Feasibility and Acceptability of a Novel Intensive Care Unit Communication Intervention ("Let's Talk") and Initial Assessment Using the Multiple Goals Theory of Communication

Background: Family members of intensive care unit (ICU) patients often report poor communication, feeling unprepared for ICU family meetings, and poor psychological outcomes after decision-making. The objective of this study was to create a tool to prepare families for ICU family meetings and assess feasibility of using Communication Quality Analysis (CQA) to measure communication quality of family meetings. Methods: This observational study was conducted at an academic tertiary care center in Hershey, PA from March 2019 to 2020. Phase 1a involved conceptual design. Phase 1b entailed acceptability testing of 2 versions of the tool (text-only, comic) with 9 family members of non-capacitated ICU patients; thematic analysis of semi-strucutred interviews was conducted. Phase 1c assessed feasibility of applying CQA to audio-recorded ICU family meetings (n = 17); 3 analysts used CQA to assess 6 domains of communication quality. Wilcoxon Signed Rank tests were used to interpret CQA scores. Results: Four themes emerged from Phase 1b interviews: participants 1) found the tool useful for meeting preparation and organizing thoughts, 2) appreciated emotional content, 3) preferred the comic form (67%), and 4) had indifferent or negative perceptions about specific elements. In Phase 1c, clinicians scored higher on the CQA content and engagement domains; family members scored higher on the emotion domain. CQA scores in the relationship and face domains had the lowest quality ratings. Conclusions: Let's Talk may help families become better prepared for ICU family meetings. CQA provides a feasible approach to assessing communication quality that identifies specific areas of strengths and weaknesses in communication.

What Counts as a Surrogate Decision?

When patients lose decision-making capacity, others must make surrogate decisions on their behalf. What counts as a surrogate decision might seem self-evident. But as clinician-researchers in the field of advance care planning, we have found that it is not always so clear-cut. In this paper, we describe how and why this is a matter of concern, a novel approach for assessing whether a surrogate decision occurred, and findings from this assessment.

Best of Graphic Medicine-The 2023 Graphic Medicine International Collective Awards

This Arts and Medicine feature reviews 4 health-related graphic medicine (comic) projects judged as the best of 2022 by the Graphic Medicine International Collective.

Inequalities in children's mental health before and during the COVID-19 pandemic: findings from the UK Household Longitudinal Study

BACKGROUND

There are concerns that child mental health inequalities may have widened during the COVID-19 pandemic. We investigated whether child mental health inequalities changed in 2020/2021 compared with prepandemic.

METHODS

We analysed 16 361 observations from 9272 children in the population representative UK Household Longitudinal Study. Child mental health was measured using the Strengths and Difficulties Questionnaire (SDQ) at ages 5 and 8 years in annual surveys 2011-2019, and at ages 5-11 years in July 2020, September 2020 and March 2021. Inequalities in cross-sectional SDQ scores among 5 and 8 year olds, before and during the pandemic, were modelled using linear regression. Additionally, interactions between time (before/during pandemic) and: sex, ethnicity, family structure, parental education, employment, household income and area deprivation on mental health were explored.

RESULTS

A trend towards poorer mental health between 2011 and 2019 continued during the pandemic (b=0.12, 95% CI 0.08 to 0.17). Children with coupled, highly educated, employed parents and higher household income experienced greater mental health declines during the pandemic than less advantaged groups, leading to narrowed inequalities. For example, the mean difference in child SDQ scores for unemployed compared with employed parents was 2.35 prepandemic (1.72 to 2.98) and 0.02 during the pandemic (-1.10 to 1.13). Worse scores related to male sex and area deprivation were maintained. White children experienced worse mental health than other ethnicities, and greater declines during the pandemic.

CONCLUSION

Mental health among UK 5 and 8 year olds deteriorated during the pandemic, although several inequalities narrowed. Interventions are needed to improve child mental health while ensuring inequalities do not widen.

Associations between SARS-CoV-2 infection and subsequent economic inactivity and employment status: pooled analyses of five linked longitudinal surveys

Introduction

Following the acute phase of the COVID-19 pandemic, record numbers of people became economically inactive (i.e., neither working nor looking for work), or non-employed (including unemployed job seekers and economically inactive people). A possible explanation is people leaving the workforce after contracting COVID-19. We investigated whether testing positive for SARS-CoV-2 is related to subsequent economic inactivity and non-employment, among people employed pre-pandemic.

Methods

The data came from five UK longitudinal population studies held by both the UK Longitudinal Linkage Collaboration (UK LLC; primary analyses) and the UK Data Service (UKDS; secondary analyses). We pooled data from five long established studies (1970 British Cohort Study, English Longitudinal Study of Ageing, 1958 National Child Development Study, Next Steps, and Understanding Society). The study population were aged 25-65 years between March 2020 to March 2021 and employed pre-pandemic. Outcomes were economic inactivity and non-employment measured at the time of the last follow-up survey (November 2020 to March 2021, depending on study). For the UK LLC sample (n=8,174), COVID-19 infection was indicated by a positive SARS-CoV-2 test in NHS England records. For the UKDS sample we used self-reported measures of COVID-19 infection (n=13,881). Logistic regression models estimated odds ratios (ORs) with 95% confidence intervals (95%CIs) adjusting for potential confounders including sociodemographic variables, pre-pandemic health and occupational class.

Results

Testing positive for SARS-CoV-2 was very weakly associated with economic inactivity (OR 1.08 95%CI 0.68-1.73) and non-employment status (OR 1.09. 95%CI 0.77-1.55) in the primary analyses. In secondary analyses, self-reported test-confirmed COVID-19 was not associated with either economic inactivity (OR 1.01 95%CI 0.70-1.44) or non-employment status (OR 1.03 95%CI 0.79-1.35).

Conclusions

Among people employed pre-pandemic, testing positive for SARS-CoV-2 was either weakly or not associated with increased economic inactivity or non-employment. Research on the recent increases in economic inactivity should focus on other potential causes.

Living alone and mental health: parallel analyses in UK longitudinal population surveys and electronic health records prior to and during the COVID-19 pandemic

BACKGROUND

People who live alone experience greater levels of mental illness; however, it is unclear whether the COVID-19 pandemic had a disproportionately negative impact on this demographic.

OBJECTIVE

To describe the mental health gap between those who live alone and with others in the UK prior to and during the COVID-19 pandemic.

METHODS

Self-reported psychological distress and life satisfaction in 10 prospective longitudinal population surveys (LPSs) assessed in the nearest pre-pandemic sweep and three periods during the pandemic. Recorded diagnosis of common and severe mental illnesses between March 2018 and January 2022 in electronic healthcare records (EHRs) within the OpenSAFELY-TPP.

FINDINGS

In 37 544 LPS participants, pooled models showed greater psychological distress (standardised mean difference (SMD): 0.09 (95% CI: 0.04; 0.14); relative risk: 1.25 (95% CI: 1.12; 1.39)) and lower life satisfaction (SMD: -0.22 (95% CI: -0.30; -0.15)) for those living alone pre-pandemic. This gap did not change during the pandemic. In the EHR analysis of c.16 million records, mental health conditions were more common in those who lived alone (eg, depression 26 (95% CI: 18 to 33) and severe mental illness 58 (95% CI: 54 to 62) more cases more per 100 000). For common mental health disorders, the gap in recorded cases in EHRs narrowed during the pandemic.

CONCLUSIONS

People living alone have poorer mental health and lower life satisfaction. During the pandemic, this gap in self-reported distress remained; however, there was a narrowing of the gap in service use.

CLINICAL IMPLICATIONS

Greater mental health need and potentially greater barriers to mental healthcare access for those who live alone need to be considered in healthcare planning.

Understanding inequalities in mental health by family structure during COVID-19 lockdowns: evidence from the UK Household Longitudinal Study

PURPOSE

The COVID-19 pandemic increased psychiatric distress and impacts differed by family structure. We aimed to identify mechanisms contributing to these inequalities.

METHODS

Survey data were from the UK Household Longitudinal Study. Psychiatric distress (GHQ-12) was measured in April 2020 (first UK lockdown; n = 10,516), and January 2021 (lockdown re-introduced following eased restrictions; n = 6,893). Pre-lockdown family structure comprised partner status and presence of children (< 16 years). Mediating mechanisms included: active employment, financial strain, childcare/home-schooling, caring, and loneliness. Monte Carlo g-computation simulations were used to adjust for confounding and estimate total effects and decompositions into: controlled direct effects (effects if the mediator was absent), and portions eliminated (PE; representing differential exposure and vulnerability to the mediator).

RESULTS

In January 2021, after adjustment, we estimated increased risk of distress among couples with children compared to couples with no children (RR: 1.48; 95% CI 1.15-1.82), largely because of childcare/home-schooling (PE RR: 1.32; 95% CI 1.00-1.64). Single respondents without children also had increased risk of distress compared to couples with no children (RR: 1.55; 95% CI 1.27-1.83), and the largest PE was for loneliness (RR: 1.16; 95% CI 1.05-1.27), though financial strain contributed (RR: 1.05; 95% CI 0.99-1.12). Single parents demonstrated the highest levels of distress, but confounder adjustment suggested uncertain effects with wide confidence intervals. Findings were similar in April 2020 and when stratified by sex.

CONCLUSION

Access to childcare/schooling, financial security and social connection are important mechanisms that need addressing to avoid widening mental health inequalities during public health crises.

