# Determinants of COVID-19 Mortality and Temporal Trends in the Health Regions of the State of São Paulo, Brazil

## TL;DR

This study explores factors influencing COVID-19 mortality in São Paulo's health regions and how these factors changed over time.

## Contribution

The study identifies 12 region-specific factors affecting COVID-19 mortality and highlights the need for tailored public health strategies.

## Key findings

- The average mortality rate was 15.1 deaths per 100,000 inhabitants.
- Higher chronic disease mortality was linked to increased COVID-19 deaths.
- A higher percentage of adults correlated with lower COVID-19 mortality.

## Abstract

Background: This study investigated the determinants of COVID-19 mortality and its temporal trends within São Paulo state’s Departamentos Regionais de Saúde (DRS) (health regions) to inform the development of targeted public health interventions. Methods: Utilizing an ecological study design, we analyzed confirmed COVID-19 cases and deaths (February 2020–December 2021) obtained from the COVID Panel, incorporating relevant social and health indicators. The Generalized Additive Model for Location, Scale, and Shape (GAMLSS) was used to identify key determinants, and temporal trends in mortality and vaccination rates were analyzed across each DRS. Results: The average mortality rate was 15.1 deaths per 100,000 inhabitants (median 7.00). Higher chronic disease mortality was associated with an increase in COVID-19 mortality. Moreover, an increase in the percentage of adults led to a decrease in deaths from COVID-19. Conclusions: COVID-19 mortality in São Paulo is shaped by a complex interplay of 12 behavioral, economic, demographic, and environmental factors. Region-specific public health policies should consider these factors, along with geographic, socioeconomic, and budgetary contexts, to effectively address health disparities across the state’s DRS.