of exposure to
adversity.
35
However, our sample did not include many asylum
seekers, refugees and recent immigrants with a lower education
level, reported to be at increased risk during the pandemic.
36
Exposure to COVID-19, experiencing COVID-19-related dis-
crimination and reporting higher levels of COVID-19-related
stigma contributed to higher mental distress. Of interest, 17.3% of
the sample reported having experienced COVID-19-related dis-
crimination, with the highest prevalence reported by East and
South Asian participants. This is not surprising in light of the
observed anti-Chinese rhetoric online, and the rapid increase in
the number of reports of in-person racist acts against Asian partici-
pants in North America.
10
In terms of exposure to the virus, Black
(38.72%), Arab (33.56%) and South Asian (28.72%) communities
were among the most exposed ethno-cultural groups, mirroring
the composition of the essential workforce in the province, with
Black, Asian, Latino and Arab residents overrepresented in the
health sector as healthcare attendants in seniorsresidences and
hospitals.
27
Such results provide preliminary evidence in the
Canadian context that aligns with reports from the UK and USA,
which indicate that communities of colour are disproportionately
affected by COVID-19 because of social and economic disparities,
including poverty, poor housing and inadequate healthcare.
13
The association of both exposure to COVID-19 and having
experienced at least one episode of COVID-19-related discrimin-
ation with mental health varied across ethno-cultural groups. Of
importance, Black participants reported the worst mental health out-
comes when exposed to the virus and/or to COVID-19-related dis-
crimination, compared with other sociocultural groups. In other
words, ones mental health depended on experiences of exposure/
discrimination: both exposure and discrimination had a differential
effect among ethno-cultural groups, putting Black participants at
higher risk of mental distress. Such results suggest that sociocultural
inequalities during the pandemic are relevant to mental health out-
comes, as well as other health disparities.
5
In light of the high rates of
COVID-19-related hospital admission and mortality among Black
Americans in the USA,
37
and despite the absence of Canadian statis-
tics on ethno-racial rates of morbidity and mortality, these results are
not surprising, and align with lessons learned from previous pan-
demics
38,39
and well-established documentation of the mental
health needs of Black Americans.
40,41
They clearly indicate that
race-conscious and culturally competent interventions, which con-
sider factors such as discrimination and historical and racial
trauma, are urgently needed.
42
Obstacles to access public health
and social services as well as protective factors, including commu-
nity- and culture-specific coping strategies, also need to be consid-
ered when planning a concerted response in a time of pandemic.
The need for multi-stakeholder interventions that use socio-peda-
gogical approaches to counter discrimination, through development
of prosocial behaviours and moral engagement,
43
should also be con-
sidered as complementary to those adopted by mental health
Table 4 Effects of exposure to COVID-19 and COVID-19-related discrimination and stigma on HSCL-10 total scores, and impact of COVID-19 on mental
health in multivariate linear and ordered logistic regression models (n= 3273)
Variables
HSCL-10 total (factor scores) Impact of COVID-19 on mental health
B95% CI Omnibus F(d.f.) η2
p
Proportional
odds ratio 95% CI Likelihood ratio χ
2
(d.f.)
Exposure to COVID-19 15.12 (1, 1705.007)*** 0.005 15.063 (1, 9398.739)***
No Reference 1
Yes 0.122*** 0.0610.183 1.360*** 1.1611.593
COVID-19-related
discrimination
12.395 (1, 1129.500)*** 0.004 0.850 (1, 1480.883)
No Reference 1
Yes 0.155*** 0.0680.241 1.102 0.8801.380
COVID-19-related stigma 0.064*** 0.0360.092 20.541 (1, 9510.511)*** 0.007 1.058 0.9841.138 2.389 (1, 31 145.131)
Both models included sociodemographic variables significant at the P< 0.05 level in Table 3 as covariates. HSCL-10, Hopkins Symptom Checklist-10.
*P< 0.05, **P< 0.01, ***P< 0.001.
