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Social inequalities in COVID-19 deaths in Canada

Technical report

Official title: Social inequalities in COVID-19 mortality by area- and individual-level characteristics in Canada, January to July/August 2020

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Executive summary

Reporting since the start of the COVID-19 pandemic has demonstrated that the burden of COVID-19 has been distributed unequally across populations and communities in CanadaFootnote 1Footnote 2Footnote 3Footnote 4Footnote 5Footnote 6Footnote 7.

As with other health conditions, many of the inequalities observed are the result of social, political, and economic disadvantagesFootnote 8 which existed in Canada long before the pandemic was declaredFootnote 9Footnote 10. The distribution of social and economic resources (e.g. social support, education, income, housing) influences people's capacity to achieve and maintain good health across the life course, shaping persistent inequalities in health-related behaviours, health service access and use, and infectious and chronic disease outcomes. These underlying social and economic conditions affect who is more likely to be exposed to the virus (Severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2) through working or living conditions, as well as their access to treatment and their likelihood of severe illness. Underlying inequalities in health are believed to contribute to early reported inequalities in COVID-19 hospitalizations and deathsFootnote 8. However, national reporting on social inequalities in COVID-19 burden remains limited.

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Organization: Public Health Agency of Canada

Published: 2021-07-07

This report aims to help fill this gap in data and evidence. It describes the degree and distribution of inequalities in COVID-19 mortality according to several key social determinants of health, a critical step in taking action to advance a health equity-focused pandemic response and preparedness for future public health eventsFootnote 11. Visualizations of the data from this report can be accessed using the online interactive COVID-19 Mortality Data Tool tab.

Background

This report is a product of the Pan-Canadian Health Inequalities Reporting (HIR) Initiative, a collaboration among the Public Health Agency of Canada, the Pan-Canadian Public Health Network, Statistics Canada, and the Canadian Institute for Health Information. Based on a framework developed by the World Health OrganizationFootnote 12, the HIR Initiative aims to strengthen the measurement, monitoring and reporting of health inequalities in Canada through improved access to data and the development of resources to improve our knowledge of health inequalities. Data from the HIR Initiative representing over 100 indicators of inequalities in health status, health behaviours and health determinants can be accessed using the online interactive Health Inequalities Data Tool.

Methodology

This report presents results at the national level for age-standardized COVID-19 mortality rates from the first part of the pandemic, according to certain factors known to be important to health equity. Inequalities were measured in relation to sex/gender, residence in large urban centres, income, dwelling type, household type, household size, as well as by a local-area measure that combines the concentration of individuals who recently immigrated to Canada, individuals who were designated as a visible minority, individuals who were born outside of Canada, and those who have no knowledge of either official language (English, French). The latter represents one dimension of the Canadian Index of Multiple Deprivation, labelled as a measure of "ethno-cultural composition"Footnote 13. The latter composite measure was used to identify sub-groups that may be particularly vulnerable to structural and systemic disadvantage and discrimination, namely due to systemic racism and economic inequalityFootnote 14.

Data for this report come from two data integration processes, both led by HIRI core partner, Statistics Canada. All data have been de-identified. One data source was an integration of the 2016 short-form Canadian Census and provisional COVID-19 mortality data from Statistics Canada's Canadian Vital Statistics - Deaths database. This data linkage allowed an identification of COVID-19 mortality rates between January 1 and July 4, 2020 across the social and demographic characteristics of individuals living in private dwellings. The other data source was an integration of 2016 Census Area Profile data with provisional COVID-19 mortality data from the Canadian Vital Statistics - Deaths database. This second data linkage allowed an identification of COVID-19 mortality rates between January 1 and August 31, 2020, across neighbourhood-level social and economic characteristics.

Both data sources are provisional and incomplete. They exclude deaths that occurred in the Yukon, for example. They also likely underestimate the true number of COVID-19 deaths, due to potential reporting delays of deaths to the Vital Statistics database. Further, the information collected on the 2016 census might have changed between then and the reported death in 2020. However, as used in previous HIR Initiative reportingFootnote 9, Canadian Vital Statistics - Deaths data integrated with other sources of socioeconomic information such as the Census represent a useful source of information on general trends and social inequalities in mortality.

Key findings

Significant inequalities in age-standardized COVID-19 mortality rates were observed for those living in large urban centers, in apartments, in areas with lower income, and areas with higher levels of ethno-cultural composition.

Overall, men experienced higher rates of COVID-19 mortality than women, despite higher rates of COVID-19 cases among women than men in the population during the study period (up to August 2020)Footnote 15. It has been proposed that higher rates of COVID-19 mortality rates among men may be partly due to sex-based immunological factorsFootnote 16, and to the higher prevalence of COVID-19 mortality risk factorsFootnote 17 among men in Canada, such as diabetes, cancer, and past or current smokingFootnote 18.

Past research on sex/gender differences in health indicate the importance that gender-related social norms, behaviours and conditions play, above and beyond biological and physiological characteristics, and in connection with other key social determinants such as socioeconomic status, in shaping health behaviours and outcomes. For example, cultural notions of masculinity are believed to explain in part why men are more likely to smoke, report higher levels of alcohol use, and not seek health services compared to womenFootnote 19.

