Educational status and COVID-19 related outcomes in India: hospital-based cross-sectional study

  1. Arvind K Sharma
  2. Rajeev Gupta
  3. Vaseem Naheed Baig
  4. Veer Teja Singh
  5. Surabhi Chakraborty
  6. Jagdish P Sunda
  7. Prahalad Dhakar
  8. Shiv Prakash Sharma
  9. Raja Babu Panwar
  10. Vishwa Mohan Katoch

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Abstract

Association of educational status, as marker of socioeconomic status, with COVID-19 outcomes has not been well studied. We performed a hospital-based cross-sectional study to determine its association with outcomes.

Methods

Successive patients of COVID-19 presenting at government hospital were recruited. Demographic and clinical details were obtained at admission, and in-hospital outcomes were assessed. Cohort was classified according to self-reported educational status into group 1: illiterate or ≤primary; group 2: higher secondary; and group 3: some college. To compare intergroup outcomes, we performed logistic regression.

Results

4645 patients (men 3386, women 1259) with confirmed COVID-19 were recruited. Mean age was 46±18 years, most lived in large households and 30.5% had low educational status. Smoking or tobacco use was in 29.5%, comorbidities in 28.6% and low oxygen concentration (SpO 2 <95%) at admission in 30%. Average length of hospital stay was 6.8±3.7 days, supplemental oxygen was provided in 18.4%, high flow oxygen or non-invasive ventilation 7.1% and mechanical ventilation 3.6%, 340 patients (7.3%) died. Group 1 patients had more tobacco use, hypoxia at admission, lymphocytopaenia, and liver and kidney dysfunction. In group 1 versus groups 2 and 3, requirement of oxygen (21.6% vs 16.7% and 17.0%), non-invasive ventilation (8.0% vs 5.9% and 7.1%), invasive ventilation (4.6% vs 3.5% and 3.1%) and deaths (10.0% vs 6.8% and 5.5%) were significantly greater (p<0.05). OR for deaths were higher in group 1 (1.91, 95% CI 1.46 to 2.51) and group 2 (1.24, 95% CI 0.93 to 1.66) compared with group 3. Adjustment for demographic and comorbidities led to some attenuation in groups 1 (1.44, 95% CI 1.07 to 1.93) and 2 (1.38, 95% CI 1.02 to 1.85); this persisted with adjustments for clinical parameters and oxygen support in groups 1 (1.38, 95% CI 0.99 to 1.93) and 2 (1.52, 95% CI 1.01 to 2.11).

Conclusion

Low educational status patients with COVID-19 in India have significantly greater adverse in-hospital outcomes and mortality.

Trial registration number

REF/2020/06/034036.

Article activity feed

  1. Version published to 10.1136/bmjopen-2021-055403
  2. ScreenIT

    SciScore for 10.1101/2021.05.17.21257364: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsIRB: Initial data on patients have been reported earlier.19,20 The registry has been approved by the college administration and institutional ethics committee (CDSCO Registration Number: CR/762/Inst/RJ/2015).
    Consent: Individual patient consent was waivered by the ethics committee as anonymized data have been used with no patient identifiers.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistical analyses: The data were computerized and data processing was performed using commercially available statistical software, SPSS v.20.0.
    SPSS
    suggested: (SPSS, RRID:SCR_002865)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    We did not obtain exact information regarding use of various non-evidence based empirical therapies (hydroxychloroquine, ivermectin, lopinavir-ritonavir, favipiravir, etc)29 or proven evidence-based therapies such as corticosteroids, remdesivir and tocilizumab,30 and this is a study limitation. A variety of approaches to conceptualization and measurement of socioeconomic status have been used. Four measures are consistently associated with greater risk: low education, low income, lower employment status, and neighborhood socioeconomic factors.31 Low education or socioeconomic status is well known as a leading modifiable risk factor for overall as well as infectious disease mortality and is an important social determinant of health.32 Previous studies in India and other low and lower middle income countries have reported strong correlation of educational status with measures of income, household wealth, occupation, etc.33,34 There are multiple social, clinical and system level contributors that lead to greater disease risk among the poor and include structural barriers to good health, particularly among the less literate and poor, increased risk of exposure (unhygienic working conditions and crowded housing), unequal access to testing and high-quality care, higher rates of associated medical conditions and less access to vaccination.7 In the present study we observed some of these barriers among our patients (crowded housing, greater tobacco use, and delayed presentation with ...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

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  3. Version published to 10.1101/2021.05.17.21257364v1 on medRxiv