Abstract
Racial and ethnic inequities in COVID-19 mortality have been well documented, but little prior research has assessed the combined roles of race and ethnicity and educational attainment. To measure inequality in COVID-19 mortality jointly by race and ethnicity and educational attainment. This cross-sectional study analyzed data on COVID-19 mortality from the 50 US states and the District of Columbia for the full calendar year 2020. It included all persons in the United States aged 25 years or older and analyzed them in subgroups jointly stratified by age, sex, race and ethnicity, and educational attainment. Population-based cumulative mortality rates attributed to COVID-19.F. Among 219.1 million adults aged 25 years or older (113.3 million women [51.7%]; mean [SD] age, 51.3 [16.8] years), 376 125 COVID-19 deaths were reported. Age-adjusted cumulative mortality rates per 100 000 ranged from 54.4 (95% CI, 49.8-59.0 per 100 000 population) among Asian women with some college to 699.0 (95% CI, 612.9-785.0 per 100 000 population) among Native Hawaiian and Other Pacific Islander men with a high school degree or less. Racial and ethnic inequalities in COVID-19 mortality rates remained when comparing within educational attainment categories (median rate ratio reduction, 17% [IQR, 0%-25%] for education-stratified estimates vs unstratified, with non-Hispanic White individuals as the reference). If all groups had experienced the same mortality rates as college-educated non-Hispanic White individuals, there would have been 48% fewer COVID-19 deaths among adults aged 25 years or older overall, including 71% fewer deaths among racial and ethnic minority populations and 89% fewer deaths among racial and ethnic minority populations aged 25 to 64 years. Public health research and practice should attend to the ways in which populations that share socioeconomic characteristics may still experience racial and ethnic inequity in the distribution of risk factors for SARS-CoV-2 exposure and infection fatality rates (eg, housing, occupation, and prior health status). This study suggests that a majority of deaths among racial and ethnic minority populations could have been averted had all groups experienced the same mortality rate as college-educated non-Hispanic White individuals, thus highlighting the importance of eliminating joint racial-socioeconomic health inequities.
Highlights
Numerous studies have documented racial and ethnic inequities in COVID-19 mortality rates in the United States.[1,2,3] Racial and ethnic inequalities are large, with cumulative mortality rate ratios (MRRs) exceeding those of other major causes of death.[3]
Age-adjusted cumulative mortality rates per 100 000 ranged from 54.4 among Asian women with some college to 699.0 among Native Hawaiian and Other Pacific Islander men with a high school degree or less
Racial and ethnic inequalities in COVID-19 mortality rates remained when comparing within educational attainment categories
Summary
Numerous studies have documented racial and ethnic inequities in COVID-19 mortality rates in the United States.[1,2,3] Racial and ethnic inequalities are large, with cumulative mortality rate ratios (MRRs) exceeding those of other major causes of death.[3] to our knowledge, few studies have assessed COVID-19 mortality inequities by race and ethnicity in combination with socioeconomic position, and the data to conduct such analyses on the national level have been unavailable until recently. One US-wide study found roughly equal cumulative mortality rates by race and ethnicity within educational attainment categories, but the data source did not allow for age standardization and, as the authors noted, the results were likely to underestimate racial and ethnic inequities because US White populations have distributions that skew older.[2] That study, along with another analysis of California’s Latinx population,[4] found that persons in the lowest socioeconomic position experienced the highest COVID-19 mortality rates within racial and ethnic groups. We assessed 3 hypotheses with our study: (1) racial and ethnic minority populations would experience higher age-adjusted COVID-19 mortality rates than the non-Hispanic White population; (2) within racial and ethnic groups, age-adjusted COVID-19 mortality rates would be highest among those with the lowest educational attainment; and (3) racial and ethnic inequalities in COVID-19 mortality rates would remain when comparing within levels of educational attainment
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