Existing research also indicates that gender norms and experiences can intersect with other sources of discrimination or disadvantage, such as lower socioeconomic status, systemic racism, and sexual orientation. This is reflected in the disproportionately higher rates of exposures to occupational risk factors (e.g. carcinogens, injury), health-affecting behaviours (e.g. smoking, elevated alcohol use), and lower use of health services across the lifecourse in men in lower socioeconomic settings compared to both women overall and men in higher socioeconomic settingsFootnote 20Footnote 21Footnote 22Footnote 23. The larger sex/gender inequalities in COVID-19 mortality in areas with lower income and greater ethno-cultural composition concentration are consistent with these previous findingsFootnote 20Footnote 21Footnote 22Footnote 23.

However, future surveillance and research are needed on the precise mechanisms through which inequalities in COVID-19 mortality are created. This report did not explore, for example, mortality rates across multiple, intersecting identities or groups, nor did it pursue multivariate analyses. This represents an important area of future inquiry.

Conclusion

When health inequalities can feasibly be prevented by collective efforts they may be considered unjust and inequitableFootnote 24Footnote 25. The higher number of COVID-19 deaths in some groups and not others suggests that these inequalities could be plausibly avoided and are considered inequitable. A health equity approach seeks to reduce inequities and to increase access to opportunities and conditions that support health for all.

This report provides national evidence of inequalities in COVID-19 mortality burden, a key first step in taking action to advance a health equity-focused pandemic response and preparedness. It builds on previous reporting by HIR Initiative, namely its 2018 Key Health Inequalities in Canada: A National Portrait report, which provides key principles for action and practices to advance health equity in Canada, so that all Canadians can experience healthy living and working conditions and environments.

Box 1. Key findings

  • Provisional Canadian Vital Statistics - Deaths data suggest that COVID-19 deaths that occurred between January and July/August 2020 were not distributed equally across sub-populations in Canada.
  • Absolute inequalities in age-standardized COVID-19 mortality were largest (differences of 15 to 30 deaths per 100,000) for :
    • residents of large urban centers (compared to those outside of urban centers)
    • residents of lowest-income areas (compared to highest-income areas)
    • residents of apartments (compared to those in single-detached homes)
    • residents in areas with the highest concentration of individuals who are visible minorities, recently immigrated to Canada or were born outside of Canada, and those or who have no knowledge of either official language (compared to areas with lowest-concentration of this composite measure).
  • These findings are aligned with public health's understanding of the role of systemic issues such as racism, economic inequality, and other social determinants of health, in shaping inequitable distributions of health risk.
  • Men experienced higher rates of COVID-19 mortality than women, however the magnitude of this sex/gender gap was even larger in areas with lower income and greater concentration of individuals who recently immigrated or were born outside of Canada, who were designated as visible minorities, and were not proficient in either official language.
  • There were 15 to 18 more deaths among men than women per 100,000 population in these groups, compared to a difference of approximately 2 to 4 more male deaths than female deaths per 100,000 population in the respective reference groups.
  • The inconsistent size of sex/gender inequalities across sub-populations highlight the importance of risk relating to gendered social experiences, namely relating to living and working conditions, above and beyond purely biological inequalities in risk.
  • Additional data and analyses are required to better assess the factors driving these health inequalities.

Introduction

Early provincialFootnote 1 Footnote 2 Footnote 3 and nationalFootnote 5Footnote 6Footnote 7 reporting has highlighted the importance of social determinants of health in shaping inequitable risks of SARS-CoV-2 infection and COVID-19 morbidity and mortalityFootnote 4. Variability in distributions of COVID-19 mortality rates across social groups can be due to several factors. As explained in Canada's Chief Public Health Officer's 2020 report From risk to resilience: An equity approach to COVID-19, COVID-19 mortality rates can be a function of several determinants. These can include: 1) differential exposure to SARS-CoV-2 and COVID-19 incidence across social strata; 2) systemic differences in distributions of underlying risk factors of COVID-19 morbidity, such as older age, heart disease, diabetes, stress, smoking and nutritional status; 3) and potential inequalities in access, use, and quality of treatmentFootnote 4. Public health research has demonstrated how inequalities in risk are often a function of systemic issues such as racism, economic inequality, and other social determinants of healthFootnote 12Footnote 9.

This report aims to contribute to the current state of knowledge of social inequalities in COVID-19 outcomes, by describing the distribution of COVID-19 mortality rates at the start of the pandemic, and absolute and relative differences in COVID-19 mortality between social groups in Canada. Two Statistics Canada provisional datasets were used, one allowing for disaggregation of COVID-19 deaths occurring between January 1 and July 4, 2020 among residents of private dwellings, by individual-level characteristics, the other allowing for disaggregation of COVID-19 deaths overall, between January 1 and August 31, 2020, by area-level characteristics (Box 2). The report discusses the limitations of these data sets (Box 2). Namely, this report presents age-standardized mortality rates across individual- and area-level measures, but does not explore multivariate analyses, nor mortality risk across joint social strata. The latter represent important areas for future inquiry.

Full detailed data disaggregation tables and data visualizations can be found on the COVID-19 Mortality Data Tool.

