Health of unpaid carers in Wales, UK: a population data linkage study.

BACKGROUND: The population of unpaid carers in Wales increased to record. There is no systematic approach to record unpaid caring status, resulting in limited quantitative evidence on unpaid carers' health. The aim of this study is to: (i) create an e-cohort of unpaid carers by linking routinely collected health and administrative datasets in Wales, UK. (ii) investigate whether long-term health conditions and multimorbidity are more prevalent amongst unpaid carers than non-carers. METHODS: Unpaid carers were identified by linking primary care dataset, National Survey for Wales data with demographic characteristics in the Secure Anonymise Information Linkage Databank. The clinical codes identified in Cambridge Multimorbidity Score were used to explore the prevalence of long-term health conditions. RESULTS: A total of 91 220 unpaid carers in Wales were identified between 1 January 2010 and 1 March 2022. Unpaid carers were found at higher risk of managing 35 of 37 long-term health conditions and multimorbidity than non-carers, exacerbated amongst younger age groups and deprived communities. CONCLUSIONS: The creation of the first e-cohort of unpaid carers in Wales provides opportunities to perform rapid analysis to systematically understand health needs and evaluate initiatives in future. To better support unpaid carers, flexible approaches focusing on early identification and prevention is crucial.

Profiles of tobacco smokers and ex-smokers in a large-scale random sample survey across Wales: an unsupervised machine-learning cluster analysis.

BACKGROUND: The Welsh government recently set a target to be smoke-free by 2030, which means reducing the prevalence of tobacco smoking in adults to 5% by then. The goal is to improve health and population life expectancy. To support this strategy, we identified profile groups with different sets of socioeconomic and demographic characteristics within the population of smokers. We compared these profiles to those identified in the ex-smoker population to provide a broader understanding of smokers and inform targeting of interventions and policy. METHODS: We did a cross-sectional study using data from the National Survey for Wales. This survey is a random sample telephone survey of individuals aged 16 years and older across Wales carried out from Sept 1, 2021 to Jan 31, 2022, weighted to be representative of the Welsh population. For the smoking subgroup, we did a weighted hierarchical cluster analysis with multiple imputation to impute missing data and repeated it for ex-smokers. In total, 63 survey variables were used in the analysis. These variables included smoking history, e-cigarette use, sociodemographics, lifestyle factors, individual-level deprivation, general health and long-term conditions, mental health, and wellbeing. FINDINGS: Among the 6407 respondents (weighted proportions: 49% male, 51% female; 28% aged 16-34 years, 46% aged 35-44 years, 26% aged ≥65 years; 95% white, 5% other ethnicity), 841 (13%) smoked and 2136 (33%) were ex-smokers. Four distinctive profiles of smokers were identified, the groups were of relatively comparable size and characterised by similarities described as (1) high-risk alcohol drinkers and without children; (2) single, mostly in social housing, and poor health and mental health; (3) mostly single, younger, tried e-cigarettes, and poor mental health; (4) older couples and poor health; when comparing the groups with each other. Cluster quality and validation statistics were considered fair: silhouette coefficient=0·09, Dunn index (Dunn2)=1·06. Generally, ex-smoker clusters differed from smoking clusters because of themes related to increased sickness, better affluence, employment, and older age (≥75 years). INTERPRETATION: This study suggests that not all smokers are the same, and they do not fall into one coherent group. Smoking cessation interventions to improve the health of ageing populations might need a different approach to consider a wider context or motivations to inform targeted quitting. It is acknowledged that smoking might be underreported because of perceived social unacceptability. FUNDING: Public Health Wales.

Effects of the COVID-19 pandemic on the mental health of clinically extremely vulnerable children and children living with clinically extremely vulnerable people in Wales: a data linkage study.

