Objective To explore the psychological, social and financial outcomes of COVID-19—and the sociodemographic predictors of those outcomes—among culturally and linguistically diverse communities in Sydney, Australia.
Design Cross-sectional survey informed by the Framework for Culturally Competent Health Research conducted between March and July 2021.
Setting Participants who primarily speak a language other than English at home were recruited from Greater Western Sydney, New South Wales.
Participants 708 community members (mean age: 45.4 years (range 18–91)). 88% (n=622) were born outside of Australia, 31% (n=220) did not speak English well or at all, and 41% (n=290) had inadequate health literacy.
Outcome measures Thirteen items regarding COVID-19-related psychological, social and financial outcomes were adapted from validated scales, previous surveys or co-designed in partnership with Multicultural Health and interpreter service staff. Logistic regression models (using poststratification weighted frequencies) were used to identify sociodemographic predictors of outcomes. Surveys were available in English or translated (11 languages).
Results In this analysis, conducted prior to the 2021 COVID-19 outbreak in Sydney, 25% of the sample reported feeling nervous or stressed most/all of the time and 22% felt lonely or alone most/all of the time. A quarter of participants reported negative impacts on their spousal relationships as a result of COVID-19 and most parents reported that their children were less active (64%), had more screen time (63%) and were finding school harder (45%). Mean financial burden was 2.9/5 (95% CI 2.8 to 2.9). Regression analyses consistently showed more negative outcomes for those with comorbidities and differences across language groups.
Conclusion Culturally and linguistically diverse communities experience significant psychological, social and financial impacts of COVID-19. A whole-of-government approach is needed to support rapid co-design of culturally safe support packages in response to COVID-19 and other national health emergencies, tailored appropriately to specific language groups and accounting for pre-existing health disparities.
- Public health
- PUBLIC HEALTH
Data availability statement
Data are available upon reasonable request.
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Strengths and limitations of this study
To date, this is the largest Australian survey exploring COVID-19-related psychological, social and financial outcomes, and the sociodemographic correlates of these outcomes, among people who primarily speak a language other than English.
This study was co-designed by researchers, multicultural health and interpreter service staff, in alignment with the Framework of Culturally Competent Health Research and enabled through recruitment methods that are inclusive and reduce barriers to participation (eg, translated surveys; engagement of trusted interpreters and multicultural health staff; use of multiple recruitment methods including through community events and networks).
To reduce survey length and burden on participants we purposefully selected a small number of items from validated measures or our previous research to explore psychological, social and financial outcomes or co-designed them specifically for this study.
Convenience sampling methods and self-report may have introduced recall and social desirability bias.
We are unable to explore changes in COVID-19-related outcomes over time.
The COVID-19 pandemic has not impacted all populations equally. People from racial and cultural minority groups in countries across the globe have been disproportionately affected, with higher rates of infection, greater risk of morbidity, higher critical care admissions and mortality, and poorer mental health and financial outcomes.1–6 Such differences reflect pre-existing health disparities and underlying social, economic and political inequalities; racial and cultural minority communities experience a higher prevalence of comorbidities associated with poor COVID-19 outcomes (eg, cardiovascular conditions), greater social deprivation and differences in occupational and environmental risk.7–9 The additional burden of structural racism also impacts care seeking and quality of care.7
While the data tell a clear story of cultural disadvantage in the USA, Canada, the UK and several Nordic countries, there remains limited evidence of the impact of COVID-19 on culturally and linguistically diverse groups in Australia despite being one of the most culturally diverse nations worldwide. Currently, people living in Australia identify with more than 270 ancestries, with almost seven million people migrating to Australia since 1945.10 In 2020, 29.8% of Australia’s population were born overseas,11 a level that is higher than most countries within the Organisation for Economic Co-operation and Development.12
Nationally representative Australian surveys exploring the financial, social and psychological impacts of the pandemic13 often systematically exclude culturally and linguistically diverse populations, and there remains a lack of disaggregated data related to COVID-19. A similar trend is observed worldwide.14 Research to date (both in Australia and internationally) has also been limited in its engagement with diverse communities. This has been exacerbated by online recruitment methods (eg, via social media networks or market research companies) and English-language data collection, which tend to prohibit participation of those who speak a language other than English as their primary language.
