Exploring the impact of shielding advice on the wellbeing of individuals identified as clinically extremely vulnerable amid the COVID-19 pandemic: a mixed-methods evaluation
BMC Public Health volume 22, Article number: 2145 (2022)
The national shielding programme was introduced by UK Government at the beginning of the COVID-19 pandemic, with individuals identified as clinically extremely vulnerable (CEV) offered advice and support to stay at home and avoid all non-essential contact. This study aimed to explore the impact and responses of “shielding” on the health and wellbeing of CEV individuals in Southwest England during the first COVID-19 lockdown.
A two-stage mixed methods study, including a structured survey (7 August—23 October 2020) and semi-structured telephone interviews (26 August—30 September 2020) with a sample of individuals who had been identified as CEV and advised to “shield” by Bristol, North Somerset & South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG).
The survey was completed by 203 people (57% female, 54% > 69 years, 94% White British, 64% retired) in Southwest England identified as CEV by BNSSG CCG. Thirteen survey respondents participated in follow-up interviews (53% female, 40% > 69 years, 100% White British, 61% retired). Receipt of ‘official’ communication from NHS England or General Practitioner (GP) was considered by participants as the legitimate start of shielding. 80% of survey responders felt they received all relevant advice needed to shield, yet interviewees criticised the timing of advice and often sought supplementary information. Shielding behaviours were nuanced, adapted to suit personal circumstances, and waned over time. Few interviewees received community support, although food boxes and informal social support were obtained by some. Worrying about COVID-19 was common for survey responders (90%). Since shielding had begun, physical and mental health reportedly worsened for 35% and 42% of survey responders respectively. 21% of survey responders scored ≥ 10 on the PHQ-9 questionnaire indicating possible depression and 15% scored ≥ 10 on the GAD-7 questionnaire indicating possible anxiety.
This research highlights the difficulties in providing generic messaging that is applicable and appropriate given the diversity of individuals identified as CEV and the importance of sharing tailored and timely advice to inform shielding decisions. Providing messages that reinforce self-determined action and assistance from support services could reduce the negative impact of shielding on mental health and feelings of social isolation.
On 22 March 2020, the Secretary of State for the UK Government announced that individuals in England who, based on understanding at the time faced the highest risk of being hospitalised by COVID-19, should “shield” themselves . Members of this group were initially advised to not leave their homes for 12 weeks and not go out for shopping, travel, or leisure. This marked the start of what came to be known as ‘shielding’ in England, which was later paused on 1 August 2020.
At the start of the pandemic, the UK Government identified the need to develop a patient list of clinically extremely vulnerable (CEV) people so that they could be sent public health advice and offered support to stay at home and avoid all non-essential contact . Those classified as CEV comprised people of all ages with specific health conditions, certain cancers, and organ transplant recipients, plus individuals identified by their General Practitioner or hospital specialist as being at a higher risk from SARS-CoV-2 infection [2, 3]. However, as there was no single mechanism available to support this identification process, a challenging and complex clinical data search was conducted across primary and secondary care settings in England. In total 2.2 million individuals were formally identified as CEV, but various delays were reported in identifying, communicating, and supporting CEV people during this initial period . For those who were able to officially register with the UK Cabinet Office as CEV , support with food, medicine, and basic care was offered by central government, local authorities, service providers, charities, rapidly-formed local support groups, neighbours, and relatives.
During the initial 12-week period of shielding over 500,000 people were provided with government-funded food parcels . The shielding advice provided in England suggested a unique combination of behaviours for CEV individuals, which included strictly avoiding contact with anyone displaying coronavirus symptoms, staying at home, not attending any gatherings, not going out for shopping, leisure or travel, and arranging for food and medication deliveries to be left without social contact. Inside the home, shielding people were advised to minimise time spent with others in shared spaces, keep two metres away from others and sleep in a different bed, use a separate bathroom if possible, and avoid using the kitchen when others were present, eating in a separate room. This specific set of guidelines was distinct from the social distancing and quarantine requirements imposed on the UK general population during the same time period .
The shielding advice combined various types of non-pharmaceutical interventions (NPIs) that are established components of the public health responses to outbreaks [6,7,8,9,10]. Yet attitudes towards such pandemic-related social interventions are known to vary among subgroups as documented by evidence for a range of positive and negative perceptions , and the extent to which they effectively reduce risk depends largely on the willingness and ability of the population to adhere to NPIs . Our understanding of the impact of extended periods of shielding is limited. The closest analogies in the literature relate to quarantine. These studies show stay-at-home and social distancing interventions used during the 2003 SARS and 2009 H1N1 pandemics were associated with detrimental mental health effects, especially in vulnerable populations that may require additional support [13,14,15,16,17]. More recently, COVID-19 related studies found that disruption to normal routines (e.g., academic delays, stopping work) was associated with increased anxiety and psychological distress [18, 19]. However, quarantine tends to be shorter, often involves different groups of people, and has a different purpose (the protection of others, rather than the protection of yourself). Given the unique nature of the official shielding advice distributed by the UK Government in March 2020, the aim of this study was to gain a better understanding from individuals identified as CEV about the effectiveness and acceptability of advice that they received to “shield” during the COVID-19 pandemic, and to explore the reported impact of shielding on their wellbeing.