Box 2. Methodology and limitations

Data sources

Data for this report come from two data integration processes. All data were de-identified. Social inequalities in age-standardized COVID-19 mortality according to individual-level characteristics were explored using Statistics Canada's provisional COVID-19 mortality data between January 1 and July 4Footnote 26, 2020, from the Canadian Vital Statistics - Deaths Database linked to individual-level data from the 2016 Canadian Census of population (short-form). The linked short-form Census was restricted to residents of private dwellings. Thus, the deaths recorded in this linkage were restricted to those occurring among individuals living in private dwellings, which represent 98% of the Canadian populationFootnote 6Footnote 27. Deaths occurring in collective dwellings, including long-term care and other institutions were excluded. As of May 2020, it was estimated that approximately 80% of COVID-19 deaths in Canada had occurred in long-term care settingsFootnote 28. A rounded total of 4,430 COVID-19 deaths (1,990 among females, 2,440 among males) were recorded in this dataset.

For area-level inequality estimates, Statistics Canada's provisional COVID-19 mortality data from January 1 and August 31, 2020Footnote 26, recorded in the Canadian Vital Statistics-Death Database were linked to Dissemination Area-levelFootnote 29 data from the 2016 Canadian Census of population via the Postal Code Conversion File plus (PCCF+). These data included all deaths with a postal code, regardless of residence at the time of death, and therefore included those that had occurred among long-term care residents. A rounded total of 9,265 COVID-19 deaths (4,990 among females, 4275 among males) were recorded in this dataset. It should be acknowledged that the Canada Post Corporation source data used to create the PCCF+ contains some large postal codes from rural areas which have links to multiple dissemination areas. Observed inequalities across social measures described herein may be less generalizable to rural areas, given that the majority of COVID-19 deaths (95%) occurred in large urban areas, and that rural dissemination area characteristics can be vulnerable to measurement error. Further, it was not possible to distinguish which of the deaths recorded in this data source occurred among residents of long-term care institutions and which occurred in private dwellings.

The Canadian Vital Statistics - Deaths dataset is distinct from COVID-19 surveillance-based case datasets. It is not updated as frequently, and therefore provides less timely data for regular epidemiologic reporting. Nonetheless, as used in previous HIR reportingFootnote 9, Canadian Vital Statistics - Deaths data represent a useful source of information on general trends and social inequalities in mortality for Canada overall.

Measures

Two ICD-10 codes were used to identify when COVID-19 was reported as a cause of death: U071 for COVID-19 specified as confirmed by a positive test result and U072 for COVID-19 described as "possible," "probable," or "pending a (positive) test result". For both data sources, age-standardized mortality rates per 100,000 population were estimated using the direct method for Canada overall and by sex, based on the 2011 standard Canadian population, using 5-year age groups.

All mortality data were disaggregated by sex. The 2016 census asked respondents to report on their sex (presumed at birth: male or female). The data source only collected information on sex, and not gender. However, as in past HIR Initiative reporting Footnote 9, this report refers to sex/gender inequalities based on the assumption that the inequalities in COVID-19 mortality between males and females are driven by determinants tied to both constructs of biological sex and genderFootnote 9. To acknowledge this interplay between sex and gender, this report refers to COVID-19 mortality rates among "men" and "women" in the Findings sections instead of among "males" and "females". An exception is the use of the expression "male-to-female ratio", which is consistent with epidemiologic reporting.

Data presented have an associated 95% confidence interval (CI). The confidence interval illustrates the degree of variability associated with a rate. Wide confidence intervals indicate high variability, thus, these rates should be interpreted and compared with due caution.

Using individual-level short-form 2016 Census linked data, the individual stratification measures were:

  • Household after-tax low-income status based on Statistics Canada's Low Income Measure (LIM) (low-income status versus not in low-income). This measure is not applicable to individuals living in the Territories nor in First Nations communities (reserves), as Statistics Canada does not develop low-income measures for the latter sub-populationsFootnote 30.
  • Structural dwelling type (apartment in building with <5 storeys, apartment in building with ≥5 storeys, flat or apartment in a duplex, row house, semi-detached house, single-detached house)
  • Household type (one person household, couple with children, couple without children, lone-parent family, multigenerational household, ≥2 person non-census family household (excluding multigenerational) and other census family household). Individuals not processed for family characteristics were excluded.
  • Household size (1, 2, 3, 4, ≥ 5 persons)

Using area-level 2016 Census Profile linked data, the area-level stratification measures were:

  • Area-level national ethno-cultural composition (quintiles) dimension of the Canadian Index of Multiple Deprivation (CIMD). The ethno-cultural composition dimension takes into account the ethno-cultural variables from the Census of population 2016. It is a Dissemination Area level composite indicator that is made up of the proportion of the population who had recently immigrated to Canada (in the five years prior to the Census), were designated as a visible minority, were born outside of Canada, or have no knowledge of either official language of Canada.
  • After tax national income per-person-equivalent neighbourhood quintiles
  • Census Metropolitan Area (CMA) urban residence versus non-CMA residence. Non-CMA areas include all other area categories.

