Introduction
Situated in the North of England, Bradford is the fifth largest metropolitan district in the country. The city has a young, multi-ethnic population of more than 500,000 people: almost one third of the city’s population is aged under 20, nearly half of the births are to women of South Asian (mostly Pakistani) heritage, and there is also a large community of families from Central and Eastern European countries (Office for National Statistics [ONS], 2011). Once a thriving industrial city, Bradford now suffers from high levels of deprivation, with a quarter of children living in poverty, and has some of the worst health and education outcomes in the country (ONS, 2011; Born in Bradford, 2021).
In addition to the deprivation and health concerns in Bradford, there are specific structural characteristics that have made the city particularly vulnerable to the COVID-19 virus, for example, a large proportion of households are multi-generational and many are classed as overcrowded (ONS, 2011). These characteristics also make the communities in Bradford vulnerable to the unintended social and economic impacts of the response to COVID-19, including financial and food insecurity, mental distress, and educational consequences for children (Marmot et al, 2020). There have been a number of large-scale ongoing and new longitudinal studies during the pandemic that have highlighted these issues; however, most of these have
BiB is an internationally recognised applied health research programme comprising health and wellbeing information on more than 30,000 Bradfordians enrolled in three birth cohort studies (McEachan et al, 2020; Born in Bradford, 2021). Participants in the BiB cohorts consent to the use of their routine health and education data for research, and to be contacted for future research studies; participants in the Born in Bradford Family Cohort Study (BiB) and Born in Bradford’s Better Start (BiBBS) cohort also complete detailed questionnaires at recruitment and in ongoing waves of data collection (McEachan et al, 2020; Born in Bradford, 2021). Recent pre-pandemic data collection meant that BiB was in a unique position to be able to conduct a longitudinal programme of research comparing pre-pandemic and pandemic outcomes in a highly diverse and deprived population.
BiB prioritises engagement, co-production, and dissemination with communities and stakeholders in the city to ensure that they have a major voice in determining research priorities, and in interpreting and disseminating these findings. This ethos was harnessed in this research programme by establishing a community steering group (comprised of lay members of the Bradford community) and liaison with the Bradford Institute for Health Research COVID-19 Scientific Advisory Group (BIHR C-SAG) (comprised of academic and public health experts) (BIHR C-SAG, 2021). Information to deliver an effective COVID-19 urgent response, and longer-term recovery from the pandemic was shared with the C-SAG which provided a mechanism for feeding back emerging findings quickly to decision makers.
Longitudinal quantitative data collection was conducted with BiB families enrolled in the three cohorts (see Figure 5.1) using domains co-produced with the aforementioned advisory panels. Surveys also included open-ended questions that asked a) adults: the three biggest worries they had; a challenge faced in the past two weeks; and anything that had become easier; b) children: three worries they had and three things that made them feel happy at the moment. Surveys were completed at three time points: Phase 1 March–June 2020; Phase 2 October–December 2020; Phase 3 June–August 2021. Participants were women who were pregnant during the pandemic, parents with children aged 0–13, and children aged 9–13 (McEachan et al, 2020). The study situated in Tower Hamlets in Chapter 6 in this collection by Cameron et al, and BiB shared co-investigators and aligned their data collection where relevant to allow comparisons between populations.
Responsive in-depth qualitative research was completed based on the findings of the surveys and on the priorities set by the community and stakeholders. This included the key topics of: experiences of having a
In this chapter, we describe the key findings from Phase 1 and 2 of the parent and child surveys and the adolescent mental health qualitative work. Together these data tell a powerful and bleak story of how the COVID-19 pandemic has exacerbated inequalities for the most vulnerable families – making things even harder for those who were already struggling prior to the pandemic, and having far less of an impact on those who were secure and healthy.
