Abraham Makanjuola

Multidisciplinary collaboration is key to strengthening the evidence base for multifaceted illness prevention interventions. We bring together health economics and behavioral science to explore the well-being benefits and social cost–benefit of volunteer gardening at an accredited botanic garden, Wales, UK. A health economics-informed social return on investment (SROI) evaluation was combined with the assessment of volunteers’ basic psychological needs (autonomy, competence, and relatedness), connection to nature, and their interrelatedness in this innovative nature-based intervention study. Pre- and post-volunteering outcome data were collected using the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS), the ICEpop CAPability measure for Adults (ICECAP-A), the 12-item diary version of the Basic Psychological Need Satisfaction and Frustration Scale (BPNSNF), the Nature Connection Index (NCI), and a bespoke Client Service Receipt Inventory (CSRI). Results indicate that volunteer gardening can provide well-being benefits to participants and cost savings to the NHS. The well-being benefits observed were estimated to generate social value in the range of GBP 4.02 to GBP 5.43 for every GBP 1 invested. This study contributes to the evidence base that simple nature-based interventions such as volunteer gardening could offer low-cost supportive environments that deliver significant well-being benefits and associated social value to local communities, including a reduced burden on overstretched local healthcare services.

Rapid review methodology was used to identify updated economic evidence on programmes or interventions designed to enable employees to remain in and return to the workforce. In Wales, there are currently 1.48 million people in employment and 58,300 people who are unemployed. This equates to an unemployment rate of 3.8% in Wales. The evidence in this report builds on a previous Wellness in Work report (Edwards et al., 2019). This review has a broad focus to understand the economic impact of well-being within the workplace. The main section of the report is on the economic benefits of keeping the workforce well. Seventy-six papers were included from databases searched for literature published between 2017 and 2023. Economics studies were found relating to common mental health conditions; severe mental health conditions; influenza vaccination; illicit drug use; smoking and vaping; healthy eating and physical activity. A range of economic evidence of low, medium, and high quality relating to interventions targeting well-being in the workforce was identified. This included high quality evidence that interventions in the workforce for employees at risk of common mental health disorders can be cost saving for businesses and the health and social care sector. There is also high quality evidence on the cost-effectiveness of interventions focusing on healthy eating and physical activity in the workplace. Some evidence gaps were also identified. Policy and practice implications: There is a need to consider the evidence presented in this rapid review on cost-effective interventions to improve the wellness of the workforce in Wales. Updated policies and procedures to improve equal employment opportunities, regardless of age, gender, or disability status are needed. Economic considerations: Amongst the G7 nations, the United Kingdom (UK) is performing relatively poorly in relation to returning to pre-pandemic employment rates. This is in part caused by the long elective (planned) surgery waiting lists present in the National Health Service (NHS) right across the UK, highlighting the circular relationship between health and the economy. Funding statement: The Centre for Health Economics and Medicines Evaluation, the Bangor Institute for Medical and Health Research, and the Swansea Centre for Health Economics were funded for this work by the Health and Care Research Wales Evidence Centre, itself funded by Health and Care Research Wales on behalf of Welsh Government.

