We’re coming to the end of the COVID-19 Evidence Alert in its current format. Since the first issue in June, we’ve been scanning for evidence on a range of prioritised themes to support the COVID response. As Phase 3 recovery plans within England are being finalised, it seems an opportune time to reflect on the evidence we’ve found so far and how this might inform reset and recovery.
The final three issues offer some brief reflections on the evidence we have scanned along with links to some of the studies which we think offer particularly interesting perspectives. These are organised by the following themes:
We will be updating the trackers as quickly as we can, so each tracker provides a one-stop collection of the evidence we’ve found since June. Our searches are by no means exhaustive so the trackers won’t be comprehensive - but they will provide you with a useful core collection of evidence and insights to inform planning and provide a baseline for future analysis, research and evaluation.
We welcome your feedback. Did we miss any important themes in our approach? How could we improve on our scans and alerts? Please share comments with us via email@example.com.
Analytical Collaboration for COVID-19
As previously described the collaboration is using its expertise to focus on questions that the NHS may lack the immediate resources to look at, which may be more medium-term, cut across sectors, or benefit from independent analysis. We are gradually publishing analytical outputs so keep an eye on these pages for useful findings. You can keep up to date by following @strategy_unit on Twitter.
The evidence base is largely concentrated towards the broader impacts of COVID-19 upon mental health and wellbeing outcomes. The mental health of health and care workers is of particular interest, due to the impact on individuals and the implications for ongoing delivery. A number of studies (both on emerging COVID impacts and on previous epidemics) reported increased stress and disturbances to mood and sleep from exposure to psychological distress 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15. Risk factors are explored with some insight into coping strategies and mitigations 1, 2, 3, 4. One study reports a reluctance to seek support for mental health issues due to stigma 1.
For existing users of mental health services, there are impacts from changes to service delivery 1, 2. Face-to-face contact has been reduced with an increased reliance on virtual consultations. Whilst studies suggest that many users are maintaining contact, there are some reports of difficulties accessing support 1. Service users report deterioration in mood and symptoms 1, 2, 3, 4, 5, 6, 7, 8, 9 and there are concerns of the disproportionate impact of COVID-19 on inequalities 1, 2, 3, 4.
For the general public, evidence suggests increased prevalence of mental health conditions, such as anxiety, arising from fear of infection, stress of lockdown and associated socioeconomic implications 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13. Social isolation and loneliness appear to be prominent risk factors for adverse mental health outcomes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 particularly for children and young people 1, 2, 3, 4, 5, 6, 7, 8 and older adults 1, 2, 3, 4, 5, 6. Lessons from previous epidemics and disasters can offer helpful insights 1, 2, 3. Lessons from SARS suggest a potential increase in death by suicide in older adult populations 1, 2. Some studies also highlight adverse impacts in relation to the wider economic and financial consequences of COVID-19 1, 2, 3, 4. Additional risk factors include bereavement 1, 2, 3, reactions to the inherent uncertainty 1 and misinformation/information overload 1, 2, 3 which may add to stress. From a community perspective, there are studies exploring the impact on wellbeing 1; potential resilience factors 1; and community recovery and resilience in relation to more vulnerable members of society 1, 2.
While most studies focus on a particular aspect of public health impacts, a useful report from July takes a broader perspective 1, providing an overview of lessons learned from previous outbreaks and economic crises as well as a framework for adopting a whole of health approach. Emerging evidence suggests adverse impacts associated with lifestyle changes during lockdown 1, 2, 3, 4. For example, changes in eating habits 1, weight gain 1, sleep patterns 1, physical activity 1, 2, alcohol intake 1, as well as increased stress and anxiety, particularly for children and young people 1, 2, 3, 4. Social isolation, changes to sleep patterns and family relationships are highlighted 1 and there are concerns regarding increased risk of abuse and neglect 1, 2. There is growing awareness of the relationship between COVID and socioeconomic factors 1. Researchers and analysts also reference concerns for vulnerable groups including people with learning disabilities; people who are shielding; children and young people; and marginalised groups 1, 2, 3, 4.
Conversely, improvements in air quality 1, 2 and reduced traffic accidents 1 have been reported, due to restricted travel; however, it is not clear how long these improvements will be sustained.
Long term conditions:
The disruption to service continuity due to the pandemic response has an impact on those people managing long term conditions, due to interrupted treatment, restricted access to services, disrupted transport services and interrupted medication supply 1, 2. Lifestyle changes during lockdown may also contribute to exacerbations or deteriorations 1 (see above section on Public Health for additional references on lifestyle changes).
Socioeconomic factors also play a part, with those people in deprived areas particularly affected. Studies also highlight the negative impact of the pandemic upon the mental health and wellbeing of those with long term conditions such as diabetes 1, 2 asthma 1, 2 arthritis 1 dementia 1 and HIV 1. The stress and anxiety of lockdown and isolation may also affect ability to self-manage.