A two-stage mixed methods study, including a structured survey and semi-structured telephone interviews with a sample of individuals who had been identified as needing to “shield” by Bristol, North Somerset & South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG).
Patient and public involvement
Given the extremely rapid and responsive nature of this research, it was not possible to involve patients or the public in the development of the study and associated materials. However, clinical staff at BNSSG CCG were involved in planning the study and facilitating participant recruitment. Additionally, preliminary results from this study were discussed with members of the BNSSG CCG during analysis and the findings will be shared with participants on publication.
A random sample of 840 people were contacted by post and invited to take part in the structured survey, stratified by index of multiple deprivation (IMD ; 240 in the lowest quintile and 150 in each of the remaining quintiles (600 in total)). Potential survey participants were given the option to respond via post or online.
All surveys were completed between 7th August 2020 and 23rd October 2020. The survey consisted of a 54-item questionnaire, including sections on sociodemographic and household characteristics, knowledge of coronavirus symptoms and public health advice, self-reported barriers and facilitators to advice and a self-assessment of mental health and wellbeing. The Patient Health Questionnaire (PHQ-9)  was used to screen for probable depression and the Generalised Anxiety Disorder Scale (GAD-7)  was used to screen for probable anxiety, both using a cut-off point of 10 to indicate the possibility of clinical presentation. The PTSD checklist (PCL-5)  was used to screen for possible post-traumatic stress disorder (PTSD), using a cut-off point of 4 to suggest a potential clinical presentation (full survey available in Supplement 1).
Data from each survey were initially analysed using summary statistics. Not all respondents answered all questions, therefore percentages given below use the number of respondents to each question as a denominator. Where relevant, variables were consolidated into binary indices and compared using a chi-squared test of independence. Statistical analyses were performed in R and RStudio (V1.1.463) .
Interviews were conducted between 26th August and 30th September 2020. At the time of interviews, all four UK nations had relaxed their lockdown measures. Non-CEV members of the general public living in England could return to work if their workplace was considered COVID safe. Non-essential shops and places of worship reopened, but strict social distancing was encouraged (i.e., staying two metres apart). Groups of six individuals from different households were allowed to meet outside. Anyone with COVID-19 symptoms, and their household contacts, were expected to isolate. Most notably, for the purposes of this study, individuals identified as CEV were advised to remain cautious and to stay at home where possible and, if they did go out, to follow strict social distancing.
All responders to the survey were eligible to participate in a qualitative interview. Forty-five respondents consented to take part in a follow-up interview, but not everyone who consented responded to subsequent communication. This homogeneous sample of CEV individuals consisted of those that completed the survey, , shared valid contact information used to identify interview participants, and consented to participate in the interview. In total 45 potential interviewees were initially approached via email and 14 responding individuals were subsequently emailed an information sheet about the study. In total, due to a loss at follow-up, 13 interviews were conducted via telephone (GL). Participants were offered a £20 shopping voucher as reimbursement for their time.
Interviews lasted between 42 to 69 min (median 54). Verbal consent from participants was recorded. A flexible topic guide developed using grounded theory approach was used to aid questioning, allowing participants to discuss emerging ideas . Participants were asked about the shielding advice they had received during the first UK lockdown (23rd March 2020 to 1st August 2020), the acceptability of this advice and their resulting behaviours (Supplement 2).
Interviews were transcribed, anonymised, and thematically analysed using NVivo 12 (QSR International) . A subset of transcripts were coded inductively to establish an initial analysis framework (CR). This framework was then applied (GL) while reading each transcript and listening to the interview audio files to help capture verbal emphases. Coding was performed iteratively within and between transcripts, using a constant comparative method . Following initial thematic analysis, two researchers (GL and PC) independently coded a selection of transcripts. Themes relating to participants’ understanding and adherence to the UK Government’s shielding advice were discussed, plus reported experiences and behaviours during the 12-week lockdown. Data were compared to the initial coding framework, with adaptations discussed, agreed, and made as required. The constant comparison between data and analysis allowed the development of codes, categories, and theories to be tested across transcripts, using a grounded theory approach to identify key themes .
Analysis of the interviews was conducted separately from the survey analysis. Data triangulation was used, whereby the data generated from the two methods were systematically reviewed and brought together by identifying common themes.
