Cultural-clinical psychology has emerged over the past decade at the intersection of cultural psychology and clinical psychology, applying a cultural lens to psychopathology and its treatment (Ryder et al., 2011; Chentsova-Dutton and Ryder, 2019). In keeping with the interdisciplinary spirit of cultural psychology, cultural-clinical psychology interfaces with a number of adjacent disciplines—including several health-related disciplines that are less well-known to cultural psychologists, such as cultural psychiatry or the social sciences of medicine. Although COVID-19 is a viral infection, there are certain parallels that warrant a closer look at this perspective. In particular, the social transmission of infectious diseases means that their spread, and hence their impact on a population, is driven in part by social behaviors which, in turn, are shaped by patterns of culturally shared beliefs in that population. This perspective has parallels in social psychological approaches that have proven useful in public health, such as the theory of planned behavior, in which personal attitudes, perceived social norms, and sense of control combine to predict health-relevant behavioral intentions (e.g., Godin and Kok, 1996; Montaño and Kasprzyk, 2015).

Cultural-clinical psychologists have adapted a tripartite understanding of disorder from the social sciences of medicine, one that maps closely onto the distinction between culture, mind, and brain. In this view, there is an important distinction between disease and illness, where the disease is the biological dysfunction and the illness is the sufferer's subjective experience of that disorder (Boorse, 1975; Eisenberg, 1977). A third term, sickness, is then used to talk about the social context in which this experience takes place (Twaddle, 1973). Even when the researcher has chosen to narrow in on a particular aspect of a disorder—for example, how the novel coronavirus interacts with lung tissue (disease), or the subjective experience of determining whether one's breathing problems are sufficient to warrant a hospital visit (illness), or local beliefs that stigmatize the recovering patient as having been careless or unclean (sickness)—the larger goal ought to be incorporation of these findings into an integrated scientific narrative.

Attending to psychological and sociocultural aspects in ways that emphasize how they interrelate with each other and with biology opens possibilities for thinking about the cultural psychology of viral diseases. In the study of culture and mental health, the idea of looping effects has helped to clarify how beliefs can interact with physiological processes to yield strikingly different symptom presentations in different cultural contexts (Kirmayer and Sartorius, 2007; Ryder and Chentsova-Dutton, 2015). Hacking (1995) originally proposed this idea to help explain how the definitions of human-made categories inevitably shift over time as a result of the feedback loops that emerge when people learn about, discuss, debate, contest, and otherwise respond to the categories themselves. Cultural psychiatrists and cultural-clinical psychologists have since pushed this concept to show how similar looping patterns can yield different categories of disorder in different cultural contexts.

Consider Clark's (1986) model of a panic attack. A person detects a sensation such as chest pain or accelerated heart rate. As they hold a belief that such experiences might signal heart trouble, they grow concerned and focus more on these sensations. The mounting anxiety is accompanied by arousal of the autonomic nervous system, which generates a number of additional sensations—including chest pain and accelerated heart rate. However, people can hold very different beliefs about what different sensations might signal. In Cambodia, for example, local beliefs about the body lead some people to become alarmed by neck stiffness or flushing, sensations that can also be exacerbated by autonomic arousal (Hinton et al., 2001). The shared biology of the autonomic nervous system combines with culturally-shaped beliefs to produce very different symptom presentations, albeit presentations with a common core (Ryder and Chentsova-Dutton, 2015). In other words, different symptomatologies and diagnostic categories emerge in different cultural contexts because of universal looping processes.

Looping effects have not yet been extensively explored for infectious diseases from a psychological perspective, although similar patterns have been observed by medical anthropologists (e.g., Alenichev, 2021). People's beliefs do not act directly on the virus itself and are not so clearly implicated in the core symptoms of the infection. Yet individually- and especially collectively-held beliefs can change important features of a socially transmitted disease, such as infection rate. Indeed, the virus itself can be changed by these processes insofar as certain practices increase spread, providing more opportunities for random genetic mutations. More predictable are the effects of particular beliefs about risk, spread, impact, and protective measures, set against the backdrop of more general beliefs about how to balance health and the economy, whether or not to trust political or medical authorities, ingrained customs such as mask-wearing when feeling ill or greeting people with a handshake, and so on.

Here, looping effects can be examined at the level of individual people: for example, if individualistic values in a given cultural context are associated with higher perceived danger and lower trust in authority, that could increase fear—and if increased fear leads to more conspiratorial thinking and reduced willingness to take protective measures, infection rates could worsen, leading to more fear, perhaps even less trust of the authorities reporting those rates, and so on. These looping effects can also be examined within social networks, and that might be the most important level for a socially-transmitted disease. A single person with a given belief will not make much difference to the spread of infectious disease, but widespread consensus around certain beliefs could do so. Often, in such cases, culturally-shaped values and beliefs are fundamentally rooted in political and socioeconomic conditions. For example, discrimination against devalued groups combined with stigma that includes beliefs about the disease-proneness of those groups could lead to worse health services in certain neighborhoods and less trust in health authorities. Those effects could lead to higher rates and greater symptom severity in devalued groups, which in turn would reinforce the “disease-prone” stereotypes. This latter example fits with work in population and public health on syndemics, in which the impact of a disease intersects with the impact of social disadvantage to create very different illness experiences (Singer et al., 2017).

