Article Text
PDF
Abstract
Objectives The aim of this study was to explore the agency of older adults and their strategies to restructure ways of being and belonging in a rapidly and radically changed social environment during the UK’s first COVID-19 lockdown in Spring 2020.
Design Qualitative study consisting of semi-structured interviews. Findings were derived from a thematic analysis of interview transcripts. We also established a patient and public involvement and engagement group who advised on study design, interview topic guide and interpretation of findings.
Setting Interviews were conducted online with older adults in the UK through their platform of choice in Spring 2020 in England, UK.
Participants We conducted 28 interviews (16 women, 12 men) with older adults over the age of 70 years. Our participants were mostly white, middle class adults.
Results From the data, we constructed three strategies that older adults used to employ agency and create spaces of belonging in their social networks despite lockdown restrictions. First, participants created a sense of belonging by being ‘good’ members of society who were knowledgeable about COVID-19. Second, older adults created new ways to socially engage with the wider community. Finally, older adults actively restructured social networks to preserve a sense of belonging.
Conclusions Older adults are actively and creatively carving a space of belonging during the societal upheaval in response to the COVID-19 lockdown and public health restrictions. Rather than internalising potential exclusionary messages based on their age, older adults instead used their agency to reimagine and transform spheres of belonging.
- qualitative research
- mental health
- public health
- social medicine
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
Strengths and limitations of this study
This study benefits from a large qualitative data set with this population cohort (n=28 interview), providing a breadth of experiences of individuals aged 70 years and older living in the UK.
Due to lockdown restrictions and the reliance on personal social networks for recruitment, participants are primarily of a certain social class and ethnicity (ie, middle class and white).
Because of the social class of our participants, findings may not be applicable to older adults belonging to other social or ethnic categories.
Introduction
In 2020, the world experienced the most serious disease outbreak in a century—COVID-19. It was officially declared as a pandemic by WHO on 11 March 2020.1
As cases began rapidly rising, the UK government encouraged those most at risk of COVID-19 to self-isolate: people with certain underlying health conditions, pregnant women and individuals aged 70 years or older.2 Full lockdown meant that people could only leave their homes to shop for basic necessities or to exercise once per day. People from different households could not meet, and all non-essential shops and businesses were closed. The UK’s strictest lockdown started on 23 March 2020 with measures only easing in July 2020.
Large-scale disease outbreaks have both physical effects on the population and serious psychosocial impacts. An early study on the mental impact of COVID-19 in China suggested it had a moderate to severe impact for a majority.3 Self-isolation may exacerbate such distress as older adults are perceived as particularly ‘vulnerable’ to social isolation.4–6 Early COVID-19 studies confirmed prolonged lockdowns may increase psychological distress,7 anxiety and depression3 and anger or fear.8 These studies suggest that older adults may be more affected psychologically and socially by lockdown measures in comparison to other groups.
A plethora of government and popular media emerged around older adults and their perceived vulnerability. This was frequently alarming and anxiety-provoking with the potential to stigmatise older adults. Many instances of blatantly ageist remarks circulated in the UK. The Prime Minister’s senior advisor, Dominic Cummings, reportedly said that the priority was to protect the economy, ‘and if that means some pensioners die, too bad,’9 while other figures, such as former BBC correspondent Max Hastings, claimed older adults were becoming a ‘dead weight’ on the National Health Service (NHS).10 Newspaper commentaries appeared, claiming ‘we needlessly sacrificed […] for the sake of the elderly’.11
The lockdown measures introduced during this time coalesced—in the minds of many older adults at least—with these circulating ageist narratives. These ageist policies act as a type of ‘chronological quarantine’ put in place by the British government.12 By advocating physical distancing and encouraging social isolation, popular discourses placed older adults outside the realm of belonging, potentially stigmatising them and stripping them of a sense of agency in their social environments. Throughout this article, we follow definition of agency by Emirbayer and Mische13 as a:
temporally embedded process of social engagement, informed by the past (in its habitual aspect), but also oriented toward the future (as a capacity to imagine alternative possibilities) and toward the present (as a capacity to contextualize past habits and future projects within the contingencies of the moment).
Our study aimed to explore in-depth lockdown experiences and how older adults used their agency to foster belonging. Temporal embeddedness was a crucial aspect of agency as the strategies we identified arose from the specific set of emergent social constraints14 wrought by, and in reaction to, the lockdown. Given the media hype about the social isolation of older adults during the pandemic, it is important to delve into the ways that older adults coped with the restrictive measures.