Observations at the area-level may not apply to all individuals within the measured area, which may represent a source of measurement misclassification bias. Nonetheless, area-based measures are beneficial, and used in HIRI past reporting for several reasons. Namely, inequalities identified by area-based socioeconomic status measures are valid, consistent, and reliable and can be tracked through time for different geographical settingsFootnote 9Footnote 31. They can also help capture constructs such as area-level health-promoting resource availabilityFootnote 32.

Limitations

The data used are provisional and incomplete. Neither dataset includes mortality data from the Yukon. They also likely underestimate deaths due to potential reporting delays. Further, the provisional Vital Statistics-Death Dataset and the 2016 short-form census were probabilistically linked to the Derived Record Depository (DRD) in the Social Data Linkage Environment (SDLE) at Statistics Canada. A small portion of the deaths attributable to COVID-19 were not linked to the 2016 short-form Census and were excluded from these tables. As a result, the cumulative total of COVID-19 deaths based on the integrated dataset is lower than true total of COVID-19 deaths.

For the 2016 Census, respondents are asked to report on their social and demographic data as of May 10, 2016 (Census day). It is possible that individuals' Census information reported in 2016, such as their dwelling type or household size, might have changed by the time deaths occurred between January 1 and August 31, 2020. This represents a possible source of measurement error.

Variability in distributions of COVID-19 mortality rates across social groups can be due to several factors. As explained in Canada's Chief Public Health Officer's 2020 report From risk to resilience: An equity approach to COVID-19, COVID-19 mortality rates are hypothesized to be a function of three broad determinants. These include: 1) differential exposure to SARS-CoV-2 and COVID-19 incidence across regions and social groups; 2) differences in distributions of underlying risk factors of COVID-19 morbidity, such as older age (a majority of COVID-19 deaths in Canada have occurred among those 70 years and olderFootnote 15), heart disease, diabetes, stress, smoking and nutritional status; 3) and potential inequalities in access, use, and quality of treatmentFootnote 4. The inequalities presented here indicate sub-populations that face systemic vulnerability to COVID-19 mortality. However, due to the limited scope of the analyses, future research is needed to determine the precise pathways through which these inequalities are created. Unlike surveillance-based case data, Vital Statistics - Deaths data do not contain information on the number and distribution of cases, nor on their characteristics such as chronic condition prevalence. These gaps make it impossible to assess whether higher rates of mortality in some sub-groups may primarily be due to their experience of higher rates of infections or to underlying morbidity risk factors. Future analyses of surveillance-based data that explore the age-standardized rate of deaths over a denominator of cases per sub-group, accounting for morbidity risk factor prevalence will be needed to fill these gaps.

Further, though mortality rates were explored at the intersection of sex/gender and individual- and area-level measures, these findings did not include an exploration of rates across joint stratum of individual- and area-level characteristics. Future assessment of social inequalities in COVID-19 mortality are needed to address these data gaps.

Results

COVID-19 mortality by area-level ethno-cultural composition

Statistics Canada's measure of area-level "ethno-cultural composition" captures the relative area-level concentration of individuals who were designated as a visible minority, who recently immigrated to Canada or were born outside of Canada, or who have no knowledge of either official language of Canada (English, French). Composition concentration quintiles (1 - lowest, to 5 - highest concentration) were used. This measure has been used in population health research and surveillance to identify sub-populations that may be particularly vulnerable to structural and systemic disadvantage and discrimination, namely due to systemic racism and economic inequalityFootnote 14.

Between January 1 and August 31, 2020, age-standardized COVID-19 mortality rates were higher in areas with higher ethno-cultural composition concentration (Figure 1). In Canada overall, the gap in COVID-19 mortality rates between areas with lowest (quintile 1) and highest (quintile 5) ethno-cultural composition concentration was of 21 deaths per 100,000 population (2.3 times higher in highest versus lowest concentration quintiles; 37 versus 16 deaths per 100,000 population).

Figure 1. Age-standardized COVID-19 mortality per 100,000 population by ethno-cultural composition quintile and by sex/gender, Canada (January 1-August 31, 2020)

Long description: Age-standardized COVID-19 mortality per 100,000 population (95 % CI) by ethno-cultural composition quintiles
Sex/gender groups Quintile 1 (lowest concentration) Quintile 2 Quintile 3 Quintile 4 Q5 (highest concentration)
Overall 16 (15, 17) 13 (12, 14) 19 (18, 20) 30 (29, 31) 37 (35, 38)
Men 18 (17, 20) 14 (13, 16) 22 (20, 24) 37 (35, 39) 44 (42, 47)
Women 14 (13, 15) 12 (11, 13) 16 (15, 17) 25 (24, 27) 31 (30, 33)

Sex/gender-based inequalities across ethno-cultural composition

Overall in Canada, between January 1 and August 31, 2020, age-standardized COVID-19 mortality was higher among men than it was for women. The relative male-to-female ratio of COVID-19 deaths was similar across levels of ethno-cultural composition (approximately 1.4 deaths among men to 1 among women). However, the absolute difference in mortality rates between men and women was approximately two times larger in areas with highest ethno-cultural composition concentration (quintile 5) (44 deaths among men to 31 among women per 100,000 population; difference of 13 deaths per 100,000 population), compared to lowest concentration areas (quintile 1) (18 deaths among men, 14 among women per 100,000 population; difference of 4 deaths per 100,000 population).