Background: A social prescribing (SP) link worker (LW) is responsible for enabling and supporting individuals, by assessing their personal goals and co-producing solutions to make use of appropriate local non-clinical resources or interventions. As an emerging new role, LWs are not regulated by professional bodies associated with SP. Therefore, currently there is no standardised training for LWs who are from varied backgrounds. As such, LWs have varying knowledge about how to deal with individuals with complex needs, which can impact on their decision-making capabilities to seek solutions and navigate complex systems. The purpose of the research was to explore LWs’ level of education, past and current training requirements as well as elicit how much LWs were willing to pay (WTP) to access and undertake training to improve their skill set. Methods: A rigorous mixed method research design was employed which included semi-structured interviews with key stakeholders and quantitative questionnaires including contingent valuation (CV) questions to a population of LWs across Wales from March to June 2020. Qualitative interviews with key stakeholders who commission and deliver social prescribing interventions employing LWs identified perceived link worker qualities and requirements for LW roles. Purposive sampling was used to identify and select individuals that have experience in managing LWs. Due to the COVID-19 pandemic, interviews were carried out exclusively online. LWs self-selected to complete the online questionnaires. Questionnaires gathered data on LW qualifications and demographic information with the CV questions gathering data on the value LW placed on accessing training in SP. Thematic narrative analysis was applied to interpret the data from the semi-structured interviews. Descriptive frequency analysis was conducted on the quantitative data generated from the online questionnaire. Findings: SP coordinators (n = 6) reported that ‘personal skills’ are the most essential skills required by LWs in SP intervention. Training is available for LWs; however, the training undertaken varies depending on the type of intervention delivered, with 70% of LWs previously undertaking training to facilitate their development as an LW. The results from the contingent valuation questionnaire (n = 54) indicated that 100% of the respondents would avail of training. LWs were asked how much they were willing to pay as a single payment for professional training; on average, LWs were WTP GBP 58 from their personal funds to access training and the associated benefits to enhance their skills and knowledge. Interpretation: The semi-structured interviews conducted with the key SP stakeholders yielded rich information and novel insight into LW training. External funding for the salary of the LW is an obstacle for LW development through training. In addition, the questionnaire results regarding stated preference techniques demonstrate that LWs place value on their professional development and would be willing to spend their own money on training to improve their knowledge and skills.

There is growing interest in green social prescribing and connecting with nature-based activities to promote social cohesion along with improving levels of health, wealth and well-being. The Outdoor Partnership is a third sector organisation based in North Wales offering nature based social prescribing interventions. Individuals experiencing poor mental health and wellbeing are referred from GPs, community mental health services, and third sector organisations to the ‘Opening the Doors to the Outdoors’ (ODO) programme which is a 12-week outdoor walking and climbing green prescribing intervention. The purpose of the ODO programme is to provide a supportive environment to increase levels of physical activity among participants leading to improvements in overall health and mental wellbeing while promoting socialisation among peers. In this evaluation of a preventative green social prescribing intervention, a mixed method social return on investment (SROI) approach used quantitative and qualitative data from ODO participants. Data collection took place from April 2022–November 2022. Mental wellbeing data was collected at baseline and at 12 weeks using the Short Warwick Edinburgh Mental Wellbeing Scale, a social trust question, an overall health question, and the International Physical Activity Questionnaire- short form. Baseline and follow-up data was available for 52 ODO participants. Results indicate that for every £1 invested in the ODO programme, social values ranging from £4.90 to £5.36 were generated.

