Exploring published literature of emerging practice as a response to challenges due to COVID-19
19 June 2020
The summary below includes articles that might help thinking about what has been learned from the COVID-19 experience so far, along with suggestions on how this might be used to support improvement in future.
Here, we look at COVID-19's unequal impact which reinforces the imperative for an integrated approach to protecting health and wellbeing.
This summary has two themes: the uneven COVID-19 impact and the uneven impacts of the public health measures.
Overview
Before the world became aware of the novel coronavirus causing COVID-19, we already knew that health inequalities were rife in human societies with evidence that life expectancy and healthy life expectancy increases as social and economic advantage does, often referred to as a “social gradient” (e.g. Marmot Review[i]). In high income (and increasingly in other) countries, chronic diseases (such as heart disease, diabetes and cancer) are a major contributor to this social gradient in health outcomes, and there is evidence that a similar pattern is associated with stress and mental health (e.g. Marmot and Bell[ii] , World Health Organization[iii]).
Whilst there is a less developed understanding of how socio-economic factors work together to influence infectious diseases outcomes (Noppert et al, Moran et al.[iv]), as this coronavirus has spread across the globe its uneven impact is becoming clear. This really is not an “equal opportunities” virus. The reasons are complex and not yet fully understood, but evidence is emerging that existing inequalities play a role in mediating the risks: of becoming infected with the virus; of suffering severe disease, and of detriment to health and wellbeing as a result of public health measures.
Amongst the early findings from the data, discussed in more detail below, has been evidence of an increased risk of severe illness and death from COVID-19 faced by people with certain underlying chronic diseases, by those from Black, Asian and minority ethnic (BAME) groups, by men, by older people, by those in certain occupations, and with increased deprivation also playing a role. The risks posed by the public health measures are also unevenly spread and risk amplifying existing inequalities, for example in mental health problems caused or exacerbated by social isolation, and (probably) through the stress of economic insecurity for many, but also potentially through health problems left undiagnosed or untreated for longer than usual.
In the largest study to-date (according to the authors) Ben Goldacre and OpenSAFELY colleagues[v] at the University of Oxford and the London School of Hygiene & Tropical Medicine (LSHTM) have released some early (and not yet peer reviewed) results analysing characteristics of people who died in hospital. Using NHS data from 17.4 million UK adults up to 25th April, their early findings include the following.
- People of Asian and Black ethnic backgrounds are at a higher risk of death and, contrary to prior speculation, this is only partially attributable to pre-existing clinical risk factors or deprivation.
- Key factors related to COVID-19 death included being male, older age, uncontrolled diabetes and severe asthma.
- A deprived background was also found to be a major risk factor: this was also only partially attributable to other clinical risk factors.
Ethnicity
In another study of a cohort of people recruited from the general population in England during 2006-2010 (then aged 40-70) Niedzwiedz and colleagues[vi] also found that, “Black and south Asian groups were more likely to test positive, and also more likely than white British to be hospitalised, with Pakistani ethnicity at highest risk within the south Asian group”. They confirm that only some of this increased risk could be explained by socioeconomic variables.
Deprivation
The Office for National Statistics (ONS) regularly updates its analysis of numbers of COVID related deaths in England and Wales. The figure below (copied from the ONS website) shows the relationship between deprivation and age-standardised mortality (death) rates for both all deaths and of COVID-19 deaths up to 31 May 2020. The bars represent mortality rates amongst different parts of the population, ordered form left to right from least deprived tenth of the population to most deprived tenth of the population (or “decile”). They show how much higher (in percentage terms) mortality rates are for each decile compared to the least deprived decile. (The least deprived decile therefore shows as zero in this figure.). This shows that the percentage increases in deaths for the most deprived areas (deciles 1-3) are proportionally worse for deaths involving COVID-19 than for overall deaths. COVID-19 seems to be magnifying health inequalities associated with deprivation.
Although not the exact equivalent National Records of Scotland (NRS) have published analysis of the impact of deprivation on COVID-19 mortality, showing that up to 10 May people living in the 20% most deprived areas of Scotland were 2.3 times more likely to die with COVID-19 than those living in the 20% least deprived areas. For all deaths it appears that this ratio is smaller at 1.9, suggesting a similar pattern as England with COVID deaths exacerbating existing patterns of inequalities.