OBJECTIVES: To determine whether clinically extremely vulnerable (CEV) children or children living with a CEV person in Wales were at greater risk of presenting with anxiety or depression in primary or secondary care during the COVID-19 pandemic compared with children in the general population and to compare patterns of anxiety and depression during the pandemic (23 March 2020-31 January 2021, referred to as 2020/2021) and before the pandemic (23 March 2019-31 January 2020, referred to as 2019/2020), between CEV children and the general population. DESIGN: Population-based cross-sectional cohort study using anonymised, linked, routinely collected health and administrative data held in the Secure Anonymised Information Linkage Databank. CEV individuals were identified using the COVID-19 shielded patient list. SETTING: Primary and secondary healthcare settings covering 80% of the population of Wales. PARTICIPANTS: Children aged 2-17 in Wales: CEV (3769); living with a CEV person (20 033); or neither (415 009). PRIMARY OUTCOME MEASURE: First record of anxiety or depression in primary or secondary healthcare in 2019/2020 and 2020/2021, identified using Read and International Classification of Diseases V.10 codes. RESULTS: A Cox regression model adjusted for demographics and history of anxiety or depression revealed that only CEV children were at greater risk of presenting with anxiety or depression during the pandemic compared with the general population (HR=2.27, 95% CI=1.94 to 2.66, p<0.001). Compared with the general population, the risk among CEV children was higher in 2020/2021 (risk ratio 3.04) compared with 2019/2020 (risk ratio 1.90). In 2020/2021, the period prevalence of anxiety or depression increased slightly among CEV children, but declined among the general population. CONCLUSIONS: Differences in the period prevalence of recorded anxiety or depression in healthcare between CEV children and the general population were largely driven by a reduction in presentations to healthcare services by children in the general population during the pandemic.

Mapping Inequities in Digital Health Technology Within the World Health Organization's European Region Using PROGRESS PLUS: Scoping Review.

BACKGROUND: The use of digital technologies within health care rapidly increased as services transferred to web-based platforms during the COVID-19 pandemic. Inequalities in digital health across the domains of equity are not routinely examined; yet, the long-term integration of digitally delivered services needs to consider such inequalities to ensure equitable benefits. OBJECTIVE: This scoping review aimed to map inequities in access, use, and engagement with digital health technologies across equity domains. METHODS: We searched 4 electronic databases (MEDLINE, ASSIA, PsycINFO, and Scopus) for quantitative and mixed methods reviews and meta-analyses published between January 2016 and May 2022. Reviews were limited to those that included studies from the World Health Organization's European region. Extracted data were mapped against Cochrane's PROGRESS PLUS (place of residence, race, ethnicity, culture, and language, occupation, gender and sex, religion, education, socioeconomic status, social capital, and other characteristics) dimensions of equity. RESULTS: In total, 404 unique citations were identified from the searches, and 2 citations were identified from other sources. After eligibility assessment, 22 reviews were included. Consistent evidence was found showing higher access to digital health technologies among patients who were of White ethnicity, were English speaking, and had no disability. There were no reviews that explored differences in access to digital health care by age, gender and sex, occupation, education, or homeless or substance misuse. Higher use of digital health technologies was observed among populations that were White, English speaking, younger, with a higher level of education, of higher economic status, and residents in urban areas. No clear evidence of differences in the use of digital technologies by occupation, gender and sex, disability, or homeless or substance misuse was found, nor was clear evidence found in the included reviews on inequalities in the engagement with digital technologies. Finally, no reviews were identified that explored differences by place of residence. CONCLUSIONS: Despite awareness of the potential impact of inequalities in digital health, there are important evidence gaps across multiple equity domains. The development of a common framework for evaluating digital health equity in new health initiatives and consistency in reporting findings is needed.

Inequalities in colorectal cancer screening uptake in Wales: an examination of the impact of the temporary suspension of the screening programme during the COVID-19 pandemic.