Communicating without words: Measuring nonverbal communication between veterinarians and farmers during routine herd health consultations

Uptake of advice and the ability to facilitate change on-farm are key elements for successful veterinary practice. However, having the necessary clinical skills and knowledge is not enough to achieve this: effective communication skills are essential for veterinarians to realize their advisory role by exploring and understanding the farmer's worldview. Research of verbal aspects of veterinarian communication supports the use of a relationship-centered communication style; we next need to study how veterinarian-farmer nonverbal communication (NVC) can influence interactions and their outcomes, which has been examined in medical and companion animal practice. In this study, we considered which aspects of NVC should be measured, and how, to provide an essential first step toward understanding the significance of NVC for veterinarians working in dairy practice, which should be of interest to researchers, veterinary educators, and practitioners. Eleven video recordings of routine consultations in the UK were analyzed for farmer and veterinarian NVC. The NVC attributes with established links to positive patient and client outcomes from medical and social science studies were chosen, and a methodology developed for their measurement, by adapting measures typically used in NVC research. Each consultation was segmented into intervals defined by the main activity and location on farm: introduction, fertility examination, discussion, and closing. This approach allowed us to analyze the content more consistently, establish which aspects of NVC featured within each interval, and whether the activity and location influenced the observed NVC. We measured 12 NVC attributes, including body orientation, interpersonal distance, head position, and body lean, which have been shown to influence empathy, rapport, and trust: key components of relationship-centered communication. Future research should seek to establish the significance of NVC in effective communication between veterinarian and farmer, building on our findings that show it is possible to measure nonverbal attributes. Veterinarians may benefit from becoming skilled nonverbal communicators and have more effective conversations during routine consultations, motivating farmers to make changes and improve herd health.

Home working and social and mental wellbeing at different stages of the COVID-19 pandemic in the UK: Evidence from 7 longitudinal population surveys

BACKGROUND

Home working has increased since the Coronavirus Disease 2019 (COVID-19) pandemic's onset with concerns that it may have adverse health implications. We assessed the association between home working and social and mental wellbeing among the employed population aged 16 to 66 through harmonised analyses of 7 UK longitudinal studies.

METHODS AND FINDINGS

We estimated associations between home working and measures of psychological distress, low life satisfaction, poor self-rated health, low social contact, and loneliness across 3 different stages of the pandemic (T1 = April to June 2020 -first lockdown, T2 = July to October 2020 -eased restrictions, T3 = November 2020 to March 2021 -second lockdown) using modified Poisson regression and meta-analyses to pool results across studies. We successively adjusted the model for sociodemographic characteristics (e.g., age, sex), job characteristics (e.g., sector of activity, pre-pandemic home working propensities), and pre-pandemic health. Among respectively 10,367, 11,585, and 12,179 participants at T1, T2, and T3, we found higher rates of home working at T1 and T3 compared with T2, reflecting lockdown periods. Home working was not associated with psychological distress at T1 (RR = 0.92, 95% CI = 0.79 to 1.08) or T2 (RR = 0.99, 95% CI = 0.88 to 1.11), but a detrimental association was found with psychological distress at T3 (RR = 1.17, 95% CI = 1.05 to 1.30). Study limitations include the fact that pre-pandemic home working propensities were derived from external sources, no information was collected on home working dosage and possible reverse association between change in wellbeing and home working likelihood.

CONCLUSIONS

No clear evidence of an association between home working and mental wellbeing was found, apart from greater risk of psychological distress during the second lockdown, but differences across subgroups (e.g., by sex or level of education) may exist. Longer term shifts to home working might not have adverse impacts on population wellbeing in the absence of pandemic restrictions but further monitoring of health inequalities is required.

Political views and organizational distrust affect rural residents’ willingness to share personal data for COVID-19 contact tracing: A cross-sectional survey study

Background

We aimed to examine the attitudes of Pennsylvania rural residents toward data sharing in the setting of the COVID-19 pandemic. Specifically, we were interested in better understanding their willingness to provide personal information for contact tracing to public health staff investigating COVID-19 cases, as well as their concerns. We used a validated scale to describe the influence of distrust of healthcare organizations on their attitudes.

Methods

We mailed 4000 surveys to rural residents identified from the electronic medical record of a healthcare system in central Pennsylvania. Data were entered into a REDCap database and analyzed using descriptive summaries, and both binomial and multivariable logistic regression.

Results

Binomial logistic regression showed that both distrust in healthcare organizations and political values influence respondents' willingness to share information with contact tracers as well as their concerns about sharing personal data. When our multivariable model was applied, political values remained and were consistently associated with willingness to share and concerns about sharing their data.

Conclusion

This study is a first step in eliciting rural residents' willingness to share personal data for contact tracing by public health officials. Understanding and addressing rural residents' willingness to share personal data and their concerns about sharing those data will help public health officials identify effective strategies for managing COVID-19 and future pandemics in rural communities. By involving community members at the ground level, public health staff can ensure residents' buy-in for the need to collect their personal data, thereby helping to mitigate the public health crises.

Graphic medicine meets human anatomy: The potential role of comics in raising whole body donation awareness in Italy and beyond. A pilot study

Cadaver dissection has always played a fundamental role in medical education. However, especially in Italy, the topic of body donation has remained partially unknown for years. The current study analyses graphic medicine as a new possible communication tool, evaluating and reflecting, with second-year students enrolled in the International School of Medicine and Surgery at the University of Bologna, about its potentialities for body donation awareness-raising in both the scientific community and the general population. For the first time in an Italian University, two graphic medicine workshops were organized focusing on human anatomy and body donation. Seminars were positively evaluated by students using a four items Likert-scale question: mean 3.54 (± SD 0.73) for the Likert question about the experiences of the workshops; 3.88 (± 0.33) for the Likert question regarding the use of graphic medicine in body donation awareness campaigns among the general population; 3.59 (± 0.65) for the Likert question regarding the use of graphic medicine in body donation awareness campaigns among the scientific community. Furthermore, the open-ended questions included in the anonymous questionnaire were analyzed using the constructivist grounded qualitative analysis, whence various themes emerged. Finally, five graphic medicine projects about body donation were created by students, proving their interest in testing this method to promote body donation, focusing the attention on different communicative aspects. Considering the results of this pilot study, the co-creative collaborative use of graphic medicine could be evaluated as an additional strategy to increase body donation awareness-raising in Italy and beyond, especially in the non-experts' community.

The Value of Advance Care Planning for Spokespersons of Patients With Advanced Illness

CONTEXT

Advance Care Planning (ACP) has fallen under scrutiny primarily because research has not consistently demonstrated patient-focused benefits.

OBJECTIVES

To better understand how spokespersons regard, engage with, and find value in ACP during decision-making for their loved ones.

METHODS

This qualitative analysis was part of a randomized controlled trial involving spokespersons of patients with advanced illness who had completed ACP. After making a medical decision on behalf of their loved one (or that loved one's death), semi-structured interviews explored spokespersons' experience of decision-making and if (and how) ACP played a role. Thematic analysis was conducted on interview transcripts.

RESULTS

From 120 interviews, five themes emerged: 1) Written advance directives (ADs) helped increase spokespersons' confidence that decisions were aligned with patient wishes (serving as a physical reminder of previous discussions and increasing clarity during decision-making and family conflict); 2) Iterative discussions involving ACP facilitated "In the moment" decision-making; 3) ADs and ACP conversations helped spokespersons feel more prepared for future decisions; 4) Spokespersons sometimes felt there was "no choice" regarding their loved one's medical care; and 5) Regrets and second-guessing were the most common negative emotions experienced by spokespersons.

CONCLUSION

Considering the recent debate about the utility of ACP and ADs, this analysis highlights the value of ACP for spokespersons involved in surrogate decision-making. Reframing the goals of ACP in terms of their benefit for spokespersons (and identifying appropriate outcome measures) may provide additional perspective on the utility of ACP.

Graphic Medicine-The Best of 2022

This Arts and Medicine feature reviews 2 books published in 2022: a clinical ethics graphic medicine casebook illustrating how ethical dilemmas in clinical practice play out in real situations; and a graphic public health comics anthology showing how comics meet the needs of risk communication and health promotion.

Conceptualization of Surrogate Decision-making Among Spokespersons for Chronically Ill Patients

IMPORTANCE

The value of advance care planning (ACP) has been the subject of recent debate because of mixed findings. This may be, in part, because trials presume that researchers and patient spokespersons share the same understanding of the role of a surrogate decision-maker. We explored how patient surrogates conceptualized and defined surrogate decision-making vs patient advocacy. Understanding how surrogates perceive their role in decision-making is important to avoid misinterpreting the effectiveness of ACP interventions.

OBJECTIVE

To understand how patient spokespersons distinguish surrogate decision-making from patient advocacy.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative thematic analysis of a subsample of participants from a randomized clinical trial at a tertiary medical center was conducted from September 27, 2012, to June 30, 2021. Participants (n = 36) were the designated spokespersons of adult patients with severe illness who had made a surrogate decision on behalf of the patient since the last follow-up. Analysis was performed from March 21, 2021, to February 7, 2022.

MAIN OUTCOMES AND MEASURES

Semistructured interviews examined how patient spokespersons conceptualize differences between surrogate decision-making and advocacy.

