Beyond the lockdowns: Lessons learned from Leicester's COVID story

Health inequalities

There are always going to be differences in health, many of which are unavoidable, older people tend to experience more ill health than younger people due to the natural ageing process for example. However, many differences in health are avoidable and unfair:

• People living in more affluent areas can often live longer than individuals who live in the most deprived areas of the city. In Leicester there is a seven-year difference in life expectancy between men living in the most and least deprived areas. Those living in the most deprived areas of Leicester will also live more years in poor health than those in the least deprived.
• The death rate for coronary heart disease is three times higher amongst unskilled men than professionals and the gap has been widening.
• Education and employment have been identified as fundamental determinants of health inequalities. It is important to reduce differences in the early years’ development of children to ensure that children from low-income families can take full advantage of opportunities at school and subsequently at work. In addition, improving people’s health can support many people into work which further enables the city to benefit from a healthy and thriving workforce population.
• Diverse Communities can experience worse health, often connected to income and the conditions in which people are living but regarding lifestyle choices there are a number of issues that contribute to such populations being less likely to make healthy lifestyle choices including inaccessible venues and facilities, lack of empathetic, experienced and reflective workforces, language and cultural barriers and affordability of activity. 

Healthy lives in Leicester

• Rates of diabetes are significantly higher in Leicester compared to England, with an estimated 31,000 adults living with diabetes in the city.
• 19% of Leicester residents aged 16+ are obese, with a further 31% classed as overweight.
• One in ten adults drinks alcohol above the recommended weekly units.
• One in five adults in Leicester eats the recommended five fruit and vegetables a day
• Around 48,500 people in Leicester are multi-morbid, meaning an individual is living with more than one long term physical or mental health condition.
• In Leicester, 25% of people living with diabetes have five or more additional health conditions, and 35% of those living with depression have three or more additional health conditions
• Leicester experiences high levels of deprivation and health inequalities which have an impact on the health and wellbeing of its residents. Its communities are diverse, and members of these communities are at an increased risk of experiencing a number of life-limiting long-term conditions at a lower Body Mass Index (BMI) including diabetes and cancer.
• The 2020/21 Active Lives Survey shows higher rates of inactivity in Leicester compared to England. 36.8% of Leicester’s population aged 16+ did less than 30 minutes of physical activity per week and are therefore classed as physically inactive compared to 27.2% in England overall.
• There are significant health inequalities in relation to physical inactivity according to age, gender, ethnicity, socioeconomic status and disability. Leicester’s Health & Wellbeing Survey (2018) highlighted that;
  • Women are generally less likely to achieve the recommended 150 minutes of physical activity each week compared to men.
  • People of Asian heritage are significantly less likely to achieve the recommended physical activity levels, compared to ethnically White residents.
  • People of Black British ethnicity are significantly more likely to be inactive.
  • Physical inactivity rates increase with age group: 65+ year olds are three times more likely to be inactive than 16-24 years olds.
  • Those in bad health, lacking formal qualifications, disabled, retired or with poor mental wellbeing were also significantly more likely to be physically inactive.
• There is also geographical variation across the city, with the proportion of residents who meet the recommended amount of exercise differing; with residents in West and South more likely to achieve the recommend amount of exercise whereas residents in the East and North are doing less. This variation is likely to be related to both deprivation and ethnicity.
• Leicester’s parks and open spaces are not used effectively, Leicester residents are significantly less likely to exercise using outdoor space than England, with only 12% using parks or the countryside for health or exercise purposes compared to 17.9% in England on a weekly basis.
• As people become busier, there has been more inclination to participate in informal activity. In the Leicester Health and Wellbeing Survey (2018) informal activities were most popular with 47% of people walking for leisure and 35% walking for travel. A fifth of respondents named heavy housework (20%) and only a sixth (17%) referred to sports.
• Leicester City has higher rates of smoking than the national average of 14.4%, however, the percentage has been gradually falling from 21.3% in 2015 to 15.4% in 2019.
• Leicester tends to have a higher number of cases of smoking during pregnancy and at the time of delivery than the national average of 9.1%. Again, the numbers have been falling, with 10.2% in 2019 and current data of 10.0% in 2021.
• Smoking among routine and manual workers is known to be a common risk group, however, they also have been changing their attitudes with a prevalence of 24.7% in 2018 to 22.6% in 2020.
• This has been the case in other at-risk groups such as those with mental health issues. Leicester City council found that 31.5% of those with poor mental well-being smoked in their Leicester City Wellbeing survey in 2018. This number has since fallen to 28.6% in 2020.

COVID-19 and healthy lives

Over the last 2 years, there has been a significant impact from the COVID 19 pandemic. The virus has posed serious challenges to the residents of Leicester with the city experiencing an extended lockdown which severely limited the opportunity for people to remain active and eat healthily, in addition the stressful experiences throughout the pandemic increased alcohol and drug consumption in many residents and cigarettes smoked by smokers.