BACKGROUND: Response to the early stages of the COVID-19 pandemic resulted in the temporary disruption of cancer screening in the UK, and strong public messaging to stay safe and to protect NHS capacity. Following reintroduction in services, we explored the impact on inequalities in uptake of the Bowel Screening Wales (BSW) programme to identify groups who may benefit from tailored interventions. METHODS: Records within the BSW were linked to electronic health records (EHR) and administrative data within the Secured Anonymised Information Linkage (SAIL) Databank. Ethnic group was obtained from a linked data method available within SAIL. We examined uptake for the first 3 months of invitations (August to October) following the reintroduction of BSW programme in 2020, compared to the same period in the preceding 3 years. Uptake was measured across a 6 month follow-up period. Logistic models were conducted to analyse variations in uptake by sex, age group, income deprivation quintile, urban/rural location, ethnic group, and clinically extremely vulnerable (CEV) status in each period; and to compare uptake within sociodemographic groups between different periods. RESULTS: Uptake during August to October 2020 (period 2020/21; 60.4%) declined compared to the same period in 2019/20 (62.7%) but remained above the 60% Welsh standard. Variation by sex, age, income deprivation, and ethnic groups was observed in all periods studied. Compared to the pre-pandemic period in 2019/20, uptake declined for most demographic groups, except for older individuals (70-74 years) and those in the most income deprived group. Uptake continues to be lower in males, younger individuals, people living in the most income deprived areas and those of Asian and unknown ethnic backgrounds. CONCLUSION: Our findings are encouraging with overall uptake achieving the 60% Welsh standard during the first three months after the programme restarted in 2020 despite the disruption. Inequalities did not worsen after the programme resumed activities but variations in CRC screening in Wales associated with sex, age, deprivation and ethnic group remain. This needs to be considered in targeting strategies to improve uptake and informed choice in CRC screening to avoid exacerbating disparities in CRC outcomes as screening services recover from the pandemic.

Challenges to self-isolation among contacts of cases of COVID-19: a national telephone survey in Wales.

BACKGROUND: Self-isolation is challenging and adherence is dependent on a range of psychological, social and economic factors. We aimed to identify the challenges experienced by contacts of coronavirus disease 2019 (COVID-19) cases to better target support and minimize the harms of self-isolation. METHODS: The Contact Adherence Behavioural Insights Study (CABINS) was a 15-minute telephone survey conducted with confirmed contacts of COVID-19 (N = 2027), identified through the NHS Wales Test Trace Protect (TTP) database. RESULTS: Younger people (aged 18-29 years) were three times more likely to report mental health concerns (adjusted odds ratio [aOR]: 3.16, 95% confidence interval [CI]: 2.05-4.86) and two times more likely to report loneliness (aOR: 1.96, CI: 1.37-2.81) compared to people aged over 60 years. Women were 1.5 times more likely to experience mental health concerns (aOR: 1.51, 95% CI: 1.20-1.92) compared to men. People with high levels of income precarity were eight times more likely to report financial challenges (aOR: 7.73, CI: 5.10-11.74) and three times more likely to report mental health concerns than their more financially secure counterparts (aOR: 3.08, CI: 2.22-4.28). CONCLUSION: Self-isolation is particularly challenging for younger people, women and those with precarious incomes. Providing enhanced support is required to minimize the harms of self-isolation.

Seeking Good Work in the COVID-19 Recovery: Shifting Priorities and Employment Choices Among Workers.

OBJECTIVE: Disruption to working lives spurred by the COVID-19 pandemic may shape people's preferences for future employment. We aimed to identify the components of work prioritized by a UK sample and the employment changes they had considered since the start of the COVID-19 pandemic. METHODS: A nationally representative longitudinal household survey was conducted in Wales at two time points between 2020 and 2021. RESULTS: Those in poorer health prioritized flexibility and were more likely to consider retiring. Those with limiting preexisting conditions or low mental well-being were more likely to consider becoming self-employed. Those experiencing financial insecurity (including those with high wage precarity or those furloughed) were more likely to consider retraining, becoming self-employed, or securing permanent employment. CONCLUSIONS: Ensuring flexible, secure, and autonomous work is accessible for individuals facing greater employment-related insecurity may be key.

Exploring the Health Impacts and Inequalities of the New Way of Working: Findings From a Cross-Sectional Study.

OBJECTIVE: The aim of the study is to provide insights into the working Welsh adult population's perceptions of the health impacts of working from home (WFH), their ability to WFH, and their WFH preferences. METHODS: Data were collected from 615 working adults in Wales between November 2020 and January 2021 in a household survey. RESULTS: More than 45% of those able to WFH reported worsened mental well-being and loneliness. Working from home worsened the diets, physical activity, smoking, and alcohol use of those in poorer health. Approximately 50% were able to WFH, although individuals living in more deprived areas, in atypical employment or with precarious income, were less able to WFH. Nearly 60% wanted to WFH to some capacity. CONCLUSIONS: The new way of working introduces new challenges to preserving workforce mental well-being, regulating health behaviors, and tackling inequalities. Hybrid models and targeted health support could make WFH healthier and more equitable.