Children and young people witnessing domestic violence and abuse (DVA) can be affected negatively in terms of their psychological, emotional, and social development. Adverse events in childhood are known to be harmful to a young persons development and influence their life course, and therefore is a significant public health issue. The aim of this rapid review is to highlight the evidence on effective interventions (and any relevant cost-effectiveness evidence) focusing on reducing the harms for children and young people who have been exposed to DVA. Twenty-five studies were identified along with three guidance documents from the Welsh Government and the National Institute for Health and Care Excellence (NICE) in the UK. Twenty papers from nineteen studies reported the effectiveness of a wide range of interventions to support children and young people who have witnessed DVA. Most studies found meaningful differences in behaviour following an intervention. However, some studies did not find any differences between the intervention and control groups following an intervention to reduce the negative effects of witnessing DVA. An included cost-effectiveness analysis suggested that for behavioural outcomes, a psychoeducational intervention delivered to parent and child in parallel is likely to be cost- effective among the interventions they compared. Two further full economic evaluation studies determined the cost-effectiveness of cognitive behavioural therapy interventions to support children and young people who have been exposed to DVA. Policy and practice implications: Economic evaluations have found preliminary evidence that cognitive therapy is a cost-effective intervention to treat children and adolescents with PTSD. Future interventions should be co-produced with relevant stakeholders and patient and public members (including children and young people). There is a need for larger, well conducted, pragmatic randomised controlled trials with longer follow-up periods. Funding statement The Bangor Institute for Medical and Health Research was funded for this work by the Health and Care Research Wales Evidence Centre, itself funded by Health and Care Research Wales on behalf of Welsh Government. What is a Rapid Review?Our rapid reviews (RR) use a variation of the systematic review (SR) approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. They follow the methodological recommendations and minimum standards for conducting and reporting rapid reviews, including a structured protocol, systematic search, screening, data extraction, critical appraisal, and evidence synthesis to answer a specific question and identify key research gaps. They take 1- 2 months, depending on the breadth and complexity of the research topic/ question(s), extent of the evidence base, and type of analysis required for synthesis. Who is this summary for?This Rapid Review was conducted as part of the Health and Care Research Wales Evidence Centre Work Programme. The above question was suggested by members of the Communities and Tackling Poverty Group, Welsh Government, and a public representative for the Health and Care Research Wales Evidence Centre. The findings of the Review will inform the Violence against Women, Domestic Abuse and Sexual Violence (VAWDASV) National Partnership Board’s Children and Young Persons working group. Background / Aim of Rapid Review Children and young people witnessing domestic violence and abuse (DVA) can be affected negatively in terms of their psychological, emotional, and social development (An et al., 2017; Anderson, 2017). Adverse events in childhood (ACEs) are known to be harmful to a young person’s development and influence their life course (Campbell et al., 2016; Edwards, 2022; Lester et al., 2020), and therefore is a significant public health issue (Bellis et al., 2019). The long shadow cast by domestic abuse can influence the prospects and potential of individuals over the life course and beyond into future generations (Bellis et al., 2019; Edwards and McIntosh, 2019; Hardcastle et al., 2018; Hughes et al., 2021; Welsh Government, 2016a). The aim of this RR is to highlight the evidence on effective interventions (and any relevant cost- effectiveness evidence) focusing on reducing the harms for children and young people who have been exposed to DVA. The review question was: What is the effectiveness and cost-effectiveness of interventions in reducing the harms for children and young people who have been exposed to domestic violence or abuse? As part of an initial search for secondary evidence, a mixed method SR by Howarth et al (2016) was identified as a suitable basis upon which to build this RR. The Howarth et al (2016) SR was funded by the National Institute for Health Research (NIHR) and conducted in England (Howarth et al., 2016). This SR was specifically chosen because it included some economic evidence and reported evidence based on the type of domestic abuse interventions for children and young people. This RR builds upon Howarth et al (2016) by updating the evidence to include more recent studies. Key Findings Twenty-five studies were identified along with three guidance documents from the Welsh Government and the National Institute for Health and Care Excellence (NICE) in the UK. Effectiveness of interventions for those exposed to domestic violence and abuse Twenty peer-reviewed papers from nineteen studies reported the