RESULTS

The study included 36 patient spokespersons (32 women [88.9%]; mean [SD] age, 62.1 [11.8] years) and found substantial variability in how the spokespersons conceptualized what it means to make a surrogate decision for another. A total of 10 spokespersons (27.8%) did not distinguish surrogate decision-making from advocacy. There were 5 definitions for both surrogate decision-making and advocacy. The 3 most common definitions of surrogate decision-making were (1) acting as the final decision-maker (18 [50.0%]), (2) doing what is best for the patient (8 [22.2%]), and (3) making decisions on behalf of patients so that their wishes are respected (6 [16.7%]). The 3 most common definitions of advocacy were (1) doing what is best for the patient (8 [22.2%]), (2) respecting patients' wishes (6 [16.7%]), and (3) providing support to the patient (6 [16.7%]). The most common pairing of definitions by an individual spokesperson involved defining surrogate decision-making as being the final decision-maker, and defining advocacy as acting in the best interest of the patient (6 [16.7%]).

CONCLUSIONS AND RELEVANCE

This qualitative study found that many spokespersons perceive their roles as surrogate decision-makers differently than clinicians and researchers likely do, often conflating surrogacy with advocacy. These findings may help explain why researchers have found that ACP does not consistently improve traditional outcomes. If spokespersons do not distinguish surrogate decision-making from advocacy, then what is being reported by spokespersons and measured by clinicians and researchers may not accurately reflect the true association of ACP with outcomes.

Psychological distress, depression, anxiety, and life satisfaction following COVID-19 infection: evidence from 11 UK longitudinal population studies

BACKGROUND

Evidence on associations between COVID-19 illness and mental health is mixed. We aimed to examine whether COVID-19 is associated with deterioration in mental health while considering pre-pandemic mental health, time since infection, subgroup differences, and confirmation of infection via self-reported test and serology data.

METHODS

We obtained data from 11 UK longitudinal studies with repeated measures of mental health (psychological distress, depression, anxiety, and life satisfaction; mental health scales were standardised within each study across time) and COVID-19 status between April, 2020, and April, 2021. We included participants with information available on at least one mental health outcome measure and self-reported COVID-19 status (suspected or test-confirmed) during the pandemic, and a subset with serology-confirmed COVID-19. Furthermore, only participants who had available data on a minimum set of covariates, including age, sex, and pre-pandemic mental health were included. We investigated associations between having ever had COVID-19 and mental health outcomes using generalised estimating equations. We examined whether associations varied by age, sex, ethnicity, education, and pre-pandemic mental health, whether the strength of the association varied according to time since infection, and whether associations differed between self-reported versus confirmed (by test or serology) infection.

FINDINGS

Between 21 Dec, 2021, and July 11, 2022, we analysed data from 54 442 participants (ranging from a minimum age of 16 years in one study to a maximum category of 90 years and older in another; including 33 200 [61·0%] women and 21 242 [39·0%] men) from 11 longitudinal UK studies. Of 40 819 participants with available ethnicity data, 36 802 (90·2%) were White. Pooled estimates of standardised differences in outcomes suggested associations between COVID-19 and subsequent psychological distress (0·10 [95% CI 0·06 to 0·13], I²=42·8%), depression (0·08 [0·05 to 0·10], I²=20·8%), anxiety (0·08 [0·05 to 0·10], I²=0·0%), and lower life satisfaction (-0·06 [-0·08 to -0·04], I²=29·2%). We found no evidence of interactions between COVID-19 and sex, education, ethnicity, or pre-pandemic mental health. Associations did not vary substantially between time since infection of less than 4 weeks, 4-12 weeks, and more than 12 weeks, and were present in all age groups, with some evidence of stronger effects in those aged 50 years and older. Participants who self-reported COVID-19 but had negative serology had worse mental health outcomes for all measures than those without COVID-19 based on serology and self-report. Participants who had positive serology but did not self-report COVID-19 did not show association with mental health outcomes.

INTERPRETATION

Self-reporting COVID-19 was longitudinally associated with deterioration in mental health and life satisfaction. Our findings emphasise the need for greater post-infection mental health service provision, given the substantial prevalence of COVID-19 in the UK and worldwide.

FUNDING

UK Medical Research Council and UK National Institute for Health and Care Research.

Inequalities in psychological distress before and during the COVID-19 pandemic among UK adults

Background

Evidence about how population mental health has evolved from before and over the COVID-19 pandemic remains mixed, with impacts on mental health inequalities being unclear. We investigated changes in mental health and sociodemographic inequalities from before and across the first year of the pandemic.

Methods

Data from 11 UK longitudinal population-based studies with pre-pandemic measures of psychological distress were analysed, estimates pooled, and stratified by age, sex, ethnicity, country and lone household status. Trends in the prevalence of poor mental health were assessed before the pandemic (TP0) and across the pandemic at three time periods (initial lockdown (TP1), easing of restrictions (TP2), and a subsequent lockdown (TP3)).

Results

In total, 49,993 adult participants were analysed across the 11 cohort studies. There was an overall worsening in mental health from pre-pandemic scores across all three pandemic timepoints, (TP1 Standardised Mean Difference: 0.15 (95% CI: 0.06 - 0.25); TP2 SMD: 0.18 (0.09 - 0.27); TP3 SMD: 0.21 (0.10 - 0.32)) with no evidence of improvement during the period of eased lockdown restrictions in summer 2020. Changes from pre-pandemic psychological distress were higher in females during the pandemic (TP3 SMD: 0.23 (0.11 - 0.35)), amongst those with degree-level education (TP3 SMD: 0.26 (0.14 - 0.38)), and adults aged 25-44 years. We did not find evidence of changes in distress differing by ethnicity, lone household status or UK nation.

Conclusions

The substantial deterioration in mental health seen in the UK during the first lockdown did not reverse when lockdown lifted and a sustained worsening was observed across the pandemic. Mental health declines have been unequal across the population and these results have implications for policy, including the need for specific investment for support for those most affected to mitigate the effects of the pandemic and measures to reduce inequalities within these specific groups.

Key messages

• A sustained deterioration in mental health was observed from before the start of the COVID-19 pandemic, and did not recover when social restrictions were eased.

• Deterioration in mental health varied by sociodemographic factors, namely age, sex, and education, and highlights a need for improved mental health care provision to minimise widening inequalities.

Intrinsic Traits Such as Personality and Decision-Making Style are Predictive of Stress in Surrogate Decision-Makers

Introduction: Despite its prominence in psychology, little is known about how personality traits play a role in the stress experiences of surrogate decision-makers. We tested the hypothesis that intrinsic traits (personality and decision-making styles) would be related to surrogates' stress in order to learn whether screening or tailoring interventions based on personality traits could help support surrogate decision-makers. Methods: This pre-specified secondary analysis evaluated data from an interventional study with dyads of patients with advanced chronic illness and their spokespersons. Measures included stress after decision-making or patient death (Impact of Events-Revised), personality (Big Five Index; BFI) and decision-making style (maximization and regret scales). Multivariate linear regressions explored the impact of personality on the stress experience; linear regressions independently modeled the impact of maximization and regret on the stress experience. Results: Of 38 spokespersons, 89.5% were women, 97.4% non-Hispanic, and 29.0% had a college degree or higher. In univariate analyses, total stress was correlated with neuroticism (r = .56, P < .01), higher scores on the regret (r = .55, P < .01) and maximization (r = .48, P < .05). In adjusted models, BFI was significantly associated with total stress (R² = 27.08, P = .02). However, only neuroticism was independently associated with total stress. Conclusions: Personality traits, particularly neuroticism, and decision-making styles predicted heightened stress in spokespersons of patients with advanced chronic illness. If ACP interventions are intended to reduce spokesperson stress, personality and decision-making style scales may help identify spokespersons most likely to benefit from ACP interventions.

Inequalities in healthcare disruptions during the COVID-19 pandemic: evidence from 12 UK population-based longitudinal studies

OBJECTIVES

We investigated associations between multiple sociodemographic characteristics (sex, age, occupational social class, education and ethnicity) and self-reported healthcare disruptions during the early stages of the COVID-19 pandemic.

DESIGN

Coordinated analysis of prospective population surveys.

SETTING

Community-dwelling participants in the UK between April 2020 and January 2021.

PARTICIPANTS

Over 68 000 participants from 12 longitudinal studies.

OUTCOMES

Self-reported healthcare disruption to medication access, procedures and appointments.

RESULTS

Prevalence of healthcare disruption varied substantially across studies: between 6% and 32% reported any disruption, with 1%-10% experiencing disruptions in medication, 1%-17% experiencing disruption in procedures and 4%-28% experiencing disruption in clinical appointments. Females (OR 1.27; 95% CI 1.15 to 1.40; I²=54%), older persons (eg, OR 1.39; 95% CI 1.13 to 1.72; I²=77% for 65-75 years vs 45-54 years) and ethnic minorities (excluding white minorities) (OR 1.19; 95% CI 1.05 to 1.35; I²=0% vs white) were more likely to report healthcare disruptions. Those in a more disadvantaged social class were also more likely to report healthcare disruptions (eg, OR 1.17; 95% CI 1.08 to 1.27; I²=0% for manual/routine vs managerial/professional), but no clear differences were observed by education. We did not find evidence that these associations differed by shielding status.

