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.

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.

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.

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.

Characteristics of those most vulnerable to employment changes during the COVID-19 pandemic: a nationally representative cross-sectional study in Wales.

BACKGROUND: The public health response to the SARS-CoV-2 (COVID-19) pandemic has had a detrimental impact on employment and there are concerns the impact may be greatest among the most vulnerable. We examined the characteristics of those who experienced changes in employment status during the early months of the pandemic. METHODS: Data were collected from a cross-sectional, nationally representative household survey of the working age population (18-64 years) in Wales in May/June 2020 (n=1379). We looked at changes in employment and being placed on furlough since February 2020 across demographics, contract type, job skill level, health status and household factors. χ2 or Fisher's exact test and multinomial logistic regression models examined associations between demographics, subgroups and employment outcomes. RESULTS: Of our respondents, 91.0% remained in the same job in May/June 2020 as they were in February 2020, 5.7% were now in a new job and 3.3% experienced unemployment. In addition, 24% of our respondents reported being placed on furlough. Non-permanent contract types, individuals who reported low mental well-being and household financial difficulties were all significant factors in experiencing unemployment. Being placed on 'furlough' was more likely in younger (18-29 years) and older (60-64 years) workers, those in lower skilled jobs and from households with less financial security. CONCLUSION: A number of vulnerable population groups were observed to experience detrimental employment outcomes during the initial stage of the COVID-19 pandemic. Targeted support is needed to mitigate against both the direct impacts on employment, and indirect impacts on financial insecurity and health.

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.

Mental health of the nursing and midwifery workforce in Wales during the COVID-19 pandemic: a cross-sectional analysis.

BACKGROUND: The mental health of the nursing and midwifery workforce in the UK became a public health concern before the COVID-19 pandemic. Poor mental health is a known factor for those considering leaving the profession, and workforce retention of younger members is crucial for the future of the sector. The aim of this study was to provide up-to-date estimates of mental wellbeing in this workforce in Wales during the COVID-19 pandemic. METHODS: We did a cross-sectional analysis of demographics, work-related information, and health data from respondents to a national online survey of registered and student nurses and midwives and health-care support workers in Wales. The survey was open between June 23 and Aug 9, 2021, and 2910 people responded (approximately 7% of the workforce). Mental wellbeing was calculated using the Short Warwick Edinburgh Mental Wellbeing Score (SWEMWBS). We measured probable clinical depression (SWEMWBS <18) and possible mild depression (SWEMWBS 18-20). We used χ2 analysis and multinomial logistic regression (adjusted for sex and staff grouping) to examine associations between age groups and mental wellbeing. FINDINGS: We analysed data from 2781 (95·6%) of 2910 respondents (129 respondents did not answer all seven SWEMWBS questions). Overall, 1622 (58·3%) of 2781 respondents had SWEMWBSs indicative of either probable clinical depression (863 [31·0%] of 2781) or possible mild depression (759 [27·3%] of 2781). Probable clinical depression was highest among those aged 18-29 years (180 [33·8%] of 532), 30-39 years (250 [35·6%] of 703), and 40-49 years (233 [33·5%] of 696). Respondents in these age groups were twice as likely to report SWEMWBSs indicative of probable clinical depression than respondents aged 60 years and older (18-29 years adjusted odds ratio [aOR] 2·38 [95% CI 1·43-3·97], p=0·0009; 30-39 years aOR 2·86 [1·77-4·64], p<0·0001; 40-49 years aOR 2·49 [1·54-4·02], p=0·0002). INTERPRETATION: This study highlights the substantial burden of poor mental wellbeing among the nursing and midwifery workforce in Wales, especially in those aged 49 years and younger. These figures, higher than previous estimates, could reflect the mental health effect of responding to the pandemic and could have long-term implications on workforce retention. FUNDING: None.

Creating an e-cohort of individuals with lived experience of homelessness and subsequent mortality in Wales, UK.

BACKGROUND: Homelessness is an extreme form of social exclusion, with homeless people experiencing considerable social and health inequities. Estimates of morbidity and mortality amongst homeless populations is limited due to the lack of recording of housing status across health datasets. The aim of this study is to: (i) identify a homelessness e-cohort by linking routine health data in Wales, and (ii) explore whether a period of reported past homelessness, places this population at greater risk of morbidity and mortality. METHODS: Homelessness identified through linkage across primary, secondary care and substance misuse datasets in the Secure Anonymised Information Linkage (SAIL) Databank. Mortality was examined through linkage to the Office for National Statistics mortality data. RESULTS: E-cohort of 15 472 individuals with lived experience of homelessness identified. Of those, 21 individuals died between February and July 2020 involving coronavirus disease of 2019 (COVID-19). Those with lived experience of homelessness had increased mortality from many causes including accidents, liver diseases and suicides. CONCLUSION: Linking multiple routine datasets provides a more comprehensive dataset of a marginalized population, including individuals who are not included in government homeless statistics. Application of the cohort demonstrated that individuals with lived experience of homelessness have increased mortality involving COVID-19 and other causes. The underlying reasons, health needs and causes of death warrant further exploration.

