Socio-economic status and COVID-19-related cases and fatalities

A scoping review on the operationalization of intersectional health research methods in studies related to the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic began in early 2020 and became a global health crisis with devastating impacts. This scoping review maps the key findings of research about the pandemic that has operationalized intersectional research methods around the world. It also tracks how these studies have engaged with methodological tenets of oppression, comparison, relationality, complexity, and deconstruction.

METHODS

Our search resulted in 14,487 articles, 5164 of which were duplicates, and 9297 studies that did not meet the inclusion criteria were excluded. In total, 14 articles were included in this review. We used thematic analysis to analyse themes within this work and Misra et al. (2021) intersectional research framework to analyse the uptake of intersectional methods within such studies.

RESULTS

The research related to the COVID-19 pandemic globally is paying attention to issues around the financial impacts of the pandemic, discrimination, gendered impacts, impacts of and on social ties, and implications for mental health. We also found strong uptake of centring research in the context of oppression, but less attention is being paid to comparison, relationality, complexity, and deconstruction.

CONCLUSIONS

Our findings show the importance of intersectional research within public health policy formation, as well as room for greater rigour in the use of intersectional methods.

The impact of the COVID-19 pandemic on the socioeconomic gradient of hypertension

The COVID-19 pandemic has brought into sharp focus the impact of socioeconomic factors on hypertension outcomes. This review examines the implications of the pandemic on the socioeconomic gradient of hypertension and explores the physiological and pathophysiological processes underlying this relationship. Changes in socioeconomic factors have disproportionately affected individuals with lower socioeconomic status, leading to adverse hypertension outcomes. The pandemic-related stressors, coupled with social isolation and disrupted daily routines, have contributed to elevated stress levels among individuals, particularly those with lower socioeconomic status. Equitable access to healthcare, enhancing health literacy and patient empowerment, and addressing social determinants of health are essential components of hypertension management strategies. By recognizing the specific challenges faced by individuals with lower socioeconomic status and implementing targeted interventions, public health efforts can help reduce the socioeconomic gradient of hypertension.

First year of COVID-19 in Brazil: Factors associated with the spread of COVID-19 in small and large cities

AIM

To test the association between sociodemographic and social characteristics with COVID-19 cases and deaths in small and large Brazilian cities.

METHODS

This ecological study included COVID-19 data available in State Health Secretaries (managed by brasil.io API) and three national databases (IBGE, DATASUS and Embrapa). Temporal spread of COVID-19 in Brazil during the first year considered as outcome: a) days until 1st case in each city since 1st in the country; b) days until 1,000 cases/100,000 inhabitants since 1st case in each city; c) days until 1st death until 50 deaths/100,000 inhabitants. Covariates included geographic region, city social and environmental characteristics, housing conditions, job characteristics, socioeconomic and inequalities characteristics, and health services and coverage. The analysis were stratified by city size into small (<100,000 inhabitants) and large cities (≥100,00 inhabitants). Multiple linear regressions were performed to test associations of all covariates to adjust to potential confounders.

RESULTS

In small cities, the first cases were reported after 82.2 days and 1,000 cases/100,000 were reported after 117.8 days, whereas in large cities these milestones were reported after 32.1 and 127.7 days, respectively. For first death, small and large cities took 121.6 and 36.0 days, respectively. However, small cities were associated with more vulnerability factors to first case arrival in 1,000 cases/100,000 inhabitants, first death and 50 deaths/100,000 inhabitants. North and Northeast regions positively associated with faster COVID-19 incidence, whereas South and Southeast were least.

CONCLUSION

Social and built environment characteristics and inequalities were associated with COVID-19 cases spread and mortality incidence in Brazilian cities.

Socioeconomic disparities in lumbar fusion rates were exacerbated during the COVID-19 pandemic

Background

The COVID-19 pandemic disrupted healthcare access and utilization throughout the US, with variable impact on patients of different socioeconomic status (SES) and race. We characterize pre-pandemic and pandemic demographic and SES trends of lumbar fusion patients in the US.

Methods

Adults undergoing first-time lumbar fusion 1/1/2004-3/31/2021 were assessed in Clinformatics® Data Mart for patient age, geographical location, gender, race, education level, net worth, and Charlson Comorbidity Index (CCI). Multivariable regression models were used to evaluate the significance of trends over time, with a focus on pandemic trends 2020-2021 versus previous trends 2004-2019.

Results

The total 217,204 patients underwent lumbar fusions, 1/1/2004-3/31/2021. The numbers and per capita rates of lumbar fusions increased 2004-2019 and decreased in 2020 (first year of COVID-19 pandemic), with large variation in geographic distribution. There was overall a significant decrease in proportion of White patients undergoing lumbar fusion over time (OR=0.997, p<.001), though they were more likely to undergo surgery during the pandemic (OR=1.016, p<.001). From 2004-2021, patients were more likely to be educated beyond high school. Additionally, patients in the highest (>$500k) and lowest (<$25k) net worth categories had significantly more fusions over time (p<.001). During the pandemic (2020-2021), patients in higher net worth groups were more likely to undergo lumbar fusions ($150k-249k & $250k-499k: p<.001) whereas patients in the lowest net worth group had decreased rate of surgeries (p<.001). Lastly, patients' CCI increased significantly from 2004 to 2021 (coefficient=0.124, p<.001), and this trend held true during the pandemic (coefficient=0.179, p<.001).

Conclusions

To the best of our knowledge, our work represents the most comprehensive and recent characterization of SES variables in lumbar fusion rates. Unsurprisingly, lumbar fusions decreased overall with the onset of the COVID-19 pandemic. Importantly, disparities in fusion patients across patient race and wealth widened during the pandemic, reversing years of progress, a lesson we can learn for future public health emergencies.

The Impact of the COVID-19 Pandemic on Black and Hispanic Americans' Work Outcomes: a Scoping Review

In early 2020, it was hypothesized that COVID-19 would lead to disproportionately negative health and work outcomes for Black and Hispanic adults, but sufficient data had yet been collected to fully support this claim. Now, we have empirical evidence, but little has been done to aggregate this information to fully understand its impact on these communities. Utilizing 44 articles from a scoping review of three databases (PubMed, Web of Science, and Business Source Complete), this study seeks to identify the primary work-related risks that help explain Black and Hispanic adults' disparate COVID-19-related work outcomes (e.g., loss of hours, job disruption, stress). Findings illuminate four primary risks faced by Black and Hispanic workers: (1) being an essential worker, (2) type of work performed, (3) workplace factors; and (4) community and geographic factors. We conclude with policy recommendations that will help inform policy and practice for economic recovery from the pandemic for other marginalized populations.

An Accessible Web-Based Survey to Monitor the Mental Health of People With Mild Intellectual Disability or Low Literacy Skills During the COVID-19 Pandemic: Comparative Data Analysis

BACKGROUND

The COVID-19 pandemic and related control measures affected the mental health of all populations. Particular subgroups are underrepresented in mainstream surveys because they are hard to reach, and study measurements are not adapted to their skills. These subgroups include people with lower cognitive and literacy skills, such as people with mild intellectual disability (MID), who were considered vulnerable during the COVID-19 pandemic given their low socioeconomic status, small social networks, increased risks of health problems, and difficulties understanding health-related information.

OBJECTIVE

This study examines the impact of the COVID-19 pandemic on mental health among people with MID or low literacy skills compared with those predominantly represented in national surveys.

METHODS

A repeated cross-sectional study of people with MID or low literacy skills and a general population sample was conducted in the Netherlands. An easy-read web-based survey was co-designed with, and tested among, people with MID or low literacy skills and conducted in 3 rounds within 1 year of the COVID-19 pandemic (T1: November to December 2020, T2: March to April 2021, and T3: September to October 2021). The survey contained questions about demographics and 6 aspects of mental health: feeling happy, feeling energized, feeling stressed, worry, feeling lonely, and sleeping problems.

RESULTS

Our adapted survey and recruitment procedure enabled 1059 persons with MID or low literacy skills to participate (T1: n=412, 38.9%; T2: n=351, 33.1%; and T3: n=296, 28%). They were significantly younger, had a lower level of education, and more often than not were born outside the Netherlands compared to the general population sample (P<.001). Approximately half of them (604/1059, 57.03%) received professional care. They displayed poorer mental health scores than the general population sample. The percentages of people with MID or low literacy skills who reported more negative feelings in T1 ranged from 20.6% (85/412) reporting feeling lonely often or almost always to 57.8% (238/412) reporting feeling happy almost never or sometimes. The general population sample's percentages were 5.4% (160/2930) and 32.2% (941/2918), respectively. Although scores improved over time in both populations, the disproportional effects remained.

CONCLUSIONS

General COVID-19-related restrictions for the entire Dutch population affected people with MID or low literacy skills more negatively than the general population. Our study underscores the relevance of including these subpopulations in public health research because they are often overlooked in regular health data. An accessible web-based survey particularly targeted at this population enabled us to do so, and we reached a group of respondents significantly different from regular survey participants. This survey's results provided insights into the health of people with MID or low literacy skills and gained knowledge to be used by care organizations and policy makers to reduce health disparities during a pandemic and in general.

Exploring the impact of recent COVID-19 infection on perfusion and functional parameters derived from gated myocardial perfusion imaging in patients undergoing evaluation for coronary artery disease

OBJECTIVE

This study seeks to evaluate how recent COVID-19 infection affects myocardial perfusion and functional parameters derived from gated myocardial perfusion imaging in patients undergoing evaluation for coronary artery disease. The goal is to enhance our understanding of COVID-19's influence on the cardiovascular system.

METHOD

Conducted at Farshchian Heart Hospital from 2022 to 2023, this case-control study enrolled patients suspected of coronary artery disease, stratified into two groups: those with confirmed COVID-19 infection within the past 6 months (study group) and those without prior COVID-19 infection (control group). Employing a 2-day protocol, stress testing and gated SPECT MPI were performed. Statistical analysis included descriptive statistics, Chi-square test, Student's t test, and Mann-Whitney U test.

