The Stockholm Syndrome: Individual and Neighborhood Risk Factors of Hospital Admission and Death During the COVID-19 Pandemic, a Two-Year Population-Based Cohort Study

Background: The coronavirus disease 2019 (COVID-19) disproportionately affects minority populations in the U.S. and UK. Sweden - like other Nordic countries – have less income and wealth inequality but lacks data on socioeconomic impact on risk of adverse outcomes due to COVID-19.Methods: This was a population-wide study of all adults in the Stockholm Region, excluding those in nursing homes or receiving in-home care. Using the real-time COVID-19 monitoring we investigated demographic and socioeconomic impact on hospitalization and mortality. We assessed multiple levels of demographic and individual data and COVID-19-outcomes. This comprises education, income, type of work and ability to work from home, living area and living conditions – including overcrowding – as well as individual country of origin and co-morbidies. Additionally, we have detailed data on the risks associated with living area. We used a Cox proportional hazards model and logistic regression to estimate associations. Area level covariates were used in a principal component analysis to generate a measurement of neighborhood deprivation.Findings: Among the 1 782 125 persons analyzed March 1st 2020-March 2022, individual effect estimates show that male sex, comorbities, higher age and not being born in Sweden increase risk of hospitalization and death. So does lower education and lower income, where lowest incomes doubled risk of death from COVID-19. Income during all five pandemic waves was inversely associated with hospitalization. Area estimates, where the model includes individual risks, show that high population density and high percentage of foreign-born inhabitants increased risk of hospitalization and death.Interpretation: Segregation and deprivation are public health issues elucidated by COVID-19. Neighborhood deprivation, prevalent in Stockholm, add to individual risk like male sex, high age and comorbidities and are associated with hospitalization and death. This finding is paramount for governments, agencies and health care institutions interested in targeted interventions.Funding: None.Declaration of Interest: None to declare.Ethical Approval: The study has been approved by the Regional Ethical Review Board, Stockholm (2021–00810).