So far, we have discussed “beliefs” in general terms. In cultural-clinical psychology, however, beliefs can be understood in a systematic way, as aspects of cultural models, clusters of consensually-understood assumptions with associated behaviors in the form of specific cultural scripts. These ideas are derived from work in cognitive science: consider the classic example of the restaurant script, in which communities hold shared assumptions about the sequence one generally follows when booking a table, checking one's coat, being seated, reading the menu, and so on (Schank and Abelson, 1977). Cultural scripts change over time and mutually constitute individuals' relations with their groups, their environment, and their bodies. In the health domain, general cultural models for normalcy and deviancy can be invoked to organize the beliefs one has about optimal, normal, suboptimal, and pathological functioning (Chentsova-Dutton and Ryder, 2020). Although this approach has to date been applied mainly to mental disorders, it can be extended to physical health and illness. Cultural models for health and illness, along with scripts for specific disorders (such as COVID-19), establish “thresholds of concern” that help people make decisions. For example: what sensations should I monitor? What signals that I might be ill? What would the recovery process look like? In the case of an emerging condition such as COVID-19, these scripts build on previous understandings and experiences of infectious diseases, but can also shift rapidly as more is learned.

Cultural values reflect widely shared priorities that can influence, for instance, specific beliefs about illness, conformity, and how to balance health and economic concerns. There is a considerable amount of research on this topic, focusing especially on individualism-collectivism. Recent years have also seen growing interest in tightness-looseness. Both dichotomies have been studied in relation to COVID-19.

Individualistic cultural contexts, as established in the cultural psychology literature, tend to prioritize an independent construal of self, as well as freedom and fulfillment of personal goals; conversely, in collectivistic societies, group ties and responsibilities are perceived more important (Triandis et al., 1986; Markus and Kitayama, 1991). In the context of the pandemic, in individualistic societies, governments might be more hesitant to take compulsory measures in response to COVID-19, such as lockdowns and mandatory mask-wearing, resulting in delayed responses to public health emergencies. Moreover, people in those societies might be less accustomed to following public health recommendations for common infectious diseases (e.g., wearing a mask whenever one has cold or flu symptoms).

Indeed, between March and May of 2020, the relative number of COVID-19 cases and deaths in more individualistic countries were considerably higher (Jiang et al., 2020). In a more recent study comparing data from 98 countries up to July of 2020, collectivism was associated with fewer cases and fewer deaths per million people cross-culturally, although GDP per capita played a stronger role in predicting those variables (Webster et al., 2021), highlighting the importance of the interplay between cultural and socioeconomic considerations in research and public policies. More recently collected data demonstrated that, by August of 2020, the fatality rate was still higher in more individualistic countries (Melton, 2020, preprint). Curiously, in a cross-state analysis in the US (a country with a highly individualistic orientation that was seriously affected by COVID-19), Webster et al. (2021) found that collectivistic states had higher case and death rates, but the racial-ethnic composition of the states were stronger predictors of both. Thus, systemic racial health disparities might play a stronger role in predicting the impact of COVID-19 than collectivism.

Individualism and collectivism have been linked with how people conceptualize the ontological reality of health and illness. In Western-educated and individualist populations, medical models are based on analytic thinking (Choi et al., 2007), which is characterized by examining each component of a system as discrete and independent from the whole, as well as zero-sum reasoning (e.g., “if X exists, then Y cannot”) (Nisbett et al., 2001). Medical approaches based on this model tend to frame illness as an intrusion within an inherently independent body, and home in on a specific set of symptoms or a specific disorder (Good, 1993; Jayasundar, 2010). Conversely, holistic thinking, which is found in populations with greater collectivism and without Western-based education, is characterized by examining the relationship between each element in a system to form the whole, where multiple pieces can simultaneously exist while moving in different directions or serving different functions (Nisbett et al., 2001). Holistic medical systems, such as Ayurveda (Jayasundar, 2010), Traditional Chinese Medicine (Koo and Choi, 2016), and multiple Indigenous medical systems (Dahlberg and Trygger, 2009; Auger et al., 2016) account for illness as an imbalance in functioning within the individual's whole physical and psychological system, and within the community and broader environmental context (Dahlberg and Trygger, 2009; Jayasundar, 2010; Koo and Choi, 2016). As a result, the frame that individuals use to understand and address COVID-19 shifts according to the cultural reasoning style and associated medical model. To illustrate, while also supporting vaccinations, Ayurvedic doctors and researchers have examined COVID-19 in terms of how the disease functions within the larger weakened system, proposing that treatment should focus on ensuring that global bodily functions are supported while strengthening immune and respiratory systems to prevent infection, and to ease the course of the disease should one contract the virus (Niraj and Varsha, 2020; Rajkumar, 2020; Rastogi et al., 2020).

Finally, tightness-looseness, a country-level measure of the strictness of societal rules, may be related to the formal and informal enforcement of, and consequent adherence to, restrictive measures such as social distancing and stay-at-home orders. Tighter societies might, for instance, enforce lockdown measures with less tolerance of non-adherence, while looser societies might adopt more lax regulations, contributing to viral spread. Cao et al. (2020) examined correlations between the impact of the pandemic in 54 different countries and the interplay between individualism-collectivism and three different indexes of tightness-looseness. The increase of reported cases and deaths per million inhabitants, as well as the case fatality rate, were all positively associated with greater individualism and looseness. Moreover, countries that experienced the most severe increases of deaths per million in the population between the 16th and the 45th days of the implementation of lockdowns had a combination of higher individualism and higher looseness (Cao et al., 2020).