Ethnocultural disparities in mental health during COVID19
7
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Table 5 Results from moderation (interaction) analyses: associations of exposure to COVID-19 and COVID-19-related discrimination and stigma with total HSCL-10 scores and impact of COVID-19 on mental health, stratified by
ethnocultural group (n= 3273)
Predictor
HSCL-10 Exposure to COVID-19 COVID-19-related discrimination COVID-19-related stigma
Moderator Estimate 95% CI Estimate 95% CI Estimate 95% CI
Ethno-cultural group White 0.149*** 0.0620.237 0.167* 0.0320.303 0.036 0.006 to 0.079
East Asian 0.157 0.071 to 0.385 0.520 0.262 to 0.158 0.036 0.059 to 0.132
South Asian 0.171 0.519 to 0.177 0.125 0.221 to 0.471 0.181* 0.0260.335
Black 0.246*** 0.1260.366 0.324*** 0.1820.466 0.111*** 0.0570.165
South-East Asian 0.134 0.449 to 0.180 0.102 0.226 to 0.429 0.113 0.018 to 0.245
Arab 0.029 0.183 to 0.124 0.047 0.150 to 0.245 0.048 0.020 to 0.117
Other 0.143 0.604 to 0.318 0.099 0.556 to 0.358 0.054 0.245 to 0.1373
P-interaction 0.019 0.050 0.181
Impact of COVID-19 on mental health
Moderator Proportional odds ratio 95% CI Proportional odds ratio 95% CI Proportional odds ratio 95% CI
Ethno-cultural group White 1.328* 1.0541.673 0.860 0.599 to 1.233 1.045 0.9321.171
East Asian 1.159 0.6492.070 1.120 0.6611.899 0.970 0.7601.239
South Asian 1.375 0.5673.331 2.127 0.8505.321 1.311 0.8831.945
Black 1.783*** 1.3032.440 1.378 0.9491.999 1.122 0.9741.293
South-East Asian 0.657 0.3031.422 0.805 0.3451.881 1.147 0.8241.596
Arab 1.234 0.8331.829 1.236 0.7502.038 1.006 0.8421.202
Other 1.265 0.3864.146 0.682 0.2202.113 0.829 0.5111.345
P-interaction 0.317 0.311 0.700
Separate models for each mental health outcome were implemented. Each interaction was tested in separate models. All models presented with HSCL-10 as outcome included age, gender, income, household size, non-COVID-19-related discrimination and prior mental health
as covariates. All models presented with impact of COVID-19 on mental health as outcome included age, gender, non-COVID-19-related discrimination, geographical location and prior mental health as covariates. HSCL-10, Hopkins Symptom Checklist-10.
*P< 0.05, **P< 0.01, ***P< 0.001.
Miconi et al
8
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practitioners. Sustained multi-sectoral work in the fields of social ser-
vices, public health and education that magnifies marginalised com-
munities lived experiences of discrimination is essential in creating
dialogic platforms that encourage perspective-taking, and build
empathy as cogent outcomes of citizen education initiatives.
44,45
In
addition, to sustainably empower marginalised communities and
help build resilience against discrimination, specific attention must
be paid to the intersections of identities gender, sexual, racial
and otherwise thereby highlighting the differential effects of preju-
dicial acts.
Exposure to the virus was significantly associated with worse
mental health outcomes among White participants at a statistical
level (P< 0.05). Likewise, COVID-19-related discrimination was
associated with higher HSCL-10 scores also among White partici-
pants. These findings indicate that White participantsmental
health was significantly affected by COVID-19-related experiences
such as exposure and discrimination. This is not surprising:
although studies rarely scrutinise it in majority groups, discrimin-
ation is a heterogeneous phenomenon stemming from individual
and group differences, and is always hurtful. Members of the major-
ity group may take their privileges for granted and, because of that,
may be on average more likely to expect protection and justice from
their environment, and less prepared to endure discrimination.
However, at a methodological level, it is important to consider
that these statistically significant effects may be attributable to the
large sample size of the White ethno-cultural group in our study.
This hypothesis is supported by the fact that regression coefficients
of the association between exposure/discrimination and mental
health among White participants are very similar to those reported
across other smaller ethno-cultural groups (which did not, however,
reach the 0.05 statistical threshold used in the present study), with
the exception of the estimates for Black participants. Overall,
these findings, with a closer look at estimates beyond P-values,
underline that exposure to COVID-19 and related discrimination
are risk factors that should not be underestimated across any
ethno-cultural group during the present pandemic, although the
Black community seems to be at increased risk of mental distress
in the present health emergency. Future studies are warranted to
shed more light on these issues.
Some differences emerged in terms of findings for each mental
health outcome. This indicates that the self-reported impact of the
pandemic on mental health and the HSCL-10 scale measure differ-
ent constructs that are associated, but not overlapping. Specifically,
our findings suggest that subjective single-item measures of the
impact of COVID-19 on mental health are more independent to
COVID-19-related experiences and socioeconomic aspects com-
pared with validated scales measuring symptoms of depression
and anxiety, such as the HSCL-10. This kind of measure of
mental health, which may be more sensitive to sociocultural varia-
tions, may be more appropriate to evaluate psychological distress
during the present situation, as the appraisal of past mental health
may be more influenced by personal factors such as memory bias
and ones subjective perceptions.
