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. Author manuscript; available in PMC: 2025 Sep 5.
Published in final edited form as: J Health Psychol. 2025 Jun 29;31(2):832–848. doi: 10.1177/13591053251344726

Flattening the curve: Factors associated with engagement in health protective behaviors at the onset of the COVID-19 pandemic among Black individuals from predominantly low-income backgrounds

Jennifer McDonald 1, Matthew Figueroa 2, Juliet Cushing 3, Austen McGuire 4, Yo Jackson 1
PMCID: PMC12410102  NIHMSID: NIHMS2093964  PMID: 40583324

Abstract

The COVID-19 pandemic had negative consequences for individuals in the United States, especially Black and low-income populations. At the start of the pandemic, efforts were made to stop the spread of COVID-19 through recommending person-level, health protective behaviors (e.g. mask wearing), but minimal research has explored what factors were related to Black and low-income individuals’ engagement in these behaviors. The current study sought to increase understanding on how (a) COVID-19 knowledge, (b) medical mistrust, and (c) COVID-19 specific worry, related to following COVID-19 recommendations at the start of the pandemic in a sample of 110 Black, predominantly low-income, caregivers of young children. Findings demonstrated that participants were frequently following the COVID-19 recommendations, and that COVID-19 specific worry was positively associated with following the recommendations. Findings help provide feedback and possible guidance for how public health initiatives may serve Black individuals from low-income communities to encourage engagement in health protective behaviors.

Keywords: Black and African America, covid-19, medical mistrust, protective health behaviors, social determinants of health

The COVID-19 pandemic had significant negative consequences on individuals in the United States (U.S.). As with past pandemics (e.g. 1918 influenza, 2010 H1NI), evidence showed an unequal distribution of negative consequences from the COVID-19 pandemic (e.g. infections, deaths, financial losses; Centers for Disease Control and Prevention [CDC], 2010; Hutchins et al., 2009). Lower socioeconomic and underrepresented populations were disproportionately affected by these consequences compared to White and/or high socioeconomic populations (e.g. Parker et al., 2020; Price-Haywood et al., 2020). Pre-existing systemic factors may help explain why disparities were observed during the onset of COVID-19, often related to longstanding mechanisms of structural racism and social determinants of health inequities (Fortuna et al., 2020; Grosicki et al., 2022). For example, before the pandemic, families whose incomes were below the federal poverty line tended to have reduced access to healthcare (e.g. not living near healthcare facilities; Green et al., 2021), making testing and treatment for infection challenging. Moreover, low-income adults were commonly employed in “essential” roles and were not provided opportunities to work remotely, increasing infection risk (Liu and Modir, 2020).

At the start of the pandemic, recommendations from national, state, and local public health organizations were made to change individuals’ behaviors, such as wearing a face mask in public spaces or cleaning commonly touched surfaces (e.g, CDC, 2025). However, concerns were raised about the willingness of people from underrepresented and low-income communities to engage in these behaviors, often due to long standing systemic injustices and discrimination. For example, reports in the news noted trepidation among Black individuals to wear face masks in public due to racial profiling (e.g. Liu and Modir, 2020). It was not clear what factors may be associated with engagement or not in individual level health protective behaviors to prevent infection. Knowing what contributed to behavior change could identify modifiable factors that may be potential targets for intervention efforts to reduce illness. The current study sought to address this gap for Black individuals from predominantly low-income families by exploring three potential factors that may have played a role in engagement in health protective behaviors during the onset of the pandemic - (a) knowledge about COVID-19, (b) trust in the healthcare, and (c) COVID-19 specific worry.

Knowledge about COVID-19

Understanding an illness and its risk factors is often thought to be the first step to preventing health sequelae and increasing an individual’s willingness to engage in protective behaviors. A common practice in public health is to implement an education campaign to inform communities about the specific steps individuals can take to either avoid or mitigate their illness risk (e.g. Khalil and Abdalrahim, 2014; Rincón Uribe et al., 2021). A similar approach was taken during the onset of COVID-19 in the U.S. to educate the public on the novel virus. For example, at the federal level, U.S. agencies spent hundreds of millions of dollars on national public education campaigns for COVID-19 (U.S. Government Accountability Office, 2022).