The degree to which interpersonal relationships are fixed or voluntary in a given group or society has been defined as relational mobility (Thomson et al., 2018). Higher relational mobility entails greater choice among numerous new connections in frequently-changing social circles, and is usually associated with geographical mobility, whereas lower relational mobility involves fewer options for new connections with others, and instead revolves around maintaining existing connections in smaller, more stable social circles. On a historical scale, cultural variation in relational mobility is rooted in histories of subsistence farming structures, with higher relational mobility associated with more independent and mobile subsistence styles (Thomson et al., 2018).

In the context of infectious diseases, relational mobility might be particularly relevant to the likelihood of potential carriers of the novel coronavirus traveling across different geographical areas, increasing the probability of new cases emerging in different regions. Indeed, by using country-level scores for relational mobility (Thomson et al., 2018) and publicly available pandemic data from Johns Hopkins University (Center for Systems Science Engineering (CSSE) at Johns Hopkins University, 2020), Salvador et al. (2020) analyzed the correlations between relational mobility and the number of COVID-19 cases and deaths in the first 30 days of the outbreak across 39 different countries. The growth of both the number of cases and the number of deaths was significantly faster in countries with higher relational mobility. This difference suggests that sociocultural ecologies in which individuals are less reserved and more likely to make acquaintances outside of their primary social groups are more vulnerable to the spread of COVID-19.

Intersectionalities between cultural and other socio-demographic categories, such as gender, age, and social class, also affect contagion rates of infectious diseases, as well as the number of reported cases across different countries. In the case of dengue in Southeast Asia, for instance, Anker and Arima (2011) observed more reported cases in males older than 15 years of age compared to other gender-by-age groups. This difference might be linked to local cultural scripts that favor the exposure of men to mosquitoes during daytime hours. Stratifying data across different ages and genders provides us with insights on how cultural characteristics contribute to how likely women, men and families are to be exposed to the infectious diseases in different societies, as well as how likely affected individuals are to look for medical care when experiencing symptoms.

Intersections of gender with different cultural practices also produced different outcomes not only for COVID-19 risks but also to how sex and gender have shaped distress during the pandemic. Across the globe, more men than women have been dying of the disease; whereas some researchers argue this finding is more related to behavioral factors than to biological differences (Galasso et al., 2020; Pujol, 2020), others argue that women have a better immune response to the virus (Takahashi et al., 2020; Zeng et al., 2020). In the behavioral sphere, gender differences might be related to local cultural and religious norms. Muurlink and Taylor-Robinson (2020) argue that the adoption of niqabs or burkas by women in more conservative Muslim cultures might work as a protective factor against contamination through face-touching. Conversely, cultural preferences for facial hair in men might increase the risk of exposure to the virus, by compromising the seal of face coverings (Muurlink and Taylor-Robinson, 2020). Furthermore, gender segregation in some communities (e.g., Amish, Orthodox Jews) along with differing levels of involvement in different spheres of society (e.g., representation gaps in specific occupations) might also interfere with the likelihood of exposure and contamination of COVID-19 (Muurlink and Taylor-Robinson, 2020). In Panama, Peru and Colombia, policies have attempted to promote social distancing by restricting the access to services upon a gender-based rotation. This has disproportionally impacted transgender populations (Perez-Brumer and Silva-Santisteban, 2020). Overall, sexual and gender minorities have experienced more coronavirus-related physical symptoms and more depression and anxiety symptoms since the emergence of the pandemic (Moore et al., 2021).

In the mental health domain, age has yielded unexpected research findings. Older adults are known to be physically more vulnerable to COVID-19 (Crimmins, 2020; Dowd et al., 2020), which led to more social isolation in order to protect this population from infection, and sparked ageism and segregation of older adults (Lichtenstein, 2021). While the isolation experience of elderly populations was expected to produce worse mental health outcomes (Vahia et al., 2020), in several countries, the levels of stress reported by younger people were consistently higher (Kowal et al., 2020). Nonetheless, differences in mental health outcomes among seniors have been observed cross-culturally. Across the 62 nations studied by Kim and Jung (2020), older adults were more distressed in countries whose state capacity was more fragile, as measured by the Fragile State Index compiled by The Fund for Peace (2020). This index is based on the assessment of elements such as extensive corruption, involuntary dislocation of the population, economic decline, institutionalized discrimination, and group-based inequality.

Finally, different social classes, historically linked to racial and ethnocultural power dynamics as discussed in upcoming sections, are related to the likelihood of death by COVID-19 due to comorbidities (e.g., heart and liver diseases) (Marmot and Allen, 2020), and presented different chronological patterns of transmission of the virus. In countries like Germany, England, the US (Berkessel et al., 2021, preprint) and Brazil (Magenta, 2020), although richer regions and social classes were affected primarily at the beginning of the pandemic, the virus spread more quickly among poorer populations in later phases and presented higher fatality rates. These findings might be connected to access to healthcare and viability of social distancing, topics to which we will return.

In some countries, the pandemic has been heavily politicized. Identification with political parties or ideologies was, at least to some extent, artificially associated with specific attitudes toward the pandemic, in turn influencing cultural scripts bound to political orientation and compliance with public health recommendations.

