Exploring the lived experience of Long Covid in black and minority ethnic groups in the UK: Protocol for qualitative interviews and art-based methods.

Some people experience prolonged symptoms following an acute COVID-19 infection including fatigue, chest pain and breathlessness, headache and cognitive impairment. When symptoms persist for over 12 weeks following the initial infection, and are not explained by an alternative diagnosis, the term post-COVID-19 syndrome is used, or the patient-defined term of Long Covid. Understanding the lived experiences of Long Covid is crucial to supporting its management. However, research on patient experiences of Long Covid is currently not ethnically diverse enough. The study aim is to explore the lived experience of Long Covid, using qualitative interviews and art-based methods, among people from ethnically diverse backgrounds (in the UK), to better understand wider systems of support and healthcare support needs. Co-created artwork will be used to build on the interview findings. A purposive sampling strategy will be used to gain diverse experiences of Long Covid, sampling by demographics, geographic locations and experiences of Long Covid. Individuals (aged >18 years) from Black and ethnic minority backgrounds, who self-report Long Covid symptoms, will be invited to take part in a semi-structured interview. Interviews will be analysed thematically. A sub-sample of participants will be invited to co-create visual artwork to further explore shared narratives of Long Covid, enhance storytelling and increase understanding about the condition. A patient advisory group, representing diversity in ethnicity and experiences of Long Covid, will inform all research stages. Stakeholder workshops with healthcare professionals and persons, systems or networks important to people's management of Long Covid, will advise on the integration of findings to inform management of Long Covid. The study will use patient narratives from people from diverse ethnic backgrounds, to raise awareness of Long Covid and help inform management of Long Covid and how wider social systems and networks may inform better healthcare service access and experiences.

Evaluation and update of the expert consensus guidelines for the assessment of the cortisol awakening response (CAR).

The cortisol awakening response (CAR) is frequently assessed in psychobiological (stress) research. Obtaining reliable CAR data, however, requires careful attention to methodological detail. To promote best practice, expert consensus guidelines on the assessment of the CAR were published (Stalder et al., 2016, PNEC). However, it is unclear whether these highly cited guidelines have resulted in actual methodological improvements. To explore this, the PNEC editorial board invited the present authors to conduct a critical evaluation and update of current CAR methodology, which is reported here. (i) A quantitative evaluation of methodological quality of CAR research published in PNEC before and after the guidelines (2013-2015 vs. 2018-2020) was conducted. Disappointingly, results reveal little improvement in the implementation of central recommendations (especially objective time verification) in recent research. (ii) To enable an update of guidelines, evidence on recent developments in CAR assessment is reviewed, which mostly confirms the accuracy of the majority of the original guidelines. Moreover, recent technological advances, particularly regarding methods for the verification of awakening and sampling times, have emerged and may help to reduce costs in future research. (iii) To aid researchers and increase accessibility, an updated and streamlined version of the CAR consensus guidelines is presented. (iv) Finally, the response of the PNEC editorial board to the present results is described: potential authors of future CAR research to be published in PNEC will be required to submit a methodological checklist (based on the current guidelines) alongside their article. This will increase transparency and enable reviewers to readily assess the quality of the respective CAR data. Combined, it is hoped that these steps will assist researchers and reviewers in assuring higher quality CAR assessments in future research, thus yielding more reliable and reproducible results and helping to further advance this field of study.

Increased Wellbeing following Engagement in a Group Nature-Based Programme: The Green Gym Programme Delivered by the Conservation Volunteers.

The wellbeing benefits of engaging in a nature-based programme, delivered by the Voluntary, Community and Social Enterprise sector, were examined in this study. Prior to attending The Conservation Volunteers' Green Gym™, attendees (n = 892) completed demographics, health characteristics and the Warwick Edinburgh Mental Wellbeing Short-Form Scale. Attendees (n = 253, 28.4%) provided a measure on average 4.5 months later. There were significant increases in wellbeing after engaging in Green Gym, with the greatest increases in those who had the lowest starting levels of wellbeing. Wellbeing increases were sustained on average 8.5 months and 13 months later in those providing a follow up measure (n = 92, n = 40, respectively). Attendees who continued to engage in Green Gym but not provide follow up data (n = 318, 35.7%) tended to be more deprived, female and self-report a health condition. Attendees who did not continue to engage in Green Gym (n = 321, 36.0%) tended to be less deprived and younger. These findings provide evidence of the wellbeing benefits of community nature-based activities and social ('green') prescribing initiatives and indicate that Green Gym targets some groups most in need.