effectiveness of a wide range of interventions to support children and young people who have witnessed DVA. Interventions included advocacy services, psychoeducation, Cognitive Behaviour Therapy, play therapy and parenting skills training. Most studies found meaningful differences in behaviour following an intervention. However, some studies did not find any differences between the intervention and control groups following an intervention to reduce the negative effects of witnessing DVA. Cost-effectiveness of interventions for those exposed to domestic violence and abuse A cost-effectiveness analysis by Howarth et al (2016) suggested that for behavioural outcomes, a psychoeducational intervention delivered to parent and child in parallel is likely to be cost-effective among the interventions that they compared if willingness to pay was approximately £8000 (ICER = 3722 per Standard Mean Difference (SMD). Two further full economic evaluation studies determined the cost-effectiveness of CBT interventions to support children and young people who have been exposed to DVA (Aas et al., 2019; Shearer et al., 2018). Both the Aas et al (2019) and the Shearer et al (2018) interventions were deemed cost-effective alternatives relative to the control groups. Both studies were undertaken from health service and personal social services perspectives (although the authors of one of the studies did not explicitly state their perspective. Future studies may need to broaden their perspectives to consider wider costs to society (Edwards and McIntosh, 2019). Best quality evidence The best available economic evidence found in this the RR were the full economic evaluation studies that included both effectiveness and cost effectiveness elements (Aas et al., 2019; Shearer et al., 2018). The best quality evidence from the remaining 17 intervention studies reporting clinical effectiveness (which did not include full economic evaluations) were those that followed strict RCT methodology and subsequently scored well in our critical appraisal. All clinical effectiveness studies were deemed to be of moderate to high quality. Policy Implications Economic evaluations have found preliminary evidence that cognitive therapy is a cost- effective intervention to treat children and adolescents with PTSD. Future interventions should be co-produced with relevant stakeholders and patient and public members (including children and young people). Research Implications There is a need for larger, well conducted, pragmatic RCTs with longer follow-up periods. Robust full health economic evaluations for new and complex interventions in this area could include economic modelling once a solid evidence base exists. Information provided from the costing studies may be useful to inform future economic evaluations of interventions to support children and young people who have witnessed domestic abuse as they detail the key resources used for interventions. A wider societal perspective able to capture a broader set of costs and benefits, for example, possible parent productivity losses, warrants further consideration. Strength of Evidence All included studies were controlled trials, with most being RCTs. Certainty in the findings were moderate to low as most of the included studies had short time horizons and small sample sizes. Greater confidence in the findings would require a more robust evidence base.

Previous research has categorised symptoms of COVID-19 / Long COVID into 12 thematic areas including: fever, myalgia, fatigue, impaired cognitive function, and that COVID-19 survivors had reduced levels of physical function, activities of daily living, and health-related quality of life. Our aim was to review the evidence for interventions or best practice to support people with Long COVID, or similar post-viral conditions characterised by fatigue, to return to normal activities. Evidence was included from guidelines, systematic reviews (SR), and primary studies. The primary studies focussed on Long COVID (LC) indicated that there should be a needs-based focus to care for those with LC. Consideration should be given to individuals living with LC in the same way as people with disabilities are accommodated in terms of workplace adjustment. Two SRs indicated that non-pharmaceutical interventions (NPIs) for patients with LC or chronic fatigue syndrome could help improve function for activities of daily life. However, the third, most recent SR, concluded that there is a lack of robust evidence for NPIs. LC fatigue management methods may be beneficial under certain conditions. One SR reported work capability as an outcome however they did not find any studies which evaluated the impact of interventions on return to work/ normal life. One primary study, on individuals with CFS, described a written self-management programme. Following this intervention there was an 18% increase in the number of patients in employment. Policy and practice implications: Long COVID is still being established as a post-viral condition