Area-level social determinants of health associated with COVID-19 mortality, study shows
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Social determinants of health, including lower socioeconomic status and a higher proportion of racially minoritized groups, correlated with higher likelihood of COVID-19-related death, according to a recent study in Clinical Infectious Diseases.
“Social determinants of health (SDOH) such as income, education, and race/ethnicity play an important role in COVID-19 outcomes. These factors can impact COVID-19-related death via a combination of the following pathways: likelihood of infection, likelihood of diagnosis once infected, and likelihood of COVID-19-related death once diagnosed,” Linwei Wang, MSc, epidemiologist at the St. Michael Hospital MAP Centre for Urban Health Solutions, told Healio. “Understanding mechanisms under which SDOH influence COVID-19-related death can help inform pandemic responses to address prevention gaps associated with SDOH.”
Using data from 11.8 million adults living in Ontario, Canada, between March 1, 2020, and March 2, 2021, Wang and colleagues assessed patterns in COVID-19-related mortality by a set of area-level SDOH factors that included socioeconomic status, ethnic diversity and housing conditions.
According to the study, the researchers used these data to determine whether patterns by SDOH can be explained by individuals’ demographic and clinical factors. They then compared these patterns by area-level SDOH in COVID-19-related mortality vs. those in non-COVID-19 mortality to understand whether the same patterns of inequities drive both COVID-19 and non-COVID-19-related death.
Of 11,810,255 individuals assessed, the researchers found 3,880 (0.03%) COVID-19-related deaths and 88,107 (0.75%) non-COVID-19 deaths.
Overall, they found that areas characterized by lower socioeconomic status — including lower median household income (HR = 1.3; 95% CI, 1.04-1.62), lower proportion with diploma or higher educational attainment (HR = 1.27; 95% CI, 1.07-1.52) and higher proportion of essential workers (HR = 1.28; 95% CI, 1.05-1.57) — higher proportion of racially minoritized groups (HR = 1.42; 95% CI, 1.08-1.87), more apartment buildings (HR = 1.25; 95% CI 1.07-1.46) and large vs. medium household size (HR = 1.3; 95% CI, 1.12-1.5) experienced higher COVID-19-related mortality, even after accounting for individual patient demographics, clinical factors and other area-level SDOH.
Wang said that these data support that the majority of social and structural inequalities in COVID-19-related mortality “stem from proximal exposures and reach of, and access to, prevention interventions.”
Wang added, however, that the negative relationship between income and COVID-19-related death after diagnosis may also reflect delayed diagnosis or access to and quality of clinical care for persons living in lower income areas.
“Moving forward, the goal of pandemic responses should include improving overall population health by addressing disproportionate acquisition and transmission risks and inequitable coverage of prevention interventions associated with SDOH,” Wang said. “Tailored strategies include but are not limited to paid sick leave and improved workplace health and safety protocols and outbreak management; and community-led and community-tailored outreach for testing, effective isolation and quarantine and vaccine programs.”
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