INTRODUCTION - The Scottish Government
EQUALITY AND FAIRER SCOTLAND DUTY ASSESSMENT OF THE HEALTH AND SOCIAL IMPACTS OF COVID-19SCOTTISH GOVERNMENT COMMUNITIES ANALYSIS DIVISIONJUNE 2020CONTENTS TOC \o "1-3" \h \z \u INTRODUCTION PAGEREF _Toc43890153 \h 2AGE PAGEREF _Toc43890154 \h 4DISABILITY PAGEREF _Toc43890155 \h 11GENDER REASSIGNMENT PAGEREF _Toc43890156 \h 21RACE PAGEREF _Toc43890157 \h 24RELIGION OR BELIEF PAGEREF _Toc43890158 \h 31SEX PAGEREF _Toc43890159 \h 33SEXUAL ORIENTATION PAGEREF _Toc43890160 \h 38SOCIO-ECONOMIC DISADVANTAGE PAGEREF _Toc43890161 \h 39INTRODUCTIONThere are numerous different ways in which COVID-19 causes harm to the people of Scotland – directly and indirectly, in the short-term and the longer-term. ‘Coronavirus (COVID-19): framework for decision making’ identifies four main categories of harm.Direct harm to people's health.Wider impact on health and social care services, how people are using those services, and how this impacts on non-COVID health harms. Despite the NHS remaining open for those who need it, there have been significant reductions in people seeking help, and deaths from non-COVID causes appear to be high compared to previous years.The restrictions that have been put in place to slow the spread of the virus can, in turn, cause harm to our broader way of living and society. This could include:Poor mental well-being resulting from anxiety and uncertainty, social isolation and loneliness.Lack of physical activity, due to the requirement to stay home as much as possible in the initial phase, and the closure of gyms and sports centres.Increase in harmful behaviours, such as substance use and online gambling, as a potential reaction to the pandemic and the lockdown measures.Reduced access to food (including children unable to benefit from their free school meals due to school closures) and other essential goods and services for people who are self-isolating for various reasons.Increased fuel poverty, if spending more time in the home requires greater use of domestic energy.Impacts of closure of educational establishments (ELC, schools, colleges and universities) on the learning and wellbeing of children, young people and their families.Increase in certain types of crime, including domestic abuse, child abuse, online grooming of children, COVID-related fraud/scams/phishing, and stigma/discrimination/harassment against groups thought to pose high risk of transmissionThe impact on our economy, causing deep uncertainty and hardship for many businesses, individuals and households.This paper considers the first three of these categories of harm. The economic impacts on individuals are considered in a separate paper.COVID-19 affects everyone, but the harms caused by the pandemic are not felt equally. This paper explores the ways in which particular groups (based on Equality Act protected characteristics and socioeconomic disadvantage) are disproportionately affected. But it is important to remember that people do not neatly fit into single boxes. Every person and every family will display a combination of different protected characteristics. Although the analysis below focuses one by one on protected characteristics, we do not want to underplay this huge variation. It is important to remember both the intersectionality of protected characteristics, and the wide range of family circumstances that influence the barriers people face and their lived experience.AGESummaryAge is likely to play a role in terms of the health and social impacts resulting from the COVID-19 pandemic, with younger and older populations being affected differently. Specific risks that may need consideration in ongoing or new action include:Underlying health conditions, common among older people, alongside ageing immune systems, result in a death rate that increases substantially with age.A lack of capacity available in social care to meet the needs of older people should carers need to self-isolate due to COVID-19.Social isolation amongst older people, who are less likely to use online communications and who make up a large percentage of those who live alone. However, survey data suggest that it may be younger adults who are at greatest risk of poor mental wellbeing during the pandemic.Increases in neglect, physical abuse, emotional abuse and/or sexual abuse towards children. High stress home environments will likely increase the likelihood of abuse, and individuals or groups may use the pandemic as an opportunity for criminal or sexual exploitation of children.Impact of the closure of early learning and childcare, schools and post school learning facilities on the learning and wellbeing of children and young people.BackgroundThe age distribution of the Scottish population in mid-2019 is shown below. One in seven (14%) people in Scotland were aged 70 and over, two-fifths of people (40%) were aged 50+, and 11% were aged 16-24.Direct harm to people’s healthMost younger people face lower health risks from COVID-19 than the general population. Older people are more likely to have underlying health conditions such as heart disease and diabetes, and ageing immune systems, and so the death rate from coronavirus increases substantially with age. As at 3 June 2020, over three quarters (76%) of all deaths involving COVID-19 to date were of people aged 75 or over. Nearly half (46%) of COVID-19 deaths registered to date related to deaths in care homes, 46% of deaths were in hospitals and 7% of deaths were at home or non-institutional settings.It is important that people are reached with accurate and clear information on how to try and protect themselves from infection. Nearly one in five (17%) of respondents to an April 2020 Ofcom survey of the public’s news consumption and attitudes agreed that they are ‘confused about what they should be doing in response to COVID-19’, and 40% agree that they are ‘finding it hard to know what’s true and what’s false about COVID-19’. Those aged 18-24 (52%) were more likely to agree that they are finding it hard to know what’s true and what’s false compared to those aged 65+ (30%). In a YouGov survey of adults in the UK, carried out on 13-20 April 2020, the percentage reporting that they were finding it difficult to stick to the social distancing rules decreased with age (from 18% of 18-24 year olds to 7% of those aged 65+).Working age adults in certain ‘key worker’ professions – including frontline health and social care workers – are also at an increased risk of contracting COVID-19.Wider impact on health and social care servicesIn 2017/18, the vast majority (77%) of clients for social care at home provided or purchased by local authorities in Scotland were aged 65 years old and over. These services give people the support, practical help and personal care that they need to live as independently as possible within their community.Many older people also receive informal care. If their carer is ill or needs to self-isolate due to COVID-19, they will no longer be able to give care. Some carers have emergency plans in place for others to step in, but most do not. In most cases, there is unlikely to be extra capacity available in social care to step in if carers are unavailable.Adults in Great Britain responding to the ONS Opinions and Lifestyle Survey in the period 17-27 April 2020 who said they were worried about the impact COVID-19 was having on their life, were then asked in which ways COVID-19 was affecting their life. Access to paid or unpaid care was being affected for 4.1% of 16-69 year olds, and 2.4% of those aged 70+.Harm to our broader way of living and societyMental wellbeingOlder people are less likely to use online communications, and 40% of those that live alone in Scotland are of pensionable age, making them at particular risk of social isolation.However, survey data suggest that it may be younger people who are at greatest risk of loneliness during the pandemic. Online YouGov surveys of adults in the UK carried out on 17-18 March and 2-3 April 2020 found that, at the time of the first survey, 10% said they had felt lonely in the previous 2 weeks because of coronavirus, rising to 24% by the time of the second survey. The equivalent figures for 16-24 year olds were 16% and 44%, respectively. The Children’s Parliament ran a survey of 3,698 children aged 8-14 in May and found that children are indicating a decline in mental wellbeing, feeling less cheerful, having less energy and feeling increasingly lonely. Early findings from a two-part survey conducted by the University of Sheffield, examining the impact of COVID-19 on young people at different stages of development (from ages 13-24) found that up to half of young people feel significantly more anxious than before the lockdown. Those whose parents are key workers reported significantly higher levels of COVID-19-related anxiety and trauma and worse overall wellbeing. Recent analysis of loneliness in Great Britain during the coronavirus pandemic, collected by ONS between 3 April and 3 May, found that just over half of those aged 16 to 24 (50.8%) have experienced lockdown loneliness, compared to just under a quarter of those aged 55-69 (24.1%). The ONS Opinions and Lifestyle Survey indicates that adults over 70 are at a somewhat lower risk than other adults of poor mental wellbeing during the pandemic.Indicators of well-being, Great Britain, 28 to 31 May 2020Percentage that report well-being is being affectedAll adults44%70 years and over36%Mean anxiety score*All adults3.770 years and over3Percentage with high anxiety (score 6-10)*All adults30%70 years and over24%Percentage feeling lonely often or always or some of the timeAll adults25%70 years and over17%Source: Office for National Statistics – Opinions and Lifestyle Survey* Anxiety is measured on a scale of 0 to 10, where 0 is “not at all” and 10 is “completely”Physical activityA recent telephone survey carried out by Ipsos MORI on behalf of the Scottish Government, 27 April to 3 May, found that many young people (aged 16-24) were exercising more both indoors and outside compared to the start of March (59% and 60% respectively). This was in contrast to just 24%-40% of those in older age groups exercising more indoors and 31%-46% of those in older age groups exercising more outside.Access to food and other essentialsOver 70s have been advised to follow enhanced social distancing, but not all will be at risk of food insecurity as a result of this. Those with sufficient financial resources, digital literacy and social networks are likely to be able to access supplies.Half of all adults in Great Britain responding to the ONS Opinions and Lifestyle Survey in the period 20-30 March 2020 said someone had offered to organise or bring food and other essentials to them, if they needed