The few studies which have been conducted have highlighted important impacts of the pandemic for our diverse communities.15 16 In a study of 656 refugees and asylum seekers who had arrived in Australia within the last 10 years (most commonly from Iraq (58.7%, n=385) and Syria (16.9%, n=111)), approximately one in five participants reported experiencing employment loss or decline due to COVID-19, with prevalent stressors related to COVID-19 infection including worries about being infected (66.5%), of a loved one being infected (72.1%) or infecting others (47.7%).17 Social stressors as a consequence of the pandemic were also common, including school closures (46.7%), reduced social activities (46.6%) and having to remain at home (41.3%), and these stressors predicted increased depression symptoms and disability outcomes.17
Our own Australian surveys (and others15 16) have also identified some differences in financial and psychological impacts of COVID-19 among those who speak a language other than English at home compared with those for whom English is their primary language. A survey of 4362 Australians conducted in April 2020, for example, showed that participants who spoke a language other than English at home rated the financial impact of COVID-19 as higher, were more likely to feel nervous or stressed as a result of the pandemic and had greater anxiety compared with those who primarily spoke English at home.18 However, 75% of participants in this survey were born in Australia and only 274 (6%) reported that they did not speak English as their main language at home. As such, our previous findings are limited in their ability to inform appropriate and tailored support for Australian communities that are typically understudied and underserved, such as those from different cultural and language groups.
There also remain limited data about the sociodemographic predictors of COVID-19-related psychological, social and financial outcomes in culturally and linguistically diverse communities. A myriad of sociodemographic factors put communities at increased risk for worsened COVID-19 outcomes. Language barriers, for example, are a well-established driver of inequitable outcomes in healthcare, often arising from worsened patient experience, unmet informational needs and discrimination.19 Further, the population whose main language is not English are also at greater likelihood of having lower socioeconomic status20 and lower health literacy21 among other sociodemographic risk factors which can compound the impact of health emergencies including COVID-19.
The aims of this study were to:
Explore the psychological, social and financial impact of the COVID-19 pandemic on culturally and linguistically diverse communities in Greater Western Sydney in New South Wales (NSW), Australia.
Examine demographic factors associated with these impacts.
This study involved a cross-sectional survey with 11 language groups.
Patient and public involvement
This study was co-designed by researchers, bilingual community members and Multicultural Health and Health Care Interpreter Service staff, and informed by the Framework for Culturally Competent Health Research22 which identifies four components of culturally competent health research. The application of this Framework to the current study is outlined in box 1.
Application of the Framework for Culturally Competent Health Research22
Assemble a culturally competent team: The research team included Multicultural Health and Health Care Interpreter Service staff and bilingual community members from estern Sydney who have extensive experience working with culturally and linguistically diverse communities. Many share the language skills and cultural background of community members in Greater Western Sydney.
Address community need: Outcome measures for this survey study were developed in partnership with Multicultural Health and Health Care Interpreter Service staff as well as bilingual community members to ensure they addressed community needs. This included the selection of broad outcome domains (psychological, social and financial impacts) as well as individual questions. The survey was reviewed by the entire study team as well as all bilingual community members involved in data collection before implementation to ensure relevance, readability and clarity of items for community members. Multicultural Health and Health Care Interpreter Service staff also played a key role in the selection of language groups for this study. The goal was to select groups based on several variables including perceived need and size of the community in Greater Western Sydney, while allowing for diversity in regard to time since migration and English-language proficiency.
Address health inequities: Multicultural Health and Health Care Interpreter Service staff worked in partnership with researchers to influence decisions about research questions and design as well as interpretation and dissemination of findings. Findings were presented as two-page infographics and disseminated to communities through local networks, as well as in the peer-reviewed literature, demonstrating commitment to feeding back the results of the research and enhancing community trust.
Address differences in power: This study built on enduring partnerships between researchers, health services and multicultural community organisations that have spanned multiple research projects. The goal for this study and others has been to bring together a range of health staff, consumers and researchers to co-create value together from the outset, placing high value on different types of knowledge, particularly the lived experiences of community members and contextually specific knowledge of our health services partners. Wherever feasible, the goal has been to redistribute knowledge-based power and replace it with mutual learning between all participants.