Limitations and future directions
There are several limitations to this study. First, the cross-sectional
design prevents us from drawing any conclusions about causality.
Longitudinal studies are needed to shed light on the trajectories of
the sociocultural correlates of mental health during the COVID-
19 pandemic. Second, our study used a convenience sample with
a relatively low response rate (37%), and included a majority of par-
ticipants with some college or a university degree; therefore, find-
ings cannot be generalised to the larger Quebec population or to
less educated populations. Third, differences may exist within the
broad ethno-cultural groups used in the present study. Studies
including larger samples and collecting more detailed ethno-cul-
tural information are warranted. Fourth, we relied on self-reported
items, and thus social desirability and response biases need to be
taken into account. In particular, we used a measure of exposure
to the virus that did not exclusively measure direct exposure to
COVID-19, but rather whether the participant had tested positive
or knew someone who tested positive for COVID-19. Future
studies should investigate whether different types of exposure are
differentially linked to mental health. Finally, our results cannot
be generalised to different countries or to other Canadian provinces,
and more research on regional and trans-national differences is
needed.
In conclusion, despite its limitations, our study provides the first
empirical evidence of the impact of sociocultural inequalities on
mental health during the COVID-19 pandemic in the Canadian
context. Public health authorities should acknowledge that pre-
existing social and ethno-racial inequalities are exacerbated by the
present pandemic, and actively monitor the evolution of the
COVID-19 across sociocultural groups. Policies and messaging
should be aimed at promoting inclusiveness at the societal level,
to reduce the discrimination of racialised minorities, protect vulner-
able groups and be better prepared for the second wave. The imple-
mentation and evaluation of multi-sectoral, community-based anti-
discrimination programmes is warranted. Efforts should ensure that
mental health services are accessible and culturally sensitive to racial
minorities during, and in the aftermath of, the pandemic.
Diana Miconi , PhD, Division of Social and Cultural Psychiatry, McGill University,
Canada; Zhi Yin Li, MScPH candidate, Department of Epidemiology, Biostatistics, and
Occupational Health, McGill University, Canada; Rochelle L. Frounfelker, ScD, Division
of Social and Cultural Psychiatry, McGill University, Canada; Tara Santavicca, MScPH
candidate, Department of Epidemiology, Biostatistics, and Occupational Health, McGill
University, Canada; Jude Mary Cénat , PhD, School of Psychology (Clinical),
University of Ottawa, Canada; Vivek Venkatesh, PhD, UNESCO co-Chair on Prevention
of Radicalisation and Violent Extremism, Concordia University, Canada;
Cécile Rousseau, MD, Division of Social and Cultural Psychiatry, McGill University,
Canada
Correspondence: Diana Miconi. Email: diana.miconi@mail.mcgill.ca
First received 3 Aug 2020, final revision 28 Oct 2020, accepted 11 Nov 2020
Supplementary material
Supplementary material is available online at https://doi.org/10.1192/bjo.2020.146.
Data availability
The data-sets generated and/or analysed during the current study are available from the cor-
responding author, upon request.
Acknowledgements
We acknowledge the support of Leger Marketing in the collection of study data, Mr Claudio
Zandonella Callegher for statistical advice and Ms. Maya Detiere-Venkatesh for her assistance
in preparing the manuscript for publication.
Author contributions
D.M. contributed to conception and design of the study, data analysis, interpretation of study
findings and writing the manuscript. Z.Y.L., R.L.F. and T.S. contributed to data analysis, inter-
pretation of study findings and writing the manuscript. J.M.C., V.V. and C.R. contributed to con-
ception and design of the study, interpretation of study findings and writing the manuscript. The
authors listed in the byline have agreed to the byline order and to submission of the manuscript
in this form. All authors agreed to act as guarantor of the work.
Funding
Our work is one of the critical research programmes supported by the McGill Interdisciplinary
Initiative in Infection and Immunity (MI4), with seed funding from the Research Institute of the
McGill University Health Centre (RI-MUHC) awarded to C.R. (grant no. ECRF-R2-03). The
research presented in this paper is that of the authors and does not reflect official policy of
the McGill Interdisciplinary Initiative in Infection and Immunity.
Ethnocultural disparities in mental health during COVID19
9
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Declaration of interests
None.
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... Second, COVID-19 is also a major target of stigma and discrimination in both the general population and frontline healthcare workers (Snider and Flaherty, 2020;WHO, 2022). COVID-19-related discrimination varies across countries and social groups, ranging from 17% to 32% in the general population Miconi et al., 2021;Zhang et al., 2021). Visible minorities, health care workers, and younger individuals are at higher risk of experiencing COVID-19-related discrimination . ...