Analysis from the COVID Analytical Collaboration offers valuable insights to inform recovery planning:
We set out to find out about the impacts of restrictions and subsequent easing, principally on health outcomes and behaviours. Our searches identified evidence on a range of themes:
Lockdown, mental health and psychological wellbeing: The evidence reviewed in our initial scan included lessons from previous epidemics and emerging lessons from countries impacted earlier than the UK 1, 2, 3, 4, 5. The evidence at that point suggested that lockdown restrictions, whilst reducing transmission 1, 2, 3, 4, 5 and mortality 1, 2, 3, have a substantial impact on psychological wellbeing, symptoms of mental ill health (PTSD; depression) and levels of distress 1, 2, 3, 4. It was also noted that lockdown policies may impact certain vulnerable groups more adversely than others (e.g. homelessness or people needing to shield) 1, 2, 3 and could exacerbate existing inequalities 1, 2. Consideration and planning for lifting lockdown restrictions 1 should therefore take into account the potential long-term impact of quarantine on the population and the potential need for support post-lockdown 1, 2, 3, 4. There is also some evidence on public perceptions 1, 2, 3, 4, 5, 6, 7 attitudes and behaviours 1, 2, 3, 4, 5, 6 as well as emerging evidence from existing and new longitudinal studies 1, 2.
Exit strategies: Earlier in the pandemic, available evidence 1, 2, 3, 4, 5, 6, 7 suggested that any relaxation of restrictions (intermittent or gradual) should be accompanied by complementary and comprehensive measures (e.g. large scale testing; contact tracing) to reduce the likelihood of a resurgence in infection rates. Without such measures, subsequent waves of infection are likely. The importance of social and behavioural science 1, 2, 3 and community engagement 1, 2, 3, 4, 5 has been highlighted in the context of encouraging adherence to policy and countering misinformation.
Social and physical distancing – there is some evidence on the effectiveness of distancing 1, 2, 3, 4, 5, 6 including lessons from earlier epidemics 1. One study explores the impact of “superspreader” events 1 and others explore the role of cluster infections 1, 2 in transmission. There has been some discussion in the literature on the origin of the 2m rule 1.
Use of face coverings – earlier on in the pandemic, there was some debate on the effectiveness of face coverings, with disagreements over interpretation of evidence and concerns that advocating their use might restrict access to masks for healthcare professionals or could discourage distancing 1. A counter argument highlights the importance of interdisciplinary evidence and the balance of harms and benefits. A number of reviews supportive of the use of face coverings helped to influence current policy 1, 2 and a recent study has explored policies to encourage uptake 1.
Impact on healthcare system demand: Some studies model the potential impact of lifting restrictions on healthcare system demand 1, 2, 3, 4. Studies from France 1 and Italy 1 suggest that without complementary measures to manage the spread of infection, lifting restrictions totally or intermittently would likely lead to a resurgence in cases, and overwhelming levels of demand on the healthcare system in the long-term (particularly for intensive-care capacity). Please note we have also prepared scans and alerts focused specifically on the impact on non-COVID care – we’ll be summarising this in our next issue of the alert, out on 2nd October.
Impact of schools reopening – there has been significant interest in the impacts of schools, colleges and universities reopening with a number of studies using models to explore potential impacts 1, 2, 3, 4 and other work exploring perspectives 1 and impacts on wider determinants of health 1, 2.
Analysis from the COVID Analytical Collaboration offers useful insights to inform screening and testing strategies:
This alert has formed part of a national evidence update service, provided by the Strategy Unit, as part of a collaboration to provide analytical support to the health and care system to help inform the initial response to COVID-19. Thank you for the very helpful feedback we have received since we published the first issue back in June. We’ll be updating the evidence trackers on our web site to include all the links from the weekly alerts. In response to feedback, we’ll be adding sub-themes to the trackers on rehabilitation needs, impacts on health outcomes, and impacts on non-Covid care, to help you navigate evidence to date.
The Strategy Unit is hosting a 6-week festival of virtual events, called Insight 2020, exploring some of the challenges facing decision-makers in health and care in 2020 and beyond; emerging models of practice to make best use of analysis to inform decision-making; and some of the exciting work that is already happening in this area.
Insight 2020: a festival of analysis and learning for the NHS, Local Government and our partners will run from 28 Sep to 13 Nov 2020. The festival will comprise a mixture of events, workshops and panels, representing conversations at a local, national and international level. For example, our festival launch session includes Ben Goldacre talking about ‘How open approaches can revolutionise health data science in the UK’ and Andi Orlowski on “Dangerous analytics…and how local analysts can save you!”, with Q&A hosted by Professor Mohammed A Mohammed. We will also be running a session on the COVID Evidence Conundrum, featuring a range of perspectives from people who have been involved in generating, using and applying evidence on COVID discussing what this means for how we use evidence to inform decisions.
Who is Insight 2020 for? We’ve collaborated with inspirational people and organisations across the sector to bring together a programme which has something for everyone who is involved with decision-making in health and care.
What will Insight 2020 look like? Sessions will be varied and flexible. People can commit as little or as much time as they’d like, and most of the sessions will be recorded so you can fit them into your schedule in a way that suits you. Every session is free.
Each week will focus on a central theme, starting with a ‘headline’ presentation on the Monday. This will be supported by targeted sessions and the week’s speakers will convene each Friday for an interactive panel discussion and Q&A to respond to the key debates raised during the week. The festival themes are:
Week 1: Our decision-making context in 2020
Week 2: The role of the Midlands Decision Support Network
Week 3: The analytical priorities of the Decision Support Network
Week 4: Building momentum around addressing health inequalities
Week 5: The decision-making toolbox
Week 6: Making the most of our decision-making resources