Research ethics approval
Ethical approval for this study was obtained on 27th May 2020 from the Heath Research Authority and Health and Care Research Wales (Project ID 284,629, REC ref 20/HRA/2549).
Survey and interview participation
Two hundred and three respondents completed the survey (Table 1). Most (110, 54%) respondents were over 69 years old, 75 (37%) were between 45 and 69 years old and 18 (9%) were between 25 and 44 years old. One hundred and ninety-one (94%) respondents identified as White British. One hundred and eighty-four respondents gave their occupation: one hundred and twenty-eight (64%) were retired, 22 (11%) working full time, 16 (8%) working part-time, seven (4%) were currently on leave or furloughed, seven (3%) were unemployed and four (2%) were stay at home parents / housemakers. 70% of survey responders lived with their family, 1% shared their property with non-family members and 29% lived alone. Nearly all survey responders (97%) had access to outside space at home, such as a garden, yard, balcony or terrace.
A total of 13 survey responders (7 female) took part in the interviews (Table 1). All interviewees were White British, with ages ranging from 25 to over 69 years. Most (8, 62%) of interview participants were retired, four were in either full or part-time work and one was a fulltime parent. One interviewee reported having no access to outside space at their home and five participants lived alone.
Acceptability of official advice to “shield”
Most respondents to the survey (80%) agreed or tended to agree that they received all information required, and most (76%) thought they tried to initially follow all advice related to shielding. People who thought they would try to follow all advice related to shielding initially were more likely to feel that they received all the information they needed (X2 = 7.396, df = 1, P = 0.007).
When explored during interview the initial timing of shielding advice was questioned by some participants, especially those who had already begun shielding before they received any official advice (Table 2, Quote 1). Interviewees reported receiving official shielding advice at various times between March and June 2020. Two participants reported never receiving an ‘official letter’ from the government advising them to shield, rather they received confirmation of their CEV status from a variety of sources such as their healthcare provider or local council. These inconsistencies were problematic for some CEV interview participants, as it meant that they did not receive any formal advice until midway through their shielding period, which ran from 23rd March – 1st August 2020 (Table 2, Quote 2).
After the initial notification to shield, most interview participants noted that they frequently sought additional information to supplement the shielding advice. The daily Government televised briefings were identified as a key information source for all interview participants at the start of the pandemic, although these updates were increasingly supplemented with information from other sources (e.g., radio, newspapers, internet searches, social media, family members, and friends) due to concerns about the comprehensibility, relevance, and consistency of these daily briefings (Quote 3 to 5). When reflecting on the televised briefings a few interview participants talked about the updates and advice not being relevant to shielding CEV individuals and that this led to feelings of being forgotten or disregarded (Table 2, Quote 6).
Attitudes and behaviours in response to shielding advice
Two thirds (66%) of the survey responders reported that all people in their household shielded with them by staying at home to avoid contact with others, and further 21% said that other household members tried to shield with them but were not able to. Members of the household were more likely to decide to shield together if all of them were over 70 or CEV (88% compared with 54% if least one person in the household was under 70 and / or not CEV) (X2 = 17.16, df = 1, P < 0.001). Interview participants reported that the shielding advice and perceived risks of COVID-19 infection were considered when deciding on their shielding behaviours and for some, shielding as a household was felt to be the only realistic approach, otherwise they would have been unable to shield in accordance with the government’s advice due to restricted living space or caring responsibilities (Table 3 – Quote 1).
None of the interview participants fully adhered to all the shielding recommendations; indeed, a spectrum of shielding adherence behaviours were reported, with advice being adapted to suit personal circumstances (Quote 2) and found to wane over time (Quote 3). Key external factors found to impact on the shielding behaviours of participants were access to outside space, food, medication supplies, and community support. In the latter case, for some interview participants the community support they received during shielding was reassuring and allowed them to “maintain shielding” (Shield 3). However, survey results showed that the types and level of support received by CEV individuals varied. For example, since being told to shield, 63% of survey responders reported receiving help that they had not needed previously. Most survey responders reported asking for additional support, mainly from family (135; 66.2%) and / or friends (48; 23.5%), and for those that received support it was chiefly from family (148; 73.3%) and / or friends (53; 26.2%). 92.1% (35/38) of people who requested organisational support (e.g., NHS, council, government, charity) during shielding received it. When explored during interview, some discussed unsolicited offers of support from their local council to help with medication and food deliveries (Quote 4) and most talked about supplementing this with ad hoc help from family, friends, or neighbours (Quote 5). None of the qualitative interviewee participants felt they could have followed the shielding advice without some external community support, as the recommended combination of NPIs was considered highly restrictive.
