Population-level changes in the mental health of UK workers during the COVID-19 pandemic: A longitudinal study using Understanding Society (preprint)

Objectives The COVID-19 pandemic has substantially affected workers mental health. We investigated changes in UK workers mental health by industry, social class, and occupation and differential effects by UK country of residence, gender and age. Methods We used representative Understanding Society data from 6,474 adults (41,207 observations) in paid employment who participated in pre-pandemic (2017-2020) and at least one COVID-19 survey. The outcome was psychological distress (General Health Questionnaire-12; score[≥]4). Exposures were industry, social class and occupation and are examined separately. Mixed-effects logistic regression was used to estimate relative (OR) and absolute (%) increases in distress before and during pandemic. Differential effects were investigated for UK countries of residence (Non-England/England), gender (Male/female), and age (Younger/Older) using 3-way interaction effects. Results Psychological distress increased in relative terms most for professional, scientific and technical (OR:3.15, 95% CI 2.17-4.59) industry in the pandemic versus pre-pandemic period. Absolute risk increased most in hospitality (+11.4%). For social class, small employers/self-employed were most affected in relative and absolute terms (OR:3.24, 95% CI 2.28- 4.63; +10.3%). Across occupations Sales and customer service (OR:3.01, 95% CI 1.61- 5.62; +10.7%) had the greatest increase. Analysis with 3-way interactions showed considerable gender differences, while for UK country of residence and age results are mixed. Conclusions Psychological distress increases during the COVID-19 pandemic were concentrated among professional and technical and hospitality industries, small employers/self-employed and sales and customers service workers. Female workers often exhibited greater differences in risk by industry and occupation. Policies supporting these industries and groups are needed.

Psychological Distress Before and During the COVID-19 Pandemic: Sociodemographic Inequalities in 11 UK Longitudinal Studies (preprint)

Background: How population mental health has evolved across the COVID-19 pandemic under varied lockdown measures is poorly understood, with impacts on health inequalities unclear. We investigated changes in mental health and sociodemographic inequalities from before and across the first year of the pandemic in 11 longitudinal studies. Methods: Data from 11 UK longitudinal population-based studies with pre-pandemic measures of psychological distress were analysed and estimates pooled. Trends in the prevalence of poor mental health were assessed across the pandemic at three time periods: initial lockdown (TP1, Mar-June 20); easing of restrictions (TP2, July-Oct 20); and a subsequent lockdown (TP3, Nov 20-Mar 21). Multi-level regression was used to examine changes in psychological distress compared to pre-pandemic; with stratified analyses by sex, ethnicity, education, age, and UK country. Results: Across the 11 studies (n=54,609), mental health had deteriorated from pre-pandemic scores across all three pandemic time periods (TP1 Standardised Mean Difference (SMD): 0.13 (95% CI: 0.03, 0.23); TP2 SMD: 0.18 (0.09, 0.27); TP3 SMD: 0.20 (0.09, 0.31)). Changes in psychological distress across the pandemic were higher in females (TP3 SMD: 0.23 (0.11, 0.35)) than males (TP3 SMD: 0.16 (0.06, 0.26)), and slightly lower in below-degree level educated persons at some time periods (TP3 SMD: 0.18 (0.06, 0.30)) compared to those who held degrees (TP3 SMD: 0.26 (0.14, 0.38)). Increased distress was most prominent amongst adults aged 35-44 years (TP3 SMD: 0.49 (0.15, 0.84)). We did not find evidence of changes in distress differing by ethnicity or UK country. Conclusions: The substantial deterioration in mental health seen in the UK during the first lockdown did not reverse when lockdown lifted, and a sustained worsening is observed across the pandemic. Mental health declines have not been equal across the population, with females, those with higher degrees, and younger adults more affected.

Risk factors for long COVID: analyses of 10 longitudinal studies and electronic health records in the UK (preprint)

