Tracking the mental health of home-carers during the first COVID-19 national lockdown: evidence from a nationally representative UK survey.

BACKGROUND: Unpaid carers who look after another member of their household (home-carers) have poorer mental health than the general population. The first COVID-19 national lockdown led to an increasing reliance on home-carers and we investigate the short- and longer-term impacts of lockdown on their mental health. METHODS: Data from 9737 adult participants (aged 16+) from the UK Household Longitudinal Study (Understanding Society) were used to explore changes in 12-item General Health Questionnaire (GHQ-12) score between (a) pre-pandemic (2019) and early lockdowns (April 2020) and (b) early and later (July 2020) lockdowns. RESULTS: GHQ-12 scores among home-carers were higher pre-lockdown and increased more than for non-carers from 2019 to April 2020 with further increases for home-carers compared with non-carers between April and July. Compared with respondents caring for a spouse/partner, those caring for a child under 18 had a particularly marked increase in GHQ-12 score between 2019 and April, as did those caring for someone with a learning disability. Home-carers of children under 18 improved from April to July while those caring for adult children saw a marked worsening of their mental health. Home-carers with greater care burden saw larger increases in GHQ-12 score from 2019 to April and from April to July, and increases through both periods were greater for home-carers who had formal help prior to lockdown but then lost it. CONCLUSIONS: The mental health of home-carers deteriorated more during lockdown than non-carers. Policies that reinstate support for them and their care-recipients will benefit the health of both vulnerable groups.

Standard multiple imputation of survey data didn't perform better than simple substitution in enhancing an administrative dataset: the example of self-rated health in England.

BACKGROUND: Health surveys provide a rich array of information but on relatively small numbers of individuals and evidence suggests that they are becoming less representative as response levels fall. Routinely collected administrative data offer more extensive population coverage but typically comprise fewer health topics. We explore whether data combination and multiple imputation of health variables from survey data is a simple and robust way of generating these variables in the general population. METHODS: We use the UK Integrated Household Survey and the English 2011 population census both of which included self-rated general health. Setting aside the census self-rated health data we multiply imputed self-rated health responses for the census using the survey data and compared these with the actual census results in 576 unique groups defined by age, sex, housing tenure and geographic region. RESULTS: Compared with original census data across the groups, multiply imputed proportions of bad or very bad self-rated health were not a markedly better fit than those simply derived from the survey proportions. CONCLUSION: While multiple imputation may have the potential to augment population data with information from surveys, further testing and refinement is required.

Associations of internet access with social integration, wellbeing and physical activity among adults in deprived communities: evidence from a household survey.

BACKGROUND: There are arguments for and against the wellbeing effects of internet use, with evidence shifting from negative to positive over time, although the effects are partly dependent upon the population sub-group concerned. There are good grounds for anticipating that the internet could be beneficial to people living in deprived communities, but this group has rarely been studied. METHODS: Data are from a cross-sectional, face-to-face survey of adult householders (n = 3804) in 15 deprived communities in Glasgow, UK. Respondents were asked whether they used the internet and, if so, how they usually accessed it: at home, via a mobile phone, in a public venue, or other means. Data were also collected on social contact and support, use of amenities, sense of community, wellbeing, loneliness, and physical activity. RESULTS: There were inequalities in internet access within deprived communities, with use of the internet lowest among older people, those with a long-standing illness, and those with no educational qualifications. Some social benefits were associated with internet access, such as frequency of contact with neighbours, available financial social support, and greater use of social amenities and shops. Internet users were also less likely to report feeling lonely and had higher mental wellbeing scores. Respondents who used the internet were also more physically active. However, community cohesion and empowerment variables were very similar among internet users and non-users. Several of the positive associations with internet access were more marked for those who accessed the internet at home and for older people. These are new findings in respect of deprived communities. CONCLUSIONS: Extending internet access for people in deprived communities is worthy of further consideration in the context of government objectives for tackling social isolation and increasing wellbeing. The results also suggest that greater digitisation of public services may not result in greater cohesion and empowerment in deprived communities, as is often assumed, but rather has the potential to reinforce social inequalities.

Occupant behaviour as a fourth driver of fuel poverty (aka warmth & energy deprivation).