with many symptoms. Patient-centred treatment options such as occupational therapy, self-management therapy and talking therapy may be considered in the same way as for other debilitating conditions. Return-to-work accommodations are needed for all workers unable to return to full-time employment. Due to the nature of the studies included, there was little reported evidence of effectiveness of getting individuals back into their normal activities. Funding statement: The Bangor Institute for Health and Medical Research was funded for this work by the Wales COVID-19 Evidence Centre, itself funded by Health & Care Research Wales on behalf of Welsh Government. Rapid Review Details: Review conducted by: Bangor Institute for Health and Medical Research (BIHMR), Bangor University. Review Team: ▪ Dr Llinos Haf Spencer, l.spencer@bangor.ac.uk ▪ Dr Annie Hendry, a.hendry@bangor.ac.uk ▪ Mr Abraham Makanjuola, a.makanjuola@bangor.ac.uk ▪ Ms Bethany Fern Anthony, b.anthony@bangor.ac.uk ▪ Mr Jacob Davies, jacob.davies@bangor.ac.uk ▪ Ms Kalpa Pisavadia, kalpa.pisavadia@bangor.ac.uk ▪ Professor Dyfrig Hughes, d.a.hughes@bangor.ac.uk ▪ Professor Deb Fitzsimmons, d.fitzsimmons@bangor.ac.uk ▪ Professor Clare Wilkinson, c.wilkinson@bangor.ac.uk ▪ Professor Rhiannon Tudor Edwards, r.t.edwards@bangor.ac.uk Review submitted to the WCEC on: 11 January 2023 Stakeholder consultation meeting: 8 ^th November 2022 Rapid Review report issued by the WCEC in: January 2022 WCEC Team: Adrian Edwards, Ruth Lewis, Alison Cooper and Micaela Gal involved in drafting the Topline Summary and editing. This review should be cited as: RR00042_ Wales COVID-19 Evidence Centre Disclaimer: The views expressed in this publication are those of the authors, not necessarily Health and Care Research Wales. The WCEC and authors of this work declare that they have no conflict of interest. TOPLINE SUMMARY: What is a Rapid Review?: Our rapid reviews (RR) use a variation of the systematic review (SR) approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. They follow the methodological recommendations and minimum standards for conducting and reporting RR, including a structured protocol, systematic search, screening, data extraction, critical appraisal, and evidence synthesis to answer a specific question and identify key research gaps. They take 1 to 2 months, depending on the breadth and complexity of the research topic/question(s), extent of the evidence base, and type of analysis required for synthesis. Who is this summary for?: Policymakers in Welsh Government to plan and deliver services for individuals with Long COVID as they re-enter training, education, employment, and informal caring responsibilities. Background / Aim of Rapid Review: Previous research has categorised symptoms of COVID-19/Long COVID into 12 thematic areas including: fever, myalgia, fatigue, impaired cognitive function, and that COVID-19 survivors had reduced levels of physical function, activities of daily living, and health-related quality of life (Amdal et al., 2021; de Oliveira Almeida et al., 2022). NICE guidelines highlight the impact of the condition on quality of life and the challenge of determining best practice based on the current evidence (National Institute for Health and Care Excellence et al., 2022). Treatments for other post-viral syndromes may also apply to people living with Long COVID (Wong and Weitzer, 2021). Our aim was to review the evidence for interventions or best practice to support people with Long COVID, or similar post-viral conditions characterised by fatigue, to return to normal activities (including return to the workforce, education, childcare, or housework). Key Findings: Evidence was included from guidelines (n=3), systematic reviews (SRs) (n=3), and primary studies (n=4). Extent of the evidence base: ▪ Two SRs included non-pharmacological interventions for Long COVID or post-viral syndromes, including Long COVID (Chandan et al., 2022; Fowler-Davis et al., 2021). The remaining SR focused on interventions for Chronic Fatigue Syndrome (CFS). ▪ The four primary studies were conducted in the UK, USA, Norway, and Turkey. The SRs included studies from across Europe, Asia, Africa, and Australasia. ▪ Included SRs and primary studies evaluated non-pharmaceutical interventions, including fatigue management, exercise therapy, Cognitive Behavioural Therapy (CBT), workplace support, self-management, sleep therapy, music therapy, and counselling. ▪ Two relevant guidelines were identified for Long COVID and one for ME/CFS. The Long COVID guideline was aimed at employers, and the ME/CFS guideline was aimed at service providers and users. Recency of the evidence base: ▪ Included papers were from 2014 to 2022. Evidence of effectiveness: ▪ The primary studies focussed on Long COVID indicated that there should be a needs-based focus to care for those with Long COVID (Lunt et al., 2022; Skilbeck, 2022; Wong et al., 2022). Consideration should be given to individuals living with Long COVID in the same way as people with