COVID-19 mortality by neighbourhood income

Statistics Canada produces a quintile measure of national after-tax neighbourhood income per single-person equivalent. These quintiles are constructed based on the distribution of dissemination area income values for the entire country.

Between January 1 and August 31, 2020, there was a prominent gap in age-standardized COVID-19 mortality between areas with the lowest-income (quintile 1) and other areas (quintiles 2 to 5) (Figure 2). In Canada overall, the difference in COVID-19 mortality rates between areas with lowest (quintile 1) and highest (quintile 5) income was of 20 deaths per 100,000 population (2.1 times higher in quintile 1 than quintile 5 areas) (Figure 2).

Figure 2. Age-standardized COVID-19 mortality per 100,000 population by neighbourhood income and by sex/gender, Canada (January 1-August 31, 2020)

Long description: Age-standardized COVID-19 mortality per 100,000 population (95 % CI)
Sex/gender groups Quintile 1 (lowest) Quintile 2 Quintile 3 Quintile 4 Quintile 5 (highest)
Overall 37 (36, 39) 20 (19, 20) 20 (19, 21) 18 (17, 19) 17 (16, 18)
Men 48 (46, 50) 24 (22, 25) 22 (20, 24) 21 (20, 23) 18 (17, 20)
Women 30 (29, 32) 16 (15, 17) 18 (17, 20) 16 (15, 17) 16 (15, 18)

Sex/gender-based inequalities across neighbourhood income

On both a relative and absolute scale, the sex/gender gap in COVID-19 mortality was higher in lowest-income areas. In lowest-income areas, the male-to-female ratio of deaths was of 1.6 and the absolute difference in mortality rates between men and women was 18 deaths per 100,000 population. In contrast, mortality rates between men and women in highest income areas (quintile 5) were not statistically significantly different (interpreted based on overlapping confidence intervals). This finding is consistent with previous research on sex/gender inequalities in morbidity and mortality in relation to socioeconomic status, which observed greater sex/gender inequalities among lower socioeconomic groupsFootnote 20Footnote 33Footnote 34. Researchers have suggested that above and beyond biological risk factors, higher mortality trends among men in lower socioeconomic contexts may relate to gendered material, social, and environmental conditions, including higher rates of exposures to occupational risk factors, associated health-affecting behaviours (e.g. smoking, elevated alcohol use), and lower use of health services across the lifecourseFootnote 20Footnote 21Footnote 22Footnote 23.

COVID-19 mortality in and outside Census Metropolitan Areas (CMAs)

Age-standardized COVID-19 mortality rates were estimated for individuals dwelling in Census Metropolitan Areas (CMAs) and those living outside of CMAs. CMAs are large urban centers with a minimum population of 100,000 residentsFootnote 35. Between January 1 and August 31, 2020, age-standardized COVID-19 mortality rates were systematically higher in urban, Census Metropolitan Areas (CMA) than in non-CMA areas overall (10 times higher; 30 more deaths per 100,000 population) and for both men and women separately (Figure 3).

Figure 3. Age-standardized COVID-19 mortality per 100,000 population by Census Metropolitan Area (CMA) residence and by sex/gender, Canada (January 1-August 31, 2020)

Long description: Age-standardized COVID-19 mortality per 100,000 population (95 % CI)
Sex/gender groups CMA Non-CMA
Overall 33 (32, 34) 4 (3, 4)
Men 39 (38, 41) 5 (4, 5)
Women 29 (28, 29) 3 (2, 3)

Sex/gender-based inequalities across areas of residence

The absolute difference in COVID-19 mortality between men and women was of 10 deaths per 100,000 population in CMAs (39 deaths among men versus 29 among women per 100,000 population), about five times larger than the difference of 2 deaths per 100,000 observed in non-CMAs (5 deaths among men versus 3 among women per 100,000 population). However, on a relative scale, the male-to-female mortality ratio was of 1.7 for non-CMAs compare to 1.4 in CMAs.

COVID-19 mortality by individual-level after-tax low-income status

Statistics Canada's "Low Income Measure (LIM)" identifies households whose household-size adjusted after-tax income is lower than half of the Canadian median adjusted incomeFootnote 30Footnote 36. It captures two groups: those living in low-income and those not living in low-income. Between January 1 and July 4, 2020, mirroring findings at the area level, private-dwelling populations in low-income experienced higher age-standardized COVID-19 mortality, overall and for both men and women (Figure 4). The gap in COVID-19 mortality rates between those in and not in low-income was of 5 deaths per 100,000 population in Canada (1.4 times higher for those in low-income than those not in low-income; 19 versus 14 deaths per 100,000, respectively) (Figure 4).

Inequalities across low-income status by sex/gender

For deaths occurring between January 1 and July 4, 2020 among private dwellings, age-standardized COVID-19 mortality was higher among men than it was for women, in both the low- and not in low-income groups (Figure 4). Mortality rate inequalities between populations in low-income and those not in low-income were slightly larger among men than women. For example, the gap was of 9 deaths per 100,000 population among men, and 4 deaths per 100,000 among women in Canada.

