Declines in racial disparities in COVID mortality in 2021 were largely driven by increases in white mortality and changing pandemic geography
Although national COVID mortality disparities declined in 2021, this decrease was largely explained by increases in mortality among White individuals and the shifting geography of the pandemic from urban to rural areas
Peer-Reviewed PublicationFOR IMMEDIATE RELEASE
Although national COVID mortality disparities declined in 2021, this decrease was largely explained by increases in mortality among White individuals and the shifting geography of the pandemic from urban to rural areas rather than decreases in mortality among non-Hispanic Black and Hispanic individuals.
The racial disparities in COVID-19 deaths became a defining part of the first year of the pandemic in the United States, prompting national efforts to reduce this disproportionate toll among Black and Hispanic communities through vaccination drives and other outreach when COVID vaccines became available in 2021. Following these efforts, federal officials and the media touted major reductions in disparities in COVID mortality rates during the Delta and Omicron waves in the second year of the pandemic, but a new study led by Boston University School of Public Health (BUSPH) shows that the declines in these disparities do not reflect substantial improvements in population health to the extent previously thought.
Published in the journal JAMA Network Open, the study found that disparities in US COVID death rates between Black and White adults narrowed substantially from the first to the second year of the pandemic, from 339 deaths to 45 deaths per 100,000 people in 2021, after accounting for age. But this sharp decline mostly resulted from an increase in COVID deaths among White people, as well as a geographical shift in mortality from large, urban cities to rural and smaller metropolitan areas, rather than from decreases in deaths among the Black population.
Similarly, Hispanic-White disparities in deaths shrunk from 172 deaths to 12 deaths, and this decline was entirely due to increases in COVID deaths among White and rural populations.
Furthermore, while the findings showed that national COVID death rates for Black, Hispanic, and Asian populations did decrease by 2021, the death rates among these groups increased in rural areas in 2021 and exceeded White death rates.
This geographical shift in US COVID mortality and continued high death rates among racial and ethnic minority populations suggest that declarations of COVID-related racial equity achievements may be coming too soon. As the Biden administration prepares to lift the COVID public health emergency on May 11, much more work still needs to be done to address this burden among all populations.
“Contrary to popular media narratives, our findings indicate that decreases in racial and ethnic disparities in COVID were mostly explained by increases in mortality for White adults and changes in pandemic geography rather than decreases in Black and Hispanic mortality,” says study corresponding author Dr. Andrew Stokes, assistant professor of global health at BUSPH. “This suggests that it may be premature to celebrate reductions in disparities because they did not largely represent reductions in mortality.”
For the study, Dr. Stokes and colleagues utilized national data to examine COVID-related deaths among nearly one million US adults 25 and older from the initial wave of the pandemic in March 2020 to the Delta and Omicron waves through February 2022. The team examined these deaths by race and ethnicity across metropolitan and nonmetropolitan areas and developed an innovative mathematical framework to identify the factors contributing to the decline in disparities.
Through this framework, the researchers estimated that the rise in COVID deaths in rural areas—which increased from five percent of all rural deaths in 2020 to about 22 percent of all rural deaths by March 2022—and the increase in mortality among the White population explained about 60 percent of the decline in disparities, and the remainder was due to the national decline in deaths among the Black population.
The team also observed concerning trends among the American Indian/Alaska Native (AIAN) population. COVID deaths for this group appeared to increase at the national level during the Delta and Omicron waves, in both urban and rural areas.
Several social, political, geographical, and structural factors may contribute to these shifts in COVID mortality rates. Vaccination and booster rates play a central role—the researchers say the politicized nature of vaccines likely led to lower uptake of the primary series among White and rural people, and Black, Hispanic, and AIAN people have received substantially fewer boosters than White people. Rural residents also experience greater rates of chronic diseases, a risk factor for severe COVID infection, as well as greater difficulty accessing care.
“The social and structural determinants of health that have contributed to the racial and ethnic disparities in mortality observed during the pandemic remain largely unaddressed,” says study first author Dielle Lundberg, research assistant at BUSPH and doctoral student at the University of Washington School of Public Health. “Ongoing work to address these determinants of health, along with increased efforts to ensure booster uptake in rural communities, especially among older adults, are still urgently needed.”
The researchers also urge community investments and policy changes that will remove social and economic barriers largely driven by structural racism, increase access to community resources, and close the racial health equity gap.
"These results underscore COVID's ongoing toll, even in the vaccinated era,” says study co-author Dr. Elizabeth Wrigley-Field, assistant professor of sociology at the University of Minnesota College of Liberal Arts. “Full protection can't rest only on vaccination or other choices that individuals can make -- it also means social policies like paid sick leave, new standards for indoor air quality in workplaces and schools, and expanding and diversifying the healthcare workforce, especially in rural areas."
The research team included additional researchers from BUSPH, Boston University College of Arts & Sciences, Boston University Center for Antiracist Research, The University of Pennsylvania, University of California, San Francisco and Santa Cruz; Stanford University, Massachusetts Institute of Technology, and The Robert Wood Johnson Foundation.