CONCLUSIONS

Healthcare disruptions during the COVID-19 pandemic could contribute to the maintenance or widening of existing health inequalities.

Comparing two advance care planning conversation activities to motivate advance directive completion in underserved communities across the USA: The Project Talk Trial study protocol for a cluster, randomized controlled trial

BACKGROUND

Advance care planning (ACP) is a process involving conversations between patients, loved ones, and healthcare providers that consider patient preferences for the types of medical therapies received at the end of life. Underserved populations, including Black, Hispanic, rural, and low-income communities are less likely to engage in ACP than other communities, a health inequity that results in lower-quality care and reduced hospice utilization. The purpose of this trial is to compare efficacy of two interventions intended to motivate ACP (particularly advance directive completion) for those living in underserved communities.

METHODS

This 3-armed cluster, randomized controlled mixed methods design is being conducted in 75 community venues in underserved communities across the USA. The goal of the trial is to compare the efficacy of two interventions at motivating ACP. Arm 1 uses an end-of-life conversation game (Hello); Arm 2 uses a nationally utilized workshop format for ACP conversations (The Conversation Project); and Arm 3 uses an attention control game (TableTopics). Events are held in partnership with 75 local community-based host organizations and will involve 1500 participants (n=20 per event). The primary outcome is completion of a visually verified advance directive at 6 months post-event. Primary analyses compare efficacy of each intervention to each other and the control arm. Secondary mixed methods outcomes include (a) other ACP behaviors and engagement; (b) communication quality; (c) impact of sociocultural environment on ACP (via qualitative interviews); and (d) implementation and sustainability. Subgroup analyses examine outcomes for Black, Hispanic, and rural groups in particular.

DISCUSSION

This trial will add to the evidence base behind various conversational ACP interventions, examine potential mechanisms of action for such interventions, and provide qualitative data to better understand the sociocultural environment of how community-based ACP interventions are experienced by underserved populations. Results will also provide important data for future researchers to learn whether visual verification of advance directives is necessary or whether reliance on self-reported outcomes is of comparable value. Data from this study will inform ways to effectively motivate underserved communities to participate in advance care planning.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04612738. Registered on October 12, 2020. All information from the WHO Trial Registration Data Set can be found within the protocol.

The UK Coronavirus Job Retention Scheme and smoking, alcohol consumption and vaping during the COVID-19 pandemic: evidence from eight longitudinal population surveys

BACKGROUND

Employment disruptions can impact smoking and alcohol consumption. During the COVID-19 pandemic, many countries implemented furlough schemes to prevent job loss. We examine how furlough was associated with smoking, vaping and alcohol consumption in the UK.

METHODS

Data from 27,841 participants in eight UK adult longitudinal surveys were analysed. Participants self-reported employment status and current smoking, current vaping and alcohol consumption (>4 days/week or 5+ drinks per typical occasion) both before and during the early stages of the pandemic (April-July 2020). Risk ratios were estimated within each study using modified Poisson regression, adjusting for a range of potential confounders, including pre-pandemic behaviour. Findings were synthesised using random effects meta-analysis.

RESULTS

Compared to stable employment and after adjustment for pre-pandemic characteristics, furlough was not associated with smoking (ARR = 1.05; 95% CI: 0.95-1.16; I²: 10%), vaping (ARR = 0.89; 95% CI: 0.74-1.08; I²: 0%) or drinking (ARR = 1.03; 95% CI: 0.94-1.13; I²: 48%). There were similar findings for no longer being employed, and stable unemployment, though this varied by sex: stable unemployment was associated with smoking for women (ARR = 1.35; 95% CI: 1.00-1.82; I²: 47%) but not men (0.84; 95% CI: 0.67-1.05; I²: 0%). No longer being employed was associated with vaping among women (ARR = 2.74; 95% CI: 1.59-4.72; I²: 0%) but not men (ARR = 1.25; 95% CI: 0.83-1.87; I²: 0%).

CONCLUSIONS

We found no clear evidence of furlough or unemployment having adverse impacts on smoking, vaping or drinking behaviours during the early stages of the COVID-19 pandemic in the UK. Differences in risk compared to those who remained employed were largely explained by pre-pandemic characteristics.

Mental and social wellbeing and the UK coronavirus job retention scheme: Evidence from nine longitudinal studies

BACKGROUND

The COVID-19 pandemic has led to major economic disruptions. In March 2020, the UK implemented the Coronavirus Job Retention Scheme - known as furlough - to minimize the impact of job losses. We investigate associations between change in employment status and mental and social wellbeing during the early stages of the pandemic.

METHODS

Data were from 25,670 respondents, aged 17-66, across nine UK longitudinal studies. Furlough and other employment changes were defined using employment status pre-pandemic and during the first lockdown (April-June 2020). Mental and social wellbeing outcomes included psychological distress, life satisfaction, self-rated health, social contact, and loneliness. Study-specific modified Poisson regression estimates, adjusting for socio-demographic characteristics and pre-pandemic mental and social wellbeing, were pooled using meta-analysis. Associations were also stratified by sex, age, education, and household composition.

RESULTS

Compared to those who remained working, furloughed workers were at greater risk of psychological distress (adjusted risk ratio, ARR = 1.12; 95%CI: 0.97, 1.29), low life satisfaction (ARR = 1.14; 95%CI: 1.07, 1.22), loneliness (ARR = 1.12; 95%CI: 1.01, 1.23), and poor self-rated health (ARR = 1.26; 95%CI: 1.05, 1.50). Nevertheless, compared to furloughed workers, those who became unemployed had greater risk of psychological distress (ARR = 1.30; 95%CI: 1.12, 1.52), low life satisfaction (ARR = 1.16; 95%CI: 0.98, 1.38), and loneliness (ARR = 1.67; 95%CI: 1.08, 2.59). Effects were not uniform across all sub-groups.

CONCLUSIONS

During the early stages of the pandemic, those furloughed had increased risk of poor mental and social wellbeing, but furloughed workers fared better than those who became unemployed, suggesting that furlough may have partly mitigated poorer outcomes.

Association between home working and mental health by key worker status during the Covid-19 pandemic. Evidence from four British longitudinal studies

Little is known about the relationship between homeworking and mental health during the Covid-19 pandemic and how it might differ by keyworker status. To understand this relationship, we use longitudinal data collected over three time points during the pandemic from three British cohort studies born in 1958 (National Child Development Study), 1970 (British Cohort Study) and 1989-90 (Next Step) as well as from a population-based study stratified by four age groups (Understanding Society). We estimate the association between life satisfaction, anxiety, depression, and psychological distress and homeworking by key worker status using mixed effects models with maximum likelihood estimation to account for repeated measurements across the pandemic, allowing intercepts to vary across individuals after controlling for a set of covariates including pre-pandemic home working propensities and loneliness. Results show that key workers working from home showed the greatest decline in mental health outcomes relative to other groups. Pre-pandemic homeworking did not significantly change the nature of such a relationship and loneliness slightly attenuated some of the effects. Finally, mental health outcomes varied across age-groups and time points. The discussion emphasises the need to pay attention to key workers when assessing the relationship between mental health and homeworking.

Communication Quality Analysis: A user-friendly observational measure of patient-clinician communication

Communication Quality Analysis (CQA) is a rigorous transcript-based coding method for assessing clinical communication quality. We compared the resource-intensive transcript-based version with a streamlined real-time version of the method with respect to feasibility, validity, reliability, and association with traditional measures of communication quality. Simulated conversations between 108 trainees and 12 standardized patients were assessed by 7 coders using the two versions of CQA (transcript and real-time). Participants also completed two traditional communication quality assessment measures. Real-time CQA was feasible and yielded fair to excellent reliability, with some caveats that can be addressed in future work. CQA ratings were moderately correlated with traditional measures of communication quality, suggesting that CQA captures different aspects of communication quality than do traditional measures. Finally, CQA did not exhibit the ceiling effects observed in the traditional measures of communication quality. We conclude that real-time CQA is a user-friendly method for assessing communication quality that has the potential for broad application in training, research, and intervention contexts and may offer improvements to traditional, self-rated communication measures.

Amoebic crab disease (ACD) in edible crab Cancer pagurus from the English Channel, UK

The genera Paramoeba and Neoparamoeba (Amoebozoa, Dactylopodida, Paramoebidae) include well-known opportunistic pathogens associated with fish (N. peruans; amoebic gill disease), lobsters, molluscs and sea urchins, but only rarely with crabs (grey crab disease of blue crabs). Following reports of elevated post-capture mortality in edible crabs Cancer pagurus captured from a site within the English Channel fishery in the UK, a novel disease (amoebic crab disease, ACD) was detected in significant proportions of the catch. We present histopathological, transmission electron microscopy and molecular phylogenetic data, showing that this disease is defined by colonization of haemolymph, connective tissues and fixed phagocytes by amoeboid cells, leading to tissue destruction and presumably death in severely diseased hosts. The pathology was strongly associated with a novel amoeba with a phylogenetic position on 18S rRNA gene trees robustly sister to Janickina pigmentifera (which groups within the current circumscription of Paramoeba/Neoparamoeba), herein described as Janickina feisti n. sp. We provide evidence that J. feisti is associated with ACD in 50% of C. pagurus sampled from the mortality event. A diversity of other paramoebid sequence types, clustering with known radiations of N. pemaquidensis and N. aestuarina and a novel N. aestuarina sequence type, was detected by PCR in most of the crabs investigated, but their detection was much less strongly associated with clinical signs of disease. The discovery of ACD in edible crabs from the UK is discussed relative to published historical health surveys for this species.