Despite some of the difficulties reported when following the shielding advice, 71% of survey responders felt that they were likely or highly likely to follow similar shielding advice for another three months if needed. A few interview participants even described the label of “shielding” as socially advantageous, as it legitimised their decision to self-isolate (Quote 6). However, over half of survey responders (56%) thought that it would be hard or very hard to follow such additional restrictions, indeed some interview participants had strong reservations about needing to shield again in the future (Quote 7).
Impact of “shielding” on health and wellbeing
Half of survey responders (51%) had successfully accessed healthcare either virtually or in person since being advised to shield, however an additional 13% experienced some problems. The remaining 36% had not tried to access healthcare. Interviewees also recounted mixed experiences, with some reporting smooth interactions with their healthcare providers, others experiencing initial breakdowns in communication with their GP practice or secondary care specialists that were quickly resolved and a minority having no healthcare interactions during shielding.
Survey responders were presented with a list of possible symptoms that could be attributed to COVID-19. Approximately half of the survey respondents (47%) reported at least one of these symptoms since being advised to shield. The most common signs reported were non-specific: “feeling tired or having low energy” (38%) and “aches and pains” (19%). Approximately a quarter (27%) of people with symptoms sought professional help either on the phone (24%) and /or in person (11%). Assuming that phone calls preceded a visit to a healthcare facility, only two people did not call a healthcare provider prior to visiting a healthcare facility. 42% of survey respondents that reported symptoms modified their behaviour to decrease contact with other people inside and / or outside their household.
Impact on physical health
Most survey respondents (81%) did not think, or were sure, they had not had coronavirus, 12% were unsure if they had had it, and 7% thought they had probably or definitely had coronavirus.
Most survey respondents answered that they had a health problem that limited their activities prior to being asked to shield (71%). Despite this, from all survey respondents 67% did not need regular help, 68% did not have health problems that required them to stay at home and 72% did not need to use a stick, walker, or wheelchair to move about (72%). Respondents aged over 69 were more likely to answer yes to at least one of these questions than younger respondents (X2 = 4.607, df = 1, P = 0.032). The majority of those surveyed thought that shielding had no impact on their physical health, although more surveyed people thought that shielding was making their physical health worse (11% strongly agreed and 26% tended to agree) than thought shielding was making their physical health better (5% strongly agreed and 6% tended to agree). Furthermore, some interviewees felt that shielding had negatively impacted on their levels of daily exercise (Table 4—Quote 1).
33% survey respondents strongly agreed (14%) or tended to agree (19%) that they had enjoyed spending more time at home while shielding. The availability of private gardens and outside spaces was mentioned by interviewees as a key resource for exercise and leisure throughout the shielding period; nevertheless some individuals still reported feeling trapped due to impact of shielding on their sense of freedom (Quote 2). An added complication for some interviewed parents was ensuring their children received sufficient exercise, while also personally maintaining a shielding status (Quote 3).
Impact on mental health
180 (90%) respondents to the survey described themselves as “somewhat” (63), “very” (51) or “extremely” (66) worried about coronavirus. Older respondents tended to be less worried about coronavirus compared with younger respondents (86% of respondents over 69 years compared with 96% of those 69 years or under were at least somewhat worried about coronavirus; X2 = 4.68, df = 1, P = 0.030).
More survey responders thought that being asked to shield had made their mental health worse (14% strongly agreed and 28% tended to agree) than thought that shielding was making their mental health better (2% strongly agreed and 4% tended to agree). When explored during interviews, various participants reported heightened emotions, worry and depression, and linked these emotions to feelings of being “locked up” for a prolonged period of time and anxiety about the future as CEV individuals (Quotes 4 to 7).
Depression and anxiety
Twenty one percent of survey respondents had a score of 10 or above on the PHQ-9 questionnaire, indicating possible depression where treatment may be recommended (Fig. 1). 15% respondents scored 10 or above on the GAD-7 questionnaire, indicating a level of anxiety where treatment may be recommended (Fig. 1). 76% of people with a PHQ-7 score of 10 or above reported in the survey that their mental health had become worse compared to 33% with a score below 10 (X2 = 21.314, df = 1, P < 0.00001); and 72% of people with a GAD-7 of 10 or above reported in the survey that their mental health had become worse compared to 38% with a score below 10 (X2 = 9.863, df = 1, P = 0.0017). In addition, there was some correlation between people with at GAD-7 score of 10 or above and those with a PHQ-7 score of 10 or above: 73% of people with GAD-7 > 10 had a PHQ-7 > 10, and 44% of people with PHQ > 10 had a GAD > 10. 4% of survey respondents had a score of four or more on the PTSD-4 scale, suggesting they could have high likelihood of developing PTSD as a result of their experience of shielding. 28% of survey respondents had felt somewhat (19%), moderately (8%) or very (2%) angry about being told to shield, although these feelings were not discussed by interview participants.
