Self-reported health status and associated factors among community-dwelling Afro-Caribbean Black Canadians: a cross-sectional comparison before and during the pandemic

Abstract

Background

Social Determinants of Health are linked to health outcomes. Racial discrimination can lead to marginalization, poor quality of care, and racial inequities in health outcomes. The COVID-19 pandemic exacerbated pre-existing health, social, and economic disparities within marginalized communities. However, data focusing on Canadian Black populations are limited. This study aims to identify how the pandemic impacted the health of Black communities and to identify associated factors, both prior to and during the pandemic, to inform areas for action and service planning.

Methods

This community-based cross-sectional study included English- or French-speaking Canadians self-identifying as African, Caribbean, or Black, in the Greater Toronto Area. The survey collected data from November 2022 to May 2023 on sociodemographic and clinical factors, and perceived health status. Data were based on retrospective self-reports. Such self-reported data are relevant to participatory research methods that require participatory data. Perceived general and mental health status, overall and by characteristics, was described. Key factors associated with perceived health before and during the pandemic were explored using multivariable logistic analysis.

Results

388 individuals, aged 1–74 years, were included, mostly English-speaking and non-Canadian-born. Respectively 81% and 76% indicated their general and mental health as good or excellent before the pandemic, compared to 49% and 45% during the pandemic. University education (OR = 3.25), physical activity (OR = 2.87) and multimorbidity (OR = 0.15) were significantly associated with self-reported general health before the pandemic, while more factors, including immigration status, age, employment status, and insurance coverage, contributed to mental health perception. During the pandemic, women reported good/excellent general health or mental health 50–60% less often than men. Multimorbidity, immigration status, and household income were also associated with general health. French-speaking Black Canadians reported a lower proportion of good/excellent mental health, but those privately insured or physically active reported 3 times higher proportions of good or excellent mental health.

Conclusions

This study provides needed health status information from a community-based sample of Black Canadians prior to and during the COVID-19 pandemic and explores how social determinants of health vary in different contexts. A comparison before and during the pandemic and community involvement strengthened this cross-sectional study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-25968-z.

Background

Health outcomes, population well-being and often health inequities are largely driven by Social Determinants of Health (SDoH) including sociodemographic characteristics (e.g. age sex), cultural (e.g. ethnicity), systemic (e.g. structural racism) or environmental aspects [1–3]. These determinants need to be considered in evaluating and caring for the health of individuals [4]. As an example, racial inequities can lead to marginalization, discriminations in health, and poor access to resources or poor quality of care, thus making race a powerful SDoH [3, 5, 6]. Research has demonstrated that Black people have poorer care access and less optimal services or treatment [7–9]. Despite the healthy immigrant effect whereby immigrants arrive to Canada with stronger health than their Canadian-born counterparts, in the long-term, Black immigrants exhibit a higher risk of diabetes than their white counterparts [10]. Moreover, the intersection or combination of multiple factors can be even more damaging and create profound social and health disparities [11]. Overall, Canadian Black populations are disproportionally affected by chronic conditions such as cancer, diabetes, dementia, intellectual disability, and multimorbidity [5, 12]. The health and healthcare disparities faced by Black communities despite Canada’s universal healthcare system highlight the need for community-based health research which looks through a social lens.

Furthermore, the COVID-19 pandemic has exacerbated pre-existing health disparities and challenges within marginalized communities [13, 14]. In Ontario, a state of emergency was declared in March 2020 and the province started implementing varied measures to counter the pandemic. Due to the increasing and fluctuating numbers of cases and deaths, successive lockdowns were implemented, followed by phased reopening in 2021–2022. Most restrictions ended by mid-2022, with remaining measures lifted in October 2022 in Canada. Policy responses such as lockdowns closed schools, churches and restaurants, and restricted travel and gatherings among Canadian populations including Black communities in Ontario. This disrupted family and community units and removed important pillars for mental health, wellbeing, and coping [15]. The pandemic response resulted in the reduction of services (such as elective surgeries, ambulatory procedures, and non-emergent activities), and the reorientation of healthcare resources (such as staff and PPE supply, and the closure of public health programs and walk-in clinics) [16–20]. This has contributed to lower survival and quality of life among persons with chronic conditions [16, 21]. A US-based study has reported excess mortality in Black populations from COVID-19 and non-COVID-19 outcomes due to the worsening of pre-existing social and health disparities [22]. Further, Kirksey and colleagues (2021) explain how the co-occurrence of the COVID-19 pandemic and historic racial inequities in healthcare access and outcomes contribute to a perfect storm for further health disparities among African-Americans [23]. It is expected that the pandemic will have negative long-term effects on the physical and mental health of populations already at risk for poor health [24–28]. Unfortunately, specific data that report on the health of Black communities in Canada is almost non-existent. A scoping review conducted up to May 2023 identified 12 articles on COVID-19 among Black people in Canada [29]. Of these 12 articles only one study on the impact of COVID-19 on the general health status of Black populations [30] was identified, two studies on the general mental health impacts of COVID-19 [20, 31] were identified and two studies identified health impacts among sub-populations, specifically homeless youth and eye care professionals [32, 33]. Though research from other global contexts may offer applicable concepts and frameworks, the Canadian context differs due to universal healthcare and immigration dynamics; therefore, perspective from this context will enrich the discussions and contribute to the evidence. Race-based data from Canadian communities is needed to support advocacy, equity, and policy-change [34].

