Health Disparities in Complicated Lower Respiratory Tract Infections: a population-based cohort study in The Hague, The Netherlands
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Introduction
International studies show that ethnic minority groups and individuals with lower socioeconomic status (SES) face higher severity of lower respiratory tract infections (LRTI). It is unclear whether these associations exist in the Netherlands and to what extent they are mediated through comorbidities and household composition. Our study investigates the relationship between sociodemographic factors and complicated LRTI before and during the COVID-19 pandemic in The Hague, the Netherlands.
Methods
A population-based cohort study was conducted using sociodemographic and insurance claims data from Statistics Netherlands, covering The Hague’s adult population in 2014-2019 (pre-COVID-19) and 2020 (COVID-19). The associations of structural determinants (age, sex, SES, migration background) and intermediary determinants (comorbidities, household composition) on complicated LRTI incidence and mortality were assessed using Poisson regression models. Complicated LRTI episodes were defined as hospital admission or death within 14 days after an emergency department visit.
Results
In 2014-2019, individuals in the lowest SES quintile displayed the highest incidence of complicated LRTI (aIRR 2.26 [95%CI:1.98–2.57]), and LRTI-associated mortality (aIRR 3.49 [95%CI:2.28– 5.34]), compared to the highest SES quintile, after adjusting for structural and intermediary determinants. Similar associations were observed in 2020. Individuals without a migration background were most affected in 2014-2019, while individuals with a migration background were more impacted in 2020.
Conclusions
Lower SES was consistently associated with a higher incidence of complicated LRTI. Populations with a migration background were particularly vulnerable during the pandemic. These findings underscore the need to consider SES and migration background in targeted treatment, prevention, and population health strategies.
Summary Box
What is already known on this topic
Studies from the United States and United Kingdom have shown that area deprivation, socioeconomic status (SES) and/or migration background are associated with a complicated course of lower respiratory tract infections (LRTI). However, the generalisability to of these findings to other countries is unclear due to differences in population composition and health systems. Furthermore, several factors mediate in the association between SES, migration background and complicated LRTI. However, their relative importance remains insufficiently understood and studies often do not take these mediating factors into account. Therefore, SES and migration background are currently rarely incorporated into European clinical or public health guidelines for LRTI prevention or treatment.
What this study adds
This study finds consistent associations between socioeconomic status (SES) and complicated LRTI both before and during the COVID-19 pandemic in an urban setting in The Netherlands, while migration background was strongly associated with complications during the first year of the pandemic. These associations were only partly mediated by comorbidities and household composition. The study also identified geographical hotspots concerning complicated LRTI incidence in The Hague, which overlapped with neighbourhoods of greater socioeconomic deprivation.
How this study might affect research, practice or policy
Current primary care and public health guidelines for LRTI prevention and treatment focus on clinical factors such as age and comorbidity, while overlooking the residual effect of SES and migration background. The data presented in this study, highlights significant health disparities in complicated LRTI, with area deprivation, lower SES and migration background strongly associated with complicated lower respiratory tract infections. This underscores the need for further research into other mediating factors and targeted interventions, such as incorporating SES as a risk factor in clinical decision making and focusing population- and public health strategies on deprived areas.