Figure 4. Age-standardized COVID-19 mortality per 100,000 population by individual low-income status (after-tax) and by sex/gender, Canada (January 1-July 4, 2020)

Long description: Age-standardized COVID-19 mortality per 100,000 population (95 % CI)
Sex/gender groups Not low-income In low-income
Overall 14 (13, 14) 19 (18, 20)
Men 18 (17, 19) 27 (25, 30)
Women 11 (10, 11) 15 (14, 17)

COVID-19 mortality by private dwelling type

In the short-form Census, six types of private dwellings are identified: single-detached house, semi-detached house, row house, apartment or flat in a duplex, apartment in a building with five or more storeys, and apartment in a building with less than five storeys. In this analysis, deaths occurring in congregate settings, including long-term care homes, were excluded. Private dwelling type captures many social and economic differences. For example, residents of single-detached homes tend to have higher reported median after-tax income compared to residents of apartments in multi-storey buildingsFootnote 37. Further, residents of detached homes also tend to report higher satisfaction with the size and number of rooms of their dwelling compared to apartment-dwellers, indicating a potential elevated risk of unsatisfactory housing conditions among apartment-dwellers in the context of the COVID-19 pandemicFootnote 38.

Figure 5. Age-standardized COVID-19 mortality per 100,000 population by dwelling type and by sex/gender, Canada (January 1-July 4, 2020)

Long description: Age-standardized COVID-19 mortality per 100,000 population (95 % CI)
Sex/gender groups Single-detached house Semi-detached house Row house Apartment in a duplex Apartment in building ≥5 storeys Apartment in building <5 storeys
Overall 9 (9, 10) 16 (13, 18) 13 (11, 15) 26 (23, 29) 23 (21, 24) 24 (23, 26)
Men 11 (11, 12) 20 (16, 24) 19 (15, 22) 37 (32, 42) 33 (30, 35) 36 (33, 39)
Women 7 (7, 8) 12 (9, 15) 9 (7, 11) 19 (16, 21) 18 (16, 19) 18 (16, 20)

Between January 1 and July 4, 2020, age-standardized COVID-19 mortality rates in the private-dwelling population were highest for individuals living in apartments (in buildings <5 storeys or ≥5 storeys, flats or duplexes) (Figure 5). Rates were not statistically significantly different across the types of buildings in which these apartments were found, as indicated by overlapping 95% confidence intervals (Figure 5).

Compared to apartment-dwelling residents, rates were lower for those living in semi-detached or row houses. The lowest COVID-19 mortality rate was observed among those living in single-detached houses (9 deaths per 100,000 population). Overall, mortality rates were 2.5 to 2.8 times higher in apartment-dwelling populations than those living in single-detached homes. There were 14 to 17 more deaths per 100,000 population that occurred in apartment-dwelling populations compared to populations living in single-detached houses (between 23 to 26 deaths compared to 9 deaths per 100,000 population, respectively).

The magnitude of the inequality in mortality between row and semi-detached house residents and those living in single-detached houses was smaller. Rates were 1.4 to 1.7 times higher for row and semi-detached house residents. Approximately 4 to 7 more deaths per 100,000 populations occurred among populations living in row and semi-detached homes versus single detached homes (13 to 16 deaths versus 9 deaths per 100,000, respectively).

Sex/gender-based inequalities across areas of residence

The magnitude of absolute sex/gender-based inequalities varied according to dwelling type. The absolute difference in rates between men and women ranged from 15 to 18 deaths per 100,000 population in apartment-dwellers, compared to 4 to 10 deaths per 100,000 population in row, or single- or semi-detached houses. On the relative scale, however, the male-to-female ratio of deaths were similar across groups (1.6 to 2.1).

COVID-19 mortality by household type

The short-form Census identifies several types of households. These include: one person households, census family household types (i.e., couples without children, couples with children, lone-parent families, multi-generational household), "other" census family household and two-or-more person non-census family households. "Other" census family households include all households where there is one census family with additional persons, or more than one census family. Two-or-more person "non census family households" include those who do not constitute a census family, based on marital or parental statusFootnote 39. The average household in Canada is comprised of 2.5 residents. Household size varies by household type, with average two-or-more person non-census-family households made up of 3 residents, multigenerational households including 5 residentsFootnote 40. Certain sub-populations such as immigrants to Canada are more likely to live in multigenerational households compared to non-immigrants (11% of immigrants versus 5% in non-immigrants)Footnote 41.

Between January 1 and July 4, 2020, the portrait of age-standardized COVID-19 mortality across private dwelling household type was heterogeneous (Figure 6). Overall mortality rates were highest among two-or-more-person non-census family households (23 deaths per 100,000 population)-that is, households that did not consist of a married or common-law couple with or without children, nor of a single parent with one or more children-and households of couples with children (19 deaths per 100,000 population) (Figure 6).

