Quality of life, capability well-being, financial strain and physical activity in the short- and medium-term COVID-19 post-lockdown phases in the UK: a repeated cross-sectional study

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Background and introduction

Health-related quality of life (HRQL) is described as emotional and physical functioning that contributes to overall quality of life1 and is an important factor in healthcare and policy decision-making. 2 Capability well-being measures broaden the scope and are complementary to HRQL when evaluating the cost-effectiveness of health and well-being interventions delivered outside of NHS settings (e.g. public health). Measures such as the EQ-5D,3,4 ICEpop CAPability measure for Adults (ICECAP-A) and Child Health Urtility 9 Dimension (CHU9D)5 were developed for use in evaluating the cost-effectiveness of health and well-being interventions for adults and children. Measures of socio-economic position including income and poverty level are important contributors to both HRQL and capability well-being. 6 The relationships between these variables are, however, complex, as access to healthcare can be socially patterned, while income can moderate availability of resources that enhance quality of life (e.g. the option to engage in recreational activities) or support an adequate standard of living (e.g. sufficient food). 6,7

The COVID-19 lockdowns had a negative impact on the UK population’s mental health and well-being,8–10 although ongoing implications are still unclear and may be unequally distributed with different facets (e.g. sadness, optimism) impacted in different ways. The ending of lockdowns was associated with an improvement in mental health for the majority of children; however, the negative effects persisted in low-income families9 and as such warrant further examination. The COVID-19 pandemic caused financial insecurity and hardship for many UK families11 and the UK ‘cost of living crisis’ is further compounding these issues. 12 These coinciding challenges may have had a detrimental impact on the population’s quality of life and well-being. For example, evidence has shown that in summer 2020 financial stress was associated with worse family well-being. 13,14 As such it is important to understand the links between these variables as the pandemic progressed. Despite its importance to policy-makers and in contrast to mental health, HRQL during the COVID-19 pandemic and period of recovery is relatively unexplored. A systematic review identified only six studies comparing pre and during COVID-19 lockdown HRQL15 in children, none of which were UK based. The majority (four of the six) of studies indicated a decline in HRQL. Similar findings are available for adults and also showed a decline, but again the data are limited. 16

Reported reductions in physical activity during COVID-19 lockdowns among both adults and children17–20 could be related to declines in HRQL and well-being. Evidence does suggest a positive relationship between physical activity and HRQL in adults21,22 and children,23 although the strength of this relationship in children is uncertain. Methodological factors such as use of a proxy rating of HRQL and measurement of physical activity contribute to this uncertainty. 23 Studies that explored this relationship during the pandemic were also limited by these issues. A study of Spanish and Brazilian children during the pandemic found that those meeting 24-hour movement guidelines had higher parent-proxy measured HRQL. 24 This is, however, in contrast to data from the UK Born in Bradford study, which reported that there was no observed relationship between self-reported physical activity and well-being among 7–13-year-old children. 25 Thus far, evidence exploring the relationship between HRQL and physical activity during the pandemic is limited to children and seems to be uncertain. There is a need to use child-reported measures of HRQL and expand the evidence base to associations in adults.

The COVID-19 pandemic has had demonstrable negative impacts on health and well-being and physical activity but the association between them is uncertain. Furthermore, current evidence is reliant on self-reported physical activity, which has particular limitations when assessing physical activity among children and young people. 25 As such, more information is needed on the effects of the pandemic on HRQL and its relationship with physical activity. The Active-6 project reported that UK children’s physical activity following COVID-19 lockdowns was lower than pre-pandemic levels in the short term, and sedentary activity was higher. 18 Screen viewing time was higher than before the lockdowns. 26 Qualitative interviews with Active-6 participants suggested that the lockdowns exacerbated fatigue and children felt emotionally overwhelmed. 27 HRQL, capability well-being and family financial strain were also collected in the study, so provide an opportunity to explore the relationship between physical activity and HRQL outcomes post COVID-19 lockdowns. This forms a unique and policy-relevant resource for intervention development and policy-making, particularly as there is currently no UK-based evidence which has examined financial hardship and its implications for the population’s health and well-being.