A conceptual framework for occupant behaviour as a driver of fuel poverty is presented, comprising: housing and use of the home; heating and energy arrangements and thermal comfort; household structure and dynamics; health and well-being; household finances; and social activity and relations. This framework informs longitudinal analysis of movements into and out of fuel poverty among households in deprived communities in Glasgow. Household surveys across ten years yielded a longitudinal sample of 3297 cases where initial and subsequent fuel poverty status was recorded using an experiential measure. A third of households changed their fuel poverty status over time: 18% moving out of fuel poverty and 16% moving in. Factors strongly associated with movements into fuel poverty included: being a single parent (OR 2.27); experiencing a mental health problem (OR 2.74); and remaining out of work (OR 1.89). Movement out of fuel poverty was less likely among those with infrequent family contact (OR 0.55) and who moved home (OR 0.66); home improvements had no effect upon the experience of fuel poverty. It is argued that the policy problem should be considered one of 'warmth and energy deprivation', accompanied by a broader interpretation of vulnerability to as well as from fuel poverty.

Perceived neighborhood ethnic diversity and social outcomes: Context-dependent effects within a postindustrial city undergoing regeneration.

This article examines whether perceived neighborhood ethnic diversity is associated with a range of social outcomes in a postindustrial city undergoing regeneration. The research included a survey in 3 types of deprived area in Glasgow: those undergoing regeneration, those directly adjoining regeneration areas, and those further removed from regeneration areas. In areas undergoing regeneration, perceived diversity was positively associated with many residential, cohesion, safety, and empowerment outcomes. This was also true, although to a lesser extent, in deprived areas at some distance from regeneration areas. In areas immediately surrounding the regeneration areas, perceived diversity had mixed associations with residential and safety outcomes and few associations with cohesion and empowerment outcomes. The results suggest that the effects of perceived diversity are context dependent within a city. Moreover, regeneration processes alter neighborhood contexts and therefore enable scale, timing, and duration of diversity to mediate the relationships between perceived diversity and social outcomes.

Leaving the labour market later in life: how does it impact on mechanisms for health?

OBJECTIVES: Negative associations between non-employment and health among older people are well established and are potentially important for successful ageing. However, opportunities to improve health through re-employment or extending working lives are limited as later-life exits from employment are often unwanted and permanent. We aim to establish a greater understanding of the psychosocial mechanisms underlying non-employment and health associations in older people to identify modifiable pathways through which the negative impact of non-employment can be ameliorated. METHODS: Using multilevel analysis of four waves of repeated panel data from a representative sample of 1551 older men and women reaching state retirement age in the West of Scotland from 1987/1988 to 2000/2004, we explored respondents' strength of agreement with 20 statements relating to their self-defined employment status, covering themes of functioning, social engagement, self-esteem, mental engagement, stress, and control and autonomy. RESULTS: Compared with those in employment, respondents who were retired, unemployed, sick/disabled and home makers were more likely to agree that this resulted in poor social engagement, low self-esteem and, with the possible exception of retirees, reduced mental engagement. Associations were particularly marked among unemployed and sick/disabled respondents who also agreed that their status was a source of worry and prevented them from feeling in control. CONCLUSION: Older people who are not in employment are at higher risk of poor physical and mental health. Interventions targeting psychosocial mechanisms such as social and mental engagement and self-esteem offer potentially valuable opportunities to improve health outcomes and promote successful ageing.

Variations in cognitive abilities across the life course: Cross-sectional evidence from Understanding Society: The UK Household Longitudinal Study.

BACKGROUND: Populations worldwide are aging. Cognitive decline is an important precursor of dementia, illness and death and, even within the normal range, is associated with poorer performance on everyday tasks. However, the impact of age on cognitive function does not always receive the attention it deserves. METHODS: We have explored cross-sectional associations of age with five cognitive tests (word recall, verbal fluency, subtraction, number sequence, and numerical problem solving) in a large representative sample of over 40,000 men and women aged 16 to 100 living in the UK. RESULTS: Women performed better on word recall tests and men had higher scores for subtraction, number sequence and numerical problem solving. However, age-cognition associations were generally similar in both genders. Mean word recall and number sequence scores decreased from early adulthood with steeper declines from the mid-60s onwards Verbal fluency, subtraction and numerical problem solving scores remained stable or increased from early to mid-adulthood, followed by approximately linear declines from around age 60. Performance on all tests was progressively lower in respondents with increasingly worse self-rated health and memory. Age-related declines in word recall, verbal fluency and number sequence started earlier in those with the worst self-rated health. There was no compelling evidence for age dedifferentiation (that the general factor of cognitive ability changes in strength with age). CONCLUSIONS: We have confirmed previously observed patterns of cognitive aging using a large representative population sample.