In Brazil, official government propaganda encouraged Brazilians to continue their routines normally. President Bolsonaro openly promoted conspiracy theories, providing misleading information about symptoms, treatments, and the severity of the pandemic in the country. These measures motivated the sector of society politically aligned with Bolsonaro, including physicians, to ignore global public health recommendations, and to acquire and utilize hydroxychloroquine, a substance used to treat malaria and other conditions with no proven efficacy against COVID-19. This resulted in several deaths and the shortage of hydroxychloroquine, depriving patients with other diseases of access to needed medication (Biller et al., 2020; Ponce, 2020; Ricard and Medeiros, 2020).

In the US, where the political system has been historically structured on a two-party basis, responses to COVID-19 have been extensively associated with partisanship. Studies using geolocation technology and debit card transaction data demonstrated that residents of Democratic counties (as determined by the 2016 presidential election) were more likely to adhere to stay-at-home orders and switch to online shopping (Painter and Qiu, 2020). Republican counties exhibited comparatively less mask use (Milosh et al., 2020), less physical distancing, and higher fatality rates (Gollwitzer et al., 2020). Behaviors and beliefs about COVID-19 are also demonstrably influenced by media consumption. Democrats frequently watch channels such as MSNBC and CNN, which recommended precautionary measures against the transmission of the disease during 2020; as a result, viewers were more likely to perceive risks associated with COVID-19, to adopt preventive behaviors and to be concerned about early lifting of government restrictions. Conversely, Republicans more frequently watch channels like Fox News, which openly and repeatedly downplayed the severity of the pandemic during 2020; viewers therefore perceived less risk associated with the pandemic and adopt fewer precautionary measures (Bruine de Bruin et al., 2020). Greater consumption of Fox News was also linked to higher reported infection and fatality growth rates (Gollwitzer et al., 2020). The politicization of the beliefs about the pandemic has also been observed in less polarized countries, such as Canada, where “anti-lockdown” parties were organized with allegedly political motivations (Keyes and Caruso-Moro, 2020).

The interaction between political polarization and attitudes toward COVID-19 can also be understood in light of Hacking's looping effects, if we consider political groups as artificially-created categories of identities that enable intentional ways of acting (see also Vesterinen, 2020). When local political categories are tied to specific beliefs and attitudes toward COVID-19, they induce self-identified members of such categories to behave in accordance with their groups.

Disease-related fears and the stigmatization of ethnocultural minorities have a long relationship. In the US, discrimination against minorities and marginalized groups has been observed across different historical epidemics: in 1892, the outbreaks of typhus fever and cholera in New York were attributed to Russian Jewish immigrants; in 1900, the bubonic plague in San Francisco was associated with Chinatown; in 1993, the hantavirus outbreak in the Four Corners area was attributed to Native Americans, and even labeled the “Navajo disease” by media at the time (Person et al., 2004). More recently, during the outbreak of severe acute respiratory syndrome (SARS) in 2012–2013, Asian-American communities, regardless of their country of origin, also experienced discrimination, and were expected to quarantine as a group, regardless of whether or not they were exposed to contaminated individuals (Person et al., 2004). Stigmatization has also occurred in non-immigrant populations in previous pandemics, such as the residents of the complex that was most affected by SARS in Hong Kong (Lee et al., 2005).

Humans have evolved with an aversion to disease, and to perceived vectors of disease. This set of protective behaviors motivated by the aversion to potential vectors has been called the behavioral immune system by Schaller et al. (2003) and has since been referred to as the parasite-stress model. While these mechanisms may have served to reduce risk of infectious disease in ancestral social environments, they have historically come at the expense of intergroup relations (Schaller et al., 2003). Because infectious disease is not always apparent, and may indeed be asymptomatic in certain carriers, the behavioral immune system works by encouraging people to avoid unfamiliar outgroup members. Managing disease threat does not happen solely by avoiding or attending to the specific individuals who are affected by an illness, but by generalizing the perceived illness threat to the entire group, including those who are not afflicted, thereby attributing stereotypes of dirtiness and disease prevalence to these groups. The consequences include prejudiced attitudes rooted in feelings of fear and disgust toward these groups, inevitably engendering discrimination, such as exclusionary policies and violent attacks (Schaller and Neuberg, 2012). Indeed, priming participants to perceive greater disease prevalence increased prejudice toward both Black and white Americans (O'Shea et al., 2020), and experimentally manipulated perceptions of immunization among immigrants has the potential to reduce prejudice toward immigrants (Huang et al., 2011).

While the occurrence of a disease within an outgroup can lead to generalized prejudice toward that outgroup, disease does not always precede discrimination. Often, due to established structures of racism, outgroups are dehumanized in such a way that they are represented as carriers of pestilence and disease (e.g., Lawson, 2009). This framing has frequently been used against the same marginalized groups, including refugees, immigrants, racialized and ethnocultural minorities, and religious minorities (e.g., Steuter and Wills, 2009; Haslam and Loughnan, 2012; Esses et al., 2013; Utych, 2018), regardless of whether or not there is an actual disease in play. Furthermore, dehumanization is embedded in larger-scale, institutional, discrimination. Racism comprises many layers; at the systemic-level, racism is the structural disadvantage of racialized, religious and ethnocultural minorities (Krieger, 1999; Paradies, 2006; Feagin and Bennefield, 2014; Krieger et al., 2017). As a result of being socialized in these systemically racist structures, people develop racial biases, with stereotyped perceptions, prejudiced attitudes and feelings, and discriminatory behavior (Fiske, 1998). These manifestations can be obvious or subtle, as well intentional and unintentional (Sue et al., 2007). In the context of disease, a feedback loop can be observed where discriminatory policies, such as racial housing segregation, against minorities who have been dehumanized and stereotyped as dirty and prone to disease lead to greater vulnerability and spread of infectious diseases (Acevedo-Garcia, 2000). Often, the behavioral immune system, systemic racism, and dehumanization processes operate hand in hand (Hodson et al., 2014).