The survey was conducted from 21 March to 9 July 2021. The first case of COVID-19 in Australia was detected in January 2020; a national emergency with social distancing rules and closure of ‘non-essential’ services followed in March 2020. Peaks of infection occurred in March 2020, and May-June 2020, and vaccinations begun in February 2021. During the study period, daily cases in New South Wales (NSW) were very low by international standards, ranging from 0 to 46 positive cases from a population of approximately 8 million people.23 A ‘stay at home’ order across Greater Sydney due to rising cases began on 23 June 2021.24 On the day the survey closed the NSW daily case count was 45, and 24% of the population had received one COVID-19 vaccination.23
Participants were recruited from Greater Western Sydney in NSW, Australia, from three adjoining regions with high cultural diversity: Western Sydney (47% of residents born overseas25), South Western Sydney (43% of residents born overseas26) and Nepean Blue Mountains (24% of residents born overseas27).
Participants were eligible to take part if they were aged 18 years or over and spoke one of the following as their main language at home: Arabic, Assyrian, Chinese, Croatian, Dari, Dinka, Hindi, Khmer, Samoan, Tongan, Spanish. Through iterative discussions with Multicultural Health and Health Care Interpreter Service staff in each participating Local Health District, we selected 11 language groups that would provide broad coverage across different global regions, and groups with varying average levels of English language proficiency (based on 2016 Australian census data28), varying access to translated materials and varying degrees of reading skill in their main language spoken at home.
Participants were recruited through bilingual Multicultural Health staff and Health Care Interpreter Service staff. Multicultural Health staff recruited participants through their existing networks, community events and community champions. Health Care Interpreter Service staff recruited participants at the end of a medical appointment and via their community network. The survey was hosted online using the web-based survey platform Qualtrics. Potential participants were offered two means of taking part: completing the survey themselves online (available in English or translated), or with assistance from bilingual staff or an interpreter who read the questions to them and recorded their responses. To ensure consistency in the phrases used for assisted survey completion, translated versions of the survey were provided to all staff assisting with survey completion. Translations were completed by translators with National Accreditation Authority for Translators and Interpreters (NAATI) accreditation where possible.
This survey formed part of a larger study that examined COVID-19-related behaviour and intentions, information sources, and impacts. Survey items reported here are those which were included in the current analysis. All other items are reported elsewhere.29–31
Demographic survey items relevant to this study included age, gender, education, whether born in Australia, years living in Australia, main language spoken at home, self-reported English language proficiency and a single-item health literacy screener.32 Chronic disease status was determined by asking participants to self-report if their doctor had ever told them they had had one or more of the following: respiratory disease, stroke, asthma, diabetes, chronic obstructive pulmonary disease, depression, anxiety, high blood pressure, cancer or heart disease. The socioeconomic status of the area of residence for each individual was defined based on the Socio-Economic Indexes for Areas (SEIFA) Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD33). IRSAD aligns the statistical local area with a decile ranking, with lower scores indicating greater socioeconomic disadvantage. The IRSAD decile was not available for some participants (n=5), for example, because they had entered digits that did not correspond to a valid Australian postcode. IRSAD decile for these participants was replaced with the median IRSAD decile for speakers of the same language in the sample. For the analysis, IRSAD deciles were re-coded into quintiles, and dichotomised (lowest quintile vs other).
Thirteen items regarding the impacts of COVID-19 were selected for this survey study in partnership with Multicultural Health and Health Care Interpreter Service staff. See table 1. Items related to financial impacts were adapted from the COmprehensive Score for financial Toxicity (COST) Scale.34 We adapted two items (‘I worry about the financial problems I will have in the future as a result of my illness or treatment’ and ‘I am able to meet my monthly expenses’) to be relevant to the COVID-19 context. Psychological items were taken verbatim from our previous COVID-19 work.18 Questions regarding social impacts (including impacts on relationships and children) were co-designed with Multicultural Health and Health Care Interpreter Service staff based on local information priorities. All items had fixed yes/no and Likert-type responses. Items were translated into 11 languages. The grade reading score of the 13 items (excluding response options) in English was Grade seven as assessed using the Hemingway Editor.
Quantitative data were analysed using IBM SPSS Statistics V.24. Descriptive statistics were generated for demographic characteristics of the analysed sample. Frequencies were weighted (using poststratification weighting) to reflect each language group’s gender and age group distribution (18–29 years, 30–49 years, 50–69 years, ≥70 years) based on 2016 census data for Western Sydney, South Western Sydney and Nepean Blue Mountains’ combined populations.28 All frequencies presented in the results section are weighted. A single participant indicated their gender as ‘other’ and was unable to be included in weighted analyses. Total recruitment for the Spanish language group was low (<50), with notable gaps for some age groups. For this reason, results for this language group are not presented in the statistical analyses, but are included in total frequencies.