Methods
Study design
We employed a qualitative methodology using semi-structured interviews. A multidisciplinary research team, comprising two social anthropologists (BW, LD), a medical sociologist (KP) and a general medical practitioner (CM), conducted this study.
Setting and data collection
Interviews were conducted during the UK’s first COVID-19 lockdown (April– June 2020) when both researchers and participants lived and worked under lockdown measures. All research activities were conducted online.
The research team actively recruited participants through their personal networks and through the social networks of the large staff cohort at Keele University’s School of Medicine, using a mixture of convenience and snowball sampling. Recruitment ended when data saturation was reached.15 16
An interview topic guide (see online supplemental file 1) was used, with themes constructed through a specially convened patient and public involvement and engagement (PPIE) group), literature reviews and the clinical experience of research team members. Two experienced social scientists (BW and KP) conducted all interviews via telephone or an online platform of the participant’s choice. Informed consent was initially obtained from all participants and later re-affirmed verbally prior to each interview. Interviews lasted between 22 and 86 min, averaging 52 min.
Supplemental material
Data analysis
Thematic analysis was iterative and ongoing throughout the study.17 Interview transcripts were read in full by BW, KP and LD to gain an overall perspective of the data. These were then coded thematically by BW and KP who developed a preliminary coding scheme with overarching themes and subthemes. In discussion with all researchers, a final coding framework was refined. The study was conducted and reported in accordance with the standards for reporting qualitative research.18
Patient and public involvement and engagement
PPIE ensures research is relevant to participants, the wider public and policymakers. Drawing on the strong foundation of involving patients and public in health and social care research at Keele University,19 20 we established an online PPIE group for this study.21 22 This group of six members (3 women and 3 men), were all older than 65 years. The PPIE group met twice: prior to data collection to discuss the interview topic guide and during data analysis to gain insight and feedback on the development of our coding framework. This collaboration shaped our findings in a way that moved beyond the tokenism inherent in much PPIE work23 and will be discussed in more detail in the Discussion section under the heading ‘Close connections’.
Results
In total, 28 older adults (16 women, 12 men) took part in the study. Interviews were recorded, transcribed, pseudonymised and assigned a unique study ID. As a token of appreciation, each participant received a £10 voucher from a large online retailer. The mean age of respondents was 75 years. Demographic details and characteristics of participants are shown in table 1.
Participant characteristics
Our recruitment approach influenced our sample. Those interviewed were mostly white, middle class and largely computer literate with internet access. This is typical for the UK: 80% of households with at least one adult aged 65 years or older have internet connection at home.24 Our findings reflect the experiences and perceptions of this demographic of older adults in the UK.
Through our data analysis, we generated three overarching themes:
being a good citizen;
staking claim to the wider community through alternate activities;
changing dynamics of care and connectedness among family and friends.
Being a good citizen
All older adults in our study were deemed ‘vulnerable’ as defined by the UK government. Many resented this broad-age categorisation of themselves while acknowledging steps taken to demonstrate their commitment to personal and public health. One path to being a ‘good’, responsible citizen during this time was to educate themselves on COVID-19: what it was, how it spread and how to prevent catching and passing it. The older adults gleaned this information from the UK government’s daily press briefings and from TV, print and online news.
For many, however, it took a pivotal moment of non-belonging to modify their behaviour. For instance, one man, a church secretary aged 75 years, commented on how being seen as out-of-place prompted him to consider government guidelines more seriously.