Inequities can be increased by the imbalance of data, for racial groups or groups made vulnerable by the multiple factors and challenges that they face [35]. Collecting specific data on racial groups is an important public health and research responsibility that contributes to fulfill Ontario Health’s commitment to social accountability, requiring assessment of needs/priorities for marginalized communities [36–39]. This will contribute to identifying and addressing potential inequities and ensure health equity especially considering the pandemic. To contribute a response to that need, this study aims to provide information on health status among Black communities and to identify associated factors both prior to and during the pandemic, to inform areas for actions, and service planning.

Black people have historically been positioned as subjects of research rather than researchers providing content and community context expertise [40, 41]. This historic and ongoing positioning has led to ethical concerns, harmful research practices, and inadequate research outcomes [40–42]. Community-driven participatory research approaches are paramount in creating rigorous, equitable, and ethically grounded research with translatable action. Therefore, this research was community-driven and included an advisory group comprised of community representatives from health and grassroot organizations at each step, including finalizing the objectives, development of the survey tools, recruitment and findings interpretation. Besides the community advisory committee, additional members of the community participated in a day-long collaborative session. The session aimed to contextualize results by drawing on content and context expertise, and to give community members the platform to voice and discuss what they identified as important.

Methods

Study design and sample

The study utilized a cross-sectional design, including data from a community-based survey of Canadians self-identifying as African, Caribbean, or Black. A cross-sectional design was deemed appropriate to capture multiple factors and outcomes as well as explore trends and individual’s experiences during the pandemic, for further investigation [43]. Reporting data retrospectively through a survey may be limited; however, the data was collected shortly after the pandemic restrictions were officially lifted in October 2022, and the pandemic was a traumatic event for all, minimizing memory bias. The pre-pandemic reports may be impacted by the perception during the pandemic and should be related to that. The target population included English or French-speaking Black persons of all ages living in the Greater Toronto Area (GTA) during the pandemic. A sample in the GTA was used since most of the Black population lives in five large urban areas in Canada, with the largest population (36.9%) in the GTA [44]. Additionally, the GTA represents Canada’s largest metropolitan area by population [45]. Therefore, the GTA adequately represents our target population. Data was collected between November 2022 to May 2023, and included retrospective self-reports, which are relevant given the short time since an event that was quite traumatic for all, and still persistent.

Data collection strategies

Targeted, community-based research may allow for better community engagement to reflect specific community needs [46]. Taking this approach reflects the Engagement, Governance, Access, and Protection (EGAP) principles proposed by the Black Health Equity Working Group [47] to guide the responsible collection and use of race-based data to advocate for the needs of Black communities. Particularly, EGAP asserts that those conducting research with Black populations ensure: (1) genuine, cyclical, accessible consultation with communities regarding data collection, management, analysis, and use; (2) community decision-making about engagement processes and data collection, management, analysis, and use, achieved through the establishment of Community Governance Tables; (3) the right of communities to access their collective data and to determine who else can access it, along with the capacity building required to enable this right; and (4) the safeguarding of all individual rights and types of data, including identifiable, de-identified, and anonymized data [47].