A cross-sectional study of physical activity behaviour and associations with wellbeing during the UK coronavirus lockdown.

This study assessed physical activity (PA) and wellbeing during lockdown. UK adults reported their PA in the previous week, perception of PA importance (more, less, same) and wellbeing, depression, anxiety and stress. One-way ANOVA compared PA and wellbeing by PA importance. The 'less' importance group did less PA than the 'more' and 'same' (p < 0.05) importance group; and scored worse on all wellbeing measures than the 'same' importance group (p < 0.01). They also had worse wellbeing, depression and anxiety than the 'more' importance group (p < 0.05). Strategies to overcome the impact of the pandemic should aim to increase PA.

Smaller Cortisol Awakening Responses Are Associated with Greater Visual Dependence in Postural Control.

There are known links between the hypothalamic-pituitary-adrenal (HPA) axis and systems responsible for regulating posture. Our aim was to explore directly, for the first time, whether an aspect of circadian HPA axis activity (the cortisol awakening response: CAR) was associated with greater visual dependency in postural control. For measurement of the CAR, electronically monitored saliva samples were collected by participants following morning awakening in their home environment. On the afternoons of the same days, postural sway was measured in the laboratory by exposing participants to static (control) and moving visual stimuli whilst standing still and upright on a force platform. Visual dependence was assessed as the increase in postural sway (path length) during exposure to the moving compared with the static condition. The 44 measurement days were derived from four days for each of eleven healthy participants (mean ± SD age: 51.18 ± 3.3 years). As expected, postural sway was greater when exposed to moving versus static cues. Mixed regression modelling showed that participants with smaller four day average CARs had greater deterioration in postural sway when presented with moving stimuli. These data are the first to document associations between the CAR and visual dependency in postural sway.

An inverted U-shaped relationship between cortisol awakening response and same-day error monitoring function in healthy males.

The cortisol awakening response (CAR) is thought to provide an energetic "boost" for the coming day and has been shown to be associated with prefrontal dependent function. The aim of the current study was to examine the relationship between the CAR and same-day neural activity following an error response task. Forty-six healthy males (22.25 years ± 1.98) collected saliva samples at 0, 30 and 45 min post-awakening to measure the CAR, and on the same afternoon event-related potential activity during error processing was measured. Although no association was observed between CAR and post-error behavior, a significant quadratic relationship was observed between CAR and Error-related Negativity (ERN) amplitude, and this association remained while controlling for confounding factors. This finding suggested the existence of an inverted U-shaped relationship between CAR and the same-day error-monitoring function in healthy males.

"It made me feel brighter in myself"- The health and well-being impacts of a residential front garden horticultural intervention.

Residential gardens make up 30% of urban space in the UK, yet unlike many other green space typologies, their role in the health and well-being agenda has largely been overlooked. A horticultural intervention introduced ornamental plants to 38 previously bare front gardens (≈ 10 m2) within an economically deprived region of North England, UK. Measures of perceived stress and diurnal cortisol profiles (as an indicator of health status) were taken pre- and post-intervention (over 3 months). Residents reported significant decreases in perceived stress post-intervention. This finding was aligned with a higher proportion of 'healthy' diurnal cortisol patterns post-intervention, suggesting better health status in those individuals. All residents derived one or more reported socio-cultural benefits as a result of the front garden plantings, although overall scores for subjective well-being did not increase to a significant level. Further qualitative data suggested that the gardens were valued for enhancing relaxation, increasing positive emotions, motivation, and pride of place. The results indicate that adding even small quantities of ornamental plants to front gardens within deprived urban communities had a positive effect on an individual's stress regulation and some, but not all, aspects of subjective well-being. The research highlights the importance of residential front gardens to human health and well-being, and thus their contribution to the wider debates around city densification, natural capital and urban planning.

Co-Creating and Evaluating an App-Based Well-Being Intervention: The HOW (Healthier Outcomes at Work) Social Work Project.