RESULT

Among the 86 patients included, 43 were in each group. Significantly higher summed stress core and summed difference score values were observed in the study group compared to the control group (p < 0.05). In addition, the study group exhibited significantly altered global left ventricular ejection fraction, end-diastolic volume, and end-systolic volume (p < 0.05). Non-perfusion findings, including transient ischemic dilation and transient right ventricular visualization, were more prevalent in the study group.

CONCLUSION

Recent COVID-19 infection is associated with impaired myocardial perfusion and altered functional parameters as detected by MPI. These findings underscore the intricate interplay between COVID-19 and cardiovascular health, emphasizing the importance of comprehensive evaluation and management strategies to address cardiac complications in affected individuals. Further research is warranted to elucidate the underlying mechanisms and optimize patient care in the context of COVID-19-associated cardiovascular manifestations.

The Uncontrollable Mortality Risk Hypothesis: Theoretical foundations and implications for public health

The 'Uncontrollable Mortality Risk Hypothesis' employs a behavioural ecological model of human health behaviours to explain the presence of social gradients in health. It states that those who are more likely to die due to factors beyond their control should be less motivated to invest in preventative health behaviours. We outline the theoretical assumptions of the hypothesis and stress the importance of incorporating evolutionary perspectives into public health. We explain how measuring perceived uncontrollable mortality risk can contribute towards understanding socioeconomic disparities in preventative health behaviours. We emphasize the importance of addressing structural inequalities in risk exposure, and argue that public health interventions should consider the relationship between overall levels of mortality risk and health behaviours across domains. We suggest that measuring perceptions of uncontrollable mortality risk can capture the unanticipated health benefits of structural risk interventions, as well as help to assess the appropriateness of different intervention approaches.

Socioeconomic Disparities and Emergency Department Visits for Diabetic Retinopathy in California

Purpose: To investigate the association between neighborhood-level socioeconomic factors, quantified by the Distressed Communities Index, and emergency department visits for diabetic retinopathy (DR). Methods: All patients who presented to the emergency department for DR in California were analyzed using the State Emergency Department Database (2018-2020). Patients were stratified by Distressed Communities Index score and DR severity. Logistic regression was applied to explore the independent correlation between Distressed Communities Index scores and proliferative DR (PDR). Results: Of 2 725 195 emergency department visits for diabetic patients, Distressed Communities Index data were available for 2 459 577 (90.3%); 39 693 were for DR, including 13 617 (34.3%) for PDR. Hispanics (44.2%) were the largest racial/ethnic group to present for PDR, followed by non-Hispanic Whites (19.6%) and non-Hispanic Blacks (19.3%). A significant association was observed between the Distressed Communities Index and emergency department visits for PDR, with distressed neighborhoods having the highest incidence (adjusted odds ratio [aOR], 1.63; 95% CI, 1.20-2.23; P = .001). Other predictors included Hispanic ethnicity (aOR, 2.21; 95% CI, 1.97-2.48; P < .001) and Black race (aOR, 1.46; 95% CI, 1.28-1.67; P < .001) compared with White race and having Medicaid (aOR, 1.37; 95% CI, 1.13-1.65; P = .001) compared with private insurance. Conclusions: The Distressed Communities Index identified patients residing in the most distressed neighborhoods as being at the highest risk for presenting to the emergency department for PDR based on 7 socioeconomic factors. Policymakers may consider the Distressed Communities Index as a tool for targeting DR prevention strategies and improving healthcare accessibility.

The Inverted U-Shaped Relationship Between Socio-Economic Status and Infections During the COVID-19 Pandemic

Although the World Health Organization has declared that the COVID-19 pandemic no longer qualifies as a global public health emergency, it still needs to explore the response of society to the COVID-19 pandemic. Socio-economic status (SES) was proven to be linearly associated with the COVID-19 pandemic, although this relationship may be more complex due to regional differences. In the study, we analyzed and revealed the effects and mechanisms of SES on infections among low, lower-middle, upper-middle and high SES group (LSG, LMSG, UMSG, and HSG, respectively). The results showed that the relationship between SES and infections was inverted U-shaped, especially in the first three phases. In Phase I, UMSG had the highest number of infections, with an average of 238.31/1M people (95%CI: 135.47-341.15/1M people). In Phases II and III, infections decreased insignificantly with increasing SES (r = -0.01, p = 0.92; r = -0.11, p = 0.22) and the highest number of infections were found in the LMSG. In Phase IV, SES was positively related to the number of infections (r = 0.54, p < 0.001). Furthermore, the nonlinear impact of multiple factors related to SES on the infections explains the complex relationships between SES and infections. SES affected infections mainly through medical resources, demographics and vaccination, and differed across the SES groups. Particularly, demographics could exert an impact on population mobility, subsequently influencing infections in LMSG, with an indirect effect of 0.01 (p < 0.05) in Phase II. This study argues for greater attention to countries with middle SES and the need for future targeted measures to cope with infectious diseases.

Assessing Electronic Health Literacy in Individuals With the Post-COVID-19 Condition Using the German Revised eHealth Literacy Scale: Validation Study

BACKGROUND

The eHealth Literacy Scale (eHEALS) is a widely used instrument for measuring eHealth literacy (eHL). However, little is known so far about whether the instrument is valid for the assessment of eHL in persons who are affected by the post-COVID-19 condition. This is particularly important as people with the post-COVID-19 condition are frequently affected by false information from the internet.

OBJECTIVE

The objective of our study was to evaluate the validity and reliability of the German Revised eHealth Literacy Scale (GR-eHEALS) in individuals with the post-COVID-19 condition.

METHODS

A cross-sectional study was conducted from January to May 2022. The self-assessment survey consisted of the GR-eHEALS, health status- and internet use-related variables, sociodemographic data, and (post)-COVID-19-related medical data. Confirmatory factor analysis (CFA), correlational analyses, and tests of measurement invariance were deployed.

RESULTS

In total, 330 participants were included in the statistical analyses. CFA revealed that the 2-factor model reached an excellent model fit (comparative fit index=1.00, Tucker-Lewis index=0.99, root mean square error of approximation=0.036, standardized root mean square residual=0.038). Convergent validity was confirmed by significant positive correlations between eHL and knowledge of internet-based health promotion programs, experience in using these programs, and the duration of private internet use. In addition, a significantly negative relationship of eHL with internet anxiety supported convergent validity. Further, significant relationships of eHL with mental health status and internal health locus of control confirmed the criterion validity of the instrument. However, relationships of eHL with physical health status and quality of life could not be confirmed. The 2-factor model was fully measurement invariant regarding gender. Regarding age and educational level, partial measurement invariance was confirmed. The subscales as well as the overall GR-eHEALS reached good-to-excellent reliability (Cronbach α≥.86).

CONCLUSIONS

The GR-eHEALS is a reliable and largely valid instrument for assessing eHL in individuals with the post-COVID-19 condition. Measurement invariance regarding gender was fully confirmed and allows the interpretation of group differences. Regarding age and educational level, group differences should be interpreted with caution. Given the high likelihood that individuals with the post-COVID-19 condition will be confronted with misinformation on the Internet, eHL is a core competency that is highly relevant in this context, in both research and clinical practice. Therefore, future research should also explore alternative instruments to capture eHL to overcome shortcomings in the validity of the GR-eHEALS.

Race, Ethnicity, and Delayed Time to COVID-19 Testing Among US Health Care Workers

Importance

Access to COVID-19 testing is critical to reducing transmission and supporting early treatment decisions; when made accessible, the timeliness of testing may also be an important metric in mitigating community spread of the infection. While disparities in transmission and outcomes of COVID-19 have been well documented, the extent of timeliness of testing and the association with demographic factors is unclear.

Objectives

To evaluate demographic factors associated with delayed COVID-19 testing among health care personnel (HCP) during the COVID-19 pandemic.

Design, Setting, and Participants

This cross-sectional study used data from the Preventing Emerging Infections Through Vaccine Effectiveness Testing study, a multicenter, test-negative, case-control vaccine effectiveness study that enrolled HCP who had COVID-19 symptoms and testing between December 2020 and April 2022. Data analysis was conducted from March 2022 to Junne 2023.

Exposure

Displaying COVID-19-like symptoms and polymerase chain reaction testing occurring from the first day symptoms occurred up to 14 days after symptoms occurred.

Main Outcomes and Measures

Variables of interest included patient demographics (sex, age, and clinical comorbidities) and COVID-19 characteristics (vaccination status and COVID-19 wave). The primary outcome was time from symptom onset to COVID-19 testing, which was defined as early testing (≤2 days) or delayed testing (≥3 days). Associations of demographic characteristics with delayed testing were measured while adjusting for clinical comorbidities, COVID-19 characteristics, and test site using multivariable modeling to estimate relative risks and 95% CIs.

Results

A total of 5551 HCP (4859 female [82.9%]; 1954 aged 25-34 years [35.2%]; 4233 non-Hispanic White [76.3%], 370 non-Hispanic Black [6.7%], and 324 non-Hispanic Asian [5.8%]) were included in the final analysis. Overall, 2060 participants (37.1%) reported delayed testing and 3491 (62.9%) reported early testing. Compared with non-Hispanic White HCP, delayed testing was higher among non-Hispanic Black HCP (adjusted risk ratio, 1.18; 95%CI, 1.10-1.27) and for non-Hispanic HCP of other races (adjusted risk ratio, 1.17; 95% CI, 1.03-1.33). Sex and age were not associated with delayed testing. Compared with clinical HCP with graduate degrees, all other professional and educational groups had significantly delayed testing.

Conclusions and Relevance

In this cross-sectional study of HCP, compared with non-Hispanic White HCP and clinical HCP with graduate degrees, non-Hispanic Black HCP, non-Hispanic HCP of other races, and HCP all other professional and education backgrounds were more likely to have delayed COVID-19 testing. These findings suggest that time to testing may serve as a valuable metric in evaluating sociodemographic disparities in the response to COVID-19 and future health mitigation strategies.