To ensure the EGAP principles are upheld and to reflect specific needs, community leaders were consulted prior to and during the research process. An advisory committee was formed comprised of 2 health organizations (Women’s Health in Women Hands - WHIWH; Entité 3 de planification de services en français), and 5 grassroots organizations (Perspective Nation; Council of Nigerian Professionals Inc. – CNP; Oasis Centre des Femmes - OCF; Victorian Association of Canada – VAC; Kay Créole d’Entraide et de Services Professionnels – KCESP). The advisory committee was involved in the development of the survey for this study (included as Supplementary Material) and directed the data collection and recruitment strategy. Following the data collection, the research team met twice with the advisory committee to reflect on the descriptive findings and propose subsequent analyses. Data visualization (tables, figures, posters) was then created for a further session of collaborative interpretation, including an additional seven (7) members of the community recruited in a snowball manner. The session included a walkthrough of the findings where members of the advisory committee and community members were able to draw from their respective knowledge and expertise individually and then collectively to highlight and give meaning to findings they identified as important. Sampling strategies directed by the advisory committee engaged individuals of varied age groups, geographical areas, sex, and socioeconomic groups. This was achieved by offering the survey online, assisted over the phone or in-person in either English or French. The survey was promoted using both poster and video formats on social media to reach a wider audience. Most engagement was achieved in person through community-oriented settings and events, namely during Black History Month or by visiting predominantly Black places of worship (churches or mosques) and restaurants in the GTA. The study engaged individuals of all ages, including children. As per Chap. 3 of the 2022 Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2), parental consent is not required for children since an age-based approach to consent is not used [48]. Instead, assent is made based on having the appropriate decision-making capacity, though some parents filled the survey on behalf of their children.

Study variables

The study variables are based on self-reported data from the survey. Relevant social and clinical factors were collected along with outcomes of interest, and questions were asked at the same time regarding aspects prior to or during the pandemic.

The study’s main outcomes were self-reported health status before and during the pandemic, measured using a Likert scale ranging from 1, very poor to 5, excellent. Two separate Likert scales were used to describe general and mental health. Self-rated general health and mental health were selected due to survey feasibility and established validity in population groups. These measures are widely used in the literature and have been reported to be a valid representation of an individual’s physical or mental health even against objective measures and in conditions such as diabetes [49, 50]. Additionally, self-reported health status has been previously used to measure health status in Black communities [51].

Independent variables were chosen to represent both individual and system-level dimensions of the SDoH, as well as clinical aspects. Individual-level factors included preferred language, city/neighbourhood, living situation, Canadian-born status, age, sex, marital status, education, household income, employment status and physical activity levels. Marital status and living arrangements are closely related to social isolation and loneliness [52], and serve as proxies for these important pandemic-specific aspects. Health insurance coverage, access to healthcare service, and clinical aspects, including co-existing chronic conditions, COVID-19 diagnosis, and vaccination status were also considered. Consistent with prior work, a count of chronic conditions was used as a measure of comorbidity [53]. All independent variables were categorical.

Analyses

We performed descriptive and bivariate analyses to describe the study population and compare the individuals’ perceived health status by characteristics, both prior to and during the pandemic. Using multivariable logistic regression models, we then explored the extent to which the sociodemographic and clinical variables were associated with health outcomes, and how this may differ before and during the pandemic. Since the scope of this paper is to explore factors, and since the pre-pandemic and pandemic data were collected simultaneously, mixed-effects models were not used to test changes [54]. All the variables were added to the model to assess the adjusted effects as independent factors, and no specific interactions between predictors (e.g. the interaction of gender with other variables) were assessed.

Sensitivity analysis excluding respondents less than 12 years old, produced findings similar to the entire study population.

The analyses were conducted using SAS software, through the SAS software studio platform version 9.4.

Results

The study sample included 388 individuals who self-identified as African, Caribbean or Black. Those who did not self-identify (n = 11) or declined to consent to continue the survey (n = 6) were excluded.

Table 1 shows the characteristics of the sample. The majority (69%) were English-speaking and 29% mentioned French as their first or preferred language. Most identified as female (58.3%), were 18–39 years of age (43.8%), predominantly lived with others in a private setting (74.4%), and were not Canadian-born (69.2%), with over a third having a university education (39.2%). About 21% reported at least one chronic condition and the majority received 1 or more doses of the COVID-19 vaccine (87.2%), while 37.5% were diagnosed with COVID-19 during the pandemic. However, close to a quarter did not access any health service in the last 5 years.

Table 1.