However, knowledge about a disease does not always translate into engagement in preventative behaviors. For example, Young et al. (2018) conducted a review of mass media health education campaigns (e.g. public posters, television advertisements) on alcohol consumption to address alcohol-related harm. The authors found that knowledge of alcohol consumption-related risks varied across studies, but little evidence was found that these efforts influenced actual alcohol consumption behavior. Sociodemographic factors, such as income status and race, and the intersection of these factors, may explain this variability in the influence of knowledge on engagement in health protective behaviors (e.g. Beauchamp et al., 2014; Ernawati et al., 2021). Thus, it is necessary to evaluate how disease knowledge may influence engagement in health protective behaviors among certain populations. This especially applies to COVID-19, as most research on disease knowledge during the initial months of the pandemic was conducted with White or middle to high income populations (e.g. Sarria-Guzmán et al., 2021). Limited research exists on how efforts to educate the public were working in Black populations and whose incomes were below the federal poverty line. Increasing understanding of what Black individuals from low-income backgrounds knew about the disease and how that knowledge related to engagement in protective behaviors is necessary to determine if disease knowledge helped mitigate the spread of the virus.

Trust in healthcare

Trust in healthcare has been identified as an important social determinant of health (Office of Disease Prevention and Health Promotion, 2025). While mistrust in the healthcare exists in all cultural groups, there are notable concerns in Black populations, especially Black individuals whose incomes are below the federal poverty threshold, emerging from generations of medical malpractice, unethical experimentation, and exploitation (e.g. forced unanesthetized surgeries on enslaved women, the Tuskegee experiments; Williamson and Bigman, 2018). Such events continue to contribute to mistrust among these communities, in combination with modern forms of racial bias in healthcare (e.g. Scharff et al., 2010). Within the literature examining illness in underrepresented populations, several studies have demonstrated an association between medical mistrust and engagement in medical recommendations and preventative behaviors (Benkert et al., 2019). For example, Kolar et al. (2015) found that Black women were more reluctant than other racial groups to receive a human papillomavirus vaccine and engage in other preventative behaviors due to mistrust of medical providers, especially those not of the same race.

Examining medical mistrust and engagement in health protective behaviors at the onset of the pandemic is especially critical given the ongoing challenges related to medical misinformation about COVID-19 (Benkert et al., 2019; Jaiswal et al., 2020). Further, more recent research with Black individuals from low-income backgrounds in the U.S. as it relates to vaccines suggests medical mistrust may have influenced individuals’ engagement in this type of health protective behavior, such that greater mistrust in healthcare is associated with lower likelihood of getting the COVID-19 vaccine (e.g. Dong et al., 2022; Morgan et al., 2023). It is possible mistrust may also have influenced engagement during the onset of the pandemic with other individual health protective behaviors. Moreover, not trusting medical advice is not universal in its effect. For example, Nguyen et al. (2022) found that those high in medical mistrust had lower vaccine intentions in a sample of Black individuals; however, there were no significant differences between the high mistrust group and the comparison group when examining health protective behaviors, such as mask wearing. The present study sought to expand the knowledge base to determine if the same kinds of mistrust of medical services and systems was present for Black individuals from mostly lower socioeconomic groups as it related to COVID-19 and how medical mistrust may relate to engagement in individual health protective behaviors. This also includes examining whether form of medical mistrust (e.g. suspicions, experienced lack of support) may play a role in this relation.

Worry about COVID-19

Worry about future illness appears to be a key motivator of compliance with health recommendations and healthy lifestyle behavior change (Mosher et al., 2008). Research on a myriad of chronic and life-threatening illnesses has identified concern regarding possible future illnesses to be related to compliance and adherence with medical guidance and treatment recommendations (Varni et al., 2018). Similar findings have been reported among various populations in the U.S., such that worry about infection or other negative consequences from COVID-19 have been associated with higher levels of engagement in health protective behaviors (e.g. wearing face masks; Moran et al., 2021). However, the findings are not all straightforward, as some research also shows that worry about future illness or worsening of health is related to nonadherence. For example, Posluszny et al. (2004) found that women who worried more about getting breast cancer were less likely to report engaging in regular breast self-exams, compared to those with less reported worry. Crowley et al. (2015) found similar results for patients with a history of myocardial infarction, such that worry about a future stroke was related to medication nonadherence. During the pandemic, concern over getting the virus was high and yet to date, it is unclear how these pandemic specific feelings related to health behaviors.

Current study

The purpose of the present study was to identify possible predictors for engaging in guidance related to health protective behaviors during the initial months of the COVID-19 pandemic. Given the lack of specific attention to the experiences of Black populations in the U.S. from low-income backgrounds, it is especially important to document the factors that may contribute to engagement in health protective behaviors in these individuals. Although not intended to be exhaustive, the areas of assessment in the current study are based on past research and represent modifiable factors that provide the field with possible and immediate targets for intervention. It was hypothesized that participants with lower levels of medical mistrust and worry about COVID-19 would be more likely to follow the COVID-19 recommendations during the initial months of the pandemic. Given mixed findings within the literature regarding knowledge of a disease, no specific hypotheses were made for this factor.