Early in the pandemic the importance of providing clear, tailored advice for patients who were required to shield, alongside appropriate support, was identified [30,31,32]. Findings from this study showed that official shielding advice offered to CEV individuals during the first lockdown in England was deemed to be sufficient by 80% of survey responders, although interviewees criticised the delayed timing of this advice and frequently sought supplementary information to inform shielding behaviours. The individual focus of shielding advice was considered impractical and restrictive by some participants, with 66% of survey responders considering it necessary to shield with all household members. Interview participants described a spectrum of rational adaptations to the advice, with adjustments based on living situation and personal perceptions of risk . Such findings suggest that it would be beneficial to engage CEV groups in the policy-making decision process for future public health emergencies; co-creation of targeted communication strategies has been shown to result in higher levels of adherence to behaviour change messages [34,35,36].
Organisational support (e.g., NHS, council, government, charity) was requested and received by 92.1% (35/38) of survey responders, although the type and amount of support varied between individuals, and was frequently supplemented with help from family, friends, or neighbours. These findings suggest that formal and informal support mechanisms and their coordination may benefit from being strengthened in future, potentially through involving pre-existing community-based organisations,  charities, volunteer organisations, and / or faith-based institutions . Lessons from previous pandemics have similarly echoed the need to establish alternative means for the public to “connect” during public health emergencies,  with suggestions that community support could provide mechanisms for disseminating updated advice and maintaining contact with high-risk and vulnerable populations . Accessing clear and accurate public health guidance via such support networks has been suggested as a protective measure against isolation and emotional distress by promoting feelings of social connection , which may help reduce symptoms of anxiety or depression [40,41,42]. Given the breadth of the CEV definition identified during the COVID-19 pandemic, research would be warranted to explore the most practical ways of utilising and aligning existing support networks for future public health emergencies.
Being formally identified as “shielding” was considered socially advantageous by some interviewees as it legitimised their socially avoidant behaviours. But for others this approach resulted in feeling “othered” as a CEV individual,  an issue that was further exacerbated by televised government briefings that lacked CEV specific advice, while providing reassurance to the general public that COVID-19 was most severe in those with underlying health conditions [44, 45]. Social isolation caused by the response to the COVID-19 pandemic has been shown to have a negative influence on mental health parameters [42, 46]. Of the surveyed CEV individuals, 90% were worried about COVID, with 35% agreeing that shielding was making their physical health worse and 43% reporting a negative impact on their mental health, which may have compounded these feelings of social isolation. Within this study we did not have information about participants’ mental health prior to the study, and simply being CEV may in some situations have mental health comorbidity . This emphasises the importance of using communication approaches in the future that avoid implied or unintentional stigmatising of any ‘vulnerable’ group, instead providing messages framed for target groups, that are identity affirming, promote social unity, raise awareness, increase societal preparedness , and are delivered by the right people . It is also important to note that 11% of survey respondents reported that shielding had a negative impacted on their physical health, which may be important when considering long-term motivations for self-isolation in this clinically vulnerable group.
A strength of this study was the integration of quantitative and qualitative data to triangulate information from patients identified as CEV, a methodological approach widely used for increasing the validity, breadth, and depth of mixed-method studies [49, 50]. However, our study population was 94% identified as White British, 64% were retired and 54% were aged over 69 years, therefore it is possible that our findings may not be generalisable to wider CEV populations due to demographic and experience bias. Nevertheless, our findings provide an important and valid insight into the acceptability of the shielding advice; attitudes and behaviours in response to this advice; and the impact of shielding on health and wellbeing for CEV individuals in Southwest England. Our study may also have been influenced by response bias, especially for interviewees who may have been more likely to want to discuss their shielding experiences. Last, as a cross-sectional study, pre-pandemic baseline values were unavailable, and therefore causality cannot be inferred. However, these results do demonstrate that this population did have mental health and support needs whilst shielding, which should be factored into future public health responses. Additionally, it was not possible to determine when participants had received the notification to shield, or indeed derive the reasons why participants in the study had been designated as CEV, which would impact understanding on their relative levels of risk. Centralised patient information systems with pre-emptive clinical designations would facilitate this disaggregation in future studies and contexts where tailored patient advice on a large scale is required.