The impact of long COVID is increasingly recognised, but risk factors are poorly characterised. We analysed questionnaire data on symptom duration from 10 longitudinal study (LS) samples and electronic healthcare records (EHR) to investigate sociodemographic and health risk factors associated with long COVID, as part of the UK National Core Study for Longitudinal Health and Wellbeing. Methods Analysis was conducted on 6,899 adults self-reporting COVID-19 from 45,096 participants of the UK LS, and on 3,327 cases assigned a long COVID code in primary care EHR out of 1,199,812 adults diagnosed with acute COVID-19. In LS, we derived two outcomes: symptoms lasting 4+ weeks and symptoms lasting 12+ weeks. Associations of potential risk factors (age, sex, ethnicity, socioeconomic factors, smoking, general and mental health, overweight/obesity, diabetes, hypertension, hypercholesterolaemia, and asthma) with these two outcomes were assessed, using logistic regression, with meta-analyses of findings presented alongside equivalent results from EHR analyses. Results Functionally limiting long COVID for 12+ weeks affected between 1.2% (age 20), and 4.8% (age 63) of people reporting COVID-19 in LS. The proportion reporting symptoms overall for 12+ weeks ranged from 7.8 (mean age 28) to 17% (mean age 58) and for 4+ weeks 4.2% (age 20) to 33.1% (age 56). Age was associated with a linear increase in long COVID between age 20-70. Being female (LS: OR=1.49; 95%CI:1.24-1.79; EHR: OR=1.51 [1.41-1.61]), poor pre-pandemic mental health (LS: OR=1.46 [1.17-1.83]; EHR: OR=1.57 [1.47-1.68]) and poor general health (LS: OR=1.62 [1.25-2.09]; EHR: OR=1.26; [1.18-1.35]) were associated with higher risk of long COVID. Individuals with asthma also had higher risk (LS: OR=1.32 [1.07-1.62]; EHR: OR=1.56 [1.46-1.67]), as did those categorised as overweight or obese (LS: OR=1.25 [1.01-1.55]; EHR: OR=1.31 [1.21-1.42]) though associations for symptoms lasting 12+ weeks were less pronounced. Non-white ethnic minority groups had lower 4+ week symptom risk (LS: OR=0.32 [0.22-0.47]), a finding consistent in EHR. Associations were not observed for other risk factors. Few participants in the studies had been admitted to hospital (0.8-5.2%). Conclusions Long COVID is clearly distributed differentially according to several sociodemographic and pre-existing health factors. Establishing which of these risk factors are causal and predisposing is necessary to further inform strategies for preventing and treating long COVID.

Predictors of COVID-19 vaccine hesitancy in the UK Household Longitudinal Study (preprint)

BackgroundVaccination is crucial to address the COVID-19 pandemic but vaccine hesitancy could undermine control efforts. We aimed to investigate the prevalence of COVID-19 vaccine hesitancy in the UK population, identify which population subgroups are more likely to be vaccine hesitant, and report stated reasons for vaccine hesitancy. MethodsNationally representative survey data from 12,035 participants were collected from 24th November to 1st December 2020 for wave 6 of the Understanding Society COVID-19 web survey. Participants were asked how likely or unlikely they would be to have a vaccine if offered and their main reason for hesitancy. Cross-sectional analysis assessed prevalence of vaccine hesitancy and logistic regression models conducted. FindingsOverall intention to be vaccinated was high (82% likely/very likely). Vaccine hesitancy was higher in women (21.0% vs 14.7%), younger age groups (26.5% in 16-24 year olds vs 4.5% in 75+) and less educated (18.6% no qualifications vs 13.2% degree qualified). Vaccine hesitancy was particularly high in Black (71.8%), Pakistani/Bangladeshi (42.3%), Mixed (32.4%) and non-UK/Irish White (26.4%) ethnic groups. Fully adjusted models showed gender, education and ethnicity were independently associated with vaccine hesitancy. Odds ratios for vaccine hesitancy were 12.96 (95% CI:7.34, 22.89) in the Black/Black British and 2.31 (95% CI:1.55, 3.44) in Pakistani/Bangladeshi ethnic groups (compared to White British/Irish ethnicity) and 3.24 (95%CI:1.93, 5.45) for people with no qualifications compared to degree educated. The main reason for hesitancy was fears over unknown future effects. InterpretationOlder people at greatest COVID-19 mortality risk expressed the greatest willingness to be vaccinated but Black and Pakistani/Bangladeshi ethnic groups had greater vaccine hesitancy. Vaccine programmes should prioritise measures to improve uptake in specific minority ethnic groups. FundingMedical Research Council Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched Embase and Medline up to November 16, 2020, using key words "vaccine hesitancy" and "COVID-19" or "SARS-CoV-2". Vaccine hesitancy is complex but also context specific. Previous research about vaccine hesitancy relates to existing adult and childhood vaccines, with limited evidence currently available on willingness to be vaccinated for newly available COVID-19 vaccines. Existing vaccination programmes often have lower uptake among more socioeconomically disadvantaged groups. Uptake of vaccines has often varied across ethnic groups, but patterns have often varied across different vaccine programmes. Added value of this studyOur study describes the sub-groups of the UK population who are more likely to be hesitant about a COVID-19 vaccine and examines possible explanations for this. We used nationally representative data from the COVID-19 survey element of the UKs largest household panel study. We asked specifically about vaccine hesitancy in relation to a COVID-19 vaccine at a time when initial results of vaccine trials were being reported in the media. We found willingness to be vaccinated is generally high across the UK population but marked differences exist across population subgroups. Willingness to be vaccinated was greater in older age groups and in men. However, some minority ethnic groups, particularly Black/Black British and Pakistani/Bangladeshi, had high levels of vaccine hesitancy but this was not seen across all minority ethnic groups. People with lower education levels were also more likely to be vaccine hesitant. Implications of all the available evidenceThe current evidence base on vaccine hesitancy in relation to COVID-19 is rapidly emerging but remains limited. Polling data has also found relatively high levels of willingness to take up a COVID-19 vaccine and suggested greater risks of vaccine hesitancy among Black, Asian and Minority Ethnic (BAME) people. Our study suggests that the risk of vaccine hesitancy differs across minority ethnic groups considerably, with Black ethnic groups particularly likely to be vaccine hesitant within the UK. Some White minority ethnic groups are also more likely to be vaccine hesitant than White British/Irish people. Herd immunity may be achievable through vaccination in the UK but a focus on specific ethnic minority and socioeconomic groups is needed to ensure an equitable vaccination programme.

