Exploring perspectives on living through the COVID-19 pandemic for people experiencing homelessness and dealing with mental ill-health and/or substance use: qualitative study

Abstract

Purpose

This study aims to explore the experiences of living through the COVID-19 pandemic for people who faced homelessness and dealt with mental health and/or substance use challenges.

Design/methodology/approach

This qualitative study was comprised of 26 1:1 interviews (16 men and 10 women), conducted between February and May 2021 with people who experienced homelessness in North East England during the COVID-19 pandemic. An inductive reflexive thematic analysis was undertaken, with input from individuals with lived experience who were involved throughout the study.

Findings

Four themes were developed. The first theme, lack of support and exacerbation of mental health and substance use difficulties, highlighted how the lack of in-person support and increased isolation and loneliness led to relapses or new challenges for many people’s mental health and substance use. The second theme, uncertainty and fear during the pandemic, explored how the “surreal” experience of the pandemic led to many people feeling uncertain about the future and when things would return to normal. The third theme, isolation and impacts on social networks, discussed how isolation and changes to relationships also played a role in mental health and substance use. Finally, opportunity for reflection and self-improvement for mental health and substance use, explored how some people used the isolated time to re-evaluate their recovery journey and focus on self-improvement.

Practical implications

The experiences shared within this study have important implications for planning the future delivery and commissioning of health and social care services for people facing homelessness, such as sharing information accessibly through clear, consistent and simple language.

Originality/value

As one of the few papers to involve people with lived experience as part of the research, the findings reflect the unique narratives of this population with a focus on improving services.

Citation

Adams, E.A., Hunter, D., Kennedy, J., Jablonski, T., Parker, J., Tasker, F., Widnall, E., O'Donnell, A.J., Kaner, E. and Ramsay, S.E. (2024), "Exploring perspectives on living through the COVID-19 pandemic for people experiencing homelessness and dealing with mental ill-health and/or substance use: qualitative study", Advances in Dual Diagnosis, Vol. 17 No. 1, pp. 1-13. https://doi.org/10.1108/ADD-06-2023-0014

Background

The rapid emergence of the COVID-19 virus led to reactive changes internationally in an attempt to mitigate negative consequences and limit virus transmission. In many high- and middle-income countries, this meant identifying populations at increased risk of infection and implementing targeted protection measures in response (Government of Canada, 2022; Public Health England, 2021; European Centre for Disease Prevention and Control, 2020; Centers for Disease Control and Prevention, 2022). With the introduction of “stay at home” measures during the pandemic, there became a growing concern for people experiencing homelessness who may have been unable to safely abide by these restrictions (Rodriguez et al., 2021; Allaria et al., 2021; Cabinet Office, 2020). Global policy responses for homeless populations varied, but similarities existed around efforts to increase access to temporary accommodation solutions, either through creating new shelters, or repurposing existing hotels (Martin et al., 2020; O’Shea et al., 2020; Kelly et al., 2021; National Social Inclusion Office, 2020; Scallan et al., 2022; Brown and Edwards, 2021). In England, such efforts were termed the “Everyone In” initiative (Cromarty, 2021), marking the first national attempt at a coordinated offer of access to accommodation for people experiencing homelessness.

People who experience homelessness have high levels of physical and mental health needs compared to the general population, including co-occurring substance use (Bramley et al., 2015; Fazel et al., 2008; Grant et al., 2004). Yet although in most cases, offers of accommodation in England were paired with access to food, health and social care including drug and alcohol support, broader COVID-19 safety measures introduced during this period resulted in the closure of many face-to-face health and social care services and/or use of socially distanced or remote support often leveraging digital technology. Evidence suggests that people experiencing homelessness were disproportionately affected by these reductions in service provision and resultant social isolation (Tsai and Wilson, 2020; Leifheit et al., 2021; Rodriguez et al., 2021). For example, qualitative studies based on a Scottish homeless service found that a reduction in services coupled with experiences of isolation and emotional impacts from the pandemic led to increased drug use, anxiety, depression and confusion/fear among some homeless people (Parkes et al., 2021b, Parkes et al., 2021a).

Although these trends are echoed elsewhere in the international literature, with increased rates of drug use and drug overdoses observed in Spain and America (Appa et al., 2021; Aguilar et al., 2021; Tucker et al., 2020) alongside a range of mental health challenges, including hopelessness, anxiety, loneliness, depression and sleep problems (Tucker et al., 2020), other studies report more positive outcomes. One Canadian case study reported periods of decreased drug use which was strongly related to periods of supported housing during the pandemic (Scallan et al., 2022). Another longitudinal study of young people experiencing homelessness found increased physical activity and improved mental well-being during the pandemic (Thomas et al., 2021). These contrasting negative and positive impacts on substance use and mental health in current evidence suggest further investigation is needed to understand the complexity of individuals’ experiences.