Methods

Participants

Participants in the current study were all caregivers recruited from a larger, longitudinal project that was occurring prior to the start of the COVID-19 pandemic examining cognitive functioning, emotion regulation, and family wellbeing. For the original project, a caregiver was eligible to participate if (a) English was their first language, (b) they were the legal guardian of a child between ages 3 and 5, and (c) they had not been previously diagnosed with an intellectual or developmental disability, or a heart condition. These inclusion criteria were used to ensure the caregiver could complete all the tasks of the larger study. Project participants were recruited from a large Midwestern Metropolitan area through partnerships with community organizations serving low-income families, including those at-risk for housing, food, and health insecurity, and those whose children were enrolled in local Head Starts. Please see Griffith et al. (2020) for more information about the larger study’s recruitment procedures.

From the larger study, 324 participants were eligible to participate in the current study. All participants were contacted via text, email, and mailed surveys. In total, 140 participants completed the current study survey. Among these participants, 30 were excluded because they identified as a race other than Black (e.g. White, Asian, Native American), resulting in a final sample size of 110 (Mage[SD] = 31.20 [7.20]; 96.3% female). Most participants self-reported as biological mothers (90.9%), followed by biological fathers (3.6%), and other type of primary caregiver (e.g. aunt, grandmother, foster parent; 5.4%). Participants identified as Black (91.8%) or as Black and another race (8.2%). According to the 2020 federal poverty level guidelines using yearly income and number of persons in the household, 35.45% of participants were at or below 50% of the federal poverty line, followed by 51%–100% of the federal poverty line (27.27%), 101%–200% above the poverty line (31.81%), and 201%–300% above the poverty line (5.45%).

Measures

Knowledge about COVID-19.

To assess awareness and knowledge about aspects of COVID-19, a set of questions pertaining to broad and regularly shared information about the transmission, infection, and treatment of COVID-19 was administered to participants. Seven items included knowledge about aspects of COVID-19 (please see Supplementary Table S1 for full questions). This questionnaire was based on a questionnaire developed by Huang and Zhao (2020) used in a study on mental health symptoms during the initial COVID-19 outbreak. Modifications were made to the Huang and Zhao (2020) measure based on information provided on the CDC’s website about COVID-19 from April and May 2020. This included adding more information on symptoms of COVID-19, as well as removing questions about “sham” treatments. Participants rated each item on a five-point Likert scale from 1 (“Not at all aware”) to 5 (“Very much aware”). A mean score for across the seven items for Knowledge was included in the analyses. The measure demonstrated good internal reliability (Cronbach’s α = 0.93).

Trust in healthcare.

The Group-Based Medical Mistrust Scale (GBMMS; Thompson et al., 2004) was administered to assess participants’ views on the healthcare system in relation to their race and ethnicity. The GBMMS is a 12-item measure that asks participants to respond to statements about their beliefs and experiences regarding medical mistrust using a five-point Likert scale from 1 (“Strongly Disagree”) to 5 (“Strongly Agree”). These 12 items form three subscales (Lack of Support, Suspicion, and Group Disparities), which were determined by the measure developers and confirmed through additional psychometric evaluation of the measure’s factor structure (Shelton et al., 2010; Thompson et al., 2004). It has demonstrated satisfactory psychometrics, including both reliability and validity, in populations similar to this study (e.g. Shelton et al., 2010; Williamson and Bigman, 2018). The mean of each subscale was used in the analyses, which included the lack of support (three items; Cronbach’s α = 0.67), suspicion (five items; Cronbach’s α = 0.93), and group disparities (four items; Cronbach’s α = 0.74) subscales.

Following COVID-19 guidelines.

To examine participants’ engagement in individual recommendations for how to protect against COVID-19 infection, a questionnaire on following COVID-19 guidelines was created. Information on the recommendations for protection against COVID-19 was obtained from the CDC website in April 2020 (CDC, 2010). This information was then reformatted into nine statements in the first-person regarding engagement in the recommendations (please see Supplementary Table S1). Participants indicated on a five-point Likert scale from 1 (“Never”) to 5 (“Always”) how often they engaged in the behavior since the beginning of March 2020. The measure demonstrated satisfactory internal reliability across all nine items, Cronbach’s α = 0.90. A mean score was calculated among all nine questions.

COVID-19 specific worry.