Stress and mental health at work are the leading causes of long-term sickness absence in the UK, with chronically poor working conditions impacting employee physiological and psychological health. Social workers play a significant part in the fabric of UK society, but have one of the most stressful occupations in the country. The aim of this project was to work with UK social workers to co-develop, implement, and evaluate a series of smartphone-based mental health initiatives. A Participatory Action Research (PAR) approach, consisting of semi-structured interviews and focus group and steering group discussions, was utilized to design the mental health and well-being interventions. Study efficacy was evaluated via a pre- and post-intervention survey and post-intervention semi-structured interviews. Interventions developed were psycho-educational, improved top-down and bottom-up communication, and provided access to a Vocational Rehabilitation Assistant for those struggling and at risk of sickness absence. Six months following dissemination, surveys demonstrated significant improvements in communication, and mean score improvements in four other working conditions. This project, therefore, demonstrates that co-developed initiatives can be positively impactful, despite post-intervention data collection being impacted by COVID-19. Future studies should build upon these findings and broaden the PAR approach nationally while taking a robust approach to evaluation.

Nursing assistants' experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa.

Manual restraint, a type of physical restraint, is a common practice in inpatient mental health settings linked to adverse physical and psychological staff and patient outcomes. However, little is known about the use of manual restraint for compulsory nasogastric feeding of patients with anorexia nervosa within inpatient eating disorder settings. The present phenomenological study aimed to explore nursing assistants' experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa. The study followed COREQ guidelines. Eight semi-structured interviews were conducted with eight nursing assistants from one UK inpatient child and adolescent eating disorder service. Interviews were transcribed verbatim and analysed using thematic analysis. Three themes were extracted: An unpleasant practice, importance of coping, and becoming desensitized and sensitized. Nursing assistants commonly experienced emotional distress, physical exhaustion, physical injury and physical aggression as a result of their manual restraint use. Nursing assistants appeared to cope with their distress by talking with colleagues and young persons who were further in their recovery, and by detaching themselves during manual restraint incidents. The findings highlight that the use of manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa in the UK is a highly distressing practice for nursing assistants. It is therefore important that sufficient supervision, support, and training are made available to staff working in these settings.

Salivary cortisol as a non-invasive window on the brain.

The validation of accurate and meaningful assessment of cortisol in saliva samples has proved revolutionary in stress research. Its many advantages have expanded the scope of investigation from traditional laboratory and clinical settings to include multidisciplinary and community-based research. These developments have given rise to a wealth insight into the links between stress and health. Here we highlight the potential of salivary cortisol as both a product and mediator of brain function, instrumental in disturbing brain health. However, the subtleties of salivary cortisol as a measure can be underestimated, leading to misinterpretation of findings. These issues are explored, with a particular emphasis on necessary methodological rigor. Notwithstanding great promise, there is undeniably more to learn so we conclude by making recommendations for future research including use of salivary cortisol in the development of integrative predictive models of stress-related risk factors and resilience across the life course.

Effectiveness of stress-relieving strategies in regulating patterns of cortisol secretion and promoting brain health.

Stress leads to ill-health and disease, and with today's fast-pace western society, engaging in strategies to relieve stress is crucial for good health across the life-course. Activities such as focusing on positive characteristics, art/music therapies, mindfulness, yoga and engaging with nature and/or physical activity have been shown to reduce stress and enhance well-being. It is thought that patterns of cortisol secretion, which are regulated by the brain, are a key mediator of stress-disease and well-being-health links. Measurement of cortisol in saliva is a non-invasive and ecologically valid tool for detecting early changes in brain health, as well as evaluating the effectiveness of strategies in relieving stress and improving brain health as well as monitoring stress-related brain changes. This chapter will review the evidence that engaging in stress-relieving strategies promotes regulation and/or restoration of patterns of cortisol secretion. If such strategies are found to be effective in healthy populations, they could potentially inform ways of promoting brain health and the prevention or delay of clinical disorders involving disorders in the brain (e.g., Parkinson's disease) and symptoms experienced with such disorders. To inform this field of research, recommendations are provided for the use of salivary cortisol as a marker of early monitoring of brain health and effectiveness of stress-alleviating interventions.

Psychological stress reactivity and future health and disease outcomes: A systematic review of prospective evidence.