Qualitative research involving people with lived experience of homelessness has the potential to elucidate their unique experiences and perspective. We worked with people with lived experience of homelessness, mental ill-health and/or substance use to understand the perspectives of living through the COVID-19 pandemic for people experiencing homelessness and the challenges and benefits it presented them in dealing with mental ill-health and/or substance use.

Methods

Recognising that reality is subjective and socially constructed, this research was informed by an interpretivist paradigm and social constructivism (Creswell and Poth, 2016). Thus, a qualitative methodology involving semi-structured interviews with people who experienced homelessness was used for this study conducted in North East England during the COVID-19 pandemic between February and May 2021.

People who have experienced homelessness, mental ill-health and/or substance use were involved in the design and conduct of our study, including collaboratively analysing the data, developing themes and co-writing the final paper. This led to the recruitment of three men (J.P., D.H., T.J.) and two women (J.K., F.T.) with lived experience of homelessness, substance use and/or mental ill-health from local lived experience groups. They became part of the core research project team as “Experts by Experience”. Approaches for involvement were determined collectively and based on best practices for community-based research with vulnerable populations (Souleymanov et al., 2016). Ethics approval for the study was granted by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University’s Research Ethics Committee (ref: 2034/6698/2020).

Potential participants were initially purposively recruited through gatekeepers in housing and voluntary sectors alongside “Experts by Experience” networks in two areas in North East England (Newcastle upon Tyne and Gateshead). Recruited participants were then invited to share study information within their networks, a snowball strategy approach (Johnson, 2014). Participants were aged 18 and over and self-identified as experiencing homelessness during the COVID-19 pandemic as well as mental health and/or substance use challenges. To recognise the breadth of homelessness in the region (Shelter, 2021), a broad definition was used including rough sleeping, staying with friends or sofa surfing, in temporary accommodations and having approached the local government for housing (Crisis, n.d.). People who were interested in participating could contact the lead researcher (E.A.A.) by telephone, email or consent to a service provider sharing their contact details with the researcher. Information sheets were shared with potential participants at least 24 h in advance of the interview and had the opportunity to ask any questions before the interview.

Given the social distancing restrictions in place across England at the time of this study, all interviews were conducted by telephone. Adjustments were made to enable people to participate, which included rescheduling interviews, working with local hostels or housing providers to provide access to a designated phone for conversations and offering to conduct interviews outside of normal working hours. Once no new themes were identified within interviews (data sufficiency/saturation), active recruitment ended, and only those who had previously expressed interest were given a two-week window to participate.

Verbal or written consent was obtained from participants before the interviews commenced. Interviews lasted around 45 min (ranging from 20 to 80 min) and were conducted by the lead researcher. All participants were offered a £30 supermarket voucher to thank them for their contribution. The topic guide was developed with input from “Experts by Experience” and those supporting people experiencing homelessness and focused on two main areas:

1. access to mental health and substance use services; and

2. the impact of the COVID-19 pandemic on their lives, mental health and substance use.

All interviews were digitally recorded, transcribed, anonymised and checked for accuracy. At the end of interviews, participants were provided with a debrief sheet, which contained signposting to local services for housing, homelessness, mental health and substance use.

E.A.A. worked with the five “Experts by Experience” through a series of workshops to conduct the analysis, which was informed by Braun and Clarke’s (2006) inductive reflexive thematic analysis. All transcripts were reviewed by E.A.A. for familiarisation and a select number were reviewed by “Experts by Experience” independently. Initial codes were then developed for transcripts. Using initial coding, preliminary themes were developed collectively and reviewed to determine patterns of shared meaning across transcripts. Theme and subthemes were refined collaboratively and discussed with all co-authors before finalisation. The non-linear stages of analysis enabled early theme development based on central concepts within transcripts (Braun and Clarke, 2021). Themes and subthemes related to access to mental health and substance use support are reported elsewhere (Adams et al., 2022).