Socioeconomic inequalities in cardiovascular disease: a causal perspective

Socioeconomic inequalities in cardiovascular disease (CVD) persist in high-income countries despite marked overall declines in CVD-related morbidity and mortality. After decades of research, the field has struggled to unequivocally answer a crucial question: is the association between low socioeconomic position (SEP) and the development of CVD causal? We review relevant evidence from various study designs and disciplinary perspectives. Traditional observational, family-based and Mendelian randomization studies support the widely accepted view that low SEP causally influences CVD. However, results from quasi-experimental and experimental studies are both limited and equivocal. While more experimental and quasi-experimental studies are needed to aid causal understanding and inform policy, high-quality descriptive studies are also required to document inequalities, investigate their contextual dependence and consider SEP throughout the lifespan; no simple hierarchy of evidence exists for an exposure as complex as SEP. The COVID-19 pandemic illustrates the context-dependent nature of CVD inequalities, with the generation of potentially new causal pathways linking SEP and CVD. The linked goals of understanding the causal nature of SEP and CVD associations, their contextual dependence, and their remediation by policy interventions necessitate a detailed understanding of society, its change over time and the phenotypes of CVD. Interdisciplinary research is therefore key to advancing both causal understanding and policy translation.

Paxlovid use is associated with lower risk of cardiovascular diseases in COVID-19 patients with autoimmune rheumatic diseases: a retrospective cohort study

BACKGROUND

Paxlovid has been shown to be effective in reducing mortality and hospitalization rates in patients with coronavirus disease 2019 (COVID-19). It is not known whether Paxlovid can reduce the risk of cardiovascular diseases (CVD) in COVID-19-surviving patients with autoimmune rheumatic diseases (AIRDs).

METHODS

TriNetX data from the US Collaborative Network were used in this study. A total of 5,671,395 patients with AIRDs were enrolled between January 1, 2010, and December 31, 2021. People diagnosed with COVID-19 were included in the cohort (n = 238,142) from January 1, 2022, to December 31, 2022. The Study population was divided into two groups based on Paxlovid use. Propensity score matching was used to generate groups with matched baseline characteristics. The hazard ratios (HRs) and 95% confidence intervals of cardiovascular outcomes, admission rate, mortality rate, and intensive care unit (ICU) admission rate were calculated between Paxlovid and non-Paxlovid groups. Subgroup analyses on sex, age, race, autoimmune diseases group, and sensitivity analyses for Paxlovid use within the first day or within 2-5 days of COVID-19 diagnosis were performed.

RESULTS

Paxlovid use was associated with lower risks of cerebrovascular complications (HR = 0.65 [0.47-0.88]), arrhythmia outcomes (HR = 0.81 [0.68-0.94]), ischemic heart disease, other cardiac disorders (HR = 0.51 [0.35-0.74]) naming heart failure (HR = 0.41 [0.26-0.63]) and deep vein thrombosis (HR = 0.46 [0.24-0.87]) belonging to thrombotic disorders in AIRD patients with COVID-19. Compared with the Non-Paxlovid group, risks of major adverse cardiac events (HR = 0.56 [0.44-0.70]) and any cardiovascular outcome mentioned above (HR = 0.76 [0.66-0.86]) were lower in the Paxlovid group. Moreover, the mortality (HR = 0.21 [0.11-0.40]), admission (HR = 0.68 [0.60-0.76]), and ICU admission rates (HR = 0.52 [0.33-0.80]) were significantly lower in the Paxlovid group than in the non-Paxlovid group. Paxlovid appears to be more effective in male, older, and Black patients with AIRD. The risks of cardiovascular outcomes and severe conditions were reduced significantly with Paxlovid prescribed within the first day of COVID-19 diagnosis.

CONCLUSIONS

Paxlovid use is associated with a lower risk of CVDs and severe conditions in COVID-19-surviving patients with AIRD.

Associations Between Psychopathological Symptom Severity Amid the Pandemic and the Childhood Sociodemographic Environment

It is well-documented that childhood socioeconomic status (SES) is associated with various health conditions in adulthood. Here, we examine the extent to which childhood SES is associated with COVID-19 pandemic anxiety and depression. Participants (n = 212), recruited from Amazon Mechanical Turk, were assessed for depression and anxiety in February 2022 for both the current context and retrospective self-perceived early pandemic depression and anxiety (April 2020). Participants also reported childhood SES and current demographics. Consistent with predated findings, we show a strong, positive correlation between depression and anxiety under both conditions. Paternal unemployment in childhood was associated with increased anxiety, while maternal occupation was not. High household education in childhood was generally associated with greater anxiety and depression, similar to past studies examining education levels and depression. However, the shift from high school to post-secondary degrees (trade school and associate's) was associated with decreased anxiety and depression, which may reflect "essential work" careers, therefore indicating a dualism. Growing up in crowded, de-individualized spaces was associated with lower anxiety and depression, suggesting better conditioning for the imposition of COVID-19 quarantines. Pandemic-related unemployment was associated with an increase in anxiety and depression. Strong political views, regardless of ideology, were associated with increased anxiety. Finally, participants in our cohort perceived their mental health to be worse in the early pandemic for anxiety and depression, up 6.6% and 7.9%, respectively. Our work suggests a complex relationship between SES, demographics, and anxiety and depression during the pandemic. These findings emphasize the importance of exploring the dynamics between early SES and mental health in adulthood, particularly during extended societal stressors.

Inequalities in healthcare use during the COVID-19 pandemic

The COVID-19 pandemic led to reductions in non-COVID related healthcare use, but little is known whether this burden is shared equally. This study investigates whether reductions in administered care disproportionately affected certain sociodemographic strata, in particular marginalised groups. Using detailed medical claims data from the Dutch universal health care system and rich full population registry data, we predict expected healthcare use based on pre-pandemic trends (2017 - Feb 2020) and compare these expectations with observed healthcare use in 2020 and 2021. Our findings reveal a 10% decline in the number of weekly treated patients in 2020 and a 3% decline in 2021 relative to prior years. These declines are unequally distributed and are more pronounced for individuals below the poverty line, females, older people, and individuals with a migrant background, particularly during the initial wave of COVID-19 hospitalisations and for middle and low urgency procedures. While reductions in non-COVID related healthcare decreased following the initial shock of the pandemic, inequalities persist throughout 2020 and 2021. Our results demonstrate that the pandemic has not only had an unequal toll in terms of the direct health burden of the pandemic, but has also had a differential impact on the use of non-COVID healthcare.

Socioeconomic deprivation and illness trajectory in the Scottish population after COVID-19 hospitalization

BACKGROUND

The associations between deprivation and illness trajectory after hospitalisation for coronavirus disease-19 (COVID-19) are uncertain.

METHODS

A prospective, multicentre cohort study was conducted on post-COVID-19 patients, enrolled either in-hospital or shortly post-discharge. Two evaluations were carried out: an initial assessment and a follow-up at 28-60 days post-discharge. The study encompassed research blood tests, patient-reported outcome measures, and multisystem imaging (including chest computed tomography (CT) with pulmonary and coronary angiography, cardiovascular and renal magnetic resonance imaging). Primary and secondary outcomes were analysed in relation to socioeconomic status, using the Scottish Index of Multiple Deprivation (SIMD). The EQ-5D-5L, Brief Illness Perception Questionnaire (BIPQ), Patient Health Questionnaire-4 (PHQ-4) for Anxiety and Depression, and the Duke Activity Status Index (DASI) were used to assess health status.

RESULTS

Of the 252 enrolled patients (mean age 55.0 ± 12.0 years; 40% female; 23% with diabetes), deprivation status was linked with increased BMI and diabetes prevalence. 186 (74%) returned for the follow-up. Within this group, findings indicated associations between deprivation and lung abnormalities (p = 0.0085), coronary artery disease (p = 0.0128), and renal inflammation (p = 0.0421). Furthermore, patients with higher deprivation exhibited worse scores in health-related quality of life (EQ-5D-5L, p = 0.0084), illness perception (BIPQ, p = 0.0004), anxiety and depression levels (PHQ-4, p = 0.0038), and diminished physical activity (DASI, p = 0.002). At the 3-month mark, those with greater deprivation showed a higher frequency of referrals to secondary care due to ongoing COVID-19 symptoms (p = 0.0438). However, clinical outcomes were not influenced by deprivation.

CONCLUSIONS

In a post-hospital COVID-19 population, socioeconomic deprivation was associated with impaired health status and secondary care episodes. Deprivation influences illness trajectory after COVID-19.

Longer-Term Mental Health Consequences of COVID-19 Infection: Moderation by Race and Socioeconomic Status

OBJECTIVE

While evidence suggests that the mental health symptoms of COVID-19 can persist for several months following infection, little is known about the longer-term mental health effects and whether certain sociodemographic groups may be particularly impacted. This cross-sectional study aimed to characterize the longer-term mental health consequences of COVID-19 infection and examine whether such consequences are more pronounced in Black people and people with lower socioeconomic status.

METHODS

277 Black and White adults (age ≥ 30 years) with a history of COVID-19 (tested positive ≥ 6 months prior to participation) or no history of COVID-19 infection completed a 45-minute online questionnaire battery.

RESULTS

People with a history of COVID-19 had greater depressive (d = 0.24), anxiety (d = 0.34), post-traumatic stress disorder (PTSD) (d = 0.32), and insomnia (d = 0.31) symptoms than those without a history of COVID-19. These differences remained for anxiety, PTSD, and insomnia symptoms after adjusting for age, sex, race, education, income, employment status, body mass index, and smoking status. No differences were detected for perceived stress and general psychopathology. People with a history of COVID-19 had more than double the odds of clinically significant symptoms of anxiety (OR = 2.22) and PTSD (OR = 2.40). Education, but not race, income, or employment status, moderated relationships of interest such that COVID-19 status was more strongly and positively associated with all the mental health outcomes for those with fewer years of education.

CONCLUSION

The mental health consequences of COVID-19 may be significant, widespread, and persistent for at least 6 months post-infection and may increase as years of education decreases.

The Relationship Between Perceived Uncontrollable Mortality Risk and Health Effort: Replication, Secondary Analysis, and Mini Meta-analysis

BACKGROUND

The Uncontrollable Mortality Risk Hypothesis (UMRH) states that those who are more likely to die due to factors beyond their control should be less motivated to invest in preventative health behaviors. Greater levels of perceived uncontrollable mortality risk (PUMR) have been associated with lower health effort in previous research, but the topic remains understudied.