disabilities are accommodated in terms of workplace adjustment (e.g. part-time hours, working from home, or hybrid working). ▪ Two SRs indicated that non-pharmaceutical interventions for patients with Long COVID or CFS could help improve function for activities of daily life (Fowler-Davis et al., 2021; Larun et al., 2019). However, the third and most recent SR concluded that there is a lack of robust evidence for non-pharmaceutical interventions (Chandan et al., 2022). ▪ Long COVID fatigue management by exercise therapy, electrical nerve stimulation, sleep and touch therapy, and behavioural self-management may be beneficial when: physical and psychological support is delivered in groups, people can plan their functional response to fatigue, strengthening rather than endurance is used to prevent deconditioning, fatigue is regarded in the context of an individual’s lifestyle and home-based activities are used (Fowler-Davis et al 2021). ▪ One SR (Chandan et al 2022) reported work capability as an outcome however they did not find any studies which evaluated the impact of interventions on return to work/ normal life. ▪ One primary study concentrated on individuals with CFS (Nyland et al., 2014). Nyland et al. (2014) described a written self-management programme featuring active coping (with CFS) strategies for daily life. Following this intervention, there was an 18% increase in the number of patients in employment (from baseline to follow-up) (Nyland et al., 2014). Best quality evidence: ▪ The three SRs (Chandan et al., 2022; Fowler-Davis et al., 2021; Larun et al., 2019) were of high quality, as was one of the cohort studies (Lunt et al., 2022). Policy Implications: ▪ Long COVID is still being established as a post-viral condition with many symptoms. The Welsh Government may seek to consider patient-centred treatment options such as occupational therapy, self-management therapy and talking therapy (such as Cognitive Behavioural Therapy) in the same way as for other debilitating conditions including ME/CFS. ▪ Return-to-work accommodations are needed for all workers unable to return to full-time employment. ▪ Due to the nature of the studies included, there was little reported evidence of effectiveness of getting individuals back into their normal activities. Strength of Evidence: Confidence in the findings is low. Only four primary studies reported outcomes relating to work capacity and return to normal activities such as childcare and housework.

Aim The aim of this rapid review was to investigate whether lifestyle coaching could provide a cost-effective alternative to counselling for the UK National Health Service (NHS) treatment of common mental health conditions such as stress, anxiety and depression. Methods A rapid review approach was used to determine the evidence of health economics evaluations in the field of mental health services. A literature search of PubMed, CINAHL, Cochrane Library, ASSIA, PsycINFO and MEDLINE produced 2807 articles. We removed 778 duplicates, and 2029 study articles remained. Two reviewers screened titles and abstracts (RG and KP), and 37 papers met the inclusion criteria of this review. Following a full-text screening, a further 27 papers were excluded due to lack of relevance. Study designs which did not include economic evaluations (n=15) or did not include an evaluation treatment of mental health conditions with talking therapies (n=15) did not meet the inclusion criteria. Ten papers were included in the final rapid review. Results The database search yielded study articles which focused on the cost-effectiveness of counselling and other talking therapies such as Cognitive Behavioural Therapy (CBT). No literature was found to determine the cost-effectiveness, or effectiveness of lifestyle coaching. Due to a lack of economic evaluations, this review could not determine the potential cost-effectiveness of lifestyle coaching as a means of addressing the backlog for mental health support such as counselling in the NHS. Conclusion This review highlights the research gap in assessing the cost-effectiveness of lifestyle coaching for treating common mental health disorders. The proposed next step is to evaluate the effectiveness and cost-effectiveness of lifestyle coaching versus current treatment as usual (counselling) by using a feasibility randomised control trial. Paper type A rapid review Strengths and limitations of this study This rapid review found a range of different economic evaluations of mental health interventions for common mental health issues. All of the study articles found were moderate to high quality, some of the included study articles met all of the checklist criteria. This rapid review found no evidence from a UK study setting. However, all study articles came from OECD countries that share similar legal structures and policies with comparable populations. Despite being mentioned in a number of studies, it is unclear what treatment as usual refers to, and is perhaps not as usual as the studies suggest.