The timeline of the Government’s response to COVID-19 in England and the corresponding timeline of the longitudinal BiB COVID-19 research
The timeline of the Government’s response to COVID-19 in England and the corresponding timeline of the longitudinal BiB COVID-19 research
The timeline of the Government’s response to COVID-19 in England and the corresponding timeline of the longitudinal BiB COVID-19 research
Overview of findings
In Phase 1, of 7,652 surveys sent to parents, 2,144 (28 per cent) participated; 2,043 were mothers and 101 partners (Dickerson et al, 2020). Of 5,298 child surveys sent out, 970 (19 per cent) participated. In Phase 2, of 2,288 adult surveys sent out, 767 (34 per cent) participated and for the child survey, of 1,841 sent out, 622 (34 per cent) children took part. Respondents in the adult and child surveys were representative of the ethnicity in the BiB cohorts. For example, in Phase 1, 47 per cent of parents and 44 per cent of children were of Pakistani heritage, 35 per cent and 41 per cent (respectively) were White British, and 46 per cent of adult participants lived in the lowest quintile of deprivation in England.
Three overarching themes were apparent across a large number of participants: (i) high levels of financial insecurity; (ii) increased mental ill health; and (iii) low levels of physical activity. These themes were evident at both survey time points, indicating long-lasting impacts of the pandemic.
Financial insecurity: “sometimes it’s eat or heat”
One of the most prominent findings from our surveys was the lack of buffering for families on low pay (Dickerson et al, 2020; BIHR C-SAG, 2021). In our first survey, one in three families said they were worse off than before the pandemic, and just over one in three (37 per cent) were financially insecure.1 In our second survey, just under one in three (31 per cent) continued to report being financially insecure.
In Phase 1 (the first UK lockdown), a large number of the main earners in families were unable to work, with 15 per cent furloughed and 11 per cent self-employed and unable to work. Financial insecurity was much higher in these families: almost two in three families (64 per cent) where the main earner was self-employed and not working, and almost one in two families (49 per cent) where the main earner was furloughed were financially insecure. Further exploration of these findings revealed that financial insecurity was more likely in families of Pakistani heritage (43 per cent) than in White
By the time of the Phase 2 survey, fewer of the main earners in families were furloughed (5 per cent), and none were self-employed but unable to work. This change in employment status may explain why 6 per cent fewer families reported being financially insecure at this time point. However, for some families things had become worse, with 4 per cent of mothers and 9 per cent of their partners having lost their job since the start of the pandemic. The loss of income during the pandemic had considerable implications for families, with one in five (20 per cent in Phase 1 and 17 per cent in Phase 2) being unable to always afford the food they needed, and just under one in ten reporting severe food insecurity by having to regularly skip meals (9 per cent and 7 per cent respectively). One in three families (37 per cent) were worried about the employment security of the main earner in Phase 1, and one in four (24 per cent) remained worried in Phase 2.
‘Loss of husband’s job completely, now having to apply for Universal Credit which will not be based on figures that are actually relevant and we already have debts. I am behind on a lot of bills, fear that in a month they will spiral out of control.’ (Adult, Phase 1)
‘Worried about the financial impact of COVID-19. I am currently furloughed from work but I worry that the virus will have an impact on the business. My husband is self-employed and is not eligible to any funds.’ (Adult, Phase 1)
At Phase 2, free-text responses indicated that families continued to struggle financially, with some suffering from severe long-term impacts of lost income: “I don’t have enough money to look after my family” (Adult, Phase 2). “Sometimes it’s eat or heat” (Adult, Phase 2).Recent job losses and the sustained job instability caused by certain job roles and industries that participants worked in were also common causes of financial worries: “Money – I’ve been given at risk redundancy notice” (Adult, Phase 2). “Our business is closed again because of the latest restrictions, I worry that we’ll miss our much needed trade” (Adult, Phase 2).Financial insecurity was also a worry for some of the children who recognised that their families
Mental ill health: “it’s a battle not to slip each day”
The surveys also uncovered increases in the mental ill health of both parents and children (Dickerson et al, 2020; BIHR C-SAG, 2021; Dickerson et al, 2022). The number of women reporting clinically important depression/anxiety increased from 11 per cent to 19 per cent, and 10 per cent to 16 per cent respectively from before the pandemic to the first COVID-19 lockdown.2 In Phase 2, 17 per cent continued to report clinically important symptoms of depression, and 13 per cent clinically important symptoms of anxiety.