The current study utilized a novel questionnaire asking about COVID-19 worry across different domains. Using a five-point Likert scale from 1 (“Not at all Worried”) to 5 (“Extremely worried”), participants responded to two items for each of the following domains: Global or larger community concerns, immediate or close social and community concerns, and individual concerns (please see Supplementary Table S1). These questions were developed from questions used as part of the Coronavirus Stressful Events Scale (Freedman et al., 2020). For the data analyses, an overall mean COVID-19 worry score was calculated by the average across all six items. This scale demonstrated satisfactory internal reliability, as determined by a Cronbach’s α = 0.92.

Demographics.

Participants completed a demographics form as part of their initial data collection activities in the larger project from which they were recruited from. Participants provided information on their date of birth, ethnicity, race, gender, family income, and family size.

Procedures

The authors’ institutional review board committee approved all procedures for the study. Informed consent was obtained from all participants via writing or electronic signature. All individuals from the larger project recruited for this study were initially notified of the opportunity via text or email and were sent a link for a Qualtrics online survey that could be completed via cell phone or computer. If participants could not be contacted initially via text or email (e.g. email or text delivery error), participants were mailed a paper copy of the survey using their last known address. Participants were notified that the survey would ask questions regarding their experience during the initial months of the COVID-19 pandemic. Following the initial request, a follow-up text/email was sent reminding participants of the opportunity to participate in the survey 1 week later. If no response was received after a second reminder, a follow-up paper survey was sent to their address. A final reminder was sent 1 week following the mailing of surveys via text message, and a second survey packet was sent to those individuals who could not be contacted via text or email. Each participant received at least two attempts to complete the survey, and each participant had the option to complete the survey online or via paper-pencil mailed surveys. Participants were compensated upon completion of the survey.

Data analysis

All data analysis steps were conducted in the R software package (R Core Team, 2023). To examine characteristics of the current sample, the means and distributions among the variables of interest were calculated, as well as the correlations between these variables. To determine the influence of the factors of interest on following the CDC’s COVID-19 recommendations, hierarchical multiple linear regression (HMLR) was utilized. In total, four models were estimated. To examine the individual influence of each factor domain, the first three models contained only the variable(s) for each primary factor investigated in the current study: (1) COVID-19 knowledge, (2) Medical mistrust (each three subscales in a single model, and then (3) COVID-19 specific worry. In the fourth model, all variables were included together in the same model. Participant age and federal poverty line status were included in each model as covariates, as there was variety in participant representation across these variables in the study, and these factors have been shown to relate to adherence to medical/healthcare related recommendations, including those related to COVID-19 (e.g. Shushtari et al., 2021). The R2 for each model was interpreted and predictors were examined for statistical significance using p < 0.05.

Results

The majority of participants completed the survey online (90.9%), while the remaining participants completed the mailed paper surveys. Study surveys were completed between June and July 2020. The means and distributions of the variables of interest are presented in Table 1, as well for individual items in Supplementary Table S1. For COVID-19 recommendations, the highest behavior engaged in on average was covering the mouth while coughing or sneezing, followed by washing hands and then using hand sanitizer. Among the medical mistrust subscales, participants reported the highest average medical mistrust on the lack of support subscale, followed by group disparities and then suspicion. Table 2 provides the correlations among the variables of interest in the current study. There were strong, positive correlations between the subscales of the GBMMS (all r’s > 0.50).

Table 1.

Descriptive Information for Variables of Interest

Demographics
Mean (SD) or % Median Range Possible range
Age (years) 31.20 (7.20) 29 22–59 18+
Gender (% female) 96.3%
Federal Poverty Line (FPL) Status
< 50% of FPL 35.45%
51%–100% of FPL 27.27%
101%–200% of FPL 31.81%
201%–300% of FPL 5.45%
COVID-19 Related Information
Mean (SD) Median Range Possible range
COVID-19 Worry 3.57 (1.21) 3.8 0–5 1–5
COVID-19 Knowledge 4.22 (1.11) 4.71 1–5 1–5
Following COVID-19 Rec. 4.56 (.59) 4.78 2.11–5 1–5
Group Based Medical Mistrust Subscales
Mean (SD) Median Range Possible range
Lack of Support 3.07 (.98) 3 1–5 1–5
Group Disparities 3.00 (.89) 3 1–5 1–5
Suspicion 2.85 (1.02) 3 1–5 1–5
Open in a new tab

N = 110.

Rec. = Recommendations; SD = Standard Deviation.

Table 2.