Effects of routine treatment with nonsteroidal anti-inflammatory drugs at calving and when lame on the future probability of lameness and culling in dairy cows: A randomized controlled trial

Claw horn lesions (CHL) are reported as the most common cause of lameness in intensive dairy systems. Despite their prevalence, the underlying pathological mechanisms and preventive strategies for CHL remain poorly understood. Recent advances have pointed to the role of inflammation in disease aetiopathogenesis. Moderating inflammation from first calving may lead to long-term benefits and a viable intervention for treating and preventing disease. We conducted a 34-mo randomized controlled trial to investigate the effects of routine treatment with the nonsteroidal anti-inflammatory drug ketoprofen at calving and during treatment for lameness, on the future probability of lameness and culling, caused by exposure to normal farm conditions. A cohort of dairy heifers were recruited from a single, commercial dairy herd between January 8, 2018, and June 22, 2020, and randomly allocated to one of 4 treatment groups before first calving. The lactating herd was lameness scored every 2 wk on a 0 to 3 scale, to identify animals that became lame (single score ≥2a) and hence required treatment. Animals in group 1 received a therapeutic trim and a hoof block on the sound claw (if deemed necessary) every time they were treated for lameness. Animals in group 2 received the same treatment as group 1 with the addition of a 3-d course of ketoprofen (single dose daily) every time they were treated for lameness. Animals in group 3 received the same treatment as group 2 with the addition of a 3-d course of ketoprofen (single dose daily) starting 24 to 36 h after each calving. Animals in group 4 received a 3-d course of ketoprofen (single dose daily) every time they were identified with lameness. No therapeutic trim was administered to this group, unless they were identified as severely lame (a single score ≥3a). Animals were followed for the duration of the study (ending October 23, 2020). Probability of lameness was assessed by a lameness outcome score collected every 14 d. Data on culling was extracted from farm records. One hundred thirty-two animals were recruited to each group, with data from 438 animals included in the final analysis (111 in group 1, 117 in group 2, 100 in group 3, and 110 in group 4). Mixed effect logistic regression models were used to evaluate the effect of treatment group on the ongoing probability of lameness. Compared with the control group (group 1), animals in group 3 were less likely to become lame (odds ratio: 0.66) and severely lame (odds ratio: 0.28). A Cox proportional hazards survival model was used to investigate the effect of treatment group on time to culling. Compared with group 1, animals in groups 2 and 3 were at reduced risk of culling (hazard ratios: 0.55 and 0.56, respectively). The lameness effect size we identified was large and indicated that treating a cohort of animals with the group 3 protocol, would lead to an absolute reduction in population lameness prevalence of approximately 10% and severe lameness prevalence of 3%, compared with animals treated in accordance with conventional best practice (group 1).

Long COVID burden and risk factors in 10 UK longitudinal studies and electronic health records

The frequency of, and risk factors for, long COVID are unclear among community-based individuals with a history of COVID-19. To elucidate the burden and possible causes of long COVID in the community, we coordinated analyses of survey data from 6907 individuals with self-reported COVID-19 from 10 UK longitudinal study (LS) samples and 1.1 million individuals with COVID-19 diagnostic codes in electronic healthcare records (EHR) collected by spring 2021. Proportions of presumed COVID-19 cases in LS reporting any symptoms for 12+ weeks ranged from 7.8% and 17% (with 1.2 to 4.8% reporting debilitating symptoms). Increasing age, female sex, white ethnicity, poor pre-pandemic general and mental health, overweight/obesity, and asthma were associated with prolonged symptoms in both LS and EHR data, but findings for other factors, such as cardio-metabolic parameters, were inconclusive.

The UK Coronavirus Job Retention Scheme and diet, physical activity, and sleep during the COVID-19 pandemic: evidence from eight longitudinal population surveys

BACKGROUND

In March 2020, the UK implemented the Coronavirus Job Retention Scheme (furlough) to minimise job losses. Our aim was to investigate associations between furlough and diet, physical activity, and sleep during the early stages of the COVID-19 pandemic.

METHODS

We analysed data on 25,092 participants aged 16-66 years from eight UK longitudinal studies. Changes in employment, including being furloughed, were based on employment status before and during the first lockdown. Health behaviours included fruit and vegetable consumption, physical activity, and sleep. Study-specific estimates obtained using modified Poisson regression, adjusting for socio-demographic characteristics and pre-pandemic health and health behaviours, were statistically pooled using random effects meta-analysis. Associations were also stratified by sex, age, and education.

RESULTS

Across studies, between 8 and 25% of participants were furloughed. Compared to those who remained working, furloughed workers were slightly less likely to be physically inactive (RR = 0.85; [95% CI 0.75-0.97]; I ² = 59%) and did not differ overall with respect to low fruit and vegetable consumption or atypical sleep, although findings for sleep were heterogenous (I ² = 85%). In stratified analyses, furlough was associated with lower fruit and vegetable consumption among males (RR = 1.11; [1.01-1.22]; I ² = 0%) but not females (RR = 0.84; [0.68-1.04]; I ² = 65%). Considering changes in quantity, furloughed workers were more likely than those who remained working to report increases in fruit and vegetable consumption, exercise, and hours of sleep.

CONCLUSIONS

Those furloughed exhibited similar health behaviours to those who remained in employment during the initial stages of the pandemic. There was little evidence to suggest that adoption of such social protection policies in the post-pandemic recovery period and during future economic crises had adverse effects on population health behaviours.

Psychological Distress Before and During the COVID-19 Pandemic Among Adults in the United Kingdom Based on Coordinated Analyses of 11 Longitudinal Studies

Importance

How population mental health has evolved across the COVID-19 pandemic under varied lockdown measures is poorly understood, and the consequences for health inequalities are unclear.

Objective

To investigate changes in mental health and sociodemographic inequalities from before and across the first year of the COVID-19 pandemic in 11 longitudinal studies.

Design, Setting, and Participants

This cohort study included adult participants from 11 UK longitudinal population-based studies with prepandemic measures of psychological distress. Analyses were coordinated across these studies, and estimates were pooled. Data were collected from 2006 to 2021.

Exposures

Trends in the prevalence of poor mental health were assessed in the prepandemic period (time period 0 [TP 0]) and at 3 pandemic TPs: 1, initial lockdown (March to June 2020); 2, easing of restrictions (July to October 2020); and 3, a subsequent lockdown (November 2020 to March 2021). Analyses were stratified by sex, race and ethnicity, education, age, and UK country.

Main Outcomes and Measures

Multilevel regression was used to examine changes in psychological distress from the prepandemic period across the first year of the COVID-19 pandemic. Psychological distress was assessed using the 12-item General Health Questionnaire, the Kessler 6, the 9-item Malaise Inventory, the Short Mood and Feelings Questionnaire, the 8-item or 9-item Patient Health Questionnaire, the Hospital Anxiety and Depression Scale, and the Centre for Epidemiological Studies-Depression across different studies.

Results

In total, 49 993 adult participants (12 323 [24.6%] aged 55-64 years; 32 741 [61.2%] women; 4960 [8.7%] racial and ethnic minority) were analyzed. Across the 11 studies, mental health deteriorated from prepandemic scores across all 3 pandemic periods, but there was considerable heterogeneity across the study-specific estimated effect sizes (pooled estimate for TP 1: standardized mean difference [SMD], 0.15; 95% CI, 0.06-0.25; TP 2: SMD, 0.18; 95% CI, 0.09-0.27; TP 3: SMD, 0.21; 95% CI, 0.10-0.32). Changes in psychological distress across the pandemic were higher in women (TP 3: SMD, 0.23; 95% CI, 0.11, 0.35) than men (TP 3: SMD, 0.16; 95% CI, 0.06-0.26) and lower in individuals with below-degree level education at TP 3 (SMD, 0.18; 95% CI, 0.06-0.30) compared with those who held degrees (SMD, 0.26; 95% CI, 0.14-0.38). Increased psychological distress was most prominent among adults aged 25 to 34 years (SMD, 0.49; 95% CI, 0.14-0.84) and 35 to 44 years (SMD, 0.35; 95% CI, 0.10-0.60) compared with other age groups. No evidence of changes in distress differing by race and ethnicity or UK country were observed.

Conclusions and Relevance

In this study, the substantial deterioration in mental health seen in the UK during the first lockdown did not reverse when lockdown lifted, and a sustained worsening was observed across the pandemic period. Mental health declines have been unequal across the population, with women, those with higher degrees, and those aged 25 to 44 years more affected than other groups.

Mining the Data: Exploring Rural Patients' Attitudes about the Use of Their Personal Information in Research

BACKGROUND

This study examines rural patients' perceived importance of knowing or being consulted about researchers' access and use of their personal data (identifiable and de-identified health information, and identifiable and de-identified non-health information) across five scenarios. This study also examines their views on stewardship or governance of their personal information by researchers in their healthcare systems.

METHODS

We conducted a survey by mail. Data were analyzed using descriptive statistics. Multivariable regression analyses were conducted across each scenario and type of personal data with the same variables included in each model.