Survey items about psychological, financial and social impacts were re-coded to facilitate a more meaningful interpretation of the results (see tables in the Results section). A mean ‘perceived financial burden’ score was also calculated by averaging the two questions about financial impacts: (1) Worry about financial problems and (2) Ability to meet weekly expenses (reverse coded). Higher scores indicate greater perceived financial burden (range: 1–5). Similarly, a mean score for the impact on children was calculated by averaging questions related to four impacts: physical activity, screen time, schooling and time with friends. Higher scores indicate more negative impacts on children (range: 1–5). Cronbach’s α for this scale was 0.805, indicating a high level of internal consistency.
Unadjusted and adjusted regression analyses were then conducted to explore the predictors of COVID-19-related psychological, social and financial outcomes. Linear regression models were used to analyse perceived financial burden (averaged across two impacts) and impacts on children (averaged across four impacts). Logistic regression models were used to analyse psychological impacts (feeling lonely or alone; feeling nervous or stressed) and impact on relationships. Age group, gender, chronic illness, education, health literacy, English-language proficiency, years lived in Australia, language group and IRSAD quintile were included in each adjusted regression model. Models predicting impacts on relationships also controlled for perceived public health threat of COVID-19, perceived financial burden and psychological variables; models predicting psychological impacts controlled for perceived public health threat of COVID-19 and perceived financial burden. All regression models also controlled for whether participants completed the survey before or after 23 June, when restrictions were announced for all of Greater Sydney.24 In line with recommendations, bivariable significance was not used as a criterion for variable selection in multivariable modelling.35 36 The significance level used to determine significant differences was 0.05.
We had a total of 708 respondents (442 (62.4%) self-completed, 266 (37.6%) received assistance through an interpreter). Sample characteristics are summarised in table 2. The mean age was 45.4 years (SE 0.78; range 18–91 years), and 51% of respondents were female (n=363). Most participants (88%, n=622) were born in a country other than Australia; 31% reported that they did not speak English well or at all (n=220); 29.7% had a university bachelor degree level or higher. Inadequate health literacy was identified for 41% of the sample (n=290).
Overall, 25.3% of participants reported feeling nervous or stressed most or all of the time over the past week. This ranged across language groups from 6% (n=5) for Chinese speakers to 38% (n=24) for Dinka speakers. 30.7% (n=89) of participants with inadequate health literacy and 21.4% (n=89) of participants with adequate health literacy reported feeling nervous or stressed most or all of the time. This was 21.4% for those who self-reported that they speak English well or very well, compared with 33.7% of those who speak English not well or not at all. See table 3, which also outlines further sociodemographic differences. In the multivariable regression model when sociodemographic factors were controlled for, language group (p<0.001), female gender (p=0.04), and having two or more chronic illnesses (p<0.001) remained significantly associated with increased nervousness or stress, as did higher perceived financial burden (p<0.001). See online supplemental table 1.
Overall, 22.3% of participants reported feeling alone or lonely most or all of the time. In regards to language groups, the range was from 5.6% (n=2) for Hindi speakers to 51.2% (n=32) for Khmer speakers. 27.8% (n=81) of participants with inadequate health literacy reported feeling alone or lonely most or all of the time; this proportion was 18.5% for participants with adequate health literacy (n=77). The proportion of participants who reported feeling alone or lonely most or all of the time was 18.3% for those who self-reported that they speak English well or very well, compared with 31.3% of those who speak English not well or not at all. See table 3. After multivariate adjustment, having two or more chronic illnesses (p<0.001) and university education (p<0.001) remained as significant correlates of feeling lonely or alone, with statistically significant differences also observed between language groups (p<0.001).
Of the 399 participants who responded to the question regarding impacts of COVID-19 on their relationship with their partner, a quarter (25.5%) reported negative effects; 62.9% said that the pandemic had no effect and 11.7% said that it had had positive effects. We observed significant differences in reporting of negative impacts on relationships across language groups (p<0.001) and across age groups such that those aged <30 years had a significantly higher proportion of people reporting negative impacts compared with each other age group (30–49 years: p<0.001; 50–69 years: p<0.001; 70 years and above: p=0.02). Those in the most disadvantaged IRSAD quintile reported more negative impacts compared with those in higher quintiles (p<0.01). We also observed significant differences in reporting of negative impacts on relationships based on financial burden (p<0.001) and psychological variables (alone/lonely: p<0.001; nervous/stressed: p<0.001). See table 4.