Long-term cost-effectiveness of interventions for obesity: A mendelian randomisation study.

BACKGROUND: The prevalence of obesity has increased in the United Kingdom, and reliably measuring the impact on quality of life and the total healthcare cost from obesity is key to informing the cost-effectiveness of interventions that target obesity, and determining healthcare funding. Current methods for estimating cost-effectiveness of interventions for obesity may be subject to confounding and reverse causation. The aim of this study is to apply a new approach using mendelian randomisation for estimating the cost-effectiveness of interventions that target body mass index (BMI), which may be less affected by confounding and reverse causation than previous approaches. METHODS AND FINDINGS: We estimated health-related quality-adjusted life years (QALYs) and both primary and secondary healthcare costs for 310,913 men and women of white British ancestry aged between 39 and 72 years in UK Biobank between recruitment (2006 to 2010) and 31 March 2017. We then estimated the causal effect of differences in BMI on QALYs and total healthcare costs using mendelian randomisation. For this, we used instrumental variable regression with a polygenic risk score (PRS) for BMI, derived using a genome-wide association study (GWAS) of BMI, with age, sex, recruitment centre, and 40 genetic principal components as covariables to estimate the effect of a unit increase in BMI on QALYs and total healthcare costs. Finally, we used simulations to estimate the likely effect on BMI of policy relevant interventions for BMI, then used the mendelian randomisation estimates to estimate the cost-effectiveness of these interventions. A unit increase in BMI decreased QALYs by 0.65% of a QALY (95% confidence interval [CI]: 0.49% to 0.81%) per year and increased annual total healthcare costs by £42.23 (95% CI: £32.95 to £51.51) per person. When considering only health conditions usually considered in previous cost-effectiveness modelling studies (cancer, cardiovascular disease, cerebrovascular disease, and type 2 diabetes), we estimated that a unit increase in BMI decreased QALYs by only 0.16% of a QALY (95% CI: 0.10% to 0.22%) per year. We estimated that both laparoscopic bariatric surgery among individuals with BMI greater than 35 kg/m2, and restricting volume promotions for high fat, salt, and sugar products, would increase QALYs and decrease total healthcare costs, with net monetary benefits (at £20,000 per QALY) of £13,936 (95% CI: £8,112 to £20,658) per person over 20 years, and £546 million (95% CI: £435 million to £671 million) in total per year, respectively. The main limitations of this approach are that mendelian randomisation relies on assumptions that cannot be proven, including the absence of directional pleiotropy, and that genotypes are independent of confounders. CONCLUSIONS: Mendelian randomisation can be used to estimate the impact of interventions on quality of life and healthcare costs. We observed that the effect of increasing BMI on health-related quality of life is much larger when accounting for 240 chronic health conditions, compared with only a limited selection. This means that previous cost-effectiveness studies have likely underestimated the effect of BMI on quality of life and, therefore, the potential cost-effectiveness of interventions to reduce BMI.

Digital Overuse and Addictive Traits and Their Relationship With Mental Well-Being and Socio-Demographic Factors: A National Population Survey for Wales.

Introduction: Population health concerns have been raised about negative impacts from overuse of digital technologies. We examine patterns of online activity predictive of Digital Overuse and Addictive Traits (DOAT). We explore associations between DOAT and mental well-being and analyse how both relate to self-reported changes in self-esteem, perceived isolation, and anxiety about health when individuals use the internet for health purposes. Methods: A cross-sectional nationally representative household survey of adults using stratified random sampling (compliance 75.4%, n = 1,252). DOAT was measured using self-reported questions adapted from a social media addiction scale (failure to cut down use, restlessness when not using, and impact on job/studies and home/social life in the last year), combined into a single DOAT score. Higher DOAT score was defined as >1 standard deviation above population mean. The Short Warwick-Edinburgh Mental Well-being Scale was used to measure mental well-being. Analyses were limited to those with internet access (n = 1,003). Results: Negative impacts of digital technology use on work and home/social lives were reported by 7.4% of respondents. 21.2% had tried but failed to cut down use in the past year. Higher DOAT was associated with higher social media and internet use but also independently associated with greater risks of low mental well-being. Higher DOAT was associated with both improvement and worsening of self-esteem, perceived isolation and anxiety about health when using the internet for health reasons, with no change in these outcomes most likely in those with lower DOAT. Lower mental well-being was associated with a similar bi-directional impact on perceived isolation and was also associated with worsening self-esteem. Conclusions: Substantial proportions of individuals report negative impacts on home, social and working lives from digital technology use, with many trying but failing to cut down use. Individuals with higher DOAT may experience improvements or worsening in self-esteem and other measures of mental well-being when using the internet for health purposes. From a public health perspective, a greater understanding of risk factors for digital overuse, its impacts on well-being and how to reasonably limit use of technology are critical for a successful digital revolution.