RESULTS

The majority of participants said it was "very important/absolutely essential" to know the purpose of the study, to be asked every time, and to know the policies governing researcher access and use of their identifiable health information. Just over two-thirds of respondents thought it "very important/absolutely essential" to know who serves on the data governance committee and to have a community member serve. Distrust in healthcare organizations was positively correlated with the scenarios while willingness to give permission to donate leftover biological specimens was negatively correlated.

CONCLUSION

Our study findings indicate that the type of personal information being accessed and used generally matters to 1,407 patients living in rural Pennsylvania. We also demonstrate that knowing their healthcare organizations' governance policies and practices for managing their personal data is important to many rural Pennsylvania patients. Biomedical researchers need to recognize and attend to those differences as much as possible in order to expand opportunities for and participation in research by residents of these rural communities.

Supplemental data for this article is available online at.

Success of a Community-Based Delivery at Recruiting Individuals from Underserved Communities for an Observational Cohort Study of an Advance Care Planning Intervention

BACKGROUND

Underserved and minority populations are often reluctant to engage in advance care planning and/or research often due to distrust in healthcare and/or research institutions.

AIM

To determine if use of a community-based delivery model can facilitate recruitment of individuals from underserved communities in research about advance care planning.

DESIGN

Recruitment data are presented from a prospective, mixed methods observational cohort study that examined the feasibility and preliminary efficacy of a community-based delivery model involving an end-of-life conversation game to motivate participants to complete advance care planning behaviors. Event attendance and research participation data are reported.

SETTING/PARTICIPANTS

Game events were held in community venues in 27 states across the US in 2018-2019. The model involved leveraging existing social networks to recruit attendees and research participants to community game day events. Attendees were eligible for research if they were adults who read/spoke English.

RESULTS

A total of 1,122 individuals attended events at 53 sites. Participants generally reported low income (48% reported $30,000 annual income). At sites with research assistants, there was a 90% consent rate (92% were Black). At community outreach sites, 45% agreed to a follow-up research phone call (49% were Black).

CONCLUSIONS

Use of the community-based delivery model successfully engaged undeserved communities in a research-based advance care planning related community outreach event. This model may be useful for overcoming underserved and minority populations' skepticism and distrust of healthcare and research that is a common barrier to progress in health agendas, especially advance care planning.

Cattle farmer psychosocial profiles and their association with control strategies for bovine viral diarrhea

Bovine viral diarrhea (BVD) is endemic in the United Kingdom and causes major economic losses. Control is largely voluntary for individual farmers and is likely to be influenced by psychosocial factors, such as altruism, trust, and psychological proximity (feeling close) to relevant “others,” such as farmers, veterinarians, the government, and their cows. These psychosocial factors (factors with both psychological and social aspects) are important determinants of how people make decisions related to their own health, many of which have not been studied in the context of infectious disease control by farmers. Farmer psychosocial profiles were investigated using multiple validated measures in an observational survey of 475 UK cattle farmers using the capability, opportunity, motivation-behavior (COM-B) framework. Farmers were clustered by their BVD control practices using latent class analysis. Farmers were split into 5 BVD control behavior classes, which were tested for associations with the psychosocial and COM-B factors using multinomial logistic regression, with doing nothing as the baseline class. Farmers who were controlling disease both for themselves and others were more likely to do something to control BVD (e.g., test, vaccinate). Farmers who did not trust other farmers, had high psychological capability (knowledge and understanding of how to control disease), and had high physical opportunity (time and money to control disease) were more likely to have a closed, separate herd and test. Farmers who did not trust other farmers were also more likely to undertake many prevention strategies with an open herd. Farmers with high automatic motivation (habits and emotions) and reflective motivation (decisions and goals) were more likely to vaccinate and test, alone or in combination with other controls. Farmers with high psychological proximity (feeling of closeness) to their veterinarian were more likely to undertake many prevention strategies in an open herd. Farmers with high psychological proximity to dairy farmers and low psychological proximity to beef farmers were more likely to keep their herd closed and separate and test or vaccinate and test. Farmers who had a lot of trust in other farmers and invested in them, rather than keeping everything for themselves, were more likely to be careful introducing new stock and test. In conclusion, farmer psychosocial factors were associated with strategies for BVD control in UK cattle farmers. Psychological proximity to veterinarians was a novel factor associated with proactive BVD control and was more important than the more extensively investigated trust. These findings highlight the importance of a close veterinarian-farmer relationship and are important for promoting effective BVD control by farmers, which has implications for successful nationwide BVD control and eradication schemes.

Pre-pandemic mental health and disruptions to healthcare, economic and housing outcomes during the COVID-19 pandemic: evidence from 12 UK longitudinal studies

BACKGROUND

The COVID-19 pandemic has disrupted lives and livelihoods, and people already experiencing mental ill health may have been especially vulnerable.

AIMS

Quantify mental health inequalities in disruptions to healthcare, economic activity and housing.

METHOD

We examined data from 59 482 participants in 12 UK longitudinal studies with data collected before and during the COVID-19 pandemic. Within each study, we estimated the association between psychological distress assessed pre-pandemic and disruptions since the start of the pandemic to healthcare (medication access, procedures or appointments), economic activity (employment, income or working hours) and housing (change of address or household composition). Estimates were pooled across studies.

RESULTS

Across the analysed data-sets, 28% to 77% of participants experienced at least one disruption, with 2.3-33.2% experiencing disruptions in two or more domains. We found 1 s.d. higher pre-pandemic psychological distress was associated with (a) increased odds of any healthcare disruptions (odds ratio (OR) 1.30, 95% CI 1.20-1.40), with fully adjusted odds ratios ranging from 1.24 (95% CI 1.09-1.41) for disruption to procedures to 1.33 (95% CI 1.20-1.49) for disruptions to prescriptions or medication access; (b) loss of employment (odds ratio 1.13, 95% CI 1.06-1.21) and income (OR 1.12, 95% CI 1.06 -1.19), and reductions in working hours/furlough (odds ratio 1.05, 95% CI 1.00-1.09) and (c) increased likelihood of experiencing a disruption in at least two domains (OR 1.25, 95% CI 1.18-1.32) or in one domain (OR 1.11, 95% CI 1.07-1.16), relative to no disruption. There were no associations with housing disruptions (OR 1.00, 95% CI 0.97-1.03).

CONCLUSIONS

People experiencing psychological distress pre-pandemic were more likely to experience healthcare and economic disruptions, and clusters of disruptions across multiple domains during the pandemic. Failing to address these disruptions risks further widening mental health inequalities.

Mental health inequalities in disruptions across multiple domains during COVID -19: an investigation in 12 population-based longitudinal studies

Disruptions related to the COVID-19 pandemic and its associated virus suppression measures have affected many worldwide but those already suffering from psychological distress may have been especially vulnerable. We investigated associations between pre-pandemic psychological distress and disruptions to healthcare, economic activity, housing, and cumulative disruptions. Data were from 59,482 participants in 12 UK longitudinal adult population surveys with both pre-pandemic and COVID-19 surveys. Participants self-reported disruptions since the start of the pandemic to: healthcare (medication access, procedures, or appointments); economic activity (negative changes in employment, income or working hours); and housing (change of address or household composition). Logistic regression models were used to estimate associations between pre-pandemic standardised psychological distress scores and disruption outcomes. Findings were synthesised using a random effects meta-analysis with restricted maximum likelihood. Approximately one to two thirds of study participants experienced some form of disruption during the pandemic. One standard deviation higher pre-pandemic psychological distress was associated with: increased odds of any healthcare disruption (odds ratio: 1.30 [95% CI: 1.20-1.40]; I2: 65%); increased odds of experiencing any economic disruption (1.11 [1.03-1.16]; I2: 61%); no associations with housing disruptions; and increased likelihood of experiencing a disruption in at least two domains (1.25 [1.18-1.32]; I2: 38%) or one domain (1.11 [1.07-1.16]; I2: 32%) compared to no disruptions. Associations did not differ by sex, ethnicity, education, or age. Individuals suffering from psychological distress pre-pandemic may need additional support to manage stressful life disruptions. Considering mental ill-health was already unequally distributed in the UK population, this may exacerbate existing inequalities related to sex, ethnicity, education and age.

Diet, physical activity, and sleep in relation to furlough during the COVID-19 pandemic in the UK: evidence from eight longitudinal studies

The recent Covid-19 pandemic, and its mitigations, are expected to have long-term consequences on the health and health behaviours. In an effort to reduce the effect of lockdown on the economy, the UK government launched their Coronavirus Job Retention Scheme (commonly known as furlough) in March 2020, which entitled employees who were unable to work to 80% of their monthly pay up to a cap of £2,500. We investigated the association between changes in economic activity and health behaviours of the working-age participants of eight longitudinal studies, during the early stages of the pandemic. Specifically, we investigate the post-pandemic levels, and the pre-to-post pandemic change, in fruit and vegetable consumption, physical activity, and sleeping patterns. We obtained study-specific estimates using modified Poisson regression, adjusting for a comparable set of potential confounders, and combined results in a random-effects meta-analyses. Compared to those who continually worked, furloughed workers were more likely to report an increase in their fruit and vegetable consumption (1.22 [1.04-1.43]; I2 = 52%), and an increase in their physical activity (1.19 [1.04-1.35]; I2 = 73%). However, furlough appears to have a polarizing effect on sleeping patterns (change from 6 - 9 h to outside this range: 1.46 [1.03, 2.08]; I2 = 75%; change from outside of the 6 -9 h to within this range: 1.78 [1.03, 3.07]; I2 = 75%), especially amongst women and those with no higher education degree. This polarization is partially explained by the age of the survey participants, indicating that sleeping patterns of the younger cohorts were more adversely affected. Furlough schemes may be associated with better diet and more physical activity, while inconsistent effects on sleeping patterns may place younger generations at particular risk of atypical sleep.

