Macquarie University, Level 3, 25C Wallys Walk, North Ryde, NSW, 2113, Australia.
Public Health. 2023 Aug;221:201-207. doi: 10.1016/j.puhe.2023.06.016. Epub 2023 Jun 21.
Although many studies have found a high correlation between socio-economic inequalities and risk of COVID-19 deaths, there is a reason to believe that much of this association is the product of differing levels of education.
We use a multi-level negative binomial regression model for analyzing COVID-19 mortality.
We present multivariate models of fortnightly (n = 60) COVID-19 deaths in 3108 US counties for the period January 20, 2020, to May 10, 2022. We model the direct (unmediated) effect of education, controlling for economy, race, geography, lack of vaccination, political orientation (vote Republican), poor health, and lack of preventative health behavior.
After controlling for correlated risk factors and indirect mechanisms that mediate education's impact on COVID-19 mortality, we find a strong direct (unmediated) correlation between low education and COVID-19 mortality (incidence rate ratio = 1.17; 95% confidence interval: 1.15, 1.20). We theorize that this correlation reflects education's relationship with (1) collective cultures, such as norms of mask wearing, and (2) individual literacy, such as ability to engage with scientific communication.
Low education is strongly correlated with COVID-19 deaths, with an effect size of a university degree comparable to that of being aged >65 years. If this correlation is indeed causal, then it would imply that low education accounts for between 1 in 10 and 1 in 7 deaths in low-education counties. Education should be conceptualized as a potential high-risk factor for COVID-19 death and be taken into account when attempting to combat COVID-19 in disadvantaged communities. The effect of education cannot be reduced to its impact on vaccination or correlation with poor health or economic status, but it seems likely that low-education communities have collective cultures that expose individuals to greater risks and lack of individual literacy that limits engagement with public health messaging.
尽管许多研究发现社会经济不平等与 COVID-19 死亡风险之间存在高度相关性，但有理由相信，这种关联在很大程度上是受教育程度不同的结果。
我们使用多水平负二项回归模型来分析 COVID-19 死亡率。
我们呈现了 2020 年 1 月 20 日至 2022 年 5 月 10 日期间美国 3108 个县每两周（n=60）COVID-19 死亡的多变量模型。我们控制经济、种族、地理、疫苗接种不足、政治倾向（投票给共和党）、健康状况不佳和缺乏预防保健行为等相关风险因素，对教育进行了模型构建，以模拟教育对 COVID-19 死亡率的直接（无中介）影响。
在控制了相关风险因素和教育对 COVID-19 死亡率的间接机制后，我们发现教育程度低与 COVID-19 死亡率之间存在很强的直接（无中介）相关性（发病率比=1.17；95%置信区间：1.15，1.20）。我们推断这种相关性反映了教育与（1）集体文化，例如戴口罩的规范，以及（2）个人文化素养，例如与科学传播互动的能力之间的关系。
教育程度低与 COVID-19 死亡密切相关，其效应大小与年龄>65 岁相当。如果这种相关性确实是因果关系，那么它意味着低教育程度的县每 10 至 7 人死亡中就有 1 人归因于低教育程度。在试图在弱势社区抗击 COVID-19 时，应该将教育视为 COVID-19 死亡的潜在高风险因素，并将其考虑在内。教育的影响不能仅仅归结为其对疫苗接种的影响或与健康状况不佳或经济地位的相关性，但是低教育程度社区可能存在使个人面临更大风险的集体文化，而且个人文化素养有限，限制了他们对公共卫生信息的参与。