Individuals who are CEV are a clinically and socially heterogenous group, and the official shielding advice provided during first UK lockdown encompassed a unique combination of NPIs that were distinct from the social distancing and quarantine requirements imposed on the UK general population during the same time period. Given the uniqueness of this population and the lack of evidence on the responses of ‘shielders’, these findings provide valuable information for policy makers and healthcare professionals regarding the impacts of shielding on the wellbeing of CEV individuals during the COVID-19 pandemic, which may assist them in making preparation for future infectious disease outbreaks or other public health emergencies. Our findings emphasise the need for future public health messaging targeted at such high-risk and vulnerable populations to be co-created with relevant members of the public, tailored to health conditions, and delivered in a more targeted way with integrated assistance from existing community support systems. Furthermore, additional work should focus on factors influencing adherence to shielding advice and long-term social distancing adaptations, as well as the long-term implications of shielding for mental health and feelings of social identity.
Availability of data and materials
The datasets used and / or analysed during the current study are available from the corresponding author on reasonable request.
National Audit Office, (2021). Protecting and supporting the clinically extremely vulnerable during lockdown. Great Britain: Ministry of Housing, Communities & Local Government, Department of Health & Social Care
Department of Health and Social Care, (2020). Clinically extremely vulnerable receive updated advice tailored to local COVID alert levels. Available from: https://www.gov.uk/government/news/clinically-extremelyvulnerable-receive-updated-advice-tailored-to-local-covid-alert-levels. Accessed Sept 2022.
NHS Digital, (2022). Shielded Patient List. Available from: https://digital.nhs.uk/coronavirus/shielded-patient-list#what-was-the-shielded-patientlist-. Accessed Sept 2022.
Goverment Digital Services, (2021). Guidance: Get support if you’re clinically extremely vulnerable to coronavirus. https://www.gov.uk/. Accessed Dec 2021.
Eraso Y, Hills S. Self-Isolation and Quarantine during the UK's First Wave of COVID-19. A Mixed-Methods Study of Non-Adherence. Int J Environ Res Public Health 2021;18(13). https://doi.org/10.3390/ijerph18137015 [published Online First: 20210630]
Centers for Disease Control and Prevention, (2020). Nonpharmaceutical Interventions (NPIs). Available from: https://www.cdc.gov/nonpharmaceutical-interventions/index.html. Accessed Sept 2022.
European Centre for Disease Prevention and Control, (2021). Non-pharmaceutical interventions against COVID-19. Available from: https://www.ecdc.europa.eu/en/covid-19/prevention-and-control/non-pharmaceutical-interventions. Accessed Sept 2022.
Chen YC, Chang SC, Tsai KS, et al. Certainties and uncertainties facing emerging respiratory infectious diseases: lessons from SARS. J Formos Med Assoc. 2008;107(6):432–42. https://doi.org/10.1016/s0929-6646(08)60150-3.
Balinska M, Rizzo C. Behavioural responses to influenza pandemics: what do we know? PLoS Curr. 2009;1:Rrn1037. https://doi.org/10.1371/currents.rrn1037 [published Online First: 20090909]
Bell D, Nicoll A, Fukuda K, et al. Non-pharmaceutical interventions for pandemic influenza, national and community measures. Emerg Infect Dis. 2006;12(1):88–94. https://doi.org/10.3201/eid1201.051371.
Teasdale E, Santer M, Geraghty AWA, et al. Public perceptions of non-pharmaceutical interventions for reducing transmission of respiratory infection: systematic review and synthesis of qualitative studies. BMC Public Health. 2014;14(1):589. https://doi.org/10.1186/1471-2458-14-589.
Margraf J, Brailovskaia J, Schneider S. Adherence to behavioral Covid-19 mitigation measures strongly predicts mortality. PLoS ONE. 2021;16(3):e0249392. https://doi.org/10.1371/journal.pone.0249392[publishedOnlineFirst:2021/03/31].
Cava MA, Fay KE, Beanlands HJ, et al. The experience of quarantine for individuals affected by SARS in Toronto. Public Health Nurs. 2005;22(5):398–406. https://doi.org/10.1111/j.0737-1209.2005.220504.x.
Hawryluck L, Gold WL, Robinson S, et al. SARS control and psychological effects of quarantine, Toronto. Canada Emerg Infect Dis. 2004;10(7):1206–12. https://doi.org/10.3201/eid1007.030703.
Mak IW, Chu CM, Pan PC, et al. Long-term psychiatric morbidities among SARS survivors. Gen Hosp Psychiatry. 2009;31(4):318–26. https://doi.org/10.1016/j.genhosppsych.2009.03.001[publishedOnlineFirst:20090415].
Pfefferbaum B, Schonfeld D, Flynn BW, et al. The H1N1 crisis: a case study of the integration of mental and behavioral health in public health crises. Disaster Med Public Health Prep. 2012;6(1):67–71. https://doi.org/10.1001/dmp.2012.2.
Carmassi C, Foghi C, Dell’Oste V, et al. PTSD symptoms in healthcare workers facing the three coronavirus outbreaks: What can we expect after the COVID-19 pandemic. Psychiatry Res. 2020;292: 113312. https://doi.org/10.1016/j.psychres.2020.113312.
