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U.S. communities with limited internet access had higher COVID-19 mortality rates during the first full year of the pandemic, according to researchers.
In a study published earlier this month in the journal JAMA Network Open, University of Chicago authors wrote that for places with more limited access between 2.4 and six deaths per 100,000 people could be prevented, depending on whether they were rural, suburban or urban.
“Adopting an asset-based approach, we believe this finding suggests that more awareness is needed about the essential asset of technological access to reliable information, remote work, schooling opportunities, resource purchasing and/or social community. Populations with limited internet access remain understudied and are often excluded in pandemic research,” they noted.
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Analyzing Centers for Disease Control and Prevention (CDC) mortality data for all U.S. counties in 50 states and the District of Columbia reported from Jan. 22, 2020 to Feb. 28, 2021, the group identified counties with a high concentration of a single racial and ethnic population and a high level of COVID-19 mortality as “concentrated longitudinal-impact counties.”
Other racial and ethnic demographic data was sourced from publicly available data sets.
The social determinants of health (SDOH) that could be associated with mortality across the counties were examined, with researchers focusing on Black, Hispanic and non-Hispanic White Americans in rural, suburban or urban areas.
Four indexes were used to measure multiple dimensions of SDOH: a socioeconomic advantage index, limited mobility index, urban core opportunity index and mixed immigrant cohesion and accessibility index.
Using modeling to examine the associations between the SDOH and county-level COVID-19 mortality rate, they found that 531 of 3,142 counties were identified as concentrated longitudinal-impact counties.
Of those counties 347 had a large population of Black Americans, 198 had a large Hispanic population and 33 had a large non-Hispanic White population.
In addition, nearly 490,000 COVID-19-related deaths were reported.
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“Most concentrated longitudinal-impact counties with a large Black or African American population compared with other counties were spread across urban, suburban and rural areas and experienced numerous disadvantages, including higher income inequality and more preventable hospital stays. Most concentrated longitudinal-impact counties with a large Hispanic or Latinx population compared with other counties were located in urban areas, and 130 of these counties had a high percentage of people who lacked health insurance. Most concentrated longitudinal-impact counties with a large non-Hispanic White population compared with other counties were in rural areas, included a large group of older adults, and had limited access to quality health care,” the study concluded.
In urban areas, the mixed immigrant cohesion and accessibility index was inversely associated with COVID-19 mortality and higher COVID-19 mortality rates were also associated with preventable hospital stays in rural areas and higher socioeconomic status vulnerability in suburban areas.
For most concentrated longitudinal-impact counties with a large Black or Hispanic populations compared with other counties, severe housing problem rates were higher than the national median level and most concentrated longitudinal-impact counties with large Black and non-Hispanic White populations had higher percentages of households without access to the internet.
The study’s results, they said, underscore how places and people intersect within the multifaceted power structures that produce and reproduce inequity in health outcomes.
“Clearly, SDOH dimensions matter for health outcomes, but the results of this study add nuance to this assumption by demonstrating that SDOH potentially shape health in unique ways, depending on a community’s rural and urban contexts as well as its racial and ethnic makeup,” the authors wrote. “We found that non-Hispanic White populations in rural areas and Hispanic or Latinx populations in urban areas were especially vulnerable to COVID-19 mortality, whereas Black or African American populations across rural and urban contexts fared poorly (in terms of mortality rate) during the first year of the pandemic. For urban, rural, and suburban communities, some dimensions of SDOH seemed to be more consequential for COVID-19 mortality rates, pointing to the social levers that might play the biggest role in moving the needle on population health in different types of communities.”
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Limitations to their study include that analyses for other racial and ethnic groups were excluded, that the cross-sectional study used an exploratory spatial data analysis approach, that the county-level scale may not capture the full picture of affected populations, that there is the potential confounding factor of vaccines being available at the end of 2020 and that they primarily analyzed SDOH barriers associated with vulnerability to COVID-19 mortality.
To address health inequities and guide policies and programs, they called for further study.
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