The COVID-19 pandemic has engendered, exposed, and exacerbated discrimination against minorities in several key ways: (1) prejudice and aggression toward minority groups associated with the disease (Gover et al., 2020); (2) disproportionate detrimental impacts of COVID in minority communities who are subject to preexisting discriminatory health inequities (Krieger et al., 2020); (3) increased vulnerability of minorities that are overrepresented in frontline and essential services (Saint-Girons et al., 2020), as well as communities in isolation, incarceration, displacement and occupied territories (Alemi et al., 2020; Santos et al., 2020); and (4) structural disadvantage in treatment access and vaccine distribution (Meyer, 2020; Power et al., 2020).

Anti-Asian racism rapidly increased after the onset of COVID-19 (e.g., Gover et al., 2020, Rich, 2020). The terms “Wuhan Virus” and “Chinese Virus,” have been used extensively (White, 2020) despite the World Health Organization's recommendation to not name diseases after regions or ethnic groups (World Health Organization, 2015), given that it is stigmatizing (e.g., Albader, 2020; Augustyn and Prazmo, 2020; De Costa, 2020; Su et al., 2020). COVID-19 has clearly been associated with East Asians both in their countries of origin and in the diaspora and has generalized to other groups that share similar phenotypic traits. East and Southeast Asian communities and individuals have been targeted globally with hate speech, including slurs, dehumanization, and slanderous, stereotyping comments about Chinese cuisine (Albader, 2020; Hu et al., 2020; Tahmasbi et al., 2021). Anti-Asian hate-crimes reports also spiked since the beginning of the pandemic in North America (Edara, 2020; Gover et al., 2020; Kotyk, 2020; Tessler et al., 2020; Tsai et al., 2020), Europe (Gao and Sai, 2020; Pellegrino, 2020; Velásquez et al., 2020, preprint) and Australia (Furlong and Finnie, 2020). In India, people from northeastern states with more phenotypically East Asian features have been discriminated against and attacked (Haokip, 2020). Even within East Asia, anti-Chinese prejudice was observed, specifically, in places like Hong Kong (Chung and Li, 2020) and South Korea (Albader, 2020).

In addition to East-Asians, Italians have been stigmatized in Europe after the country was severely affected by the virus (Pellegrino, 2020). Religious minorities have also been targeted as causes of the coronavirus. “Alt-right” groups in the US (Teter, 2020) and Canada (Currie, 2020) blamed Jews for the pandemic, and increased anti-Jewish discourse was observed in online spaces (Woodyatt, 2020). Increased anti-Muslim bias was reported in India with the onset of the pandemic, most notably with conspiratorial rumors blaming Indian Muslims for the spread of coronavirus (Mukherjee, 2020; Zajaczkowska, 2020). Within China, African migrant communities were blamed for the disease, and experienced an increase in anti-Black racism, such as evictions and refused services (Castillo and Amoah, 2020; Human Rights Watch, 2020).

Racism has also disproportionately impacted minority communities that were already vulnerable to health complications due to pre-existing inequities. The constant experience of systemic racism (i.e., segregation, food deserts, policing and criminalization, exclusion from employment and healthcare services) and of racism in everyday interactions (i.e., racist slurs, attacks, microaggressions, etc.) across generations inevitably harms and weakens the physical and mental health of minority group members (Krieger, 2014; Krieger et al., 2017). This health disadvantage creates disparities in the prevalence of serious chronic illnesses and greater mortality rates in racialized and ethnic minority groups (Pascoe and Smart Richman, 2009; Paradies et al., 2015). As a result of the prevalence of pre-existing health conditions in disadvantaged populations, members of such groups were more vulnerable to developing severe or fatal complications from COVID-19 (Krieger et al., 2020).

Black populations were among the most affected communities in terms of infection, hospitalization, severity of cases and mortality, notably in the US, Canada, and Britain (Egede and Walker, 2020; Gaynor and Wilson, 2020; Jain et al., 2020; Krieger et al., 2020; Public Health England, 2020). Other ethnic minority groups such as Latin-Americans (Krieger et al., 2020; Yearby and Mohapatra, 2020), South Asians and East Asians (Public Health England, 2020) have also been disproportionately impacted. In India, minority castes and tribes have been among the most vulnerable (Acharya and Porwal, 2020). Indigenous peoples in North America, Brazil, Australia and New Zealand have a higher risk of exposure, and have been diagnosed with more severe and fatal COVID-19 cases as a result of several factors, including health inequities that predate the pandemic, higher levels of frontline exposure, poverty, homelessness, displacement, overcrowding, and food and water insecurity (Arriagada et al., 2020; Furlong and Finnie, 2020; McLeod et al., 2020; Polidoro et al., 2020; Power et al., 2020; Saint-Girons et al., 2020; Yashadhana et al., 2020).

