How did the COVID-19 pandemic affect access to condoms, chlamydia and HIV testing, and cervical cancer screening at a population level in Britain? (Natsal-COVID).

OBJECTIVES: To investigate how differential access to key interventions to reduce STIs, HIV and their sequelae changed during the COVID-19 pandemic. METHODS: British participants (18-59 years) completed a cross-sectional web survey 1 year (March-April 2021) after the initial lockdown in Britain. Quota-based sampling and weighting resulted in a quasi-representative population sample. We compared Natsal-COVID data with Natsal-3, a household-based probability sample cross-sectional survey (16-74 years) conducted in 2010-2012. Reported unmet need for condoms because of the pandemic and uptake of chlamydia testing/HIV testing/cervical cancer screening were analysed among sexually experienced participants (18-44 years) (n=3869, Natsal-COVID; n=8551, Natsal-3). ORs adjusted for age and other potential confounders describe associations with demographic and behavioural factors. RESULTS: In 2021, 6.9% of women and 16.2% of men reported unmet need for condoms because of the pandemic. This was more likely among participants: aged 18-24 years, of black or black British ethnicity, and reporting same-sex sex (past 5 years) or one or more new relationships (past year). Chlamydia and HIV testing were more commonly reported by younger participants, those reporting condomless sex with new sexual partners and men reporting same-sex partners; a very similar distribution to 10 years previously (Natsal-3). However, there were differences during the pandemic, including stronger associations with chlamydia testing for men reporting same-sex partners; with HIV testing for women reporting new sexual partners and with cervical screening among smokers. CONCLUSIONS: Our study suggests differential access to key primary and secondary STI/HIV prevention interventions continued during the first year of the COVID-19 pandemic. However, there was not strong evidence that differential access has changed during the pandemic when compared with 2010-2012. While the pandemic might not have exacerbated inequalities in access to primary and secondary prevention, it is clear that large inequalities persisted, typically among those at greatest STI/HIV risk.

Implementation in an emergency: Qualitative longitudinal research on the experience of implementing Covid-19 prevention in English schools

Implementation studies rarely examine how health interventions are delivered in emergencies. Informed by May's general theory of implementation (GTI), we undertook qualitative longitudinal research to investigate how schools in England implemented Covid-19-prevention measures and how this evolved over the 2020–2021 school year in a rapidly changing epidemiological and policy context. We conducted 74 semi-structured interviews over two time-points with headteachers, teachers, parents and students across eight primary and secondary schools. School leaders rapidly made sense of government guidance despite many challenges. They developed and disseminated prevention plans to staff, parents and students. As defined by GTI, ‘cognitive participation' and ‘collective action' to enact handwashing, one-way systems within schools and enhanced cleaning were sustained over time. However, measures such as physical distancing and placing students in separated groups were perceived to conflict with schools' mission to promote student education and wellbeing. Commitment to implement these was initially high during the emergency phase but later fluctuated dependant on perceived risk and local disease epidemiology. They were not considered sustainable in the long term. Adherence to some measures, such as wearing face-coverings, initially considered unworkable, improved as they were routinised. Implementing home-based asymptomatic testing was considered feasible. Formal and informal processes of ‘reflexive monitoring' by staff informed improvements in intervention workability and implementation. Leaders also developed skills and confidence, deciding on locally appropriate actions, some of which deviated from official guidance. However, over time, accumulating staff burnout and absence eroded school capacity to collectively enact implementation. Qualitative longitudinal research allowed us to understand how implementation in an emergency involved the above emergent processes. GTI was useful in understanding school implementation processes in a pandemic context but may need adaptation to take into account the changing and sometimes contradictory objectives, time-varying factors and feedback loops that can characterise implementation of health interventions in emergencies.

Qualitative longitudinal research on the experience of implementing Covid-19 prevention in English schools.

