Cited by 136COVID-19 epidemiological studiesHealth disparities and outcomesCOVID-19 Clinical Research Studies

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Social inequalities and COVID-19 mortality in the city of São Paulo, Brazil

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Ribeiro, Karina Braga, Ribeiro, Ana Freitas, Veras, Maria Amélia de Sousa Mascena, de Castro, Marcia Caldas·2021·International Journal of Epidemiology

DOI 10.1093/ije/dyab022PMC PMC7989375

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Abstract

Background: Heterogeneity in COVID-19 morbidity and mortality is often associated with a country's health-services structure and social inequality. This study aimed to characterize social inequalities in COVID-19 mortality in São Paulo, the most populous city in Brazil and Latin America. Methods: We conducted a population-based study, including COVID-19 deaths among São Paulo residents from March to September 2020. Age-standardized mortality rates and unadjusted rate ratios (RRs) [with corresponding 95% confidence intervals (CIs)] were estimated by race, sex, age group, district of residence, household crowding, educational attainment, income level and percentage of households in subnormal areas in each district. Time trends in mortality were assessed using the Joinpoint model. Results: Males presented an 84% increase in COVID-19 mortality compared with females (RR = 1.84, 95% CI 1.79–1.90). Higher mortality rates were observed for Blacks (RR = 1.77, 95% CI 1.67–1.88) and mixed (RR = 1.42, 95% CI 1.37–1.47) compared with Whites, whereas lower mortality was noted for Asians (RR = 0.63, 95% CI 0.58–0.68). A positive gradient was found for all socio-economic indicators, i.e. increases in disparities denoted by less education, more household crowding, lower income and a higher concentration of subnormal areas were associated with higher mortality rates. A decrease in mortality over time was observed in all racial groups, but it started earlier among Whites and Asians. Conclusion: Our results reveal striking social inequalities in COVID-19 mortality in São Paulo, exposing structural inequities in Brazilian society that were not addressed by the governmental response to COVID-19. Without an equitable response, COVID-19 will further exacerbate current social inequalities in São Paulo.

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Authors: Ribeiro, K. B., Ribeiro, A. F., Veras, M. A. D. S. M., & de Castro, M. C.
Affiliations: Faculdade de Ciências Médicas da Santa Casa de São Paulo (BR)
Universidade Municipal de São Caetano do Sul (BR)
Harvard TH Chan School of Public Health, Department of Global Health and Population, Boston, United States of America
Corresponding author: Ribeiro, Karina Braga
ORCID: Ribeiro, Karina Braga
Ribeiro, Ana Freitas
Veras, Maria Amélia de Sousa Mascena
Venue: International Journal of Epidemiology
Publisher: Oxford University Press (OUP)
Published: 2021-02-28
Volume: 50
Issue: 3
Pages: 732-742
ISSN: 0300-5771 (ISSN-L)
1464-3685
DOI: 10.1093/ije/dyab022
PMC: PMC7989375
OpenAlex: W3134855230
Cited by: 134
References: 41
Citations by year: 2026: 7 · 2025: 13 · 2024: 27 · 2023: 23 · 2022: 47 · 2021: 17
FWCI: 11.02
Type: journal article
Language: en
Open access: hybrid
doi.org
Licence: public-domain
academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor)
Locations: International Journal of Epidemiology (publishedVersion, public-domain)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Funders: Governo Brasil
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 inequality, health disparities, racial disparities, sex differences, socioeconomic status, household crowding, educational attainment, income, urban districts, São Paulo, mortality trends, COVID-19 pandemic response
MeSH terms: COVID-19, SARS-CoV-2, Brazil, Cities, Crowding, Family Characteristics, Female, Humans, Male, Mortality, Socioeconomic Factors

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Social inequalities and COVID-19 mortality in the city of São Paulo, Brazil

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