BACKGROUND: Acute psychological stress activates the sympatho-adrenal medullary (SAM) system and hypothalamo-pituitary adrenal (HPA) axis. The relevance of this stress reactivity to long-term health and disease outcomes is of great importance. We examined prospective studies in apparently healthy adults to test the hypothesis that the magnitude of the response to acute psychological stress in healthy adults is related to future health and disease outcomes. METHODS: We searched Medline Complete, PsycINFO, CINAHL Complete and Embase up to 15 Aug 2019. Included studies were peer-reviewed, English-language, prospective studies in apparently healthy adults. The exposure was acute psychological stress reactivity (SAM system or HPA axis) at baseline. The outcome was any health or disease outcome at follow-up after ≥1 year. RESULTS: We identified 1719 papers through database searching and 1 additional paper through other sources. Forty-seven papers met our criteria including 32,866 participants (range 30-4100) with 1-23 years of follow-up. Overall, one third (32 %; 83/263) of all reported findings were significant and two thirds (68 %; 180/263) were null. With regard to the significant findings, both exaggerated (i.e. high) and blunted (i.e. low) stress reactivity of both the SAM system and the HPA axis at baseline were related to health and disease outcomes at follow-up. Exaggerated stress reactivity at baseline predicted an increase in risk factors for cardiovascular disease and decreased telomere length at follow-up. In contrast, blunted stress reactivity predicted future increased adiposity and obesity, more depression, anxiety and PTSD symptoms, greater illness frequency, musculoskeletal pain and regulatory T-Cell percentage, poorer cognitive ability, poorer self-reported health and physical disability and lower bone mass. CONCLUSION: Exaggerated and blunted SAM system and HPA axis stress reactivity predicted distinct physical and mental health and disease outcomes over time. Results from prospective studies consistently indicate stress reactivity as a predictor for future health and disease outcomes. Dysregulation of stress reactivity may represent a mechanism by which psychological stress contributes to the development of future health and disease outcomes.

The Current and Retrospective Intentional Nature Exposure Scales: Development and Factorial Validity.

Both nature exposure and green exercise (GE) can improve health. However, there are no scales examining frequency of engagement; or that consider interaction with nature. There are also no scales assessing these variables during childhood. The aim of this study was to develop a modified (NES-II) and retrospective (RNES-II) version of the Nature Exposure Scale to incorporate GE and to examine their factor structure and reliability. Exploratory factor analysis (EFA) explored the factor structure of the scales; followed by confirmatory factor analysis to confirm the model fit. Fit indices for the one factor five item NES-II and RNES-II models identified by EFA were poor. Use of modification indices resulted in a good model fit; NES-II: χ(5, n = 385) = 2.638; χnormed = 0.879; CFI= 1.000; RMSEA < 0.001 with 90%CI = 0.000-0.082; SRMR = 0.009; AIC = 36.638. RNES-II: χ(2, n = 385) = 7.149; χnormed = 3.574; CFI = 0.995; RMSEA = 0.082 with 90%CI = 0.023-0.151; SRMR = 0.015; AIC = 43.149. Both models demonstrated very good reliability (α = 0.84; 89 respectively). These findings indicate that the scales can be used to assess current and retrospective nature exposure. However, due to the removal of item one, the authors recommend that the scales be named the 'intentional nature exposure scale' and 'retrospective intentional nature exposure scale'.

Physical fitness and prior physical activity are both associated with less cortisol secretion during psychosocial stress.

BACKGROUND: Evidence linking fitness and decreased psychosocial stress comes from studies of athletes and typically relies upon self-report measures. Furthermore, there is little evidence regarding the impact of physical activity (PA) prior to a stressor. The aims of this study were to determine whether fitness and prior PA influence cortisol concentrations during psychosocial stress. METHODS: Seventy-five non-athletic participants took part in a submaximal walk prior to the Trier Social Stress Test for Groups (TSST-G). During the walk, fitness was assessed using heart rate (HR). A further 89 participants took part in the TSST-G without the walk. Stress responsiveness was assessed using salivary cortisol collected at 10-min intervals on seven occasions. RESULTS: Hierarchical multiple regression revealed that average walking HR accounted for 9% of the variance in cortisol secretion (P = .016), where a higher HR was associated with higher cortisol secretion. Between-subjects ANCOVA revealed that the walking group had a significantly lower cortisol secretion than the non-walking group (P = .009). CONCLUSIONS: These findings indicate that fitter individuals have reduced cortisol secretion during psychosocial stress. They also indicate that prior PA can reduce cortisol concentrations during psychosocial stress and are suggestive of a role of PA in reducing the impact of stress on health.

Salivary diurnal cortisol profiles in patients suffering from chronic breathlessness receiving supportive and palliative care services: A cross-sectional study.