We conducted further analyses to explore associations between key variables and a clinically important increase in anxiety and depression. We completed univariate logistical regression analyses using pre-pandemic and Phase 1 data. The findings from this analysis showed that the odds of a clinically important increase in depression were: more than eight times greater in mothers who felt lonely; more than six times greater in mothers who were financially insecure; and for depression (but not anxiety), more than three times greater for mothers who did no physical activity.
In White British mothers, the odds of an increase in clinically important depression were 12 per cent higher than in Pakistani heritage mothers. When we separated out the regression analyses by ethnicity, we found some interesting differences. Mothers of Pakistani heritage had greater odds of depression and anxiety if they were lonely or had an average/poor relationship with their partner than White British mothers. Pakistani heritage mothers had a much reduced odds in depression or anxiety if they lived in a large household compared to White British mothers. In contrast, mothers of White British ethnicity had greater odds of depression or anxiety if they were financially insecure and/or physically inactive compared to Pakistani heritage mothers reporting the same exposures.
‘Mental health, I have had previous issues in the past and am struggling and don’t feel like I can approach my GP at the minute as it isn’t an emergency.’ (Adult, Phase 1) ‘I have anxiety and am not able to do the things I used to do as a coping mechanism. My son is autistic and challenging and I am unable to have quality “me” time.’ (Adult, Phase 2)
‘I have four children, one a disabled child and one a toddler. Being isolated from friends and family, and having no future plans because of the restrictions and being a stay-at-home mum and a carer for my son is extremely difficult mentally. I feel like since March I have lost my identity and my confidence. My anxiety has increased exponentially.’ (Adult, Phase 2)
Many parents expressed concerns about their children’s mental ill health, and children also reported concerns about their own mental health: “Mental health of children (especially youngest). Desperately missing social interaction with friends, school and all his sporting activities. He is getting increasingly angry” (Adult, Phase 1). “Daughter had mental health crisis which has impacted upon her ability to eat” (Adult, Phase 2). “Worry of developing a mental illness” (Child, Phase 1). “Getting depression” (Child, Phase 2).
Qualitative findings on children’s mental health: “her whole little life has changed dramatically”
In response to the survey findings in Phase 1, and in consultation with our community steering group, a qualitative research study was undertaken to understand more about children’s experiences of mental health during the pandemic. Parents and children were purposively sampled based on ethnicity and responses to the mental health questions in the Phase 1 child survey. Qualitative interviews were completed with 21 children and their parents (Lockyer et al, 2020). Four key themes emerged that were linked to the children’s mental distress.
‘He’s kind of, you know, nervous because he keeps hearing this many or how many people died, these people, you know, how many people are positive for this virus and this and this. So first, you know, for few weeks he was keep looking at those news, everybody every day, you know, telling me, telling me. Then I told him, “No, stop looking at this news, yeah, because it’s too much for you.” Yeah, because he was taking in that, you know, then he was worried, he was saying, “I’m not going outside,” first’. (Family 14, Parent). ‘She wouldn’t even take the dog out, it seemed to really affect her … she’s reading about the coronavirus every day and seeing things, so it did scare her at the beginning and she didn’t, I don’t think she left the house for about eight weeks’. (Family 11, Parent)
‘Everything from like going to school and going straight out after school, to being at home, it has, it stopped for her, her whole little life has changed dramatically. So the mood being down from being sociable to being at home all the time.’ (Family 4, Parent)
‘Because I used to wake up with, like, a plan for the day and what I was going to do. And now, there isn’t really a big point in getting up so early, might as well have another hour in bed.’ (Family 9, Child)
‘I’d say we did have a lot of tears, a lot of kind of storming off saying he couldn’t do his work and that kind of thing. And obviously then he’d got a lot, very, he’d have a lot of, well, I call them strops, tantrums, kind of thing, he’d just, yeah, he’d just storm off and kind of answer back and stuff. However, since kind of they did finish school and again, as a few things have started, since his football started again the change has been quite dramatic actually. He’s just so much happier. And he does, he has settled down, he’s stopped wetting the bed again. He’s gone back to school today actually, first day back.’ (Family 15, Parent)
‘I just missed hugging [my friends], even when I got to school I couldn’t hug them. I was only able to keep in touch with my best friend because I don’t think Mummy had any other, like any other of my friends emails or anybody, so.’ (Family 16, Child)
‘I mean, it’s different [than seeing them face-to-face] because you’re not really having a laugh and a joke about things you’ve just seen or what’s just happened. It’s kind of, trying to make up a random conversation about something. You’re not, like, having a laugh with them. It feels more formal. It don’t feel sort of laughy and jokey.’ (Family 9, Child)
The concerns around school closures and periods of self-isolation for children have often focused on lost education, but it is clear from our findings here, and later on, that the impact for children on their mental health and physical activity is also of real concern.