Of the 262 participants who reported having children aged less than 18 years, 72.8% reported spending more time looking after their children as a result of the pandemic (n=191). The majority agreed (somewhat or strongly) that COVID-19 has meant that their children spent less time with friends (68.5%), are less physically active (64.2%) and have more screen time (63.3%). Across the entire sample, 44.9% agreed that their children were finding school harder. Mean perceived negative impact on children was rated 3.5 (out of 5; 95% CI 3.3 to 3.7). In the multivariate analysis, reporting of negative impacts on children varied significantly across language groups (p<0.001). Reporting of negative impacts on children was significantly associated with the most disadvantaged IRSAD quintile (p=0.02) and with chronic illness, with participants with one (p=0.01) or two or more (p<0.001) chronic illnesses significantly more likely to report negative impacts compared with those without chronic illness. See online supplemental table 2.
Overall, 38.6% of participants reported that their employment status has changed because of COVID-19. This was most commonly a reduction in hours of employment. See figure 1. In total, 63.6% of participants reported somewhat or more worry about financial problems as a result of the COVID-19 pandemic, and 53.7% reported that they were having difficulty meeting their financial expenses.
Mean perceived financial burden was 2.9 on a 5-point scale (95% CI 2.8 to 2.9). As shown in table 5 and online supplemental table 3, perceived financial burden was similar across health literacy and language proficiency categories. Financial burden differed across language groups and was highest for Khmer speakers (M=3.6; 95% CI 3.4 to 3.8) and lowest for Spanish speakers (M=2.1; 95% CI 1.7 to 2.6).
In the multivariable regression model, we also observed significant differences in mean perceived financial burden across language groups (p<0.001). As well as differences by language, mean perceived financial burden was significantly lower for the oldest age group compared with the youngest after controlling for other sociodemographic factors (p<0.001). People with one chronic illness (p=0.01) or two or more (p<0.001) reported significantly more financial burden compared with those without chronic illness.
This is the largest Australian survey exploring COVID-19-related psychological, social and financial outcomes, and the sociodemographic predictors of those outcomes, among people who primarily speak a language other than English to be conducted to date. Even prior to the July 2021 COVID-19 outbreak in NSW, which disproportionately impacted the communities and geographical areas included in this study, we observed broad negative psychological, social and financial impacts of the pandemic. Over a quarter of the sample reported feeling nervous or stressed most or all of the time, and 22% felt lonely or alone most or all of the time. Over half worried about financial problems and reported being somewhat or less able to meet their weekly expenses. A quarter of participants reported negative impacts on their spousal relationship and the majority of participants with children under 18 years reported that even out of lockdown their children spent less time with friends as a result of the pandemic (68.5%), were less physically active (64.2%) and had more screen time (63.3%). Regression analyses consistently showed distinct patterns of COVID-19 impacts for different language groups and more negative outcomes for those living with chronic illness and comorbidities.
The impacts of COVID-19 have been explored across a number of countries with different population groups. Direct comparisons are difficult on account of varying survey items, different data collection time points, and wide-ranging case numbers, morbidity and mortality from COVID-19 across geographical contexts. However, since the beginning of the pandemic, studies have spotlighted sociodemographic disparities in outcomes worldwide37 and broad impacts for culturally and linguistically diverse groups.38 A cross-sectional survey among culturally and linguistically diverse communities in Greater Western Sydney (n=198) conducted earlier in the pandemic (August–September 2020), for example, similarly identified financial and social impacts, with 40% of participants indicating that their financial situation and ability to access social services were ‘worse’ as a result of COVID-19.38 Our findings build on this by offering further nuance (eg, highlighting associated worry about financial problems) and elucidating a range of other impacts including additional impacts on children. Our study also uniquely showcases differences in outcomes across language groups.
