Inequality and COVID-19 in Sweden: Relative risks of nine bad life events, by four social gradients, in pandemic vs. prepandemic years

Adam Altmejd, Evelina Björkegren, Torsten Persson, and Olof Östergren

The COVID-19 pandemic struck societies directly and indirectly, not just challenging population health but disrupting many aspects of life. Different effects of the spreading virus—and the measures to fight it—are reported and discussed in different scientific fora, with hard-to-compare methods and metrics from different traditions. While the pandemic struck some groups more than others, it is difficult to assess the comprehensive impact on social inequalities. This paper gauges social inequalities using individual-level administrative data for Sweden’s entire population. We describe and analyze the relative risks for different social groups in four dimensions—gender, education, income, and world region of birth—to experience three types of COVID-19 incidence, as well as six additional negative life outcomes that reflect general health, access to medical care, and economic strain. During the pandemic, the overall population faced severe morbidity and mortality from COVID-19 and saw higher all-cause mortality, income losses and unemployment risks, as well as reduced access to medical care. These burdens fell more heavily on individuals with low income or education and on immigrants. Although these vulnerable groups experienced larger absolute risks of suffering the direct and indirect consequences of the pandemic, the relative risks in pandemic years (2020 and 2021) were conspicuously similar to those in prepandemic years (2016 to 2019).

Heterogeneous impacts of COVID-19 on incomes

Adrian Adermon, Lisa Laun, Costanza Naguib, Martin Olsson, Jan Sauermann, and Anna Sjögren

An important question for policymakers is which groups experienced the largest income losses in the pandemic, and how well they were protected by the welfare system. Understanding this will allow potential holes in the safety net to be patched before another crisis. It is also useful to know which policies protected different groups, to better understand the distributional effects of changing these policies. In this project, we study the heterogeneous impacts of the COVID-19 pandemic on individual incomes for the full Swedish population. We apply state-of-the-art causal machine learning methods (specifically, the generalized random forest), which allow us to identify potentially narrow groups which were hit especially hard by the pandemic. These groups will be defined by complex interactions among characteristics such as age, gender, nationality, level of education, sector of employment, family structure. The approach is data-driven, which prevents ad hoc methodological decisions that could result in detection of heterogeneity that is not really present, and helps avoid selective reporting of findings. Since we have access to a wide range of income sources, including labor incomes; transfers from pre-pandemic benefit systems; and transfers from specific pandemic measures, we are able to study heterogeneity in pandemic impacts separately across these different income measures, as well as for their sum.

The Impact of the COVID-19 Pandemic on the Surgical Treatment of Colorectal Cancer Patients in Sweden

Anders Hansson Elliot, AnnaMia Ekström, and Ulf Gustafsson

In March 2020, during the initial phase of the COVID-19 pandemic, a significant portion of healthcare resources in Sweden and worldwide were redirected towards pandemic control. This also impacted surgical procedures, including those for imperative cases such as cancer and acute/subacute conditions. Some newly operated patients became infected with SARS-CoV-2, leading to perioperative deaths. This situation triggered a national and international debate on the criteria for performing surgeries during a pandemic. Various national perioperative guidelines were developed despite the lack of concrete evidence.

Did more generous unemployment insurance benefits contribute to worker reallocation during the COVID-19 pandemic?

Jan Sauermann, Olle Törnquist, and Sebastian Butschek

This project explores how changes to Sweden’s unemployment insurance (UI) system during the COVID-19 pandemic influenced job search outcomes and labor market mobility. In response to rising unemployment, the Swedish government temporarily expanded UI access and generosity – reducing the membership requirement and increasing benefit levels. Using nationwide register data, we study whether unemployed individuals shifted toward more stable sectors and how the UI reforms affected job-finding rates, job quality, and firm characteristics. The project applies causal methods – including regression discontinuity and regression kink designs – to assess the impact of policy changes on employment trajectories during a time of economic disruption.

How does unemployment insurance protect the families of workers who lose their jobs?

Anna Sjögren, Lisa Laun, Hanna Mühlrad, and Jan Sauermann

This project examines how expanded access to unemployment insurance (UI) during the COVID-19 pandemic influenced the economic and social well-being of Swedish families. By comparing families of job-losers who qualified for UI due to pandemic-era reforms to those who did not, the study explores how UI affects family income, reliance on means-tested benefits, household stability, and children’s outcomes – such as school performance and mental health. The project contributes to a broader research agenda on the role of the welfare state in mitigating the consequences of economic shocks.

