Mental health in relation to changes in sleep, exercise, alcohol and diet during the COVID-19 pandemic: examination of four UK cohort studies.

BACKGROUND: Responses to the COVID-19 pandemic have included lockdowns and social distancing with considerable disruptions to people's lives. These changes may have particularly impacted on those with mental health problems, leading to a worsening of inequalities in the behaviours which influence health. METHODS: We used data from four national longitudinal British cohort studies (N = 10 666). Respondents reported mental health (psychological distress and anxiety/depression symptoms) and health behaviours (alcohol, diet, physical activity and sleep) before and during the pandemic. Associations between pre-pandemic mental ill-health and pandemic mental ill-health and health behaviours were examined using logistic regression; pooled effects were estimated using meta-analysis. RESULTS: Worse mental health was related to adverse health behaviours; effect sizes were largest for sleep, exercise and diet, and weaker for alcohol. The associations between poor mental health and adverse health behaviours were larger during the May lockdown than pre-pandemic. In September, when restrictions had eased, inequalities had largely reverted to pre-pandemic levels. A notable exception was for sleep, where differences by mental health status remained high. Risk differences for adverse sleep for those with the highest level of prior mental ill-health compared to those with the lowest were 21.2% (95% CI 16.2-26.2) before lockdown, 25.5% (20.0-30.3) in May and 28.2% (21.2-35.2) in September. CONCLUSIONS: Taken together, our findings suggest that mental health is an increasingly important factor in health behaviour inequality in the COVID era. The promotion of mental health may thus be an important component of improving post-COVID population health.

Longitudinal predictors of weapon involvement in middle adolescence: Evidence from the UK Millennium Cohort Study.

This study uses longitudinal data from the UK Millennium Cohort Study (N = 13,277) to examine the childhood and early adolescence factors that predict weapon involvement in middle adolescence, which in this study is exemplified by having carried or used a weapon. It finds that childhood experiences of low family income and domestic abuse between parents predict weapon involvement at age 17 years. Other predictors include childhood externalizing problems and self-harm in early adolescence. Further early adolescent behaviors and experiences that predict weapon involvement are own substance use, peer substance use, school exclusion, and high levels of electronic gaming. These findings provide concrete areas for targeting risk factors both in childhood and the early adolescent period, with an indication that early intervention and prevention are likely to reduce the need for later action.

Longitudinal association of conduct and emotional problems with school exclusion and truancy: A fixed effect analysis of the UK Millennium Cohort Study.

BACKGROUND: There is a need for causally stronger research on the association between child mental health and school exclusion and truancy. This study examines school exclusion and truancy in relation to both conduct and emotional problems and considers these problems both as predictors and as outcomes of school exclusion and truancy. METHOD: The sample included 15,236 individuals from the Millennium Cohort Study, a UK longitudinal birth cohort study. Conduct and emotional problems were assessed from childhood to adolescence (age 7, 11, 14 and 17 years), and reports of school exclusion and truancy were collected at age 11 and 14. Fixed effect analyses were used. RESULTS: Increases in conduct problems and emotional symptoms were associated with subsequent exclusion (OR 1.22, [95% CI 1.08-1.37] and OR 1.16, [1.05-1.29], respectively). Emotional symptoms, but not conduct problems, predicted truancy (OR 1.17, [1.07-1.29]). These estimates were similar for males and females. Exclusion was associated with an increase in conduct problems at age 14 (0.50, [0.30-0.69]), and for males, it was associated with an increase in emotional symptoms both at age 14 (0.39, [0.12-0.65]) and 17 (0.43, [0.14-0.72]). Truancy was associated with an increase in conduct problems at age 14 (0.41, [0.28-0.55]), and for females also at age 17 (0.22, [0.03-0.42]), and it was associated with increased emotional symptoms at age 14 (0.43, [0.25-0.62]) and 17 (0.44, [0.21-0.66]), which was similar for males and females. CONCLUSION: Results indicate a bidirectional association between emotional symptoms and school exclusion and truancy, as an increase in these symptoms was associated with later truancy and exclusion, and emotional symptoms increased following both school events. For conduct problems, the association was bidirectional for school exclusion, but unidirectional for truancy as these symptoms did not lead to truancy, but an increase in conduct problems was observed after both exclusion and truancy.

Designing a generic, adaptive protocol resource for the measurement of health impact in cash transfer pilot and feasibility studies and trials in high-income countries.

