Question
To what extent are inequities in educational attainment and occupational characteristics associated with racial and ethnic inequities in COVID-19 mortality?
Findings
In this cohort study of 25 million working-age adults in California, differences in the distribution of education and occupation across racial and ethnic groups were associated with racial and ethnic inequities in COVID-19 mortality, particularly for Latinx adults. If every working-age Californian had the COVID-19 mortality risk associated with the lowest-risk educational and occupational position, there would have been an estimated 8441 (43%) fewer deaths in this population.
Meaning
Educational and occupational disadvantage are important factors associated with risk for COVID-19 mortality, but eliminating avoidable excess risk associated with low-education, essential, on-site, and low-wage jobs is unlikely to be sufficient alone to achieve equity.
Importance
Racial and ethnic inequities in COVID-19 mortality may be driven by occupation and education, but limited evidence has assessed these mechanisms.
Objective
To estimate whether occupational characteristics or educational attainment explained the associations between race and ethnicity and COVID-19 mortality.
Design, Setting, and Participants
This population-based retrospective cohort study of Californians aged 18 to 65 years linked COVID-19 deaths to population estimates within strata defined by race and ethnicity, gender, age, nativity in the US, region of residence, education, and occupation. Analysis was conducted from September 2020 to February 2022.
Exposures
Education and occupational characteristics associated with COVID-19 exposure (essential sector, telework option, wages).
Main Outcomes and Measures
All confirmed COVID-19 deaths in California through February 12, 2021. The study estimated what COVID-19 mortality would have been if each racial and ethnic group had (1) the COVID-19 mortality risk associated with the education and occupation distribution of White people and (2) the COVID-19 mortality risk associated with the lowest-risk educational and occupational positions.
Results
Of 25 235 092 participants (mean [SD] age, 40 [14] years; 12 730 395 [50%] men), 14 783 died of COVID-19, 8 125 565 (32%) had a Bachelor’s degree or higher, 13 345 829 (53%) worked in essential sectors, 11 783 017 (47%) could not telework, and 12 812 095 (51%) had annual wages under $51 700. COVID-19 mortality ranged from 15 deaths per 100 000 for White women and Asian women to 139 deaths per 100 000 for Latinx men. Accounting for differences in age, nativity, and region of residence, if all races and ethnicities had the COVID-19 mortality associated with the occupational characteristics of White people (sector, telework, wages), COVID-19 mortality would be reduced by 10% (95% CI, 6% to 14%) for Latinx men, but increased by 5% (95% CI, −8% to 17%) for Black men. If all working-age Californians had the COVID-19 mortality associated with the lowest-risk educational and occupational position (Bachelor’s degree, nonessential, telework, and highest wage quintile), there would have been 43% fewer COVID-19 deaths among working-age adults (8441 fewer deaths; 95% CI, 32%-54%), with the largest absolute risk reductions for Latinx men (3755 deaths averted; 95% CI, 3304-4255 deaths) and Latinx women (2329 deaths averted; 95% CI, 2038-2621 deaths).
Conclusions and Relevance
In this population-based cohort study of working-age California adults, occupational disadvantage was associated with excess COVID-19 mortality for Latinx men. For all racial and ethnic groups, excess risk associated with low-education, essential, on-site, and low-wage jobs accounted for a substantial fraction of COVID-19 mortality.