PURPOSE

To examine the evidence for the UMRH by replicating a previous study investigating the effects of PUMR on social gradients in health effort, and conducting a mini meta-analysis of the overall relationship between PUMR and health effort.

METHODS

We replicated Pepper and Nettle (2014), who reported a negative relationship between PUMR and health effort, and that the positive effect of subjective socioeconomic position on health effort was explained away by PUMR. We also compared the predictive effect of PUMR on health effort with that of dimensions from the Multidimensional Health Locus of Control scale-a well-used measure of a similar construct, which is frequently found to be associated with health behavior. Finally, we conducted a mini meta-analysis of the relationship between PUMR and health effort from the available research.

RESULTS

PUMR was negatively associated with health effort, and mediated 24% of the total effect of subjective socioeconomic position on health effort, though this mediation effect was weaker than in Pepper and Nettle (2014). PUMR was shown to be a substantially stronger predictor of health effort than the relevant dimensions of the MHLC scale. Finally, our mini meta-analysis indicated a medium-sized negative relationship between PUMR and health effort.

CONCLUSIONS

Our findings offer support for the role of PUMR in mediating the relationship between subjective socioeconomic position and health effort. The results highlight the importance of measuring and understanding PUMR in studying socioeconomic inequalities in health behaviors. We discuss potential areas for future research, including determining the accuracy of PUMR, investigating influential cues, examining the role of media in shaping risk perceptions, and understanding individuals' awareness of their own perceptions of mortality risk.

Demographic and Socioeconomic Trends in Cervical Fusion Utilization from 2004 Through 2021 and the COVID-19 Pandemic

BACKGROUND

Cervical fusion rates increased in the U.S. exponentially 1990-2014, but trends leading up to/during the COVID-19 pandemic have not been fully evaluated by patient socioeconomic status (SES). Here, we provide the most recent, comprehensive characterization of demographic and SES trends in cervical fusions, including during the pandemic.

METHODS

We collected the following variables on adults undergoing cervical fusions, 1/1/2004-3/31/2021, in Optum's Clinformatics Data Mart: age, Charlson Comorbidity Index, provider's practicing state, gender, race, education, and net worth. We performed multivariate linear and logistic regression to evaluate associations of cervical fusion rates with SES variables.

RESULTS

Cervical fusion rates increased 2004-2016, then decreased 2016-2020. Proportions of Asian, Black, and Hispanic patients undergoing cervical fusions increased (OR = 1.001,1.001,1.004, P < 0.01), with a corresponding decrease in White patients (OR = 0.996, P < 0.001) over time. There were increases in cervical fusions in higher education groups (OR = 1.006, 1.002, P < 0.001) and lowest net worth group (OR = 1.012, P < 0.001). During the pandemic, proportions of White (OR = 1.015, P < 0.01) and wealthier patients (OR ≥ 1.015, P < 0.01) undergoing cervical fusions increased.

CONCLUSIONS

We present the first documented decrease in annual cervical surgery rates in the U.S. Our data reveal a bimodal distribution for cervical fusion patients, with racial-minority, lower-net-worth, and highly-educated patients receiving increasing proportions of surgical interventions. White and wealthier patients were more likely to undergo cervical fusions during the COVID-19 pandemic, which has been reported in other areas of medicine but not yet in spine surgery. There is still considerable work needed to improve equitable access to spine care for the entire U.S.

POPULATION

The trade-off between health system resiliency and efficiency: evidence from COVID-19 in European regions

The objective of this paper was to investigate the existence of a trade-off between health system resilience and the economic efficiency of the health system, using data for 173 regions in the European Union and the European Free Trade Association countries. Data Envelopment Analysis was used to measure the efficiency of regional health systems before the COVID-19 pandemic. Then, a spatial econometrics model was used to estimate whether this measure of efficiency, adjusted for several covariates, has a significant impact on regional health system resilience during the COVID-19 pandemic, measured by the number of COVID-19 deaths per hundred thousand inhabitants. The results show that COVID-19 death rates were significantly higher in regions with higher population density, higher share of employment in industry, and higher share of women in the population. Results also show that regions with higher values of the health system efficiency index in 2017 had significantly higher rates of COVID-19 deaths in 2020 and 2021, suggesting the existence of a trade-off between health system efficiency and health system resilience during the COVID-19 pandemic.

Ethnic and racial differences in self-reported symptoms, health status, activity level, and missed work at 3 and 6 months following SARS-CoV-2 infection

Introduction

Data on ethnic and racial differences in symptoms and health-related impacts following SARS-CoV-2 infection are limited. We aimed to estimate the ethnic and racial differences in symptoms and health-related impacts 3 and 6 months after the first SARS-CoV-2 infection.

Methods

Participants included adults with SARS-CoV-2 infection enrolled in a prospective multicenter US study between 12/11/2020 and 7/4/2022 as the primary cohort of interest, as well as a SARS-CoV-2-negative cohort to account for non-SARS-CoV-2-infection impacts, who completed enrollment and 3-month surveys (N = 3,161; 2,402 SARS-CoV-2-positive, 759 SARS-CoV-2-negative). Marginal odds ratios were estimated using GEE logistic regression for individual symptoms, health status, activity level, and missed work 3 and 6 months after COVID-19 illness, comparing each ethnicity or race to the referent group (non-Hispanic or white), adjusting for demographic factors, social determinants of health, substance use, pre-existing health conditions, SARS-CoV-2 infection status, COVID-19 vaccination status, and survey time point, with interactions between ethnicity or race and time point, ethnicity or race and SARS-CoV-2 infection status, and SARS-CoV-2 infection status and time point.

Results

Following SARS-CoV-2 infection, the majority of symptoms were similar over time between ethnic and racial groups. At 3 months, Hispanic participants were more likely than non-Hispanic participants to report fair/poor health (OR: 1.94; 95%CI: 1.36-2.78) and reduced activity (somewhat less, OR: 1.47; 95%CI: 1.06-2.02; much less, OR: 2.23; 95%CI: 1.38-3.61). At 6 months, differences by ethnicity were not present. At 3 months, Other/Multiple race participants were more likely than white participants to report fair/poor health (OR: 1.90; 95% CI: 1.25-2.88), reduced activity (somewhat less, OR: 1.72; 95%CI: 1.21-2.46; much less, OR: 2.08; 95%CI: 1.18-3.65). At 6 months, Asian participants were more likely than white participants to report fair/poor health (OR: 1.88; 95%CI: 1.13-3.12); Black participants reported more missed work (OR, 2.83; 95%CI: 1.60-5.00); and Other/Multiple race participants reported more fair/poor health (OR: 1.83; 95%CI: 1.10-3.05), reduced activity (somewhat less, OR: 1.60; 95%CI: 1.02-2.51; much less, OR: 2.49; 95%CI: 1.40-4.44), and more missed work (OR: 2.25; 95%CI: 1.27-3.98).

Discussion

Awareness of ethnic and racial differences in outcomes following SARS-CoV-2 infection may inform clinical and public health efforts to advance health equity in long-term outcomes.

Prevalence and factors associated with the death of older people hospitalized due to Covid-19 in the state of Paraná

OBJECTIVE

To estimate the prevalence and to analyze the factors associated with the death of older people hospitalized due to Covid-19 in the state of Paraná.

METHOD

Cross-sectional study conducted with secondary data from older people with a positive diagnosis of Covid-19 living in the State of Paraná, collected from March 1, 2020 to August 31, 2021. Prevalence ratios were obtained by adjusting the regression model.

RESULTS

A total of 16,153 deaths of older people hospitalized in the State of Paraná were analyzed. The adjusted model revealed an association between death and some factors such as: belonging to the age group of 75 to 84 years (PR = 1.28; CI95% = 1.24-1.32) and 85 years or over (PR = 1.52; CI95% = 1.45-1.59); male (PR = 1.17; CI95% = 1.13-1.21); obesity (PR = 1.23; CI95% = 1.16-1.29); other morbidities (PR = 1.25; CI95% = 1.20-1.30); and having used ventilatory support (PR = 2.60; CI95% = 2.33-2.86). Older people vaccinated against influenza had a probability of death reduced by 11% (PR = 0.89; CI95% = 0.86-0.93).

CONCLUSION

The association of age, sex, and diagnosis of previous comorbidities with unfavorable outcomes from Covid-19 was identified. Having received the flu vaccine provided protection to elderly people who contracted SARS-CoV-2.

Socioeconomic status is negatively associated with immunosenescence but positively associated with inflammation among middle-aged women in Cebu, Philippines

BACKGROUND

Socioeconomic status (SES) gradients in health are well-documented, and while biological pathways are incompletely understood, chronic inflammation and accelerated immune aging (immunosenescence) among lower SES individuals have been implicated. However, previous findings have come from samples in higher income countries, and it is unclear how generalizable they are to lower- and middle-income countries (LMIC) with different infectious exposures and where adiposity-an important contributor to chronic inflammation-might show different SES patterning. To address this gap, we explored associations between SES and inflammation and immunosenescence in a sample of women in Cebu, Philippines.

METHODS

Data came from the mothers of the Cebu Longitudinal Health and Nutrition Survey birth cohort (mean age: 47.7, range: 35-69 years). SES was measured as a combination of annual household income, education level, and assets. Chronic inflammation was measured using C-reactive protein (CRP) in plasma samples from 1,834 women. Immunosenescence was measured by the abundance of exhausted CD8T (CD8 + CD28-CD45RA-) and naïve CD8T and CD4T cells, estimated from DNA methylation in whole blood in a random subsample of 1,028. Possible mediators included waist circumference and a collection of proxy measures of pathogen exposure.

RESULTS

SES was negatively associated with the measures of immunosenescence, with slight evidence for mediation by a proxy measure for pathogen exposure from the household's drinking water source. In contrast, SES was positively associated with CRP, which was explained by the positive association with waist circumference.

CONCLUSIONS

Similar to higher income populations, in Cebu there is an SES-gradient in pathogen exposures and immunosenescence. However, lifestyle changes occurring more rapidly among higher SES individuals is contributing to a positive association between SES and adiposity and inflammation. Our results suggest more studies are needed to clarify the relationship between SES and inflammation and immunosenescence across LMIC.

