As we enter a new year and a new national lockdown, it is clear that the continuing coronavirus pandemic, the restrictions imposed to prevent its spread and the knock-on social and economic impacts will clearly have far reaching consequences on peoples’ lives for years to come. Having worked in the field of life course epidemiology for over 20 years, Professor Rebecca Hardy, CLOSER Director, reflects on how a life course approach can aid understanding of the likely long-term impacts of the pandemic.
A life course approach in research emphasises how experiences and exposure to risk and protective factors in earlier life have an impact on later life health and social outcomes. It also highlights the importance of identifying sensitive periods during the life course, where exposure may have particularly large effects on an outcome, and accumulation of exposure, whereby the length of time exposed is key in development of the outcome. Additionally, it emphasises the importance of trajectories in multiple life domains across life and life course transitions.
While in the short term a life course perspective might address the pre-pandemic characteristics which lead to vulnerability to infection and severity of illness, in the future, the long-term impacts of infection on later health and ageing, with consideration of the age at which infection occurred, will be studied. As is very clear, however, there are experiences and exposures, other than the infection itself, which will likely exhibit long-term impacts on health, well-being and life chances. Although children, adolescents and young adults are less affected by the infection, early life, being a period of rapid development and change, is a sensitive period for exposure to many risk factors. For example, there is a wealth of recent research indicating that adverse childhood experiences encompassing a range of exposures such as family conflict, abuse and parental health problems and death may have lifelong consequences for mental and physical health. Existing life course research is therefore able to shed light on the potential likely long-term impacts of pandemic-related exposures in younger generations, which can help to shape policy to alleviate such effects.
Mental health is one of the most studied aspects of the pandemic to date, and high levels of mental health symptoms have been reported. Research using longitudinal studies has the significant advantage of being able to compare mental health during the pandemic with that prior to the pandemic in the same individuals. For example, analyses from CLOSER Partner Studies, ALSPAC and Generation Scotland showed increases in anxiety and depression, particularly in younger age groups, women, those with pre-existing physical and mental health conditions and the more socioeconomically disadvantaged.
It was clear, even before the pandemic, that poor mental health among young people was a pressing social and public health challenge. Adolescence is a key period of life in the development of mental health symptoms and the period of life when gender differences emerge. Longitudinal studies have demonstrated the tracking of mental health across the life course, and that mental health symptoms and disorders are associated with multiple adverse physical health outcomes, including coronary heart disease, in later life. Thus, in order to provide services now and in future, it will be vital to understand whether the mental health impacts of the pandemic will be transient, or whether they continue across life, and the other traits that are associated with vulnerability to the mental health impact of the pandemic.
Obesity, development and health-related behaviours
Obesity, along with mental health, in children and adolescents was also a major public health challenge prior to COVID-19. Obesity is a risk factor for severe disease and COVID-19 mortality, to add to its relationships to many other health conditions. It is currently unclear what the effects of the pandemic will be on levels of obesity, but there is evidence that the pandemic is affecting health behaviours – some for the better and some for the worse – and that this varies across different groups of the population. Data from the Millennium Cohort Study suggests that changes in younger people have generally been towards more healthy behaviours, with increases in exercise, fruit and vegetable intake and less frequent alcohol consumption reported. There has been a great increase in the number of families experiencing food insecurity, according to CLOSER Partner Study, Understanding Society, implying that multiple aspects of malnutrition, including undernutrition and stunting, and overweight and obesity, may need to be monitored and considered in the future.
We know from existing research how growth and development across childhood and adolescence, and even growth of the foetus in utero, has long lasting effects on health. For instance, undernutrition in utero and poor height growth in childhood, along with rises in adiposity during puberty, are associated with higher coronary heart disease risk. It would therefore be pertinent to track the growth and development of children to establish whether this had been affected during the pandemic, and to track social inequalities. Further to this, like mental health, health behaviours exhibit some tracking across life, and life transitions can be key points in the life course where changes are most likely. There is the potential to capitalise on the better health behaviours in younger people established during the pandemic, and to understand the motivation behind such changes.
Economic and educational inequalities
The pandemic has exposed existing socioeconomic inequalities in the UK and appears to be widening them. Those already struggling financially are even more likely to be struggling during the pandemic, while the more advantaged are better off, according to findings from the British Birth Cohort Studies. The closure of schools during the first and current lockdown has necessitated children to learn from home. Data from Understanding Society found that children from more disadvantaged families devoted less time to schoolwork at home after a month of lockdown in April 2020. More disadvantaged children were more likely to lack access to equipment (computer, tablet, laptop etc.) required for home learning.
Decades of existing research from longitudinal studies show that socioeconomic disadvantage in childhood (irrespective of adult socioeconomic position) and accumulation of disadvantage over the life course, have long-term detrimental impacts on multiple health outcomes, including mortality, cardiovascular disease, obesity and functional capability in old age. Hence, action is required to prevent further widening of socioeconomic inequalities. In addition, it is important to ensure that inequalities in educational achievement are not increased during the pandemic given that education is a key driver of inter-generational social mobility.
Implications for the future
Monitoring the multiple short- and long-term impacts of the pandemic will require data from longitudinal studies pre-, during and post-pandemic. As always with life course research, we cannot be sure whether associations observed in previous generations will be generalisable to the experience of children today, and therefore longitudinal follow-up of all generations tracking key social and health indicators will be critical. However, based on what we know, action is required in order to prevent the potential harmful effects on younger generations in years to come, and to prevent the widening of long-term inequalities in social and health outcomes. A life course approach will play a key role as it will be critical to understanding how the impacts of the pandemic will depend on life stage and pre-existing vulnerability.
To read more blogs in the COVID-19: Perspectives series, visit our COVID-19 Longitudinal Research Hub.
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Prof Rebecca Hardy can be found on Twitter @rebeccajhardy