Often, these health inequities and treatment barriers exist because one's marginalized racialized or ethnic minority group is also subject to class marginalization, making access and affordability of resources and treatment challenging (e.g., Acharya and Porwal, 2020; Egede and Walker, 2020; Saint-Girons et al., 2020). Another way that class marginalization intersects with racism is through economic and employment disparities, where racialized and ethnic minorities face exclusion from higher status and higher income professions and are therefore segregated and relegated to lower-income and lower-status employment (Darity Jr, 2003; Sørensen, 2004; Armstrong et al., 2008). Minorities are therefore more likely to be exposed to COVID-19 because they are overrepresented in essential and frontline jobs and services, in prison systems, as well as in areas experiencing conflict and war, occupation and displacement. Racialized and ethnic minorities populate frontline and essential services, including healthcare and social services, agriculture, and food industries; workers in these sectors have been in more contact with patients and potentially infected peoples through their labor (Krieger, 2020). Migrant workers, indigenous peoples, and ethnic minorities around the world, including in India (Kesar et al., 2020; Sengupta and Jha, 2020), North America (Evans, 2020; Krieger, 2020; Saint-Girons et al., 2020), and Brazil (Teixeira, 2020) have been working in low-income and high-risk jobs, such as domestic labor, agriculture, transportation, and healthcare support. Another exposure risk for Indigenous peoples in North America has been the presence of others entering indigenous territory during the pandemic. This includes white, upper-middle class tourists (Leonard, 2020), as well as workers in resource extraction, since governments included mining industries in the category of essential services, prioritizing industry profit over Indigenous health (Bernauer and Slowey, 2020).

Ethnocultural minorities were already overrepresented in prisons due to structural disadvantage, including disproportionately elevated policing, criminal sentencing and incarceration of minority populations, and of Black, Indigenous and Latin-American communities in particular (Maynard, 2017; Mesic et al., 2018; Chartrand, 2019; Jahn et al., 2020). Incarcerated people are another marginalized segment of the population that experiences health inequities within a social institution that already poses higher risks of illness and infectious diseases, even those that are treatable (e.g., tuberculosis). Racialized and ethnocultural minorities in the prison system are among those with the highest rates of COVID-19 infection due to negligent safety and sanitation practices, overcrowding and scarce resources (Akiyama et al., 2020; di Giacomo et al., 2020; Gulati et al., 2020; Hagan et al., 2020; Lemasters et al., 2020; Santos et al., 2020). This has been the case in the US (Macmadu et al., 2020), the country with the world's largest incarcerated population (Akiyama et al., 2020), in Australia (Stewart et al., 2020), Brazil (Santos et al., 2020), and in countries with migrant detention prisons such as the US and Canada (Treisman, 2020).

Minority populations in displacement, conflict zones and occupied territories have also been at increased risk for contracting COVID-19. Refugees in camps are more vulnerable to the spread of COVID-19 due to lacking sanitation measures and basic infrastructure, greater population density, little to no secure housing, and greater health vulnerabilities due to injury and trauma (Alemi et al., 2020). This has been the case for Rohingyan refugees in Bangladesh (Islam and Yunus, 2020), Syrian refugees in different parts of West Asia and Europe (Kassem and Jaafar, 2020; Moawad and Andres, 2020), and refugees from South and Central America and the Caribbean (Brito, 2020). Refugees are also at risk of incarceration, which then places them at greater risk of exposure through the prison systems, or of deportation, which increases the risk of COVID-19 exposure and transmission across borders (Brito, 2020). The Nagorno-Karabakh War has led to additional losses due to COVID-19 (Kazaryan et al., 2020). Bombardments, destruction of houses, schools and hospitals, and the resulting displacement of peoples contributed to very high rates of COVID-19 in Armenia. Palestinians have also been more vulnerable to COVID-19 due to already limited resources, medical supplies, and infrastructure (Hammoudeh et al., 2020); in addition, Palestinians who normally worked in Israel have lost their livelihood due to the lockdown (Newman, 2020).

Discrimination is experienced by minorities through the lack of accessibility to treatment, as a result of segregation and exclusionary infrastructure. Marginalized minorities have limited access to healthcare, including medical care for COVID-19 (Evans, 2020; Polidoro et al., 2020; Yashadhana et al., 2020). In countries without universal healthcare, like the US, economically disenfranchised minority groups face economic barriers to receiving treatment (Spronk, 2020). Culturally-appropriate and adapted services are lacking, and can prevent minorities from seeking and benefiting from these services (Saint-Girons et al., 2020). Some Indigenous nations in the US are not even legally eligible to receive healthcare and are excluded from life-saving treatment as a result (Power et al., 2020). Other vulnerable populations such as refugees and undocumented peoples have difficult access to health services overall, which has also translated to difficulties receiving treatment for COVID-19 (Moawad and Andres, 2020). In addition, many healthcare services were already known to treat minority groups unfairly and cruelly (Goodman et al., 2017; Shingler, 2020). These bigger systemic disadvantages have contributed to minorities' historically justifiable distrust in a healthcare system that was designed to best serve dominant groups (Farquharson and Thornton, 2020; Iacobucci, 2020; Warren et al., 2020; Yearby and Mohapatra, 2020).

The disparities in access to healthcare and treatment are related to how the COVID-19 vaccines end up being distributed. The WHO has sponsored a COVID-19 Vaccine Global Access Facility (COVAX) to ensure equitable distribution of the vaccine globally (World Health Organization, 2020). However, many richer countries (e.g., the US, Canada and Britain) have already negotiated private deals with pharmaceutical companies for early access to a number of vaccines outside of the WHO (Meyer, 2020); whether these vaccines will be distributed equitably between countries, and within a given nation to minorities who have already been disadvantaged before and throughout the pandemic, is an ongoing concern.