Occupation and gender
The ONS published provisional analysis by different occupation of 2,494 deaths (to 20 April) involving the coronavirus (COVID-19) in the working age population (those aged 20 to 64 years) in England and Wales. Note that the analysis is adjusted for age, but not for other factors such as ethnic group or place of residence. Key findings on rates of death (with actual numbers given in brackets) involving COVID-19 are given below.
- For the whole working age population in England and Wales, the rate of death involving COVID-19 was statistically higher in males, with 9.9 deaths per 100,000 (1,612 deaths) compared with 5.2 deaths per 100,000 females (882 deaths).
- Men working in the lowest skilled occupations had the highest rates, with 21.4 deaths per 100,000 males (225 deaths). Men working as security guards had one of the highest rates, with 45.7 deaths per 100,000 (63 deaths). A number of other specific occupations were found to have raised rates of death among men, including: taxi drivers and chauffeurs (36.4 deaths per 100,000); bus and coach drivers (26.4 deaths per 100,000); chefs (35.9 deaths per 100,000); and sales and retail assistants (19.8 deaths per 100,000).
- Men and women working in social care, (including care workers and home carers) had significantly raised rates, with rates of 23.4 deaths per 100,000 males (45 deaths) and 9.6 deaths per 100,000 females (86 deaths).
- Healthcare workers were not found to have higher rates of death when compared with the general population. Note that there are caveats to this finding including some healthcare workers possibly having reduced exposure to COVID-19 during lockdown, for instance, because of people not having dental or optician appointments.
Uneven impacts of the public health measures
Evidence is also emerging of the impacts of COVID-19 public health measures, in particular lockdown and social distancing. And there are early signs which, when combined with what we already understand about the importance of, for example, schooling to children in poverty do indicate a heightened risk of exacerbating health inequalities. A selection of issues is described below. The route out of lockdown will need to carefully navigate these issues.
Domestic violence
Early signs are concerning with research by a domestic abuse charity reportedly finding evidence from internet searches that during the first three weeks of lockdown in the UK the number of women killed by men is the highest it’s been for at least 11 years and is double that of an average 21 days over the last 10 years (Guardian article). Whilst this statistic on its own is not conclusive, there are other indications giving serious concern. In late April for instance, Refuge, which runs the National Domestic Abuse Helpline, reported to a parliamentary select committee an increase of calls of around 50% above the average during lockdown (more details).
School closures
As has been widely discussed in the Scottish media recently there is concern that extended school closures risk having detrimental consequences particularly for children living in poverty. There is good reason for this concern. Alongside evidence of the risk of exacerbating food insecurities, there is also research suggesting that educational gaps between children from lower and higher socioeconomic backgrounds often widens during school holiday period (cited in a Lancet comment piece (pdf)[vii]). Although this situation is not exactly comparable to school holidays, a recent report from the National Foundation for Educational Research[viii] reports that, measured on several indicators, disadvantaged children in England are significantly less engaged in remote learning. For example:
- teachers from the most deprived schools report that parental engagement is significantly lower than teachers in the least deprived schools (41 per cent compared to 62 per cent), and
- 93 per cent of school leaders from the most deprived schools have some pupils with limited access to IT at home compared with 73 per cent of school leaders from the least deprived schools.
Disabilities
Glasgow Disability Alliance carried out a survey on the impact of COVID-19 on disabled people and concluded that COVID-19 and the response to it “supercharges existing inequalities”. Drawing on interviews and 1,177 responses to a postal survey to over 5,000 of their members, they report that:
- existing inequalities are being exacerbated: reports that food poverty, isolation and digital exclusion are becoming more intense and more prevalent, and
- the Covid-response has led to key services such as social care, and mental health support services, being removed at a time when they are even more vital to disabled people.
Mental health
According to global research conducted in early May and reported by IPSOS almost 3 in 10 (28%) in the UK say they are suffering from anxiety under lockdown, and this increases to a third among women (34%). A quarter of Britons report concerns about over-eating and under-exercising with women again most likely to be experiencing this. Sixteen per cent of Britons are experiencing insomnia and depression while in lockdown due to the coronavirus outbreak, and over 1 in 10 (13%) say their consumption of alcoholic beverages has increased.
