Reluctance to seeking COVID-19 testing or treatment isn’t unusual: People worry about the invasive nasal swab procedure, fear the economic or social impacts of a positive test result, or dread the medical bills that may pile up if they go to the doctor.

But for some populations, the hesitance to seek COVID-19 testing or treatment is much deeper seated. For Latinos in the United States, anxiety stems from an ingrained distrust of the medical establishment and fears of facing questions about their immigration status.

Another group that may steer clear of the health care system is people with histories of substance abuse, who may fear judgment, bias or even legal trouble if they seek help.

The University of Nebraska–Lincoln’s Arthur “Trey” Andrews is using funding from the Office of Research and Economic Development’s COVID-19 Rapid Response Grant Program to better understand how the pandemic is affecting these two groups. Through surveys, he’s collecting information about their willingness to seek testing, treatment and future vaccines; ability to obtain other types of health care; and access to mental health services to cope with COVID-related distress. Armed with a better understanding of these groups’ experiences, Andrews will collaborate with state and local leaders to develop public health interventions aimed at reducing COVID-19 illness and mortality and guiding people to relevant health care professionals and mental health resources.

“The idea is to understand, over the months and years that we’ll be dealing with COVID, what’s going to be the impact of not being able to access services or testing among high-risk groups, which for us is Latino meatpacking communities and people with substance use histories,” said Andrews, assistant professor of psychology and ethnic studies and associate director of the university’s Minority Health Disparities Initiative.

Understanding these dynamics is crucial because of the heightened COVID-19 risks these groups face. Workers in Nebraska’s meatpacking facilities cannot work from home, and many live in multi-generational households that facilitate viral transmission. In addition, Latinos are more likely to have diabetes and obesity, conditions closely linked to worse outcomes among COVID-19 patients.

In Nebraska, Latinos make up roughly 28% of positive COVID-19 cases and about 18% of deaths, despite being just 11% of the state’s population.

People with substance abuse histories may also suffer disproportionately from COVID-19. A recent National Institutes of Health-funded study found that people with substance abuse disorders are more likely to both contract COVID-19 and to suffer more severe outcomes like hospitalization and death. Compromised lung and cardiovascular function, and marginalization of people with addiction problems, are likely culprits.

Another possible driver, Andrews said, is that people with substance abuse problems may fear legal trouble or stigmatization if they seek health care. Similarly, some Latinos may want to stay off the radar, fearing immigration-related legal trouble or deportation. This pattern of avoidance means both groups often wait until a later point in the COVID-19 disease course to seek treatment.

“If you’re delaying testing for a week, or waiting until things get really severe because you may not trust the sources, what that likely means is that you’re getting tested at a point where it’s already much more severe than it is for others,” Andrews said.

Late testing can also significantly limit the range of treatments available. The antibody treatments developed by Eli Lilly and Regeneron appear to reduce the risk of hospitalization by roughly 65% to 75% in high-risk groups — but only when taken early. The Food and Drug Administration advises both treatments be given as soon as possible after a positive test and within 10 days of symptom onset.

To develop a more comprehensive picture of how these groups are managing and perceiving the pandemic, Andrews is using ORED funding to recruit two 200-member cohorts — one of people who use drugs or are in recovery, the other of Latino meatpacking community members in Crete, Lexington and Grand Island — which he will survey every three months for the next year. He will collect information about their attitudes and behavior surrounding COVID-19 exposure and treatment; health care utilization and current health status; mental health; and experiences with discrimination and stigma. Their responses will form the foundation of public health communication strategies that guide people to medical resources and encourage evidence-based practices.

Because Latino communities often rely on interpersonal relationships for health advice, Andrews aims to identify trusted sources of information — for example, church leaders, school employees or particular health care professionals — in order to disseminate COVID-related messaging and combat skepticism.

Working with trusted sources may be key to encouraging COVID-19 vaccination among Latinos. Andrews said early anecdotal evidence indicates Nebraska’s Latino population may be disinclined to get a future vaccine, which aligns with a longstanding pattern of Latino Americans receiving adult vaccinations at lower rates than non-Latino whites. This could be problematic, as experts estimate that roughly 70% of the population needs to be vaccinated to provide herd immunity via interrupted transmission chains.

For people with substance abuse histories, Andrews is exploring whether health care providers’ reduced services during the pandemic have triggered substance abuse relapses or led to substance substitution, such as increased alcohol consumption. Nationally, this seems to be the case: Data show that drug overdoses have spiked about 18% during the pandemic, and alcohol sales have risen at least 25% since March.

“Treatment center shutdowns will limit other coping resources,” said Andrews, who has tackled similar research questions as part of Nebraska’s NIH-funded Rural Drug Addiction Research Center. “This can be dangerous for people who may be having intense cravings. We hope to be able to use digital tools to connect people, create support bubbles, things of that nature. We want to work with them to understand the risk of relapse and help them manage stress.”

Andrews said one of the project’s most novel aspects is its focus on COVID-19 experiences as traumatic events. It’s an outgrowth of his work as director of the Latinx Mental Health and Treatment Outcomes laboratory, which investigates how traumatic event exposure drives mental health inequities and how technology can boost the availability of mental health resources. Now, Andrews is exploring the extent to which COVID experiences are traumatic events leading to PTSD, depression and other lingering mental health problems.

As an example, Andrews cited a hypothetical person whose mother or father is diagnosed with COVID-19.

“When they get the diagnosis, you don’t know what’s going to happen. For two or three weeks, there is uncertainty,” Andrews said. “You’re wondering, ‘Can I visit the hospital? Are they going to die because of COVID?’ That person may never get COVID themselves, but being connected to someone who experiences COVID may be traumatic in and of itself.”

He’s hoping his surveys will reveal how many people are experiencing COVID as a trauma and may need additional mental health resources. In the future, he hopes to build on his experience designing trauma-focused apps to deploy novel treatments.

COVID-19 Ethnic Studies Minority Health Disparities Initiative Psychology