Cao W, Fang Z, Hou G, et al. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res. 2020;287:112934. https://doi.org/10.1016/j.psychres.2020.112934.
Zhang SX, Wang Y, Rauch A, et al. Unprecedented disruption of lives and work: Health, distress and life satisfaction of working adults in China one month into the COVID-19 outbreak. Psychiatry Res. 2020;288:112958. https://doi.org/10.1016/j.psychres.2020.112958.
Ministry of Housing Communities & Local Government, (2019). English indices of deprivation 2019 https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019 [accessed Dec 2021].
Kroenke K, Spitzer RL, Williams JB, et al. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345–59. https://doi.org/10.1016/j.genhosppsych.2010.03.006[publishedOnlineFirst:2010/07/17].
Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. https://doi.org/10.1001/archinte.166.10.1092[publishedOnlineFirst:2006/05/24].
Ashbaugh AR, Houle-Johnson S, Herbert C, et al. Psychometric Validation of the English and French Versions of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). PLoS ONE. 2016;11(10):e0161645. https://doi.org/10.1371/journal.pone.0161645[publishedOnlineFirst:2016/10/11].
R Core Team, (2020). A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna. [Available from: URL https://www.R-project.org/].
Guest G, Namey EE, Mitchell ML. Collecting Qualitative Data: A Field Manual for Applied Research. 55 City Road 55 City Road, London: SAGE Publications, Ltd, 2013.
Glaser BG, Strauss AL. The discovery of grounded theory: Strategies for qualitative research: Routledge 2017.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa.
Glaser BG. The Constant Comparative Method of Qualitative Analysis. Soc Probl. 1965;12(4):436–45. https://doi.org/10.2307/798843.
Charmaz K. Constructing grounded theory. London: SAGE Publications Ltd; 2006.
Michie S, West R, Rogers MB, et al. Reducing SARS-CoV-2 transmission in the UK: A behavioural science approach to identifying options for increasing adherence to social distancing and shielding vulnerable people. Br J Health Psychol. 2020;25(4):945–56. https://doi.org/10.1111/bjhp.12428[publishedOnlineFirst:2020/05/20].
Smith GD, Spiegelhalter D. Shielding from covid-19 should be stratified by risk. BMJ. 2020;369:m2063. https://doi.org/10.1136/bmj.m2063.
Torjesen I. Covid-19: Charities call for clear advice after “utter mess” of shielding texts. BMJ. 2020;369:m2173. https://doi.org/10.1136/bmj.m2173.
Morton K, Towler L, Groot J, et al. Infection control in the home: a qualitative study exploring perceptions and experiences of adhering to protective behaviours in the home during the COVID-19 pandemic. BMJ Open. 2021;11(12):e056161. https://doi.org/10.1136/bmjopen-2021-056161[publishedOnlineFirst:2021/12/03].
Ghio D, Lawes-Wickwar S, Tang MY, et al. What influences people’s responses to public health messages for managing risks and preventing infectious diseases? A rapid systematic review of the evidence and recommendations. BMJ Open. 2021;11(11):e048750. https://doi.org/10.1136/bmjopen-2021-048750.
Braunack-Mayer AJ, Street JM, Rogers WA, et al. Including the public in pandemic planning: a deliberative approach. BMC Public Health. 2010;10(1):501. https://doi.org/10.1186/1471-2458-10-501.
Kemper S, Bongers MEJ, Slok ENE, et al. Patient and public engagement in decision-making regarding infectious disease outbreak management: an integrative review. BMJ Glob Health. 2021;6(11):e007340. https://doi.org/10.1136/bmjgh-2021-007340.
Abbas MZ. Public Understanding and Voluntary Responsibility to Mitigate COVID-19 Pandemic: Role of Local Community Organizations in Information Sharing and Health Literacy. Asia Pac J Public Health. 2021;33(4):451–2. https://doi.org/10.1177/10105395211002656[publishedOnlineFirst:2021/03/18].
Barmania S, Reiss MJ. Health promotion perspectives on the COVID-19 pandemic: The importance of religion. Glob Health Promot. 2021;28(1):15–22. https://doi.org/10.1177/1757975920972992[publishedOnlineFirst:2020/11/25].
McKinlay AR, Fancourt D, Burton A. A qualitative study about the mental health and wellbeing of older adults in the UK during the COVID-19 pandemic. BMC Geriatr. 2021;21(1):439. https://doi.org/10.1186/s12877-021-02367-8.
Santini ZI, Jose PE, York Cornwell E, et al. Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analysis. Lancet Public Health. 2020;5(1):e62–70. https://doi.org/10.1016/s2468-2667(19)30230-0[publishedOnlineFirst:2020/01/09].