to self-isolate or became unwell. This rose to 83% for those aged 70 years and over. Similarly, the 2018 Scottish Household Survey found that the likelihood of saying you can rely on someone in your neighbourhood increases with age.Involvement with other people in the neighbourhood by age, 2018Age16-2425-3435-4445-5960-7475+ Could rely on someone in neighbourhood for help81%79%85%87%89%93%Could rely on someone in neighbourhood to look after home78%77%85%88%90%94%Could turn to someone in neighbourhood for advice or support 72%68%77%78%83%86%Source: Scottish Household SurveyIn a YouGov survey of Scottish adults carried out on 14-16 April 2020, the percentage agreeing that they worried about being able to get what they need from the supermarkets generally decreased with age (from 41% of 18-24 year olds to 31% of 55-64 year olds and 38% of those aged 65+).The telephone survey carried out by Ipsos MORI on behalf of the Scottish Government, 27 April to 3 May, found that those aged 16-24 were more likely to be experiencing difficulty getting the food or medicine they need (16%) than those aged 25-34 and 55-69 (both 8%). There is a clear relationship between age and use of internet, with lower rates of internet use among older adults. In 2018, 100% of adults aged 16 to 24 reported using the internet, compared to 38% of those aged 75 and over.left20447000Use of the internet by age, 2018 povertyJust over a quarter (28%) of older households were estimated to be in fuel poverty in 2018, similar to other households without children (27%) but a higher fuel poverty rate than families (17%).EducationLarge numbers of children and young people are unable to attend early learning and childcare, school, college or university. Disrupted education at a critical time will likely lead to negatively affected, and potentially long-term, educational and social outcomes. This is particularly the case for young people in families that lack study space and/or access to home computing. Results from The Children’s Parliament survey of 3,698 children aged 8-14 in May found that children are reporting less choice and a declining sense of fun or pride in their work as well as increased levels of boredom with regards to home schooling. With schools closed, there is an expectation that parents will support their child’s learning from home. This is likely to impact families with different protected characteristics and socio-economic circumstances in different ways – and these differential impacts are considered under the relevant sections.CrimeFor most children, home represents a source of security and safety. But for a minority, the opposite is the case. Violence by caregivers is the most common form of violence experienced by children. Children are also often victims of domestic abuse (by witnessing it, being used as part of the abuse, etc), the rates of which are thought to have increased as a result of COVID-19. Emerging qualitative evidence suggests lockdown has provided perpetrators with opportunities to increase the frequency and severity of their abuse. There is some evidence that suggests children are witnessing abuse more frequently. As children do not have access to safe spaces, there are fewer opportunities for them to report and therefore the perpetrator is less cautious to conceal abusive behaviours.It is likely that self-isolation may lead to an increase in instances of neglect, physical abuse, emotional abuse or sexual abuse to children. High stress home environments will likely increase the likelihood of abuse and individuals or groups may use the pandemic as an opportunity for criminal or sexual exploitation of children. This is also a time when children will be less visible to a range of professionals who would normally be engaging with them. There has been a reduction in referrals to children's services during the lockdown period (likely linked to reductions in contact with education and universal health services), with consequent concerns about at risk children not receiving the support and protection they need.Increased time at home due to self-isolation, and children’s reliance on online platforms for distance learning, will likely lead to increased time on the internet and an increased chance that some children will be exposed to online sexual groomers. The Internet Watch Foundation, the UK’s primary charity responsible for finding and removing videos and images of children suffering sexual abuse on the internet, has released a statement that they are “bracing themselves for a spike in public reports of child sexual abuse on the internet as more and more people stay at home during the coronavirus pandemic.”Fraudsters are exploiting the spread of coronavirus in order to carry out fraud and cybercrime. Police have reported an increase in coronavirus related scams. Many fraudsters choose a scam to employ against a particular grouping of people. For example, they may assume that older people are more likely to be at home during the day, and therefore more likely to be susceptible to doorstep crime. Younger people may be more targeted by online fraud, on the assumption that older people are less likely to use the internet, although this may not be the case in future as more older people go online. A Scottish Government analysis of fraud recorded by the police in 2018-19 found a median victim age of 48 (with a median age of 60 when looking specifically at phishing scams).Harmful behavioursThe prevalence of hazardous or harmful drinking differs significantly by age, with those aged 75 and over less likely to drink at hazardous or harmful levels than other adults (12% compared with 22-27% for other age groups). Non-drinking prevalence is highest among those aged 65 and over (30% of those aged 75 and over and 21% of those aged 65-74); prevalence ranged from 13% to 15% for the younger age groups. The mean number of units of alcohol usually consumed per week also differs by age, with lower levels of consumption among those aged 75 and over than among other age groups (8.4 units, compared with 11.8-14.0 units for younger age groups). However, the proportion of drinkers who drank alcohol on more than five days in the past week increases with age (from 1% for those aged 16-24 to 28% for those aged 75 and over).Those aged 16 to 24 are most likely to have taken illicit drugs in the last 12 months, with almost one-in-five (19.2%) in this category reporting use compared to around one-in-two-hundred of those aged 60 and over (0.5%).Gambling activity also varies by age, with the youngest and oldest age groups having the lowest gambling participation rates (in 2017, 51% of those aged 16-24 and 44% of those aged 75 and over report having gambled in the past 12 months), and participation being highest among those aged 45-54 (73%). However, these patterns are highly influenced by National Lottery only gambling activity. By looking at any gambling activity excluding National Lottery only play, different participation patterns by age emerge. Gambling activity (excluding National Lottery only) is at its highest for those aged of 25-34 (at 58%) and then gradually decreases as age increases, down to 25% among those aged 75 and over. Problem gambling is also significantly associated with age: adults aged 16-54 are more likely to be problem gamblers than those aged 55 and over.DISABILITYSummaryDisabled people are likely to experience a range of health and social impacts resulting from the COVID-19 pandemic. Specific risks that may need consideration in ongoing or new action include: Increased vulnerability to ill-health or death arising from COVID-19 due to pre-existing health conditions; difficulties implementing measures to reduce transmission; and/or due to possible postponement of treatments for pre-existing conditions.Exacerbation of already poor physical and mental health due to loneliness and reductions in mental wellbeing experienced during isolation and restrictions in the ability to undertake physical activity. Difficulties accessing food and other essential supplies due to shortages of food in shops, difficulties affording food, inability to get online shopping slots and isolation.Disruptions to social care arrangements due to care staff being redeployed to work on COVID-19, lack of personal protective equipment for carers, and family members being unable to provide unpaid care due to themselves being ill or isolating.BackgroundDisability is defined in the Equality Act 2010 as ‘a long-term limiting mental or physical health condition, that has a substantial negative effect on your ability to do normal daily activities that has lasted, or is expected to last, more than 12 months. The Scottish Health Survey estimates that, in 2018, 33% of adults (and 12% children) in Scotland were disabled, defined as having a limiting long-standing condition, and 46% of adults (and 6% of children) had a non-limiting longstanding illness.The prevalence of disability is greater for certain groups in Scotland, including:Older people: in 2018, over half of adults aged 75 and above (56%) were disabled compared with 19% of adults aged 16-24.Adults with the lowest household incomes: in 2018, 51% of adults with household incomes in the bottom quintile (less than ?14,300) were disabled compared with 23% adults with household incomes in the top quintile (?49,400 and above). Women: in 2018, 36% of women were disabled compared with 30% of men. Direct harm to people’s healthDisabled people are more likely to experience ill-health from contracting COVID-19 than the general population, due to higher prevalence of pre-existing health conditions and poorer overall health. Around 170,000 adults in Scotland have been defined on medical grounds as clinically extremely vulnerable due to having an existing health condition that puts them at very high risk of severe illness from COVID-19. An additional group of people are required to follow enhanced social distancing, because pre-existing health conditions or circumstances mean they are at increased risk of severe illness from COVID-19. These people require additional protection from infection and therefore possibly support accessing food and essential supplies until the highest infection risk has passed. A large proportion of disabled people will fall into these groups. Prior to the pandemic, a substantially lower percentage of disabled adults in Scotland (40%) reported ‘good’ or ‘very good’ health compared with non-disabled adults (90%). Disabled adults have a range of limiting long-term physical health conditions, such as those affecting the heart and respiratory system, which are linked to increased vulnerability to COVID-19 (Figure 1). An increased percentage of disabled adults (40%) also engaged in two or more health risk behaviours (smoker, obesity, low physical activity, harmful drinking) compared with all adults (29%) and non-disabled adults (23%).Prevalence of longstanding conditions among disabled adultsSource: Scottish Health Survey 2018 Of those who died with COVID-19 in April, 91% had at least one pre-existing condition. The most common pre-existing condition was dementia and Alzheimer’s disease (31% of all deaths involving COVID-19) followed by ischaemic heart disease (13%).It is also possible that disabled people may be at increased risk of contracting COVID-19 due to barriers experienced in enacting preventative measures. Briefing by the World Health Organisation (WHO) states that disabled people may face greater challenges implementing regular handwashing and social distancing measures because of additional support needs. There may also be a requirement for some disabled people to use touch to obtain information from the environment or physical support, increasing the likelihood of virus transmission.Issues with the accessibility of information communicated about COVID-19 have been highlighted. On 21 April 2020, the Scottish Independent Living Coalition released a statement saying that more should be done to improve communications and the quality of information to disabled people during the COVID-19 pandemic to ensure accessibility, including the provision of British Sign Language (BSL) within healthcare settings.Wider impact on our health and social care servicesDue to the poorer physical and mental health experienced by disabled people on average, it is more likely that disabled people will require treatment for pre-existing health conditions during the pandemic. There have been news reports that screening and treatment of pre-existing health conditions being delayed in order to prioritise the COVID-19 response,,. A recent UK-wide survey of over 2,000 people with experience of mental health conditions revealed concern around access to mental health support for new and pre-existing conditions during the pandemic. There was also concern among practitioners and volunteers working in the mental health sector about the safety of their clients. In 2017, just under a third of disabled people in Scotland had a mental disorder of some kind (see Figure 1) and disabled adults had a higher prevalence of at least one symptom of anxiety or depression (44% and 40%, respectively) compared to non-disabled adults (18% and 13%, respectively). Disabled people are more likely to require health treatment and social care than the general population, and are therefore likely to be disproportionately impacted by disruptions to new or pre-existing health and care arrangements. A survey of 842 older and disabled adults conducted between 30 March and 3 April by the Research Institute for Disabled Customers, looking at the impacts of government measures on disabled and older people, found that 50.4% of respondents with care support needs are no longer receiving health or personal care visits to their home. Disabled people may rely on unpaid care from relatives, but also are more likely to be providing care themselves. In 2017 and 2018, 15% of adults in Scotland were providing regular help or care for a sick, disabled or frail person. The percentage of adults providing regular help or care for a sick, disabled or frail person was higher among disabled adults (19%) than non-disabled adults (13%). Furthermore, the percentage of adults who spent 50 or more hours providing help or unpaid care was higher among disabled people (20%) than non-disabled people (13%). If unpaid carers become unwell or need to self-isolate during pandemic, their usual provision of care to others may be disrupted.However, the proportion of adults with chronic or long-term health conditions responding to the ONS opinions and Lifestyle Survey in the period 17-27 April who said that their access to paid or unpaid care had been affected (4.3%) and their caring responsibilities had been affected (8.9%) was comparable to all adults (3.1% and 19%, respectively) . Harm to our broader way of living and societyMental wellbeingA range of evidence shows that disabled people have poorer mental health than non-disabled people. Recent data from the Scottish Health Survey shows that, in 2018, disabled people had lower mental wellbeing than non-disabled people (45 compared to 52 on a scale of 14 to 72). Disabled adults also had lower life satisfaction in 2018 (6.8 on a scale between 0 and 10) than non-disabled adults (8.2) and adults with a non-limiting longstanding illness (8.1).Data from the Opinions and Lifestyle Survey covering the 14th to the 24th of May reported that 62.4% of disabled people were worried about the effect of the coronavirus pandemic on their well-being, compared to 49.6% of non-disabled people. Prior to the pandemic, loneliness was more prevalent among disabled people than the general population. In 2018, a higher percentage of disabled adults in Scotland (39%) said that they felt lonely some, most or all of the time in the preceding week compared with all adults (21%) and non-disabled adults (16%). Recent ONS data shows that in 2018 to 2019 disabled adults in England were less likely to feel like they have someone there if they needed help (59%) compared to all adults (68%). A recent Lancet Psychiatry report suggests that people with mental health issues may be at greater risk of the impacts of social isolation, and suggests real time monitoring of mental health issues across the general population and within high-risk groups including disabled people. There is some evidence to suggest that the pandemic has influenced mood in the general population. Data from a YouGov weekly mood tracker shows that since the poll began in July 2019 until early March, the most common emotion among adults in Britain was “happy” . However, by mid-March, happiness dropped to the sixth most commonly cited emotion behind five negative ones. The most recent data covering 17-20 April shows that the most commonly cited emotion was “frustrated” (experienced by 43% of the adults surveyed). Data breakdowns are not available for disabled people, but a similar drop in happiness is likely to further exacerbate the already poorer mental wellbeing and experience of loneliness felt by disabled people.The ONS Opinions and Lifestyle Survey indicates that people with underlying health conditions or long-term illness may be at a slightly greater risk of poor mental wellbeing during the pandemic.Indicators of well-being, Great Britain, 28 to 31 May 2020Percentage that report well-being is being affectedAll adults44%Underlying health condition47%Mean anxiety score*All adults3.7Underlying health condition3.7Percentage with high anxiety (score 6-10)*All adults30%Underlying health condition32%Percentage feeling lonely often or always or some of the timeAll adults25%Underlying health condition29%Source: Office for National Statistics – Opinions and Lifestyle Survey* Anxiety is measured on a scale of 0 to 10, where 0 is “not at all” and 10 is “completely”Digital exclusion is also an issue for people with learning disabilities as they may not have access to or be able to effectively access online support and services and connect with friends and family.Physical activityMeasures to limit the transmission of COVID-19, including restrictions on outdoor exercise and the closure of indoor exercise facilities, may exacerbate the already poorer physical and mental health experienced by disabled people. Prior to the pandemic in 2018, a lower proportion of disabled adults in Scotland (50%) met physical activity recommendations and a lower proportion made one or more visits to the outdoors per week (47%) compared to non-disabled adults (70% and 64%, respectively). The most common reason for not doing any/more sport or exercise among disabled adults was their health not being good enough (34%). Disabled people may also face some additional barriers to undertaking physical activity outdoors. Data from the Scottish Household Survey shows that, in 2018, 62% of disabled people lived within a 5-minute walk of their local green or blue space compared with 67% of non-disabled adults. In addition, the closure of indoor physical activity venues across the UK, such as gyms and swimming pools, will limit accessible opportunities for disabled people to exercise.Access to food and other essentialsSocial distancing and self-isolation among high risk groups (including those with underlying health conditions) and vulnerable groups (e.g. disabled and needing care) will require some necessities and services brought to them, such as food, medicine or care. The impacts experienced by disabled people whilst implementing social distancing and isolation will depend on their support networks, digital connectedness and ability to afford food and essential supplies.In the first weeks of the pandemic, there were news reports that disabled people were impacted by consumer stockpiling and the inability to secure grocery deliveries . A statement by Scope on 19 March reported that many disabled people were worried about panic buying leading to a lack of essential supplies and a scarcity of supermarket home-delivery slots. Recent data from a YouGov poll commissioned by the Food Foundation shows that disabled adults were disproportionately affected by food insecurity during the first three weeks of lockdown arising due to all three drivers measured - financial hardship, lack of food in shops and isolation. The increased prevalence of food insecurity is consistent with the experience of disabled people prior to the pandemic. In 2017 and 2018, 18% disabled adults in Scotland worried about running out of food due to lack of money or other resources, compared to 5% of non-disabled people and 9% of all adults. A report commissioned by the Trussell Trust, published in 2019, showed that almost three quarters of people referred to food banks in their UK-wide network had someone in their household with a health issue, of which over half reported poor mental health and a sixth reported a physical disability. During the pandemic, some disabled people are likely to need to rely on the support of others to bring them supplies. Some disabled people may already have care arrangements in place. A recent report by the ONS showed that nearly 3 in 10 parents aged over 70 years with a self-defined disability in the UK (29%) got their shopping delivered by an adult child not living with them and 18% received cooked meals from their adult children in the period 2017 to 2018 . It is unclear what proportion of these care arrangements have been disrupted due to COVID-19.Disabled people may experience several barriers in accessing support during the pandemic. The proportion of adults in