Socio‐Demographic Inequalities in COVID‐19 Health Care Access and Experiences in the United Kingdom: Intersectional and Mixed‐Methods Analyses of Open and Closed Questions in a Prospective Cohort Study

Alastair Comery; Nathan Cheetham; Anoushka  Beattie; Vicky Bowyer; J. D. Carpentieri; Claire Steves

doi:10.1111/hex.70692

Socio‐Demographic Inequalities in COVID‐19 Health Care Access and Experiences in the United Kingdom: Intersectional and Mixed‐Methods Analyses of Open and Closed Questions in a Prospective Cohort Study

Alastair Comery
, Nathan Cheetham
, Anoushka Beattie
, Vicky Bowyer
, J. D. Carpentieri
, Claire Steves

The COVID Symptom Study Biobank Consortium
Kings College London
UCL Institute of Education
Guys and St Thomas' NHS Foundation Trust and Kings College London

Research output: Contribution to journal › Article › peer-review

Abstract

Introduction: Inequalities in health care access and experiences during the COVID‐19 pandemic have been observed along
axes of social advantage. It is less well understood how access to care varied intersectionally with combinations of multiple
social factors, and how social advantage shaped care experiences for COVID‐19 illness.
Methods: We analysed responses to both closed (N = 3516) and open (N = 335) survey questions relating to health and social
care access and experiences during the first two and a half years of the COVID‐19 pandemic in the United Kingdom
community‐based cohort, COVID Symptom Study Biobank. Causal effects of individual socio‐demographic variables on access
to health and social care were estimated with multivariable regression models, weighted for inverse probability of survey
completion and adjusted for potential confounders. Associations between care access issues and social strata comprising
combinations of sex, education level and local area deprivation were estimated using the intersectional multilevel analysis of
individual heterogeneity and discriminatory accuracy (MAIHDA) approach. Responses to open questions on health care
experiences for COVID‐19 illness were deductively coded and quantitatively analysed to estimate associations between socio‐
demographic advantage and various aspects of care experiences.
Results: Gradients in health and social care access along the lines of social advantage were observed in intersectional MAIHDA
models, with the predicted probability of access issues highest for the stratum comprising female participants with lowest
education and highest deprivation levels (42.9%, 95% CI: 31.9%–54.6%), and lowest for male participants with highest education
and lowest deprivation (18.7%, 95% CI: 12.8%–26.7%). Socially disadvantaged participants also reported receiving poorer care for
COVID‐19, with lower likelihood of reporting receiving adequate care and specialist care for long COVID, and higher likelihood
of negative experiences of care versus advantaged participants.
Conclusions: Inequalities in likelihood of health and social care access issues were observed, as well as inequalities in care
experiences specifically for COVID‐19, with issues accessing care and poorer experiences more likely to be reported by
individuals with greater social disadvantage.

Original language	English
Number of pages	20
Journal	Health Expectations
Volume	29
Issue number	3
Early online date	1 Jun 2026
DOIs	https://doi.org/10.1111/hex.70692
Publication status	Published - 1 Jun 2026

Data Availability Statement

For the purposes of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any Accepted Author Manuscript version arising from this submission.

Access to data in the COVID Symptom Study Biobank is available to bona fide health researchers on application to the COVID Symptom Study Biobank Management Group. Further details are available online at https://cssbiobank.com/information-for-researchers, including application forms and contact information.

The analysis code used in this study is available openly on GitHub at https://github.com/nathan-cheetham/CSSBiobank_CareExperiences. Anonymised COVID Symptom Study data are available to researchers to be shared with researchers according to their protocols in the public interest through Health Data Research UK (HDRUK) and Secure Anonymised Information Linkage consortium, housed in the UK Secure Research Platform (Swansea, UK) at https://web.www.healthdatagateway.org/dataset/fddcb382-3051-4394-8436-b92295f14259.

Acknowledgements

We thank COVID Symptom Study Biobank participants, in particular those who participated in various studies while experiencing ongoing symptoms. We are grateful to the CSS Biobank Volunteer Advisory Panel for their input on the development of the biobank and feedback on the design of this study and its significance for patients and the wider public. We are grateful to the staff at Zoe Ltd (including Christina Hu and Joan Capdevila Pujol) for their work on the CSS app, for enabling recruitment to the CSS Biobank and sharing and maintaining CSS data. Wethank Katie Doores, Michael Malim, Carl Graham, Jeffrey Seow, Sam Acors, and Neo Kouphou for antibody testing of participant blood samples

Funding

The CSS Biobank is supported by the Chronic Disease Research Foundation. Nathan J. Cheetham was supported by the UK Research and Innovation and National Institute for Health and Care Research CONVALESCENCE grant (COV-LT-0009, MC_PC_20051) and Medical Research Council grant (MR/Y003624/1). Claire J. Steves, Anoushka Beattie, Alastair B. Comery and J. D. Carpentieri were supported by grant [COV-LT-0009, MC_PC_20051]. ZOE Ltd provided in-kind support for all aspects of building, running and supporting the COVID Symptom Study app and service to all users worldwide. The funders of the study had no role in the design of the study, data collection, data analysis, interpretation or writing of the report. All authors had full access to all data within the study. The corresponding authors had final responsibility for the decision to submit for publication.