Implementation studies rarely examine how health interventions are delivered in emergencies. Informed by May's general theory of implementation (GTI), we undertook qualitative longitudinal research to investigate how schools in England implemented Covid-19-prevention measures and how this evolved over the 2020-2021 school year in a rapidly changing epidemiological and policy context. We conducted 74 semi-structured interviews over two time-points with headteachers, teachers, parents and students across eight primary and secondary schools. School leaders rapidly made sense of government guidance despite many challenges. They developed and disseminated prevention plans to staff, parents and students. As defined by GTI, 'cognitive participation' and 'collective action' to enact handwashing, one-way systems within schools and enhanced cleaning were sustained over time. However, measures such as physical distancing and placing students in separated groups were perceived to conflict with schools' mission to promote student education and wellbeing. Commitment to implement these was initially high during the emergency phase but later fluctuated dependant on perceived risk and local disease epidemiology. They were not considered sustainable in the long term. Adherence to some measures, such as wearing face-coverings, initially considered unworkable, improved as they were routinised. Implementing home-based asymptomatic testing was considered feasible. Formal and informal processes of 'reflexive monitoring' by staff informed improvements in intervention workability and implementation. Leaders also developed skills and confidence, deciding on locally appropriate actions, some of which deviated from official guidance. However, over time, accumulating staff burnout and absence eroded school capacity to collectively enact implementation. Qualitative longitudinal research allowed us to understand how implementation in an emergency involved the above emergent processes. GTI was useful in understanding school implementation processes in a pandemic context but may need adaptation to take into account the changing and sometimes contradictory objectives, time-varying factors and feedback loops that can characterise implementation of health interventions in emergencies.

Implementation of COVID-19 Preventive Measures and Staff Well-Being in a Sample of English Schools 2020-2021.

BACKGROUND: We examined fidelity and feasibility of implementation of COVID-19 preventive measures in schools, and explored associations between adherence to these measures and staff well-being, to inform policy on sustainable implementation and staff wellbeing. METHODS: Surveys were conducted across 128 schools in England with 107 headteachers and 2698 staff-members with reference to autumn term 2020, examining school-level implementation of preventive measures, adherence, and teacher burnout (response rates for headteacher and staff surveys were 84% and 59%, respectively). RESULTS: The median number of measures implemented in primary and secondary schools was 33 (range 23-41), and 32 (range 22-40), respectively; most measures presented challenges. No differences were found regarding number of measures implemented by school-level socio-economic disadvantage. High adherence was reported for staff wearing face-coverings, staff regularly washing their hands, (secondary only) desks facing forwards, and (primary only) increased cleaning of surfaces and student hand-washing. Adherence to most measures was reported as higher in primary than secondary schools. Over half of school leaders and 42% (517/1234) of other teaching staff suffered from high emotional exhaustion. Higher teacher-reported school-wide adherence with measures was consistently associated with lower burnout for leaders and other teaching staff. CONCLUSIONS: Findings indicate a tremendous effort in implementing preventive measures and an urgent need to support investments in improving teacher wellbeing.

Initial Impacts of COVID-19 on Sex Life and Relationship Quality in Steady Relationships in Britain: Findings from a Large, Quasi-representative Survey (Natsal-COVID).

Intimate relationships are ubiquitous and exert a strong influence on health. Widespread disruption to them may impact wellbeing at a population level. We investigated the extent to which the first COVID-19 lockdown (March 2020) affected steady relationships in Britain. In total, 6,654 participants aged 18-59 years completed a web-panel survey (July-August 2020). Quasi-representativeness was achieved via quota sampling and weighting. We explored changes in sex life and relationship quality among participants in steady relationships (n = 4,271) by age, gender, and cohabitation status, and examined factors associated with deterioration to a lower-quality relationship. A total of 64.2% of participants were in a steady relationship (of whom 88.9% were cohabiting). A total of 22.1% perceived no change in their sex-life quality, and 59.5% no change in their relationship quality. Among those perceiving change, sex-life quality was more commonly reported to decrease and relationship quality to improve. There was significant variation by age; less often by gender or cohabitation. Overall, 10.6% reported sexual difficulties that started/worsened during lockdown. In total, 6.9% reported deterioration to a "lower quality" relationship, more commonly those: aged 18-24 and aged 35-44; not living with partner (women only); and reporting depression/anxiety and decrease in sex-life quality. In conclusion, intimate relationship quality is yet another way in which COVID-19 has led to divergence in experience.

Risk factors for SARS-CoV-2 infection in primary and secondary school students and staff in England in the 2020/2021 school year: a longitudinal study.

OBJECTIVES: Investigate risk factors for SARS-CoV-2 infections in school students and staff. METHODS: In the 2020/2021 school year, we administered polymerase chain reaction, antibody tests, and questionnaires to a sample of primary and secondary school students and staff, with data linkage to COVID-19 surveillance. We fitted logistic regression models to identify the factors associated with infection. RESULTS: We included 6799 students and 5090 staff in the autumn and 11,952 students and 4569 staff in the spring/summer terms. Infections in students in autumn 2020 were related to the percentage of students eligible for free school meals. We found no statistical association between infection risk in primary and secondary schools and reported contact patterns between students and staff in either period in our study. Using public transports was associated with increased risk in autumn in students (adjusted odds ratio = 1.72; 95% confidence interval 1.31-2.25) and staff. One or more infections in the same household during either period was the strongest risk factor for infection in students and more so among staff. CONCLUSION: Deprivation, community, and household factors were more strongly associated with infection than contacts patterns at school; this suggests that the additional school-based mitigation measures in England in 2020/2021 likely helped reduce transmission risk in schools.