Figure 6. Age-standardized COVID-19 mortality per 100,000 population by household type and by sex/gender, Canada (January 1 -July 4, 2020)

Long description: Age-standardized COVID-19 mortality per 100,000 population (95 % CI)
Sex/gender groups Lone-parent family Multi-generational household One person household Other census family household Couple without children Couple with children ≥2 person non-census family household
Overall 13 (12, 15) 14 (13, 16) 15 (14, 15) 15 (13, 17) 16 (16, 17) 19 (17, 22) 23 (20, 27)
Men 19 (14, 23) 17 (14, 20) 22 (21, 24) 16 (13, 20) 18 (17, 19) 24 (20, 27) 32 (25, 39)
Women 12 (10, 13) 13 (11, 15) 11 (11, 12) 13 (11, 16) 14 (12, 15) 10 (7, 14) 19 (15, 23)

Sex/gender-based inequalities across household type

The magnitude of sex/gender-based inequalities varied according to household type. The absolute difference in rates between men and women ranged from 11 to 13 deaths per 100,000 population in households of couples with children (2.3 male-to-female ratio), one-person households (2 male-to-female ratio), and two-or-more-person non-census family household (1.7 male-to-female ratio). In lone-parent families, the difference in rates between men and women was of 7 deaths per 100,000 population (1.6 male-to-female ratio). In contrast, rates between men and women were not statistically significantly different in multigenerational and "other census family" households (interpreted conservatively, based on overlapping 95% confidence intervals). Evidence on the distribution of COVID-19 mortality risk factors between men and women across household types is very limited, and therefore the etiology of these patterns is difficult to explain. It is possible, for example, that the larger sex/gender gap within households of couples with children may be capturing the lower risk of SARS-CoV-2 transmission among women who took leave from work to care for children at homeFootnote 42, however, future research on this subject is needed.

COVID-19 mortality by household size

In the 2016 short-form Census, five household sizes were recorded: one, two, three, four, or five or more person households. Between January 1 and July 4, 2020, overall, no statistically significant differences in age-standardized COVID-19 mortality were observed according to private household size (interpreted conservatively, based on overlapping 95% confidence intervals) (Figure 7).

However, the magnitude of sex/gender-based inequalities in COVID-19 mortality varied according to household size. Specifically, difference in rates between men and women ranged from 10 to 11 deaths per 100,000 population in one- and three-person households (male-to-female ratio of 2 in each, respectively). In contrast, differences were of 4 to 10 deaths per 100,000 in the other household sizes.

Figure 7. Age-standardized COVID-19 mortality per 100,000 population by household size and by sex/gender, Canada (January 1-July 4, 2020)

Long description: Age-standardized COVID-19 mortality per 100,000 population (95 % CI)
Sex/gender groups 1 person 2 persons 3 persons 4 persons 5 persons or more
Overall 15 (14, 15) 15 (15, 16) 15 (14, 17) 14 (11, 16) 17 (15, 19)
Men 22 (21, 24) 18 (17, 19) 21 (18, 24) 16 (12, 19) 20 (16, 23)
Women 11 (11, 12) 12 (11, 13) 11 (9, 12) 11 (9, 14) 15 (12, 17)

Conclusion

These provisional data suggest that COVID-19 deaths that occurred between January and July/August 2020 were not distributed equally across sub-populations in Canada. The largest inequalities in COVID-19 mortality were observed between four groups: residents of large urban centers (CMAs) (versus non-CMA residents); residents of areas with highest ethno-cultural composition concentration (quintiles 4 and 5 versus quintile 1 areas); residents of areas with lowest income (quintile 1 versus quintile 5 areas) and apartment-dwellers (versus, residents of single detached homes). Age-standardized mortality rates were higher among men than women, and sex/gender inequalities were larger in the latter four sub-populations than in their respective reference populations.

The inequalities presented here indicate sub-populations that have faced systemic vulnerability to COVID-19 mortality. These findings are aligned with those from previous provincial and national reportingFootnote 1Footnote 2Footnote 3Footnote 4Footnote 5 Footnote 6Footnote 7Footnote 43Footnote 44, as well as public health's understanding that structural determinants such as systemic racism, economic inequality, and other social determinants of health, shape inequitable distributions of infectionsFootnote 45Footnote 46Footnote 47Footnote 48 and morbidity riskFootnote 12Footnote 9Footnote 49Footnote 50. Public health measures such as closures of non-essential workplaces had differential impacts on SARS-CoV-2 transmission rates across community socioeconomic profiles, given differences in local area-level prevalence of workers who could work from homeFootnote 51.

Overall, men experienced higher rates of COVID-19 mortality than women, despite higher rates of COVID-19 cases among women than men in the population at that timeFootnote 15. Surveillance data indicate that as of August 30, 2020, there were approximately 67,850 COVID-19 cases among women, and 55,660 cases among men (male-to-female ratio of 0.82)Footnote 15. Further, as of August 30, 2020, 90% of COVID-19 deaths in Canada occurred among those aged 70 years and above, and in that age-group too, cases among women (approximately 17,070 cases) outnumbered those among men (approximately 10,030 cases) (male-to-female ratio of 0.58)Footnote 15. Among working-age adults, the sex/gender difference in case counts has been attributed, at least in part, to the over-representation of women in certain settings and occupations that may be at greater risk of exposure to the virus, such as teaching, health and care work, as well as elevated testing rates in the latter settingsFootnote 52Footnote 42.

