An Ecological Study on the Mortality Impact of the COVID-19 Pandemic According to Country Development Status and...

The COVID-19 pandemic caused stark global mortality disparities, influenced by a complex interplay of demographic, economic, and health factors. This ecological study investigates associations between country macroscopic variables and COVID-19 accumulated mortality ratio (AMR) across 174 countries and may serve as a preparation for new pandemics.

The study applies bidirectional stepwise multiple linear regression. To ensure statistical validity, we conducted diagnostic tests for multicollinearity and heteroscedasticity, applying robust M-estimation where necessary to minimize root mean squared error. The analysis covered six distinct stratifications based on development status (developed, developing, least developed, and combinations), and incorporated temporal analyses across three specific annual periods: 21 January 2020-20 January 2021; 21 January 2021-20 January 2022; and 21 January 2022-10 January 2023.

AMR per country values, accumulated between 21 January 2020 and 10 January 2023, and data on the prevalence of health conditions, and socioeconomic descriptive variables were extracted from Our World in Data (OWID) and other public data sites, like the World Bank.

The percentage of population aged over 65 years has the most consistent association with increased AMR globally. Obesity prevalence and income inequality (Gini index) were positively associated with AMR regardless of country development status. Conversely, the study finds a consistent negative correlation with diabetes prevalence, while the prevalence of respiratory diseases is a significant association only for developed nations. Socioeconomic factors were significantly associated with AMR, but this influence is stronger in developed countries than in the developing and least developed countries.

While population aging is the primary association with increased AMR, the mortality impact of comorbidities and socioeconomic factors is heavily conditioned by a country's development stage, pointing to the necessity of development-status-aware public health strategies for incoming pandemics.