Parents' and teachers' attitudes to and experiences of the implementation of COVID-19 preventive measures in primary and secondary schools following reopening of schools in autumn 2020: a descriptive cross-sectional survey.

OBJECTIVE: To assess implementation and ease of implementation of control measures in schools as reported by staff and parents. DESIGN: A descriptive cross-sectional survey. SETTING: Staff and parents/guardians of the 132 primary schools and 19 secondary schools participating in COVID-19 surveillance in school kids (sKIDs and sKIDsPLUS Studies). MAIN OUTCOME MEASURE: Prevalence of control measures implemented in schools in autumn 2020, parental and staff perception of ease of implementation. RESULTS: In total, 56 of 151 (37%) schools participated in this study, with 1953 parents and 986 staff members completing the questionnaire. Most common measures implemented by schools included regular hand cleaning for students (52 of 56, 93%) and staff (70 of 73, 96%), as reported by parents and staff, respectively, and was among the easiest to implement at all times for students (57%) and even more so, for staff (78%). Maintaining 2-metre distancing was less commonly reported for students (24%-51%) as it was for staff (81%-84%), but was one of the most difficult to follow at all times for students (25%) and staff (16%) alike. Some measures were more commonly reported by primary school compared to secondary school parents, including keeping students within the same small groups (28 of 41, 68% vs 8 of 15, 53%), ensuring the same teacher for classes (29 of 41, 71% vs 6 of 15, 40%). On the other hand, wearing a face covering while at school was reported by three-quarters of secondary school parents compared with only parents of 4 of 41 (10%) primary schools. Other measures such as student temperature checks (5%-13%) and advising staff work from home if otherwise healthy (7%-15%) were rarely reported. CONCLUSIONS: Variable implementation of infection control measures was reported, with some easier to implement (hand hygiene) than others (physical distancing).

Prevalence and correlates of fearing a partner during the COVID-19 pandemic in Britain: Findings from Natsal-COVID

IntroductionThe COVID-19 pandemic and lockdown restrictions (e.g., only interacting within households) induced personal and relationship stressors, which might create conditions that increase intimate partner violence (IPV). We estimated the prevalence and correlates of experiencing IPV in the first year of the pandemic.MethodWe used data from the Natsal-COVID Wave 2—a web-panel survey undertaken one year after the initial British lockdown from 23 March 2020. Quotas and weighting were used to achieve a quasi-representative sample of the British general population. Participants were asked about fearing a partner, which is a simple and effective way to identify IPV experiences.ResultsIn our sample (n = 6302), 9.0% of women and 8.7% of men reported fearing a partner in the first year of the pandemic—about three-quarters of whom reported this occurring more than once. Sociodemographic characteristics associated with fearing a partner during this period included being younger, having had a same-sex sexual partner in the past five years, and being in a relationship. Fearing a partner reportedly affected most of these participants in multiple aspects of their lives. Controlling for age, women (73.3%) were more likely than men (49.9%) to indicate that fearing a partner made them feel anxious or depressed;men were more likely to report increased substance use (30.8% vs. 18.4%) and affected work/studies (30.0% vs. 20.0%).DiscussionPopulation-level estimates of IPV during the pandemic highlight harmful experiences that occurred alongside other wide-ranging hardships, and the associations presented identify key populations with potential ongoing need.

Epidemiology of SARS-CoV-2 infection among staff and students in a cohort of English primary and secondary schools during 2020-2021.

Background: There remains uncertainty about the epidemiology of SARS-CoV-2 among school students and staff and the extent to which non-pharmaceutical-interventions reduce the risk of school settings. Methods: We conducted an open cohort study in a sample of 59 primary and 97 secondary schools in 15 English local authority areas that were implementing government guidance to schools open during the pandemic. We estimated SARS-CoV-2 infection prevalence among those attending school, antibody prevalence, and antibody negative to positive conversion rates in staff and students over the school year (November 2020-July 2021). Findings: 22,585 staff and students participated. SARS-CoV-2 infection prevalence among those attending school was highest during the first two rounds of testing in the autumn term, ranging from 0.7% (95% CI 0.2, 1.2) among primary staff in November 2020 to 1.6% (95% CI 0.9, 2.3) among secondary staff in December 2020. Antibody conversion rates were highest in the autumn term. Infection patterns were similar between staff and students, and between primary and secondary schools. The prevalence of nucleoprotein antibodies increased over the year and was lower among students than staff. SARS-CoV-2 infection prevalence in the North-West region was lower among secondary students attending school on normal school days than the regional estimate for secondary school-age children. Interpretation: SARS-CoV-2 infection prevalence in staff and students attending school varied with local community infection rates. Non-pharmaceutical interventions intended to prevent infected individuals attending school may have partially reduced the prevalence of infection among those on the school site. Funding: UK Department of Health and Social Care.