Correlations Between Variables of Interest

1 2 3 4 5 6
1. COVID-19 Knowledge
2. COVID-19 Worry .23
3. Follow CDC COVID-19 Recommendations .24 .22
4. GBMMS- Lack of Support subscale .06 −.08 −.08
5. GBMMS- Group Disparities subscale .07 −.01 −.08 .59 *
6. GBMMS- Suspicion subscale .09 .10 −.19 .72 * .54 *
7. Participant Age .14 .01 −.02 −.13 −.11 −.16
8. FPL Status .08 −.03 −.08 .13 .01 .09 .01
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N = 110,

*

= p < .05.

CDC = Centers for Disease Control and Prevention, Recs = Recommendations, GBMMS = Group-Based Medical Mistrust Scale. FPL = Federal poverty line.

Regression analyses

The findings from the HMLR are presented in Table 3. In Model 1, COVID-19 knowledge was significantly, positively associated with following the CDC’s COVID-19 recommendations (b = 0.12[SE = 0.06], p < 0.05). This finding suggests that participants who tended to report more knowledge/awareness of aspects of COVID-19 tended to report following the CDC’s recommendations more often. In Model 2, none of the subscales associated with medical mistrust were significantly associated with following the CDC’s COVID-19 recommendations. In Model 3, COVID-19 specific worry was significantly, positively associated with following the CDC’s COVID-19 recommendations (b = 0.10[SE = 0.05], p < 0.05), suggesting that participants who reported higher levels of pandemic worry tended to more frequently follow the COVID-19 recommendations, compared to those participants with less COVID-19 specific worry. In the full model that contained all the predictors examined in the current study, COVID-19 knowledge was no longer significantly associated with following the CDC’s COVID-19 recommendations. However, the group disparities subscale of the GBMMS was now significantly, negatively associated with following the CDC’s COVID 19 recommendations (b = −0.21[SE = 0.09], p < 0.05), indicating that participants who tended to report more perceived disparities in care received because of their race or ethnicity tended to follow COVID-19 recommendations less frequently. In the full model, COVID-19 worry was still significantly, positively associate with following the CDC’s COVID-19 recommendations (b = 0.10[SE = 0.05], p < 0.05).

Table 3.

Regression Models Examining Predictors of Following the COVID-19 Recommendations

Model Outcome Variable: Following COVID-19 Recommendations
Model Predictor Variables Model 1 (N = 96) Model 2 (N = 92) Model 3 (N = 97) Model 4 (N = 91)
Age −.00 (.01) −.00 (.01) .00 (.01) −.00 (.01)
FPL status −.09 (.09) −.12 (.10) −.08 (.09) −.12 (.10)
COVID Knowledge Variables
COVID-19 Knowledge .12 (.06) * .10 (.06)
Medical Mistrust Variables
GBMMS-LOS .11 (.10) .14 (.09)
GBMMS-GD −.17 (.09) −.21 (.09) *
GBMMS-Suspicion −.03 (.09) −.03 (.08)
COVID-19 Worry Variables
COVID-19 Worry .10 (.05) * .10 (.05) *
Multiple R 2 .05 .07 .05 .16
Adjusted R 2 .03 .01 .02 .08
Open in a new tab

Total N = 110.

*

= p < .05.

Bold coefficients also indicate p’s < .05. Beta estimates are provided and the standard errors are provided in the parentheses. FPL: Federal poverty line. GBMMS = Group-Based Medical Mistrust Scale, LOS = Lack of Support subscale, GD = Group Disparities subscale, Suspicion = Suspicion subscale.

Discussion

The COVID-19 pandemic had many negative consequences on the lives of individuals in the U.S., especially among those individuals from underrepresented populations (e.g. Parker et al., 2020; Price-Haywood et al., 2020). A notable public health approach to “flatten the curve” (i.e. to reduce the number of infections) at the beginning of the pandemic was to promote the use of health protective behaviors among individuals (e.g. wearing face masks, frequently washing hands; CDC, 2010). However, it is largely unknown what factors may have contributed to engagement in these behaviors among racial minority and low-income populations. The current study analyzed three primary factors-knowledge of COVID-19, medical mistrust, and COVID-19 worry- in a sample of Black caregivers from predominantly low-income backgrounds.

Consistent with previous descriptive studies (e.g. Neighbors et al., 2023), the current study observed that most individuals reported that they were following the COVID-19 health recommendations. This was demonstrated by mean scores across all nine recommendations assessed in the current study being between “sometimes” and “almost always” (i.e. means > 4.00 on a five-point Likert scale). These results, when combined with larger epidemiological and population level studies that have found higher numbers of infections and deaths in Black and low-income populations compared to White and high-income groups (e.g. Price-Haywood et al., 2020), suggest that lack of engaging in health protective behaviors may not fully explain the high infection rates and deaths in racial minority and low-income communities. Rather, it may be the case that stronger influences on higher rates of infection and deaths observed within these populations come from longstanding inequities within the systems of care these individuals receive (e.g. Grosicki et al., 2022), including inequities unique to the COVID-19 pandemic (e.g. availability to work from home).

