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Occupation and Educational Attainment Characteristics Associated With COVID-19 Mortality by Race and Ethnicity in California

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

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.

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Article Information

Accepted for Publication: March 3, 2022.

Published: April 22, 2022. doi:10.1001/jamanetworkopen.2022.8406

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Matthay EC et al. JAMA Network Open.

Corresponding Author: Ellicott C. Matthay, PhD, Center for Health and Community, University of California, San Francisco, 550 16th St, 2nd Flr, Campus Box 0560, San Francisco, CA 94143 (ellicott.matthay@ucsf.edu).

Author Contributions: Dr Matthay 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. Drs Duchowny and Riley contributed equally to this work.

Concept and design: Matthay, Duchowny, Riley, Thomas, Glymour.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Matthay, Duchowny, Riley, Thomas.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Matthay, Duchowny.

Obtained funding: Matthay, Bibbins-Domingo.

Administrative, technical, or material support: Duchowny, Thomas, Bibbins-Domingo.

Supervision: Bibbins-Domingo.

Conflict of Interest Disclosures: Dr Glymour reported receiving grants from the National Institutes of Health and National Institute on Aging outside the submitted work. No other disclosures were reported.

Funding/Support: This study was funded by the National Institute on Alcohol Abuse and Alcoholism (grant K99 AA028256) and the National Institute on Aging (grant K99 AG066846).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors, and does not necessarily represent the official views of the National Institutes of Health or the California Department of Public Health.

Additional Contributions: The California Department of Public Health provided the death data for the study.