Non-COVID-19 health services
And of course another key indirect effect has been change in the availability, accessibility and uptake of health services in both acute and primary care. For instance in April Dr Gregor Smith, Scotland’s interim Chief Medical Officer, said there had been a 72% reduction in urgent suspected cancer referrals by doctors, with GPs reporting far fewer people than usual coming forward with "symptoms and signs" of cancer. Similarly he said that the number of people seeking help at accident and emergency departments in Scotland's hospitals is also down 54% compared to the weekly average over the last three years (BBC news article).
Going forward
The more we can understand, the more chance we have of managing the crisis in the most equitable way going forward. The approach needs to take account of a wide range of issues as touched on above, including how we ease (and if necessary reinstate) lockdown measures and open shutdown sectors of the economy, how we prioritise the restart of school education and paused health and care services, and how we preserve and support the community and third sector response. As Anderson and colleagues[ix] say, this process should be informed by “principles and methods that consider the complex interplay between socioeconomic status and health disparities”, and suggest a framework based on this to help identify equitable policies to deal with broader effects on health and society.
Understanding how the health and social care system responds to inequalities is part of HIS’s work on health and social care learning. We’re gathering ideas, insights and examples of positive emerging practice.
Sources:
[i] Marmot M, Allen J, Goldblatt P, et al. Fair society, healthy lives. Strategic review of health inequalities in England, 2010.
[ii] Marmot Michael, Bell Ruth. Social determinants and non-communicable diseases: time for integrated action BMJ 2019; 364:l251 http://dx.doi.org/10.1136/bmj.l251
[iii] World Health Organization and Calouste Gulbenkian Foundation. Social determinants of mental health. Geneva, World Health Organization, 2014.
[iv] Noppert GA, Kubale JT, Wilson ML Analyses of infectious disease patterns and drivers largely lack insights from social epidemiology: contemporary patterns and future opportunities. J Epidemiol. Community Health 2017;71:350-355 https://jech-bmj-com.knowledge.idm.oclc.org/content/71/4/350 (paywall) ; PRE-PRINT Inequality in acute respiratory infection outcomes in the United States: A review of the literature and its implications for public health policy and practice. Elizabeth Moran, John Kubale, Grace Noppert, Ryan E Malosh, Jon L Zelner, medRxiv 2020.04.22.20069781; doi: https://doi.org/10.1101/2020.04.22.20069781
[v] OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. The OpenSAFELY Collaborative, Williamson, Walker, Bhaskaran, Bacon, Bates, Morton, Curtis, Mehrkar, Evans, Inglesby, Cockburn, Mcdonald, MacKenna, Tomlinson, Douglas, Rentsch, Mathur, Wong, Grieve, Harrison, Forbes, Schultze, Croker, Parry, Hester, Harper, Perera, Evans, Smeeth, Goldacre, medRxiv 2020.05.06.20092999; doi: https://doi.org/10.1101/2020.05.06.20092999
[vi] Niedzwiedz, C.L., O’Donnell, C.A., Jani, B.D. et al. Ethnic and socioeconomic differences in SARS-CoV-2 infection: prospective cohort study using UK Biobank. BMC Med 18, 160 (2020). https://doi.org/10.1186/s12916-020-01640-8
[vii] COVID-19, School Closures, and Child Poverty: A Social Crisis in the Making” Wim Van Lancker Zachary Parolin, www.thelancet.com/public-health Vol 5 May 2020, PMID: 32275858 PMCID: PMC7141480 DOI: 10.1016/S2468-2667(20)30084-0
[viii] Lucas, M., Nelson, J. and Sims, D. (2020). Schools’ Responses to Covid-19: Pupil Engagement in Remote Learning. Slough: NFER.
[ix] Anderson Geoffrey, Frank John William, Naylor C David, Wodchis Walter, Feng Patrick. Using socioeconomics to counter health disparities arising from the covid-19 pandemic BMJ 2020; 369 :m2149