Flourishing (or lack thereof) during COVID-19: College students'social-psychological well-being during the Fall 2020 semester

Objective: This exploratory quantitative study examined college students' social-psychological well-being during the COVID-19 pandemic. Participants: The sample included 1,723 students (undergraduate and graduate) at a public research university. Methods: Paired samples t-test were utilized to compare students' social-psychological well-being pre-pandemic, at the start of the Fall 2020 semester, and toward the end of the Fall 2020 semester. Regression analyses were utilized to identify predictors of students' social-psychological well-being at the start and toward the end of the Fall 2020 semester. Results: Students experienced a significant decrease in social-psychological well-being pre-pandemic to the start of the Fall 2020 semester and most had not returned to pre-pandemic levels toward the end of the semester. While demographics, housing arrangements, and course modality impacted social-psychological well-being, they only explained a small percentage of the variance in students' well-being. Conclusion: Students continued to experience low mental well-being during the Fall 2020 semester.

An online questionnaire survey on the sexual function of Chinese male adults in the COVID-19 pandemic with loosened controls

The coronavirus disease 2019 (COVID-19) may have a negative impact on the sexual health of male adults. An online questionnaire survey was conducted among male adults from February 04, 2023 to March 15, 2023 to analyze the impact of COVID-19 on the sexual health of male adults in China. Participants provided about their medical, social, lifestyle, and family situations information through questionnaires including the Brief Sexual Function Inventory (BSFI). Sexual function problems were defined based on predetermined cutoff values of the BSFI domain scores. A total of 1,250 male adults were included with median age as 32 years. According to the analysis of statistical results, sexual drive and erections firm enough to have sexual intercourse were reported to be present only a few days or less last month among 14.8 % and 11.1 % of COVID-19 survivors, respectively. Compared with uninfected persons, COVID-19 survivors had significantly lower scores on all BSFI domains and an increased risk of problems with sexual drive and erectile. In multivariate models of COVID-19 survivors, age ≥30 years, rural resident, lower education level, manual worker, lower income, and shorter duration from recovery to survey date were significantly associated with poorer overall sexual function. In this study, COVID-19 survivors was reported to have significantly poorer sexual function than uninfected persons. The COVID-19 may have had a significant impact on the sexual health of Chinese male adults. We need to focus on sexual dysfunction in COVID-19 survivors, and proactively provide effective interventions.

Report of 5146 Cases of Coronavirus Disease 2019-Related Mortality From Cook County, Illinois Causes of Death, Demographics, and Comorbidities

ABSTRACT

A cross-sectional study used 5216 laboratory-confirmed coronavirus disease 2019 (severe acute respiratory syndrome coronavirus 2)-related mortality cases in Cook County of Illinois. The data set included each case's demographic data, manner of death, and comorbidities. The age ranged from 0 to 108 years, with a median of 73.5 years. There were few mortality cases in the age group younger than 30 years, and the incidence of fatal infection increased with age. We demonstrated an increased incidence of mortality in males compared with females (P < 0.01). The urban population had a higher incidence of fatal infection than the suburban population (P < 0.01). We found a significant increase (P < 0.01) in the incidence of fatal coronavirus disease 2019 (severe acute respiratory syndrome coronavirus 2) infection in African American males compared with background frequencies. Latino population demonstrated younger ages at death compared with the non-Latino population. Obesity and hypertension significantly predict fatal outcomes in the younger age group. In comparison, dementia and hypertensive and arteriosclerotic cardiovascular disease are significant predictive factors in the older age group. In a large data set, we demonstrated that the demographical distribution of the population and comorbidities is associated with the risk of fatal complications and death.

Is there a relationship between internet access and COVID-19 mortality? Evidence from Nigeria based on a spatial analysis

With over 6.5 million deaths due to COVID-19, it has become an issue of global health concern. Early findings have identified several social determinants of deaths from COVID-19. However, very few studies have been done on the relationship between internet access and COVID-19 mortality in the context of developing countries. Using geospatial methods, this study examines the relationship between internet access and COVID-19 mortality disparity in Nigeria. In contrast to the widely reported relationship in the literature that internet access lowers the risk of COVID-19 mortality, the current study finds that geographical locations with the highest internet access are the hotspots of COVID-19 mortality in Nigeria, especially some parts of southwest Nigeria. In addition, findings show that population density and unemployment are risk factors of COVID-19 mortality. The study recommends educating the population on the use of online health information and the need to adhere strictly to non-pharmaceutical and vaccination interventions to reduce the number of deaths caused by the virus.

Impact of sociodemographic and economic determinants of health on COVID-19 infection: incidence variation between reference periods

OBJECTIVES

The COVID-19 pandemic hit Portugal in March 2020, causing widespread disruption to various aspects of society. While extensive research has been conducted on the significance of socio-economic disparities in infection risk, this study aims to enhance our understanding of their evolving relationship over time by analysing four distinct periods in 2020.

STUDY DESIGN AND METHODS

This retrospective observational ecological study included individuals residing in the Primary Healthcare Cluster areas of Almada-Seixal and Western Lisbon and Oeiras, who tested positive for SARS-CoV-2 through a polymerase chain reaction (PCR) test between the 2nd of March and the 8th of November of 2020. Using incidence rates for each specific neighbourhood (n = 29) and period, we explored the relationship between neighbourhood-level socio-economic variables and the risk of infection using negative-binomial regression models.

RESULTS

In the analysed period, a total of 8562 confirmed COVID-19 cases were identified. Overall incidence rates for each period were sequentially 2.74, 5.03, 3.99 and 14.29 COVID-19 cases per 100,000 person-days. Housing overcrowding, illiteracy rate and place of birth were associated with increased risk of infection, while age, congregate living, and employment in the secondary sector exhibited the opposite association. No association was consistent across all time periods.

CONCLUSIONS

Our findings support the idea that the influence of socio-economic determinants of health is not immutable throughout time. In a pandemic context where information, knowledge, beliefs, and behaviours are ever-changing and evolving, a dynamic, inclusive, and adaptable approach to disease control can lead to a more equitable distribution of improved outcomes, benefiting all strata of society.

Incidence and risk factors related to SARS-CoV-2 infection, reinfection, and seroconversion: Analysis of a healthcare workers cohort from a university hospital in Colombia

Objectives

To determine the incidence and factors associated with SARS-CoV-2 infection and seroconversion among healthcare workers (HCWs) during the COVID-19 pandemic in a university hospital in Colombia.

Methods

We analyzed the CoVIDA-Fundación Santa Fe de Bogotá (FSFB) cohort, consisting of 419 HCWs from the FSFB university hospital. The cohort was followed during active surveillance (June 25, 2020, to April 30, 2021) and passive surveillance (May 01, 2021, to March 16, 2022) periods. Incidence rates for SARS-CoV-2 infection, reinfection, and seroconversion were estimated, considering pre- and post-COVID-19 vaccination. Cox proportional-hazards models were used to identify factors related to infection and seroconversion during the active surveillance period.

Results

COVID-19 incidence rate ranged between 16-52 cases per 1000 person-month. SARS-CoV-2 reinfections were rare, ranging between less than one case to 13 cases per 1000 person-month. The seroconversion rates ranged between 52-55 cases per 1000 person-month. High socioeconomic level was a protective factor for SARS-CoV-2 infection, while SARS-CoV-2 infection was the main factor associated with seroconversion.

Conclusion

This study provides insights into the incidence and risk factors of SARS-CoV-2 infection among HCWs in a Colombian university hospital. The findings may offer valuable guidance for reducing virus spread within healthcare settings.

Racial, socioeconomic, and neighborhood characteristics in relation to COVID-19 severity of illness for adolescents and young adults

This study tests the hypotheses that insurance status, race and ethnicity, and neighborhood characteristics are associated with hospital admission and severe health outcomes (Intensive Care Unit [ICU] admission and oxygen assistance) for youth and young adults who present to the emergency department (ED) with COVID-19 in a single, academic health system in Illinois, Rush University System for Health (RUSH). Demographic and clinical data from the electronic health record were collected for all 13- to 24-y-old patients seen at RUSH who tested positive for COVID-19 between March 2020 and 2021. Individual-level and neighborhood characteristics were analyzed to determine their association with hospital admission and severe health outcomes through generalized estimating equations. As of March 2021, 1,057 patients were seen in the ED within RUSH in which non-Hispanic White (odds ratio [OR], 2.96; 95% CI, 1.61-5.46; P = 0.001) and Hispanic (OR, 3.34; 95% CI, 1.84-6.10; P < 0.001) adolescents and youth were more likely to be admitted to the hospital compared with non-Hispanic Black/other adolescents and youth. Patients with public insurance or who were uninsured were less likely to be admitted to the ICU compared with those with private insurance (OR, 0.24; 95% CI, 0.09-0.64; P = 0.004). None of the neighborhood characteristics were significantly associated with hospital admission or severe health outcomes after adjusting for covariates. Our findings demonstrated that race and ethnicity were related to hospitalization, while insurance was associated with presentation severity due to COVID-19 for adolescents and young adults. These findings can aid public health investigators in understanding COVID-19 disparities among adolescents and young adults.

Income inequality and its association with COVID-19 cases and deaths: a cross-country analysis in the Eastern Mediterranean region

INTRODUCTION

There is limited evidence on the associations between economic and social disparities in the Eastern Mediterranean region (EMR) with COVID-19 infections and deaths. This study aims to investigate the relationship between income inequalities using Gini coefficients and COVID-19 cases and deaths per million population in the EMR countries.

METHODS

Country-level data on monthly COVID-19 cases and deaths between March 2020 and October 2021, along with data on selected confounders, were collected from publicly available databases. Mixed-effect negative binomial and inverse hyperbolic sine transformation regressions were estimated to examine the association.

RESULTS

The study showed that, in the EMR, a unit increase in Gini coefficient is associated with approximately 7.2% and 3.9% increase in COVID-19 cases and deaths per million population, respectively. The magnitude and direction of the association between income inequality and COVID-19 cases and deaths per-million population still remain the same after excluding four warzone countries from the analysis.