Psychological distress among people with probable COVID-19 infection: analysis of the UK Household Longitudinal Study (preprint)

Studies exploring the longer-term effects of experiencing COVID-19 infection on mental health are lacking. We explored the relationship between reporting probable COVID-19 symptoms in April 2020 and psychological distress (measured using the General Health Questionnaire) one, two, three, five and seven months later. Data were taken from the UK Household Longitudinal Study, a nationally representative household panel survey of UK adults. Elevated levels of psychological distress were found up to seven months after probable COVID-19, compared to participants with no likely infection. Associations were stronger among younger age groups and men. Further research into the psychological sequalae of COVID-19 is urgently needed.

Mental health and health behaviours before and during the COVID-19 lockdown: Longitudinal analyses of the UK Household Longitudinal Study (preprint)

BackgroundThere are concerns that COVID-19 mitigation measures, including the "lockdown", may have unintended health consequences. We examined trends in mental health and health behaviours in the UK before and during the initial phase of the COVID-19 lockdown and differences across population subgroups. MethodsRepeated cross-sectional and longitudinal analysis of the UK Household Longitudinal Study, including representative samples of adults (aged 18+) interviewed in four survey waves between 2015 and 2020 (n=48,426). 9,748 adults had complete data for longitudinal analyses. Outcomes included psychological distress (General Health Questionnaire-12 (GHQ)), loneliness, current cigarette smoking, use of e-cigarettes and alcohol consumption. Cross-sectional prevalence estimates were calculated and multilevel Poisson regression assessed associations between time period and the outcomes of interest, as well as differential associations by age, gender, education level and ethnicity. ResultsPsychological distress increased one month into lockdown with the prevalence rising from 19.4% (95% CI 18.7%-20.0%) in 2017-19 to 30.3% (95% CI 29.1%-31.6%) in April 2020 (RR=1.3, 95% CI: 1.1,1.4). Groups most adversely affected included women, young adults, people from an Asian background and those who were degree educated. Loneliness remained stable overall (RR=0.9, 95% CI: 0.6,1.5). Smoking declined (RR=0.9, 95% CI=0.8,1.0) and the proportion of people drinking four or more times per week increased (RR=1.4, 95% CI: 1.3,1.5), as did binge drinking (RR=1.5, 95% CI: 1.3,1.7). ConclusionsPsychological distress increased one month into lockdown, particularly among women and young adults. Smoking declined, but adverse alcohol use generally increased. Effective measures are required to mitigate adverse impacts on health. O_LSTWhat is already known on this topicC_LSTO_LICountries around the world have implemented radical COVID-19 lockdown measures, with concerns that these may have unintended consequences for a broad range of health outcomes. C_LIO_LIEvidence on the impact of lockdown measures on mental health and health-related behaviours remains limited. C_LI O_LSTWhat this study addsC_LSTO_LIIn the UK, psychological distress markedly increased during lockdown, with women particularly adversely affected. C_LIO_LICigarette smoking fell, but adverse drinking behaviour generally increased. C_LI

Multimorbidity, Polypharmacy, and COVID-19 infection within the UK Biobank cohort. (preprint)