It was, probably, about a week after they announced that they were going to lock us in. […] I used to bank the church money on a Monday. And I went down into the bank, to bank the money that week and both tellers in the bank looked at me and said, ‘You should not be here’. […] You know, when the people in bank say to you, ‘You should not be here. You should get somebody younger to do this.’ It makes you think, doesn’t it? You know. Am I being stupid? No, not me. I’m being stubborn. I think that’s what decided me. I’ve got to be good. (OA10)
A similar story about being out-of-place came from another participant. She recounted: ‘We heard from a friend that her father of 88 had gone to the paper shop and was stopped by a policeman asking him where he was going’ (OA11, F, 70). She, like other participants, believed these exchanges stemmed from media portrayals:
Sometimes, I feel that the media are part of the problem. You can read things in the paper. Like, we’ve had, ‘70-year-olds won’t be let out until 2022’, and just stories that are absolute rubbish, but it’s in print. People believe it. There has been so many things in the papers from people who are over 70 saying, like me, we want to be treated as individuals. Don’t put us all together because we are aware that there are many 70-year-olds who do need to be protected. That is fine. But it’s not all of us. (OA11, F, 70)
These social opinions and media commentaries made many feel that only their bodies were considered rather than the whole person, which caused discomfort and frustration. Several, however, recognised it as an opportunity to ‘be good’, as OA10 recounted. Others felt it was akin to a national obligation to follow all guidelines and recommendations. One participant described this sense of duty as follows:
[It is] a reminder to oneself and to other people. Because a mask doesn’t protect yourself, it protects somebody else. But it’s like wearing a badge, isn't it, or a marketing campaign? It should be constantly in your face because it is easy. We wear the uniform [ie, gloves, facemask, hand sanitiser] when we go out and that’s important, and have done from the start. (OA09, M, 76)
Another participant commented ‘personally, I think I could survive it because I think I’m fit enough and strong enough not to really fall into that category of people who are vulnerable’. Yet he still adhered to government guidelines for the benefit of others: ‘if I caught the virus, and if for some reason I pass it on, I’d just feel absolutely dreadful about it’. (OA08, M, 74).
While age may increase susceptibility to the virus, participants resented being lumped into a broad age-based category. They described experiences where they, or acquaintances, were told by community members that they did not belong in social spaces. Yet if and when they did have to venture outside of their homes, they described how they would ‘be good’ and undertake all appropriate precautions.
Agency in the community
The second overarching theme revolves around how older adults created an alternative sense of communal belonging in a more socially accepted way. Most participants lived in small village communities, and the pandemic provided them with new social avenues. For instance, many remarked on the stronger relationships they had with neighbours and others in their community. A newly found sense of conviviality fostered a broader communal sense of belonging. This conviviality among strangers and acquaintances underpinned interactions that many of the older adults had during the UK’s first lockdown period in 2020.
We interviewed most of our participants when the UK government only permitted individuals to leave home once per day for exercise. For many of our participants, this became a daily walk. Even those who did not previously walk before the pandemic began taking advantage of the once-a-day excursion out of the house. As one older adult noted:
People are all friendly. We’re all talking to one another. There’s all ‘good mornings’ and ‘how are yous’ and this sort of thing. I’m getting used to the regular dog walkers now. Some people want to stop and have a chat as well, which is great. (OA03, F, 73)
Being outside allowed some participants to engage convivially with community members. Others used different forms of technology to reach out to those in the wider community. One woman, for instance, took to writing a daily blog for other older adults in the village where she mocked the new daily struggles they were all experiencing—such as the frustrations of doing your very first online grocery shop—which she then emailed to community members. She added humour to these blogs; for example, in one she noted ‘The big story of the day is I reversed my car out of the garage and altered the clock’ and compared herself, with the daily writings and widening circle of readers, with Jessica Fletcher in the popular TV show Murder She Wrote. She remarked how her readers reacted to these daily blogs, with some telephoning her if they had not received the next one by a certain time, or left gifts on her porch.
Other interviewees positioned themselves more actively in the community as conveyors of pertinent information. For instance, one woman (OA22) recounted how the local supermarket had formed a solution to the lack of available home delivery slots. They allowed community members to telephone the supermarket with their shopping lists, permitted them to pay by card over the phone and provided same-day deliveries free of charge. On learning of the initiative, OA22 proceeded to contact each member in her group to confirm they knew of it.
She ensured that those who could benefit from this system (particularly those older adults who attended her social group), knew that it was ‘Now simple, quick, easy. No internet, supermarket prices. I could stand up and make a speech about it because it is so simple’ (OA22, F, 82). This participant acted as a conduit for this information by reaching out to her wider network.
Actively engaging with the community took many forms. While many described interacting with those in their physical space, often during the course of a daily walk, others used the internet or telephone to engage with a wider range of community members. In these examples, participants engaged with others in ways that they had not done prior to the lockdown.
Dynamics of care and belonging
The third theme revolves around the different ways in which older adults redefined care. Physical distancing, coupled with the ban on mixing with those from other households, meant close relationships with family and friends were fragmented and reconfigured. Older adults faced the conundrum of how to reshape or redefine these relationships to provide a sense of belonging and recentre themselves as intimate, social beings.