... Third, stigmatization of mental illness and COVID-19 may interact. The COVID-19 pandemic has not only fueled inequities and mental health consequences but also increased specific forms of discrimination (Snider and Flaherty, 2020; Miconi et al., 2021;WHO, 2022). COVID-19-related discrimination interacts with other forms of social adversity, mental health consequences (e.g., psychological distress and anti-Asian violence in the US), and mental illness-related stigma . ...
... COVID-19-related discrimination and stigma are associated with poorer mental health, marginalization, lower quality of life, diminished treatment feasibility, and lower stated intention of vaccination Miconi et al., 2021;Yuan et al., 2022). Sociocultural inequities in mental health related to COVID-19 also contribute to distrust toward government and health institutions . ...
... Most studies conducted in the DRC also showed that the most important predictor of mental health problems related to COVID-19 and EVD was the stigmatization associated with them in the local population (Cénat et al., 2021e, 2021b(Cénat et al., 2021e, , 2021d(Cénat et al., 2021e, , 2020b. Studies conducted in various countries during the COVID-19 pandemic showed similar results (Adom et al., 2021;Miconi et al., 2021;Taylor et al., 2020). ...
... First, the results revealed that EVD stigmatization at Wave 1, COVID-19-related stigmatization (Wave 2), exposure to EVD and COVID-19 at Wave 2, and mental distress at time 1 and being of Protestant faith were the risk factors for mental distress at Wave 2. In cross-sectional studies of communities affected by EVD, related stigmatization has consistently been a significant risk factor for mental health problems (Cénat et al., 2021d(Cénat et al., , 2021b(Cénat et al., , 2021e, 2020b. Although we did not identify any longitudinal studies examining the association between stigmatization and mental health problems during the COVID-19 pandemic, cross-sectional studies have shown strong association between them (Cénat et al., 2021e, 2021bMiconi et al., 2021). However, for resilience, results showed that the negative association found was not significant. ...
... The results confirmed this hypothesis. Results from crosssectional studies have shown that COVID-19-related stigmatization has a strong association with mental health problems (Cénat et al., 2021d;Miconi et al., 2021). This study clarifies the nature of this association, which remains very important despite the weight of other variables including exposure to EVD and COVID-19 and EVD-related stigmatization. ...
Article
Background Associated with high mortality rate, fear, and anxiety, Ebola Virus Disease (EVD) is a significant risk factor for mental distress. This longitudinal study aims to investigate the prevalence and predictors associated with mental distress among populations affected by EVD outbreaks in the Province of Equateur in DR Congo. Methods Surveys were administered in zones affected by the 2018 EVD outbreak in Equateur Province with a 16-month interval. Measures assessed sociodemographic characteristics, mental distress (GHQ-12), COVID-19 and EVD exposure and related stigmatization, and Resilience. Models of logistic regression and path analysis were used to estimate factors related to mental distress outcomes. Results Prevalence of mental distress decreased from Wave 1 to Wave 2 (Mental distress T1= 57.04%, Mental distress T2= 40.29%, x²= 23.981, p<.001). Clinical mental distress score at follow-up was predicted by greater levels of exposure to Ebola at baseline (B= .412, p<.001) and at Wave 2 (B= .453, p<.001) as well as Ebola stigmatization at baseline (B= .752, p<.001), and Protestant religion (B= .474, p=.038). Clinical mental distress score at follow-up was significantly associated with higher levels of exposure to COVID-19 (B= .389, p=.002) and COVID-19 related stigmatization (B= .480, p<.001). COVID-19 related stigmatization partially mediated the association between exposure to EVD (Time 1) and mental distress (B= .409, p<.001). Conclusions Although a decrease in mental distress symptoms was observed, its prevalence remains high. The results show that mental health programs need to develop better health and education communication strategies to reduce stigmatization.
... The proportion of non-Italian participants in the study was 15.3%. Several studies show that COVID-19 pandemic increased pre-existing social and health-related inequities, and this is also true in the field of mental health (Gibson et al., 2021;Miconi et al., 2021;Reme et al., 2022;Sommer and DeLisi, 2022). There is also evidence that, in some contexts, LAI treatments are disproportionately used in patients of ethnical and cultural minorities: for instance, in the USA they are more used in Black patients than in White patients (Brown et al., 2014;Lawson et al., 2015). ...
