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Cited by 29COVID-19 epidemiological studiesHealth disparities and outcomesCOVID-19 Clinical Research Studies

Differential Patterns by Area-Level Social Determinants of Health in Coronavirus Disease 2019 (COVID-19)–Related Mortality and Non–COVID-19 Mortality: A Population-Based Study of 11.8 Million People in Ontario, Canada

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Wang, Linwei, Calzavara, Andrew, Baral, Stefan, Smylie, Janet, Chan, Adrienne K, Sander, Beate, Austin, Peter C, Kwong, Jeffrey C +1 more·2023·Clinical Infectious Diseases
DOI 10.1093/cid/ciac850PMC PMC9620355
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Abstract

Background: Social determinants of health (SDOH) have been associated with coronavirus disease 2019 (COVID-19) outcomes. We examined patterns in COVID-19–related mortality by SDOH and compared these patterns to those for non–COVID-19 mortality. Methods: Residents of Ontario, Canada, aged ≥20 years were followed from 1 March 2020 to 2 March 2021. COVID-19–related death was defined as death within 30 days following or 7 days prior to a positive COVID-19 test. Area-level SDOH from the 2016 census included median household income; proportion with diploma or higher educational attainment; proportion essential workers, racially minoritized groups, recent immigrants, apartment buildings, and high-density housing; and average household size. We examined associations between SDOH and COVID-19–related mortality, and non-COVID-19 mortality using cause-specific hazard models. Results: Of 11 810 255 individuals, we observed 3880 COVID-19–related deaths and 88 107 non–COVID-19 deaths. After accounting for demographics, baseline health, and other area-level SDOH, the following were associated with increased hazards of COVID-19–related death (hazard ratio [95% confidence interval]: lower income (1.30 [1.04–1.62]), lower educational attainment (1.27 [1.07–1.52]), higher proportions essential workers (1.28 [1.05–1.57]), racially minoritized groups (1.42 [1.08–1.87]), apartment buildings (1.25 [1.07–1.46]), and large vs medium household size (1.30 [1.12–1.50]). Areas with higher proportion racially minoritized groups were associated with a lower hazard of non–COVID-19 mortality (0.88 [0.84–0.92]). Conclusions: Area-level SDOH are associated with COVID-19–related mortality after accounting for demographic and clinical factors. COVID-19 has reversed patterns of lower non–COVID-19 mortality among racially minoritized groups. Pandemic responses should include strategies to address disproportionate risks and inequitable coverage of preventive interventions associated with SDOH.

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Authors
Wang, L., Calzavara, A., Baral, S., Smylie, J., Chan, A. K., Sander, B., Austin, P. C., Kwong, J. C., & Mishra, S.
Affiliations
  • St. Michael's Hospital (CA)
  • Institute for Clinical Evaluative Sciences (CA)
  • Johns Hopkins University (US)
  • Sunnybrook Health Science Centre (CA)
  • University Health Network (CA)
Corresponding author
Mishra, Sharmistha
ORCID
Venue
Clinical Infectious Diseases
Publisher
Oxford University Press (OUP)
Published
2022-10-28
Volume
76
Issue
6
Pages
1110-1120
ISSN
  • 1058-4838 (ISSN-L)
  • 1537-6591
DOI
10.1093/cid/ciac850
PMC
PMC9620355
OpenAlex
W4307493348
Cited by
29
References
3
Citations by year
2026: 5 · 2025: 6 · 2024: 13 · 2023: 4 · 2022: 1
FWCI
3.55
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Infectious Diseases (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
Funders
  • Canadian Institutes of Health Research
  • St. Michael’s Hospital Foundation
  • ICES
  • MOH and the MLTC
  • a Tier 2 Canada Research Chair in Mathematical Modelling and Program Science
  • University of Toronto Department of Family and Community Medicine
Topics
  • Physical Sciences › Mathematics › Modeling and Simulation › COVID-19 epidemiological studies
  • Social Sciences › Health › Health disparities and outcomes
  • Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
Keywords
COVID-19 mortality, social determinants of health, non-COVID-19 mortality, racial and ethnic minorities, household income, educational attainment, essential workers, housing conditions, apartment buildings, household size, Ontario, health disparities, pandemic response, census data, cause-specific mortality, new immigrants, high-density housing, racial disparities in mortality
MeSH terms
COVID-19, Humans, Income, Ontario, Surveys and Questionnaires, Social Determinants of Health

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