CONCLUSION

This increase in COVID-19 cases and deaths is underpinned by the fact that a large number of the population in the region is living in conditions of poverty, with inadequate housing, comorbidities and limited or virtually no access to essential healthcare services. Healthcare policy-makers across countries in the region need to implement effective interventions in areas of income inequality, where it may be linked to increasing the risk of COVID-19 cases and deaths.

The Effect of Comorbidities and Complications on COVID-19 Mortality: A Detailed Retrospective Study in Western Romania

COVID-19 continues to impact global health systems even after being declared over, with some patients exhibiting severe complications linked to pre-existing conditions. This study aimed to investigate the association between comorbidities, complications, and survival outcomes among COVID-19 survivors in Western Romania. Our hypothesis posited that comorbidities and complications significantly influence survival rates. We conducted a retrospective analysis of 1948 COVID-19 survivors admitted from January to December 2021, with 192 selected for detailed analysis based on inclusion and exclusion criteria. The severity of COVID-19 was classified according to WHO guidelines, and conditions like hypertension and obesity were defined using criteria from the European Society of Hypertension (ESH), the European Society of Cardiology (ESC), and WHO, respectively. Among the 192 patients, 33 had mild, 62 had moderate, and 97 had severe COVID-19. The median age across the severity groups was 63.2 years. Patients undergoing tracheostomy had a mortality rate of 83.3% versus 22.2% for non-tracheostomy patients (p < 0.001) and presented with significantly higher lung injury, hospitalization duration, and complications. Remarkably, tracheostomized patients were 17.50 times more likely to succumb to the disease (95% CI 4.39-116.91, p < 0.001). Furthermore, pneumothorax increased the mortality risk significantly (OR 22.11, 95% CI 5.72-146.03, p < 0.001). Intriguingly, certain conditions like grade I hypertension and grade II obesity showed a protective effect against mortality, whereas type 2 diabetes mellitus increased mortality risk (univariate OR 2.89, p = 0.001). The presence of certain comorbidities and complications significantly impacts the survival rates of COVID-19 patients in Western Romania. Notably, tracheostomy, pneumothorax, and T2DM were associated with increased mortality. This study underscores the importance of personalized patient care and provides insights for healthcare policymakers in Western Romania to improve clinical management strategies.

Association of Social Vulnerability and COVID-19 Mortality Rates in Texas between 15 March 2020, and 21 July 2022: An Ecological Analysis

BACKGROUND

Despite the key role of social vulnerability such as economic disadvantage in health outcomes, research is limited on the impact of social vulnerabilities on COVID-19-related deaths, especially at the state and county level in the USA.

METHODS

We conducted a cross-sectional ecologic analysis of COVID-19 mortality by the county-level Minority Health Social Vulnerability Index (MH SVI) and each of its components in Texas. Negative binomial regression (NBR) analyses were used to estimate the association between the composite MH SVI (and its components) and COVID-19 mortality.

RESULTS

A 0.1-unit increase in the overall MH SVI (IRR, 1.27; 95% CI, 1.04-1.55; p = 0.017) was associated with a 27% increase in the COVID-19 mortality rate. Among the MH SVI component measures, only low socioeconomic status (IRR, 1.55; 95% CI, 1.28-1.89; p = 0.001) and higher household composition (e.g., proportion of older population per county) and disability scores (IRR, 1.47; 95% CI, 1.29-1.68; p < 0.001) were positively associated with COVID-19 mortality rates.

CONCLUSIONS

This study provides further evidence of disparities in COVID-19 mortality by social vulnerability and can inform decisions on the allocation of social resources and services as a strategy for reducing COVID-19 mortality rates and similar pandemics in the future.

Differential care-seeking behaviors during the beginning of the COVID-19 pandemic in Michigan: a population-based cross-sectional study

BACKGROUND

At the beginning of the COVID-19 pandemic in the United States in the spring of 2020, many Americans avoided the healthcare system, while those with COVID-19 symptoms were faced with decisions about seeking healthcare services for this novel virus.

METHODS

Using a probability sample (n = 1088) from the Michigan adult population of PCR-confirmed COVID-19 cases who were diagnosed prior to July 31, 2020, we used logistic regression to examine sociodemographic and symptom severity predictors of care-seeking behaviors. The analyses examined three different outcomes: (1) whether respondents sought care and, among those who sought care, whether they sought care from (2) a primary care provider or (3) an emergency room. Final models were adjusted for sex, age, race and ethnicity, income, education, marital status, living arrangement, health insurance, and self-reported symptom severity.

RESULTS

We found that participants ages 65 and older had 4.00 times higher odds of seeking care than 18-34-year-olds (95% CI: 2.21, 7.24), while adults reporting very severe symptoms had roughly 15 times higher odds of seeking care than those with mild symptoms (95% CI: 7.73, 27.01). Adults who were non-Hispanic Black or were uninsured had lower odds of seeking care from a primary care physician versus seeking care from other locations in comparison to adults who were non-Hispanic White or were privately insured, respectively (non-Hispanic Black: aOR = 0.27, 95% CI: 0.16, 0.44; Uninsured: aOR = 0.19, 95% CI: 0.09, 0.42). Conversely, adults who were older or reported more severe symptoms had higher odds of seeking care from an emergency room versus other locations in comparison to adults who were younger or reported less severe symptoms (Age 65+: aOR = 2.96, 95% CI: 1.40, 6.28; Very Severe Symptoms: aOR = 6.63, 95% CI: 3.33, 13.20).

CONCLUSIONS

Our results suggest differential utilization of healthcare services early in the COVID-19 pandemic. Further analyses are needed to examine the reasons for these differences.

Outcomes of breakthrough COVID-19 infections in patients with hematologic malignancies

Patients with hematologic malignancies have both an increased risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and higher morbidity/mortality. They have lower seroconversion rates after vaccination, potentially leading to inferior coronavirus disease 2019 (COVID-19) outcomes, despite vaccination. We consequently evaluated the clinical outcomes of COVID-19 infections in 243 vaccinated and 175 unvaccinated patients with hematologic malignancies. Hospitalization rates were lower in the vaccinated group when compared with the unvaccinated group (31.3% vs 52.6%). However, the rates of COVID-19-associated death were similar at 7.0% and 8.6% in vaccinated and unvaccinated patients, respectively. By univariate logistic regression, females, older patients, and individuals with higher modified Charlson Comorbidity Index scores were at a higher risk of death from COVID-19 infections. To account for the nonrandomized nature of COVID-19 vaccination status, a propensity score weighting approach was used. In the final propensity-weighted model, vaccination status was not significantly associated with the risk of death from COVID-19 infections but was associated with the risk of hospitalization. The predicted benefit of vaccination was an absolute decrease in the probability of death and hospitalization from COVID-19 infections by 2.3% and 22.9%, respectively. In conclusion, COVID-19 vaccination status in patients with hematologic malignancies was associated with a decreased risk of hospitalization but not associated with a decreased risk of death from COVID-19 infections in the pre-Omicron era. Protective strategies, in addition to immunization, are warranted in this vulnerable patient population.

Gender differences in estimated excess mortality during the COVID-19 pandemic in Thailand

BACKGROUND

There is a limited body of research specifically examining gender inequality in excess mortality and its variations across age groups and geographical locations during the COVID-19 pandemic. This study aims to fill this gap by analyzing the patterns of gender inequality in excess all-cause mortality in Thailand during the COVID-19 pandemic.

METHODS

Data pertaining to all-cause deaths and population between January 1, 2010, and December 31, 2021, were obtained from Thailand's Bureau of Registration Administration. A seasonal autoregressive integrated moving average (SARIMA) technique was used to estimate excess mortality during the pandemic between January 2020 to December 2021. Gender differential excess mortality was measured as the difference in age-standardized mortality rates between men and women.

RESULTS

Our SARIMA-based estimate of all-cause mortality in Thailand during the COVID-19 pandemic amounted to 1,032,921 deaths, with COVID-19-related fatalities surpassing official figures by 1.64 times. The analysis revealed fluctuating patterns of excess and deficit in all-cause mortality rates across different phases of the pandemic, as well as among various age groups and regions. In 2020, the most pronounced gender disparity in excess all-cause mortality emerged in April, with 4.28 additional female deaths per 100,000, whereas in 2021, the peak gender gap transpired in August, with 7.52 more male deaths per 100,000. Individuals in the 80 + age group exhibited the largest gender gap for most of the observed period. Gender differences in excess mortality were uniform across regions and over the period observed. Bangkok showed the highest gender disparity during the peak of the fourth wave, with 24.18 more male deaths per 100,000.

CONCLUSION

The findings indicate an overall presence of gender inequality in excess mortality during the COVID-19 pandemic in Thailand, observed across age groups and regions. These findings highlight the need for further attention to be paid to gender disparities in mortality and call for targeted interventions to address these disparities.

Trends in COVID-19 Vaccine Hesitancy and Uptake Among Persons Living With HIV in Washington, DC

OBJECTIVE

The COVID-19 pandemic has disproportionately affected older people, people with underlying health conditions, racial and ethnic minorities, socioeconomically disadvantaged, and people living with HIV (PWH). We sought to describe vaccine hesitancy and associated factors, reasons for vaccine hesitancy, and vaccine uptake over time in PWH in Washington, DC.

METHODS

We conducted a cross-sectional survey between October 2020 and December 2021 among PWH enrolled in a prospective longitudinal cohort in DC. Survey data were linked to electronic health record data and descriptively analyzed. Multivariable logistic regression was performed to identify factors associated with vaccine hesitancy. The most common reasons for vaccine hesitancy and uptake were assessed.

RESULTS

Among 1029 participants (66% men, 74% Black, median age 54 years), 13% were vaccine hesitant and 9% refused. Women were 2.6-3.5 times, non-Hispanic Blacks were 2.2 times, Hispanics and those of other race/ethnicities were 3.5-8.8 times, and younger PWH were significantly more likely to express hesitancy or refusal than men, non-Hispanic Whites, and older PWH, respectively. The most reported reasons for vaccine hesitancy were side effect concerns (76%), plans to use other precautions/masks (73%), and speed of vaccine development (70%). Vaccine hesitancy and refusal declined over time (33% in October 2020 vs. 4% in December 2021, P < 0.0001).