Centers for Disease Control and Prevention. Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. February 11, 2020. Accessed August 2, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
Mackey  K , Ayers  CK , Kondo  KK ,  et al.  Racial and ethnic disparities in COVID-19-related infections, hospitalizations, and deaths: a systematic review.   Ann Intern Med. 2021;174(3):362-373. doi:10.7326/M20-6306PubMedGoogle ScholarCrossref
Azar  KMJ , Shen  Z , Romanelli  RJ ,  et al.  Disparities in outcomes among COVID-19 patients in a large health care system in california.   Health Aff (Millwood). 2020;39(7):1253-1262. doi:10.1377/hlthaff.2020.00598PubMedGoogle ScholarCrossref
Escobar  GJ , Adams  AS , Liu  VX ,  et al.  Racial disparities in COVID-19 testing and outcomes: retrospective cohort study in an integrated health system.   Ann Intern Med. 2021;174(6):786-793. doi:10.7326/M20-6979PubMedGoogle ScholarCrossref
Muñoz-Price  LS , Nattinger  AB , Rivera  F ,  et al.  Racial disparities in incidence and outcomes among patients with COVID-19.   JAMA Netw Open. 2020;3(9):e2021892. doi:10.1001/jamanetworkopen.2020.21892PubMedGoogle ScholarCrossref
McClure  ES , Vasudevan  P , Bailey  Z , Patel  S , Robinson  WR .  Racial capitalism within public health—how occupational settings drive COVID-19 disparities.   Am J Epidemiol. 2020;189(11):1244-1253. doi:10.1093/aje/kwaa126PubMedGoogle ScholarCrossref
Laster Pirtle  WN .  Racial capitalism: a fundamental cause of novel coronavirus (COVID-19) pandemic inequities in the United States.   Health Educ Behav. 2020;47(4):504-508. doi:10.1177/1090198120922942PubMedGoogle ScholarCrossref
Hawkins  D .  Differential occupational risk for COVID-19 and other infection exposure according to race and ethnicity.   Am J Ind Med. 2020;63(9):817-820. doi:10.1002/ajim.23145PubMedGoogle ScholarCrossref
Chen  YH , Glymour  M , Riley  A ,  et al.  Excess mortality associated with the COVID-19 pandemic among Californians 18-65 years of age, by occupational sector and occupation: March through November 2020.   PLoS One. 2021;16(6):e0252454. doi:10.1371/journal.pone.0252454PubMedGoogle ScholarCrossref
Samuel  LJ , Gaskin  DJ , Trujillo  AJ , Szanton  SL , Samuel  A , Slade  E .  Race, ethnicity, poverty and the social determinants of the coronavirus divide: U.S. county-level disparities and risk factors.   BMC Public Health. 2021;21(1):1250. doi:10.1186/s12889-021-11205-wPubMedGoogle ScholarCrossref
Hawkins  D , Davis  L , Kriebel  D .  COVID-19 deaths by occupation, Massachusetts, March 1-July 31, 2020.   Am J Ind Med. 2021;64(4):238-244. doi:10.1002/ajim.23227PubMedGoogle ScholarCrossref
Hawkins  D .  Social determinants of COVID-19 in Massachusetts, United States: an ecological study.   J Prev Med Public Health. 2020;53(4):220-227. doi:10.3961/jpmph.20.256PubMedGoogle ScholarCrossref
Reitsma  MB , Claypool  AL , Vargo  J ,  et al.  Racial/ethnic disparities in COVID-19 exposure risk, testing, and cases at the subcounty level in California.   Health Aff (Millwood). 2021;40(6):870-878. doi:10.1377/hlthaff.2021.00098PubMedGoogle ScholarCrossref
Benitez  J , Courtemanche  C , Yelowitz  A .  Racial and ethnic disparities in COVID-19: evidence from six large cities.   J Econ Race Policy. 2020;3(4):243-261. doi:10.1007/s41996-020-00068-9Google ScholarCrossref
Figueroa  JF , Wadhera  RK , Lee  D , Yeh  RW , Sommers  BD .  Community-level factors associated with racial and ethnic disparities in COVID-19 rates in Massachusetts.   Health Aff (Millwood). 2020;39(11):1984-1992. doi:10.1377/hlthaff.2020.01040PubMedGoogle ScholarCrossref
Figueroa  JF , Wadhera  RK , Mehtsun  WT , Riley  K , Phelan  J , Jha  AK .  Association of race, ethnicity, and community-level factors with COVID-19 cases and deaths across U.S. counties.   Healthc (Amst). 2021;9(1):100495. doi:10.1016/j.hjdsi.2020.100495PubMedGoogle ScholarCrossref
Selden  TM , Berdahl  TA .  COVID-19 and racial/ethnic disparities in health risk, employment, and household composition.   Health Aff (Millwood). 2020;39(9):1624-1632. doi:10.1377/hlthaff.2020.00897PubMedGoogle ScholarCrossref
Bui  DP , McCaffrey  K , Friedrichs  M ,  et al.  Racial and ethnic disparities among COVID-19 cases in workplace outbreaks by industry sector—Utah, March 6–June 5, 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(33):1133-1138. doi:10.15585/mmwr.mm6933e3Google ScholarCrossref
Merolla  DM , Jackson  O .  Structural racism as the fundamental cause of the academic achievement gap.   Sociol Compass. 2019;13(6):e12696. doi:10.1111/soc4.12696Google ScholarCrossref
