Publication date: Aug 23, 2026
Community resilience during COVID-19 has been linked to social conditions, public-health capacity, and acute-care resources, but the contribution of pre-pandemic realized preventive-care engagement remains incompletely characterized. We examined whether county-level preventive-care engagement was associated with all-cause excess mortality during the COVID-19 period in the United States. In this ecological study, county-specific linear trends fitted to the age-adjusted all-cause premature-death/YPLL-75 indicator for 2012-2018 were used to predict expected mortality in 2020-2022. Excess mortality was the percentage difference between observed and expected values; resilience was its negative. We estimated adjusted associations for four preventive-care indicators using five-fold cross-fitted double/debiased machine learning (DML), with learner, fold, state-clustered, external-demographic, and spatial lag/error sensitivities. Across 3,079 counties, mean excess mortality in 2020-2022 was 15. 2%. In the primary DML sample (n=2,921), one-standard-deviation higher influenza-vaccination and mammography-screening rates were associated with 0. 106 SD (p
| Concepts | Keywords |
|---|---|
| All-cause excess mortality | |
| COVID-19 | |
| Double machine learning | |
| Ecological study | |
| Health disparities | |
| Mortality resilience | |
| Preventive healthcare | |
| Spatial epidemiology |
Semantics
| Type | Source | Name |
|---|---|---|
| disease | MESH | COVID-19 |
| disease | MESH | death |
| disease | MESH | influenza |