Interrogating structural inequalities in COVID-19 Mortality in England and Wales

BackgroundNumerous observational studies have highlighted structural inequalities in COVID-19 mortality in the UK. Such studies often fail to consider the complex spatial nature of such inequalities in their analysis, leading to the potential for bias and an inability to reach conclusions about the most appropriate structural levels for policy intervention. MethodsWe use publicly available population data on COVID-19 related- and all-cause mortality between March and July 2020 in England and Wales to investigate the spatial scale of such inequalities. We propose a multiscale approach to simultaneously consider four spatial scales at which processes driving inequality may act and apportion inequality between these. ResultsAdjusting for population age structure, number of care homes and residing in the North we find highest regional inequality in March and June/July. We find finer-grained within-region increased steadily from March until July. The importance of spatial context increases over the study period. No analogous pattern is visible for non-COVID mortality. Higher relative deprivation is associated with increased COVID-19 mortality at all stages of the pandemic but does not explain structural inequalities. ConclusionsResults support initial stochastic viral introduction in the South, with initially high inequality decreasing before the establishment of regional trends by June and July, prior to reported regionality of the "second-wave". We outline how this framework can help identify structural factors driving such processes, and offer suggestions for a long-term, locally-targeted model of pandemic relief in tandem with regional support to buffer the social context of the area. Key MessagesO_LIRegional inequality in COVID-19 mortality declined from an initial peak in April, before increasing again in June/July. C_LIO_LIWithin-region inequality increased steadily from March until July. C_LIO_LIStrong regional trends are evident in COVID-19 mortality in June/July, prior to wider reporting of regional differences in "second wave". C_LIO_LIAnalogous spatial inequalities are not present in non-COVID related mortality over the study period. C_LIO_LIThese inequalities are not explained by age structure, care homes, or deprivation. C_LI