Socioeconomic inequalities in health-related quality of life during the COVID-19 pandemic: a six-country comparison using the EQ-5D-5 L

PURPOSE: Despite the growing attention to health inequalities, there is no global consensus on how to measure socio-economic status. This study examined inequalities in health-related quality of life (HRQoL) during the early phase of the COVID-19 pandemic across six countries-China, Italy, the Netherlands, Sweden, the United Kingdom (UK), and the United States (US)-using three SES indicators: education level, income, and work status. METHODS: Between April and June 2020, individuals aged 18-75 years old completed a web-based survey. HRQoL was measured using the EQ-5D-5L Level Sum Score (LSS), where higher scores indicate poorer health. Country-specific differences in LSS across SES groups were assessed using Kruskal-Wallis and Mann-Whitney U tests. Multiple linear regression models, adjusted for age, gender, and chronic conditions, were used to explore associations between SES indicators and HRQoL. No formal correction for multiple testing was applied. RESULTS: Data from 17,607 respondents were analyzed. In all countries except Italy, individuals with lower education levels reported significantly higher LSS scores. The largest disparity was observed in the UK. In the Netherlands, Sweden, the UK, and the US, lower-income groups also had higher LSS scores, while no such differences were observed in China or Italy. Across all countries, unemployed individuals consistently reported worse HRQoL. Regression analyses confirmed that younger age, chronic conditions, and unemployment were strongly associated with poorer HRQoL. CONCLUSIONS: Substantial SES-related health inequalities in HRQoL were observed during the COVID-19 pandemic, especially in the UK. Work status emerged as a particularly strong and consistent predictor across countries.