Characteristics of the study sample

Characteristics	n	%
All	388	100
Preferred language spoken
English	269	69.3
French	112	28.9
Other	7	1.8
City/Neighborhood
Toronto	248	66.0
Durham region: Ajax, Oshawa, Pickering, Whitby	32	8.5
Halton region: Oakville, Milton,	21	5.6
Peel region: Brampton, Mississauga,	43	11.4
Other GTA: York (Vaughan, Markham), Alliston	9	2.4
Other (outside of GTA): Cambridge, Cornwall, Dundalk, Guelph, Kingston, Bowmanville, Ridgemont, Kitchener, Windsor, Peterborough, Hamilton*	23	6.1
Living situation
Alone	80	20.7
With others in private setting	288	74.4
Other (congregate setting, shelter, etc.)	19	4.9
Born in Canada
Yes	112	30.8
No (0–4 years in Canada)	105	28.8
No (5–14 years in Canada)	95	26.1
No (15 + years in Canada)	52	14.3
Age group (mean 34.6 years)
01–17	65	17.7
18–39	161	43.8
40–59	122	33.3
60+	20	5.4
Sex
Male	157	40.9
Female	224	58.3
Prefer not to say	3	0.8
Marital Status
Single	192	49.9
Married/Common Law/Living together	149	38.7
Divorced/Separated	32	8.3
Widowed	12	3.1
Education
High school or less	118	30.4
Diploma or trade	118	30.4
University	152	39.2
Household income
< 35k	136	42.1
35k-75	110	34.1
75k +	77	23.8
Employment status
Full-time	152	39.6
Part-time	51	13.3
Student	91	23.7
Other (self-employed, retired, caregiver)	38	9.9
Unemployed	52	13.5
Insurance coverage
None	64	16.5
OHIP only	178	45.9
Both OHIP and private	129	33.3
Private only	17	4.4
Access to healthcare service in the last 5 years
Yes	300	77.3
No	88	22.7
Self-assessed Physical activity
Inactive	90	23.2
Active	298	76.8
Chronic conditions
None	307	79.1
1 condition	29	7.5
2 + conditions	52	13.4
Diagnosed with COVID-19
Yes	144	37.5
No	240	62.5
COVID-19 Vaccine
not vaccinated	49	12.8
vaccinated 1 + doses	335	87.2

* This includes people who were visiting the GTA during events at the time of the survey

Most participants, respectively 81.4% and 76% indicated that their general health and mental health were good or excellent before the pandemic (Table 2). When asked to rate the same during the pandemic, fewer individuals reported good/excellent general health (48.7%) or mental health (44.6%). Comparatively, over 60% of respondents reported that their physical and mental health had not been good for one or more days in the last month and that prevented them from doing their usual activities.

Table 2.

Perceived health status before and during the pandemic

Perceived health status	Before n	Before %	During n	During %
General health
Poor/Very poor	6	1.6	65	16.8
Fair	66	17.0	134	34.5
Good/Excellent	316	81.4	189	48.7
Mental health
Poor/Very poor	31	8.0	84	21.7
Fair	62	16.0	131	33.8
Good/Excellent	295	76.0	173	44.6
# of days physical health not good during the past 30 days
None (0 days)			142	36.6
Few days (1 to 3 days)			119	30.7
Multiple times (4 to 7 days)			69	17.8
Quite often (8 to 14 days)			33	8.5
Most of the time (15 to 21 days			11	2.8
Almost every day (> 21 days)			14	3.6
# of days mental health not good during the past 30 days
None (0 days)			129	33.3
Few days (1 to 3 days)			108	27.8
Multiple times (4 to 7 days)			73	18.8
Quite often (8 to 14 days)			39	10.1
Most of the time (15 to 21 days			20	5.2
Almost every day (> 21 days)			19	4.9
# of days not feeling well keep you from doing your usual activities during the past 30 days
None (0 days)			127	32.9
Few days (1 to 3 days)			127	32.9
Multiple times (4 to 7 days)			73	18.9
Quite often (8 to 14 days)			32	8.3
Most of the time (15 to 21 days			22	5.7
Almost every day (> 21 days)			5	1.3

Factors individually associated with Good/Excellent health outcomes before and during the pandemic

In the bivariate analyses (Table 3), we found that factors significantly associated with the outcomes differed between the periods of observation (before and during the pandemic), but a few were somewhat similar for both outcomes. During the pandemic, Francophones reported lower rates of good/excellent general health (38.4% vs. 52.0% for anglophones) and mental health (27.7% vs. 51.3%). Preferred language was not associated with the outcomes prior to the pandemic. All immigrants were more likely to report good/excellent general and mental health before the pandemic. However, during the pandemic, only the proportion of new immigrants (0–4 years in Canada) reporting good/excellent general health (61.7%) was higher than Canadian-born (48.2%).

Table 3.