The COVID-19 Schools Infection Survey in England: Protocol and Participation Profile for a Prospective Observational Cohort Study.

BACKGROUND: One of the most debated questions in the COVID-19 pandemic has been the role of schools in SARS-CoV-2 transmission. The COVID-19 Schools Infection Survey (SIS) aims to provide much-needed evidence addressing this issue. OBJECTIVE: We present the study protocol and participation profile for the SIS study, aimed at assessing the role of schools in SARS-CoV-2 infection and transmission within school settings, and investigating how transmission within and from schools could be mitigated through the implementation of school COVID-19 control measures. METHODS: SIS was a multisite, prospective, observational cohort study conducted in a stratified random sample of primary and secondary schools in selected local authorities in England. A total of 6 biobehavioral surveys were planned among participating students and staff during the 2020-2021 academic year, between November 2020 and July 2021. Key measurements were SARS-CoV-2 virus prevalence, assessed by nasal swab polymerase chain reaction; anti-SARS-CoV-2 (nucleocapsid protein) antibody prevalence and conversion, assessed in finger-prick blood for staff and oral fluid for students; student and staff school attendance rates; feasibility and acceptability of school-level implementation of SARS-CoV-2 control measures; and investigation of selected school outbreaks. The study was approved by the United Kingdom Health Security Agency Research Support and Governance Office (NR0237) and London School of Hygiene & Tropical Medicine Ethics Review Committee (reference 22657). RESULTS: Data collection and laboratory analyses were completed by September 2021. A total of 22,585 individuals-1891 staff and 4654 students from 59 primary schools and 5852 staff and 10,188 students from 97 secondary schools-participated in at least one survey. Across all survey rounds, staff and student participation rates were 45.2% and 16.4%, respectively, in primary schools and 30% and 15.2%, respectively, in secondary schools. Although primary student participation increased over time, and secondary student participation remained reasonably consistent, staff participation declined across rounds, especially for secondary school staff (3165/7583, 41.7% in round 1 and 2290/10,374, 22.1% in round 6). Although staff participation overall was generally reflective of the eligible staff population, student participation was higher in schools with low absenteeism, a lower proportion of students eligible for free school meals, and from schools in the least deprived locations (in primary schools, 446/4654, 9.6% of participating students were from schools in the least deprived quintile compared with 1262/22,225, 5.7% of eligible students). CONCLUSIONS: We outline the study design, methods, and participation, and reflect on the strengths of the SIS study as well as the practical challenges encountered and the strategies implemented to address these challenges. The SIS study, by measuring current and incident infection over time, alongside the implementation of control measures in schools across a range of settings in England, aims to inform national guidance and public health policy for educational settings. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/34075.

Methodology of Natsal-COVID Wave 1: a large, quasi-representative survey with qualitative follow-up measuring the impact of COVID-19 on sexual and reproductive health in Britain.

Background: Britain's National Surveys of Sexual Attitudes and Lifestyles (Natsal) have been undertaken decennially since 1990 and provide a key data source underpinning sexual and reproductive health (SRH) policy. The COVID-19 pandemic disrupted many aspects of sexual lifestyles, triggering an urgent need for population-level data on sexual behaviour, relationships, and service use at a time when gold-standard in-person, household-based surveys with probability sampling were not feasible. We designed the Natsal-COVID study to understand the impact of COVID-19 on the nation's SRH and assessed the sample representativeness. Methods: Natsal-COVID Wave 1 data collection was conducted four months (29/7-10/8/2020) after the announcement of Britain's first national lockdown (23/03/2020). This was an online web-panel survey administered by survey research company, Ipsos MORI. Eligible participants were resident in Britain, aged 18-59 years, and the sample included a boost of those aged 18-29. Questions covered participants' sexual behaviour, relationships, and SRH service use. Quotas and weighting were used to achieve a quasi-representative sample of the British general population. Participants meeting criteria of interest and agreeing to recontact were selected for qualitative follow-up interviews. Comparisons were made with contemporaneous national probability surveys and Natsal-3 (2010-12) to understand bias. Results: 6,654 participants completed the survey and 45 completed follow-up interviews. The weighted Natsal-COVID sample was similar to the general population in terms of gender, age, ethnicity, rurality, and, among sexually-active participants, numbers of sexual partners in the past year. However, the sample was more educated, contained more sexually-inexperienced people, and included more people in poorer health. Conclusions: Natsal-COVID Wave 1 rapidly collected quasi-representative population data to enable evaluation of the early population-level impact of COVID-19 and lockdown measures on SRH in Britain and inform policy. Although sampling was less representative than the decennial Natsals, Natsal-COVID will complement national surveillance data and Natsal-4 (planned for 2022).