The role of material, psychosocial and behavioral factors in mediating the association between socioeconomic position and allostatic load (measured by cardiovascular, metabolic and inflammatory markers).

Lower socioeconomic position (SEP), both accumulated across the life course and at different life-stages, has been found to be associated with higher cumulative physiological burden, as measured by allostatic load. This study aimed to identify what factors mediate the association between SEP and allostatic load, as measured through combining cardiovascular, metabolic and inflammatory markers. We explored the role of material, psychological and behavioral factors, accumulated across two periods in time, in mediating the association between SEP and allostatic load. Data are from the West of Scotland Twenty-07 Study, with respondents followed over five waves of data collection from ages 35 to 55 (n=999). Allostatic load was measured by summing nine binary biomarker scores ('1'=in the highest-risk quartile) measured when respondents were 55years old (wave 5). SEP was measured by a person's accumulated social class over two periods All mediators and SEP were measured at baseline in 1987 and 20years later and combined to form accumulated measures of risk. Material mediators included car and home ownership, and having low income. The General Health Questionnaire (GHQ-12) was used as the psychosocial mediator. Behavioral mediators included smoking, alcohol consumption, physical activity and diet. Path analysis using linear regressions adjusting for sex were performed for each of the potential mediators to assess evidence of attenuation in the association between lower SEP and higher allostatic load. Analyses by mediator type revealed that renting one's home (approximately 78% attenuation) and having low income (approx. 62% attenuation) largely attenuated the SEP-allostatic load association. GHQ did not attenuate the association. Smoking had the strongest attenuating effect of all health behaviors (by 33%) with no other health behaviors attenuating the association substantially. Material factors, namely home tenure and income status, and smoking have important roles in explaining socioeconomic disparities in allostatic load, particularly when accumulated over time.

Loneliness, social relations and health and well-being in deprived communities.

There is a growing policy concern about the extent of loneliness in advanced societies, and its prevalence among various social groups. This study looks at loneliness among people living in deprived communities, where there may be additional barriers to social engagement including low incomes, fear of crime, poor services and transient populations. The aim was to examine the prevalence of loneliness, and also its associations with different types of social contacts and forms of social support, and its links to self-reported health and well-being in the population group. The method involved a cross-sectional survey of 4302 adults across 15 communities, with the data analysed using multinomial logistic regression controlling for sociodemographics, then for all other predictors within each domain of interest. Frequent feelings of loneliness were more common among those who: had contact with family monthly or less; had contact with neighbours weekly or less; rarely talked to people in the neighbourhood; and who had no available sources of practical or emotional support. Feelings of loneliness were most strongly associated with poor mental health, but were also associated with long-term problems of stress, anxiety and depression, and with low mental well-being, though to a lesser degree. The findings are consistent with a view that situational loneliness may be the product of residential structures and resources in deprived areas. The findings also show that neighbourly behaviours of different kinds are important for protecting against loneliness in deprived communities. Familiarity within the neighbourhood, as active acquaintance rather than merely recognition, is also important. The findings are indicative of several mechanisms that may link loneliness to health and well-being in our study group: loneliness itself as a stressor; lonely people not responding well to the many other stressors in deprived areas; and loneliness as the product of weak social buffering to protect against stressors.

The role of health behaviours across the life course in the socioeconomic patterning of all-cause mortality: the west of Scotland twenty-07 prospective cohort study.

