Continuing inequalities in COVID-19 mortality in England and Wales, and the changing importance of regional, over local, deprivation

Abstract

Background: Observational studies have highlighted that where individuals live is far more important for risk of dying with COVID-19, than for dying of other causes. Deprivation is commonly proposed as explaining such differences. During the period of localised restrictions in late 2020, areas with higher restrictions tended to be more deprived. We explore how this impacted the relationship between deprivation and mortality and see whether local or regional deprivation matters more for inequalities in COVID-19 mortality. Methods: We use publicly available population data on deaths due to COVID-19 and all-cause mortality between March 2020 and April 2021 to investigate the scale of spatial inequalities. We use a multiscale approach to simultaneously consider three spatial scales through which processes driving inequalities may act. We go on to explore whether deprivation explains such inequalities. Results Adjusting for population age structure and number of care homes, we find highest regional inequality in October 2020, with a COVID-19 mortality rate ratio of 5.86 (95% CI 3.31 to 19.00) for the median between-region comparison. We find spatial context is most important, and spatial inequalities higher, during periods of low mortality. Almost all unexplained spatial inequality in October 2020 is removed by adjusting for deprivation. During October 2020, one standard deviation increase in regional deprivation was associated with 2.45 times higher local mortality (95% CI, 1.75 to 3.48). Conclusions Spatial inequalities are greatest in periods of lowest overall mortality, implying that as mortality declines it does not do so equally. During the prolonged period of low restrictions and low mortality in summer 2020, spatial inequalities strongly increased. Contrary to previous months, we show that the strong spatial patterning during autumn 2020 is almost entirely explained by deprivation. As overall mortality declines, policymakers must be proactive in detecting areas where this is not happening, or risk worsening already strong health inequalities.

Time-sensitive testing pressures and COVID-19 outcomes: are socioeconomic inequalities over the first year of the pandemic explained by selection bias?

“…Accordant results across the included SEP measures are consistent with SEP encompassing a range of resources relevant to health, representing a fundamental cause of health inequalities, irreducible to a single factor [ 48 ]. Many previous studies have only considered area-level SEP [ 6 , 9 , 49 ]. This is often the only available data when using population-based COVID-19 data but limits our understanding of how within-area differences in SEP affect COVID-19 outcomes.…”

“…In England using the Office for National Statistics (ONS) index of multiple deprivation (IMD) data and COVID-19 testing data from Public Health England (PHE), it was found that the association between more disadvantaged area-level SEP and worse COVID-19 outcomes reversed towards the end of 2020, with higher levels of neighbourhood deprivation appearing protective against COVID-19 infection and mortality [ 6 , 9 ]. This was a period when locally targeted lockdown restrictions were implemented, with lower area-level deprivation becoming risk-inducing for infection and severity for several months before reverting [ 6 , 9 , 25 , 26 ].…”

Socioeconomic inequality in SARS-CoV-2 testing and COVID-19 outcomes in UK Biobank over the first year of the pandemic: can inequalities be explained by selection bias?

“…Despite a trend towards worsening inequalities, we found an attenuation of the effect of SEP on SARS-CoV-2 infection at time-period 3 when local lockdown restrictions were introduced, supporting previous conclusions from population level data for SEP and SARS-CoV-2 infection. 10,14,35…”

“…Individual and contextual risk factor associations for COVID-19 have changed over time. 7-10 Like many high-income countries, in the UK, higher SEP was protective for infection and severity during the early stages of the pandemic. 11-13 However, as shown from Public Health England (PHE) and Office for National Statistics (ONS) data, this association reversed towards the end of 2020 when locally targeted lockdown restrictions were implemented, with high area-level SEP becoming risk-inducing for infection and severity for several months before reverting.…”

“…11-13 However, as shown from Public Health England (PHE) and Office for National Statistics (ONS) data, this association reversed towards the end of 2020 when locally targeted lockdown restrictions were implemented, with high area-level SEP becoming risk-inducing for infection and severity for several months before reverting. 7,10,14,15…”