Mental health of COVID-19 patients and their family members

Fang Fang, Unnur Valdimarsdóttir, Tove Fall, Mary Barker, and Shiyu Li

This project investigates the risk of mental illness among individuals diagnosed with COVID-19 and their family members in Sweden. Using nationwide register data from SWECOV, we will assess how COVID-19 disease severity influences the development of mental health conditions such as depression, anxiety, and suicidal behavior. The study includes two large cohort analyses comparing individuals with and without COVID-19, and their relatives, to explore the psychological impact of infection, hospitalization, and bereavement. By linking COVID-19 records to health, medication, and demographic registers, the project will provide comprehensive insights into the long-term mental health burden of the pandemic.

Did COVID-19 have lasting effects on the spatial allocation of local services?

Oskar Nordström Skans, Adam Gill, and Lena Hensvik

The COVID-19 pandemic had a massive temporary effect on people’s mobility patterns. Recent evidence suggests that part of this adjustment is here to stay – the pandemic appears to have had lasting effects on the incidence of working-from-home n many countries. Data from the US indicates that this may change the spatial economic structure of cities – the rise of the “donut” city. In this paper, we focus on the allocation of services as an indicator of real spatial effects of increased WFH induced by the pandemic. To this end, we use Swedish geo-located data on sales in restaurants (and other personal services) by neighborhood to investigate the extent to which these services have shifted from work-intensive neighborhoods towards residential neighborhoods during and after the pandemic. From aggregate data we know that the restaurant sector as a whole has recovered well, but did this recovery involve systematic spatial reallocation because of increased incidence of work from home?

Age at migration and COVID-19

Oskar Nordström Skans, Olof Åslund, Erik Grönqvist, and Tram Pham

This project analyzes how age at migration affected outcomes and behavior during the most severe phases of the COVID-19 pandemic. The project focuses primarily on outcomes in adulthood among people who immigrated to Sweden as children (or who were born just after their parents arrived).

We quantify how COVID-19 disparities differ between individuals as a function of how much of their childhood was spent in Sweden. Previous research has shown that host-country exposure during childhood have large causal effects on adulthood outcomes in such diverse dimensions such as Height, Education, Earnings and Social Integration at the Housing, Marriage and Labor markets. The project will document if these effects of early host country exposure also transmit into different health outcomes during the pandemic as measured by the incidence, hospitalization, ICU-cases and mortality, differences in protective behavior (vaccination), and assesses to what extent disparities are mediated by segregation processes.

Inequalities in mortality going in and out of the pandmic: The contribution of age and cause of death to changes in life expectancy by education during 2015-2022.

Olle Lundberg, Olof Östergren, Adam Altmejd, Marcus Ebeling, and Karin Modig

Life expectancy in Sweden decreased between 2019 and 2020 from 84.7 to 84.3 years for women and from 81.3 to 80.6 for men. Between 2020 and 2021, life expectancy increased to 84.8 years among women and 81.2 years among men. The loss of life expectancy in 2020 was largely recovered in 2021 and among women, life expectancy in 2021 was higher than before the pandemic. However, both the decrease in life expectancy and the recovery in 2021 differed by educational attainment. Individuals with low education experienced a more dramatic decline in life expectancy and a more modest recovery.

Medical scandals and vaccine hesitancy

Svenja Miltner, and Jonatan Riberth

In this project we consider the effects on vaccine hesitancy and health care utilization from an unusual medical scandal. Following the 2009–2010 swine flu pandemic, Sweden adopted a mass vaccination campaign where 60% of the Swedish population was vaccinated against the Swine flu. A number of individuals developed narcolepsy, a severe, incurable neurological disease, from the swine flu vaccine. We use individual level data on Covid and swine flu vaccinations to measure vaccine hesitancy during the Covid-19 pandemic among the affected individuals.

Individual and aggregate consequences of post-covid conditions

Adam Altmejd, Torsten Persson, Olof Östergren, Anna Mia Ekström, Oskar Nordström Skans, Maxim Kan, and Nicola Orsini

The purpose of the project is to describe how long-COVID, or post-COVID-19, conditions (PCC), have affected Swedish society. The project will start by describing (i) those who suffer from PCC, (ii) whether the burden of disease is unequally distributed across social groups, and (iii) some of the implications for those diagnosed. Next, we will evaluate if vaccines provide some protection from PCC. We will also estimate the labor-market effects of PCC. One key aim is to understand the losses of individual labor supply, as well as of aggregate output. We will therefore study to what extent PCC has added to the burden of long-term sick leave, (and thus the total amount of absenteeism). To do so, we will analyze how much PCC has afflicted groups that tended to have few sick days before the onset of COVID-19 vs. groups that tended to have many sick days, for other types of sickness, before the pandemic. For the latter groups, it will be interesting to identify whether these types of sickness—like (some forms of) PCC—are hard to diagnose and treat. Additionally, we would study whether post-Covid diagnosis is at least as common in patients with mild or undiagnosed Covid-19 as in those hospitalized with severe Covid-19. Also, we would examine whether patients with post-Covid diagnosis, especially after a mild infection, have similar risk factors to those with fatigue/depression and to some extent addiction problems.