BACKGROUND: Socioeconomic differentials in mortality are increasing in many industrialised countries. PURPOSE: This study aims to examine the role of behaviours (smoking, alcohol, exercise, and diet) in explaining socioeconomic differentials in mortality and whether this varies over the life course, between cohorts and by gender. METHODS: Analysis of two representative population cohorts of men and women, born in the 1950s and 1930s, were performed. Health behaviours were assessed on five occasions over 20 years. RESULTS: Health behaviours explained a substantial part of the socioeconomic differentials in mortality. Cumulative behaviours and those that were more strongly associated with socioeconomic status had the greatest impact. For example, in the 1950s cohort, the age-sex adjusted hazard ratio comparing respondents with manual versus non-manual occupational status was 1.80 (1.25, 2.58); adjustment for cumulative smoking over 20 years attenuated the association by 49 %, diet by 43 %, drinking by 13 % and inactivity by only 1%. CONCLUSIONS: Health behaviours have an important role in explaining socioeconomic differentials in mortality.

When in the lifecourse? Socioeconomic position across the lifecourse and biological health score.

PURPOSE: Educational attainment is associated with multiphysiological wear and tear. However, associations with measures of socioeconomic position (SEP) across different life-stages are not established. METHODS: Using regression models and data from 8105 participants from the UK Household Longitudinal Study (Understanding Society), we examined associations of lifecourse SEP with an overall biological health score (BHS). BHS is broader than usual measures of biological 'wear and tear' and is based on six physiological subsystems (endocrine, metabolic, cardiovascular, inflammatory/immune, liver, and kidney), with higher scores indicating worse health. Lifecourse SEP was based on respondents' parental, first, and most recent occupations. RESULTS: Associations with SEP at all life-stages demonstrated higher BHS with increasing disadvantage (e.g. slope index of inequality (SII) (95 % CI) for most recent SEP: 0.04 (0.02, 0.06)). There was little difference in the magnitude of associations for SEP measured at each life-stage. Cumulative disadvantage across the lifecourse showed a stepped association with increasing BHS (SII (95 % CI): 0.05 (0.04, 0.07)). Associations were largely driven by metabolic, cardiovascular, and inflammatory systems. CONCLUSION: Our results suggest that disadvantaged SEP across the lifecourse contributes cumulatively to poorer biological health, highlighting that every life-stage should be a target for public health policies and intervention.

Individual, social and area level factors associated with older people's walking: Analysis of an UK household panel study (Understanding Society).

BACKGROUND: Among older people, walking is a popular and prevalent activity. Walking is key to increasing physical activity levels and resulting physical and mental health. In the context of rapidly ageing populations, it is important to better understand what factors are associated with walking among older people, based on the socioecological model of health. METHODS: We used data from Understanding Society (n:6450), a national panel survey of UK adults aged 65 years and over living in Great Britain. Slope Indices of Inequality (SII) were calculated for weekly walking hours for older people according to individual, social and area characteristics. These include health, loneliness and social isolation, previous walking and sporting activity, residential self-selection, contact with neighbours, number of close friends and social activity. Spatial area-level data described local area crime, walkability, and proximity to retail, greenspace, and public transport amenities. RESULTS: Multivariable models indicated that poor health, particularly requiring help with walking, was the strongest predictor of weekly walking hours (SII (95% CI) comparing those needing help vs. no help: -3.58 (-4.30, -2.87)). However, both prior sporting activity (most vs. least active: 2.30 (1.75, 2.88)) and walking for pleasure (yes vs. no: 1.92 (1.32, 2.53)) were strongly associated with increased walking several years later. Similarly having close friends (most vs. fewest, 1.18 (0.72, 1.77)) and local retail destinations (any vs. none: 0.93 (0.00, 1.86)) were associated with more weekly walking. CONCLUSIONS: Past engagement in physical activity and walking for pleasure are strong predictors of walking behaviour in older people, underscoring the importance of implementing and sustaining walking interventions across the lifespan to ensure continued engagement in later years and the associated health benefits. However, poor health significantly impedes walking in this demographic, emphasising the need for interventions that offer both physical assistance and social support to promote this activity.

Psychiatric disorder as a risk factor for cancer: different analytic strategies produce different findings.

