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How did COVID-19 mortality rates during 2020 in the United States vary by race and ethnicity in combination with educational attainment?
In this cross-sectional study of 219.1 million adults aged 25 years or older, most racial and ethnic minority populations had higher age-adjusted mortality rates than non-Hispanic White populations, including when comparing within levels of educational attainment. If all racial and ethnic populations had experienced the same mortality rates as college-educated non-Hispanic White populations, 71% fewer deaths among racial and ethnic minority populations would have occurred.
This study suggests that 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 COVID-19 mortality rates.
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.
Design, Setting, and Participants
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.
Main Outcomes and Measures
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.
Conclusions and Relevance
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.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: September 29, 2012.
Published: November 23, 2021. doi:10.1001/jamanetworkopen.2021.35967
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Feldman JM et al. JAMA Network Open.
Corresponding Author: Justin M. Feldman, ScD, FXB Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA 02115 (firstname.lastname@example.org).
Author Contributions: Dr Feldman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Feldman.
Drafting of the manuscript: Feldman.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Feldman.
Administrative, technical, or material support: Feldman.
Conflict of Interest Disclosures: None reported.
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