Methodology of Natsal-COVID Wave 1: a large, quasi-representative survey with qualitative follow-up measuring the impact of COVID-19 on sexual and reproductive health in Britain [version 2;peer review: 2 approved]

Background: Britain’s National Surveys of Sexual Attitudes and Lifestyles (Natsal) have been undertaken decennially since 1990 and provide a key data source underpinning sexual and reproductive health (SRH) policy. The COVID-19 pandemic disrupted many aspects of sexual lifestyles, triggering an urgent need for population-level data on sexual behaviour, relationships, and service use at a time when gold-standard in-person, household-based surveys with probability sampling were not feasible. We designed the Natsal-COVID study to understand the impact of COVID-19 on the nation’s SRH and assessed the sample representativeness. Methods: Natsal-COVID Wave 1 data collection was conducted four months (29/7-10/8/2020) after the announcement of Britain’s first national lockdown (23/03/2020). This was an online web-panel survey administered by survey research company, Ipsos MORI. Eligible participants were resident in Britain, aged 18-59 years, and the sample included a boost of those aged 18-29. Questions covered participants’ sexual behaviour, relationships, and SRH service use. Quotas and weighting were used to achieve a quasi-representative sample of the British general population. Participants meeting criteria of interest and agreeing to recontact were selected for qualitative follow-up interviews. Comparisons were made with contemporaneous national probability surveys and Natsal-3 (2010-12) to understand bias. Results: 6,654 participants completed the survey and 45 completed follow-up interviews. The weighted Natsal-COVID sample was similar to the general population in terms of gender, age, ethnicity, rurality, and, among sexually-active participants, numbers of sexual partners in the past year. However, the sample was more educated, contained more sexually-inexperienced people, and included more people in poorer health. Conclusions: Natsal-COVID Wave 1 rapidly collected quasi-representative population data to enable evaluation of the early population-level impact of COVID-19 and lockdown measures on SRH in Britain. Although sampling was less representative than the decennial Natsals, Natsal-COVID will complement national surveillance data and Natsal-4 (planned for 2022).

School Closures During Social Lockdown and Mental Health, Health Behaviors, and Well-being Among Children and Adolescents During the First COVID-19 Wave: A Systematic Review.

IMPORTANCE: School closures as part of broader social lockdown measures during the COVID-19 pandemic may be associated with the health and well-being of children and adolescents. OBJECTIVE: To review published reports on the association of school closures during broader social lockdown with mental health, health behaviors, and well-being in children and adolescents aged 0 to 19 years, excluding associations with transmission of infection. EVIDENCE REVIEW: Eleven databases were searched from inception to September 2020, and machine learning was applied for screening articles. A total of 16 817 records were screened, 151 were reviewed in full text, and 36 studies were included. Quality assessment was tailored to study type. A narrative synthesis of results was undertaken because data did not allow meta-analysis. FINDINGS: A total of 36 studies from 11 countries were identified, involving a total of 79 781 children and adolescents and 18 028 parents, which occurred during the first wave of the COVID-19 pandemic (February to July 2020). All evaluated school closure as part of broader social lockdown during the first COVID-19 wave, and the duration of school closure ranged from 1 week to 3 months. Of those, 9 (25%) were longitudinal pre-post studies, 5 (14%) were cohort, 21 (58%) were cross-sectional, and 1 (3%) was a modeling study. Thirteen studies (36%) were high quality, 17 (47%) were medium quality, and 6 (17%) were low quality. Twenty-three studies (64%) were published, 8 (22%) were online reports, and 5 (14%) were preprints. Twenty-five studies (69%) concerning mental health identified associations across emotional, behavioral, and restlessness/inattention problems; 18% to 60% of children and adolescents scored above risk thresholds for distress, particularly anxiety and depressive symptoms, and 2 studies reported no significant association with suicide. Three studies reported that child protection referrals were lower than expected number of referrals originating in schools. Three studies suggested higher screen time usage, 2 studies reported greater social media use, and 6 studies reported lower physical activity. Studies on sleep (10 studies) and diet (5 studies) provided inconclusive evidence on harms. CONCLUSIONS AND RELEVANCE: In this narrative synthesis of reports from the first wave of the COVID-19 pandemic, studies of short-term school closures as part of social lockdown measures reported adverse mental health symptoms and health behaviors among children and adolescents. Associations between school closure and health outcomes and behaviors could not be separated from broader lockdown measures.