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About Boston University School of Public Health
Founded in 1976, Boston University School of Public Health is one of the top five ranked private schools of public health in the world. It offers master's- and doctoral-level education in public health. The faculty in six departments conduct policy-changing public health research around the world, with the mission of improving the health of populations—especially the disadvantaged, underserved, and vulnerable—locally and globally.
JOURNAL
JAMA Network Open
METHOD OF RESEARCH
Observational study
SUBJECT OF RESEARCH
People
ARTICLE TITLE
COVID-19 Mortality by Race and Ethnicity in US Metropolitan and Nonmetropolitan Areas, March 2020 to February 2022
ARTICLE PUBLICATION DATE
2-May-2023
COI STATEMENT
Dr. Nsoesie reported receiving personal fees from Novartis outside the submitted work and participating in the Artificial Intelligence/Machine Learning Consortium to Advance Health Equity and Researcher Diversity Program team at the National Institutes of Health through the Intergovernmental Personnel Act Mobility Program. Dr Stokes reported receiving grants from Johnson & Johnson and Swiss Re outside the submitted work. No other disclosures were reported.
At start of COVID-19 pandemic, masking compliance of shoppers in Chinese store influenced their in-store behaviors
Compliant mask wearers spent 25% less time shopping than before pandemic
Peer-Reviewed PublicationAs the coronavirus began to spread globally, face masks were recommended in public settings to protect against transmission, and compliance varied significantly. In a new study of people shopping in a large Chinese store in early 2020, researchers examined the motives behind customers’ compliance with mask recommendations and how their shopping behaviors changed with the onset of the pandemic. The study found that customers changed their in-store behaviors significantly based on their compliance with masking recommendations.
The study, by researchers at Carnegie Mellon University (CMU), Harvard University, and Renmin University, is published in Marketing Science.
“At the start of the COVID-19 pandemic, a variety of psychological factors drove individuals’ reactions to masking recommendations, making the pandemic a large-scale social experiment,” says Kannan Srinivasan, Professor of Management, Marketing, and Information Systems at Carnegie Mellon University's Tepper School of Business, who led the study.
Srinivasan and colleagues examined customers at a large store of a retail chain in China, using recordings from high-resolution cameras at entries, checkout counters, and other locations inside the store. Researchers collected videos from January 1-23, 2020 (which they classified as the pre-pandemic period) and from February 1 to May 31, 2020. The World Health Organization issued a statement about the outbreak of the novel coronavirus, and China presented evidence of human-to-human transmission on January 23. The store was closed from January 24-31, 2020.
Based on studies on social influence and mask wearing, researchers identified three types of customers: Fully compliant customers (54%) wore masks and seemed motivated primarily by concerns about their own health risk. Partially compliant customers (29%) also wore masks, but wore them improperly, and were motivated by the desire to comply with social norms. Non-compliant customers (17%) did not wear masks and were unmotivated by health concerns or social norms. To infer motives behind wearing masks, the researchers used advanced facial recognition mechanisms to detect whether a customer wore a mask and measured the mask fit (operationalized as the extent of mask coverage) for those who did. Fully compliant customers wore their masks over a larger area above the nose than partially compliant customers.
The researchers used the store videos to examine changes in individuals’ shopping behaviors at the onset of the pandemic, contrasting them with the individuals’ shopping behaviors before the pandemic. In particular, they looked at customers’ attempts to practice social distancing and the amount of time spent in the store, as well as at what kinds of masks customers wore.
Fully compliant mask wearers remained at a greater distance from cashiers when shopping during the pandemic than they did before the pandemic. They were five times more likely than other mask wearers to wear highly protective N95 masks while shopping and spent 25% less time shopping than they did before the pandemic. In contrast, partially compliant mask wearers did not distance themselves from cashiers, were less likely to wear high-quality masks, and shopped for the same duration of time as they did before the pandemic. Similarly, non-mask wearers did not distance themselves from cashiers and did not change the duration of their shopping time.
“Our findings have implications for businesses, health practitioners, and policymakers,” suggests Shunyuan Zhang, Assistant Professor of Marketing at Harvard Business School, who coauthored the study.
In particular:
- Retailers can target different customers in different ways: For example, for fully compliant customers, they can explain their efforts to reduce shopping time and mitigate store congestion, and for the partially compliant, they can emphasize the importance of social responsibility.
- Public-health practitioners can message more effectively when their efforts are customized to appeal to individual motives. For example, practitioners may benefit from applying the same principles to efforts involving vaccine compliance.
- In regions with large numbers of partially compliant or non-compliant individuals, policymakers can redouble educational efforts to encourage more masking.
The study was funded by the National Natural Science Foundation of China.
JOURNAL
Marketing Science
ARTICLE TITLE
Frontiers: Unmasking Social Compliance Behavior During the Pandemic
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