INTRODUCTION: In the context of the COVID-19 pandemic, upstream interventions that tackle social determinants of health inequalities have never been more important. Evaluations of upstream cash transfer trials have failed to capture comprehensively the impacts that such systems might have on population health through inadequate design of the interventions themselves and failure to implement consistent, thorough research measures that can be used in microsimulations to model long-term impact. In this article, we describe the process of developing a generic, adaptive protocol resource to address this issue and the challenges involved in that process. The resource is designed for use in high-income countries (HIC) but draws on examples from a UK context to illustrate means of development and deployment. The resource is capable of further adaptation for use in low- and middle-income countries (LMIC). It has particular application for trials of Universal Basic Income but can be adapted to those covering other kinds of cash transfer and welfare system changes. METHODS: We outline two types of prospective intervention based on pilots and trials currently under discussion. In developing the remainder of the resource, we establish six key principles, implement a modular approach based on types of measure and their prospective resource intensity, and source (validated where possible) measures and baseline data primarily from routine collection and large, longitudinal cohort studies. Through these measures, we seek to cover all areas of health impact identified in our theoretical model for use in pilot and feasibility studies. RESULTS: We find that, in general, self-reported measures alongside routinely collected linked respondent data may provide a feasible means of producing data capable of demonstrating comprehensive health impact. However, we also suggest that, where possible, physiological measures should be included to elucidate underlying biological effects that may not be accurately captured through self-reporting alone and can enable modelling of long-term health outcomes. In addition, accurate self-reported objective income data remains a challenge and requires further development and testing. A process of development and implementation of the resource in pilot and feasibility studies will support assessment of whether or not our proposed health outcome measures are acceptable, feasible and can be used with validity and reliability in the target population. DISCUSSION: We suggest that while Open Access evaluation instruments are available and usable to measure most constructs of interest, there remain some areas for which further development is necessary. This includes self-reported wellbeing measures that require paid licences but are used in a range of nationally important longitudinal studies instead of Open Access alternatives.

Clustering of adverse health and educational outcomes in adolescence following early childhood disadvantage: population-based retrospective UK cohort study.

BACKGROUND: Disadvantage in early childhood (ages 0-5 years) is associated with worse health and educational outcomes in adolescence. Evidence on the clustering of these adverse outcomes by household income is scarce in the generation of adolescents born since the turn of the millennium. We aimed to describe the association between household income in early childhood and physical health, psychological distress, smoking behaviour, obesity, and educational outcomes at age 17 years, including the patterning and clustering of these five outcomes by income quintiles. METHODS: In this population-based, retrospective cohort study, we used data from the Millennium Cohort Study in which individuals born in the UK between Sept 1, 2000, and Jan 1, 2002, were followed up. We collected data on five adverse health and social outcomes in adolescents aged 17 years known to limit life chances: psychological distress, self-assessed ill health, smoking, obesity, and poor educational achievement. We compared how single and multiple outcomes were distributed across early childhood quintile groups of income, as an indicator of disadvantage, and modelled the potential effect of three income-shifting scenarios in early childhood for reducing adverse outcomes in adolescence. FINDINGS: We included 15 245 adolescents aged 17 years, 7788 (51·1%) of whom were male and 7457 (48·9%) of whom were female. Adolescents in the lowest income quintile group in childhood were 12·7 (95% CI 6·4-25·1) times more likely than those in the highest quintile group to have four or five adverse adolescent outcomes, with poor educational achievement (risk ratio [RR] 4·6, 95% CI 4·2-5·0) and smoking (3·6, 3·0-4·2), showing the largest single risk ratios. Shifting up to the second lowest, middle, and highest income groups would reduce multiple adolescent adversities by 4·9% (95% CI -23·8 to 33·6), 32·3% (-2·7 to 67·3), and 83·9% (47·2 to 120·7), respectively. Adjusting for parental education and single parent status moderately attenuated these estimates. INTERPRETATION: Early childhood disadvantage is more strongly correlated with multiple adolescent adversities than any of the five single adverse outcomes. However, shifting children from the lowest income quintile group to the next lowest group is ineffective. Tackling multiple adolescent adversities requires managing early childhood disadvantage across the social gradient, with income redistribution as a central element of coordinated cross-sectoral action. FUNDING: UK Prevention Research Partnership.

Meta-evaluation of a whole systems programme, ActEarly: A study protocol.