Intimate physical contact between people from different households during the COVID-19 pandemic: a mixed-methods study from a large, quasi-representative survey (Natsal-COVID).

OBJECTIVES: Physical distancing as a non-pharmaceutical intervention aims to reduce interactions between people to prevent SARS-CoV-2 transmission. Intimate physical contact outside the household (IPCOH) may expand transmission networks by connecting households. We aimed to explore whether intimacy needs impacted adherence to physical distancing following lockdown in Britain in March 2020. METHODS: The Natsal-COVID web-panel survey (July-August 2020) used quota-sampling and weighting to achieve a quasi-representative population sample. We estimate reporting of IPCOH with a romantic/sexual partner in the 4 weeks prior to interview, describe the type of contact, identify demographic and behavioural factors associated with IPCOH and present age-adjusted ORs (aORs). Qualitative interviews (n=18) were conducted to understand the context, reasons and decision making around IPCOH. RESULTS: Of 6654 participants aged 18-59 years, 9.9% (95% CI 9.1% to 10.6%) reported IPCOH. IPCOH was highest in those aged 18-24 (17.7%), identifying as gay or lesbian (19.5%), and in steady non-cohabiting relationships (56.3%). IPCOH was associated with reporting risk behaviours (eg, condomless sex, higher alcohol consumption). IPCOH was less likely among those reporting bad/very bad health (aOR 0.54; 95% CI 0.32 to 0.93) but more likely among those with COVID-19 symptoms and/or diagnosis (aOR 1.34; 95% CI 1.10 to 1.65). Two-thirds (64.4%) of IPCOH was reported as being within a support bubble. Qualitative interviews found that people reporting IPCOH deliberated over, and made efforts to mitigate, the risks. CONCLUSIONS: Given 90% of people did not report IPCOH, this contact may not be a large additional contributor to SARS-CoV-2 transmission, although heterogeneity exists within the population. Public health messages need to recognise how single people and partners living apart balance sexual intimacy and relationship needs with adherence to control measures.

Initial impacts of the COVID-19 pandemic on sexual and reproductive health service use and unmet need in Britain: findings from a quasi-representative survey (Natsal-COVID).

BACKGROUND: The COVID-19 pandemic has affected sexual and reproductive health (SRH) service use and unmet need, but the impact is unknown. We aimed to determine the proportion of participants reporting sexual risk behaviours, SRH service use and unmet need, and to assess remote sexually transmitted infection (STI) testing service use after the first national lockdown in Britain. METHODS: We used data from the National Surveys of Sexual Attitudes and Lifestyles (Natsal)-COVID cross-sectional, quasi-representative web survey (Natsal-COVID Wave 1). Adults aged 18-59 years who resided in England, Scotland, or Wales completed the survey between July 29 and Aug 10, 2020, which included questions about the approximate 4-month period after announcement of the initial lockdown in Britain (March 23, 2020). Quota-based sampling and weighting were used to achieve a quasi-representative population sample. Participants aged 45-59 years were excluded from services analysis due to low rates of SRH service use. Among individuals aged 18-44 years, we estimated reported SRH service use and inability to access, and calculated age-adjusted odds ratios (aORs) among sexually experienced individuals (those reporting any sexual partner in their lifetime) and sexually active individuals (those reporting any sexual partner in the past year). Unweighted denominators and weighted estimates are presented hereafter. FINDINGS: 6654 individuals had complete interviews and were included in the analysis. Among 3758 participants aged 18-44 years, 82·0% reported being sexually experienced, and 73·7% reported being sexually active. 20·8% of sexually experienced participants aged 18-44 years reported using SRH services in the 4-month period. Overall, 9·7% of 3108 participants (9·5% of men; 9·9% of women) reported being unable to use a service they needed, although of the participants who reported trying but not being able to use a SRH service at least once, 76·4% of participants also reported an instance of successful use. 5·9% of 1221 sexually active men and 3·6% of 1560 sexually active women reported use of STI-related services and 14·8% of 1728 sexually experienced women reported use of contraceptive services, with SRH service use highest among individuals aged 18-24 years. Sexually active participants reporting condomless sex with new partners since lockdown were much more likely to report using STI-related services than those who did not report condomless sex (aOR 23·8 [95% CI 11·6-48·9]) for men, 10·5 [3·9-28·2] for women) and, among men, were also more likely to have an unsuccessful attempt at STI-service use (aOR 13·3 [5·3-32·9]). Among 106 individuals who reported using STI testing services, 64·4% accessed services remotely (telephone, video, or online). Among 2581 women aged 25-59 years, 2·4% reported cervical screening compared with an estimated 6% in a comparable 4-month period before the pandemic. INTERPRETATION: Many people accessed SRH care during the initial lockdown; however, young people and those reporting sexual risk behaviours reported difficulties in accessing services and thus such services might need to address a backlog of need. FUNDING: Wellcome Trust, The Economic and Social Research Council, The National Institute for Health Research, Medical Research Council/Chief Scientist Office and Public Health Sciences Unit, and UCL Coronavirus Response Fund.