Physical activity: “I’m scared to go out”
The findings from our survey highlighted that a large proportion of both adults and children were falling short of government recommendations for physical activity during the pandemic.3 In our surveys, we found that more than one in ten adults (12 per cent Phase 1; 14 per cent Phase 2) were doing no exercise at all, and one in four (26 per cent Phase 1; 34 per cent Phase 2) were exercising only one to two times a week. A lack of any physical activity was far greater in Pakistani heritage parents (17 per cent) than in White British parents (7 per cent) (Dickerson et al, 2020).
We compared the physical activity data in the children’s Phase 1 survey with pre-pandemic baseline physical activity data (Bingham et al, 2021). This analysis found a significant reduction in the number of children who were meeting the Government guidelines for physical activity during the first lockdown: two in three children (69 per cent) met the guidelines pre-pandemic, but fewer than one in three (29 per cent) did in Phase 1. There was a clear association between ethnicity and reduced physical activity, with significantly fewer Pakistani heritage children (23 per cent) meeting guidelines than White British children (34 per cent).
We used multivariable regression analysis to explore the factors associated with a child being sufficiently active. One key finding was that leaving the home for 30–60 minutes doubled the odds of a child being sufficiently active, and leaving the home for more than 60 minutes increased these odds
‘Now I’m that lazy, I do less. I’m less eager to be more active, like go outside. I’m like, “Oh, I have to go outside now,” I’m like, I don’t want to, I just want to, you know, lie down on my bed and just watch my phone all day … And I used to be much more active before lockdown and now I can’t do it.’ (Family 18, Child)
The persistent patterns of low physical activity during the pandemic places adults and children at greater risk of developing, or exacerbating, non-communicable diseases and co-morbidities such as obesity, diabetes, and respiratory illnesses (Marmot et al, 2020; Born in Bradford, 2021). South Asian children are already at a higher risk of being overweight/obese, making regular physical activity even more important for these children (Sivasubramanian et al, 2021).
Methods reflection: free-text responses
The free-text questions completed by BiB participants gave families the opportunity to share their concerns in their own words and to elucidate the quantitative findings. We did not, however, anticipate the powerful effect that these free-text responses would have on our research team, key stakeholders, and the survey findings. Qualitative survey data of this type is often dismissed due to the brevity of some responses and the inability of the researcher to ask participants to expand or explain their meaning further (Braun et al, 2020). However, while individual responses in our survey may lack depth when viewed in isolation, when taken as a whole, they tell us a complex story of Bradford families’ pandemic experiences. These responses
These responses have influenced and informed several complementary research studies, including qualitative interview studies on experiences during pregnancy (BIHR C-SAG, 2021, Brawner et al, 2021), adolescent mental wellbeing (Lockyer et al, 2020), health beliefs (Lockyer et al, 2021), and vaccine hesitancy (Dickerson et al, 2021). These same questions have also been asked in other studies (for example Tower Hamlets study by Cameron et al, Chapter 6; Gibson et al, 2021). Most significantly, however, these findings have enabled us to rapidly inform local decision makers about the concerns and circumstances of families, using their own words. This enabled a more resonant and powerful communication of our research to those who could, and did, work to improve the situation of Bradford families.