England who reported that they would feel “very uncomfortable” asking a neighbour to collect a few shopping essentials for them was higher among disabled people (29%) than non-disabled people (25%). Analysis of Scottish Household Survey data shows that 10.5% of disabled adults – equivalent to 107,000 people – disagreed that if they were along and needed help they could rely on someone in their neighbourhood to help them compared to 8.1% of all adults. In addition, evidence suggests that disabled people may be less experienced in ordering grocery deliveries online. Data from the Scottish Health Survey showed that, in 2018, a greater proportion of adults with a physical or mental health condition do not use the internet (27%) compared to adults with no physical or mental health condition (8%). Similarly ONS data, published in August 2019, shows that a lower proportion of disabled adults in Great Britain used the internet for shopping (73%) compared to non-disabled adults (85%).Reports from disabled people’s organisations suggest that disabled people may be making increased use of helplines during the pandemic. On 18 March, the Multiple Sclerosis society reported that calls to their free helpline had more than doubled, with the majority of calls related to COVID-19, and a quarter of calls to the national helpline run by Scope were about COVID-19. Despite this evidence of helpline use, it is possible that some disabled people may face difficulties in accessing helplines and resources available online. Adapting service delivery to reduce risk of infection may also negatively impact on people with disability. For example, moving GP consultations from face to face interaction to phone conversations must take into account the needs of those who might struggle or be unable to access services this way (such as deaf people). Special exceptions will need to be made for people with complex disabilities, particularly those who need communication support.?If people with complex disabilities aren’t well supported in hospital and care settings they may not be able to understand their care and treatment, which may exacerbate or create physical and mental health problems. EducationPrior to the pandemic, there was no significant difference in the use of regular childcare between parents of disabled and non-disabled children in Scotland. However, some concerns have been raised about the impact of school closures on families with a disabled child. In their letter on 19 March, the Equality and Human Rights Commission stated that only a small proportion of children with special educational needs will still able to attend school, which will have a profound impact on families. News reports have similarly claimed that children with special educational needs and their families may be particularly affected by school closures due to additional caring responsibilities and lack of support.In addition, whilst schools and educational establishments are closed, disabled school pupils and students may find it harder to participate in distance learning and engage social contact with peers due to accessibility issues. This may impact on their educational attainment, widening the disability attainment gap.Fuel povertyHouseholds with a disabled person are jointly more likely to be in fuel poverty and be more vulnerable to the effects of living in fuel poverty. Research by Scope, published in 2018, showed that disabled people may face higher energy costs. Around a third of disabled adults felt that their health condition had an impact on how much they spent on energy and analysis of energy bills showed that whilst the average UK household spent ?1,214 a year on energy, over a quarter of households with a disabled person spent over ?1,500. Increased time spent at home as a result of self-isolation may increase already higher energy costs for disabled people.In general, evidence suggests that disabled people faced increased costs of living prior to the pandemic. Research by Scope in 2019 estimated that disabled adults in the UK face extra costs of ?583 a month. On average, these extra costs are equal to almost half the income of a disabled person after housing costs. A statement from Scope on 19 March highlights that the COVID-19 pandemic is likely to further exacerbate the costs of living faced by disabled people. However, whilst costs for disabled people may increase, a lower proportion of adults with chronic or long-term health conditions responding to the ONS opinions and Lifestyle Survey in the period 17-27 April said that their household finances had been affected (16.7%) compared to all adults (29.3%).CrimeDisabled adults in Scotland were more likely to be victims of crime in 2017/18 than non-disabled adults. In that year, 15% of disabled people have been a victim of at least one crime compared to 12% of non-disabled people. Evidence from the Scottish Household Survey suggests that people with long-term physical health conditions are more likely to experience discrimination and/or harassment, with higher rates of discrimination and harassment since 2013.Evidence suggests that disabled people may also be at increased risk of domestic abuse. ONS statistics show that, in the year ending March 2019, 1 in 7 (14%) disabled adults aged 16 to 59 years in England and Wales experienced a form of domestic abuse compared with 1 in 20 (5%) non-disabled adults of the same age. It is possible that self-isolation and social distancing might lead to an increase in domestic abuse targeted at disabled people and reduce disabled people’s ability to report abuse due to reduced social contact. In some cases the perpetrator may also be the victims’ carer, which can put them at increased risk. On 6 April, Refuge reported a 255 increase in calls to the National Domestic Abuse Helpline and online requests for help since the lockdown. It is important to note that the National Domestic Abuse Helpline is for those in England and Wales. In Scotland Scottish Women’s Aid runs the helpline, available here. Visits to the National Domestic Abuse website were also 150% higher than during the final week of February. There is no equivalent Scottish data available. It is important to note that all reported data is limited as it is very difficult to know what is actually happening on the ground during lockdown, especially with regard to hidden crimes such as domestic abuse.Reduced policing capacity during the pandemic may impact on perceptions of confidence in the ability of police. Data from the Scottish Crime and Justice Survey 2017-18 reported that the confidence in the ability of the police ranged from 50% to 66% across six domains measured, between 3 to 6 percentage points below non-disabled people. More evidence is required to examine the impact of the COVID-19 pandemic on perceptions of the police among disabled people.Due to the COVID-19 pandemic, various adaptations have been made to proceedings of the criminal justice system in Scotland, including expanding remote attendance for court and tribunal procedures and emergency release of prisoners. Disabled prisoners may be negatively impacted by these adaptations. In their letter on the 19 March, the Equality and Human Rights Commission highlighted that people with a learning disability or who are experiencing mental ill health can find it difficult to participate fully in proceedings using courtroom video and audio links and so may impact on the ability of disabled people to access a fair trial. In relation to the emergency release of prisoners, the availability of specialist services in the community may be a factor in the release of disabled prisoners. For example, electronic monitoring is not considered appropriate for offenders with mental health issues or learning disabilities.GENDER REASSIGNMENTSummaryTrans people are likely to experience a number of specific health and social impacts resulting from the COVID-19 pandemic.Specific risks that may need consideration in ongoing or new action include: Lack of access to gender-affirming health care potentially deemed non-essential, which could lead to negative mental health outcomes for those intending to use it.Hormone prescriptions, some of which require administration by a practice nurse, may not be readily available. This can lead to anxiety and unwanted side-effects of hormonal changes, and could potentially contribute to unsafe self-injection or use of unverified drugs.Abuse from unsupportive families or partners who some trans people may be required to spend time with due to the ‘lockdown’. This could contribute to increased stress or distress, and increased risk of abuse or exacerbation of existing abuse, with less likelihood that others will identify the abuse or be able to intervene.Increased levels of mental health problems including depression, anxiety and self-harm, which are already prevalent amongst the trans community. In the current crisis situation, these problems are likely to be exacerbated by all of the issues outlined above, as well as the general stress of the crisis. At the same time, many NHS and third-sector mental health services have less capacity to offer support.BackgroundAround 1% of the population are trans. As of 2011, 12,500 adults in the UK had sought medical interventions related to their gender dysphoria. The number of trans people accessing Gender Identity Clinics each year is increasing. Trans people seek medical assistance with their transition at any age. The median age is 42.Wider impact on health and social care servicesConcerns have been raised that there is a danger health care providers might deem Gender Identity Services ‘non-essential’ during this pandemic.Trans people often have ongoing hormone prescriptions, and/or hormone blocker medications. Some prescriptions require administration by a practice nurse, while others can be self-administered with support and training. In the current crisis, it appears that some GP practices are turning away patients, and are not offering advice or alternate routes for care. This may lead to anxiety from patients, unwanted side-effects of hormone changes, and ultimately contribute to problems such as unsafe self-injection or shortages in supply chains of other hormone preparations as patients attempt to switch. Scottish Trans has published guidance that addresses these concerns. Prior to the pandemic reaching the UK, BBC News reported how some trans people had started to self-medicate with hormones bought online from unregulated sources due to lengthy waiting times to access health services. COVID-19 will likely exacerbate this problem, putting the physical and mental health of trans people at risk.Trans people consistently report significantly worse experiences in healthcare, including direct