CONCLUSIONS

This study is one of the largest analyses of vaccine hesitancy among PWH in a US urban area highly affected by HIV and COVID-19. Multilevel culturally appropriate approaches are needed to effectively address COVID-19 vaccine concerns raised among PWH.

Risk preferences, preventive behaviour, and the probability of a loss: Empirical evidence from the COVID-19 pandemic

RATIONALE

A theoretical model of optimal choice under risk, in which an individual chooses the level of prevention to avoid a loss, has the ambiguous prediction that a higher risk-taking preference increases the probability of a loss.

OBJECTIVE

To empirically investigate the prediction in the case of COVID-19 with individual-level survey data.

DATA

Survey data from the Understanding America Study (UAS). The UAS Coronavirus Tracking Survey followed 8628 respondents from March 2020 until July 2021 (29 survey waves) and data was gathered on having contracted COVID-19, vaccination, and preventive behaviour. Separate UAS modules gathered data on individuals' risk preferences; twice before and once during the COVID-19 pandemic. UAS also gathered data on pre-pandemic health and socio-economic status. Combining these data, and dropping missing observations, provided longitudinal data for 4335 respondents (96,370 observations) of whom 530 contracted COVID-19.

RESULTS

In support of the theoretical prediction, the empirical findings show that a one-standard deviation higher risk-taking preference is associated with about a one-third higher probability of contracting COVID-19 within two weeks. Furthermore, the findings show that individuals' risk-taking preference is negatively associated with the preventive behaviour of social distancing and not associated with getting vaccinated. There is, however, no support for preventive behaviour being associated with the probability of contracting COVID-19. The exception is for being vaccinated, which is negatively associated with the probability of contracting COVID-19. The findings, therefore, do not support that the positive association of the risk-taking preference with the probability of contracting COVID-19 is mediated through observed preventive behaviour.

CONCLUSIONS

The findings support the importance of individuals' risk-taking behaviour for contracting COVID-19 and, more generally, the importance of loss prevention as a risk management tool for individuals.

COVID-19 case rates, spatial mobility, and neighbourhood socioeconomic characteristics in Toronto: a spatial-temporal analysis

OBJECTIVES

This study has two primary research objectives: (1) to investigate the spatial clustering pattern of mobility reductions and COVID-19 cases in Toronto and their relationships with marginalized populations, and (2) to identify the most relevant socioeconomic characteristics that relate to human mobility and COVID-19 case rates in Toronto's neighbourhoods during five distinct time periods of the pandemic.

METHODS

Using a spatial-quantitative approach, we combined hot spot analyses, Pearson correlation analyses, and Wilcoxon two-sample tests to analyze datasets including COVID-19 cases, a mobile device-derived indicator measuring neighbourhood-level time away from home (i.e., mobility), and socioeconomic data from 2016 census and Ontario Marginalization Index. Temporal variations among pandemic phases were examined as well.

RESULTS

The paper identified important spatial clustering patterns of mobility reductions and COVID-19 cases in Toronto, as well as their relationships with marginalized populations. COVID-19 hot spots were in more materially deprived neighbourhood clusters that had more essential workers and people who spent more time away from home. While the spatial pattern of clusters of COVID-19 cases and mobility shifted slightly over time, the group socioeconomic characteristics that clusters shared remained similar in all but the first time period. A series of maps and visualizations were created to highlight the dynamic spatiotemporal patterns.

CONCLUSION

Toronto's neighbourhoods have experienced the COVID-19 pandemic in significantly different ways, with hot spots of COVID-19 cases occurring in more materially and racially marginalized communities that are less likely to reduce their mobility. The study provides solid evidence in a Canadian context to enhance policy making and provide a deeper understanding of the social determinants of health in Toronto during the COVID-19 pandemic.

Estimating the time-varying reproduction number for COVID-19 in South Africa during the first four waves using multiple measures of incidence for public and private sectors across four waves

OBJECTIVES

The aim of this study was to quantify transmission trends in South Africa during the first four waves of the COVID-19 pandemic using estimates of the time-varying reproduction number (R) and to compare the robustness of R estimates based on three different data sources, and using data from public and private sector service providers.

METHODS

R was estimated from March 2020 through April 2022, nationally and by province, based on time series of rt-PCR-confirmed cases, hospitalisations, and hospital-associated deaths, using a method that models daily incidence as a weighted sum of past incidence, as implemented in the R package EpiEstim. R was also estimated separately using public and private sector data.

RESULTS

Nationally, the maximum case-based R following the introduction of lockdown measures was 1.55 (CI: 1.43-1.66), 1.56 (CI: 1.47-1.64), 1.46 (CI: 1.38-1.53) and 3.33 (CI: 2.84-3.97) during the first (Wuhan-Hu), second (Beta), third (Delta), and fourth (Omicron) waves, respectively. Estimates based on the three data sources (cases, hospitalisations, deaths) were generally similar during the first three waves, but higher during the fourth wave for case-based estimates. Public and private sector R estimates were generally similar except during the initial lockdowns and in case-based estimates during the fourth wave.

CONCLUSION

Agreement between R estimates using different data sources during the first three waves suggests that data from any of these sources could be used in the early stages of a future pandemic. The high R estimates for Omicron relative to earlier waves are interesting given a high level of exposure pre-Omicron. The agreement between public and private sector R estimates highlights that clients of the public and private sectors did not experience two separate epidemics, except perhaps to a limited extent during the strictest lockdowns in the first wave.

Mental health, stress, and well-being measured before (2019) and during (2020) COVID-19: a Swedish socioeconomic population-based study

OBJECTIVES

Compare mental health, stress, and well-being in the Swedish population as measured before and during the COVID-19 pandemic.

METHODS

Repeated cross-sectional design using data measured before (Jan-2019; n = 2791) and during (Oct/Nov-2020; n = 2926) COVID-19 pandemic in Swedish population-representative cohorts. Following constructs were measured: anxiety (Beck Anxiety Inventory), depression (Beck Depression Inventory-II), stress (Perceived Stress Scale-10 items), health-related quality of life (HRQOL[Functional Assessment of Cancer Therapy-General Population]) and self-rated health (SRH) was assessed with a single-item question.

RESULTS

When adjusting for age, sex, education, and income there were significantly higher levels of anxiety (M̂ = 9.15 vs. 8.48, p < 0.01) and depression (M̂ = 3.64 vs. 3.30, p = 0.03), lower levels of stress (M̂ = 14.06 vs. 14.91, p < 0.001), but worsened HRQOL (M̂ = 76.40 vs. 77.92, p < 0.01) and SRH (M̂ = 6.91 vs. 7.20, p < 0.001), observed in 2020 compared to 2019. For the negative effects seen in anxiety, depression, HRQOL, and SRH, higher income and education had a protective effect. The decrease in stress was also correlated with higher income.

CONCLUSIONS

The COVID-19 pandemic led to a small but significant worsening in mental health and well-being in the general Swedish population, where higher socioeconomic status seemed to have a protective effect.

Effectiveness of the Booster Dose in Protecting against COVID-19, Colombia 2022

Vaccination has proven to be one of the most effective strategies against the COVID-19 pandemic. Several studies have evaluated and confirmed its effectiveness in different populations, particularly in reducing severe outcomes such as hospitalization and death. Some studies have investigated the effectiveness of vaccination against the infection, identifying the need for booster doses. This study aimed to explore the effectiveness of the vaccination schedule on the probability of infection in a sample of Colombian patients during the fourth wave of the COVID-19 pandemic, which was associated with the emergence and predominance of the Omicron variant. A cross-sectional study was conducted on individuals who underwent RT-PCR testing for COVID-19 detection in a dedicated laboratory in Bogotá, Colombia, between 30 December 2021 and 7 February 2022. A total of 1468 subjects was included in the study, of whom 36.6% (n = 538) had a positive PCR test for COVID-19. The comparison between fully vaccinated individuals with a booster dose and those without the booster dose revealed a 28% reduction in the odds of infection (OR = 0.719 CI 0.531-0.971). Age (OR = 1.009 CI 1.001-1.018) and low economic status (OR = 1.812 CI 1.416-2.319) were associated with an increased risk of infection. These findings suggest the need for a booster vaccination in the general population to improve the prevention rates of SARS-CoV-2 infection and mitigate severe outcomes.

Associations between an international COVID-19 job exposure matrix and SARS-CoV-2 infection among 2 million workers in Denmark

OBJECTIVES

This study investigates the associations between the Danish version of a job exposure matrix for COVID-19 (COVID-19-JEM) and Danish register-based SARS-CoV-2 infection information across three waves of the pandemic. The COVID-19-JEM consists of four dimensions on transmission: two on mitigation measures, and two on precarious work characteristics.

METHODS

The study comprised 2 021 309 persons from the Danish working population between 26 February 2020 and 15 December 2021. Logistic regression models were applied to assess the associations between the JEM dimensions and overall score and SARS-CoV-2 infection across three infection waves, with peaks in March-April 2020, December-January 2021, and February-March 2022. Sex, age, household income, country of birth, wave, residential region and during wave 3 vaccination status were accounted for.

RESULTS

Higher risk scores within the transmission and mitigation dimensions and the overall JEM score resulted in higher odds ratios (OR) of a SARS-CoV-2 infection. OR attenuated across the three waves with ranges of 1.08-5.09 in wave 1, 1.06-1.60 in wave 2, and 1.05-1.45 in those not (fully) vaccinated in wave 3. In wave 3, no associations were found for those fully vaccinated. In all waves, the two precarious work dimensions showed weaker or inversed associations.

CONCLUSIONS

The COVID-19-JEM is a promising tool for assessing occupational exposure to SARS-CoV-2 and other airborne infectious agents that mainly spread between people who are in close contact with each other. However, its usefulness depends on applied restrictions and the vaccination status in the population of interest.