Yang XY, Peng S, Yang T, et al. Changing trends of mental and behavioral responses and associations during the COVID-19 epidemic in China: a panel study. Health Educ Res. 2021;36(2):151–8. https://doi.org/10.1093/her/cyab012[publishedOnlineFirst:2021/03/17].
Zavlis O, Butter S, Bennett K, et al. How does the COVID-19 pandemic impact on population mental health? A network analysis of COVID influences on depression, anxiety and traumatic stress in the UK population. Psychol Med 2021:1–9. https://doi.org/10.1017/s0033291721000635 [published Online First: 2021/03/17]
Logie CH, Turan JM. How Do We Balance Tensions Between COVID-19 Public Health Responses and Stigma Mitigation? Learning from HIV Research AIDS Behav. 2020;24(7):2003–6. https://doi.org/10.1007/s10461-020-02856-8[publishedOnlineFirst:2020/04/09].
Abrams T, Abbot D. Disability, Deadly Discourse, and Collectivity amid Coronavirus (COVID-19). Scandinavian Journal of Disability Research 2020;22(1):168–74. https://doi.org/10.16993/sjdr.732
Chen B, McNamara DM. Disability Discrimination, Medical Rationing and COVID-19. Asian Bioeth Rev 2020:1–8. https://doi.org/10.1007/s41649-020-00147-x [published Online First: 2020/09/10]
Shevlin M, McBride O, Murphy J, et al. Anxiety, depression, traumatic stress and COVID-19-related anxiety in the UK general population during the COVID-19 pandemic. BJPsych Open. 2020;6(6):e125. https://doi.org/10.1192/bjo.2020.109[publishedOnlineFirst:2020/10/20].
Kaplan RM, Glassman JR, Milstein A. Effects of Mental Health on the Costs of Care for Chronic Illnesses. Psychiatr Serv. 2019;70(11):1013–9. https://doi.org/10.1176/appi.ps.201900098[publishedOnlineFirst:20190805].
Neville FG, Templeton A, Smith JR, et al. Social norms, social identities and the COVID-19 pandemic: Theory and recommendations. Soc Pers Psychol Compass. 2021;15(5):e12596. https://doi.org/10.1111/spc3.12596.
Moran-Ellis J, Alexander VD, Cronin A, et al. Triangulation and integration: processes, claims and implications. Qual Res. 2006;6(1):45–59. https://doi.org/10.1177/1468794106058870.
Heath L. Triangulation: Methodology. In: Wright JD, editor. International Encyclopedia of the Social & Behavioral Sciences. 2nd ed. Oxford: Elsevier; 2015. p. 639–44.
G.L., P.C., H.L., M.H., S.D., I.O., C.R., R.R. and L.Y. are supported by the NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation at the University of Bristol in partnership with UK Health Security Agency (UK HSA).
L.S. and J.R. are supported by the NIHR HPRU in Emergency Preparedness and Response at King’s College London in partnership with UK HSA.
L.Y. is an NIHR Senior Investigator and her research programme is partly supported by NIHR Applied Research Collaboration (ARC)-West, NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, and the NIHR Southampton Biomedical Research Centre (BRC).
C.R. is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emerging and Zoonotic Infections at the University of Liverpool in partnership with UK HSA in collaboration with the Liverpool School of Tropical Medicine and The University of Oxford, the NIHR HPRU in Gastrointestinal Infections at the University of Liverpool in partnership with UK HSA, in collaboration with the University of Warwick and the NIHR HPRU in Behavioural Science and Evaluation at the University of Bristol, in partnership with UK HSA. C.R. is based at UK HSA.
The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care or UK HSA. The funders had no role in the design of the study, collection, analysis and interpretation of the data, or in writing the manuscript.
This work was supported by the National Institute of Health Research (NIHR) Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol, in partnership with UK Health Security Agency (UK HSA; previously Public Health England) and by UK Research and Innovation (UKRI)/Department of Health and Social Care (DHSC) COVID-19 Rapid Response Call 2 [MC_PC 19071].
Ethics approval and consent to participate
This study received ethical approval on 27 May 2020 from the Heath Research Authority and Health and Care Research Wales (Project ID 284629, REC ref 20/HRA/2549). The data and results of this research are published with consent from the respondents. All eligible participants included in the study provided written informed consent. All methods were carried out in accordance with relevant guidelines and regulations.
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All participants provided written or oral consent for data to be included in publications.
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Lasseter, G., Compston, P., Robin, C. et al. Exploring the impact of shielding advice on the wellbeing of individuals identified as clinically extremely vulnerable amid the COVID-19 pandemic: a mixed-methods evaluation. BMC Public Health 22, 2145 (2022). https://doi.org/10.1186/s12889-022-14368-2