prejudice. In some cases, this can deter people from accessing healthcare. Trans people may therefore be less likely to seek help when experiencing worsening physical health, and possibly receive worse care when they do access it.Harm to our broader way of living and societySome trans people, particularly young trans people, may have unsupportive families. In some cases, families or partners may be abusive. The ‘lockdown’ situation is likely to result in trans people spending more time at home, having less access to support services, and/or having to leave alternative accommodation such as university or college accommodation or insecure rented accommodation. This could contribute to increased stress or distress, and increased risk of abuse or exacerbation of existing abuse, with less likelihood that others will identify the abuse or be able to intervene.Transgender young people who are not ‘out’ to other members of their household may experience increased stress and/or gender dysphoria in lockdown.Some trans people may have lost contact with family and friends as a result of transition. Trans people who are recommended to self-isolate may have fewer resources to draw upon, and be less able to seek support from friends, family, or neighbours.Mental wellbeingTrans people are known to be at higher risk of mental health problems such as depression, anxiety and ultimately self-harm and suicidal behaviours. In the current crisis situation, these problems are likely to be exacerbated by all of the issues outlined above, as well as the general stress of the crisis. At the same time, many NHS and third-sector mental health services have less capacity to offer support, or may be offering support through new means (e.g. online). Results from the online survey conducted by the LGBT Foundation showed that 57% of Trans people would like to access support for their mental health.RACESummaryThere are substantial differences between people of different ethnic origins, both within and between groups. Key groups who may be disadvantaged by COVID-19 include Gypsy/Travellers, international students; seasonal migrants in communal accommodation and asylum seekers and refugees but as noted above there are still unanswered questions around the potential increased rate of infection, serious illness and death amongst minority ethnic people. Specific risks that may need consideration in ongoing or new action include: Higher prevalence of poverty in some minority ethnic groups which may increase risk of food insecurity. It will be important that food projects recognise different dietary requirements and access issues for diverse communities. Higher likelihood of multi-generational families which may increase risk of infection. There may be a need for further advice on self-isolation or shielding in these circumstances. Higher rates of underlying illness especially diabetes and cardio-vascular disease, which may mean there are higher numbers in shielded groups and may indicate a need for some specialised advice and support. Inability to communicate adequately because of language, stigma, prejudice or other cultural differences in health and social care settings are likely to lead to negative outcomes. This is particularly the case while people are attending primary care settings unaccompanied. Considerations around the housing context for ethnic minorities especially around relationships between tenants and landlords. Attainment issues which may arise both for those ethnicities with tradition of high attainment (in terms of anxiety and sense of loss) and those who tend to be more disadvantaged (in terms of staying motivated, access to resources and remaining on track). Increases in racially motivated hate crime. Monitoring of hate crime data will be needed to ensure that any spikes in racially aggravated hate crime due to COVID-19 are dealt with. Support for minority groups. Ethnic minorities were more likely to say that they didn’t have support in times of crisis. While ethnic minorities are unable to access traditional community spaces (including religious buildings) due to COVID-19 there may be an even greater need to ensure that routes are open for people to provide and receive culturally appropriate practical and social support.BackgroundExisting social inequalities in the areas of poverty, health, housing and employment may mean that minority ethnic groups are disproportionately impacted by the negative fall-out of this public health emergency. The best data on ethnicity is the 2011 Census but this is quite dated. The Scottish Household Survey in 2018, estimated that just over 11% of the population were ethnic minorities (6.6% were white non British; 2.8% Asian and 1.7% other). Data from early learning and childcare registrations in 2019 showed that 9.3% of children registered had a home language other than English. This is an increase of 3.2 percentage points since 2010. Any analysis of race should be treated with some caution for two main reasons. First, there is huge variation both between people in the same ethnic group and between ethnic groups and second, the data on ethnicity is often based on small samples and fine grained analysis is rarely possible. Scottish data is available in the equality evidence finder although it is again often hampered by small sample sizes. A range of administrative data for England can be found in the Race Disparity Audit which may in some cases be used with caution to consider UK trends. This site includes summary data for different ethnic groups which help to illustrate the vast differences between different ethnicities. For example, according to the Race Disparity summaries people of Indian ethnic background showing high levels of attainment, income and home ownership whilst people of Black Caribbean background on average display much greater disadvantage in terms of attainment, employment, housing, income and problems with the law. Not all of these factors necessarily hold true in Scotland. Ethnicity can sometimes interlink with problems of language and knowledge and trust of systems, especially for more recent migrants. This cultural difference may further exacerbate impacts, as people find themselves less informed about the virus and how to stay safe, and less knowledgeable about the different support routes available to them.Direct harm to people’s healthThere is some current debate on whether minority ethnic people could be at greater clinical risk from COVID-19. Public Health Scotland released preliminary analysis of COVID-19 and ethnicity data on 20 May. The analysis appears to show that there is not a higher level of COVID-19 cases than would be expected, given the size of our black, Asian and minority ethnic population. However, it is crucial to note that the data is very limited. Additional analysis is being undertaken, and will be improved and updated as more data becomes available.As well as structural economic factors noted above, the following are likely to increase the likelihood and/or severity of infection. As the UK Women’s Budget Group recent briefing on social care described “The COVID-19 care crisis has foregrounded the vulnerability of the care workforce of whom the vast majority – 84% of those working in residential and domiciliary care – are women, and BAME and migrant groups are overrepresented”. This over-representation in key industries will increase the risk of infection. Ethnic minority households are more likely to be overcrowded and multi-generational, compared to white British households. For example, in Scotland’s 2011 Census, 12.8% of people describing their ethnicity as Pakistani shared accommodation with more than one household; rates were lower for Bangladeshi (5.7%); Indian (5.4%) and Polish (4.5%) but still high compared to White Scottish (1.4%). These differences are pertinent in regard to the spread of COVID-19 and highlight particular risks for people from minority ethnic groups who are elderly or have pre-existing health conditions, if household members continue to mix as they go to work or to undertake essential shopping.Early data showed that the virus was more deadly for people with underlying health conditions. Prevalence of some health conditions is known to be higher in certain ethnic groups, for example Type 2 diabetes is 6 times more likely in people of South Asian descent and type 2 diabetes 3 times more likely in African and Afro-Caribbean people. In Scotland, as in other parts of the UK, people from black and minority ethnic groups have lower cancer rates but higher incidence of coronary heart disease and cardio vascular disease. Presence of these conditions are more likely to increase the severity of COVID-19 which will also increase the anxiety around catching it and require people to self-isolate in their homes for longer.It is recognised that cultural issues, language and stigma can be additional barriers to black and ethnic minority people when it comes to seeking help and asking for appropriate medicines or support.For example, research from Edinburgh University showed disparities when seeking support for mental health services and there is some evidence in England that Black, mixed race and Asian females are more likely to experience mental disorder than white British females. There is no apparent difference for men. If this trend is also found in Scotland, it might be important for consideration of the detrimental impact of social isolation on mental health. A study carried out in Scotland concluded that an inability to speak English was perceived as a major disadvantage in accessing palliative care services. The study noted that trying to organise interpreters at short notice was seen as “impossible”, which created problems for those trying to access services at the end of life. Likewise English data shows patient experience for hospital care was worse for Bangladeshi and Pakistani ethnicity. These findings are slightly dated and in some cases not specific to Scotland, but they still may be indicative of wider cultural impacts across the health and social care sector that could produce negative outcomes. At a time when individuals are attending hospital without access to family or friends, the potential lack of communication or cultural understanding could be particularly worrying.Issues around discrimination or misunderstanding of cultural differences may not only be an issue for patients. One suggested explanation of why the first 10 doctors in the UK named as having died from the virus were all from minority ethnic groups is that they may have felt less able to complain about inadequate personal protective equipment (PPE). People of East Asian ethnicity may also be at increased risk of discrimination and harassment because the pandemic