Results

Twenty-six people experiencing homelessness were interviewed; ten identified as women and 16 as men. The average age was 40 years (standard deviation 11.4, range 25–71 years) and all self-identified as White British. No further participant characteristics were recorded, and characteristics have been reported aggregated to ensure anonymity. Four themes were developed from the analysis of the data:

1. lack of support and exacerbation of mental health and substance use difficulties;

2. uncertainty and fear during the pandemic;

3. isolation and impacts on social networks; and

4. opportunity for reflection and self-improvement for mental health and substance use.

Lack of support and exacerbation of mental health and substance use difficulties

Individuals spoke about how they felt that access to mental health and substance use support had been deprioritised while health and care system efforts focused on combatting the virus. Individuals felt frustrated that they could not access mental health and substance use support during this period, and, in some cases, this left them feeling helpless. Many people spoke about using drugs as a coping mechanism and others spoke about how they considered suicide in response to not being able to cope with their emotions and adversity.

I think it’s failing us the pandemic. Because people are starting to use excuses to say they can’t help you as much as they normally do. And mostly it’s failure. It seems like the system is failing us. (Male, 40s)

I’ve tried to take my life. Just not having the support and just feeling like I've been left. (Female, 30s)

People were further frustrated by the inconsistencies between easing of restrictions and which venues/places could reopen. There was particular frustration in relation to the challenges they faced accessing in-person support.

I can’t go to an AA meeting because of lockdown because of social distancing, yet I can go in a pub and get pissed out my skull. It’s really- it’s a bit of mind-bender for me, it really is. (Male, 40s)

Others spoke about how their present situations (such as inadequate housing or being unable to leave home) exacerbated pre-existing mental health challenges.

Yes, so it’s been a rollercoaster. It’s just been up and down, up and down. The full time I’m trying to live in a hostel system. […] It’s just been a rollercoaster of emotions. (Female, 40s)

I found it really, really scary, really difficult where the walls were closing in. I couldn’t watch the news. It started to a point where I just physically wouldn’t go out even if I just needed a loaf of bread, where I wouldn’t go to the local shop. (Female, 40s)

The isolation, loneliness and reduction in services brought about by the pandemic resulted in some relapses in participants’ mental health and substance use. People shared how they suddenly found themselves facing new mental health and substance use challenges. This meant, for some people who were using drugs, that they were suddenly requiring mental health support or those who had faced mental health challenges began to use drugs/alcohol.

I’ve basically went back to using drugs to deal with the loneliness and deal with the isolation and to deal with the solitude. People can think that’s an excuse, yes it is, it’s a bloody good one as well. It’s a bloody good excuse because I’m on my own, I'm isolated, I've got no outside communication. Hardly [any] contact with other people face to face much so I’m using drugs again to deal with it. Basically, everything I’ve achieved before the lockdown, which took years and years and years to achieve, like being stable on my script, not using, dealing with people, it has all been wiped away really because of lockdown. (Male, 30s)

I kind of really just bottle things up a lot and end up exploding and taking it out on myself and trying to commit suicide. (Female, 20s)

Uncertainty and fear during the pandemic

During interviews, people spoke about the large volume of information that was available from varying sources regarding the COVID-19 virus. Individuals felt overwhelmed with the amount of information about the virus and explained that it was often hard to determine the accuracy of the information provided. In addition, some participants spoke about “conspiracy theories” and concerns around misinformation. This was a particular concern given many had experienced mental health or substance use related paranoia or delusions and expressed distrust in the government. This led to some participants struggling to grasp the severity of the situation at the beginning of the pandemic.

It’s just, something that I’m not used to. I cannot understand it in a way. There’s too much information out there. It’s just all these conspiracy theories about it and I don’t know. […] You are listening to the news and the media and then you are listening to other stuff then you don’t know what’s right and what’s wrong. (Male, 30s)

Over time, and with continued information about the pandemic and its severity, many people transitioned into feeling afraid of catching the virus and the uncertainty of what catching the virus would entail. People also spoke about the realisation that they had existing vulnerabilities (such as pre-existing health conditions or post-surgery aftercare), which shaped their experience of the pandemic. Furthermore, the uncertainty on how long the pandemic would last, led to added concern and heightened anxiety.

Actually, I came out of the hospital in [date removed], but it was the start of the covid lockdown […] so, I was shielding at the time, but I still had to get out and get my shopping even though I wasn’t meant to. (Female, 40s)

Well, the scariest part is if we don’t find a cure for it basically. I know we’ve got these vaccinations now, but you never know, they say in some countries they’re having a third wave. […] I’m scared this vaccination might not work; it might mutate and I’m worried. (Male, 40s)

When mass vaccination began, people experiencing homelessness were a priority group. Although vaccination was not consistently discussed across interviews, one person explained they felt forced into getting a vaccine and expressed concerns about the contents of the vaccines and unknown long-term side effects, reiterating the lack of clarity around information during the pandemic.

