key: cord-0323567-47yxtywh
authors: French, M.; Spencer, M.; Walker, M.; Patel, A.; Clarke, N.; Hughes, R.; Taylor, C.; Orwin, M.; Elliott, A.; Worsley, K.; Casson, J.; Milan, S.; Bowen, M.; Sedda, L.
title: Understanding the impact of the COVID-19 pandemic on a socially deprived UK coastal town: a preliminary exploratory analysis of health and socioeconomic data
date: 2021-12-27
journal: nan
DOI: 10.1101/2021.12.22.21268232
sha: c54b09d02cb009830ef1dd4413e266309d9fd763
doc_id: 323567
cord_uid: 47yxtywh

Introduction In addition to the direct impact of COVID-19 infections on health and mortality, a growing body of literature indicates there are wide-ranging indirect impacts of the COVID-19 pandemic and associated public health measures on population health and wellbeing. Exploring these indirect impacts in the context of a socially deprived UK coastal town will help identify priority areas to focus COVID-19 recovery efforts on. Methods Data on primary care diagnosis, hospital admissions, and several socioeconomic outcomes between 2016 and Spring 2021 in the UK town of Fleetwood were collected and analysed in an exploratory analysis looking at pre- and post- COVID-19 patterns in health and social outcomes. Weekly and monthly trends were plotted by time and differences between periods examined using Chi-squared and t-tests. Results Initial falls in hospital admissions and diagnoses of conditions in primary care in March 2020 were followed by sustained changes to health service activity for specific diagnostic and demographic groups, including for chronic kidney disease and young people. Increases in the number of people receiving Universal Credit and children eligible for free school meals appear to be greater for those in the least deprived areas of the town. Discussion These exploratory findings provide initial evidence of the sustained impact of the pandemic across several health and social outcomes. Examining these trends in multivariate analyses will further test these associations and establish the strength of the medium term impact of the pandemic on the population of this coastal town. Advanced modelling of this data is ongoing and will be published shortly.

This work was funded by the NHS, Wyre Council, Healthier Fleetwood and Lancaster University EPSRC Impact 24

Accelerator Account. We thank all the members of Healthier Fleetwood, Future Fleetwood and the Fleetwood 25 public for their support. 26

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee 28 approvals have been obtained. 29

The details of the IRB/oversight body that provided approval or exemption for the research described are 31

given below: 32 outcomes. Weekly and monthly trends were plotted by time and differences between 50 periods examined using Chi-squared and t-tests. 51

Initial falls in hospital admissions and diagnoses of conditions in primary care in March 2020 53 were followed by sustained changes to health service activity for specific diagnostic and 54 demographic groups, including for chronic kidney disease and young people. Increases in the 55 number of people receiving Universal Credit and children eligible for free school meals 56 appear to be greater for those in the least deprived areas of the town. 57

These exploratory findings provide initial evidence of the sustained impact of the pandemic 59 across several health and social outcomes. Examining these trends in multivariate analyses 60 will further test these associations and establish the strength of the medium term impact of 61 the pandemic on the population of this coastal town. Advanced modelling of this data is 62 ongoing and will be published shortly. Fleetwood are amongst some of the 10% most deprived areas in the country and, like other 134 deprived areas, experience some of the associated poor physical and mental health 135 outcomes (24). 136

As a coastal community without a large employer or industry, Fleetwood is a place that is 137 geographically and economically 'on the periphery', vulnerable to feeling the worst effects of 138 phenomena such as financial crises and pandemics (25,26). It also has a population older than 139 the English average, with 22% of its population aged over 65-years-old, compared to 18% 140 nationally (27). A report released early on in the pandemic suggested that people in coastal 141 areas were particularly vulnerable to the health and welfare effects of COVID-19 ( 2 8 ) . 142

However, coastal towns also offer opportunities to improve health and wellbeing, with good 143 air quality and access to outdoors providing some protective effects against poor health (29). 144

145 Data were originally collected as part of routine clinical care or routine service delivery and 146 surveillance in Fleetwood (Table 1) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Rates and counts were plotted with time (month or week depending on data availability). Differences 205 between the pre-March 2020 and post-March 2020 periods were tested using t-tests (continuous data) 206

or Chi-squared tests (categorical data) when looking at group differences, with a p-value <0.05 207 threshold for statistical significance. 208

Hospital admissions 210 The unadjusted trend in overall hospital admissions of residents in Fleetwood is shown in Figure 1 . 211 These plots suggest there was a fall in hospital admissions following the onset of the COVID-19 pandemic in 212 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (Table 3) . 232

In contrast to respiratory-related admissions, admissions primarily related to cardiovascular disease 234 dropped sharply after March 2020 but appear to have increased again to normal levels by Autumn 235

Admissions related to mental health 237

Further patterns were observed for mental health-related hospital admissions. There was no apparent 238 immediate impact in admissions of patients with a primary diagnosis of mental health following 239 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The changes in rates of new diagnoses between the pre-and post-March 2020 period were compared for each 271 diagnostic group across different sexes, age groups, and areas of income deprivation (Table 3) The number of street crime incidents in Fleetwood recorded by the police saw an increase in 2020, 288 particularly in the first half of that year. As the plots in Figure 4 suggest, the trend in overall street crime 289 in 2020 appears to be related to spikes in the number of anti-social behaviour incidents in that 290 period, which likely include the breaking of COVID-19-related restrictions. 291 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (Table 4 ). Chi-squared tests indicated that this difference was only statistically 295 significant for anti-social behaviour crimes (90.19% vs 88.75% in Most Deprived Areas, p<0.01) ( Table  296   4 Universal Credit under the 'searching for work' condition, meaning they are required to look for 307 work while receiving financial support. 308 Table 4 shows the monthly average ACC rate for Fleetwood in the pre-and post-March 2020 periods. (Table 4) . 313