Among the health protective behaviors assessed, wearing a face mask was the lowest rated item but still in the “sometimes” to “almost always” range. While reasons for not wearing a mask were not assessed, this may not be surprising for several reasons. For one, there were notable shortages in masks during the initial months of the pandemic, which may have been even more challenging for families from low-income backgrounds to obtain compared to higher income families (e.g. Missoni et al., 2021). Additionally, mask wearing became a highly polarizing behavior and signal for social identity (e.g. Earle-Richardson et al., 2024); thus, it may have also been that participants avoided wearing a mask for political or other value-based reasons. For the current sample, it is also important to consider previously reported concerns with racial profiling for mask wearing (e.g. Liu and Modir, 2020), which may have swayed participants in the current study away from mask wearing in public to avoid further discrimination.

Knowledge about COVID-19

The current study identified knowledge about COVID-19 as a predictor of engagement with COVID-19 guidelines when examined in its own independent model. Prior literature has demonstrated a racial disparity in health literacy, a construct closely related to disease knowledge (Berkman et al., 2004), between White and non-White Americans (Berkman et al., 2011). Health literacy has also been established as a potential mediator, explaining racial/ethnic disparities in health outcomes, such as medication adherence (Mantwill et al., 2015). These findings are in line with more recent work, which has similarly identified racial disparities in health literacy in the context of COVID-19 and has identified the mediating role of health literacy or knowledge in associations between race and pandemic-related health outcomes (e.g. vaccine confidence; Hurstak et al., 2023). The current findings demonstrate similar themes; however, it is important to consider the extant literature largely examines the broader construct of health literacy rather than disease-specific knowledge as a predictor of health outcomes. It is also important to note that the association between COVID-19 knowledge and engagement with COVID-19 guidelines was not significant in the full model. Rather, higher perceived racial/ethnic disparities in care was associated with less engagement with COVID-19 guidelines in the full model, demonstrating the nuanced relationship between these factors. As the these are likely related but distinct constructs, further study is warranted to characterize the unique roles of knowledge, medical mistrust, perceived disparities in care, and worry in predicting engagement with pandemic-related recommendations.

Trust in healthcare

The present study found that medical mistrust did not have a statistically significant relation to engagement with COVID-19 guidelines when examined in its own model. When the regression model was expanded to include all variables, the Group Disparities (GBMMS-GD) medical mistrust subscale had a statistically significant influence on participants’ engagement with COVID-19 guidelines. This suggests there may be a nuanced relation between medical mistrust, COVID-19 knowledge, and COVID-19 worry, which may be partially explained by the fact that medical mistrust is a phenomenon intertwined with structural inequalities, racism, classism, and stigma present in the other independent variables (Jaiswal and Halkitis, 2019). For example, COVID-19 knowledge can be influenced by race, socioeconomic class, and the intersection of these identities, through access to primary care providers and access to the internet amongst other factors. COVID-19 worry included assessment of worry about how the healthcare system could manage the pandemic, which relates to mistrust about the healthcare system. As such, accounting for these related variables in the same model may have reduced bias or variability among the predictor variables, allowing for a more precise estimate of the subscales of the GBMMS in the full model. Still, this study observed that participants who on average reported more perceived group disparities in healthcare (e.g. feeling that people of their race/ethnicity group are not treated the same as people of other groups by healthcare workers) also followed the COVID-19 recommendations less frequently on average. This finding is consistent with previous research that reported medical mistrust is associated with low engagement in preventative care, such as delayed checkups and disease screening among Black individuals (e.g. Hammond, 2010; Smith et al., 2022). Existing research into medical mistrust and COVID-19 prevention has predominantly focused on vaccination, finding that increasing medical mistrust decreases Black Americans’ likelihood of vaccinating against COVID-19 (e.g. Morgan et al., 2023). This study found that, for this specific group of Black individuals who were mostly from low-income back- grounds, those patterns of group-based medical mistrust may also apply to engagement in individual level health protective behaviors. Racial, ethnic, and socioeconomic inequality in medicine, historically and currently, could contribute to the group disparities medical mistrust that affected rates of engagement in the current study (Jaiswal and Halkitis, 2019; Smith et al., 2022). Furthermore, mistrust in the federal government could have contributed to the results given that COVID-19 recommendations were disseminated by the CDC, NIH, White House, and other federal politicians directly (Jaiswal et al., 2020; Nagler et al., 2020).

