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Inequality in mortality according to regional deprivation during the COVID-19 pandemic
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Min Hui Moon, Min-Hyeok Choi, Young Gyu Ko
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Epidemiol Health. 2025;e2025022. Published online April 29, 2025
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DOI: https://doi.org/10.4178/epih.e2025022
[Accepted]
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 Abstract
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Abstract
OBJECTIVES
Vulnerability to coronavirus disease 2019 (COVID-19) is significantly greater in regions with lower socioeconomic status. However, detailed analyses of regional socioeconomic disparities have rarely been conducted in South Korea. This study aimed to identify and compare mortality inequalities associated with regional socioeconomic status across different areas of South Korea during the COVID-19 pandemic.
METHODS Using cause-of-death statistics from 2020 to 2022, we calculated age-standardized mortality rates (ASMRs) for total mortality, COVID-19 mortality, and pneumonia mortality. The socioeconomic status of each region was assessed using the regional deprivation index. Additionally, we calculated the rate difference (RD), rate ratio (RR), slope index of inequality (SII), and relative index of inequality (RII) for each socioeconomic level to examine the extent of mortality inequality and its temporal changes. These analyses were stratified by sex and urban-rural classification.
RESULTS The total mortality rate, as well as COVID-19-specific and pneumonia-specific mortality rates, increased during the COVID-19 pandemic. The ASMR for COVID-19 was higher in rural areas (ASMR, 27.79), which have lower healthcare accessibility, compared to urban areas (ASMR, 26.63). However, mortality inequality indicators for COVID-19 were more pronounced in urban areas compared to rural areas (SII [urban: 2.72; rural: -0.05], RII [urban: 0.10; rural: 0.00]). Notably, significant inequalities were observed among men residing in urban areas.
CONCLUSIONS In disaster situations such as the COVID-19 pandemic, it is essential to implement strategies aimed at reducing overall mortality rates and addressing regional socioeconomic inequalities.
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Summary
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Unequal burdens of COVID-19 infection: a nationwide cohort study of COVID-19-related health inequalities in Korea
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Jeangeun Jeon, Jieun Park, Min-Hyeok Choi, Hongjo Choi, Myoung-Hee Kim
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Epidemiol Health. 2023;45:e2023068. Published online July 31, 2023
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DOI: https://doi.org/10.4178/epih.e2023068
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Abstract
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 Supplementary Material
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Abstract
OBJECTIVES
While the Korean government’s response to the coronavirus disease 2019 (COVID-19) pandemic is considered effective given the relatively low mortality rate, issues of inequality have been insufficiently addressed. This study explored COVID-19-related health inequalities in Korea.
METHODS Age standardization for various health inequality indices was derived using data from the Korean National Health Insurance Service, the Korea Disease Control and Prevention Agency, and the Microdata Integrated Service of Statistics Korea. The slope index of inequality (SII) and relative index of inequality (RII) were calculated for socioeconomic variables, while absolute difference (AD) and relative difference (RD) were used for gender and disability inequalities.
RESULTS We observed a number of COVID-19-related health outcome inequalities. Gender inequality was particularly noticeable in infection rates, with the rate of women 1.16 times higher than that of men. In contrast, socioeconomic inequality was evident in vaccination rates, with a 4.5-fold (SII, -4.519; 95% confidence interval, -7.403 to -1.634) difference between the highest and lowest household income groups. Regarding clinical progression post-infection, consistent findings indicated higher risk for men (RD for hospitalization, 0.90; severe cases, 0.54; and fatality, 0.65), individuals with disabilities (RD for hospitalization, 2.27; severe cases, 2.29; and fatality, 2.37), and those from lower socioeconomic groups (SII for hospitalization, 1.778; severe cases, 0.089; and fatality, 0.451).
CONCLUSIONS While the infection risk was nearly ubiquitous, not everyone faced the same level of risk post-infection. To prevent further health inequalities, it is crucial to develop a thoughtful policy acknowledging individual health conditions and resources.
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Summary
Korean summary
2020년 10월-2022년 4월까지의 국내 코로나-19 확진자 데이터와 건강보험 빅데이터, 사망등록통계를 연계하여 건강결과의 불평등 지표를 산출한 결과, 감염율, 백신접종율, 입원율, 중증화율, 치명률에서 소득수준(건강보험료 소득분위 기준), 성별, 장애유무에 따른 건강결과의 불평등이 확인되었다. 감염율은 여성이 남성보다 높았고, 백신접종율은 장애인과 의료급여 수급권자의 비율이 낮게 나타났고, 코로나-19로 인한 입원율과 중증화율, 치명율에서는 남성, 의료급여 수급권자, 장애인의 취약성이 두드러졌다. 본 연구의 분석결과는 국내 방역정책이 기존의 사회불평등을 충분하게 고려하지 못했을 가능성이 크며, 미래 감염병 관리 시 이를 고려하여 불평등을 완화시킬 수 있는 방향의 정책적 전략이 필요하다는 점을 시사한다.
Key Message
This study sought to investigate COVID-19-related health inequalities in Korea by linking COVID-19 registry data to the KNHIS big data and the cause of death data for the period October 2020 - April 2022. COVID-19-related health outcome inequalities were observed in infection, vaccination, hospitalization, clinical progress, and fatality by household income, gender, and disability. The infection rate was higher in women, the vaccination proportion was lower in the disabled and medical-aid beneficiaries, and men, the disabled and medical-aid beneficiaries were vulnerable in clinical progression post-infection which implies that a policy necessarily should consider existing socioeconomic inequalities for future pandemics.
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Citations
Citations to this article as recorded by  - Genome diversity of SARS-CoV-2 lineages associated with vaccination breakthrough infections in Addis Ababa, Ethiopia
Abebe M. Aga, Demise Mulugeta, Atsbeha Gebreegziabxier, Girum Taye Zeleke, Aderajew Mekonnen Girmay, Gutema Bulti Tura, Abaysew Ayele, Ahmed Mohammed, Tigist Belete, Tefera Taddele, Rajiha Abubeker, Fanos Tadesse Woldemariyam, Tesfaye Gelanew, Yeweynshet
BMC Infectious Diseases.2025;[Epub] CrossRef - The role of area deprivation index in health care disruptions among cancer survivors during the SARS-CoV-2 pandemic
R.W. Wagner, A. Natori, S. Prinsloo, A.K. Otto, E. Saez-Clarke, J.M. Ochoa, S.S. Tworoger, C.M. Ulrich, C.A. Hathaway, S. Ahmed, J.L. McQuade, A.R. Peoples, M.H. Antoni, F.J. Penedo, L. Cohen
Public Health.2024; 232: 52. CrossRef - Universal health coverage saves more lives among severely ill COVID-19 patients: A difference-in-differences analysis of individual patient data in South Korea
Daseul Moon, Jeangeun Jeon, Jieun Park, Min-Hyeok Choi, Myoung-Hee Kim, Hongjo Choi
Health Research Policy and Systems.2024;[Epub] CrossRef
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