Changed patterns of familial care
Familial relationships were at the centre of participants’ narratives. Prepandemic, several cared for family members (particularly grandchildren). Many older adults thus expressed distress from having to physically distance from family members. Furthermore, the COVID-19 restrictions prevented them from many intimate family moments (birthdays, births, other celebrations and milestones).
A shift took place for many older adults, in renegotiating their place within the family, from providing care to receiving care during lockdown. One participant remarked that she was ‘fit and well’ and ‘quite prepared to join the queues for the supermarket’ for her weekly shop. Since lockdown began, however, she had not done her weekly shopping ‘simply because we didn’t want to add to our children’s stress’ (OA11, F, 70). Her children felt it too risky for her to physically go to the supermarket, which meant that she arranged online orders where possible or one of her children shopped for her. She wanted to avoid additional strain on her relationship with her children, while emphasising in the interview she did not perceive herself as vulnerable and was perfectly fit and able to do the shopping.
Not all transitions from providing to receiving care went smoothly. Some repudiated the idea of being ‘vulnerable’ and in need of protection from society. Those interviewees felt that COVID-19 guidelines for older adults severely curtailed their sense of agency. For instance, the children of one participant ‘threatened’ him to follow the guidelines, to which he eventually relented:
You know, the kids have threatened to take my shoes away if I do anything silly […] I mean, you know, when they [the government] first talked about it [lockdown], I was going to rebel because that’s me. I don’t like being told what to do. But, once, when one […] said to me, ‘Dad, you’re 75. If you end up in hospital and they’re short of ventilators, you will not go on a ventilator.’ And I thought: crumbs. That’s quite a point. And that’s when I thought, okay. I’m going to change my state of mind, and obey this. And I have done. (OA10, M, 75)
Maintaining friendship circles
Dynamics of belonging and care also shifted among friendship groups, although in subtler ways. During lockdown, many older adults found they had to work more proactively to maintain these bonds. One participant claimed that because friends had to take ‘more time and effort’ to keep in touch, many friendships had actually grown stronger during this time (OA10, M, 75).
Care was carefully crafted to ensure all friends felt they belonged and shared in the additional effort of contact that lockdown necessitated. Friends, for instance, often formed phone chains with a designated ‘caller’ to check in with one another. As one older adult explained, ‘Say I ring today, my friend, she’ll ring me at the weekend and then my other friend, she'll ring me in the week and then we take it in turns to ring one another’ (OA27, F, 76). These phone chains preserved their social circle without unduly burdening one member and kept communication flowing.
Some friend groups went further and tried to preserve the vestiges of their prepandemic social routine as best they could. For instance, one group maintained their traditional ‘pub nights’ (OA01, F, 70). As one woman explained:
We meet every Friday now in lieu of our fish and chips at the pub. It’s actually a pub crawl anyway. We start in one pub, normally, and have a drink, and then we move to another one. But now we do it online with Zoom, and we have quiz questions. We did a quiz on Friday and everybody had five questions, you know. Kept us old folk entertained. (OA01, F, 70)
Keeping the same weekly social routine as prelockdown meant that her friendship circle remained strong while resisting the notion that a lockdown meant restricting social interactions. Each member of this circle ensured that they kept the bonds of friendship strong by actively making the effort to use social technology to keep in touch and by using it creatively to host an online pub quiz for everyone. She was not alone in keeping these cherished pub nights alive. In the case of another participant, she and her friend used Skype to video call one another and virtually ‘share’ a drink at what they laughingly called ‘The COVID Arms’.
Discussion
Agency and belonging
In this article, we demonstrated how older adults rejected or subverted the perceived dominant media alarmist projections and targeted measures to isolate them. Older adults employed strategies to restructure or create a new sense of belonging. This sense of belonging (or not) ‘has the power to change lives, to make communities and collectives, to bring together and separate in the most intimate, loving, accepting, exclusionary or violent ways’.25 Older adults in our study similarly discussed how they created new or altered spheres of belonging and care in the face of lockdown restrictions, which seemed to largely remove older adults from the visible social world.