Worry about COVID-19

Worry related to the COVID-19 pandemic emerged as one of the more robust predictors, such that COVID-19 worry overall was significantly associated with following COVID-19 recommendations in its independent model and the full model. This finding aligns with previous research on illness and disease, where worry about the illness and disease serves as a factor to increase engagement in the behaviors that may prevent or mitigate negative consequences of that disease or illness (e.g. Reed et al., 2021). This also includes some recent research during the COVID-19 pandemic, including worry about COVID-19 specifically and general worry or stress (e.g. Rose and Edmonds, 2021). The findings of the current study expand on this research by demonstrating similar phenomena in a sample of individuals predominantly from families who were below the federal poverty line and who all identified as Black (Moran et al., 2021). It is likely not too surprising that worry in this population was prevalent and related to following COVID-19 recommendations. For example, even early in the COVID-19 pandemic, data emerged that communities of color and who were living below the federal poverty line were experiencing higher rates of negative consequences related to the pandemic, such as increase hospitalizations, deaths, and financial loss (Parker et al., 2020; Price-Haywood et al., 2020). Thus, one possibility is that participants could have been seeing and hearing about these consequences of the pandemic for similar individuals and communities and in turn developing greater worries of experiencing the same outcomes.

One example of how this study is unique in comparison to previous literature is the inclusion of items on the worry scale at the individual (e.g. individual death), community (e.g. friends becoming infected), and system (e.g. government’s ability to manage the pandemic) levels. Worry was on average in the moderate to high range for participants based on the mean score for the total scale and mean scores for each individual item. When examining the individual items of the COVID-19 worry scale, there were clear trends in level of worry (i.e. mean scores) increasing as the domain of questions increased beyond the individual. For example, the highest individual mean scores were the questions asking about system level worry in how the government and health systems would be able to handle COVID-19. There are several potential reasons why worry at the system levels may be greater than for the personal level items. One possibility could be related to the novelty of the situation at the beginning of the COVID-19 pandemic combined with the overburdened and under-resourced medical and government systems (e.g. hospitals running out of beds and important medical equipment), with such instances being widely covered in the news and news consumption of COVID-19 being shown to increase worry (e.g. Schmidt et al., 2022). Another reason may also be related to the historical context of low income and racial minority families receiving unequal treatment from these systems, both generally and during specific pandemic and epidemic events (CDC, 2010; Hutchins et al., 2009). As a result, it may also be the case that the overall uncertainty at the level of the government overall may have indicated that there would be even more uncertainty and thus negative consequences for this population. Furthermore, it is necessary to consider that all participants were caregivers of at least one young child. This may have also contributed to greater levels of worry from COVID-19 beyond the individual since these caregivers were also likely experiencing the added worry of their family’s health and experiencing the closure of other additional community systems of care (e.g. daycare and school closures; Adams et al., 2021).

Limitations

This study had several limitations. First, many of the measures included in the current study were modified instruments or developed at the start of the pandemic, and their psychometric properties outside of this study are largely unknown. Further, many of the measures were limited in their scope of content specific to the COVID-19 pandemic (e.g. only asking about engagement in health protective behaviors for COVID-19 but not other prominent health concerns). There was also limited statistical power for the final model by the sample size. Limitations related to the demographic characteristics of the current sample were also present, as most of the sample were women who were caregivers and recruited from a midwestern city. As such, the findings cannot be generalized to all Black and low-income Americans or other historically marginalized groups. Further, there was limited vantage into the intersection of gender, caregiving, and other aspects of identity which may explain variance within this community. Moreover, another limitation is the potential for recall bias, as the current study asked participants to retrospectively report on their perceptions of the pandemic and their behaviors since the start of the pandemic (i.e. ≈ 3-month timeframe). For example, this may have biased participants’ responses by increasing the chances of them inaccurately overestimating their engagement in past health protective behaviors and/or underestimating pandemic-related stress, which has been documented in surveys occurring the COVID-19 pandemic (e.g. Hipp et al., 2020).

Future directions and conclusions

Despite these limitations, the current findings offer several avenues for future research and recommendations to improve public health. One avenue would be to further explore messaging strategies that may increase engagement with preventive guidelines surrounding infectious diseases. Given the disproportionate impact of the pandemic on Black and low-income communities, awareness and education initiatives that are accessible or tailored to these communities may prove worthwhile for reducing health disparities and improving overall public health, while also decreasing concerns about medical mistrust. Studies have shown that certain types of messaging may be more effective than others in increasing knowledge about infectious diseases in Black communities (Rabin and Kohler, 2023). For example, randomized-controlled trials have found that physician-delivered video messaging can help reduce disease-related knowledge gaps and having a race/ethnicity-concordant physician can increase information-seeking behavior (e.g. Alsan et al., 2021; Torres et al., 2021).