Policy and practice implications of our findings
The results from our COVID-19 longitudinal BiB study reflect findings that are emerging around the country: that the response to the pandemic has had unintended negative consequences, with the greatest impact being on those families who were already vulnerable. It has exacerbated inequalities in financial security, mental ill health and physical activity and these impacts have continued throughout the pandemic. To recover effectively from the pandemic, additional support will be needed to support the most vulnerable families (Marmot et al, 2020), and the UK Government’s pledge of ‘levelling up’ (to reduce the inequalities experienced by many) will require even more resources now than it did pre-pandemic.
While the furlough scheme and support to self-employed workers was introduced by the UK Government to provide financial support, our findings suggest that the loss of even a small proportion of income for those on low wages is enough to tip families into perilous financial difficulty, and potentially further exacerbate health inequalities. Economic support for communities in areas of high deprivation, and specific financial advice and support to families who have been hardest hit during the pandemic are needed as we enter the next phase of managing the recovery from the pandemic.
The self-reported worsening of mental ill health by parents and children during the pandemic is also of concern. More needs to be done to reach and support those with long-term mental ill health caused by the pandemic. Policy and decision makers should also make provision for the continuing need to support and protect vulnerable families from financial, food and housing insecurity, and loneliness, all of which were associated with poor mental health in adults in this study.
Being able to leave the home environment was found to be significantly associated with children being sufficiently physically active during the first COVID-19 lockdown. The Government guidance during the first and all subsequent lockdowns has been to minimise the time spent outside of the home, and in the first lockdown this was restricted to up to one hour a day. Our findings illustrate the importance of allowing extended time outside of the home for children to be physically active, with relevant public health messaging directed at parents to emphasise both the importance and safety of this.
Impact of our research and future research
By co-producing our research with communities, key policy and decision makers, we have produced findings that are both meaningful and readily translatable into local practice. Emerging findings have been rapidly disseminated to community and stakeholder groups using briefing notes, meetings, and informal communication channels (for example WhatsApp groups). This provided an opportunity to contextualise findings within our communities and to spark further conversations about emerging priorities, and also help to develop recovery plans within the city to address these (BIHR C-SAG, 2021).
We have also worked with our community steering group to co-produce accessible, bite-size summaries of key findings to share with our families and communities. Our community advisors were keen that we use these findings to empower local communities, so findings were combined with positive actions that could be taken to address the issues we had discovered. We will continue to follow our families during the recovery from the pandemic and look at the full trajectories of the COVID-19 Government responses on vulnerable families using our Phase 3 survey. Key areas for future research include understanding the persistence of (and resilience from) mental ill-health and physical inactivity triggered by the pandemic and how to best address these with culturally appropriate interventions.
The rich insights from our BiB COVID-19 research with seldom-listened-to communities has only been possible because of the enthusiasm
Acknowledgements
We would like to acknowledge the input of the wider Bradford Institute for Health Research COVID-19 Scientific Advisory Group and the Community Steering group in this research programme.
Notes
For financial insecurity we used the question: ‘How well would you say you are managing financially right now?’ Answer options are: living comfortably, doing all right, just about getting by, finding it quite difficult, finding it very difficult. The final three options were grouped and categorised as indicating current financial insecurity.
For depression we used total scores on the PHQ8 and standard categorisations (0 to 4 no depression, 5 to 9 mild depression, 10 to 14 moderate depression, 15 to 19 moderately severe depression and 20 to 24 severe depression). Similarly, for anxiety we employed total scores on the GAD7 and standard categorisations (0 to 4 no anxiety, 5 to 9 mild anxiety, 10 to 14 moderate anxiety and 15 to 21 severe anxiety). Moderate, moderately severe, and severe categories were collapsed to indicate clinically important symptoms of depression and anxiety. For regression analyses, we used an increase of five or more points as a clinically important increase in symptoms.
Government guidelines recommend that adults accumulate 150 minutes of moderate-to-vigorous physical activity (MVPA) across a week, with a suggested guide of 30 minutes’ activity five days a week. For children, guidelines recommend achieving an average of 60 minutes of MVPA daily.
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