Article
The COVID-19 pandemic is having an important impact on the practice of mental health services and on schizophrenia patients, and heterogeneous and conflicting findings are being reported on the reduction of long-acting injectable (LAI) antipsychotics use. Aims of the study were to assess the total number of patients treated with LAI, the start of novel LAI and the discontinuation of LAI treatments, analyzing register data of the first year of the pandemic, 2020, compared to a pre-pandemic reference year, 2019. Data from two outpatient centers were retrieved, for a total of 236 participants in 2020: no significant differences were observed comparing 2020 and 2019 when considering the total number of patients on LAI treatment (p = 0.890) and the number of dropouts (p = 0.262); however, a significant reduction in the start of LAI was observed (p = 0.022). In 2020, second generation LAI were more prescribed than first generation LAI (p = 0.040) while no difference was observed in 2019 (p = 0.191). These findings attest the efficacy of measures adopted in mental health services to face the consequences of COVID-19 and shed further light on the impact of the pandemic on the clinical practice of mental health services and on the continuity of care of people with schizophrenia.
... Accumulating research has documented the impact of biases and discriminatory behaviors by healthcare providers on patients' physical and mental health. Patients who have low SES (Arpey et al., 2017;Woo et al., 2004), belong to a racial/ethnic minority group (Hoffman et al., 2016;Miconi et al., 2020), are LGBTQþ (Cahill & South, 2002;Willging et al., 2006), are immigrants (Hacker et al., 2015), are experiencing serious mental illness (Kaufman et al., 2012), or have obesity (Phelan et al., 2015) experience barriers to care, as well as biased treatment from providers. The expectation of insufficient care may cause distress or mistrust in healthcare settings, and overall poorer mental health (Phelan et al., 2015). ...
Article
Full-text available
Social and economic inequality are chronic stressors that continually erode the mental and physical health of marginalized groups, undermining overall societal resilience. In this comprehensive review, we synthesize evidence of greater increases in mental health symptoms during the COVID-19 pandemic among socially or economically marginalized groups in the United States, including (a) people who are low income or experiencing homelessness, (b) racial and ethnic minorities, (c) women and lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) communities, (d) immigrants and migrants, (e) children and people with a history of childhood adversity, and (f) the socially isolated and lonely. Based on this evidence, we propose that reducing social and economic inequality would promote population mental health and societal resilience to future crises. Specifically, we propose concrete, actionable recommendations for policy, intervention, and practice that would bolster five "pillars" of societal resilience: (1) economic safety and equity, (2) accessible healthcare, including mental health services, (3) combating racial injustice and promoting respect for diversity, equity, and inclusion, (4) child and family protection services, and (5) social cohesion. Although the recent pandemic exposed and accentuated steep inequalities within our society, efforts to rebuild offer the opportunity to re-envision societal resilience and policy to reduce multiple forms of inequality for our collective benefit.
... Our results also showed an association between being isolated in a non-home setting (hospital or isolation facility) during the disease course and an increased level of perceived For instance, a study conducted in Canada among 3273 residents in Quebec found a statistical association between ethnicity and the higher level of COVID-19 perceived stigma (p<0.001). 49 Another study from the United States showed a significant association between ethnicity and COVID-19-related stigma. 50 Notably, the highest proportion of the non-Arab population in Qatar, as well as in our study, were Filipinos (n=59, 14.6%) and Indians (n=54, 13.4%) of Asian origin. ...
Article
Background and objectives Perceived stigma related to infectious diseases is of public health importance and can adversely impact patients' physical and mental health. This study aims to identify the level of perceived stigma among COVID-19 survivors in Qatar and investigate its predictors. Methods An analytical cross-sectional design was employed. Four hundred and four participants who had a positive COVID-19 PCR test were randomly selected from medical records. The selected participants were interviewed to collect sociodemographic and health-related information. Perceived stigma was assessed using the COVID-19 perceived stigma scale-22 (CPSS-22) that was developed by the researchers. A descriptive analysis followed by a bivariate analysis investigated possible associations between the perceived stigma levels and independent variables. A multivariable analysis was performed using logistic regression to identify any significant associations with perceived stigma. The validity and reliability of the developed tool were also tested. Results The prevalence of COVID-19 perceived stigma was twenty-six percent (n=107, 26.4%) at 95% CI [22.4-30.4]. Factors associated with higher COVID-19 perceived stigma were male gender, being a manual worker, non-Arabic ethnicity, low educational level, living alone, and being isolated outside the home. However, only occupation, ethnicity, and low educational level predicted COVID-19 perceived stigma in multivariable analysis. The CPSS-22 showed excellent reliability (Cronbach's alpha 0.92). Conclusion Perceived stigma was relatively common among participants. Designing programs and interventions targeting male manual workers and those of low-educational levels may assist policymakers in mitigating the stigma related to COVID-19.