Patler  C , Gleeson  S , Schonlau  M .  Contesting inequality: the impact of immigrant legal status and education on legal knowledge and claims-making in low-wage labor markets.   Soc Probl. 2020;spaa029. doi:10.1093/socpro/spaa029Google ScholarCrossref
Riley  AR , Chen  YH , Matthay  EC ,  et al.  Excess mortality among Latino people in California during the COVID-19 pandemic.   SSM Popul Health. 2021;15:100860. doi:10.1016/j.ssmph.2021.100860PubMedGoogle ScholarCrossref
Chen  YH , Glymour  MM , Catalano  R ,  et al.  Excess mortality in California during the coronavirus disease 2019 pandemic, March to August 2020.   JAMA Intern Med. 2021;181(5):705-707. doi:10.1001/jamainternmed.2020.7578PubMedGoogle ScholarCrossref
Jones  CP .  Invited commentary: “race,” racism, and the practice of epidemiology.   Am J Epidemiol. 2001;154(4):299-304. doi:10.1093/aje/154.4.299PubMedGoogle ScholarCrossref
State of California. Essential workforce. 2020. Accessed July 6, 2021. https://covid19.ca.gov/essential-workforce/
Angrist  J , Pischke  JS . 3.1 Regression fundamentals. In:  Mostly Harmless Econometrics. Princeton University Press; 2008:28-50.
Snowden  JM , Rose  S , Mortimer  KM .  Implementation of G-computation on a simulated data set: demonstration of a causal inference technique.   Am J Epidemiol. 2011;173(7):731-738. doi:10.1093/aje/kwq472PubMedGoogle ScholarCrossref
Laster Pirtle  WN , Wright  T .  Structural gendered racism revealed in pandemic times: intersectional approaches to understanding race and gender health inequities in COVID-19.   Gend Soc. 2021;35(2):168-179. doi:10.1177/08912432211001302Google ScholarCrossref
Hawkes  S , Buse  K .  COVID-19 and the gendered markets of people and products: explaining inequalities in infections and deaths.   Can J Dev Stud. 2021;42(1-2):37-54. doi:10.1080/02255189.2020.1824894Google ScholarCrossref
Efron  B , Tibshirani  R .  Bootstrap methods for standard errors, confidence intervals, and other measures of statistical accuracy.   Stat Sci. 1986;1(1):54-75. doi:10.1214/ss/1177013815Google ScholarCrossref
Billingsley  S , Brandén  M , Aradhya  S , Drefahl  S , Andersson  G , Mussino  E .  COVID-19 mortality across occupations and secondary risks for elderly individuals in the household: a population register-based study.   Scand J Work Environ Health. 2022;48(1):52-60. doi:10.5271/sjweh.3992PubMedGoogle ScholarCrossref
Hawkins  RB , Charles  EJ , Mehaffey  JH .  Socio-economic status and COVID-19-related cases and fatalities.   Public Health. 2020;189:129-134. doi:10.1016/j.puhe.2020.09.016PubMedGoogle ScholarCrossref
Chadeau-Hyam  M , Bodinier  B , Elliott  J ,  et al.  Risk factors for positive and negative COVID-19 tests: a cautious and in-depth analysis of UK biobank data.   Int J Epidemiol. 2020;49(5):1454-1467. doi:10.1093/ije/dyaa134PubMedGoogle ScholarCrossref
Abedi  V , Olulana  O , Avula  V ,  et al.  Racial, economic, and health inequality and COVID-19 infection in the United States.   J Racial Ethn Health Disparities. 2021;8(3):732-742. doi:10.1007/s40615-020-00833-4PubMedGoogle ScholarCrossref
Alobuia  WM , Dalva-Baird  NP , Forrester  JD , Bendavid  E , Bhattacharya  J , Kebebew  E .  Racial disparities in knowledge, attitudes and practices related to COVID-19 in the USA.   J Public Health (Oxf). 2020;42(3):470-478. doi:10.1093/pubmed/fdaa069PubMedGoogle ScholarCrossref
Zuvekas  SH , Taliaferro  GS .  Pathways to access: health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999.   Health Aff (Millwood). 2003;22(2):139-153. doi:10.1377/hlthaff.22.2.139PubMedGoogle ScholarCrossref
US Centers for Disease Control and Prevention. Workplace prevention strategies. February 11, 2020. Accessed February 25, 2022. https://www.cdc.gov/coronavirus/2019-ncov/community/workplaces-businesses/index.html
Ndugga  N , Hill  L , Artiga  S , Haldar  S . Latest data on COVID-19 vaccinations by race/ethnicity. October 26, 2021. Accessed November 3, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-by-race-ethnicity/
Wrigley-Field  E , Garcia  S , Leider  JP , Robertson  C , Wurtz  R .  Racial disparities in COVID-19 and excess mortality in Minnesota.   Socius. 2020;6:2378023120980918. doi:10.1177/2378023120980918PubMedGoogle ScholarCrossref
Braveman  PA , Cubbin  C , Egerter  S ,  et al.  Socioeconomic status in health research: one size does not fit all.   JAMA. 2005;294(22):2879-2888. doi:10.1001/jama.294.22.2879PubMedGoogle ScholarCrossref
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