BACKGROUNDIt is now well recognised that the risk of severe COVID-19 increases with some long-term conditions (LTCs). However, prior research primarily focuses on individual LTCs and there is a lack of data on the influence of multimorbidity ([≥]2 LTCs) on the risk of COVID-19. Given the high prevalence of multimorbidity, more detailed understanding of the associations with multimorbidity and COVID-19 would improve risk stratification and help protect those most vulnerable to severe COVID-19. Here we examine the relationships between multimorbidity, polypharmacy (a proxy of multimorbidity), and COVID-19; and how these differ by sociodemographic, lifestyle, and physiological prognostic factors. METHODS AND FINDINGSWe studied data from UK Biobank (428,199 participants; aged 37-73; recruited 2006-2010) on self-reported LTCs, medications, sociodemographic, lifestyle, and physiological measures which were linked to COVID-19 test data. Poisson regression models examined risk of COVID-19 by multimorbidity/polypharmacy and effect modification by COVID-19 prognostic factors (age/sex/ethnicity/socioeconomic status/smoking/physical activity/BMI/systolic blood pressure/renal function). 4,498 (1.05%) participants were tested; 1,324 (0.31%) tested positive for COVID-19. Compared with no LTCs, relative risk (RR) of COVID-19 in those with 1 LTC was no higher (RR 1.12 (CI 0.96-1.30)), whereas those with [≥]2 LTCs had 48% higher risk; RR 1.48 (1.28-1.71). Compared with no cardiometabolic LTCs, having 1 and [≥]2 cardiometabolic LTCs had a higher risk of COVID-19; RR 1.28 (1.12-1.46) and 1.77 (1.46-2.15), respectively. Polypharmacy was associated with a dose response increased risk of COVID-19. All prognostic factors were associated with a higher risk of COVID-19 infection in multimorbidity; being non-white, most socioeconomically deprived, BMI [≥]40 kg/m2, and reduced renal function were associated with the highest risk of COVID-19 infection: RR 2.81 (2.09-3.78); 2.79 (2.00-3.90); 2.66 (1.88-3.76); 2.13 (1.46-3.12), respectively. No multiplicative interaction between multimorbidity and prognostic factors was identified. Important limitations include the low proportion of UK Biobank participants with COVID-19 test data (1.05%) and UK Biobank participants being more affluent, healthier and less ethnically diverse than the general population. CONCLUSIONSIncreasing multimorbidity, especially cardiometabolic multimorbidity, and polypharmacy are associated with a higher risk of developing COVID-19. Those with multimorbidity and additional factors, such as non-white ethnicity, are at heightened risk of COVID-19. Author summaryO_ST_ABSWhy was this study done?C_ST_ABSO_LIMultimorbidity is a growing global challenge, but thus far LTC prognostic factors for severe COVID-19 primarily involve single conditions and there is a lack of data on the influence of multimorbidity on the risk of COVID-19. C_LIO_LIAs countries move from the lockdown phase of COVID-19, clinicians need more information about risk stratification to appropriately advise patients with multimorbidity about risk prevention steps. C_LI What did the researchers do and find?O_LIParticipants with multimorbidity ([≥]2 LTCs) had a 48% higher risk of a positive COVID-19 test, those with cardiometabolic multimorbidity had a 77% higher risk, than those without that type of multimorbidity. C_LIO_LIThose from non-white ethnicities with multimorbidity had nearly three times the risk of having COVID-19 infection compared to those of white ethnicity C_LIO_LIPeople with multimorbidity with the highest risk of COVID-19 infection were the most socioeconomically deprived, those with BMI [≥]40 kg/m2, and those with reduced renal function. C_LI What do these findings mean?O_LIIndividuals with [≥]2 LTCs, especially if these are cardiometabolic in nature, should be particularly stringent in adhering to preventive measures, such as physical distancing and hand hygiene. C_LIO_LIOur findings have implications for clinicians, occupational health and employers when considering work-place environments, appropriate advice for patients, and adaptations that might be required to protect such staff, identified here, as higher risk. C_LI

Occupation and risk of COVID-19: prospective cohort study of 120,621 UK Biobank participants (preprint)