is often strongly-associated with China.Many migrants work in seasonal agricultural jobs, often with communal sleeping arrangements and facilities, accommodation which would make self-isolation extremely difficult. In the 2017 farm business survey, respondents reported that they provided accommodation for over 6,500 seasonal migrant workers (80% of the respondents’ workforce). Caravans accounted for 80% of this accommodation. Other sectors also recruit seasonal works, for example fish and seafood processing. With Brexit and the timing of the pandemic there may be fewer migrant workers currently in Britain, but this remains an issue.Refugees face a range of barriers including housing, language and knowledge of where to access support. As of December 2019, 3,818 asylum seekers were receiving Section 95 support, 3,784 of whom were living in Glasgow. Unlike seasonal workers and Gypsy /Travellers, refugees will generally be known to the public sector – but as a policy area reserved to the UK Government, approaches to support are constrained.Gypsy/travellers have an increased likelihood of pre-existing poor health, and living conditions may not be conducive to fighting the virus. Gypsy/Travellers living on private sites may be even less likely than those living on public sector sites to be engaged with services and accessing vital information.There are also structural barriers preventing certain members of ethnic minority groups from accessing NHS services. Due to immigration controls, there are those for whom access to NHS services is restricted except through health charging arrangements (with hospital staff required to demand proof of entitlement to free healthcare). This is often referred to as “no recourse to public funds”. On top of this some refugees and migrants are understandably concerned about patient data sharing between the NHS and the Home Office and, therefore, may delay or forgo accessing services when needed.Harm to our broader way of living and societyMental wellbeingThe fact that ethnic minority households are more likely to be multi-generational may help ease any sense of loneliness and support mental wellbeing. However, this could also be a negative – for example, if relationships in the household are strained, or the accommodation is particularly overcrowded. Access to food and other essentialsMinority ethnic groups may be at a disadvantage when accessing food for two reasons. First as key workers they will be limited on the times that they can shop for food. Recent action by supermarkets to allow special times for NHS workers to shop will be helpful in this regard but may miss other key workers who do not have NHS cards but are also constrained. Second, as a higher proportion of ME people are in poverty it is likely that a higher proportion will also be experiencing food insecurity. Samples are too small to provide data at present. Food insecurity may be increased by the access and cost of specific food requirements such as Halal foods and traditional celebration foods such as for Passover and Ramadan. Gypsy Travellers will also be more vulnerable to food insecurity as their accommodation isn't suitable for holding large supplies of food and many delivery companies are unwilling to deliver to campsites. It will be important that projects to increase access to food cater for different diets and access diverse communities.There is some evidence that ethnic minorities may find it more difficult to access support, with Scottish Household Survey 2018 estimating that 12.8% of ethnic minority households said that they did not have anyone in their neighbourhood that they could rely on to help.Data in Scotland shows that the majority of people in non-white British ethnic groups felt a sense of belonging to their local community and neighbourhood. In fact in terms of community buildings, ethnic minorities were more likely to say that they had a space to meet than White British (68% compared to 59%, SHS, 2018). In the COVID-19 situation, though, having a space or building to congregate is less useful and if social interaction relies more heavily on a central building, it may be more difficult to move this into a virtual or digital arena.EducationFor many ethnic minorities, school attendance and attainment is highly important to the young person and the wider family. Data from school statistics show that higher educational attainment is more prevalent amongst ethnic minority school leavers across all listed groups than White Scottish and White non-Scottish school leavers.Percentage of school leavers from publicly funded secondary schools in Scotland by follow-up destinationFollow-up destinationWhite - ScottishWhite - non-ScottishMixed or multiple ethnic groupsAsian - ChineseAsian - IndianAsian - PakistaniAsian - OtherAfrican/ Black/ CaribbeanHigher Education37.542.348.073.865.958.657.156.9Further Education22.326.316.613.713.723.720.125.9Source: Scottish GovernmentOn one hand, this may mean that children and young people have the self-discipline to continue to do any schoolwork set by teachers. On the other, it may also lead to greater anxiety over the loss of educational resources.Lower income households often have lower attainment and although this does not necessarily hold for all ethnic minorities, there are some ethnicities where educational attainment tends to be disadvantaged. Disruption to schooling could disadvantage these groups even further. The joint framework for Gypsy/ Travellers recognises that children are at increased risk of missing out on support as they will potentially have had inconsistent attendance at school or attended multiple schools and many will lack access to digital resources to support learning.CrimeRacial crime remains the most commonly reported hate crime in Scotland. There were 2,880 charges reported in 2018-19, 12% less than in 2017-18. This is 37% less than the peak in such charges in 2011-12, and the lowest number reported since consistent figures became available in 2003-04. However, there is some evidence of increased racism and xenophobia since the COVID-19 outbreak amongst minority ethnic communities in the UK – especially East Asians. An Ipsos Mori poll published on 14 February 2020 showed that as a result of the COVID-19 outbreak, one in seven people would avoid people of Chinese origin or appearance and one in ten would avoid eating in Asian restaurants. Other news reports have pointed to an increase in racially fuelled attacks. As the pandemic has spread across the world, it is not clear whether these attacks have decreased or not. It is also not clear whether similar evidence of an increase is found in Scotland.Harmful behavioursAn academic article looking at ethnic differences in problem drinking found that men born in England and Wales were 64% less likely to die as a result of alcohol compared with native Scottish males. There was a 72% lower incidence of alcohol-related deaths among Pakistani born men in Scotland compared with Scottish-born men. Similarly, a report on problem drug use in Scotland also states that there is less of an ethnic dimension.Data on gambling in Scotland showed that less than 1% of the respondents to the health survey were seen as problem gamblers. Data on ethnicity was not available for Scotland but England and Wales data from 2016 shows that gambling participation was highest among White adults; six in ten (59%) White adults had gambled in the past 12 months, compared with 46% of Black adults, 45% of adults in other minority ethnic groups and 32% of Asian adults. For online gambling the pattern was slightly different; similar proportions of adults in the White group and other minority ethnic groups had gambled online (both 10%), compared with 5% of Black adults and just 2% of Asian adults. There is considerable demographic variation: problem gamblers are more likely to be male, aged?25 to 34, and from some ethnic minorities (mixed race or Black rather than Asian). It is not known what the impact of prolonged social distancing will mean for take-up of online gambling but this does not appear to be a particular issue for ethnic minorities.RELIGION OR BELIEFBackgroundIn 2018, Christian (Church of Scotland, Roman Catholic and Other Christian) represented 46% of the adult population (SHS, 2018). Over the past decade there has been an increase in the proportion of adults reporting not belonging to a religion, from 40% in 2009 to just over a half of adults (50%) in 2018. There has also been a corresponding decrease in the proportion reporting belonging to 'Church of Scotland', from 32% to 23%. In 2018, around 1.6% of the population were of Muslim faith and 1.9% of other faiths. New data from the Census in 2021 will give more detailed data on religion and belief in Scotland. Data from the 2011 Census are summarised in the table below.Religion in Scotland, 2011PercentageNumberChurch of Scotland32.4%1,718,000Roman Catholic15.9%841,000Other Christian5.5%291,000Buddhist0.2%13,000Hindu0.3%16,000Jewish0.1%6,000Muslim1.4%77,000Sikh0.2%9,000Other religion0.3%15,000No religion36.7%1,941,000Religion not stated7.0%368,000Source: National Records of ScotlandHarm to our broader way of living and societyThe coronavirus pandemic has impacted religion in various ways, including the cancellation of the worship services of various faiths and the closure of Sunday Schools. Religious groups have been forced to sacrifice major festivals that punctuate their practice over the year. Christians were unable to attend Holy Week services, Muslims have experienced Ramadan without communal Iftar meals each day. The Jewish community experienced Passover without extended Seders, and Sikhs were unable to mark the festival of Vaisakhi.The Health Protection (Coronavirus) (Restrictions) (Scotland) Regulations 2020 require that places of worship are closed for the duration of this emergency period, with effect from 26 March. However the 2020 Regulations do provide exceptions to this closure. A place of worship can continue to be opened and used for:funeralsto broadcast an act of worshipto provide essential voluntary services or urgent public support services (for example, provision of food banks or blood donation sessions)Despite these exceptions, the majority of faith communities in Scotland closed (and continue to keep closed) their places of worship to all services, including funeral services.Most religions are structured around congregating for regular prayer and worship in community buildings such as churches, synagogues, mosques, and temples. For some religions this building or centre has a much broader role in the community, providing food and support throughout the week.Closure of buildings is disruptive to religious communities, and while many have offered worship