Factors influencing initiation of health behaviour conversations with patients: Cross-sectional study of nurses, midwives, and healthcare support workers in Wales.

AIM: To identify factors influencing healthcare professionals' engagement in health behaviour conversations with patients. DESIGN: Cross-sectional survey. METHODS: Between April and June 2019, an online survey of 1338 nurses, midwives and healthcare support workers was conducted. The survey assessed whether staff felt comfortable initiating health behaviour conversations with patients about five behaviours (reducing alcohol intake; stop smoking; being more active; reducing their weight; and improving their diet) and barriers to conversation initiation. Health professionals' own health-related behaviours, self-rated health and mental wellbeing, and socio-demographic characteristics were recorded. Logistic regression models were built to assess factors associated with feeling comfortable initiating health behaviour conversations for each topic. RESULT: Less than 50% of respondents reported feeling comfortable initiating health behaviour conversations with patients. Female staff, young professionals (18 to 29 years), those in lower staff grades and those with poorer health and low mental wellbeing were less likely to report feeling comfortable having health behaviour conversations across all topics. Those who did not adhere to physical activity and dietary guidelines were less likely to initiate a conversation about being more active and having a healthy diet, respectively. Not having time to discuss the topic, suitable space to hold a conversation, and feeling worried about offending/upsetting patients were the main barriers reported. CONCLUSION: Around 6 in 10 members of the nursing, midwifery and healthcare support workforce in Wales potentially do not feel comfortable to initiate a health behaviour conversation with patients about health and wellbeing. Feeling less comfortable to initiate a conversation was associated with staff demographics and organizational factors. IMPACT: We identified those less likely to initiate health behaviour conversations as well as personal and organizational barriers to initiation. This will help to target and tailor interventions to ensure staff are equipped and enabled to hold health behaviour conversations with patients.

Adult support during childhood: a retrospective study of trusted adult relationships, sources of personal adult support and their association with childhood resilience resources.

BACKGROUND: Adverse childhood experiences (ACEs) can affect health and well-being across the life course. Resilience is an individual characteristic that is known to help negate the effect of adversities and potentially transform toxic stress into tolerable stress. Having access to a trusted adult during childhood is critical to helping children build resiliency. Here, we aim to understand the relationship between always having access to trusted adult support and childhood resilience resources, and examine which sources of personal adult support and the number of sources of adult support, best foster childhood resilience. METHODS: A Welsh national cross-sectional retrospective survey (n = 2497), using a stratified random probability sample. Data were collected via face-to-face interviews at participants' places of residence by trained interviewers. Analyses use chi-square and binary logistic regression methods. Outcome measures were childhood resilience resources, access to an always-available trusted adult, and sources of personal adult support. RESULTS: Prevalence of access to an always-available trusted adult decreased with increasing number of ACEs from 86.6% of individuals with no ACEs, to 44.4% of those with four or more ACEs (≥ 4). In addition, for those experiencing ≥ 4 ACEs, individuals with no access to a trusted adult were substantially less likely than those with access, to report childhood resilience resources. For example, for individuals with ≥ 4 ACEs, those with access to an always-available trusted adult were 5.6 times more likely to have had supportive friends and 5.7 times more likely to have been given opportunities to develop skills to succeed in life, compared to those with no access to a trusted adult. When looking at sources of personal adult support, resilience levels increased dramatically for those individuals who had either one parent only or two parents as sources of support, in comparison to those without parental support. CONCLUSIONS: Analyses here suggest strong relationships between elements of childhood resilience, constant access to trusted adults and different sources of personal adult support. While the eradication of ACEs remains unlikely, actions to strengthen childhood access to trusted adults may partially ease immediate harms and protect future generations.

Addressing the Digital Inverse Care Law in the Time of COVID-19: Potential for Digital Technology to Exacerbate or Mitigate Health Inequalities.