Objectives: To investigate COVID-19 risk by occupational group. Design: Prospective study of linked population-based and administrative data. Setting: UK Biobank data linked to SARS-CoV-2 test results from Public Health England from 16 March to 3 May 2020. Participants: 120,621 UK Biobank participants who were employed or self-employed at baseline (2006-2010) and were 65 years or younger in March 2020. Overall, 29% (n=37,890) were employed in essential occupational groups, which included healthcare workers, social and education workers, and other essential workers comprising of police and protective service, food, and transport workers. Poisson regression models, adjusted for baseline sociodemographic, work-related, health, and lifestyle-related risk factors were used to assess risk ratios (RRs) of testing positive in hospital by occupational group as reported at baseline relative to non-essential workers. Main outcome measures: Positive SARS-CoV-2 test within a hospital setting (i.e. as an inpatient or in an Emergency Department). Results: 817 participants were tested for SARS-CoV-2 and of these, 206 (0.2%) individuals had a positive test in a hospital setting. Relative to non-essential workers, healthcare workers (RR 7.59, 95% CI: 5.43 to 10.62) and social and education workers (RR 2.17, 95% CI: 1.37 to 3.46) had a higher risk of testing positive for SARS-CoV-2 in hospital. Using more detailed groupings, medical support staff (RR 8.57, 95% CI: 4.35 to 16.87) and social care workers (RR 2.99, 95% CI: 1.71 to 5.24) had highest risk within the healthcare worker and social and education worker categories, respectively. In general, adjustment for covariates did not substantially change the pattern of occupational differences in risk. Conclusions: Essential workers in health and social care have a higher risk of severe SARS-CoV-2 infection. These findings underscore the need for national and organisational policies and practices that protect and support workers with elevated risk of SARS-CoV-2 infection.

Modifiable and non-modifiable risk factors for COVID-19: results from UK Biobank (preprint)

Background Information on risk factors for COVID-19 is sub-optimal. We investigated demographic, lifestyle, socioeconomic, and clinical risk factors, and compared them to risk factors for pneumonia and influenza in UK Biobank. Methods UK Biobank recruited 37-70 year olds in 2006-2010 from the general population. The outcome of confirmed COVID-19 infection (positive SARS-CoV-2 test) was linked to baseline UK Biobank data. Incident influenza and pneumonia were obtained from primary care data. Poisson regression was used to study the association of exposure variables with outcomes. Findings Among 428,225 participants, 340 had confirmed COVID-19. After multivariable adjustment, modifiable risk factors were higher body mass index (RR 1.24 per SD increase), smoking (RR 1.38), slow walking pace as a proxy for physical fitness (RR 1.66) and use of blood pressure medications as a proxy for hypertension (RR 1.40). Non-modifiable risk factors included older age (RR 1.10 per 5 years), male sex (RR 1.64), black ethnicity (RR 1.86), socioeconomic deprivation (RR 1.26 per SD increase in Townsend Index), longstanding illness (RR 1.38) and high cystatin C (RR 1.24 per 1 SD increase). The risk factors overlapped with pneumonia somewhat; less so for influenza. The associations with modifiable risk factors were generally stronger for COVID-19, than pneumonia or influenza. Interpretation These findings suggest that modification of lifestyle may help to reduce the risk of COVID-19 and could be a useful adjunct to other interventions, such as social distancing and shielding of high risk. Funding British Heart Foundation, Medical Research Council, Chief Scientist Office.

Ethnic and socioeconomic differences in SARS-CoV2 infection in the UK Biobank cohort study (preprint)

Background Understanding of the role of ethnicity and socioeconomic position in the risk of developing SARS-CoV-2 infection is limited. We investigated this in the UK Biobank study. Methods The UK Biobank study recruited 40-70 year olds in 2006-2010 from the general population, collecting information about self-defined ethnicity and socioeconomic variables (including area-level socioeconomic deprivation and educational attainment). SARS-CoV-2 test results from Public Health England were linked to baseline UK Biobank data. Poisson regression with robust standard errors was used to assess risk ratios (RRs) between the exposures and dichotomous variables for: being tested, having a positive test and testing positive in hospital. We also investigated whether ethnicity and socioeconomic position were associated with having a positive test amongst those tested. We adjusted for covariates including age, sex, social variables (including healthcare work and household size), behavioural risk factors and baseline health. Results Among 428,225 participants in England, 1,474 had been tested and 669 tested positive between 16 March and 13 April 2020. Black, south Asian and white Irish people were more likely to have confirmed infection (RR 4.01 (95%CI 2.92-5.12); RR 2.11 (95%CI 1.43-3.10); and RR 1.60 (95% CI 1.08-2.38) respectively) and were more likely to be hospital cases compared to the White British. While they were more likely to be tested, they were also more likely to test positive. Adjustment for baseline health and behavioural risk factors led to little change, with only modest attenuation when accounting for socioeconomic variables. Socioeconomic deprivation and having no qualifications were consistently associated with a higher risk of confirmed infection (RR 2.26 (95%CI 1.76-2.90); and RR 1.91 (95%CI 1.53-2.38) respectively). Conclusions Some minority ethnic groups have a higher risk of confirmed SARS-CoV-2 infection in the UK Biobank study which was not accounted for by differences in socioeconomic conditions, measured baseline health or behavioural risk factors. An urgent response to addressing these elevated risks is required.