Development of the model
The theoretical model is designed to enable a better understanding of the components, the relationship between them and their contribution to the outcome – individual mortality risk during times of health crisis.
The model (Fig. 1) is composed of three components: external pressures, individual & community resources and outcomes.
Part a: external pressures
At a time of great upheaval such as the present pandemic, numerous external pressures or changes exert influence on individuals and communities, affecting their behavior and way of life, and ultimately health outcomes and survival chances. These external pressures can include Environmental factors (e.g. changes in pollution levels, traffic, climate, access to green space), Economic factors (e.g. high unemployment rate, government handouts, failing economy), Political/Organizational factors (e.g. restrictions on movement, lockdowns, instability) and Social factors (e.g. social distancing, isolation, sense of community). These factors may influence direct health effects such as the chance of being exposed to and getting sick with COVID-19 (manual employment, travelling on public transport); as well as indirect health effects (mental health effect of lockdowns, social isolation, poorer control of chronic disease).
Part B: individual and community vulnerability
Individual resources that a person possesses include wealth (including finances, property, savings); health (both physical and mental; comorbidities); employment (stability, income, job satisfaction, flexibility - the latter being particularly relevant to the current pandemic, manifested for example as the ability to work remotely); and social support (both practical and emotional). These resources determine the individual’s resilience and ability to adapt to change.
The resources of the community in which the individual lives further influence resilience – the existence or lack of social capital, neighborhood safety, community centers, investment in education, green spaces, sports facilities, transport networks and crime rates. High individual and community resources increase the ability to adapt, and reduce mortality risk associated with the major event like the current pandemic; while low resources reduce the ability to adapt and increase mortality risk. Furthermore, individual and community resources affect health behaviors, which in turn are associated with health outcomes, for example unemployment may lead to poorer nutrition and less physical activity, and social isolation may lead to depression or increased risk behaviors such as alcohol consumption, smoking, narcotic use or unhealthy eating. High individual and community resources may increase opportunities for positive health behaviors such as more free time to do sport, reduced work pressure, more family time due to working from home as well as increasing sense of control over events. Low resources may decrease opportunities for positive health behaviors and reduce sense of control. Available resources may also affect use of and access to healthcare, whether financial or logistical access, including help with adapting to online services.
Resilience
According to the salutogenic model of health, a person’s confidence that they have the resources to cope with change affects their health [26]. This confidence, sometimes called sense of coherence, can provide resilience against disease and has been linked both with health behaviors and disease outcomes [27, 28]. In the context of COVID-19, high individual and community resources might increase resilience and the ability to adapt to external pressures and change, thereby reducing mortality risk [29]. In contrast, low resources might reduce resilience and the ability to adapt, increasing mortality risk.
Increased mortality rate
Alongside deaths caused directly by COVID-19, there are rising concerns due to the dramatic decline in health care utilization leading to delayed diagnosis of disease, including acute life-threatening conditions. In India, poor residents of deprived neighborhoods had difficulty accessing healthcare for non-COVID conditions during lockdowns [30]. In Israel, populations at higher risk, such as breast cancer patients, reported less contact with health care professionals during April 2020, the time of the first peak of pandemic spread [31].
Furthermore, despite increased availability of telemedicine services, patients who are not technologically proficient may be at greater risk of missing out on essential care. Patients with fewer resources, including older patients, those with a language barrier (immigrants), or without internet access, will have more obstacles to accessing telemedicine. Indeed, in a study of rheumatologists from around the world, while most had switched to remote appointments, 17% reported that around a quarter of their patients did not have access to telehealth video, especially those from below the poverty line [32]. It has been demonstrated that social networks influence individuals’ adaptation to new technologies in organizations [33]. Older senior citizens (70+) have been found to use the internet less frequently. The increasing number of public and private services that are re-designed as online solutions, and the emergence of new applications, further excludes those seniors, and others with low digital literacy, from active participation [34]. In times of a health crisis, access to online sources of information and advice is especially important.
Additionally, physical distancing used as the main mitigation strategy during the current pandemic, especially in the first 12 months (before the emergence of safe and effective vaccines), has had a substantial impact on both the economic situation and mental health state of individuals. The prevalence of depression among US adults increased approximately three-fold [35]. Mounting experience shows that large scale events such as the current pandemic are almost always accompanied by a myriad of mental health consequences with increased rates of depression, post-traumatic stress disorders, substance abuse, domestic violence and child abuse [36]. Mental health issues deplete resources and reduce resilience. As such, there are great concerns about a significant rise in suicide rates and acute stress-related medical conditions, such as acute myocardial infarction or acute ischemic stroke—which can ultimately result in increased mortality [36]. Individuals with pre-existing mental health issues or at risk of social isolation (ie. weakened resources), start from a more precarious point, and are more likely to feel the negative effects of the changes [37, 38].
A Canadian study found that minority groups experience greater COVID-19 related mental health issues compared to non-minority groups, including depression and anxiety [39]. In a US study, individuals with lower social resources, lower economic resources and greater exposure to stressors (losing a job, death of a family member from COVID-19, experiencing financial problems) were more susceptible to depression, with lower income respondents at 2.37 times higher risk of depression [35]. A survey conducted before the pandemic demonstrated that people with low family savings had more depressive symptoms [40]. In times of health and economic crisis like the current pandemic, the absence of a financial safety net in the form of family savings, job security or property might explain the higher prevalence of depression among the weaker segments of the population.
Decreased mortality rate
Individuals who enjoy high individual and community resources may have been able to benefit from the change in circumstances imposed by the pandemic. Mitigation strategies implemented across the world have included temporary lockdowns for a majority of the population, and social restrictions, with continued employment allowed solely for those considered essential workers. Less traffic has led to lower rates of car accidents (a decrease of ~ 20%) [41]. work-related accidents (~ 70%) [15] and air pollution (~ 30%) [12, 13]. Influenza cases reduced dramatically, with hardly any noted cases in some countries in comparison to high rates of flu morbidity in previous years [19].
Imposed restrictions initiated by the pandemic may also have had a positive influence. Transitions to remote working from home may reduce stress related conditions often associated with hectic working and commuting routines, among those with the ability and circumstances to do so. However, remote working is only possible for those in certain jobs, generally more stable and better paid professions, while individuals in physical or menial jobs, often more precarious to begin with, do not reap this benefit. A strong social support network is also likely to help in adapting to the new reality.