through livestream amidst the pandemic, some people will still be excluded if they do not have suitable digital access. This could have negative impacts on wellbeing for people who rely heavily on their religious community.There may also be significant impacts if centres play a key role in other service provision such as community food provision and broader help and support.SEXSummaryWomen are likely to experience a range of health and social impacts resulting from the COVID-19 pandemic that differ significantly from men. Specific risks that may need consideration in ongoing or new action include: Increased risk of infection for women as they make up the majority of people providing care, both paid and unpaid and are more likely to be key workers.Increased risk of severe health conditions for women, as they make up a larger percentage of the population with long-term health conditions, although severity of COVID-19 is worse in men.Resource diversion and treatment suspension for non-COVID related health issues particularly impacts on women with service needs around pregnancy and maternity. For procedures that require in-person medical attention, the strain on resources may lead to impaired health outcomes.Increased caring responsibilities due to the closure of nurseries and schools will likely fall upon women, who may need to juggle this responsibility alongside part or full-time employment. This issue is further compounded for lone parents, of whom 90% are women.Increased levels of domestic abuse towards women, and an inability for some to access the usual routes to support and safety. Self-isolation is likely to disrupt livelihoods and the ability to earn a living for many families, increasing stress and the potential to exacerbate conflicts and violence. It is possible that coercive control may also intensify if women are stuck inside a home with an abuser and without regular interaction with any other people.BackgroundJust over half (51%) of Scotland’s population are women. The ratio of women to men is higher in older age groups, reflecting women’s longer life expectancy.Estimated population by age & sex, mid-2019 (NRS)Direct harm to people’s healthPeople outside the shielded group but with pre-existing health conditions or circumstances that mean they are at increased risk of severe illness from COVID-19 are required to follow enhanced social distancing. This includes pregnant women and over 70s (of which women make up a larger portion). Women also make up a larger percentage of the population in Scotland living with a long-term health condition. Women make up the majority of people providing care, both paid and unpaid, and the majority of health workers. Women are also disproportionately likely to be key workers, with employed women more than twice as likely to be in this group than employed men. It is particularly noticeable in female parents, who are generally more likely to be key workers than non-parents, with 39% of working mothers classified as key workers before the crisis, compared to only 27% of the working population as a whole. This, coupled with a lack of necessary personal protective equipment (PPE) makes them more likely to be exposed to COVID-19 and the detrimental health effects associated with it.However, death rates from COVID-19 are similar for men and women, and much higher for men when age differences are taken into account.There are no available data sources to provide definitive estimates of the numbers of people involved in prostitution in Scotland but an internal investigation by Scottish Government in 2016 looked at 1800 adverts for sexual services across 4 websites in Scotland on a single day and found that the majority of those providing services were women. A number of news agencies are reporting that some sex workers are continuing to work, including those in Scotland-. There is also some emerging qualitative data from services supporting women in prostitution and Commercial Sexual Exploitation (CSE) in Scotland that social isolation has put women in prostitution at increased risk. Risks result from a number of practices, including maintaining face-to-face contact with men and engaging in higher risk practices (such as unprotected sex) to counteract the negative economic impacts lockdown has produced. Wider impact on health and social care servicesInternational research has shown that women are less likely to receive treatment generally, as women’s pain and diagnosis is treated differently to that of men. In the UK women are more likely than men to seek out medical advice but this is not reflected in their health outcomes. In their report on Women and COVID-19, Engender suggests that this is important to keep in mind when looking at gender as a determinant of health beyond sex-specific conditions and should influence our response to the healthcare needs of women during this crisis.Counselling and other mental health support has been moved to telephone and video conferencing. Women’s Budget Group suggests that this will have a negative impact on women with ongoing mental health conditions.A telephone survey of Scottish adults carried out by Ipsos MORI on behalf of the Scottish Government, 27 April to 3 May, found that, among the substantial minority (44%) who reported that they were less happy now than on a typical day before the coronavirus pandemic, women were more likely to say that they were ‘a lot less happy’ (22%) than men (15%). Among the 40% of respondents who reported that they were more anxious than on a typical day before the pandemic, women were more likely to report being ‘a lot more anxious’ (20%) than men (13%).There is a risk, as has happened internationally with other health emergencies, that supply chains of medicines and contraceptives may be affected and key medical staff may be redistributed,. This would in turn put a strain on health professionals to effectively deal with non-COVID related issues. Of particular concern, with regards to women, are staffing and resourcing issues related to pregnancy and maternity services. For procedures that require in-person medical attention, the strain on resources may lead to impaired health outcomes.Harm to our broader way of living and societyPhysical activityData from the Scottish Health Survey (SHeS) shows that in 2018, 62% of women meet the guidelines for Moderate or Vigorous Physical Activity (MVPA) compared to 70% of men.DietResults from the telephone survey of Scottish adults carried out by Ipsos MORI on behalf of the Scottish Government, 27 April to 3 May, found that women were more likely than men to report that they were eating more than at the start of March (50% and 36%, respectively).EducationEngender has highlighted how the closure of nurseries and schools will mean that the bulk of caring responsibilities will fall upon women, who may need to juggle this responsibility alongside part or full-time employment. Engender presents data from the United Nations on women in heterosexual relationships that estimates they ‘do 2.6 times as much unpaid caregiving and domestic work as their heterosexual partners’. This issue is further compounded for lone parents, of whom 90% are women. There is also recent evidence from the Institute for Fiscal Studies that under lockdown, compared with fathers, mothers are spending less time on paid work but more time on household responsibilities.CrimeInternational evidence suggests that there have been significant increases in the number of domestic abuse reports around the world-. Data from England and Wales shows that there has been a reported increase in the use of domestic abuse helplines and websites since the introduction of social distancing measures. Self-isolation is likely to disrupt livelihoods and the ability to earn a living for many families, increasing stress and the potential to exacerbate conflicts and violence. As resources become more scarce, women may also be at greater risk of economic abuse. Isolation will also likely shut down routes to support and safety for women, who may face even greater barriers to finding time away from the perpetrator to seek help. It is possible that coercive control may intensify if women are stuck inside a home with an abuser and without regular interaction with any other people.As mentioned in the section on ‘age’, it is likely that self-isolation may lead to an increase in instances of neglect, physical abuse, emotional abuse or sexual abuse to children. With the exception of physical abuse, the level of abuse experienced during childhood is more prevalent for females than for males across all abuse types. Roughly one third of all known child sexual abuse material the IWF finds on the internet is posted by children themselves after they have been groomed and the majority is generated by girls. Harmful behavioursThere is recent evidence to suggest that the gap between men and women with regards to the prevalence of substance use disorders (SUDs) is narrowing and in some instances non-existent. There are, however, differences with regards to the effects, physiological and psychological, that these disorders have. Adverse medical, psychiatric and functional consequences associated with SUDs are often more severe in women. There is limited evidence on the gendered differences in susceptibility to partake in online gambling. A recent systematic review found that men were typically more likely than women to be at-risk or problem gamblers but that problem gambling amongst women was strongly associated with unemployment and psychological distress. The authors caveat that the majority of findings were limited by the number of studies and highlighted a need to further understand the gender differences with regards to gambling. If it is the case, however, that unemployment and psychological distress may lead more women to gamble online, then the current crisis may significantly impact on women.SEXUAL ORIENTATIONBackgroundAround 3% of adults responding to Scottish Government core surveys self-identified as lesbian, gay, bisexual or other. However, it is likely this undercounts the number of adults self-identifying as LGBO. LGBO respondents may not feel comfortable being open with a survey interviewer, and some respondents might see this question as intrusive and personal.Wider impact on health and social care servicesStonewall has reported that for some LGBT people, existing inequalities such as restricted access to healthcare will deepen as a result of the health crisis. The LGBT Foundation found that found that 34% of LGBT people responding to its online survey have had a medical appointment cancelled, and 23% have either been unable to access medication or were worried that they might not be able to access medication.Mental wellbeingResults