INTRODUCTION: Living in an area with high levels of child poverty predisposes children to poorer mental and physical health. ActEarly is a 5-year research programme that comprises a large number of interventions (>20) with citizen science and co-production embedded. It aims to improve the health and well-being of children and families living in two areas of the UK with high levels of deprivation; Bradford in West Yorkshire, and the London Borough of Tower Hamlets. This protocol outlines the meta-evaluation (an evaluation of evaluations) of the ActEarly programme from a systems perspective, where individual interventions are viewed as events in the wider policy system across the two geographical areas. It includes investigating the programme's impact on early life health and well-being outcomes, interdisciplinary prevention research collaboration and capacity building, and local and national decision making. METHODS: The ActEarly meta-evaluation will follow and adapt the five iterative stages of the 'Evaluation of Programmes in Complex Adaptive Systems' (ENCOMPASS) framework for evaluation of public health programmes in complex adaptive systems. Theory-based and mixed-methods approaches will be used to investigate the fidelity of the ActEarly research programme, and whether, why and how ActEarly contributes to changes in the policy system, and whether alternative explanations can be ruled out. Ripple effects and systems mapping will be used to explore the relationships between interventions and their outcomes, and the degree to which the ActEarly programme encouraged interdisciplinary and prevention research collaboration as intended. A computer simulation model ("LifeSim") will also be used to evaluate the scale of the potential long-term benefits of cross-sectoral action to tackle the financial, educational and health disadvantages faced by children in Bradford and Tower Hamlets. Together, these approaches will be used to evaluate ActEarly's dynamic programme outputs at different system levels and measure the programme's system changes on early life health and well-being. DISCUSSION: This meta-evaluation protocol presents our plans for using and adapting the ENCOMPASS framework to evaluate the system-wide impact of the early life health and well-being programme, ActEarly. Due to the collaborative and non-linear nature of the work, we reserve the option to change and query some of our evaluation choices based on the feedback we receive from stakeholders to ensure that our evaluation remains relevant and fit for purpose.

Changes in the behavioural determinants of health during the COVID-19 pandemic: gender, socioeconomic and ethnic inequalities in five British cohort studies.

BACKGROUND: The COVID-19 pandemic is expected to have far-reaching consequences on population health. We investigated whether these consequences included changes in health-impacting behaviours which are important drivers of health inequalities. METHODS: Using data from five representative British cohorts (born 2000-2002, 1989-1990, 1970, 1958 and 1946), we investigated sleep, physical activity (exercise), diet and alcohol intake (N=14 297). We investigated change in each behaviour (pre/during the May 2020 lockdown), and differences by age/cohort, gender, ethnicity and socioeconomic position (childhood social class, education attainment and adult financial difficulties). Logistic regression models were used, accounting for study design and non-response weights, and meta-analysis used to pool and test cohort differences in association. RESULTS: Change occurred in both directions-shifts from the middle part of the distribution to both declines and increases in sleep, exercise and alcohol use. Older cohorts were less likely to report changes in behaviours while the youngest reported more frequent increases in sleep, exercise, and fruit and vegetable intake, yet lower alcohol consumption. Widening inequalities in sleep during lockdown were more frequent among women, socioeconomically disadvantaged groups and ethnic minorities. For other outcomes, inequalities were largely unchanged, yet ethnic minorities were at higher risk of undertaking less exercise and consuming lower amounts of fruit and vegetables. CONCLUSIONS: Our findings provide new evidence on the multiple changes to behavioural outcomes linked to lockdown, and the differential impacts across generation, gender, socioeconomic circumstances across life, and ethnicity. Lockdown appeared to widen some (but not all) forms of health inequality.

Father departure and children's mental health: How does timing matter?

Father's permanent departure from the household in childhood has the potential to affect child mental health. The event is non-random, and a major limitation in most previous studies is lack of adequate control for unobserved confounders. Using five waves of data spanning ages 3 to 14 from the Millennium Cohort Study, a UK-wide nationally representative longitudinal study, this paper uses fixed effect models to examine the effect of paternal absence on children's mental health (i.e. externalising and internalising problems) in a sample of 6245 children. Heterogeneity of effects are examined by gender and maternal education. A novel aspect is to examine how the timing of departure matters, and to assess whether there are developmental periods that are especially sensitive to paternal departure, and whether effects are temporary or enduring. We find that paternal departure has a negative effect on child mental health, particularly on internalising symptoms. Striking gender differences emerge in examining effects by timing and duration. There are no short-term effects of departure in early childhood, and only weak evidence of females showing an increase in internalising symptoms in the medium-term. Paternal departure in later childhood, on the other hand, is associated with an increase in internalising problems in both males and females, and increased externalising symptoms for males only. We do not find maternal education to be a protective factor.