It has been proposed that higher rates of COVID-19 mortality among men, despite their lower case counts, may be partly due to sex-based immunological factorsFootnote 16, as well as to the higher prevalence of COVID-19 mortality risk factors among men compared to women. COVID-19 mortality risk factors include current or former tobacco use and chronic health conditionsFootnote 17. Past HIR Initiative reporting indicates that among older adults in Canada, men have higher rates of diabetes, cancer, chronic obstructive pulmonary disease, and report higher smoking prevalence compared to womenFootnote 18. Further, past research on sex/gender differences in health and mortality indicate the importance of gender-related social norms, behaviours and conditions in shaping health behaviours and outcomes, above and beyond biological and physiological characteristics, and in connection with other key social determinants such as socioeconomic status. For example, cultural notions of masculinity are believed to explain in part why boys and men are more likely to smoke, report higher levels of alcohol use, and not seek health services compared to women and girlsFootnote 19. Intersections between gender norms and other sources of discrimination or disadvantage, such as lower socioeconomic status and systemic racism, have been reflected in the disproportionately higher rates of exposures to occupational risk factors (e.g. carcinogens, injury), health-affecting behaviours (e.g. smoking, elevated alcohol use), and lower use of health services among men in lower socioeconomic settings compared to both women overall and men in higher socioeconomic settingsFootnote 20 Footnote 21Footnote 22Footnote 23. The larger sex/gender inequalities in COVID-19 mortality in areas with lower income and greater concentration of individuals who recently immigrated or were born outside of Canada, who were designated as visible minorities, and were not proficient in either official language (compared to areas with higher income and lower ethno-cultural composition concentration) are consistent with previous these previous findings of larger sex/gender inequalities in overall mortality in lower socioeconomic settingsFootnote 20 Footnote 21Footnote 22Footnote 23.

However, due to the limited scope of the analyses, future research is needed to determine the precise pathways through which the observed inequalities manifest. They may be due to differential exposure to SARS-CoV-2 infection, differences in distributions of chronic conditions and other underlying risk factors of COVID-19 morbidityFootnote 53Footnote 54 and/or potential inequalities in access, use, and quality of treatmentFootnote 4. Future research and surveillance are required to fill these knowledge gaps. Further, this report did not explore, for example, mortality rates across multiple, intersecting identities or groups. Nor did it explore COVID-19 burden across a full range of social determinants of health, due to absence of measures in the 2016 short-form Census data source. Missing were measures of individual-level gender and sexual orientation, as proxy measures of various forms of sexism; Indigeneity measures, to identify distinction-based differences in the experience of the pandemic and the effects of anti-Indigenous racism and colonialism; or race/ethnicity, as a proxy measure of racismFootnote 50. Certain regions of Canada have begun disaggregating COVID-19 data using these measuresFootnote 55Footnote 56Footnote 2. These represent important areas of future inquiry, as do future assessment of inequalities at later time points during the pandemic, including following the advent of variants of concernFootnote 57, and immunization campaigns.

When health inequalities can plausibly be avoided or redressed by collective action, they may be deemed unjust and inequitableFootnote 24Footnote 25. The observed elevated burden of COVID-19 mortality between January and July/August 2020, in some groups and not others, suggests that COVID-19 mortality inequalities can be avoided, and are therefore inequitable. This report provides national evidence of inequalities in COVID-19 mortality burden, a key first step in taking action to advance a health equity-focused pandemic response and preparedness for future events. It build on previous reporting by HIRI, namely its 2018 Key Health Inequalities in Canada: A National Portrait report, which provides key principles for action and practices to advance health equity in Canada, so that all Canadians can experience healthy living and working conditions and environments.

Box 3. Acknowledgements

This report is a product of the Pan-Canadian Health Inequalities Reporting (HIR) Initiative. This Initiative is a collaborative effort of the Pan-Canadian Public Health Network (PHN), the Public Health Agency of Canada (PHAC), Statistics Canada, and the Canadian Institute for Health Information (CIHI).

The PHN, a coordinating body of federal, provincial and territorial public health departments, provided guidance and input on this report through its Technical Advisory Committee on COVID-19. PHAC led the report writing, consultations, coordination of expert reviews, and provided overall project management. Statistics Canada provided methodological expertise, data analysis, and expert review.

At PHAC the Social inequalities in COVID-19 mortality by area- and individual-level characteristics in Canada, January to July/August 2020 report was prepared and led by a core team within the Social Determinants of Health Division: Alexandra Blair, Sai Yi Pan, Colin Steensma, and Malgorzata Miszkurka, with support from Beth Jackson, Nasim Khatibsemnani, Natalie Osorio, Dolon Chakravartty, Muhim Abdalla, and Ali El-Samra.

At Statistics Canada, data integration and data analyses for this report were led by Nicole Aitken, Rajendra Subedi, Fei-Ju Yang, and Lawson Greenberg from the Centre for Population Health Data.

Insightful feedback on this report was provided by external and internal reviewers, listed here in alphabetical order of surname. (A) External – Nicole Aitken (Statistics Canada), Tia Carpino (Women and Gender Equality Canada), Geoff Hynes (CIHI), Evasha Rasasakaram (CIHI), Dana Riley (CIHI), Rajendra Subedi (Statistics Canada), Fei-Ju Yang (Statistics Canada). (B) At PHAC – Kate Hill MacEachern, Marie-Claire Ishimo, Laura MacDougall, Ahalya Mahendra, Susan Scruton.

The analyses and conclusions in this report do not necessarily reflect those of the reviewers or their affiliated organizations.

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