An Evaluation of the Impact of Social and Structural Determinants of Health on Forgone Care during the COVID-19 Pandemic in Baltimore, Maryland

The Coronavirus 2019 (COVID-19) pandemic led to widespread disruptions in healthcare utilization. This included forgone care, defined as someone who perceives a need for healthcare but does not receive it. These disruptions exacerbated the morbidity and mortality associated with the pandemic and disproportionately impacted those who experience inequities across the social and structural determinants of health (SSDoH). Existing literature on the impacts of the pandemic on healthcare utilization predominately describe outpatient and hospital trends. However, very few studies have captured patient-reported forgone care. The purpose of this dissertation was to investigate the impacts of the COVID-19 pandemic on healthcare access and utilization by specifically looking at forgone chronic and preventive care, emergent care, and elective and dental procedures among adults living in Baltimore, MD. Cross-sectional survey data were abstracted from two parent studies that used different, yet complimentary sampling strategies that increased representation of minoritized and under-resourced populations. The resulting combined analytic sample provided a platform to explore forgone care within one urban city that has historically suffered from systemic and structural racism, leading to widespread disparities across the SSDoH. Several cross-cutting themes emerged as important considerations in this exploration of forgone care during the COVID-19 pandemic. First, individuals experiencing housing instability had higher rates and odds of forgone care when comparing those who reported not experiencing housing instability. Second, under-resourced and marginalized individuals who require frequent engagement with the health system suffered higher rates and odds of forgone care. Third, the correlates of forgone care are likely indicative of existing health disparities. Finally, community-level determinants of health were found not to account for forgone care, above and beyond individual-level factors. Understanding the overall rate of forgone care during the COVID-19 pandemic and its intersections with the SSDoH provides a more comprehensive view of the health impacts of the pandemic. It can also inform the development of models of care that can help dismantle systems that perpetuate inequities across the SSDoH and that can be leveraged during future public health emergencies to maintain individual and community health