Agency presupposes a capacity to intervene and transform a person’s social world.26 Although older adults in England were not directly excluded during the COVID-19 lockdown, many felt targeted for exclusion. In our study, we demonstrated that older adults were not passively internalising the government’s label of ‘vulnerable’ with its emphasis on protection and the popular media’s interpretation with its isolationist emphasis on removing older adults from society. Such discourses, predicated on a biomedical model, saw them as at-risk bodies. This reductionism of the whole person to the vulnerable body runs the risk of helplessness, isolation and powerlessness.27 Our participants actively contested these social narratives and carved out spaces of belonging which were not necessarily dependent on physical proximity to others.
Being ‘good’
If belonging can be considered as a ‘set of practices’,25 then older adults in our study were using their agentive potential to engage in certain practices to demonstrate a sense of belonging, even while being discouraged from inhabiting certain physical spaces (ie, by not belonging). These experiences of ‘not-belonging’ remained salient in their pandemic experience. Not-belonging is ‘a collection of people, practices, objects, germs and performances that are, somehow, not meant to be in a place’.25 For our participants, this constituted individuals over the age of 70 years, and the place represented any enclosed public spaces such as banks and shops. This abrupt experience of ‘non-belonging’ drove many participants to change their behaviours.
Yet rather than completely detach from society, our participants repositioned themselves not as apart from society, but as a part of society. To do so, they acted as good, caring citizens, using their agency to seek out information about COVID-19 to protect themselves and others. In this way, they asserted themselves as ‘responsible’ citizens who engaged in activities to protect others.28 This can be considered social bonding, a prosocial behaviour in which voluntary behaviours help or benefit others and includes making and maintaining social connections for an enhanced quality of life.29 Most crucially, it demonstrates belongingness to a wider national culture, one in which they share the responsibility of protecting the health of the population and preventing extreme pressure on the UK’s NHS. This ‘readiness to give and contribute to the interests of those who co-constitute a social collective’30 allowed them to demonstrate their right to belong.
Community-making and belonging
Being seen as a visible member of society was another way in which our participants demonstrated agency and belonging. Often this took the form of conviviality with others in physical spaces and through ‘performances of belonging’.25 These performances ranged from the creation of shared experiences (as in the blog) or shared solutions to community problems (changes to supermarket deliveries).
Much has been written about community-making based on physical proximity25 and the role conviviality plays among older adults. For example, getting out of the house was one of the main underpinnings to feeling connected among ethnically diverse older adults in New Zealand and allowed them to exercise their social agency.31 This connectedness did not translate directly to social interactions per se. Being out in the world allowed them to feel connected by portraying themselves as social beings who belonged.32 Since this passive sense of sociality and belonging was no longer possible as most shops were closed, the conviviality that community members extended to each other, such as greetings exchanged during a daily walk, felt all the more valuable. These brief exchanges allowed participants to keep active social ties which in turn promoted social bonding28 and may have reaffirmed an emotional bond with their immediate environment, which also has positive benefits on mental health33 despite lockdown restrictions.
Technology further facilitated this sense of friendliness to those in the wider community. Online interactions provided strategies for discernibly reinserting oneself back into society after the initial lockdown disruption and offered a space of inclusion. It did so through social recognition by and interaction with others, which served to provide those who are somehow marginalised with a sense of agency, security and confidence.30 These wider community patterns of interaction and care that older adults actively engaged with provided an avenue to reinsert themselves as social beings despite the more official narratives of vulnerability and isolation.
Close connections
Social accessibility, or the ways in which people will actively work within constraints to maintain their social networks,34 offers a lens through which to understand how older adults maintained or recreated their spheres of belonging among close relationships. This accessibility is central because ‘a sense of belonging with others […] comes about both through connectivity and attachment’.25 Ensuring connectivity despite the lockdown restrictions—such as through the use of telephones or through online platforms—preserved these attachments and thus belonging.
Family relationships, however, experienced more radical shifts than friendships. Much of the active restructuring came from renegotiating dynamics of care to still place older adults at the heart of their families, rather than those who needed protection from families (who could potentially carry the deadly virus). As such, several participants experienced a shift from providing to receiving care. Participants chose to receive care to avoid excessively burdening their adult children, many of whom took on caregiving roles (such as providing groceries).
The desire to avoid burdening others, especially children, exists in the literature on older adults. In a study of older adults in New Zealand, researchers explained that what ‘helped and hindered participants to connect was an emphatically expressed desire not to burden others. Participants strove to portray themselves as resourceful and agentic’.31 This idea permeated our participants’ narratives as they sought to strike the balance between receiving assistance from family members and ensuring they were seen as fully capable adults.