... The COVID-19 pandemic has led to significant adverse mental health impacts among the general population, with emerging data indicating that these impacts are distributed along a social gradient wherein populations experiencing structural vulnerabilities are most affected [1, 29,30]. However, there is a paucity of literature examining the range of pandemic related mental health impacts over time or among population subgroups who experience disproportionate "risk". ...
Article
Full-text available
Objectives: Adverse mental health impacts of the COVID-19 pandemic are well documented; however, there remains limited data detailing trends in mental health at different points in time and across population sub-groups most impacted. This paper draws on data from three rounds of a nationally representative cross-sectional monitoring survey to characterize the mental health impacts of COVID-19 on adults living in Canada (N = 9,061). Methods: Descriptive statistics were used to examine the mental health impacts of the pandemic using a range of self-reported measures. Multivariate logistic regression models were then used to quantify the independent risks of experiencing adverse mental health outcomes for priority population sub-groups, adjusting for age, gender, and survey round. Results: Data illustrate significant disparities in the mental health consequences of the pandemic, with inequitable impacts for sub-groups who experience structural vulnerability related to pre-existing mental health conditions, disability, LGBTQ2+ identity, and Indigenous identity. Conclusion: There is immediate need for population-based approaches to support mental health in Canada and globally. Approaches should attend to the root causes of mental health inequities through promotion and prevention, in addition to treatment.
... Isolation through confinement and quarantine in the context of COVID-19 have been associated with negative psychological outcomes including stress, depression and post-traumatic stress disorders (21,22). Moreover, ethnic and racial minorities have been disproportionally affected by the pandemic due to pre-existing social and economic inequalities (i.e., poverty, discrimination, poor access to healthcare) (23). Families with young children may be particularly impacted. ...
Article
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Background Migrant women with young children, including asylum seekers and refugees, have multiple vulnerability factors that put them at increased risk of social isolation and loneliness, which are associated with negative health outcomes. This study explored the experiences of social isolation and loneliness among migrant mothers with children aged 0–5 years as well as their perceptions on possible health impacts. Methods A qualitative descriptive study was conducted at La Maison Bleue, a non-profit organization providing perinatal health and social services to vulnerable women in Montreal, Canada. Recruitment and data collection occurred concurrently during the COVID-19 pandemic, between November and December 2020. Eleven women participated in individual semi-structured interviews and provided socio-demographic information. Interview data were thematically analyzed. Results Migrant women in this study described social isolation as the loss of family support and of their familiar social/cultural networks, and loneliness as the feelings of aloneness that stemmed from being a mother in a new country with limited support. Multiple factors contributed to women's and children's social isolation and loneliness, including migration status, socioeconomic circumstances, language barriers, and being a single mother. Women expressed that the COVID-19 pandemic exacerbated pre-existing experiences of social isolation and loneliness. Mothers' experiences affected their emotional and mental health, while for children, it reduced their social opportunities outside the home, especially if not attending childcare. However, the extent to which mothers' experiences of social isolation and loneliness influenced the health and development of their children, was less clear. Conclusion Migrant mothers' experiences of social isolation and loneliness are intricately linked to their status as migrants and mothers. Going forward, it is critical to better document pandemic and post-pandemic consequences of social isolation and loneliness on young children of migrant families. Supportive interventions for migrant mothers and their young children should not only target social isolation but should also consider mothers' feelings of loneliness and foster social connectedness and belongingness. To address social isolation and loneliness, interventions at the individual, community and policy levels are needed.
Article
This systematic review and meta-analysis examined the prevalence and factors associated with vaccine hesitancy and vaccine unwillingness in Canada. Eleven databases were searched in March 2022. The pooled prevalence of coronavirus disease 2019 (COVID-19) vaccine hesitancy and unwillingness was estimated. Subgroup analyses and meta-regressions were performed. Out of 667 studies screened, 86 full-text articles were reviewed, and 30 were included in the systematic review. Twenty-four articles were included in the meta-analysis; 12 for the pooled prevalence of vaccine hesitancy (42.3% [95% CI, 33.7%–51.0%]) and 12 for vaccine unwillingness (20.1% [95% CI, 15.2%−24.9%]). Vaccine hesitancy was higher in females (18.3% [95% CI, 12.4%−24.2%]) than males (13.9% [95% CI, 9.0%−18.8%]), and in rural (16.3% [95% CI, 12.9%−19.7%]) versus urban areas (14.1% [95%CI, 9.9%−18.3%]). Vaccine unwillingness was higher in females (19.9% [95% CI, 11.0%−24.8%]) compared with males (13.6% [95% CI, 8.0%−19.2%]), non-White individuals (21.7% [95% CI, 16.2%−27.3%]) than White individuals (14.8% [95% CI, 11.0%−18.5%]), and secondary or less (24.2% [95% CI, 18.8%−29.6%]) versus postsecondary education (15.9% [95% CI, 11.6%−20.2%]). Factors related to racial disparities, gender, education level, and age are discussed.