from the online survey conducted by the LGBT Foundation showed that 42% of LGBT people would like to access support for their mental health, with the number rising to 66% for BAME LGBT people. Harm to our broader way of living and societyLGBT young people are disproportionately represented in the young homeless population. As many as 24% of young homeless people are LGBT, and 77% state that their LGBT identity was a causal factor in becoming homeless, with 69% of homeless LGBT young people having experienced violence, abuse or rejection from the family home. The current lockdown can exacerbate this situation.A news report highlighted that, due to the collapse of employment opportunities and closure of colleges and universities, some LGBT people have been forced to return home to self-isolate with family opposed to their sexualitySOCIO-ECONOMIC DISADVANTAGESummaryThose in socio-economic disadvantage are likely to face a number of health and social impacts due to the current pandemic. Specific risks that may need consideration in ongoing or new action include:High risk of COVID-19 infection due to the fact that the workforce still actively employed and not home working include many roles that are characterised by low and/or unstable income. On top of this, households experiencing poverty may need to make more frequent low value shopping trips than households with higher incomes and tend to rely on public transport more, significantly increasing their chances of infection.Limited access to washing facilities and/or lack of personal safe space is of particular concert to those affected by homelessness who live in B&Bs, hostels or other temporary accommodation. Childcare concerns surrounding those with low income, as they may lack the space, resources and/or flexible working arrangements to meet the unexpected need for childcare during this crisis.Access to food for children in poor and low income households who may be reliant on access to school meals to meet their daily nutritional requirements.Potential widening of the educational attainment gap, as school closures will be of particular concern to young people in families that lack access to resources such as home computing and internet access.Potential increase in fuel poverty, as those staying home every day will require greater use of domestic energy.BackgroundThe Fairer Scotland Duty came into force in April 2018. It requires public bodies in Scotland to actively consider when making strategic decisions how they can reduce inequalities of outcome caused by socio-economic disadvantage.Direct harm to people’s healthThe age-standardised rate of deaths involving COVID-19 in the most deprived quintile (86.5 per 100,000 population) is more than double (2.3 times higher) than in the least deprived quintile (38.2 per 100,000 population). The gap is smaller when considering the rate of deaths from all causes (1.9 times higher in the most deprived quintile than in the least deprived quintile.Higher rates of infection are likely among socio-economically disadvantaged groups for a number of reasons. The workforce still actively employed and not home working are at raised risk of COVID-19 infection, and this risk varies by type of work. Those at high professional risk of infection, e.g. social care staff, cleaners, delivery workers, supermarket staff, are in sectors and roles characterised by low and/or unstable income. During the pandemic there has been substantial demand for these workers, which may have maintained working incomes. However, due to their normal low incomes they may be at risk of greater economic impacts if they do not earn enough to meet the minimum level for Statutory Sick Pay.A majority of poverty in Scotland is experienced by households with one adult in full or part-time employment; 60% of working-age adults in relative poverty live in working households. Much of this low-paid work may be unstable, or in the form of self-employment. EHRC Scotland have expressed concerns about the protections offered to ‘gig economy’ workers in relation to current arrangements. Individuals in such employment who are concerned that their earnings cannot be immediately replaced by benefits or government support schemes may choose to try to keep working to keep money coming in.Households experiencing poverty may need to make more frequent low value shopping trips than households with higher incomes. And those in the lowest SIMD quintile rely on public transport, particularly buses and coaches, to a greater extent than those in the highest.In addition, existing health inequalities in conditions associated with heightened risk from COVID-19 (in particular CVD, COPD, diabetes and being overweight) mean that the severe effects of an infection including mortality are likely be experienced by a greater proportion of lower-income groups than higher-income groups, and particularly people who are homeless.People affected by homelessness and living in B&B or some hostel-type temporary accommodation may have limited access to washing facilities or a lack of personal safe space for self-isolation (due to shared washing and cooking facilities). Substance dependency and/or severe mental ill health may impact on individual decisions on self-isolation.Families experiencing poverty are more likely to live in smaller accommodation with no outdoor areas.Harm to our broader way of living and societyMental wellbeingThe pandemic and measures to contain and mitigate it have the potential to increase the extent of mental health problems and associated inequalities for socio-economically disadvantaged groups. This is coupled with the fact that people living in financial hardship tend to be at increased risk of mental health problems and lower mental wellbeing. The Poverty Alliance has recently reported concerns at present among community organisations about the mental health impacts of the pandemic and associated measures, with one organisation reporting a higher than normal number of calls being received from people with suicidal ideation.CrimeFamilies living in poverty and in cramped conditions are particularly vulnerable to family tensions and violence. With lockdown in effect, opportunities to escape from volatile situations are limited, which may increase the risk of negative physical and psychological effects.If disadvantaged individuals encounter more challenges in observing social distancing, they will be less likely to adhere to the guidelines. If they do breach guidelines, they may be at greater risk of coming to the attention of police and receiving a fine for doing so. Areas associated with multiple deprivation experience crime at higher rates and may therefore have a higher police presence. These fines would account for a greater proportion of weekly income for a household experiencing poverty.EducationClosure of schools & ELC providers will affect low income and single parent families especially severely, as they may lack the space, resources or flexible working arrangements to meet an unexpected need for childcare. Many children from poor and low income households may be reliant on access to school meals to meet their daily nutritional requirements.Long school closures, especially if they prevent children gaining formal qualifications, risk creating a cohort of pupils who carry disadvantage throughout their lives. The problem will be greater for young people in families that lack access to resources such as home computing and internet access, or those living in chaotic households. In particular, high quality learning and childcare in early years is known to improve the cognitive attainment of children from more deprived households more than that of children from more affluent households.Access to food and other essentialsRestrictions on public transport will limit access to essential services for people without a private car. Low income households are likely to be in areas with less well-stocked , and people who cannot afford to bulk-buy or pay more for food in short supply are at a disadvantage. Some foodbanks reported shortages due to panic buying as well as a substantial surge in demand. With less facility to store supplies, low income householders may need to make more frequent trips to shop, or travel further to try and find affordable food.People living in deprived areas are less likely to say that could rely on people in their neighbourhood for help and support, and less likely to offer such support.Involvement with other people in the neighbourhood by SIMD, 2018Adults20% most deprived 20% least deprived1 2 3 4 5 Could rely on someone in neighbourhood for help 80%83%88%87%90%Could rely on someone in neighbourhood to look after home 79%82%86%89%90%Could turn to someone in neighbourhood for advice or support 72%74%78%80%80%Would offer help to neighbours in an emergency 86%89%91%93%94%Source: Scottish Household SurveyLocal authority or third sector centres offering advice on housing, debt, utilities, welfare or legal rights, as well as benefits and social care offices and non-NHS services for physical or mental health, are used more by those on low incomes than more prosperous groups. These services may be closed, offering limited or transformed availability or their provision disrupted by staff sickness, bereavement and self-isolation. This is at a time when demand for their service is considerably increased, particularly from the unusually large numbers of new applicants for social security benefits.Lower income households are less likely to have a broadband connection, may lack sufficient smart devices (phones or tablets) for everyone’s needs, or sufficient data, and may rely on libraries and other community resources now closed to make use of the internet. This will leave them without the access that connected households have to:home schooling resourcesjustice procedures or documents moved to online availability during the crisisadvice, information and job or benefits applications onlineshopping and arranging deliveriesentertainment and online social or family interactionDigital exclusion thus risks exacerbating the effects on attainment of school closures, food insecurity and the health impacts of social isolation.Fuel povertyStaying in the home every day will require greater use of domestic energy, adding to household bills, and a greater reliance on telephones will increase those costs. The Poverty Alliance reported that one organisation’s crisis fund for people experiencing fuel poverty had been exhausted, given the unprecedented demand. In addition, households on pre-payment meters may find that there are fewer locations available to make payments or willing to accept non-contactless payments ................
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