I got the jab the other day. I didn’t want to have the vaccine, but I got it the other day after I was pressured by three doctors and the staff here to have it. I’d already said no in the first instance, but then they came back and they said, “Well, you have to have it. Twenty-seven thousand people have had it. This one has had it, that one has had it”. I went, “Fair enough, but I don’t have to have it. I don’t want to have it. Tell me what’s in it and I might have it”. You don’t know the effect that these vaccines are going to have on the body in ten/fifteen years’ time. (Male, 30s)

Isolation and impacts on social networks

During the early months of the pandemic, safety measures (such as social distancing and the “stay at home” order) and reductions in in-person service provision were introduced nationally to reduce the spread of the virus. With restrictions in place and fines introduced to encourage compliance with the “stay at home” order, many people were left feeling trapped; a particular concern for people who were housed in multiple unit occupancies (such as hostels) or even small single unit accommodations with minimum space.

I think before the lockdown, you know, you just took it for granted that you could get out […] I can’t get out all the time, I can’t go and visit people. You’re just stuck on your own, it’s horrible. (Female, 50s)

I Just felt like I was like a caged animal stuck in the flat. (Female, 40 s)

When speaking about changes over the last year, people recognised that the reasons they interacted with people have changed. It became clear that several individuals sought emotional and informal psychological support from family and friends, suggesting that the pandemic served to highlight the existence/lack of social networks.

So I’ve got a girlfriend now who comes and stays over, because I live by myself, I’ve created a bubble with her, and her family […] if I hadn’t met her, I think things would be a lot harder this time round, because with it being so cold, winter, dark, this third lockdown would have been really, really hard. (Male, 20s)

Like I met this lass in the last hostel I was in and like she’s like me best mate now. And she’s been through similar stuff uh, and we both help each other, so she’s a good support network. (Female, 20s)

In contrast, others spoke about losing people during the pandemic or being unable to seek support from family and friends as a result of pandemic restrictions/measures. This loss of social contact led to many people feeling alone and isolated which likely exacerbated existing mental health difficulties. In some cases, people spoke about how their housing officer or support worker would be the only person they would speak to.

I would’ve been able to call on family for housing support and somewhere to stay but my step dad [caught] Covid and had to go to hospital and mother tested positive so I've not been able to seek refuge or shelter due to the laws surrounding isolation and shielding which has worsened my situation considerably. (Male, 30s)

[…] No, I haven’t really been in touch with any- I haven’t really got any friends. (Female, 30s)

One participant described the negative impact of not having support and social interaction, explaining that no one would have noticed had he died.

[…] I could have taken my own life in here and I could have been lying on that bed for weeks and weeks, literally through the whole lockdown, and nobody would know. I know it sounds completely awful, depressing, but the only thing that would probably alert anybody was the smell of a decomposing body. (Male, 50s)

Opportunity for reflection and self-improvement for mental health and substance use

When discussing the impact of the COVID-19 pandemic on mental health and substance use, people reflected on how the pandemic has influenced their recovery journeys and acknowledged recovery as an ongoing process.

[…] if you’re not working on your recovery you’re working on your relapse. (Male, 30s)

I call it recovery because there is no cure. You are always recovering. Every day, if you get up every day, you are recovering. (Female, 40s)

Some individuals reflected on how the pandemic led to them seeing others face the same hardships they have been struggling with previously. This created some degree of validation and normalisation of the depression and mental health challenges individuals had experienced.

For the last few years before the pandemic, I was going through really, really, really hard times. I felt like I was the only one […] I felt very isolated and very sick due to depression, mental health and losing loved ones and things over the last few years. This last year, seeing people going through it. It’s strange, it’s almost like people have sort of joined me in what I was already going through. (Male, 20s)

Although many people experienced relapses or faced new challenges, others found the pandemic allowed them to reflect on and improve their mental health and substance use. Although there was recognition that the pandemic has been challenging, many people reported feeling that the forced isolation and distancing led them to be separated from others and reflect on their own well-being.

