Residential context and COVID-19 mortality among adults aged 70 years and older in Stockholm: a population-based, observational study using individual-level data

Abstract

Background: Housing characteristics and neighbourhood context are considered risk factors for COVID-19 mortality among older adults. The aim of this study was to investigate how individual-level housing and neighbourhood characteristics are associated with COVID-19 mortality in older adults.

Methods: For this population-based, observational study, we used data from the cause-of-death register held by the Swedish National Board of Health and Welfare to identify recorded COVID-19 mortality and mortality from other causes among individuals (aged ≥70 years) in Stockholm county, Sweden, between March 12 and May 8, 2020. This information was linked to population-register data from December, 2019, including socioeconomic, demographic, and residential characteristics. We ran Cox proportional hazards regressions for the risk of dying from COVID-19 and from all other causes. The independent variables were area (m²) per individual in the household, the age structure of the household, type of housing, confirmed cases of COVID-19 in the borough, and neighbourhood population density. All models were adjusted for individual age, sex, country of birth, income, and education.

Findings: Of 279 961 individuals identified to be aged 70 years or older on March 12, 2020, and residing in Stockholm in December, 2019, 274 712 met the eligibility criteria and were included in the study population. Between March 12 and May 8, 2020, 3386 deaths occurred, of which 1301 were reported as COVID-19 deaths. In fully adjusted models, household and neighbourhood characteristics were independently associated with COVID-19 mortality among older adults. Compared with living in a household with individuals aged 66 years or older, living with someone of working age (<66 years) was associated with increased COVID-19 mortality (hazard ratio 1·6; 95% CI 1·3-2·0). Living in a care home was associated with an increased risk of COVID-19 mortality (4·1; 3·5-4·9) compared with living in independent housing. Living in neighbourhoods with the highest population density (≥5000 individuals per km²) was associated with higher COVID-19 mortality (1·7; 1·1-2·4) compared with living in the least densely populated neighbourhoods (0 to <150 individuals per km²).

Interpretation: Close exposure to working-age household members and neighbours is associated with increased COVID-19 mortality among older adults. Similarly, living in a care home is associated with increased mortality, potentially through exposure to visitors and care workers, but also due to poor underlying health among care-home residents. These factors should be considered when developing strategies to protect this group.

Funding: Swedish Research Council for Health, Working Life and Welfare (FORTE), Swedish Foundation for Humanities and Social Sciences.

Figure 1

Cox proportional hazard regression for death from COVID-19 and from all other causes among individuals aged 70 years and older All models control for individual age, sex, education, income, and country of birth. HR=hazard ratio.

Figure 2

Cox proportional hazard regression for death from COVID-19 and from all other causes, stratified by age group All models control for individual age, sex, education, income, and country of birth. HR=hazard ratio.

Figure 3

Cox proportional hazard regression for death from COVID-19 and from all other causes, stratified by sex All models control for individual age, education, income, and country of birth. HR=hazard ratio.