As many of our lifestyle services had to adapt quickly to new measures such as social distancing, not much data was recorded during this time, however, looking at the data pre and post-pandemic, we can see a steady trend in the uptake of the Live Well services[ii]. This includes the weight management service, physical health services and stop-smoking services.

Requirements for self-isolation particularly amongst the clinically vulnerable and the emergence of newer variants posing need for harsher and ongoing restrictions impeded the return of employees to physical workspaces and limited social interaction and opportunities for physical activity. This not only reduced the positive mental benefits of social engagement but also physical activity from meeting friends and commuting to work.

As a result of the pandemic many food businesses increased their delivery and take away options resulting in larger numbers accessing more unhealthy food whilst also becoming less physically active. This increasing consumption of out-of-home meals has been an important contributing factor in the increasing rates of obesity, with higher rates noticed in the unemployed, sick, disabled, BME group and those between ages 16 and 34. The 2020/21 cohort for National Child Measurement Programme data collection is much smaller due to issues with data collection during the pandemic, which may affect the quality of the data presented, however the data did show fairly drastic increases in unhealthy weight amongst reception and year 6 children in Leicester during the pandemic. NCMP data for 2021-2022 shows that shows that unhealthy weight levels in CYP across the City are improving, however it has not reduced to pre-COVID levels.

The pandemic impacted on activity levels nationally but was most acute in disadvantaged groups and areas of high deprivation. The most recent Sport England Active Lives survey (covering May 2020-May 2021) shows that compared to 12 months earlier there were 700,000 fewer active adults, and 1 million more inactive adults in this timeframe.

It was noticed that during lockdown many food providers developed more take away and delivery options across the city, increasing the availability of highly calorific food to residents across the city, this, combined with inactivity and increases in smoking and alcohol consumption adopted by many of the population as a coping mechanism during lockdown meant that many of our residents noted a negative impact on health.

Healthy lives COVID response

Encouraging a healthy lifestyle throughout the COVID-19 pandemic remained a priority for the City’s Public Health team and partners. COVID-19 had a negative impact on both peoples mental and physical health including unhealthy weight, physical inactivity, smoking and alcohol and the national restrictions imposed on the public and services provided further challenges in delivering healthy lifestyle related services and advice.

As a result, providers of physical activity, smoking cessation and weight management very quickly developed and implemented virtual support for customers. This ensured that support to lose weight and stop smoking were delivered over the telephone or zoom and clients continued to receive the support they needed to continue to adopt healthy lifestyle behaviours. However virtual support was not without its challenges, accurate recording of quit rates and weight/measurements proved difficult to provide. Differences in clients type and accuracy of scales at home, self-reported weight loss and inability to carbon monoxide test meant that monitoring and evaluating services outcomes had to take additional issues into consideration in regards to accuracy of results.  

Leicester experienced an extended lockdown and the impact of this on residents was in some cases quite severe resulting in increases in unhealthy lifestyle behaviours and poorer mental health including weight gain, physical inactivity, increased smoking and alcohol consumption. As a result, our Adult Weight Management Service found that during the pandemic it was more beneficial to implement a harm reduction approach and encourage weight maintenance rather than focus on weight loss during lockdown. Given the challenges people were facing with food shopping and National restrictions that prevented people from being physically active this approach was deemed to be the most beneficial and realistic to service users. The service noted that consumption of unhealthy food was increasing and activity decreased due to the amount of time people spent at home and the increase in availability of unhealthy food deliveries. It was therefore more beneficial to the client to support them to not increase their weight during lockdown rather than pursue further weight loss due to the restrictions that were beyond anyone’s individual control. The weight management service did notice a slight reduction in clients joining the virtual courses with some people opting to be added to a waiting list for when face to face courses were re-launched. However, there were nearly 350 people who attending a virtual weight management course. Whilst there were some comments from patients who missed the interaction with others and the group exercise sessions, many found the regular calls from the dieticians / nutritionists on the groups to be extremely valuable. One client rated the service as 10 out of 10 and said the calls helped them a lot when they have been stuck at home.

In regards to physical activity, working from home and lockdown drastically decreased the levels of physical activity across the city. National restrictions meant that the population apart from essential workers must work from home and were limited to 1 hours exercise per day. Whilst we did see larger numbers than usual using this time to visit a park or local green space, the reductions in daily activity through the loss of active travel, commuting, PE in schools, ability to visit friends and socialise, attending leisure centres and gyms etc for formal activity meant a general reduction in physical activity for the majority of residents in Leicester. Many of our physical activity providers such as Live Well Leicester, Active Leicester, Inspire Together and professional sports clubs adapted to virtual support and guidance through online activities, newsletters, activity challenges and competitions to encourage the public to be active. The Public Health team developed new messaging for our outdoor gyms to ensure that they continued to be utilised safely by residents during the pandemic.