It may also be worthwhile to identify strategies that may address perceived racial/ethnic disparities in care, as this was found to predict less engagement with guidelines in the current study. Rather than taking an approach that highlights the highly prevalent racial, ethnic, and socioeconomic disparities that exist, which has shown to induce negative affect in Black Americans at varying socioeconomic levels (Landrine and Corral, 2015), a more balanced approach may be more effective. For example, one study examining messaging strategies for colorectal screening intentions in Black Americans found that a culturally targeted message that highlights how Black Americans can actively address racial disparities increased normative beliefs, especially for those with high medical mistrust (Aspiras et al., 2023). As such, identifying culturally competent public health strategies may be instrumental in improving the health and wellbeing of Black communities from low-income backgrounds, in addition to increasing healthcare trust. It is important to highlight that strategies to address medical mistrust and racial/ethnic health disparities should be promoted in tandem with strategies that dismantle the systemic and structural inequalities that have generated these disparities.

Increasing trust in healthcare systems more broadly may also prove to be a crucial component of increasing the health and wellbeing of Black Americans from low-income backgrounds, as well potentially decreasing worry about disease. Given that structural inequalities produce the conditions needed for medical mistrust and worry to emerge, strategies to address health and COVID-19 disparities may include structural reform to the healthcare system. A review of vaccine hesitancy found that Black Americans thought of primary care providers (e.g. family physician or nurse) as their most trusted source of COVID-19 vaccine information as opposed to health institutions and government agencies, and that increasing access to primary care providers increases the likelihood that an individual can develop a personal relationship with and trust in healthcare professionals (Restrepo and Krouse, 2022). For Black Americans from low-income backgrounds, this could lead to increased engagement with preventative health measures such as vaccination, wearing a mask, and social distancing, which in turn may decrease worry about illness. Forging relationships with minority providers and elevating their presence in communities to help share information may be key in disseminating important information regarding health.

Future research should also account for important methodological considerations when conducting research in this domain. For example, research could expand on the GBMMS by asking participants experiential or behavioral questions about their regularity of physician visits, tendency to avoid healthcare due to mistrust, and their feelings of medical mistrust in relation to systemic inequalities, with a focus on how not only race but also how the interaction of socioeconomic status plays a role in their responses and behaviors. Moreover, as demonstrated in the current study given the observed differences in worry perception, future work in this area should also ensure that any assessment of worry about COVID-19 or notable illness include a multidimensional assessment of worry or risk perception. For example, this might include evaluating worry or risk perception of an illness that the individual has for themselves, as well as their family, community, and larger societal systems. As was observed related to the everchanging landscape of managing the COVID-19 pandemic, assessment of worry or risk perception for illness may also need to be dynamic and change across time depending on trends in the illness progression or the emergence of significant, new protective actions (e.g. development of a new vaccine).

Taken together, as the results of the current study demonstrate, there are multiple but modifiable factors that may contribute to engagement in individual protective behaviors to reduce ill- ness spread and burden. It is essential that future research in this domain seek to evaluate these myriad of factors among historically underrepresented communities to improve understanding and thus service for improving their health. Professionals and public health entities can utilize the lessons learned from the onset of the pandemic in future preparedness activities, as well as continue to build relationships with current stakeholders within the communities of marginalized individuals.

Supplementary Material

Supp Material

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by National Institute of Mental Health grant 5R01MH079252–09 (YJ). Dr. McGuire was supported by grant T32MH018869 from the National Institute of Mental Health (PI: Danielson/Kilpatrick).

Grant numbers

National Institute of Mental Health- 5R01MH0 79252–09 (PI: Jackson) and T32MH018869 (PI: Danielson/Kilpatrick).

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval

All methods were approved by the University of Kansas Institutional Review Board for Human Subjects (STUDY00140647). The study we report was conducted in line with the ethical guidelines of the American Psychological Association.

Informed consent

Informed consent was obtained from all participants via writing or electronic signature.

Consent to participate

Informed consent was obtained from all participants via writing or electronic signature.

Consent to publication

As part of informed consent, participants consented to the presentation and publication of the study findings in de-identified, group format.

Data sharing statement

Data can be made available upon reasonable request to Yo Jackson.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supp Material
NIHMS2093964-supplement-Supp_Material.docx (40.4KB, docx)

Data Availability Statement

Data can be made available upon reasonable request to Yo Jackson.

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