Personality traits, in particular those of the “Big Five,” have been studied in the context of the pandemic, as an attempt to associate individual tendencies with behavioral responses to COVID-19. Across different countries, higher conscientiousness was linked to taking more precautionary measures and preparedness (e.g., stocking food), stronger feelings of insecurity in public spaces, and greater likelihood of keeping up with the news (Aschwanden et al., 2020; Asselmann et al., 2020; Carvalho et al., 2020). Openness-to-experience was linked to less intense feelings of insecurity in public, and extraversion was associated with less social distancing and sheltering in place, as well as shorter estimates for the duration of the pandemic (Aschwanden et al., 2020; Asselmann et al., 2020; Carvalho et al., 2020; Götz et al., 2020). Greater agreeableness was associated with stronger compliance with governmental recommendations, more precautionary measures, news attentiveness, and higher levels of trust in physicians (Asselmann et al., 2020; Götz et al., 2020; Qian and Yahara, 2020; Zajenkowski et al., 2020). Cross-cultural similarities suggest, to the extent that personality models can be mapped across different cultures, that these four traits are more homogeneously associated with similar behavioral outcomes in the countries considered by these studies. Nonetheless, in the case of neuroticism, cultural influences might have mediated the relation between this trait and behavioral responses in different countries. High neuroticism was correlated with fewer precautions in the United States (Aschwanden et al., 2020) and in Germany (Asselmann et al., 2020), but not in Japan (Qian and Yahara, 2020). However, to our knowledge, no study has yet explored potential explanations for the particular interplay between this trait and cultural context.

Personality traits associated with the dark triad (narcissism, Machiavellianism and psychopathy) have also been explored. Modersitzki et al. (2020) and Zajenkowski et al. (2020) found correlations between dark triad traits with the underestimation of the risks imposed by the pandemic. Additionally, collective narcissism may be particularly relevant to the emergence of nationalism under pandemic conditions (Bieber, 2020; Su and Shen, 2020; Woods et al., 2020). Collective narcissism involves a strong identification with one's own perceived group, accompanied by feelings of collective entitlement, unrealistic beliefs about the group, and outgroup hostility as a reaction to perceived threat (Zemojtel-Piotrowska et al., 2021). This trait has been classified into two types: agentic (unrealistic beliefs about the group's competence or dominance) and communal (unrealistic beliefs about the group's helpfulness or tolerance) (Nowak et al., 2020). Although collective narcissism is ultimately an individual trait, it is ingrained within and reinforced by broader political polarization and nationalist ideology. In Poland, Zemojtel-Piotrowska et al. (2021) observed that the agentic (but not the communal) form of collective narcissism was related to more perceived COVID-19 threats, and that such perceived threat mediated the relationship between collective narcissism and positive attitudes toward the European Union, as well as negative attitudes toward China. Both agentic and communal collective narcissism were negatively correlated with preventive behaviors such as washing hands, disinfecting objects, and staying home (Nowak et al., 2020). In the US and the UK, collective narcissism was associated with dissemination of conspiracy theories related to COVID-19 (Sternisko et al., 2020, preprint), which we will explore in more detail below.

Individual attitudes and beliefs about the risks, prevention, and even the existence of COVID-19, are influenced by cultural factors, and motivate behaviors that affect the risks of contagion. Pre-symptomatic individuals contaminated with the novel coronavirus can spread it for up to four days before developing any symptoms (Christakis, 2020), and sudden spikes in cases are often attributed to “super-spreaders,” who are (knowingly or unknowingly) contaminated with the virus and participate in public gatherings, infecting disproportionally more people (Bruns et al., 2020). These gatherings may include parties, sport events, religious ceremonies, weddings, and funerals (Aherfi et al., 2020; Dave et al., 2020; Shanahan, 2020; Yasir, 2020). People who hold beliefs such as the non-existence of COVID-19, or who are skeptical about the dangers that the pandemic poses to society, are more prone to becoming a super-spreader.

Compliance with government recommendations has also been linked to individual beliefs about the effectiveness of the precautionary measures to protect oneself and the community, the dangers to one's own health (Clark et al., 2020), and the expectations about how official restrictions will develop (Bodas and Peleg, 2020; Briscese et al., 2020). Governments that were perceived as organized, consistent, and knowledgeable were more trusted during the pandemic (Han et al., 2021), but trust in the government was shown to be less relevant than beliefs about the efficacy of precautionary measures (Wong and Jensen, 2020), and more relevant to the tendency to underestimate the risks of the pandemic (Clark et al., 2020). In Italy, one of the first countries to adopt stay-at-home policies, residents reported being more likely to decrease self-isolation efforts if they were negatively surprised by an extension of the lockdown (Briscese et al., 2020). In Israel, 94% of individuals were willing to comply with quarantine recommendations if they were guaranteed financial support from the government for eventual lost wages, whereas only 57% expressed willingness to quarantine otherwise (Bodas and Peleg, 2020). In countries where the government denied the existence or severity of the pandemic, such as Brazil and the US (Anderson, 2020; Phillips, 2020; Reuters, 2020), and countries where the government actively promoted pseudoscience as a treatment, such as Tanzania and Madagascar (Resnick, 2020), trust in the government resulted in the decrease of efficient precautionary measures against COVID-19.

