Social determinants of mortality from COVID-19: A simulation study using NHANES
Open accessAbstract
Background: The COVID-19 epidemic in the United States is widespread, with more than 200,000 deaths reported as of September 23, 2020. While ecological studies show higher burdens of COVID-19 mortality in areas with higher rates of poverty, little is known about social determinants of COVID-19 mortality at the individual level. Methods and findings: We estimated the proportions of COVID-19 deaths by age, sex, race/ethnicity, and comorbid conditions using their reported univariate proportions among COVID-19 deaths and correlations among these variables in the general population from the 2017–2018 National Health and Nutrition Examination Survey (NHANES). We used these proportions to randomly sample individuals from NHANES. We analyzed the distributions of COVID-19 deaths by race/ethnicity, income, education level, and veteran status. We analyzed the association of these characteristics with mortality by logistic regression. Summary demographics of deaths include mean age 71.6 years, 45.9% female, and 45.1% non-Hispanic white. We found that disproportionate deaths occurred among individuals with nonwhite race/ethnicity (54.8% of deaths, 95% CI 49.0%–59.6%,p< 0.001), individuals with income below the median (67.5%, 95% CI 63.4%–71.5%,p< 0.001), individuals with less than a high school level of education (25.6%, 95% CI 23.4% –27.9%,p< 0.001), and veterans (19.5%, 95% CI 15.8%–23.4%,p< 0.001). Except for veteran status, these characteristics are significantly associated with COVID-19 mortality in multiple logistic regression. Limitations include the lack of institutionalized people in the sample (e.g., nursing home residents and incarcerated persons), the need to use comorbidity data collected from outside the US, and the assumption of the same correlations among variables for the noninstitutionalized population and COVID-19 decedents. Conclusions: Substantial inequalities in COVID-19 mortality are likely, with disproportionate burdens falling on those who are of racial/ethnic minorities, are poor, have less education, and are veterans. Healthcare systems must ensure adequate access to these groups. Public health measures should specifically reach these groups, and data on social determinants should be systematically collected from people with COVID-19.
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Caregiver loss is even more heavily concentrated in vulnerable populations than shown in our results.
“Our ability to observe more specific geographic and demographic disparities is constrained by the limitations of available data, but we can infer from other analyses that caregiver loss is even more heavily concentrated in vulnerable populations than shown in our results.”
From Parental and Other Caregiver Loss Due to COVID-19 in the United States: Prevalence by Race, State, Relationship, and Child Age (2023) · cites this paper as [28]
The Discussion says COVID-19 mortality disproportionately affects socially disadvantaged groups and that the disparities found by its simulation are likely underestimated. The paper studies deaths, not caregiver loss, so it does not establish that caregiver loss is more concentrated in vulnerable populations than the citing authors’ results show. (LLM, conf=0.84)
Experimental — accuracy not yet measuredLow-income individuals are at highest risk of death from COVID-19, and low-income counties faced disproportionately large shares of COVID-19 deaths, even after controlling for other indicators of wellbeing.
“Low-income individuals are at highest risk of death from COVID-19 and low-income counties faced disproportionately large shares of COVID-19 deaths, even after controlling for other indicators of wellbeing in two studies focused on individual and communitylevel associations with COVID-19 mortality rates of all persons [11, 28].”
From Parental and Other Caregiver Loss Due to COVID-19 in the United States: Prevalence by Race, State, Relationship, and Child Age (2023) · cites this paper as [28]
The Results report that people below median income accounted for a disproportionate 67.5% of simulated COVID-19 deaths, and the Discussion describes disproportionate mortality among low- or middle-income families. The paper does not establish that low-income individuals had the highest risk. The county-level finding appears to be attributed to the other study cited in the sentence, not this one. (LLM, conf=0.85)
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COVID-19 Pandemic: Public Health Risk Assessment and Risk Mitigation Strategies
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Acceptance Rates of COVID-19 Vaccine Highlight the Need for Targeted Public Health Interventions
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Global priorities for large-scale biomarker-based prospective cohorts
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Self-citationEditorial: The Impact of Migration and Resettlement on Health
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Children Who Lose a Parent in the COVID-19 Era: Considerations on Grief and Mourning
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Is Mandatory Vaccination in Population over 60 Adequate to Control the COVID-19 Pandemic in E.U.?
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- Authors
- Seligman, B., Ferranna, M., & Bloom, D. E.
- Affiliations
- Harvard University (US)
- Corresponding author
- Seligman, Benjamin
- Venue
- PLOS Medicine
- Publisher
- Public Library of Science (PLoS)
- Published
- 2021-01-11
- Volume
- 18
- Issue
- 1
- Pages
- e1003490
- ISSN
- 1549-1277 (ISSN-L)
- 1549-1676
- PMC
- PMC7799807
- OpenAlex
- W3119998633
- Cited by
- 103
- References
- 46
- Citations by year
- 2026: 1 · 2025: 4 · 2024: 11 · 2023: 15 · 2022: 39 · 2021: 32 · 2020: 1
- FWCI
- 9.36
- Type
- journal article
- Language
- en
- Update notices
- correction (2021-12-29)
- Open access
- gold
- doi.org
- Licence
- public-domain
- creativecommons.org/publicdomain/zero/1.0/ (vor)
- Locations
- PLoS Medicine (publishedVersion, public-domain)
- Europe PMC (PubMed Central) (publishedVersion, public-domain)
- PubMed Central (publishedVersion, public-domain)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- U.S. Department of Veterans Affairs
- Bill and Melinda Gates Foundation (OPP1158136)
- Harvard T.H. Chan School of Public Health
- Topics
- Physical Sciences › Mathematics › Modeling and Simulation › COVID-19 epidemiological studies
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Social Sciences › Health › Health disparities and outcomes
- Keywords
- COVID-19 mortality, social determinants of health, racial and ethnic disparities, income inequality, educational attainment, veteran status, comorbidities, health disparities, NHANES, health care access, public health measures, age and sex differences in mortality, health equity policy, health workforce diversity, health workforce shortage
- MeSH terms
- COVID-19, SARS-CoV-2, Aged, Ethnicity, Female, Health Services Needs and Demand, Humans, Male, Mortality, Public Health, Socioeconomic Factors, United States, Comorbidity, Healthcare Disparities, Veterans Health, Quality Improvement, Social Determinants of Health
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