Proportion of Good/Excellent general and mental health by social and clinical factors

	Good/Excellent General health		Good/Excellent Mental health
	Before %	During %	Before %	During %
All	81.4	48.7	76.0	44.6
Preferred language		*		*
English	81.8	52.0	75.5	51.3
French	79.5	38.4	77.7	27.7
City/Neighborhood			a
Toronto	80.2	47.6	77.8	43.6
Durham	81.3	46.9	68.8	51.3
Halton	90.5	42.9	66.7	27.7
Peel	86.1	58.1	76.7	53.5
Other GTA	77.8	55.6	44.4	57.1
Other (outside GTA)	87.0	52.2	91.3	37.5
Living situation
Alone	76.3	42.5	75.0	37.5
With others in private setting	83.0	49.7	76.4	45.8
Other (congregate setting, shelter, etc.)	79.0	63.2	73.7	52.6
Born in Canada	*		*
Yes	75.0	48.2	67.9	45.5
No	84.5	50.9	78.9	46.0
Born in Canada	a	*	*	a
Yes	75.0	48.2	67.9	45.5
No (0–4 years in Canada)	86.0	61.7	86.9	49.5
No (5–14 years in Canada)	83.2	41.6	72.3	35.6
No (15 + years in Canada)	84.6	46.2	78.9	51.9
Age group	a	a		*
01–17	90.8	61.5	81.5	64.6
18–39	82.6	47.8	72.7	42.9
40–59	80.3	45.9	82.0	37.7
60+	70.0	30.0	75.0	45.0
Sex	a	*		*
Male	85.4	61.2	80.3	57.3
Female	78.6	40.6	72.8	35.7
Marital Status		a		*
Single	81.8	55.2	74.5	51.0
Married/Common Law/Living together	81.2	44.3	76.5	37.6
Divorced/Separated	78.1	34.4	84.4	34.4
Widowed	83.3	50.0	83.3	66.7
Education		a	a	*
High school or less	83.1	54.2	72.0	59.3
Diploma or trade	76.3	40.7	72.0	39.0
University	84.2	50.7	82.2	37.5
Household income		*
< 35k	78.7	36.8	74.3	39.7
35k-75	79.1	50.0	74.6	37.3
75k +	85.7	55.8	76.6	49.4
Employment status		a		a
Full-time	82.9	49.3	76.3	43.4
Part-time	72.6	35.3	68.6	29.4
Student	84.6	56.0	78.0	52.8
Other	79.0	44.7	84.2	44.7
Unemployed	82.7	50.0	71.2	48.1
Insurance		*		*
None	85.9	57.8	71.9	54.7
OHIP only	80.3	42.7	77.0	37.6
Both OHIP and private	79.8	48.8	75.2	45.0
Private only	88.2	76.5	88.2	76.5
Access to healthcare service in last 5 years
Yes	82.7	48.3	75.3	44.7
No	77.3	50.0	78.4	44.3
Physical activity	*		a	*
Inactive	67.8	43.3	68.9	33.3
Active	85.6	50.3	78.2	48.0
Chronic conditions	*	*	*	*
None	87.3	52.4	80.8	47.9
1 condition	79.3	51.7	75.9	51.7
2 + conditions	48.1	25.0	48.1	21.2

^a p < 0.20 * p < 0.05

While there were no significant differences before the pandemic, percentage of women who reported good or excellent health were consistently lower than men during the pandemic. Age was associated with mental health, but not general health, and only during the pandemic. During the pandemic, younger participants reported higher rates of good/excellent mental health (64.6%) compared to older participants. The observations were similar for marital status, where single respondents reported good mental health (51.0%) during the pandemic at higher rates than others, with no differences before the pandemic.

Also, the type of health insurance coverage was associated with general and mental health during the pandemic but not prior to. Namely, those with private insurance more frequently reported good or excellent general and mental health during the pandemic. Each of education, household income and employment status were associated with only one outcome and solely during the pandemic. On the other hand, physical activity and chronic conditions had the most consistent impact on all outcomes both before and during the pandemic. More physically active individuals reported good/excellent general health before the pandemic, and mental health during the pandemic. Less people with 2 or more conditions reported good health both before and during the pandemic.

Adjusted association of factors with Good/Excellent health Outcomes, before and during the pandemic

The regression models included factors that were individually associated with at least one outcome in one period. As such neighborhood location, living situations and access to healthcare service in last 5 years were not included in the adjusted models.

Key factors before the pandemic

For the self-reported general health, only physical activity and chronic conditions were significantly associated. The chance of reporting good/excellent health was about 3 times higher among individuals physically active (OR = 2.87; 95%CI 1.37–9.88) (Fig. 1). Individuals with 2 or more chronic conditions had lower odds of reporting good/excellent health (OR = 0.15; 95% CI 0.06–0.37). Even though those with a university education reported good health in a higher proportion (OR = 3.25; 95% CI 1.07–9.88), this is likely a false positive considering that the overall contribution of education was not significant.

Fig. 1.