Although restricted to particular sociocultural contexts, research has linked individual differences to the likelihood of adhering to COVID-19 conspiracy theories (Biddlestone et al., 2020; Jovančević and Milićević, 2020; Uscinski et al., 2020). In some cases, distrust in authorities is historically linked to institutional abuse practiced against specific minority groups (e.g., the Tuskegee Study performed by the US government on Black patients; see Centers for Disease Control Prevention, 2021), which we will not discuss in the present review.

COVID-19 conspiracy theories typically consist of claims that the perils of the pandemic have been exaggerated by political groups, that the novel coronavirus was created in a laboratory and released as a bioweapon (Uscinski et al., 2020; van Bavel et al., 2020), or that COVID-19 vaccines will change one's DNA (Goodman and Carmichael, 2020). In Europe and North America, cellphone towers that would allegedly transmit coronavirus were damaged and destroyed (Chan et al., 2020; Valiante, 2020). In Brazil, conspiracy theories about China led 50% of Brazilians to reject the possibility of receiving the Chinese Sinovac vaccine before it was even available in the country (Amâncio, 2020; Londoño et al., 2020; Valle, 2020). In North America, COVID-19 fueled the surfacing of the far-right conspiracy theory movement QAnon, which has been causing ruptures between people and their families (Blackwell, 2020).

In a study on cultural orientation and COVID-19, Biddlestone et al. (2020) analyzed the correlations between engagement in COVID-19 conspiracy theories, intention to reduce the spread of the virus, and cultural orientation toward collectivism and individualism. The authors differentiated horizontal individualism (the view of the self as autonomous, with preference for equality) and vertical individualism (view of the self as autonomous, with acceptance of inequality) and horizontal and vertical collectivism (view of the self as part of the collective, with emphasis on equality and acceptance of inequality, respectively), following the approach of Triandis and Gelfand (1998). Vertical and horizontal types of collectivism—but neither type of individualism—were positively associated with intentions to engage in social distancing. Vertical individualism, in particular, was correlated with adherence to COVID-19 conspiracy theories (Biddlestone et al., 2020). Other research has similarly found that individualistic worldviews are associated with less perceived risks from COVID-19, besides lowering intentions to adopt preventive measures against the transmission of the virus (Dryhurst et al., 2020; Huang et al., 2020).

In the US context, psychological predispositions to reject expert information and accounts of major events, partisan and ideological motivations, and religiosity are also predictors of beliefs in COVID-19 conspiracy theories (Uscinski et al., 2020). Belief in conspiracy theories also correlated with increased levels of fear and pessimism, while optimism and higher levels of general trust correlated with more engagement in preventive behaviors (Jovančević and Milićević, 2020).

In a study performed in 26 countries, Kowal et al. (2020) concluded that people in countries and areas that were more severely affected by COVID-19 were more stressed. Additionally, higher levels of stress were reported by women, people staying with children, single people, younger people, and people with lower levels of education. However, higher levels of education seemed to correlate with higher reports of depressive symptoms and lower levels of life satisfaction at the beginning of the pandemic, particularly in the US (Wanberg et al., 2020). In different countries, health professionals, particularly nurses, have experienced increased levels of stress (Barzilay et al., 2020; Ilczak et al., 2020).

Individual differences in optimism and intolerance of uncertainty under COVID-19 have been shown to impact mental well-being as well as adaptation to the new circumstances imposed by the pandemic. Higher levels of optimism are correlated with better work routine adjustment both in professionals who are working from home (Biron et al., 2020) and in health care professionals (Zhang et al., 2020). The cultural context also plays a role in individual adjustment, notably collectivism and collective optimism (a shared optimism about a group), as these characteristics favor the sense of mutual obligation in times of crisis and effective coping strategies, like positive reappraisal (Biron et al., 2020).

Finally, intolerance of uncertainty (difficulty accepting feelings and thoughts related to uncertain scenarios) can also impact mental health. Cultural contexts differ widely in terms of how much uncertainty one is accustomed to, the amount of uncertainty believed to be tolerable, and available practices that help mitigate the adverse effects of uncertainty. The pandemic led to a worldwide increase in uncertainty, due both to fear of a hitherto unknown virus combined with the sudden changes in routines, social interactions, financial and professional security, and grieving rituals. Here, we should consider the extent to which new uncertainties and changes damage people's access to basic needs, as well as what “uncertainty” means to different populations. For instance, the political pressure to re-open commerce in different parts of the world has more impact on individuals who are not privileged enough to “move on with life as usual” (Manderson and Levine, 2020); thus, the duration of the uncertainty experienced by certain groups can be strikingly different.

Individual experiences of distress are heavily influenced by the degree to which a cultural and socioeconomic context enables, rewards, or prevents adaptation to change. In the US, workers in industries like technology were able to switch into a home-office work routine, keep high-paying jobs and move to more affordable and less crowded regions, having reported decreased levels of stress (Peyser, 2020). In contrast, people with low socioeconomic status are less likely to be able to self-isolate due to life circumstances (Templeton et al., 2020), and those with lower-income employment who were already in a riskier socioeconomic bracket were more likely to lose their jobs entirely or be forced to keep working in high-exposure conditions in order to save their livelihoods (Rollston and Galea, 2020).