I’ve been clean for the last year. I’ll be a year in September. (Male, 40s)

I haven’t been able to see anybody really. I think that’s probably been a godsend to me because half my friends are all drug users or alcoholics and I’m ex for both of them so it’s probably a good thing I don’t get pulled back into it. (Male, 30s)

But before lockdown, it was just- I think we were all a bit fuzzy-headed, if that’s a word, before that. […] At one time, I didn’t have a TV or a phone or a radio in my room, I was sitting in my little room, and it was like a time for self-reflection. And obviously, it’s been so peaceful and quiet outside, I just loved it. (Female, 30s)

Some people reported finally receiving housing through new initiatives (such as the “Everyone In” programme) rolled out in response to the pandemic. This stability in accommodation was perceived to positively influence mental health and substance use.

Personally, for me, this year has actually been quite good. (Laughter) It sounds a bit daft because it’s been quite good because, obviously, I was homeless for, let’s say, six years and then the pandemic happened and I got put into shared accommodation and then I’ve obviously got my own flat through it so it’s been quite a good one for me. (Male, 20s)

Discussion

This study explored the perspectives of people experiencing homelessness in North East England on living through the COVID-19 pandemic and the impact it had on their daily lives alongside mental health and/or substance use challenges. The findings highlight the unique circumstances of this population and their starkly contrasting experiences of the pandemic. The negative experiences shared regarding new and continued challenges for mental health and substance use among homeless people present potential target areas for future interventions, for example, the need for interventions around isolation and loneliness. The positive findings relating to improvements in mental health and substance use recovery and self-reflection could be important areas for future research and potential mechanisms for individual recovery journeys for people experiencing homelessness. The findings also highlight the importance of social and environmental circumstances, and access to both formal and informal support, in shaping individual experiences of the COVID-19 pandemic.

Previous studies have highlighted both the increases and decreases in mental health and substance use during the COVID-19 pandemic (National Social Inclusion Office, 2020; Tucker et al., 2020; Appa et al., 2021; Aguilar et al., 2021; Thomas et al., 2021; Corey et al., 2022). However, qualitative narratives capturing the lived experience and perspectives of people who experienced homelessness alongside mental health and substance use difficulties are missing from the current evidence base (Rodriguez et al., 2021; Parkes et al., 2021a, Pixley et al., 2022). Findings from our study provide a nuanced understanding for why changes occurred within this population or not.

One of the findings in our study related to negative mental health impacts of the pandemic among people experiencing homelessness of both new and existing difficulties. The loneliness, isolation and general sense of feeling left behind or forgotten by services led to many people facing relapses and experiencing new problems, including severe anxiety, depression, suicidal thoughts, drug use and drinking. Increases in mental ill-health and drug use during the pandemic has been noted in quantitative evidence (Tucker et al., 2020; Aguilar et al., 2021; Scallan et al., 2022). However, during the pandemic, these issues of depression, isolation, anxiety were experienced, not just by homeless populations, but much more widely by the general population (Groarke et al., 2020; Kwong et al., 2021). Interestingly for some people, social restrictions were seen as a benefit, helping them separate themselves from people who were negative influences on their substance use or mental health, whereas for others it offered an opportunity to focus on their mental health and well-being. By stark contrast, there were others with limited social networks who spoke about severe isolation, coping with drug use and in some cases feeling suicidal. Similarly another cross-UK study found challenges during the pandemic were most acutely felt among people experiencing homelessness with limited social networks (Dawes et al., 2022). The relationship between social networks, homelessness trajectories and substance use patterns has been previously explored (DiGuiseppi et al., 2020; Neale and Stevenson, 2015; Neale and Brown, 2016; Hawkins and Abrams, 2007; Ravenhill, 2008).

Despite study participants all having mental health and substance use challenges, conversations highlighted the wider impacts of the COVID-19 pandemic on their lives and the role environmental circumstances (such as housing and having access to space). Many spoke about the struggles of balancing the uncertainty and restrictions the pandemic introduced, particularly around volume of (mis)information. Existing evidence has highlighted the poor communication and messaging of information surrounding COVID-19 and related regulations for people experiencing homelessness (Rodriguez et al., 2022). Our research builds on these findings by highlighting that the lack of clear communication and ambiguity often led to mistrust, confusion and paranoia among people experiencing homelessness. This is particularly concerning given the high rates of psychosis and more specifically paranoia often present among people experiencing homelessness (Fazel et al., 2008; Bebbington et al., 2005; Powell and Maguire, 2018). These experiences were compounded by environmental circumstances such as access to adequate housing, space and not feeling confined. Some people spoke about the positives of finally being housed due to new COVID-19 housing initiatives (such as “Everyone In”); others spoke about how they lost their job or lost a family member, which led them to access hostel provision for the first time. Alongside other studies highlighting the complexity of individual situations for experiencing homelessness during the COVID-19 pandemic (Dawes et al., 2022; Parkin et al., 2021), we recommend a need to recognise that the needs and priorities of those experiencing homelessness changed throughout the pandemic and will likely continue to change over their cycle of homelessness.