Covid-19 in Swedish elderly care – the impact of health- and social care services on mortality in nursing homes

Ulrika Winblad, Wilhelm Linder, Douglas Spangler, and David Isaksson

Nursing homes (NHs, SÄBO) and their residents were severely affected by the covid-19 pandemic with NH-residents (approximately 1% of the Swedish population) constituting approximately 40% of covid-19 related deaths. As the share of older individuals are increasing in Sweden, research on elderly care will be of uttermost importance in order to protect the elderly from future epi- and pandemics. This project relates to previous work by the Swedish Coronavirus Commission where data from SweCov was used to investigate covid-19 infections and mortality at Swedish NHs. Noticeably, two reports included in the preparatory documents from The Coronavirus Commission introduced a novel method for clustering individuals (and individual health data) to their respective NHs. In theory, structural factors of NHs (e.g. NH size) can affect both the covid-19 incidence and mortality (e.g. availability of nurses). Using this novel approach of selecting NH-residents using linked individual level data, Broms et al. reported that high NH staff turnover, lack of nurses, and larger NHs were associated with an increase in covid-19 infections and mortality.

Symptoms reported through the Swedish Healthcare Guide 1177 for disease surveillance and hospital predictions

Tove Fall, Jonas Björk, Ulf Hammar, Per Lundmark, and Georgios Varotsis

Disease surveillance is crucial during a pandemic because it allows informed decisions and evaluation of the effectiveness of implemented policies. Our study aims to develop new methods for real-time surveillance of respiratory virus spread and to predict surges in hospital admissions based on >4 million yearly calls to the Swedish Healthcare Guide 1177 phone-line, a largely untapped resource for syndromic surveillance. We have two main aims:

1. Development of methods to estimate the daily infection prevalence at a local level 2020-2022 based on national health inquiry calls to Swedish Healthcare Guide 1177 phone-line linked to subsequent PCR and antibody test results using COVID-19 as a model.
2. Development of an adaptive 7-14 days forecasting model for hospital admissions for respiratory infections using data from national health inquiry calls to Swedish Healthcare Guide 1177 phone-line.

Preparation and evaluation of simplified analytical procedures for syndromic surveillance to apply in future epidemics will be a part of the study.

Understanding social inequalities in Covid-19 testing behavior

Olof Östergren, Arizo Karimi, Emelie Counil, Jonas Björk, Tove Fall, and Karl Gauffin

Groups with lower socioeconomic status have suffered disproportionately from severe Covid-19. However, more cases were detected among individuals in higher socioeconomic positions. These seemingly conflicting observations are in part attributed to differences in testing behavior; individuals in lower socioeconomic positions in Sweden had lower testing rates and higher positivity rates compared to those in higher positions.

The propensity to get tested can depend on several things. Some factors may motivate the individual to get tested while others can make the individual more likely to avoid taking a test. Here, we use register data to identify potential individual and structural factors that may influence testing behavior and evaluate if these contribute to socioeconomic differences in testing behavior.

Predictors of COVID-19 outcomes among residents of Swedish long-term care facilities—a nationwide study of the year 2020

Jenna Najar, Rasmus Broms, Marina Nistotskaya, and Carl Dahlström

What is the primary question addressed by this study? This study examines predictors for SARS-CoV-2 infection and COVID-19 death among residents of long-term care facilities (LTCFs), using Swedish nation-wide data for the whole pandemic year of 2020.

What is the main finding of this study? We found that several factors were associated with SARS-CoV-2 infection and COVID-19 death. All-cause dementia was a particularly strong predictor of COVID-19 death, especially among those aged 65-75 years.

Sweden's COVID-19 Recession: How Foreign and Domestic Infections Struck against Firms and Workers

Anders Akerman, Karolina Ekholm, Torsten Persson, and Oskar N. Skans

The COVID-19 pandemic had massive contractionary effects on most economies across the globe. However, the economic effects varied tremendously both within and across countries. We use highly granular Swedish micro-data to document the economic effects of the COVID-19 pandemic on Swedish private-sector firms and their workers.

The study shows that trading firms suffered larger output losses if they exported to, or imported from, countries with high COVID-rates and/or disruptive COVID restrictions. Service sector firms that operated in locations with many COVID cases were forced to reduce their output due to falling local consumption. This is striking since Sweden had very limited regional variation in restrictions and recommendations.