Initially, the research team (none of whom are older adults) interpreted these accounts as a parent-child role reversal with the potential for prematurely infantilising older adults.35 36 We presented this interpretation to the study’s PPIE group for discussion. Several recounted that they too experienced or heard similar accounts during lockdown. When asked if these made them feel less independent or autonomous, the PPIE members (themselves older adults in the UK during lockdown) stated that it did not. Rather than feeling belittled or reduced to a child-like state, parents proudly told how their children urged them to stay at home and isolate while they provided care to them in the form of groceries and other necessities. This narrative was not one of dependency, but rather of pride in the steps that children would take to protect and care for their parents. Agency had not necessarily been removed; rather, this shift from being the provider to the recipient of care preserved familial closeness during this socially tumultuous time.
This example encapsulates Staley’s23 assertion that researchers ‘do not know what they do not know’ and demonstrates a strength of involving patients/public in research. For our study, this type of ‘reality check’37 from those who are older adults with the experience of grown children provided experiential knowledge that the researchers simply did not have. This finding highlights the importance of PPIE groups on the interpretation of results beyond merely a tokenistic gesture.
Limitations
Our options to recruit a more diverse sample were limited because of the COVID-19 restrictions, and we therefore relied on the personal and professional networks of researchers and participants for recruitment. Consequently, those in this study cannot be said to be representative of the UK as a whole, which is often the case in qualitative research. Most study participants were white, middle class individuals living in a village. They had access to private or safe outdoor spaces, which many admitted played a significant role in their ability to cope. Furthermore, several interviewees explicitly stated that they were not concerned over the financial implications of the pandemic for themselves.
These class and ethnicity characteristics undoubtedly impacted on the resources they had at their disposal to cope with the hardships experienced during the lockdown such as social networks for connection as well as goods provision, financial resources and access to technology and information. These characteristics coupled with living in a village, in which social ties were already established, provided them with resources to cope.
Conclusion
Much of the attention thus far on older adults has focused on the negative implications of the pandemic and relegated older adults to a passive role. Findings remain mixed; WHO38 express concern over the well-being of older adults due to the pandemic while other researchers acknowledge some will suffer from poorer well-being and others will remain less affected.7 39 Additional research suggests younger adults experience more loneliness and distress during these times40 while others remark that it is those at either end of the spectrum that experience increased loneliness (ie, <25 or >65 years)41 or find that symptoms of depression or anxiety decrease after age 75 years.42 While the pandemic’s impact remains to be fully determined, research links feelings of belonging with psychological or social resilience.30 Belonging fosters resilience, meaning the inverse—that non-belonging may result in a decline in health and well-being—is also likely to be true. Isolating entire groups deemed ‘vulnerable’ may reinforce a feeling of non-belonging which might harm those it seeks to protect. This study provided insights into the strategies that older adults applied to combat these deleterious effects and strengthen their sense of agency and belonging in a lockdown world. Future research should expand on these existing strategies to exert agency and reclaim belonging, while exploring the longer-lasting effects of being symbolically removed from society.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study was approved by Keele FMHS RECID: MH-200123. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors thank all older adults who participated in this interview study, as well as the members of the PPIE group. The authors would like to acknowledge the non-author contributions of the Q-COVID-19 team in Keele’s School of Medicine: Alina Andras, Paul Campbell, Toby Helliwell, Tom Kingstone, Michelle Robinson and Thomas Shepherd.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @BrianneWenning, @LDikomitis
Contributors BW: provided input in protocol writing, facilitated recruitment of participants, interviewed 24 participants, led on data analysis and manuscript drafting. KP: provided input in protocol writing, interviewed 4 participants, contributed to data analysis and manuscript drafting. CM: co-designed and co-led the study with LD, contributed to research team meetings and manuscript drafting. LD: co-designed and co-led the study with CM, developed study protocol, prepared project documents and ethics application, substantially contributed to data analysis and manuscript drafting, and is the guarantor. All authors have read the draft critically, made contributions and approved the final text.
Funding This work was supported by funding from the Keele University Faculty of Medicine and Health Sciences (award number N/A). CM is funded by the National Institute for Health Research (NIHR) Applied Research Collaboration West Midlands and the NIHR School for Primary Care Research.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the ‘Methods’ section for further details.
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.