Transmission of SARS-CoV-2 by children and young people in households and schools: A meta-analysis of population-based and contact-tracing studies.

BACKGROUND: The role of children and young people (CYP) in transmission of SARS-CoV-2 in household and educational settings remains unclear. We undertook a systematic review and meta-analysis of contact-tracing and population-based studies at low risk of bias. METHODS: We searched 4 electronic databases on 28 July 2021 for contact-tracing studies and population-based studies informative about transmission of SARS-CoV-2 from 0 to 19 year olds in household or educational settings. We excluded studies at high risk of bias, including from under-ascertainment of asymptomatic infections. We undertook multilevel random effects meta-analyses of secondary attack rates (SAR: contact-tracing studies) and school infection prevalence, and used meta-regression to examine the impact of community SARS-CoV-2 incidence on school infection prevalence. FINDINGS: 4529 abstracts were reviewed, resulting in 37 included studies (16 contact-tracing; 19 population studies; 2 mixed studies). The pooled relative transmissibility of CYP compared with adults was 0.92 (0.68, 1.26) in adjusted household studies. The pooled SAR from CYP was lower (p = 0.002) in school studies 0.7% (0.2, 2.7) than household studies (7.6% (3.6, 15.9) . There was no difference in SAR from CYP to child or adult contacts. School population studies showed some evidence of clustering in classes within schools. School infection prevalence was associated with contemporary community 14-day incidence (OR 1.003 (1.001, 1.004), p<0.001). INTERPRETATION: We found no difference in transmission of SARS-CoV-2 from CYP compared with adults within household settings. SAR were markedly lower in school compared with household settings, suggesting that household transmission is more important than school transmission in this pandemic. School infection prevalence was associated with community infection incidence, supporting hypotheses that school infections broadly reflect community infections. These findings are important for guiding policy decisions on shielding, vaccination school and operations during the pandemic.

Impacts of COVID-19 on sexual behaviour in Britain: findings from a large, quasi-representative survey (Natsal-COVID).

OBJECTIVES: Physical restrictions imposed to combat COVID-19 dramatically altered sexual lifestyles but the specific impacts on sexual behaviour are still emerging. We investigated physical and virtual sexual activities, sexual frequency and satisfaction in the 4 months following lockdown in Britain in March 2020 and compared with pre-lockdown. METHODS: Weighted analyses of web panel survey data collected July/August 2020 from a quota-based sample of 6654 people aged 18-59 years in Britain. Multivariable regression took account of participants' opportunity for partnered sex, gender and age, to examine their independent associations with perceived changes in sexual frequency and satisfaction. RESULTS: Most participants (86.7%) reported some form of sex following lockdown with physical activities more commonly reported than virtual activities (83.7% vs 52.6%). Altogether, 63.2% reported sex with someone ('partnered sex') since lockdown, three-quarters of whom were in steady cohabiting relationships. With decreasing relationship formality, partnered sex was less frequently reported, while masturbation, sex toy use and virtual activities were more frequently reported. Around half of all participants perceived no change in partnered sex frequency compared with the 3 months pre-lockdown, but this was only one-third among those not cohabiting, who were more likely to report increases in non-partnered activities than those cohabiting. Two-thirds of participants perceived no change in sexual satisfaction; declines were more common among those not cohabiting. Relationship informality and younger age were independently associated with perceiving change, often declines, in sexual frequency and satisfaction. CONCLUSIONS: Our quasi-representative study of the British population found a substantial minority reported significant shifts in sexual repertoires, frequency and satisfaction following the introduction of COVID-19 restrictions. However, these negative changes were perceived by some more than others; predominantly those not cohabiting and the young. As these groups are most likely to experience adverse sexual health, it is important to monitor behaviour as restrictions ease to understand the longer term consequences, including for health services.