Adjusted impact of factors affecting good/excellent health outcomes before the pandemic (n = 321)

Many more factors contributed to mental health perception among the Black respondents. Besides education and chronic conditions, reporting good or excellent mental health was also associated with immigration status, age, employment status and insurance coverage. Non-Canadian-born who have been in the country for 0 to 4 years reported good/excellent mental health 4 times more frequently than Canadian-born. Middle-aged respondents reported good health 3 times more frequently than younger adults 18–39. Not having health insurance was associated with a lower rate of good mental health (OR = 0.29; 95% CI 0.11–0.74). However, those self-employed or retired reported good mental health more frequently (OR = 4.89; 95% CI 1.16–20.55) than those working full-time.

Key factors during the pandemic

Different characteristics were associated with perceived health status during the pandemic (Fig. 2). Namely, sex was a common significant determinant, with women reporting good or excellent general health or mental health 50–60% less often than men. The odds of reporting good general or mental health were also lower for those with 2 or more conditions.

Fig. 2.

Adjusted impact of factors affecting good/excellent health outcomes during the pandemic (n = 321)

As for mental health, French-speaking Black Canadians reported a lower proportion of good/excellent levels (OR = 0.35 95%CI 0.18–0.69), while individuals who have private insurance reported good/excellent level more often (OR = 2.76; 95% CI 1.5–5.1). More physically active respondents reported good or excellent levels of mental health 3 times more often than those not physically active.

Collaborative interpretation and discussion

In line with the community-based approach taken in this project, community members were involved in a collaborative interpretation session to make meaning of the preliminary results. Among others, the results reviewed included the perceived health status proportions and changes. Perspectives gathered during the session are included in this discussion using italics.

Overall, we found that the Black population included in this study reported a relatively lower level of perceived general or mental health prior to the pandemic (respectively 81% and 76% good to excellent), compared to the Ontario general population. In Ontario, around 89% of respondents 12 and older reported good, very good or excellent perceived health in 2019–2020 [55, 56]. However, the perception was greatly diminished with regards to health during the pandemic, as less than 50% of the Black study population rated it as excellent or good, compared to 59% in Ontario in 2021 who said it was excellent or very good.

The restrictions, social disconnect and economic effects resulting from the pandemic countermeasures may explain the overall decrease in the proportion of good perceived health in all population groups. Authors found that marginalized groups, namely Black populations, were more impacted by the restrictions during the pandemic [57, 58]. Norton and colleagues concluded that the restrictions in hospital visitation may have limited opportunities for advocacy and support for Black women [57]. Also, closing churches that represent a key resource and aspect of Black communities’ support system may have led to deterioration in mental health [58]. Moreover, Black people faced more socio-economic disparities related to adequate housing and have encountered a higher rate of job loss during the pandemic [30, 32]. We also found that the reported COVID-19 incidence was quite high among the respondents, at 37.5% while the highest weekly positivity rate in 2022 was around 30% in the Ontario population [59]. These findings are consistent with four other studies which noted higher rates of infection among Black Canadians, listing socio-economic disparities such as overcrowding, existence of health inequalities and front-line work as contributing factors [29].

All this could contribute to the lower rating of their health. In the same line, during the collaborative interpretation gathering, community members commonly mentioned challenges that came with the pandemic and negatively impacted health, such as non-affordable good food, social isolation due to the confinement and resulting in mental health issues, fear preventing people from looking for services or help, systemic barriers including reduced prevention, healthcare services and quality of care:

"Avant le COVID-19 les gens mangeaient mieux parce qu’ils pouvaient se payer de meilleures nourritures; ils pouvaient se déplacer pour se socialiser et ressourcer. Ce qui enrichissait leur santé en général."

Translation

Before COVID-19, people ate better because they could afford better food; they could travel to socialize and recharge/relax. This enriched their overall health.

"Beaucoup de salles d’urgence des hôpitaux et csc sont fermées ou travaillent en diminution. Des personnes vont à l’hôpital et retournent chez elles sans être vues/soignées […]. Ainsi en conséquence retournent à la maison plus malades, frustrées anxieuses et déprimées."

Translation

Many emergency rooms in hospitals and clinics are either closed or working less. People go to hospital and return home without being seen/treated […]. As a result, they return home feeling sicker, more frustrated, anxious and depressed.

"Health and quality of service have declined dramatically with labor shortages and inflation. Emergency rooms are shrinking, and many are closed; home care and compassionate care services have not increased. Many have lost their caregivers. So fewer services and fewer quality services, especially for vulnerable people."

“Impact of information and pressure on people, all this social media commotion […] the fear etc., worked to degrade the health."

However, they felt they were able to cope, thanks to traditional ways and the connections they could somewhat keep with others:

“Traditional medicine was also about connecting and mental support in the Black community. The Black community is good at talking to each other. We had that kind of connection where we shared remedies and recipes, [thus the pandemic] impact was lesser in regard to emotional healing”.