Strengths and limitations of the study

This study reported the experiences and views of people experiencing homelessness over one year after initial restrictions and pandemic measures were introduced in England. This allowed participants to reflect on changes across the year and in some cases reflect on longer-term impacts and consequences. The use of a broad definition and self-identification of homelessness allowed for narratives to be shared from voices who might have otherwise not been explored (e.g. those who experience more hidden forms of homelessness such as those sleeping on couches or staying with friends and family). The reflective process during analysis with those with lived experience led to a more nuanced understanding of the experiences and the development of themes (Braun and Clarke, 2019), and was a unique aspect of this study compared to previously published research (Tucker et al., 2020; Appa et al., 2021; Aguilar et al., 2021; Thomas et al., 2021; Parkes et al., 2021b, Parkes et al., 2021a).

The findings should be considered with recognition of some limitations resulting from the design of the study. As participants were recruited from two urban regions in North East England, they may not reflect the experiences of those residing in rural or coastal areas or other parts of the globe. In addition, all participants in our study identified as White British and refugee populations were not included within the study’s definition of homelessness. Further research is needed to explore the experiences of refugee populations and those of other ethnicities.

Implications for practice and policy

Study findings will help providers and policymakers for health, social care and housing to better understand that the COVID-19 pandemic did not uniformly impact people experiencing homelessness. Findings also highlight that support will need to be adapted to support people who are new or returning to services and at different stages of their mental health and substance use recovery. With increased levels of isolation and loneliness among people who are homeless, services need to recognise there could be heightened stress and anxiety about accessing services in-person or in group-based settings. Efforts should be made to provide people with options for how they engage and access services moving forward to resolve any related anxiety. Many people shared confusion and frustration related to the amount of COVID-19 information and misinformation and having to navigate it. Future health-care campaigns should consider communicating issues in a way that uses clear, consistent and simple language to make it easily understandable. Working with people with lived experience of homelessness could reduce the risk of poor or inaccessible communication. As well, working with people with lived experience of homelessness or those who support them to identify ways to combat potential misinformation is key to ensuring people can make informed decisions and understand current health issues.

Conclusion

The pandemic placed existing and new adversity at the forefront for public health. Moving forward, policymakers and practitioners need to consider the immediate and longer-term impacts the pandemic has had on the lives of people experiencing homelessness. Future research should continue to explore the broader health impacts, aside from the virus itself, faced as a result of the pandemic for people experiencing homelessness.

Acknowledgements

The authors thank the members of our Advisory Group who provided input on initial theme development, Kate Dotsikas, Cassey Muir and Claire Smiles, and our colleagues in practice from Crisis Skylight Newcastle, Fulfilling Lives Newcastle Gateshead and Tyne Housing to name a few.

Declarations.

Ethics approval: Ethics approval for the study was granted by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University’s Research Ethics Committee (ref: 2034/6698/2020). Verbal or written consent was obtained from participants before the interviews commenced.

Availability of data and materials: The data generated and/or analysed during the current study are not publicly available as due to the highly sensitive nature of the data and to protect participant’s confidentiality as they could contain potentially identifiable information, but summaries are available from the corresponding author on reasonable request.

Competing interests: All authors declare they have no competing interests.

Funding: This research was funded by the National Institute for Health and Care Research (NIHR) School for Public Health Research (SPHR) development fund for early career researchers (ECRs) (PD-SPH-2015), and by the NIHR Public Health Policy Research Unit (PH-PRU) (Grant Reference PHSEZQ47-21-A). EAA was supported by the NIHR School for Public Health Research (SPHR) Pre-doctoral Fellowship, Grant Reference Number PD- SPH-2015. EAA is now funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) North East and North Cumbria (NENC) (NIHR200173). AO is an NIHR Advanced Fellow. EK is supported by an NIHR Senior Investigator award and is Director of the NIHR Applied Research Collaboration North East and North Cumbria. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. NIHR funding acknowledgement and disclaimer: This report is independent research commissioned and funded by the National Institute for Health and Care Research Policy Research Programme. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health and Care Research, the Department of Health and Social Care or its arm’s length bodies, and other Government Departments.