Where available, variables have been stratified by income deprivation area, capturing differences 314 between areas in Fleetwood among the 20% most deprived areas nationally ('Most' in Table 4 ) and 315 those that are less deprived comparatively ('Least' in Table 4 ). Post-March 2020, the proportion of 316 younger claimants and those living in the least deprived areas of Fleetwood grew (Table 4 ). Figure 5  317 shows the time trends in claimant rates split by age. 318 319 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Table 5 suggest that 2020 338 rates appear to counter the trend somewhat, with rates of NEET increasing slightly and those on 339 apprenticeships decreasing on the 2019 figure, although these changes are very small. Furthermore, 340 when comparing the pre and post-March 2020 period, the post-March 2020 rates are higher overall, 341 although this is not statistically significant (Table 4) . 342

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint As the plot in Figure 7 and summary statistics in Table 4 show, the mean rate of pupils entitled to receive 347 free school meals per 1000 pupils grew in the post-COVID-19 period in both the most and least income 348 deprived areas in Fleetwood. While the numbers of pupils eligible for free school meals is much higher in 349 the most deprived areas both pre-and post-COVID-19, the rate of pupils eligible for free school meals 350 per 1000 pupils increased by 40% in the least deprived areas (120 pre vs 167 post, p=0.04), compared to 351 24% in the most deprived areas (344 pre vs 428 post, p<0.01). 352

The findings reported in this manuscript are those from an exploratory analysis of routinely collected 354 secondary health and socioeconomic data for Fleetwood residents. Temporal and spatial data were collected 355 to examine differences in outcomes in different areas of Fleetwood, a socially deprived coastal town in 356 North West England. While exploring mostly univariate associations between key variables of interest, 357 these initial findings indicate the degree to which the health and social wellbeing of residents of 358

Fleetwood have been impacted in the first 18 months following the COVID-19 pandemic. The results 359 point towards some key areas that call for more comprehensive analysis using survival, multivariate time 360 series and spatial analyses. These areas of interest include the large and sustained falls in hospital 361 admissions for respiratory-related conditions, the changes in the age and sex demographics of incidence 362 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. per 500,000 population (30). While these will not all be COPD diagnoses, many patients with suspected 377 COPD are likely to have been put on a 'waiting list' to be formally diagnosed before being placed on a 378 COPD register. While some falls in diagnosis may relate to system barriers rather than patients not being 379 seen in primary care, they could nonetheless lead to delays in care management and quicker 380 deterioration for some patients. Additionally, the rate of hospital admissions where the primary 381 diagnosis is a non-COVID-19 respiratory condition has also remained consistently low throughout the 382 study period, suggesting that falls in admissions documented early on in the pandemic are persisting into 383 2021 (7). 384

This exploratory analysis also points towards changing patterns to patient and population demographics 385 of some health and socioeconomic outcomes in the pre-and post-March 2020 periods. Some of the 386 associations in the pre-March 2020 period have been reversed, as is the case for women making up a 387 much lower proportion of diagnoses for chronic kidney disease or peripheral arterial disease, a pattern 388 not easily explained. Other trends may have more apparent explanations. For example, the increase in 389 the proportion of depression diagnoses among young people aligns to a growing research literature 390 pointing towards the impact the pandemic has had on that population group's mental wellbeing, 391 who have experience substantial disruptions to school, social, and working life (31,7). Within this 392 population, sub-groups may be particularly affected. There is evidence to suggest that among 16-25 393 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ; https://doi.org/10.1101/2021.12.22.21268232 doi: medRxiv preprint young people during COVID have been reduced social support, activities, and increased loneliness, it 396 may be that mental wellbeing will increase with greater social interactions (32). Assessing the longevity 397 of this impact will require longitudinal research that follows this population over many years. 398

Several socioeconomic outcomes, including the rate of children eligible to receive free school meals, 399 the number of street crimes, and unemployment, appear to have increased in the medium term in 400 areas classified as the 'least deprived' in Fleetwood. This does not necessarily contradict suggestions 401 made elsewhere that the COVID-19 pandemic will exacerbate social inequalities in health and social 402 outcomes, with a greater impact on those experiencing socioeconomic disadvantage (19). The apparent 403 changes in the 'least deprived' areas could indicate the pre-pandemic vulnerability of population groups 404 experiencing moderate but not severe financial insecurity. When compared to all other 405 neighbourhoods in England, the 'least deprived' areas in Fleetwood sit in the middle of national 406 deprivation rankings. Other studies have suggested that those in middle-income housing, particularly 407 those who were in work but on low pay, may have experienced the greatest financial disruption to 408 their lives (17). It is possible that some residents in the 'least deprived' areas of Fleetwood were more 409 vulnerable than others to the economic impacts of the pandemic. 410

There are early indications that the COVID-19 pandemic has had an impact on several health and social 412 outcomes in Fleetwood, a predominantly socially deprived town in North West England. An exploratory 413 analysis of these impacts suggests they may be patterned differently depending on health conditions, 414 patient and population demographics, and area income deprivation. Examining these trends in 415 multivariate analyses will test these associations and establish the strength of the impact on residents 416 in this coastal community. 417 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ; https://doi.org/10.1101/2021.12.22.21268232 doi: medRxiv preprint

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