BACKGROUND: Reported associations between psychiatric disorders and cancer incidence are inconsistent, with cancer rates in psychiatric patients that are variously higher than, similar to, or lower than the general population. Understanding these associations is complicated by difficulties in establishing the timing of onset of psychiatric disorders and cancer, and by the possibility of reverse causality. Some studies have dealt with this problem by excluding patients with cancers predating their psychiatric illness; others have not considered the issue. METHODS: We examined associations between psychiatric hospitalization and cancer incidence in a cohort of 1,165,039 Swedish men, and we explored the impact of different analytic strategies on these associations using real and simulated data. RESULTS: Relative to men without psychiatric hospitalization, we observed consistent increases in smoking-related cancers in those with psychiatric hospitalizations, regardless of analytic approach (eg, hazard ratio = 1.73 [95% confidence interval = 1.52-1.96]). However, associations with cancers unrelated to smoking were highly dependent on analytic strategy. In analyses based on the full cohort, we observed no association or a modest increase in cancer incidence in those with psychiatric hospitalizations (1.14 [1.07-1.22]). In contrast, when men whose cancer predated their psychiatric hospitalizations were excluded, future cancer incidence was lower in psychiatric patients (0.72 [0.67-0.78]). Results from simulated data suggest that even modest exclusions of this type can lead to strong artifactual associations. CONCLUSIONS: Psychiatric disorder-cancer incidence associations are complex and influenced by analytic strategy. A better understanding of the temporal relationship between psychiatric disorder and cancer incidence is required.

Health improvement for disadvantaged people in Nepal - an evaluation.

BACKGROUND: An evaluation of progress with participatory approaches for improvement of health knowledge and health experiences of disadvantaged people in eight Districts of Eastern Nepal has been undertaken. METHODS: A random selection of Village Development Committees and households, within the eight Districts where participation and a Rights-based Approach had been promoted specifically by local NGOs were compared with similar villages and households in eight Districts where this approach had not been promoted. Information was sought by structured interview and observation by experienced enumerators from both groups of householders. Health knowledge and experiences were compared between the two sets of households. Adjustments were made for demographic confounders. RESULTS: Complete data sets were available for 628 of the 640 households. Health knowledge and experiences were low for both sets of households. However, health knowledge and experiences were greater in the participatory households compared with the non-participatory households. These differences remained after adjustment for confounders. CONCLUSIONS: The study was designed to evaluate progress with participatory processes delivered by non-governmental organisations over a five year period. Improvements in health knowledge and experiences of disadvantaged people were demonstrated in a consistent and robust manner where interventions had taken place.

Impact of subjective and objective neighbourhood characteristics and individual socioeconomic position on allostatic load: A cross-sectional analysis of an all-age UK household panel study.

Research suggests that individuals living in more disadvantaged neighbourhoods experience higher levels of stress but this has generally been based on self-reported stress. We used survey-based neighbourhood quality indicators and biomarker data from Understanding Society, linked to census and crime statistics to explore associations of allostatic load (AL), an objective biomarker-based measure of cumulative stress, with subjective and objective neighbourhood characteristics. Analyses of 6887 respondents living in England show greater AL among those living in more disadvantaged areas, with objective measure associations stronger than subjective. Neighbourhood inequalities in AL were lower among respondents with higher individual SEP. These results suggest that individual-level SEP mitigates against the impact of negative, particularly objective, neighbourhood characteristics. Policies to reduce health inequalities should consider both individual and neighbourhood circumstances.

Examining the impact of different social class mechanisms on health inequalities: A cross-sectional analysis of an all-age UK household panel study.