Shifting priorities and employment choices among workers in Wales during the COVID-19 pandemic: a longitudinal analysis.

BACKGROUND: Employment is a determinant of health. The COVID-19 pandemic disrupted working lives, forcing individuals to adapt to new ways of working. These shifts might shape people's priorities and their consideration of changes for future work. We examined how these outcomes differed depending on self-reported health status. METHODS: In this longitudinal analysis, we used data from the COVID-19 Employment and Health in Wales Study; a nationally-representative household survey of workers aged 18-64 years. Timepoint 1 (T1) data were collected between May 27, 2020, and June 22, 2020, and timepoint 2 (T2) data between Nov 30, 2020, and Jan 29, 2021. Participants who responded at both timepoints were eligible. Respondents selected five employment priorities at both timepoints, and the employment changes they considered during the COVID-19 pandemic at T2 only. We used multivariable logistic regressions (including sociodemographics, current employment factors, and self-reported health) and examined associations with health firstly for employment priorities, and secondly for the consideration of employment changes. Health measures were self-reported general health, limiting pre-existing health conditions (both using National Survey for Wales validated questions), and mental wellbeing (using the shortened Warwick Edinburgh Mental Well-being Scale). FINDINGS: We analysed data from 592 respondents (382 [65%] women). 766 (56%) of 1358 T1 respondents were excluded as no T2 responses were provided. Those who self-reported poor general health were consistently more likely to prioritise flexible working arrangements than those rating fair or above (T1 adjusted odds ratio [aOR] 2·06 [95% CI 1·10-3·88], p=0·033; T2 aOR 1·87 [95% CI 1·05-3·33], p=0·034). Those with low (as opposed to average) mental wellbeing were more likely to consider securing a permanent contract (aOR 5·49 [95% CI 1·32-22·81], p=0·023, and those with limiting pre-existing conditions were four times more likely to consider becoming self-employed (aOR 4·00 [95% CI 1·35-11·84], p=0·011) than those without. INTERPRETATION: Promoting the adoption of flexible working policies and supporting those in poor health to obtain flexible employment could benefit people in Wales. Those with low mental wellbeing might seek the security of permanent employment, and those with limiting pre-existing conditions might value the autonomy of self-employment. FUNDING: None.

Impact of the temporary suspension of the Bowel Screening Wales programme on inequalities during the COVID-19 pandemic: a retrospective register-based study.

BACKGROUND: Response to the COVID-19 pandemic resulted in the temporary disruption of routine services in the UK National Health Service, including cancer screening. Following the reintroduction of services, we explored the impact on inequalities in uptake of the Bowel Screening Wales (BSW) programme to identify groups who might benefit from tailored intervention. METHODS: BSW records were linked to electronic health record and administrative data within the Secured Anonymised Information Linkage (SAIL) Databank Trusted Research Environment. We examined uptake in the first 3 months (from August to October, 2020) of invitations following the reintroduction of the BSW programme compared with the same period in the preceding 3 years. We analysed inequalities in uptake by sex, age group, income deprivation quintile, urban and rural location, ethnic group, and uptake between different periods using logistic regression models. FINDINGS: Overall uptake remained above the 60% Welsh standard during the COVID-19 pandemic period of 2020-21 but declined compared with the pre-pandemic period of 2019-20 (60·4% vs 62·7%; p<0·001). During the COVID-19 pandemic period of 2020-21, uptake declined for most demographic groups, except for older individuals (70-74 years) and those in the most deprived quintile. Variation by sex, age, income deprivation, and ethnic groups was observed in all periods studied. Among low-uptake groups, including males, younger individuals (60-64 years), those living in most deprived areas, and ethnic minorities, uptake remains below the 60% Welsh standard. INTERPRETATION: Despite the disruption, uptake remained above the Welsh standard and inequalities did not worsen after the programme resumed activities. However, variations associated with sex, age, deprivation, and ethnicity remain. These findings need to be considered in targeting strategies to improve uptake and informed choice in colorectal cancer screening such as co-producing information products with low-uptake groups and upscaling the use of GP-endorsed invitations and reminder letters for bowel screening. FUNDING: Health Data Research UK, UK Medical Research Council, Administrative Data Research UK, and Health and Care Research Wales.