Digital technologies have been transforming methods of health care delivery and have been embraced within the health, social, and public response to the COVID-19 pandemic. However, this has directed attention to the "inverse information law" (also called "digital inverse care law") and digital inequalities, as people who are most in need of support (in particular, older people and those experiencing social deprivation) are often least likely to engage with digital platforms. The response to the COVID-19 pandemic represents a sustained shift to the adoption of digital approaches to working and engaging with populations, which will continue beyond the COVID-19 pandemic. Therefore, it is important to understand the underlying factors contributing to digital inequalities and act immediately to avoid digital inequality contributing to health inequalities in the future. The response to COVID-19 represents a sustained shift to adopting digital approaches to working and engaging with populations which will continue beyond this pandemic. Therefore it is important that we understand the underlying factors contributing to digital inequalities, and act now to protect against digital inequality contributing to health inequalities in the future.

The causal effects of health conditions and risk factors on social and socioeconomic outcomes: Mendelian randomization in UK Biobank.

BACKGROUND: We aimed to estimate the causal effect of health conditions and risk factors on social and socioeconomic outcomes in UK Biobank. Evidence on socioeconomic impacts is important to understand because it can help governments, policy makers and decision makers allocate resources efficiently and effectively. METHODS: We used Mendelian randomization to estimate the causal effects of eight health conditions (asthma, breast cancer, coronary heart disease, depression, eczema, migraine, osteoarthritis, type 2 diabetes) and five health risk factors [alcohol intake, body mass index (BMI), cholesterol, systolic blood pressure, smoking] on 19 social and socioeconomic outcomes in 336 997 men and women of White British ancestry in UK Biobank, aged between 39 and 72 years. Outcomes included annual household income, employment, deprivation [measured by the Townsend deprivation index (TDI)], degree-level education, happiness, loneliness and 13 other social and socioeconomic outcomes. RESULTS: Results suggested that BMI, smoking and alcohol intake affect many socioeconomic outcomes. For example, smoking was estimated to reduce household income [mean difference = -£22 838, 95% confidence interval (CI): -£31 354 to -£14 321] and the chance of owning accommodation [absolute percentage change (APC) = -20.8%, 95% CI: -28.2% to -13.4%], of being satisfied with health (APC = -35.4%, 95% CI: -51.2% to -19.5%) and of obtaining a university degree (APC = -65.9%, 95% CI: -81.4% to -50.4%), while also increasing deprivation (mean difference in TDI = 1.73, 95% CI: 1.02 to 2.44, approximately 216% of a decile of TDI). There was evidence that asthma decreased household income, the chance of obtaining a university degree and the chance of cohabiting, and migraine reduced the chance of having a weekly leisure or social activity, especially in men. For other associations, estimates were null. CONCLUSIONS: Higher BMI, alcohol intake and smoking were all estimated to adversely affect multiple social and socioeconomic outcomes. Effects were not detected between health conditions and socioeconomic outcomes using Mendelian randomization, with the exceptions of depression, asthma and migraines. This may reflect true null associations, selection bias given the relative health and age of participants in UK Biobank, and/or lack of power to detect effects.

Welsh Primary Schoolchildren's Perceptions of Electronic Cigarettes: A Mixed Methods Study.

There are concerns that the growing popularity of e-cigarettes promotes experimentation among children. Given the influence of the early years on attitude and habit formation, better understanding of how younger children perceive vaping before experimentation begins is needed, to prevent uptake and inform tobacco control strategies. We explored Welsh primary schoolchildren's (aged 7-11) awareness of e-cigarettes relative to tobacco smoking, their understanding of the perceived risks and benefits and their intentions and beliefs about vaping. Data was collected using a mix of methods in June and July 2017 from 8 purposively selected primary schools across Wales. Four hundred and ninety-five children (52% female) aged 7 years (n = 165), 9 years (n = 185) and 11 years (n = 145) completed a class-administered booklet encompassing a draw and write exercise and survey. Ninety-six children participated in 24 peer discussion groups comprised of 2 boys and 2 girls from each year group. Data were analysed independently and findings triangulated. Survey analyses used frequencies, descriptive statistics and chi-squared tests. Content analysis was undertaken on the draw and write data and peer discussion groups were analysed thematically. Study findings highlight that primary schoolchildren have general awareness of e-cigarettes. Vaping was perceived to be healthier than smoking and there was some recognition that e-cigarettes were used for smoking cessation. Understanding of any health harms was limited. Few children intended to smoke or vape in the future but almost half thought it was okay for grownups. Children's perceptions were influenced by exposure through family and friends. Findings suggest a need for e-cigarette education in primary schools, to highlight the associated risks of e-cigarette experimentation including the potential for tobacco initiation.