Aims and objectives

The aim of this paper is to assess the differences in parent and child HRQL and capability well-being during the short- and medium-term post-lockdown phases of the COVID-19 pandemic. The relationships between these outcomes, family financial strain and accelerometer-measured physical activity are also explored.

Methods

The data in this paper are part of the Active-6 study, which examined the impact of the COVID-19 pandemic on the physical activity and sedentary behaviour of 10–11-year-old children and their parents/carers. 18,26–31 We report child and parent/carer questionnaire and accelerometer data collected at two time points post COVID-19 lockdowns, to assess physical activity and related measures18 in the short- and medium-term post-lockdown phases of the pandemic.

Schools in the southwest of England were recruited from a sample of 50 that had previously participated in the B-Proact1v longitudinal study between 2017 and 2018. 32 All children aged 10–11 and one parent or carer per family were eligible to take part, including all children in families where there were two or more eligible children. Detailed information on recruitment is reported elsewhere. 17 Data were collected in two waves, with 23 schools participating in Wave 1 (May–December 2021) and 27 schools in Wave 2 (January–July 2022), including 22 participating in both waves, with 393 and 436 child–parent pairs recruited, respectively. Sample size calculations were conducted for the primary outcome of the Active-6 study only (difference in children’s weekday MVPA). 28

Results

The majority of the parent/carers were female, White British and aged 40–44 years (Table 2). Around two-fifths lived in areas in the lowest deprivation quintile (Wave 1 45.3% and Wave 2 39.5%), and over half were educated to degree level or higher, indicating an affluent, educated sample. Questionnaire missing data were low and ranged from 6% (Wave 1 FESS) to 8% (Wave 2 EQ-5D-5L and EQ-5D VAS) (Appendix 1, Table 8). In both waves mean adult and child HRQL values were high, as would be expected in a non-clinical sample. Mean adult HRQL was lower than previously published norms, but capability well-being was higher than comparable pre-pandemic data. Mean child HRQL was higher than pre-pandemic comparable data. Adult and child HRQL measures were negatively skewed. A ceiling effect was observed for the EQ-5D-5L, with 41% scoring the maximum score at Wave 1 and 36% at Wave 2 (Table 3).

Is there a relationship between financial strain and HRQL and capability well-being?

Adult HRQL and capability well-being measures were inversely associated with financial strain, with HRQL decreasing as financial strain increased (Figures 1–4; Appendix 1, Table 9). For children (CHU9D), the relationship was less clear, with a slight non-linear association (Appendix 1, Table 9; Figure 4). The linear relationship between financial strain and measures of HRQL/capability well-being was modelled explicitly via mixed models (Table 6). Coefficients reflect the change in outcome measure as a result of an increase of 10 points in FESS score (scale 13–65). All coefficients are negative, indicating that as financial strain increases, HRQL/capability well-being decreases in both adults and children. The association was smaller for children (CHU9D) than adults.

TABLE 6 - Association between financial strain and HRQL/capability well-being measures

Difference in outcome associated with a 10-unit change in FESS score.

Note

All models allow for clustering at school and child level and are adjusted for IMD and highest household education. Parent models additionally adjust for parent gender and age group, and child models additionally adjust for child gender.

Outcome		Unadjusted model			Adjusted model
		Difference in outcomea	95% confidence interval	p-value	Difference in outcomea	95% confidence interval	p-value
Adult HRQL	EQ-5D-5L	−0.05	−0.07 to −0.04	< 0.001	−0.05	−0.06 to −0.04	< 0.001
Adult self-rated health	EQ-5D-VAS	−5.95	−7.05 to −4.84	< 0.001	−5.72	−6.89 to −4.55	< 0.001
Adult capability well-being	ICECAP-A	−0.05	−0.06 to −0.04	< 0.001	−0.05	−0.06 to −0.05	< 0.001
Child HRQL	CHU9D	−0.01	−0.02 to 0.00	0.001	−0.01	−0.01 to 0.00	0.010

FIGURE 1.