Although part of the trends may be related to the public discourse during the pandemic, the size of the issue and differences observed may not be completely ignored, downplayed or attributed to such discourse, but could rather reflect a real discomfort and bearing suffered by marginalized population groups during the crisis. In fact, not all groups have been equally impacted. Clinical status, namely reporting 2 or more chronic conditions was expectedly associated with poorer general and mental health both prior to and since the pandemic. As such they should have received particular attention and support to better mitigate the impact of the pandemic crisis. However, the association was somewhat lessened during the pandemic, indicating that while health needs negatively impacted people’s health, the pandemic and related consequences have affected all groups with or without health issues. Other studies prior to the pandemic also found that chronic conditions were associated with poor self-perceived health [60].

Nevertheless, differences or inequities may be created or exacerbated by crises like the pandemic. In our findings, we also observed that the way participants perceived their general or mental health differed between women and men. While sex did not appear to be a significant factor related to perceived health prior to the pandemic, women were clearly less likely than men to report good or excellent health during the pandemic. Many studies have generally found that women reported lower perceived health than men, even before the pandemic [61, 62]. The lack of significance prior to the pandemic, in this sample of Black participants is therefore unexpected, but maybe an indication that Black women are more resilient. However, the pandemic may have made things worse and less tolerable. Community members involved in the collaborative interpretation pointed out varied difficulties and barriers faced by women with the pandemic:

"Its [the system] ability to respond to women’s health concerns was undermined. That led to a general dissatisfaction."

“Women’s habitat was not suitable for confinement.”

Moreover, the social responsibilities that Black women have, may also impede their well-being and may have contributed to worsen their health during the pandemic. As Gausman & Langer [63] noted, women, who are more likely to be caregivers, may have suffered more stress or fatigue during the pandemic. As participants stated:

“[…] they [women] were limited to seek help and speak to family and friends and there was no other resources. Charge of responsibility put on women such as schooling, [helping] the kids [for] online school and sometimes dealing with kids with special needs. Also, the other issue was racism, in terms of health”.

Like sex, language appeared to be a risk factor during the pandemic but not before, with francophones reporting good or excellent health less frequently than anglophones. Though the association was reduced or faded in multivariate models, it is important to note that language barriers may add to the challenges faced by individuals and contribute to exacerbate the negative impact of other leading risk factors. In discussing with francophone community members, they sadly noted the reduction of services may have impacted francophones harder, since they already lacked appropriate services in their language. In addition, there were limited resources in French, including communication related to the pandemic measures, which made it more challenging to navigate the pandemic and its negatives consequences for francophones:

“Pénurie de main d’œuvre en santé fait que la quantité et la qualité des services de santé diminuent énormément. Ainsi, ça a de gros impacts sur la santé des gens en général et beaucoup plus sur la santé des Francophones."

Translation

The shortage of manpower means that the quality and quantity of healthcare services is diminishing. This has a major impact on people’s health in general, and much more so on the health of Francophones.”

“PHU were delivering info[rmation] only in English because they don’t have any obligation to offer services in French. Very hard to get public health in French. How do people who can’t read English get the right information? They have to rely on social media”.

Kemei and colleagues [64] found that there was sharing of COVID-19 misinformation in Black Canadian communities through social media platforms among family, friends and community members and leaders and suggest that misinformation contributes to higher rates of infection.

Nevertheless, some factors may have a positive impact on people’s health. For example, having private insurance alone or in combination with OHIP appeared to play a positive role with the pandemic, namely when it came to perceived mental health. With the stress put on the system during the pandemic, it is understandable that those with additional support available through private insurance fared better than others. The pandemic revealed the limitation of the public health system to offer adequate and accessible mental health services, due in part to a provincial health insurance plan that does not cover psychologists and other registered mental health providers [65].

Another protective factor, physical activity played a wider role in mental health during the pandemic (but not prior to). The association was also only significant for general perceived health before the pandemic (but not during). In fact, as the opportunities to pursue physical activities may have been reduced during pandemic, it seems like those already physically active or who found ways to be, were able to cope better with the challenges of the pandemic and this positively impacted their mental state. Physical activity has been found to positively impact mental health in multiple ways [66]. As people acknowledged during the collaborative interpretation, being physically active is key for multiple reasons, and may intersect with other factors to impact health. For example,

“for those affected by diabetes, there is a certain number of steps they have to take everyday. If they don’t have the opportunity to go out and walk then their health will deteriorate”.

