Key Points Question Are population-level social factors associated with coronavirus disease 2019 (COVID-19) incidence and mortality? Findings In this cross-sectional study including 4 289 283 COVID-19 cases and 147 074 COVID-19 deaths, county-level sociodemographic risk factors as assessed by the Social Vulnerability Index were associated with greater COVID-19 incidence and mortality. Meaning These findings suggest that to address inequities in the burden of the COVID-19 pandemic, these sociodemographic risk factors and their root causes must be addressed.

Context.-A prominent hypothesis regarding social inequalities in mortality is that the elevated risk among the socioeconomically disadvantaged is largely due to the higher prevalence of health risk behaviors among those with lower levels of education and income.Objective.-To investigate the degree to which 4 behavioral risk factors (cigarette smoking, alcohol drinking, sedentary lifestyle, and relative body weight) explain the observed association between socioeconomic characteristics and allcause mortality.Design.-Longitudinal survey study investigating the impact of education, income, and health behaviors on the risk of dying within the next 7.5 years.Participants.-A nationally representative sample of 3617 adult women and men participating in the Americans' Changing Lives survey.Main Outcome Measure.-All-cause mortality verified through the National Death Index and death certificate reviews.Results.-Educational differences in mortality were explained in full by the strong association between education and income. Controlling for age, sex, race, urbanicity, and education, the hazard rate ratio of mortality was 3.22 (95% confidence interval [CI], 2.01-5.16) for those in the lowest-income group and 2.34 (95% CI, 1.49-3.67) for those in the middle-income group. When health risk behaviors were considered, the risk of dying was still significantly elevated for the lowestincome group (hazard rate ratio, 2.77; 95% CI, 1.74-4.42) and the middle-income group (hazard rate ratio, 2.14; 95% CI, 1.38-3.25).Conclusion.-Although reducing the prevalence of health risk behaviors in lowincome populations is an important public health goal, socioeconomic differences in mortality are due to a wider array of factors and, therefore, would persist even with improved health behaviors among the disadvantaged.

It has been hypothesized that exposure to stress and negative life events is related to poor health outcomes, and that differential exposure to stress plays a role in socioeconomic disparities in health. Data from three waves of the Americans' Changing Lives study (n = 3,617) were analyzed to investigate prospectively the relationship among socioeconomic indicators, five measures of stress/negative life events, and the health outcomes of mortality, functional limitations, and self-rated health. The results revealed that (1) life events and other types of stressors are clearly related to socioeconomic position; (2) a count of negative lifetime events was positively associated with mortality; (3) a higher score on a financial stress scale was predictive of severe/moderate functional limitations and fair/poor self-rated health at wave 3; and (4) a higher score on a parental stress scale was predictive of fair/poor self-rated health at wave 3. The negative effects of low income on functional limitations attenuated to insignificance when waves 1 and 2 stress/life event measures were controlled for, but other socioeconomic disparities in health change remained sizable and significant when adjusted for exposure to stressors. The results support the hypothesis that differential exposure to stress and negative life events is one of many ways in which socioeconomic inequalities in health are produced in society.

The results indicate that understanding and alleviating social disparities in health are both theoretically and methodologically quintessential problems of life course analysis and research.

Objective. To better understand medical decision making in the context of ''preference sensitive care,'' we investigated factors associated with breast cancer patients' satisfaction with the type of surgery received and with the decision process. Data Sources/Data Collection. For a population-based sample of recently diagnosed breast cancer patients in the Detroit and Los Angeles metropolitan areas (N 5 1,633), demographic and clinical data were obtained from the Surveillance, Epidemiology, and End Results tumor registry, and self-reported psychosocial and satisfaction data were obtained through a mailed survey (78.4 percent response rate). Study Design. Cross-sectional design in which multivariable logistic regression was used to identify sociodemographic and clinical factors associated with three satisfaction measures: low satisfaction with surgery type, low satisfaction with the decision process, and decision regret. Principal Findings. Overall, there were high levels of satisfaction with both surgery and the decision process, and low rates of decision regret. Ethnic minority women and those with low incomes were more likely to have low satisfaction or decision regret. In addition, the match between patient preferences regarding decision involvement and their actual level of involvement was a strong indicator of satisfaction and decision regret/ambivalence. While having less involvement than preferred was a significant indicator of low satisfaction and regret, having more involvement than preferred was also a risk factor. Women who received mastectomy without reconstruction were more likely to report low satisfaction with surgery (odds ratio [OR] 5 1.54, po.05), low satisfaction with the process (OR 5 1.37, po.05), and decision regret (OR 5 1.55, po.05) compared with those receiving breast conserving surgery (BCS). An additional finding was that as patients' level of involvement in the decision process increased, the rate of mastectomy also increased ( po.001). Conclusions. A significant proportion of breast cancer patients experience a decision process that matches their preferences for participation, and report satisfaction with both the process and the outcome. However, women who report more involvement in the decision process are significantly less likely to receive a lumpectomy. Thus, increasing patient involvement in the decision process will not necessarily increase use of BCS or lead to greater satisfaction. The most salient aspect for satisfaction with the decision 745