Regional variation in COVID-19 positive hospitalisation across Scotland during the first wave of the pandemic and its relation to population density: A cross-sectional observation study

PLoS One. 2021 Jul 9;16(7):e0253636. doi: 10.1371/journal.pone.0253636. eCollection 2021.


Background: There have been large regional differences in COVID-19 virus activity across the UK with many commentators suggesting that these are related to age, ethnicity and social class. There has also been a focus on cases, hospitalisations and deaths rather than on hospitalisation rates expressed per 100,000 population. The purpose of our study was to examine regional variation in COVID-19 positive hospitalisation rates in Scotland during the first wave of the pandemic and the possibility that these might be related to population density.

Methods and findings: This was a repeated point prevalence study. The number of COVID-19 positive patients hospitalised in the eleven Scottish mainland health boards peaked at 1517 on 19th April, then fell to a low of 243 on 16th August before rising slightly to 262 on 15th September. In July, August and September only four boards had more than 5 hospitalised patients. There was a statistically significant relationship between hospitalisation rates and population density on 97.7% of individual days during the first wave of the pandemic (Pearson's r 0.62-0.93, with 123 of a possible 174 days having p values <0.001). Multiple linear regression analyses performed on data from the 11 mainland boards across six time points suggest that population density accounted for 70.2% of the variation in hospitalisation rate in April, 72.3% in May, 81.2% in June, 91.0% in July, 91.0% in August, and 88.1% in September. Neither population median age nor median social deprivation score at health board level were statistically significant in the final model for hospitalisation.

Conclusion: There were large differences in crude COVID-19 hospitalisation rates across the 11 mainland Scottish health boards, that were significantly related to population density. Given that lockdown was originally introduced to prevent the NHS from being overwhelmed, we believe our results support a regional rather than a national approach to lifting or reimposing more restrictive measures, and that hospitalisation rates should be part of the decision making process.

Publication types

  • Observational Study

MeSH terms

  • Adult
  • COVID-19 / epidemiology*
  • COVID-19 / therapy*
  • COVID-19 / transmission*
  • Cross-Sectional Studies
  • Female
  • Hospitalization*
  • Humans
  • Male
  • Middle Aged
  • Pandemics*
  • Population Density
  • SARS-CoV-2*
  • Scotland / epidemiology

Grants and funding

The authors received no specific funding for this work.