Health care disruption inequalities during Covid-19: Evidence from eleven longitudinal studies

Like other health systems worldwide, the UK, the National Health Service (NHS) has faced major disruptions due to high Covid-19 burden and repeated lockdown measures. These disruptions can have both short and long-term health impacts. The NHS provides free healthcare and prioritises equity of delivery, but despite this, inequalities in access to health care remain and it is plausible that pandemic-related disruptions affect different groups disproportionally, thus widening health inequalities. This paper investigates associations between well-established axes of health inequality (sex, age, social class, education and ethnicity) and self-reported health care disruptions (medication access, procedures, or appointments) in over 65,000 participants across eleven longitudinal studies in the UK. Participants reported disruptions from March 2020 through to as late as January 2021. We obtained study-specific estimates using logistic regression models and combined them in a random-effects meta-analysis. Analyses were adjusted for sex, age and ethnicity where relevant. Between 10.1% (Millennium Cohort Study) and 31.8 % (Understanding Society) of study participants reported experiencing health care disruptions. Results show that females (OR: 1.27 [95%CI: 1.15,1.4]; I2=56%), older participants (e.g. OR: 1.39 [1.13,1.72]; I2=77% for 65-75y vs 45-54y), and non-white ethnic minorities (OR: 1.17 [1.02,1.34]; I2=0% vs white) were more likely to report healthcare disruptions. Those in a more disadvantaged social class (e.g. OR: 1.18 [1.08, 1.21]; I2=0% for manual/routine vs managerial/professional) were also more likely to report healthcare disruptions, but no clear differences were observed for education. Our findings highlight inequities in healthcare disruptions, which, if unaddressed, could contribute to the maintenance or widening of existing health inequalities.

Which is most important for mental health: Money, poverty, or paid work? A fixed-effects analysis of the UK Household Longitudinal Study

BACKGROUND

The relative importance of income, poverty and unemployment status for mental health is unclear, and understanding this has implications for income and welfare policy design. We aimed to assess the association between changes in these exposures and mental health.

METHODS

We measured effects of three transition exposures between waves of the UK Household Longitudinal Study from 2010/11-2019/20 (n=38,697, obs=173,859): income decreases/increases, moving in/out of poverty, and job losses/gains. The outcome was General Health Questionnaire (GHQ), which measures likelihood of common mental disorder (CMD) as a continuous (GHQ-36) and binary measure (score ≥4 = case). We used fixed-effects linear and linear probability models to adjust for time invariant and time-varying confounders. To investigate effect modification, we stratified analyses by age, sex and highest education.

RESULTS

A 10% income decrease/increase was associated with a 0.02% increase (95% CI 0.00, 0.04) and 0.01% reduction (95% CI -0.03, 0.02) in likelihood of CMD respectively. Effect sizes were larger for moving into poverty (+1.8% [0.2, 3.5]), out of poverty (-1.8%, [-3.2, -0.3]), job loss (+15.8%, [13.6, 18.0]) and job gain (-11.4%, [-14.4, -8.4]). The effect of new poverty was greater for women (+2.3% [0.8, 3.9] versus +1.2% [-1.1, 3.5] for men) but the opposite was true for job loss (+17.8% [14.4, 21.2] for men versus +13.5% [9.8, 17.2] for women). There were no clear differences by age, but those with least education experienced the largest effects from poverty transitions, especially moving out of poverty (-2.9%, [-5.7, -0.0]).

CONCLUSIONS

Moving into unemployment was most strongly associated with CMD, with poverty also important but income effects generally much smaller. Men appear most sensitive to employment transitions, but poverty may have larger impacts on women and those with least education. As the COVID-19 pandemic recedes, minimising unemployment as well as poverty is crucial for population mental health.

Does Caregiver Participation in Advance Care Planning Using a Decision Support Tool Together With Patients Reduce Caregiver Strain, Burden and Anxiety Over Time? A Post-Hoc Analysis of a Randomized Controlled Trial

CONTEXT

Surrogate decision makers experience significant amounts of anxiety, burden, and strain in their role as caregivers and decision makers for loved ones.

OBJECTIVES

To investigate longitudinally whether surrogate decision makers engaging in ACP together with their loved one reduces perceived anxiety, burden, and strain felt by surrogate decision makers.

METHODS

Post-hoc analysis of a randomized controlled trial evaluating caregivers' perceived self-efficacy to serve as surrogate decision makers. The trial employed a 2×2 study design of patient/caregiver dyads who engaged in advance care planning (ACP) using a standard living will form vs "Making Your Wishes Known" (MYWK), and having the patient engage in ACP alone vs together with the family caregiver. Surrogates completed validated survey instruments surveys longitudinally to compare levels of anxiety, burden, and strain.

RESULTS

246 of 285 dyads completed the measures. No significant reductions in anxiety, burden, or strain were found longitudinally in surrogate decision makers using MYWK together with loved one's vs other control groups. Increases in strain and anxiety were seen across all study groups and increases in burden across 2/4 study groups. Strain and burden increased most in the MYWK Together arm (▴ = +2.22 and ▴ = +1.91 respectively).

CONCLUSION

Family caregivers who engaged in ACP together with patients using the decision support tool MYWK did not experience less strain, burden, or anxiety longitudinally compared to other study arms. These results may help inform the design of future studies and interventions that promote caregivers' involvement in ACP interventions.

What Surrogates Understand (and Don't Understand) About Patients' Wishes After Engaging Advance Care Planning: A Qualitative Analysis

BACKGROUND

The goal of advance care planning (ACP) is to improve end-of-life decision-making for patients and their spokespersons, but multiple studies have failed to show substantial or consistent benefit from ACP. Understanding how and why ACP under-performs in the setting of complex medical decision-making is key to optimizing current, or designing new, ACP interventions.

AIM

To explore how ACP did or did not contribute to a spokespersons' understanding of patient wishes after engaging in ACP.

DESIGN

Thematic analysis of 200 purposively sampled interviews from a randomized control trial of an ACP decision aid.

SETTING/PARTICIPANTS

200 dyads consisting of patients 18 years or older with advanced serious illness and their spokesperson at 2 tertiary care centers in Hershey, PA and Boston, MA. Participants were interviewed 1 month after completing ACP.

RESULTS

ACP helped participants: 1) express clear end-of-life wishes, 2) clarify values, and 3) recognize challenges associated with applying those wishes in complex situations. Shortcomings of ACP included 1) unknown prognostic information or quality-of-life outcomes to inform decision-making, 2) skepticism about patients' wishes, and 3) complicated emotions impacting end-of-life discussions.

CONCLUSIONS

Helping patients and their spokespersons better anticipate decision-making in the face of prognostic and informational uncertainty as well as the emotional complexities of making medical decisions may improve the efficacy of ACP interventions.

Multiple model triangulation to identify factors associated with lameness in British sheep flocks

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Multiple model triangulation identifies variables that are likely true positives.

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Triangulation increases confidence in which managements to recommend in practice.

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Effective management of ewes can lower prevalence of lameness in ewes and lambs.

Identification of factors associated with an outcome can be challenging when the number of explanatory variables is large in relation to the number of observations. Multiple model triangulation, where results from several model types are combined, improves the likelihood of identifying true predictor variables. The aim of this study was to use triangulation to identify covariates likely to be truly associated with the prevalence of lameness in sheep flocks in Great Britain.

Data were collected using a questionnaire sent to 3200 sheep farmers in Great Britain in 2018. The useable response rate was 14.1 %. The geometric mean prevalence of lameness was 1.4 % (95 % CI 1.2−1.7) for ewes, and 0.6 % (95 % CI 0.5−0.9) for lambs, however, approximately 60 % flocks had >2% prevalence of lameness in ewes.

Four model types were investigated, two generalised linear models (negative binomial and quasi-Poisson) built using stepwise selection, and two elastic net models (Poisson and Gaussian distributions) refined with selection stability estimation.

Triangulated covariates were those selected in three or all four models – 10 for ewes and 12 for lambs. Higher prevalence of lameness in ewes was associated with 5−100% feet bleeding during routine foot trimming compared with not foot trimming, footbathing the flock to treat severe footrot (SFR) and always using formalin in footbaths, both compared with not footbathing, using FootVax™ for <1 year compared with not using FootVax™, and never quarantining new or returning sheep to the farm for >3 weeks compared with always. Lower prevalence of lameness in ewes was associated with vaccinating with FootVax™ for >5 years compared with not vaccinating, peat soil compared with no peat soil, and having no lame ewes to treat.

Higher prevalence of lameness in lambs was associated with 5−100% feet bleeding during routine foot trimming, always foot trimming ewes with SFR, not knowingly selecting replacement ewes from ewes that were never lame compared with always, replacement sheep purchased and homebred compared with only homebred, treating lambs >3 days after recognition of lameness compared with 0-3 days and footbathing the flock to treat interdigital dermatitis compared with not footbathing at all. Lower prevalence of lameness in lambs was associated with peat soil, flocks in Scotland versus England, an altitude of >230−500 m compared with ≤230 m, never using antibiotic injection to treat lambs with SFR compared with always, and having no lame lambs to treat.