Research priorities for mental health in schools in the wake of COVID-19.

Children and young people (CYP) have suffered challenges to their mental health as a result of the COVID-19 pandemic; effects have been most pronounced on those already disadvantaged. Adopting a whole-school approach embracing changes to school environments, cultures and curricula is key to recovery, combining social and emotional skill building, mental health support and interventions to promote commitment and belonging. An evidence-based response must be put in place to support schools, which acknowledges that the mental health and well-being of CYP should not be forfeited in the drive to address the attainment gap. Schools provide an ideal setting for universal screening of mental well-being to help monitor and respond to the challenges facing CYP in the wake of the pandemic. Research is needed to support identification and implementation of suitable screening methods.

Measuring the impact of COVID-19 on sexual and reproductive health in the UK: web-panel surveys with qualitative follow-up

Background The UK's National Surveys of Sexual Attitudes and Lifestyles (Natsal) have been done every 10 years since 1990, and provide a key data source to underpin sexual and reproductive health policy. The COVID-19 pandemic disrupted many lifestyle aspects, triggering an urgent need for population-level data on sexual behaviour, relationships, and service use at a time when gold-standard, in-person, household-based surveys with probability sampling were not feasible. We designed the Natsal-COVID study to understand the effect of COVID-19 on the nation's sexual and reproductive health. Methods Data were collected over 4 months (survey wave one;July 29 to Aug 10, 2020) and 1 year (wave two;March 27 to April 26, 2021) after the announcement of the UK's first lockdown (March 23, 2020). Data were collected online via web-panel surveys administered by Ipsos MORI. Eligible participants were UK residents aged 18–59 years, and the samples included a boost of those aged 18–29 years. Questions covered participants' sexual behaviour, relationships, and sexual and reproductive health service use. Quotas and weighting were used to achieve a quasi-representative sample of the UK general population. Participants meeting criteria of interest and agreeing to be recontacted were selected for qualitative follow-up interviews over the months of October and November, 2020. Comparisons were made with contemporaneous national probability surveys (2019 Annual Population Survey and 2018 Health Survey for England) and Natsal-3 (2010–12) to understand bias in sociodemographic characteristics, general health, and sexual behaviours. We obtained ethical approval from the ethics committees of the University of Glasgow College of Medical, Veterinary & Life Sciences College (reference 20019174) and the London School of Hygiene & Tropical Medicine Research (reference 22565). Findings 6654 participants completed wave one of the study, of which 45 (0·7%) completed qualitative interviews. A further 6658 participants completed wave two, of which 2098 (31·5%) were wave one participants. Compared with probability surveys, the weighted Natsal-COVID participants were more educated, less sexually experienced, and in poorer health. In wave one, we found that 20·8% of respondents (95% CI 19·3–22·3%) reported using sexual and reproductive health services in the first 4 months of lockdown, whereas 9·7% (8·6–10·8%) reported difficulty accessing services. Wave two allowed for the generation of 1-year estimates, including of chlamydia testing (5·4% [4·7–6·2%]), HIV testing (7·2% [6·4–8·1%]), and cervical cancer screening (10·3% [9·2–11·6%]). Qualitative interviews suggested that participants often required repeated attempts to access sexual and reproductive health services. Interpretation Natsal-COVID rapidly collected quasi-representative population data to evaluate the population-level effect of COVID-19 and lockdown measures on sexual and reproductive health in the UK and to inform sexual and reproductive health policy. Although less representative than the decennial Natsals, Natsal-COVID will complement national surveillance data and Natsal-4 (planned for 2022). Funding Natsal is a collaboration between University College London (UK), the London School of Hygiene & Tropical Medicine (UK), the University of Glasgow (UK), Örebro University Hospital (Sweden), and NatCen Social Research (UK). The Natsal Resource, which is supported by the Wellcome Trust (via grant number 212931/Z/18/Z), with contributions from the UK's Economic and Social Research Council and National Institute for Health Research, supports the Natsal-COVID study through funding from the University College London COVID-19 Rapid Response Fund and the MRC/CSO Social and Public Health Sciences Unit (Core funding, grant numbers MC_UU_00022/3 and SPHSU18). The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.