The Association Between Education and Basic Needs Insecurity for Marshallese During the COVID-19 Pandemic

Journal of Racial and Ethnic Health Disparities https://doi.org/10.1007/s40615-021-01125-1 The Association Between Education and Basic Needs Insecurity for Marshallese During the COVID‑19 Pandemic Jennifer A. Andersen1 · Don E. Willis1 · Joseph R. Malhis1 · Christopher R. Long1 · Pearl A. McElfish1 Received: 7 June 2021 / Revised: 29 July 2021 / Accepted: 29 July 2021 © W. Montague Cobb-NMA Health Institute 2021 Abstract Background The purpose of this study was to explore the prevalence of basic needs insecurity and to examine the association between education and basic needs insecurity during the COVID-19 pandemic for Marshallese living in the USA. Methods Survey data describing Marshallese experiences during the pandemic were analyzed using descriptive statistics and complementary log–log regression to test the association between education and basic needs insecurity. Results Marshallese respondents reported no usual source of care (46%), less healthcare (22.3%), and difficulty obtaining medication (34.8%). Nearly 80% reported being food insecure, and 47.5% reported being housing insecure. Marshallese with a high school education or less had higher odds of reporting being food and housing insecure. Discussion Basic needs insecurities are a serious threat to the health of Marshallese during the pandemic. Results from this study can inform interventions addressing food and housing insecurity, access to healthcare, and medication access for Marshallese communities. Keywords Marshallese · Basic needs · COVID-19 · Education · Food and housing insecurity Background The first cases of COVID-19 were diagnosed in the USA in early 2020 [1]. The subsequent pandemic disproportionally burdened racial and ethnic minority groups in the USA. For example, in Benton and Washington Counties in Arkansas, home to the largest population of Marshallese in the continental USA, Marshallese people represent approximately 2.5% of the total population but made up 19% of the COVID-19 cases [2]. Between March and June of 2020, 9% of COVID-19-positive Marshallese in these Arkansas counties was hospitalized for COVID-related complications compared to just 1% of all COVID-19-positive cases nationally. Marshallese accounted for 38% of COVID-19 deaths in Benton and Washington counties during that same period [2]. Marshallese living in other states in the USA were equally hard hit by COVID-19 [3]. For example, Marshallese in Spokane County, Washington account for 1% of * Pearl A. McElfish 1 College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 N. College Avenue, Fayetteville, AR 72703, USA the county’s population but represent a third of the county’s COVID-19 cases [4]. Fundamental cause theory posits that socioeconomic status (SES) is a fundamental cause of health disparities [5]. SES represents access to a number of resources, including money, knowledge, prestige, power, and advantageous social connections that work to protect health regardless of the historical context [5]. Education is an important component of SES for which health gradients have been observed [5, 6]. Education is considered a fundamental cause in part because credentials provide opportunities to secure higher-status occupations which, in turn, provide advantages both in terms of access to more resources as well as less involvement in conditions which might expose someone to hazards [6]. Prior to the pandemic, Marshallese people experienced widespread social and health disparities [7, 8]. Limited access to healthcare, food insecurity, and housing insecurity are all associated with a wide range of negative health outcomes including asthma, diabetes, poor self-rated health, overweight/obesity, and poor mental health [9, 10]. Although much has been written about healthcare disparities and growing food insecurity across the USA since the pandemic began [11], no research to date has explored the 13 Vol.:(0123456789) Journal of Racial and Ethnic Health Disparities social and health disparities among Marshallese during this unique economic and public health crisis. Following calls to view COVID-19 as a syndemic—a set of interconnected and interacting health problems that co-contribute to excess disease in a population [12, 13]— we explore the prevalence of basic needs insecurity among an understudied population of Marshallese living in the continental USA and Hawaii and examine the association between education and healthcare access, food insecurity, and housing insecurity. Methods Participants and Data Collection Community-based recruitment was completed via e-mail, Facebook, and phone calls from Marshallese community health workers. Inclusion criteria specified participants be self-reported Marshallese living in the continental USA and Hawaii and at least 18 years of age. Recruitment took place from July 27, 2020, to November 22, 2020. All study information was provided in English and Marshallese. Consent and survey data were documented in Research Electronic Data Capture (REDCap), a web-based software designed for research and data collection and management. The survey utilized a Completely Automated Public Turing test to tell Computers and Humans Apart (CAPTCHA) feature to prevent fraudulent responses. Participants received a $20 gift card if they completed the survey. Measures Questions from the Behavioral Risk Factor Surveillance System captured demographic information [14]. Questions from the PhenX toolkit were used to ask other COVID-19 questions [15]. Variables of interest were dichotomized (yes/no) and included the following: (1) had a regular source of care; (2) obtained less healthcare during COVID-19; (3) difficulty obtaining needed medications during COVID-19; (4) food insecurity during COVID-19; and (5) housing insecurity during COVID-19. Housing instability was defined as selfreported difficulty in paying rent, mortgage, or utility bills in the past year. Food insecurity was defined by an affirmative response to either of two questions asking if, during the COVID-19 pandemic, the respondent (1) worried that their food would run out before they had money to buy more or (2) the food that the respondent bought did not last and they did not have the money to buy more. The main independent variable of interest, education, was a categorical variable of high school or less, some college or a technical degree, and a bachelor’s degree or higher. Dichotomous variables for sex (male/female), time in the USA (< 10 years/10 years or 13 more), and English proficiency (proficient/not proficient), as well as a continuous variable for age, were used to control for differences in demographic characteristics and level of acculturation. Analysis Descriptive statistics were calculated to characterize the sample and responses to survey questions, with means and standard deviations for continuous variables and the frequency and percentages for categorical variables. Complementary log–log regression w (...truncated)