Article
Purpose: The purpose of this study was to obtain a deep understanding of experiences of stigma among people infected with COVID-19 in South Korea. Methods: Data were collected through in-depth interviews from March 2021 to November 2021 with nine people who had been infected with COVID-19. The data were analyzed using Colaizzi's phenomenological method. Results: Six theme clusters emerged from participants' stigma experiences: “I've become the coronavirus itself”, “a desperate defense to protect myself”, “pointing a finger at oneself”, “a scapegoat for the public interest”, “the aftereffects caused by social prejudice” and “an isolated loner”. Conclusion: The results of this study suggest that people infected with COVID-19 suffered considerable emotional distress and were hindered in their daily life recovery due to stigma. Based on this study, medical staff who treat patients infected with COVID-19 should understand their stigma in depth and strive to develop and implement the necessary instruments and nursing intervention programs to reduce this stigma.
Preprint
This follow-up report examines the negative mental health outcomes of COVID-19 on racialized working women in Canada. Through the use of surveys and interviews, we seek to better understand how racialized women are coping with the pandemic and the ways in which they can be further supported in both the immediate pandemic and long-term, post-pandemic stages. It is important to note that the conclusions of this report apply to participants in the study and cannot be generalized to the wider population. Perhaps the most valuable insight gathered from the surveys and interviews was that the political economy of mental health matters. The harsh reality is that addressing mental health is a privilege and luxury enjoyed by a few. We cannot have discussions on ways to improve mental health without addressing the root causes of this societal problem: social, economic, environmental, and structural inequities.
Article
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Objective The current paper examines the intersection between social vulnerability, individual risk, and social/psychological resources with adult suicidality during the COVID‐19 pandemic. Method Data come from a national sample (n =10, 368) of U.S. adults. Using an online platform, information was gathered the third week of March 2020, and post‐stratification weighted to proportionally represent the U.S. population in terms of age, gender, race/ethnicity, income, and geography. Results Nearly 15 percent of sampled respondents were categorized as high risk, scoring 7+ on the Suicide Behaviors Questionnaire‐Revised (SBQ‐R). This level of risk varied across social vulnerability groupings: Blacks, Native Americans, Hispanics, families with children, unmarried, and younger respondents reported higher SBQ‐R scores than their counterparts (p < 0.000). Regression results confirm these bivariate differences, and also reveal that risk factors (food insecurity, physical symptoms, and CES‐D symptomatology) are positive and significantly related to suicidality (p < 0.000). Additionally, resource measures are significant and negatively related to suicidality (p < 0.000). Conclusions These results provide some insight on the impact COVID‐19 is having on the general U.S. population. Practitioners should be prepared for what will likely be a significant mental health fall‐out in the months and years ahead.
Article
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Significance This paper presents a large-scale analysis of the impact of lockdown measures introduced in response to the spread of novel coronavirus disease 2019 (COVID-19) on socioeconomic conditions of Italian citizens. We leverage a massive near–real-time dataset of human mobility and we model mobility restrictions as an exogenous shock to the economy, similar to a natural disaster. We find that lockdown measures have a twofold effect: First, their impact on mobility is stronger in municipalities with higher fiscal capacity; second, they induce a segregation effect: mobility contraction is stronger in municipalities where inequality is higher and income per capita is lower. We highlight the necessity of fiscal measures that account for these effects, targeting poverty and inequality mitigation.
Article
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Mental health clinicians and researchers must be prepared to address the unique needs of BlackAmericans who have been disproportionately affected by the COVID-19 pandemic. Race-conscious and culturally competent interventions that consider factors such as discrimination, distrust of health care providers, and historical and racial trauma as well as protective factors including social support and culturally sanctioned coping strategies are needed. Research to accurately assess and design treatments for the mental health consequences of COVID-19 among Black Americans is warranted.