Scatter plot of parent/carer HRQL against financial strain. Note that points are jittered to avoid overplotting due to the underlying discrete nature of variables.

FIGURE 2.

Scatter plot of parent/carer EQ-5D VAS against financial strain. Note that points are jittered to avoid overplotting due to the underlying discrete nature of variables.

FIGURE 3.

Scatter plot of parent/carer capability well-being (ICECAP-A) against financial strain. Note that points are jittered to avoid overplotting due to the underlying discrete nature of variables.

FIGURE 4.

Scatter plot of child HRQL (CHU9D) against parent-reported financial strain. Note that points are jittered to avoid overplotting due to the underlying discrete nature of variables.

Discussion

The Active-6 project collected detailed data on HRQL, capability well-being, and financial strain in the period after the COVID-19 lockdowns were lifted in addition to accelerometer-measured MVPA. The data presented in this study make an important contribution to the field as to the best of our knowledge there is no comparable study that has used the CHU9D to measure children’s HRQL in the short to medium term after lockdown.

There were no differences in HRQL and capability well-being in either adults or children when comparing the short and medium post-lockdown phases of the pandemic. The Australian DETECT study54 collected adolescent (aged 12–18) CHU9D data from May 2020, finding higher levels of distress compared to data collected six years before. It is important to note, however, that the DETECT team did not score the CHU9D using recommended scoring algorithms, which limits comparability to our study and the wider field. Active-6 children’s HRQL and parent capability well-being were better than observed in studies of similar populations observed before the COVID-19 pandemic (CHU9D 0.83–0.84,49,50 ICECAP-A 0.8116). Related qualitative studies suggested some Active-6 child participants experienced increased mental health challenges, such as emotional overwhelm, and physical fatigue in the short-term post-lockdown phase. 27 Sadness and tiredness are facets of HRQL measured by the CHU9D, yet the scores we observed did not support the qualitative data. Interview and focus-group participants may not be representative of the Active-6 sample, however, or the CHU9D may not be sensitive to COVID-19 lockdown-related changes. In contrast to child HRQL, adult HRQL was below the 2014 estimates of population norms (estimate 0.9448) in both waves. While we are unable to explore causation using the Active-6 dataset due to lack of pre-COVID-19 data, many aspects of the experience of the COVID-19 pandemic and related lockdowns could have contributed to poorer adult HRQL. For example, social isolation could have exacerbated mental health difficulties and COVID-19 infection could have disrupted families’ usual activities.

It might be expected that lockdowns would impact capability well-being more than HRQL due to the measures’ focus on broader outcomes; however, we saw no difference in adult or child capability well-being between the two waves. It may be that any changes in HRQL or capability well-being during lockdowns were alleviated by the lifting of restrictions or that changes persisted post-lockdown, thus any differences were not evident at Wave 1 data collection. Alternatively, the measures used could be insensitive to impacts of lockdowns, or lockdowns may have had no effect on HRQL or capability well-being at all. For children’s capability well-being, the Active-6 findings are markedly different to those found in the CONTRAST study. 55 In CONTRAST, the majority of domains indicated no change or worsening since pre-COVID-19 where only ‘feeling safe and at ease’, ‘being able to seek support’ and questions regarding relationships reported no change or a positive impact. In Active-6 data, most responses indicated that children’s capability well-being had improved since the lockdown. These differences may be due to the CONTRAST study’s older sample (aged 11–15), the data collection during different phases of the pandemic or other demographic characteristics. Despite piloting, children aged 10–11 may have struggled to understand and answer the questions in Active-6. The CONTRAST study’s recruitment using social media could also contribute to these differences.