Disadvantaged Students Utilize School Campus and Its Resources More Than Non-disadvantaged Students

Introduction Disadvantaged populations were disproportionately affected by the COVID-19 pandemic, both in the medical and educational settings. Lower-income families often do not have a laptop/desktop computer, adequate internet connection, or a dedicated study space. This unfortunately contributed to poorer academic performance during distance learning. To combat this, the Kirk Kerkorian School of Medicine (KKSOM) did not close down campus during the pandemic. This study analyzes the utilization of campus and live Zoom lectures by KKSOM students and its impact on educational outcomes. Methods We sent an Institutional Review Board (IRB)-approved survey to KKSOM students and asked about study locations, Zoom lecture attendance, and relationship quality during the pandemic. The class of 2024 had a unique experience as they were first-year students during the start of the COVID-19 pandemic and the transition to online learning. However, they always had access to campus and technological resources. We compared the survey scores from a Qualtrics electronic survey and the National Board of Medical Examiners (NBME) scores of students who self-indicated disadvantaged status, first-generation, underrepresented minority, and lower socioeconomic status to those who did not meet these criteria. Data analysis was done using SPSS software version 28.0.1.1 (IBM Corp., Armonk, NY). Results  First-generation students studied on campus more frequently than their counterparts (31% versus 20%, p < 0.05) and less at home in general (55.4% versus 67.5%, p < 0.05). Lower socioeconomic status (SES) students attended live Zoom lectures more often as well (56.6% versus 43.1%, p < 0.05). Lastly, no significant differences were found between disadvantaged and non-disadvantaged groups for the class of 2024 in the NBME exam scores or relationship quality scores. Conclusion Our results suggest that students from disadvantaged backgrounds spend more time studying on campus than at home. Additionally, during the COVID-19 pandemic, they attended live Zoom lectures more often than their non-disadvantaged counterparts. Access to campus was not restricted for KKSOM students during the pandemic. This may be one explanation for the lack of disparity between disadvantaged and non-disadvantaged students with regard to academic performance and relationship quality. This makes a strong argument for the importance of campus accessibility for the success of students, especially those from disadvantaged backgrounds.

Retrospective analysis of equity-based optimization for COVID-19 vaccine allocation

Marginalized racial and ethnic groups in the United States were disproportionally affected by the COVID-19 pandemic. To study these disparities, we construct an age-and-race-stratified mathematical model of SARS-CoV-2 transmission fitted to age-and-race-stratified data from 2020 in Oregon and analyze counterfactual vaccination strategies in early 2021. We consider two racial groups: non-Hispanic White persons and persons belonging to BIPOC groups (including non-Hispanic Black persons, non-Hispanic Asian persons, non-Hispanic American-Indian or Alaska-Native persons, and Hispanic or Latino persons). We allocate a limited amount of vaccine to minimize overall disease burden (deaths or years of life lost), inequity in disease outcomes between racial groups (measured with five different metrics), or both. We find that, when allocating small amounts of vaccine (10% coverage), there is a trade-off between minimizing disease burden and minimizing inequity. Older age groups, who are at a greater risk of severe disease and death, are prioritized when minimizing measures of disease burden, and younger BIPOC groups, who face the most inequities, are prioritized when minimizing measures of inequity. The allocation strategies that minimize combinations of measures can produce middle-ground solutions that similarly improve both disease burden and inequity, but the trade-off can only be mitigated by increasing the vaccine supply. With enough resources to vaccinate 20% of the population the trade-off lessens, and with 30% coverage, we can optimize both equity and mortality. Our goal is to provide a race-conscious framework to quantify and minimize inequity that can be used for future pandemics and other public health interventions.

Health inequalities in post-COVID-19 outcomes among adults aged 50+ in Europe: has COVID-19 exposed divide between postcommunist countries and Western Europe?

BACKGROUND

COVID-19 affected people and countries disproportionately and continues to impact the health of people. The aim is to investigate protective health and socio-geographical factors for post-COVID-19 conditions in adults aged 50 years and older in Europe.

METHODS

Using longitudinal data from the Survey of Health, Ageing and Retirement in Europe, collected from June to August 2021, protective factors against post-COVID-19 condition among 1909 respondents who self-reported a positive COVID-19 test result were investigated using multiple logistic regression models.

RESULTS

Male adults living outside of Czechia, Poland, Hungary and Slovakia (Visegrad group, V4), who received the COVID-19 vaccination, tertiary or higher education, had a healthy weight (body mass index, BMI 18.5-24.9 kg/m2) and no underlying health condition/s, showed protective effects against post-COVID-19 condition. Health inequalities associated with BMI were observed in education attainment and comorbidities, with higher BMI having lower education attainment and higher comorbidities. Health inequality was particularly evident in individuals in V4 with higher obesity prevalence and lower attainment of higher education than those living in other regions in the study.

CONCLUSION

Our study suggests that healthy weight and higher education attainment are predictors associated with a lower incidence of post-COVID-19 condition. Health inequality associated with education attainment was particularly relevant in V4. Our results highlight health inequality in which BMI was associated with comorbidities and educational attainment. To reduce obesity prevalence among older people with lower education, raising awareness about the risks of obesity and providing assistance in maintaining a healthy weight are needed.

Comparison of socio-economic determinants of COVID-19 testing and positivity in Canada: A multi-provincial analysis

BACKGROUND

The effects of the COVID-19 pandemic have been more pronounced for socially disadvantaged populations. We sought to determine how access to SARS-CoV-2 testing and the likelihood of testing positive for COVID-19 were associated with demographic factors, socioeconomic status (SES) and social determinants of health (SDH) in three Canadian provinces.

METHODS

An observational population-based cross-sectional study was conducted for the provinces of Ontario, Manitoba and New Brunswick between March 1, 2020 and April 27, 2021, using provincial health administrative data. After excluding residents of long-term care homes, those without current provincial health insurance and those who were tested for COVID-19 out of province, records from provincial healthcare administrative databases were reviewed for 16,900,661 healthcare users. Data was modelled separately for each province in accordance to a prespecified protocol and follow-up consultations among provincial statisticians and collaborators. We employed univariate and multivariate regression models to examine determinants of testing and test results.

RESULTS

After adjustment for other variables, female sex and urban residency were positively associated with testing, while female sex was negatively associated with test positivity. In New Brunswick and Ontario, individuals living in higher income areas were more likely to be tested, whereas in Manitoba higher income was negatively associated with both testing and positivity. High ethnocultural composition was associated with lower testing rates. Both high ethnocultural composition and high situational vulnerability increased the odds of testing positive for SARS-CoV-2.

DISCUSSION

We observed that multiple demographic, income and SDH factors were associated with SARS-CoV-2 testing and test positivity. Barriers to healthcare access identified in this study specifically relate to COVID-19 testing but may reflect broader inequities for certain at-risk groups.

Predictors of student mask mandate policies in United States school districts during the COVID-19 pandemic

Introduction

Although factors such as urbanicity, population demographics, and political affiliation have been linked with COVID-19 masking behavior and policy in community settings, little work has investigated factors associated with school mask policies. We sought to characterize United States state and school district student COVID-19 masking policies during the 2021-22 school year and determine predictors of these mandates at four time points, including before and after federal guidance relaxed school mask recommendations in February 2022.

Methods

Student mask policies for US states and the District of Columbia, as well as a sample of 56 districts were categorized as prohibited, recommended, or required in September 2021, November 2021, January 2022, and March 2022 based on the Johns Hopkins eSchool+ Initiative School Reopening Tracker. Changes in policies over time were characterized. Generalized estimating equations and logistic regression were used to evaluate whether political affiliation of governor, urbanicity, economic disadvantage, and race/ethnic composition of district students, and county-level COVID-19 incidence predicted the presence of a district mask mandate at any time point and at all four time points.

Results

State and district policies changed over time. Districts that implemented student mandates at any point were more likely to be in states with Democratic governors (AOR: 5.52; 95% CI: 2.23, 13.64) or in non-rural areas (AOR: 8.20; 95% CI: 2.63, 25.51). Districts that retained mask mandates at all four time points were more likely to have Democratic governors (AOR: 5.39; 95% CI: 2.69, 10.82) and serve a smaller proportion of economically disadvantaged students (AOR: 0.97; 95% CI: 0.95, 0.99). Districts serving a larger proportion of students from minoritized racial/ethnic groups were more likely to have mask mandates at any or all timepoints. Notably, county-level COVID-19 prevalence was not related to the presence of a mask mandate at any or all time points. By March 2022, no factors were significantly associated with district mask policy.

Discussion

Political, geographic, and demographic characteristics predicted the likelihood of student mask mandates in the 2021-22 school year. Public health promotion messages and policy must account for variation in these factors, potentially through centralized and consistent messaging and unbiased, trustworthy communication.

Unequal burdens of COVID-19 infection: a nationwide cohort study of COVID-19-related health inequalities in Korea

OBJECTIVES

While the Korean government's response to the coronavirus disease 2019 (COVID-19) pandemic is considered effective given the relatively low mortality rate, issues of inequality have been insufficiently addressed. This study explored COVID-19-related health inequalities in Korea.

METHODS

Age standardization for various health inequality indices was derived using data from the Korean National Health Insurance Service, the Korea Disease Control and Prevention Agency, and the Microdata Integrated Service of Statistics Korea. The slope index of inequality (SII) and relative index of inequality (RII) were calculated for socioeconomic variables, while absolute difference (AD) and relative difference (RD) were used for gender and disability inequalities.

RESULTS

We observed a number of COVID-19-related health outcome inequalities. Gender inequality was particularly noticeable in infection rates, with the rate of women 1.16 times higher than that of men. In contrast, socioeconomic inequality was evident in vaccination rates, with a 4.5-fold (SII, -4.519; 95% confidence interval, -7.403 to -1.634) difference between the highest and lowest household income groups. Regarding clinical progression post-infection, consistent findings indicated higher risk for men (RD for hospitalization, 0.90; severe cases, 0.54; and fatality, 0.65), individuals with disabilities (RD for hospitalization, 2.27; severe cases, 2.29; and fatality, 2.37), and those from lower socioeconomic groups (SII for hospitalization, 1.778; severe cases, 0.089; and fatality, 0.451).

CONCLUSIONS

While the infection risk was nearly ubiquitous, not everyone faced the same level of risk post-infection. To prevent further health inequalities, it is crucial to develop a thoughtful policy acknowledging individual health conditions and resources.