Article
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The COVID-19 pandemic might lead to more mental health problems. However, few studies have examined sleep problems, depression, and posttraumatic symptoms among the general adult population during the COVID-19 outbreak, and little is known about coping behaviors. This survey was conducted online in China from February 1st to February 10th, 2020. Quota sampling was used to recruit 2993 Chinese citizens aged ≥18 years old. Mental health problems were assessed with the Post-Traumatic Stress Disorders (PTSD) Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the Center for Epidemiological Studies Depression inventory, and the Pittsburgh Sleep Quality Index. Exposure to COVID-19 was measured with questions about residence at outbreak, personal exposure, media exposure, and impact on livelihood. General coping style was measured by the brief Coping Style Questionnaire (SCSQ). Respondents were also asked 12 additional questions about COVID-19 specific coping behaviors. Direct exposure to COVID-19 instead of the specific location of (temporary) residence within or outside the epicenter (Wuhan) of the pandemic seems important (standardized beta: 0.05, 95% confidence interval (CI): 0.02–0.09). Less mental health problems were also associated with less intense exposure through the media (standardized beta: −0.07, 95% CI: −0.10–−0.03). Perceived negative impact of the pandemic on livelihood showed a large effect size in predicting mental health problems (standardized beta: 0.15, 95% CI: 0.10–0.19). More use of cognitive and prosocial coping behaviors were associated with less mental health problems (standardized beta: −0.30, 95% CI: −0.34–−0.27). Our study suggests that the mental health consequences of the lockdown impact on livelihood should not be underestimated. Building on cognitive coping behaviors reappraisal or cognitive behavioral treatments may be most promising.
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COVID-19 has changed our lives and it appears to be especially harmful for some groups more than others. Black and Asian ethnic minorities are at particular risk and have reported greater mortality and intensive care needs. Mental illnesses are more common among Black and ethnic minorities, as are crisis care pathways including compulsory admission. This editorial sets out what might underlie these two phenomena, explaining how societal structures and disadvantage generate and can escalate inequalities in crises.
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Never before has there been such a high level of mobilization around mental health during an epidemic (Pappa et al. 2020). International agencies, with the UN General Secretary at the forefront, the Director of the World Health Organization, as well as researchers, policy makers and civil society leaders have all drawn attention to the need for mental health care for people affected by COVID-19. In the so-called developed countries, many training courses and guidelines have been developed to help mental health professionals to offer telepsychotherapy in order to comply with the physical distancing measures taken to prevent the spread of the COVID-19 pandemic. In many low- and middle-income countries (LMICs), a mental health commission has been implemented within the response committees to fight the pandemic. These measures have been part of unprecedented efforts to raise awareness on mental health issues.
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This study sought to identify factors associated with depression, anxiety, and PTSD symptomatology in U.S. young adults (18-30 years) during the COVID-19 pandemic. This cross-sectional online study assessed 898 participants from April 13, 2020 to May 19, 2020, approximately one month after the U.S. declared a state of emergency due to COVID-19 and prior to the initial lifting of restrictions across 50 U.S. states. Respondents reported high levels of depression (43.3%, PHQ-8 scores ≥ 10), high anxiety scores (45.4%, GAD-7 scores ≥ 10), and high levels of PTSD symptoms (31.8%, PCL-C scores ≥ 45). High levels of loneliness, high levels of COVID-19-specific worries, and low distress tolerance were significantly associated with clinical levels of depression, anxiety, and PTSD symptoms. Resilience was associated with low levels of depression and anxiety symptoms but not PTSD. Most respondents had high levels of social support; social support from family, but not from partner or peers, was associated with low levels of depression and PTSD. Compared to Whites, Asian Americans were less likely to report high levels across mental health symptoms, and Hispanic/Latinos were less likely to report high levels of anxiety. These factors provide initial guidance regarding clinical management for COVID-19-related mental health problems.
Article
As the number of COVID-19 cases rose in the US and around the world in early 2020, conservative elites in the US racialized the pandemic, referring to the coronavirus as the “Chinese flu” or the “Wuhan virus.” Existing research suggests that this linking of the viral pandemic to a social group will “activate” anti-Asian attitudes in the mass public, helping bring those attitudes to bear on behaviors and attitudes related to COVID-19. Despite anecdotal evidence of a spike in discriminatory behavior targeted at Asians across western countries, little empirical evidence for this “othering” hypothesis exists. Using a large survey (n = 4311) benchmarked to national demographics, we analyze the relationship between attitudes toward Asian Americans, xenophobia, concern about contracting the coronavirus, and a variety of behavioral outcomes and policy attitudes. We find evidence that anti-Asian attitudes are associated with concern about the virus but also with xenophobic behaviors and policy preferences. These relationships are unique to Asian American attitudes, are not related to attitudes toward other outgroups, and do not hold for a variety of placebo outcomes. Together our findings suggest that anti-Asian attitudes were activated and were associated with a variety of COVID-19 attitudes and behaviors in the early stages of the pandemic.