Families experiencing the most financial strain had worse HRQL and capability well-being, with scores well below population norms. Children from families experiencing most financial strain also appeared to have lower HRQL. This observed relationship between greater financial strain and lower HRQL/capability well-being is an important finding for future research and policy. Adult HRQL and capability well-being scores for families reporting the highest level of financial strain were below population norms and the comparable population scores. Similar relationships have been observed in the USA and Canada, where financial insecurity or material hardship (e.g. inability to afford food or rent) were associated with poorer family well-being at repeated time points during the pandemic,14 and increased financial stress was associated with increased socioemotional and behavioural difficulties in children. 56 Our finding that financial strain appeared to increase slightly between Wave 1 and Wave 2 could reflect early effects of the ‘cost of living crisis’12 on health and well-being. Equally, the economic impacts of COVID-19 may have accumulated over time, with families initially able to absorb changes in income due to reduced opportunities to spend disposable income on holidays or leisure activities, for example. Qualitative findings from the Active-6 study indicate that children’s extra-curricular physical activity behaviour has changed, with participation in more affordable school-based active clubs increasing. 31 This may reflect how families have had to adapt to the new economic context.

Family financial strain showed indications of worsening between data collection waves, but differences are difficult to interpret. There is limited use of the FESS in the UK, so the interpretation of absolute values and the impact of those changes in the context of this study is challenging. Mean scores obtained in the FESS validation study47 (conducted in 1997 in the USA) were 43.30 for single mothers and ranged from 29 to 30 for single and married fathers and married mothers. Mean scores in Active-6 were 26.3 (Wave 1) and 27.5 (Wave 2), suggesting marginally less financial strain, although our data were collected 25 years later and in a different context. Nevertheless, our study provides a unique insight into the financial challenges facing the UK population during the pandemic and as the ‘cost of living crisis’ begins to deepen, and therefore will provide a useful resource for future studies. Perceived financial strain could be an important measure to collect in future research. IMD (derived from home postcode) is typically used as an indicator of deprivation; however, financial shocks such as loss of income are unlikely to affect a family’s residential address immediately, if at all. Identifying individuals or families unable to afford resources crucial for living healthy and fulfilling lives may be advantageous for quickly highlighting more targeted opportunities for public health interventions.

Physical activity had no mediating effect on differences in adult and child HRQL/capability well-being between waves. Existing evidence exploring associations between children’s physical activity and HRQL/well-being during the pandemic is mixed,24,25 although no mediation analysis examining phases of the pandemic has been conducted. Our finding that those experiencing most financial strain had poorest HRQL could have implications for the provision of interventions aiming to improve population well-being through physical activity. To avoid exacerbating inequalities, affordability of new interventions and the financial situation of the target population should be important physical activity policy-making considerations.

Conclusions

Active-6 is the first study to explore the relationships between perceived financial hardship, HRQL capability well-being, and physical activity during the COVID-19 pandemic. We used validated outcome measures recommended for use in UK policy-making. While HRQL and capability well-being showed no differences as the pandemic progressed, families experiencing financial hardship had notably worse HRQL and capability well-being in both waves. This was most pronounced in children of parents reporting most financial difficulties. Using robust methods to collect accelerometer data, we did not observe a mediating effect of physical activity on HRQL.

Additional information

List of abbreviations

CHU9D

Child Health Utility 9 Dimension

EDI

equality, diversity and inclusion

FESS

Family Economic Strain Scale

HRQL

health-related quality of life

IMD

Index of Multiple Deprivation

MVPA

moderate to vigorous physical activity

PPI

patient and public involvement

SD

standard deviation

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Appendix 1 Child capability well-being questions

The questions below are about how things have changed since the UK went into lockdown in January 2021.

We are interested in whether you think that you have been able to have more or less of these things since the January 2021 lockdown restrictions began. For each question below, please select which statement best describes how you feel at the moment.