Yet, physical activity is not as accessible to Black Canadians as White Canadians due to racial discrimination and inequities in health and determinants of health for Black Canadians, which results in Black Canadians reporting lower levels of physical activity [6]. Between 2010 and 2013, 40.8% of Black Canadians aged 18 years and older reported being active or moderately active, compared to 54.2% of White Canadians [67]. For example, social isolation may have been worse when dealing with socioeconomic limitations. Living in an apartment, a building without amenities or in a basement, will not provide the same opportunities as someone living in a house with a backyard, or in a luxurious building with a gym. Overall, we observed that there were more social determinants that contributed to mental health ratings (e.g. age, education, employment), whereas for general health, it was mainly clinical/biological aspects including physical activity and multimorbidity, that play a significant role. While we could still observe the healthy immigrant effect on perceived health prior to the pandemic, it appears that the pandemic has hit people in a way that this effect has faded for recent immigrants, namely with regards to mental health perception. Also, people more educated, or self-employed, i.e. likely to have more flexibility with work, fared better with regards to their mental health. This is in line with other studies in varied contexts and population groups, reporting that socioeconomic factors such as income, education, are associated with self-rated health [60–62].

A comparison before and during the pandemic contributes to the strength of this cross-sectional study; however, it is not without limitations. The study used a cross-sectional design, which is exploratory and descriptive in nature and may not imply causality in the relationships observed. Key limitations include biases related to a survey study such as selection, memory or recall bias, and a lack of chronology [43, 68]. Namely participants were required to recall how they felt in a previous period, when the entire population had lived a traumatic pandemic experience that may have impacted perspectives. Though selection bias is likely given the cross-sectional design, the recruitment approaches used, and the involvement of community members have helped with the representativeness of the sample, in a context where racial data, namely focusing on Black Canadian groups, are scarce. While Ontario has the largest population of Black Canadians, and there is a limited Black population in rural areas of Canada (with 94.3% living in metropolitan areas) [45], the Canadian provinces are very diverse and have their unique characteristics. Given the diversity of the population groups in Canada, it is worth exploring this topic in varied contexts and continue to advocate for race-based data in different parts of the country

Conclusion

This study provides needed information on health status in a community-based sample of Black Canadians and explores how social determinants of health vary in different contexts and situations. The study provides much needed information on this specific community and may support decision making, through a better understanding of the challenges they face. As denoted by many community members, “Health status continues to deteriorate. It’s all there: we need to work on all aspects”. “Strategies must imperatively be put in place to heal the wounds.” A crucial aspect that was mentioned is to provide supports services that are accessible and culturally safe, while considering holistic care and alternative medicine. Education and awareness are also an important step in improving mental health, and “to recognize and prevent mental illness” that can be a taboo in the community. As noted by one participant: “every service offered should have a “mental health” component”.

Authors' contributions

AK: PI, original idea, grant writing, recruitment, survey, analyses and paper writing. NM: grant writing, research support, paper review. LR: co-PI, grant writing, research support, paper review. HG: research coordination, recruitment, survey. AB: Help with paper drafting and formatting. ST: Help with paper drafting. WT: research support and oversight, recruitment, collaborative interpretation of findings. CO: research support and oversight, recruitment, collaborative interpretation of findings. EK: research support and oversight, recruitment, collaborative interpretation of findings. AA: research support and oversight, recruitment, collaborative interpretation of findings. DG: research support and oversight, recruitment, collaborative interpretation of findings. MN: research support and oversight, recruitment, collaborative interpretation of findings. MRT: research support and oversight, recruitment, collaborative interpretation of findings.

Funding

The study is funded by the Canadian Institute of Health Research (CIHR), grant #WI4 179980, to Dr. Kone Pefoyo.

Data availability

The data is securely stored at Lakehead University according to the disposition in the REB approval, and only accessible to authorized personnel. Data may be made available upon request but only if allowed and deemed reasonable through ethics and community approvals following EGAP principles. The data are not publicly available otherwise.

Declarations

Ethics approval and consent to participate

The research was reviewed and approved by Lakehead University Research Ethics Board in 2022 (approval #1469407). It was then renewed annually in 2023, 2024, and 2025. Participants provided informed consent before filling out the survey and received a gift card upon eligibility and after completing the survey. As per Chap. 3 of the 2022 Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2), an age-based approach to consent is not used and parental consent is not required. Instead, assent is made based on having the appropriate decision-making capacity. Most children in the sample (n = 43) consented for themselves. The remaining children (n = 5) had the questionnaire filled by a parent. Analyses excluding respondents less than 12 years old, produced similar findings.

Consent for publication

Yes.

Competing interests

The authors declare no competing interests.