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 4 Quality Education

Keywords

COVID-19
Health care access
Health inequalities
Intersectionality
Long COVID
Mixed methods
Patient experience
Quality of care

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Socio‐Demographic Inequalities in COVID‐19 Health Care Access and Experiences in the United Kingdom: Intersectional and Mixed‐Methods Analyses of Open and Closed Questions in a Prospective Cohort Study. / Comery, Alastair; Cheetham, Nathan; Beattie, Anoushka et al.
In: Health Expectations, Vol. 29, No. 3, 01.06.2026.

Research output: Contribution to journal › Article › peer-review

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abstract = "Introduction: Inequalities in health care access and experiences during the COVID‐19 pandemic have been observed along axes of social advantage. It is less well understood how access to care varied intersectionally with combinations of multiple social factors, and how social advantage shaped care experiences for COVID‐19 illness. Methods: We analysed responses to both closed (N = 3516) and open (N = 335) survey questions relating to health and social care access and experiences during the first two and a half years of the COVID‐19 pandemic in the United Kingdom community‐based cohort, COVID Symptom Study Biobank. Causal effects of individual socio‐demographic variables on access to health and social care were estimated with multivariable regression models, weighted for inverse probability of survey completion and adjusted for potential confounders. Associations between care access issues and social strata comprising combinations of sex, education level and local area deprivation were estimated using the intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) approach. Responses to open questions on health care experiences for COVID‐19 illness were deductively coded and quantitatively analysed to estimate associations between socio‐ demographic advantage and various aspects of care experiences. Results: Gradients in health and social care access along the lines of social advantage were observed in intersectional MAIHDA models, with the predicted probability of access issues highest for the stratum comprising female participants with lowest education and highest deprivation levels (42.9\%, 95\% CI: 31.9\%–54.6\%), and lowest for male participants with highest education and lowest deprivation (18.7\%, 95\% CI: 12.8\%–26.7\%). Socially disadvantaged participants also reported receiving poorer care for COVID‐19, with lower likelihood of reporting receiving adequate care and specialist care for long COVID, and higher likelihood of negative experiences of care versus advantaged participants. Conclusions: Inequalities in likelihood of health and social care access issues were observed, as well as inequalities in care experiences specifically for COVID‐19, with issues accessing care and poorer experiences more likely to be reported by individuals with greater social disadvantage.",

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AU - Cheetham, Nathan

AU - Beattie, Anoushka

AU - Bowyer, Vicky

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AB - Introduction: Inequalities in health care access and experiences during the COVID‐19 pandemic have been observed along axes of social advantage. It is less well understood how access to care varied intersectionally with combinations of multiple social factors, and how social advantage shaped care experiences for COVID‐19 illness. Methods: We analysed responses to both closed (N = 3516) and open (N = 335) survey questions relating to health and social care access and experiences during the first two and a half years of the COVID‐19 pandemic in the United Kingdom community‐based cohort, COVID Symptom Study Biobank. Causal effects of individual socio‐demographic variables on access to health and social care were estimated with multivariable regression models, weighted for inverse probability of survey completion and adjusted for potential confounders. Associations between care access issues and social strata comprising combinations of sex, education level and local area deprivation were estimated using the intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) approach. Responses to open questions on health care experiences for COVID‐19 illness were deductively coded and quantitatively analysed to estimate associations between socio‐ demographic advantage and various aspects of care experiences. Results: Gradients in health and social care access along the lines of social advantage were observed in intersectional MAIHDA models, with the predicted probability of access issues highest for the stratum comprising female participants with lowest education and highest deprivation levels (42.9%, 95% CI: 31.9%–54.6%), and lowest for male participants with highest education and lowest deprivation (18.7%, 95% CI: 12.8%–26.7%). Socially disadvantaged participants also reported receiving poorer care for COVID‐19, with lower likelihood of reporting receiving adequate care and specialist care for long COVID, and higher likelihood of negative experiences of care versus advantaged participants. Conclusions: Inequalities in likelihood of health and social care access issues were observed, as well as inequalities in care experiences specifically for COVID‐19, with issues accessing care and poorer experiences more likely to be reported by individuals with greater social disadvantage.

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KW - Health care access

KW - Health inequalities

KW - Intersectionality

KW - Long COVID

KW - Mixed methods

KW - Patient experience

KW - Quality of care

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