We conclude triangulation identified reliable management practices for farmers to implement to minimise lameness in sheep.

Pre-school childcare and inequalities in child development

Centre-based childcare may benefit pre-school children and alleviate inequalities in early childhood development, but evidence on socio-emotional and physical health outcomes is limited. Data were from the UK Millennium Cohort Study (n = 14,376). Inverse-probability weighting was used to estimate confounder-adjusted population-average effects of centre and non-centre-based childcare (compared to parental care only) between ages 26-31 months on (age 3): internalising and externalising symptoms, pro-social behaviour, independence, emotional dysregulation, vocabulary, school readiness, and body mass index. To assess impacts on inequalities, controlled direct effects of low parental education and lone parenthood on all outcomes were estimated under two hypothetical scenarios: 1) universal take-up of centre-based childcare; and 2) parental care only. On average, non-centre based childcare improved vocabulary and centre-based care improved school readiness, with little evidence of other benefits. However, socio-economic inequalities were observed for all outcomes and were attenuated in scenario 1 (universal take-up). For example, inequalities in externalising symptoms (according to low parental education) were reduced from a confounder-adjusted standard deviation difference of 7.8 (95% confidence intervals: 6.7-8.8), to 1.7 (0.6-2.7). Inequalities by parental education in scenario 2 (parental care only) were wider than in scenario 1 for externalising symptoms (at 3.4; 2.4-4.4), and for emotional dysregulation and school readiness. Inequalities by lone parenthood, which were smaller, fell in scenario 1, and fell further in scenario 2. Universal access to centre-based pre-school care may alleviate inequalities, while restricted access (e.g. during lockdown for a pandemic such as Covid-19) may widen some inequalities in socioemotional and cognitive development.

Randomized controlled field trial comparing quarter and cow level selective dry cow treatment using the California Mastitis Test

Selective use of antibiotic dry cow treatment can be implemented at the cow or quarter level, with the latter having the potential to further reduce antibiotic use. Our objective was to compare these 2 approaches in 6 herds in the United Kingdom in which environmental mastitis predominated. Eight hundred seven cows were enrolled and categorized as having a high cell count (n = 401) or low cell count (n = 406) in the last 3 mo of lactation and clinical mastitis history. All quarters of all enrolled cows received an internal teat sealant. Within each category, cows were randomly allocated to 1 of 3 groups; in one group antibiotic treatment was allocated at cow level (i.e., all 4 quarters received antibiotic), whereas in the 2 remaining groups antibiotic treatment was allocated at quarter level, based on California Mastitis Test (CMT) findings. Two different thresholds, score 1 and 2, were used to determine likely infection status. Quarter milk samples were collected at dry off and postcalving for bacteriological culture and somatic cell count (SCC). Cows were monitored for clinical mastitis from dry off until 100 d in milk. Cow level SCC and milk yield data were collated from farm records. Within each category, the 2 quarter level treatment groups were compared with cow level treatment at dry off. Leaving quarters untreated with intramammary antibiotic in cows in the high cell count group, with a CMT <2 or <1, reduced antibiotic use by 55% and 31%, respectively, and resulted in no difference in the odds of being infected with any pathogen postcalving, but was associated with a higher SCC at the first test day. Intramammary antibiotic treatment of quarters with a CMT ≥1 in cows in the low cell count category at dry off was not associated with any reduction in the odds of being infected with a major pathogen postcalving but was associated with a decrease in the odds of being infected with a minor mastitis pathogen postcalving. The use of antibiotics in quarters of cows categorized as low cell count at dry off, increased the proportion of quarters treated with antibiotic from 0% at cow level to 31% (CMT ≥ 1) and 12% (CMT ≥ 2) at quarter level, only resulting in a reduction in SCC of around 20,000 cells/mL at the first test day, if all quarters with CMT score ≥1 were treated with antibiotic. No differences in clinical mastitis incidence and milk yield in the first 100 d in milk were detected between any of the treatment groups. These study findings support selective quarter level dry off treatment only in cows with cow level SCC >200,000 cells/mL at dry off.

A history of lameness and low body condition score is associated with reduced digital cushion volume, measured by magnetic resonance imaging, in dairy cattle

Claw horn lesions (CHL) are the result of a failing of the functional anatomy of the hoof in dairy cows. The digital cushion is understood to be a vital structure in the prevention of CHL. Claw horn lesions have previously been shown to lead to pathological change to the pedal bone; however, their effects on the digital cushion are unknown. The primary aim of this study was to examine associations between the history of CHL through an animal's life and the structure of the digital cushion at slaughter using magnetic resonance imaging. The retrospective cohort study resulted in the scanning of 102 pairs of hindfeet, collected from adult Holstein dairy cows culled from a research herd, using a 3-Tesla research-grade magnetic resonance imaging scanner. Volume and fat measurements were calculated for each digital cushion within each claw from a modified Dixon Quant sequence. Animal-level variables were constructed around the animals' lactating lifetime, with lameness scores and body condition score collected at least every 2 wk. The combined volume of digital cushion in the lateral claws was used as the outcome variable in multivariable linear models. The volume of the digital cushion was negatively associated with the number of lameness events or CHL recorded. Furthermore, animals with body condition score >3, culled later in lactation, or of a greater body weight were more likely to have a higher volume of digital cushion in the lateral claws. We propose that the observations made in the current study are the effects of a range of factors broadly associated with genetic, developmental, and disease-related inputs. Our understanding of how we can select for genetically more robust animals and how we can precondition the hoof before first calving needs to be improved to reduce the risk of future CHL in adult dairy cattle. Furthermore, understanding optimal treatment regimens and their effect on hoof anatomy may reduce the recurrence of CHL in the current lactation and future lactations.

Low Skepticism and Positive Attitudes About Advance Care Planning Among African Americans: a National, Mixed Methods Cohort Study

BACKGROUND

African Americans have low engagement in advance care planning (ACP). This has been attributed to healthcare distrust and skepticism about ACP. A better understanding of these attitudes is needed to address health disparities related to end-of-life care.

OBJECTIVE

To explore the ACP-related values and beliefs of diverse African American communities across the USA and then the perceived value of an inexpensive end-of-life conversational game.

DESIGN

Prospective, convergent, mixed methods cohort study involving fifteen underserved, African American communities across the USA.

PARTICIPANTS

Of the 428 who attended events at purposively sampled sites, 90% consented to the research; 37% participated in one of 15 focus groups (n = 141).

INTERVENTION

An end-of-life conversation game, played in groups of 4-6.

MAIN MEASURES

The validated, 7-item ACP values and beliefs questionnaire (scaled 7 = least skeptical, 49 = most skeptical) was administered pre-game. Post-game focus groups explored perceptions about ACP and the intervention.

KEY RESULTS

Participants had positive attitudes (low skepticism) about ACP with a median score of 12.00 (7.00, 20.00). Values and beliefs did not significantly differ by geographical region; however, rural areas were observed to be slightly more skeptical than urban areas (median score 14.00 vs. 11.00, p = 0.002). Themes from focus groups converged with survey data showing participants valued the ACP process and consider further engagement in ACP to be worthwhile. Subthemes emphasized the need for and value of ACP.

CONCLUSIONS

Skepticism about ACP may contribute to low rates of ACP engagement in underserved African American communities. The positive attitudes uncovered in our study either negate previous findings or suggest reduced skepticism.

TRIAL REGISTRATION

This study has been registered at clinicaltrials.gov ( NCT03456921 ).

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

Background

Social contact, including remote contact (by telephone, email, letter or text), could help reduce social inequalities in depressive symptoms and loneliness among older adults.

Methods

Data were from the 8th wave of the English Longitudinal Study of Aging (2016/17), stratified by age (n = 1578 aged <65; n = 4026 aged 65+). Inverse probability weighting was used to estimate average effects of weekly in-person and remote social contact on depressive symptoms (score of 3+ on 8-item CES-D scale) and two measures of loneliness (sometimes/often feels lonely vs hardly ever/never; and top quintile of UCLA loneliness scale vs all others). We also estimated controlled direct effects of education, partner status, and wealth on loneliness and depressive symptoms under two scenarios: 1) universal infrequent (<weekly) in-person social contact; and 2) universal weekly remote social contact.

Results

Weekly in-person social contact was associated on average with reduced odds of loneliness, but associations with remote social contact were weak. Lower education raised odds of depressive symptoms and loneliness, but differences were attenuated with infrequent in-person contact. Respondents living alone experienced more depressive symptoms and loneliness than those living with a partner, and less wealth was associated with more depressive symptoms. With universal infrequent in-person contact, these differences narrowed among those aged under 65 but widened among those aged 65+. Universal weekly remote contact had relatively little impact on inequalities.

Conclusions

Reduced in-person social contact may increase depressive symptoms and loneliness among older adults, especially for those aged 65+ who live alone. Reliance on remote social contact seems unlikely to compensate for social inequalities.

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In-person but not remote contact associated with less depression/loneliness.

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In-person contact < weekly reduces educational inequalities in depression/loneliness.

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In those aged 65+ partner/wealth inequalities widen with <weekly in-person contact.

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Weekly remote contact has little impact on inequalities in depression/loneliness.