ABSTRACT The COVID-19 pandemic and related mitigating measures have brought on tremendous financial hardship for vulnerable Americans, with nearly 15% unemployment at its peak and millions falling into poverty. There have been striking racial and socioeconomic disparities in these hardships, particularly for Black and Latinx families, which build on longstanding inequities in income, housing, and other social determinants of health. Recent research has demonstrated the impact of the pandemic and its resulting socioeconomic inequities on disparities in mental health and healthcare utilization. It is increasingly recognized that policies play a role in mitigating or exacerbating these disparities. For example, mandated closures lead to job and income loss, which disproportionately affect low-income and minority women. Conversely, economic support policies ensure that vulnerable families have the resources to stay healthy at home. While some studies have examined the effects of state-level COVID-19-related policies, there has been little systematic documentation of county-level policies and their effects on disadvantaged groups. The goal of this study is to leverage, expand upon, and link existing national data sets to test the hypothesis that county-level public health and social policies have affected disparities in mental health and healthcare utilization. In Aim 1, we will gather county-level COVID-19- related policy data for 2020-2021 for a nationwide sample of 250 counties, selected to ensure coverage of over half of the U.S. population as well as diversity in racial/ethnic, socioeconomic, and urban/rural composition. Policies will be drawn from online sources and grouped into 3 domains chosen due to likely impacts on mental health and utilization: (1) containment and closure, (2) economic support, and (3) public health. We will characterize geographic and temporal variation in county-level policies and make this database freely available. In Aim 2, we will examine which county-level COVID-19-related policies contributed to or ameliorated pandemic-related disparities in mental health and health behaviors, linking the policy database from Aim 1 with national health surveys that provide individual-level data on self-reported psychological distress, smoking, alcohol use, and illicit drug use. In Aim 3, we will estimate the association of county-level COVID-19-related policies with disparities in healthcare utilization for mental health problems, linking the policy database from Aim 1 with national data sets that provide individual-level data on healthcare utilization. Aims 2 and 3 exploit temporal and geographic variation in county-level policies and employ quasi-experimental methods to estimate policy effects. Conducted in close collaboration with other SBECCC investigators, the expected outcome of this research is the creation of a county-level policy database that will serve as a valuable resource for researchers and stakeholders working to understand how local policies contributed to and continue to influence pandemic- related health disparities, as well as specific evidence on policy effects on mental health outcomes. This will guide policies and interventions to reduce mental health burden especially for vulnerable communities.

PROJECT NARRATIVE County governments in the U.S. passed policies during the COVID-19 pandemic that led to job loss, as well as policies that provided economic support. The goal of this research is to catalog the timing and distribution of county COVID-related policies across 250 counties nationwide. We will also assess whether these policies affected mental health and healthcare utilization among vulnerable groups like racial/ethnic minorities and low-income people.