BACKGROUND: Socioeconomic inequalities are well established across health, morbidity and mortality measures. Social class theory describes how social groups relate, interact and accrue advantages/disadvantages relative to one another, with different theorists emphasising different dimensions. In the context of health inequalities, different social class measures are used interchangeably to rank population groups in terms of health rather than directly exploring the role of social class in creating inequalities. We aim to better understand how four distinct social class mechanisms explain differences in a range of self-reported and biological health outcomes. METHODS: We use data from the UK Household Longitudinal Study, a representative population survey of UK adults, to identify measures pertaining to Early years, Bourdieusian, Marxist, and Weberian social class mechanisms. Using logistic and least-squares regression we consider the relative extent to which these mechanisms explain differences in health (Self-reported health, SF12 Physical (PCS) and Mental (MCS) Component Scores, General Health Questionnaire; N = 21,446) and allostatic load, a biomarker-based measure of cumulative stress (N = 5003). RESULTS: Respondents with higher social position according to all social class measures had better self-rated, physical and mental health, and lower allostatic load. Associations with Marxist social class were among the strongest (e.g. Relative Index of Inequality for very good/excellent self-rated health comparing highest versus lowest Marxist social class: 4.96 (4.45, 5.52), with the Weberian measure also strongly associated with self-rated (4.35 (3.90, 4.85)) and physical health (Slope Index of Inequality for SF12-PCS: 7.94 (7.39, 8.48)). Health outcome associations with Bourdieusian and Marxist measures were generally stronger for women and older respondents, and physical health associations with all measures were stronger among those aged 50+ years. CONCLUSIONS: The impact of social class on health is multi-faceted. Policies to reduce health inequalities should focus more on unequal capital ownership, economic democracy and educational inequalities, reflecting Marxist and Weberian mechanisms.

Pre-conception inter-pregnancy interval and risk of schizophrenia.

It is hypothesised that the risk of schizophrenia may be elevated in children conceived following a short inter-pregnancy interval, when maternal folate stores are still being replenished. We examined the relationship between inter-pregnancy interval and schizophrenia risk in a longitudinal, population-based cohort. Risk of schizophrenia was increased by approximately 150% in those born following a pregnancy interval of ≤6 months, but was not increased if the interval after birth of the participant, before conception of the subsequent sibling, was ≤6 months. These findings support the hypothesis that folate (or other micronutrient) deficiency during fetal development may be an important risk factor for schizophrenia.

A study of preoperative factors associated with a poor outcome following laparoscopic bile duct exploration.

BACKGROUND: The aim of this study was to identify preoperative factors associated with poor outcome following laparoscopic bile duct exploration. METHODS: Data regarding potential preoperative factors were collected prospectively and from a review of patient records of 436 patients who had undergone a laparoscopic bile duct exploration. A multivariate analysis was performed to identify significant predictors of five adverse outcomes: postoperative complication (stratified), conversion to open operation, prolonged hospital stay, bile leak following choledochotomy, and failure of surgical clearance of the duct. RESULTS: The mean age was 57 years (range = 18-91) and 74% were female. No complications were experienced by 66.5% and 17% had a minor Clavien Grade I complication. There was one death. Clinically significant Clavien Grade II-V complications occurred more frequently in those of increasing age [OR = 1.03 (CI = 1.01-1.05), p = 0.02]. Increasing serum bilirubin [OR = 1.01 (CI = 1.00-1.01), p = 0.01] was associated with conversion to an open operation. Male sex [OR = 0.52 (CI = 0.27-0.99), p = 0.05], previous upper abdominal surgery [OR = 4.89 (CI = 1.10-21.74), p = 0.04], immunosuppressants [OR = 9.75 (CI = 1.06-89.93), p = 0.05], and a larger preoperative common bile duct diameter [OR = 1.16 (CI = 1.08-1.25), p < 0.001] were predictors of a prolonged hospital stay. No factors were identified as predictors of a controlled bile leak. Previous failed ERCP was not associated with adverse outcome. CONCLUSION: Laparoscopic exploration of the bile duct is safe but age, comorbidity, and degree of jaundice increase the risk slightly.

Social contact and inequalities in depressive symptoms and loneliness among older adults: A mediation analysis of the English Longitudinal Study of Ageing.

BACKGROUND: Social contact, including remote contact (by telephone, email, letter or text), could help reduce social inequalities in depressive symptoms and loneliness among older adults. METHODS: Data were from the 8th wave of the English Longitudinal Study of Aging (2016/17), stratified by age (n = 1578 aged <65; n = 4026 aged 65+). Inverse probability weighting was used to estimate average effects of weekly in-person and remote social contact on depressive symptoms (score of 3+ on 8-item CES-D scale) and two measures of loneliness (sometimes/often feels lonely vs hardly ever/never; and top quintile of UCLA loneliness scale vs all others). We also estimated controlled direct effects of education, partner status, and wealth on loneliness and depressive symptoms under two scenarios: 1) universal infrequent (