The COVID-19 morbidities model has been widely used since 2020 to support Test and Trace and assess the cost-effectiveness of the COVID-19 vaccination programme. The current iteration of the Long COVID model covers several morbidities associated with COVID-19, which are essential to plan for elective care in the future and identify which services to prioritise. However, there are uncertainties in the model around the long-term health-related quality of life (HRQoL) impact of COVID-19, which is primarily based on data for severe COVID disease or hospitalised patients at present. The COVID-19 morbidities model requires updating to address gaps and reflect the latest HRQoL evidence. The aim of this rapid review was to provide updated HRQoL evidence for the COVID-19 morbidities model to better support decision-making in relation to COVID-19 policy. Thirteen primary studies were identified. People who had an initial mild COVID-19 illness or were not treated in hospital can have a decreased HRQoL post-COVID. However, the extent, severity, and duration of this is not consistent. The evidence on the long-term impact of a mild COVID-19 infection on HRQoL is uncertain. Implications for policy and practice include: An initial mild COVID-19 illness can lead to a reduction in HRQoL and impaired mental health, but there is evidence indicating that patients can show significant recovery up to normal levels after one year. Employers should be aware that employees may have prolonged experiences of impaired mental health, including anxiety, depression, and fatigue, following COVID-19 disease, even if their initial disease was mild (not hospitalised). Public health agencies should make patients with mild COVID-19 disease aware of the potential for ongoing symptoms and ways to mitigate and manage them through raised awareness and education. Health Boards should review their provision of long-COVID services in relation to the extent of impacts identified. Better quality studies that report longitudinal follow-up data on HRQoL for a representative cohort of patients who have had mild COVID-19 are required. Funding statement: The Bangor Institute for Health and Medical Research, Bangor University was funded for this work by the Wales Covid-19 Evidence Centre, itself funded by Health & Care Research Wales on behalf of Welsh Government. Rapid Review Details: Review conducted by: Bangor Institute for Health and Medical Research Rapid Review Team Review Team: Dr Llinos Haf Spencer, l.spencer@bangor.ac.uk Dr Annie Hendry, a.hendry@bangor.ac.uk Mr Abraham Makanjuola, a.makanjuola@bangor.ac.uk Mr Jacob Davies, j.davies@bangor.ac.uk Miss Kalpa Pisavadia, kalpa.pisavadia@bangor.ac.uk Professor Dyfrig Hughes, d.a.hughes@bangor.ac.uk Professor Deb Fitzsimmons, d.fitzsimmons@swansea.ac.uk Professor Clare Wilkinson, c.wilkinson@bangor.ac.uk Professor Rhiannon Tudor Edwards, r.t.edwards@bangor.ac.uk Review submitted to the WCEC in: July 2022 Rapid Review report issued by the WCEC in: August 2022 WCEC Team: Adrian Edwards, Ruth Lewis, Alison Cooper and Micaela Gal involved in drafting, Topline Summary, editing etc. This review should be cited as: RR00040. Wales COVID-19 Evidence Centre. What is the long-term impact of COVID-19 on the Health-Related Quality of Life of individuals with mild symptoms (or non-hospitalised): A rapid review. July 2022. This report can be downloaded here: https://healthandcareresearchwales.org/wales-covid-19-evidence-centre-report-library Disclaimer: The views expressed in this publication are those of the authors, not necessarily Health and Care Research Wales. The WCEC and authors of this work declare that they have no conflict of interest. TOPLINE SUMMARY: What is a Rapid Review?: Our rapid reviews use a variation of the systematic review approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. They follow the methodological recommendations and minimum standards for conducting and reporting rapid reviews, including a structured protocol, systematic search, screening, data extraction, critical appraisal, and evidence synthesis to answer a specific question and identify key research gaps. They take 1-2 months, depending on the breadth and complexity of the research topic/ question(s), extent of the evidence base, and type of analysis required for synthesis. Who is this summary for?: The Department of Health and Social Care (DHSC), who have previously created a COVID-19 morbidities model to support the COVID-19 pandemic response . It will also inform Welsh Government policy through work conducted by the Technical Advisory Cell. Background / Aim of Rapid Review: The COVID-19 morbidities model has been widely used since 2020 to support Test and Trace and assess the cost-effectiveness of the COVID-19 vaccination programme. The current iteration of the Long COVID model covers several morbidities associated with COVID-19, which are essential to plan for elective care in the future and identify which services to prioritise. However, there are