Enduring prevalence

UK local authorities that experience sustained high levels of COVID-19 are termed areas of enduring prevalence (AEP) according to the UK Scientific Advisory Group for Emergencies (2021). Researchers working on Theme 3 of the PROTECT NCS conducted a study in order to examine why some local authority areas have high, sustained levels of COVID-19 prevalence.

The research team conducted interviews with Directors of Public Health (DsPH) in 19 local authority areas across England, between July and October 2021.  Nine interviews were carried out in areas that had been identified by SAGE as AEP, and ten interviews were conducted in ‘comparison areas’ (CA).

CAs were identified by DsPH, the Association of Directors of Public Health (ADPH) or Public Health England as being similar to the AEP, for example in terms of deprivation levels or population mix but had lower levels of COVID-19 prevalence.

Data on a range of indicators including deprivation, ethnicity, overcrowded households, and factors related to employment was also collected for the local authority areas included in the research.

Two reports were produced as part of the project. Report 1 considers key drivers of COVID-19 prevalence and variations between local authority areas. The research suggests that health existing health inequalities influence the wider picture of prevalence rates of COVID-19.

Structural factors including deprivation, employment, and housing, converging with demographic factors including ethnicity and age, and vaccination rates, are key drivers of prevalence, and there are key differences in these drivers both within local authorities, and to a lesser extent, between AEP and CA.

A second report discusses mitigation strategies that were implemented by DsPH during the course of the pandemic. Strategies implemented included local contact tracing, testing and vaccination efforts, isolation support, communication campaigns, engagement with communities, business, and education.

No major differences between strategies used by DsPH in AEP and CA were found, and other than differences in structural indicators such as levels of deprivation, the research did not identify any major differences between AEP and CA in barriers and facilitators of COVID-19 control.

Recommendations for future research include consultation with a wider range of stakeholders in order to provide a broader insight into the impact of, and interactions between, factors that had an impact on prevalence rates, along with further research to understand community needs, attitudes, and beliefs with regards to COVID-19 in order to tailor future messaging and mitigation efforts.

Recommendations for future research also include further research on the experiences of employers and employees. This is being explored in the Phase 3 Greater Manchester Case Study project, which includes interviews with public health and environmental health teams, as well as online surveys for employers and employees, in order to examine changes in COVID-19 transmission risk, response and resilience in Greater Manchester workplaces during the course of the pandemic.


The research has been widely disseminated at a range of local, regional, national and international forums, conferences and events, including presentations to HSE and UK Health Security Agency (UKHSA) and at conferences including the PROTECT Conference  and Symposium, as well as the International Festival of Public Health 2022, Partnership for European Research in Occupational Safety and Health (PEROSH) Wellbeing At Work Conference 2022, and the Society for Social Medicine Annual Scientific Conference 2022.


Project Team

  • Chris Armitage, The University of Manchester
  • Anna Coleman, The University of Manchester
  • David Fishwick, Health and Safety Executive (HSE)
  • Amit Gaokar, Rochdale Borough Council
  • Nicola Gartland, The University of Manchester
  • Angelique Hartwig, The University of Manchester
  • Sheena Johnson, The University of Manchester
  • Atiya Kamal, Birmingham City University
  • Cath Lewis, The University of Manchester
  • Eleanor Roaf, Trafford Council
  • Janet Ubido, The University of Manchester
  • Martie van Tongeren, The University of Manchester