Chronic breathlessness is a common source of psychological and physical stress in patients with advanced or progressive disease, suggesting that hypothalamic-pituitary-adrenal (HPA) axis dysregulation may be prevalent. The aim of this study was to measure the salivary diurnal cortisol profile in patients receiving supportive and palliative care for a range of malignant and non-malignant conditions and to compare the profile of those experiencing moderate-to-severe disability due to breathlessness against that of patients with mild/no breathlessness and that of healthy controls. Saliva samples were collected over two consecutive weekdays at 3, 6, and 12h after awakening in 49 patients with moderate-to-severe breathlessness [Medical Research Council (MRC) dyspnoea grade ≥3], 11 patients with mild/no breathlessness (MRC dyspnoea grade ≤2), and 50 healthy controls. Measures of breathlessness, stress, anxiety, depression, wellbeing and sleep were examined concomitantly. The diurnal cortisol slope (DCS) was calculated for each participant by regressing log-transformed cortisol values against collection time. Mean DCS was compared across groups using ANCOVA. Individual slopes were categorised into one of four categories: consistent declining, consistent flat, consistent ascending and inconsistent. Controlling for age, gender and socioeconomic status, the mean DCS was significantly flatter in patients with moderate-to-severe breathlessness compared to patients with mild/no breathlessness and healthy controls [F (2, 103)=45.64, p<0.001]. Furthermore, there was a higher prevalence of flat and ascending cortisol profiles in patients with moderate-to-severe breathlessness (23.4%) compared to healthy controls (0%). The only variable which correlated significantly with DCS was MRC dyspnoea grade (rs=0.29, p<0.05). These findings suggest that patients with moderate-to-severe breathlessness have evidence of HPA axis dysregulation and that this dysregulation may be related to the functional disability imposed by breathlessness.

Assessment of the cortisol awakening response: Real-time analysis and curvilinear effects of sample timing inaccuracy.

The cortisol awakening response (CAR) is typically measured in the domestic setting. Moderate sample timing inaccuracy has been shown to result in erroneous CAR estimates and such inaccuracy has been shown partially to explain inconsistency in the CAR literature. The need for more reliable measurement of the CAR has recently been highlighted in expert consensus guidelines where it was pointed out that less than 6% of published studies provided electronic-monitoring of saliva sampling time in the post-awakening period. Analyses of a merged data-set of published studies from our laboratory are presented. To qualify for selection, both time of awakening and collection of the first sample must have been verified by electronic-monitoring and sampling commenced within 15min of awakening. Participants (n=128) were young (median age of 20 years) and healthy. Cortisol values were determined in the 45min post-awakening period on 215 sampling days. On 127days, delay between verified awakening and collection of the first sample was less than 3min ('no delay' group); on 45days there was a delay of 4-6min ('short delay' group); on 43days the delay was 7-15min ('moderate delay' group). Cortisol values for verified sampling times accurately mapped on to the typical post-awakening cortisol growth curve, regardless of whether sampling deviated from desired protocol timings. This provides support for incorporating rather than excluding delayed data (up to 15min) in CAR analyses. For this population the fitted cortisol growth curve equation predicted a mean cortisol awakening level of 6nmols/l (±1 for 95% CI) and a mean CAR rise of 6nmols/l (±2 for 95% CI). We also modelled the relationship between real delay and CAR magnitude, when the CAR is calculated erroneously by incorrectly assuming adherence to protocol time. Findings supported a curvilinear hypothesis in relation to effects of sample delay on the CAR. Short delays of 4-6min between awakening and commencement of saliva sampling resulted in an overestimated CAR. Moderate delays of 7-15min were associated with an underestimated CAR. Findings emphasize the need to employ electronic-monitoring of sampling accuracy when measuring the CAR in the domestic setting.

Hair cortisol concentrations in relation to ill-being and well-being in healthy young and old females.

Hair cortisol concentration (HCC) provides a retrospective measure of long-term (i.e. over a period of months) cortisol secretion and has been shown to be elevated in relation to chronic stress conditions. However associations in healthy participants with subjective ill-being are less clear and associations with well-being have not been explored. The current study examined HCC in relation to independent comprehensive measures of ill-being (stress, depression, anxiety) and well-being (subjective happiness, life satisfaction, psychological well-being) in healthy young and old females (mean±SD: 19.5±2.2years and 78.6±6.7years respectively, total N=115). The data supported evidence of increased total cortisol secretion with increased age. No association between ill-being and HCC was found in either the young or older group of participants. A positive association between HCC and well-being was found in the older participant group which was independent of ill-being and potential confounds. These findings do not support associations between HCC and ill-being in healthy young or old females. However the results suggest that HCC is able to distinguish levels of well-being in healthy older females.