In comparing our findings to Australian studies which did not specifically focus on culturally and linguistically diverse communities, we also see some similarities. Nationally representative data from the Australian Bureau of Statistics, for instance, showed that in June 2021, one in five (20%) Australians experienced high or very high levels of psychological distress in the last 4 weeks, and 28% of people 18 years and over reported feeling nervous in that survey.13 Previous work has also confirmed negative impacts of COVID-19 on children’s social connectedness and amount of screen time.39 40 The psychological impacts found in this study are also comparable to our national survey conducted in April 2020, at the outset of the pandemic when stay-at-home orders had been in place for 3 weeks. In this earlier study, we found that 26% of participants reported feeling nervous or stressed most or all of the time, and 27% felt lonely or alone most or all of the time.18 Similar proportions of negative outcomes over time may reflect a pattern of community resilience, which has been referred to elsewhere.38 Alternatively, given that case numbers and community restrictions were low at the time of data collection in the current study, our findings could also reflect the inadequate COVID-19 response for culturally and linguistically diverse communities.
Our findings showcase a broad range of impacts of COVID-19 among culturally and linguistically diverse Australian communities. A multilevel, whole-of-government approach is needed to address these, with policy and sustainable infrastructure to disseminate timely, understandable and culturally appropriate information about financial, social and mental health resources and services and to co-design tailored support packages for different language groups.41 Qualitative studies have highlighted a large number of community-driven initiatives and actions that have emerged as a response to COVID-19, as well as embodied and communal ways of coping.42 Using a strengths-based perspective, we must acknowledge the multiple capacities and resources of our culturally and linguistically diverse communities and provide properly resourced opportunities to work directly with them to address unique challenges that they face, as identified in this study. Our findings reinforce the need to prioritise support for community members living with comorbidities who are likely to bear a disproportionate impact.
Strengths and limitations
This study was co-designed by researchers and multicultural health service staff, and enabled through recruitment methods that are inclusive and reduce barriers to participation, such as translated versions of the survey, engagement of interpreters and multicultural health staff who are trusted in their communities, and use of multiple recruitment methods (including through community events and networks). This approach wholly aligns with the Framework of Culturally Competent Health Research.22 However, practical constraints limited the number of languages we could include, and restricted data collection to three regions in Greater Sydney only. We also used convenience sampling methods.
To reduce survey length and burden on participants we purposefully selected a small number of items from validated measures or our previous research to explore psychological, social and financial impacts, or co-designed them specifically for this study. Self-report may have introduced recall and social desirability bias.
Finally, the results of this study reflect a particular point in time when there were very low numbers of community-acquired cases of COVID-19 in Australia, and for the most part, no government-imposed restrictions on movement and activities in NSW. It is likely that psychological well-being outcomes and financial and social stress worsened after the July 2021 outbreak and the imposition of stay-at-home orders, in line with previous research.39 43 We are unable to explore changes in impacts over time in this study.
Culturally and linguistically diverse communities experience significant impacts of COVID-19, with distinct patterns of impacts for different language groups. We must work with communities to address unique challenges they face and tailor interventions and supports accordingly. As COVID-19 continues to disproportionately impact the most culturally and linguistically diverse communities in Sydney and worldwide, responses must too reflect the diversity of our communities through co-production and tailored support packages.
Data availability statement
Data are available upon reasonable request.
Patient consent for publication
This study involves human participants and was approved by the Western Sydney Local Health District Human Research Ethics Committee (Project number 2020/ETH03085). Participants gave informed consent to participate in the study before taking part.
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Contributors DMM: formal analysis, investigation; data curation; writing—original draft; JA: conceptualisation, methodology, formal analysis, investigation; data curation; writing—review and editing; project administration; OM: formal analysis, investigation; data curation; writing—review and editing; project administration; CB: conceptualisation, methodology, investigation; writing—review and editing; project administration; EC: formal analysis, writing—review and editing; KP: conceptualisation, methodology, writing—review and editing; HD: conceptualisation, methodology, writing—review and editing; CB: conceptualisation, methodology, writing—review and editing; DM: conceptualisation, methodology, investigation; writing—review and editing; DZ: conceptualisation, methodology, investigation; writing—review and editing; UT: conceptualisation, methodology, investigation; writing—review and editing; YS: conceptualisation, methodology, investigation; writing—review and editing; TC: conceptualisation, methodology, investigation; writing—review and editing GV: conceptualisation, methodology, investigation; writing—review and editing; KJM: conceptualisation, methodology, formal analysis, writing—review and editing; project administration, guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.