uncertainties in the model around the long-term health-related quality of life (HRQoL) impact of COVID-19, which is primarily based on data for severe COVID disease or hospitalised patients at present . The COVID-19 morbidities model requires updating to address gaps and reflect the latest HRQoL evidence. The aim of this Rapid Review was to provide updated HRQoL evidence for the COVID-19 morbidities model to better support decision-making in relation to COVID-19 policy. The latest edition of the model was published by the DHSC team in December 2020. The review focused on studies reporting on the long-term impact on HRQoL of patients who had experienced mild symptoms or were not treated in hospital . Inclusion was limited to studies that used validated HRQoL measures, which can be mapped onto EuroQol Quality of Life Measure – 5 dimensions (EQ-5D) and conducted in OECD countries. Two existing systematic reviews were used to identify relevant primary studies published before January 2021, with new searches focusing on the period between January 2021 to June 2022. Key Findings: Thirteen primary studies were identified. Extent of the evidence base: Most studies (n=8) were cross-sectional surveys or reported on HRQoL outcomes at a single time point post-COVID (n=2). Only three studies (one of which was a case report) provided longitudinal follow-up data , which included changes from baseline or reported data at multiple time points. Only two studies reported on HRQoL beyond six months follow-up : One study reported data at three months, six months, and twelve months follow-up and one study measured outcomes at six to eleven months. Five studies measured HRQoL at three months post COVID-19, one at four months, and one at five months. Three studies reported data at two months or less post COVID-19. Two studies (one was a case report) focused solely on patients with mild infection , whilst the remaining eleven studies also included patients with moderate or severe/critical COVID-19 illness. Three studies included participants categorised as non-hospitalised or hospitalised patients. twelve studies recruited patients attending outpatients or health care settings; one study recruited a general Swedish population who had a previous COVID-19 infection. The studies were conducted in Turkey (n=2), Denmark (n=1), Sweden (n=1), USA (n=2), Chile (n=1), Ukraine (n=1), Mexico (n=1), Austria (n=2), and The Netherlands (n=2). No UK-based studies were identified. Recency of the evidence base: Three studies published in 2022 were conducted in 2021 (Akova & Gedikli, 2022; Bileviciute-Ljungar et al., 2022; Tanriverdi et al., 2022). Summary of results: People who had an initial mild COVID-19 illness or were not treated in hospital can have a decreased HRQoL post-COVID. However, the extent, severity, and duration of this is not consistent. Best evidence available: Han et al., (2022) recruited outpatients who had mild initial COVID-19 disease and measured HRQoL at six to eleven months follow-up; 436/2092 (21%) outpatients responded to the survey. The findings indicated that the burden of persistent symptoms was significantly associated with poorer long-term health status, poorer quality of life , and psychological distress. Siegerink et al., (2021) measured HRQoL at three months, six months, and twelve months follow-up , and recruited patients presenting at hospital with COVID-19, a proportion of whom were not hospitalised . At three months follow-up, 22% (n=9) of the non-hospitalised group reported abnormal Hospital Anxiety and Depression Scale (HADS) scores (cut-off at 16). After six months, this decreased to 16% (for n=4), and 14.8% at twelve months (n=4). Labarca et al., (2021) reported a change from baseline in percentage satisfaction with HRQoL . They found 50% of the (n=18) ‘mild’ (non-hospitalised) COVID-19 patients reported an individual change in HRQoL , categorised as a change of ≥ 10% on a Visual Analogue Scale (VAS) at four months follow-up . Policy Implications: An initial mild COVID-19 illness can lead to a reduction in HRQoL and impaired mental health, but there is evidence indicating that patients can show significant recovery up to normal levels after one year. Employers should be aware that employees may have prolonged experiences of impaired mental health, including anxiety, depression, and fatigue, following COVID-19 disease, even if their initial disease was ‘mild’ (not hospitalised). Public health agencies should make patients with mild COVID-19 disease aware of the potential for ongoing symptoms and ways to mitigate and manage them through raised awareness and education. Health Boards should review their provision of long-COVID services in relation to the extent of impacts identified. Better quality studies that report longitudinal follow-up data on HRQoL for a representative cohort of patients who have had mild COVID-19 are required. Strength of Evidence: The evidence on the long-term impact of a mild COVID-19 infection on HRQoL is uncertain.