COVID-19 had an impact on all sections of society, including people with disabilities.
The authors aimed to explore the needs and experiences of people with disabilities in Zambia during the COVID-19 pandemic.
In this hermeneutic phenomenological study, we used a semi-structured interview guide to collect data from a purposive and snowball sample of 40 people with disabilities and their caregivers. The participants were from 11 districts in 6 provinces in Zambia. The in-depth interviews were done between July 2022 and November 2022. Data were managed in NVivo and analysed using reflexive thematic analysis.
The three themes included: (1) awareness and experience of public health measures on COVID-19 among people with disabilities; (2) experience of othering and stigmatisation as people with disability during the COVID-19 pandemic and (3) experience of COVID-19 symptoms and having COVID-19 among people with disabilities.
Interventions were largely unresponsive to the needs of people with disabilities, exacerbating the risk of exposure to infection. In future, adaptations like emergency risk communication in braille, audio and sign language interpretation in adapted communication formats should be made. Further studies are needed to quantify the gaps in access to health, explore policies and strategies to improve health outcomes for people with disabilities in LMICs like Zambia.
The findings may contribute to the development and enhancement of policies and interventions responsive to the needs of people with disabilities in future pandemics in the Zambian context.
COVID-19 affected everyone (Finn & Andrew
For example, the Zambian government, in collaboration with partners, implements social protection programmes that strive to target people with disabilities among other marginalised populations (MCDSS
The first reported case of COVID-19 in Zambia was in March 2020, with the first fatality following the same year (Chipimo et al.
However, people with disabilities could face additional barriers to following preventative measures, which may increase their risk of infection, and an even higher risk of serious illness and mortality if they receive suboptimal care and have underlying conditions (WHO
This article provides evidence for how COVID-19 public health prevention measures were experienced among people with disabilities in Zambia. In-depth interviews were used to explore their knowledge of COVID-19 and experiences following preventive measures in people with disabilities and/or their caregivers in 5 selected provinces (11 districts) of Zambia. It may carry implications for how pandemics can deepen inequities and how pandemic preparedness strategies should be adapted to be inclusive of people with disability.
We used a hermeneutic phenomenological study (González-Díaz et al.
This study was undertaken during the different COVID-19 waves in 11 urban and rural districts across five provinces in Zambia. These included Lusaka, Chongwe, Kafue (Lusaka province); Mkushi, Mumbwa, Kabwe (Central province); Mongu (Western Province); Ndola and Chingola (Copperbelt province); Livingstone and Monze (Southern Province). The study population, included in this article, were people with disabilities and their caregivers.
We used purposive sampling with maximum variation (Patton
Social demographic characteristics of people with disabilities (
| Variable | Frequency ( |
Proportion (%) |
|---|---|---|
| Female | 22 | 55.0 |
| Male | 18 | 45.0 |
| Christian | 39 | 98.0 |
| Muslim | 1 | 2.0 |
| Hearing impairment | 5 | 12.5 |
| Speech impairment | 5 | 12.5 |
| Vision impairment | 9 | 22.5 |
| Physical impairment | 12 | 30.0 |
| Developmental impairment or cerebral palsy | 6 | 15.0 |
| Intellectual impairment | 3 | 7.5 |
| Urban | 7 | 17.5 |
| Peri-urban | 18 | 45.0 |
| Rural | 15 | 37.5 |
Note: Participants’ sociodemographic characteristics, with age mean of 36 years; age range: 10–74 years.
Data collection was done through in-depth interviews between July 2022 and November 2022. Earlier, Q.E.S. (a female PhD student) received research training in qualitative research and disability-inclusive research practices from the University of Ghana by LMB (secondary supervisor) and a team of global health and disability researchers from the London School of Hygiene and Tropical Medicine (LSHTM) to sharpen her skills to conduct this study. Interviews were conducted in English, Nyanja, Tonga and sign language. The interview guide was pilot-tested, and the findings of that test were used to refine the tool. All interviews were audio-recorded and transcribed. The interview transcripts were kept on a password-protected computer in a safe place. Interviews were anonymised by the removal of personal identification features like names and were replaced with in-depth interview numbers. The data were checked for accuracy and consistency by Q.E.S. and the research assistants. L.M.B. and V.B. (supervisors) also conducted quality checks of the research. We interviewed a maximum of eight participants per impairment category hearing, (speech, vision, physical developmental and intellectual impairment) to cater for data saturation. These were recruited until no new relevant knowledge was forthcoming. See
We employed reflexive thematic analysis, following Braun and Clark’s six-phase approach for coding and theme development (Braun & Clarke
Regarding authority to conduct research, ethical clearance was obtained from the London School of Hygiene and Tropical Medicine (reference: 22616) and the University of Zambia Biomedical Research Ethics Committee, clearance number 1269-2020 and 3324-2022. Informed consent to participate was obtained directly from all participants above the age of 18 years in Zambia. For children below the age of 18 years and for adults who lacked the capacity to consent on their own (e.g. severe cognitive impairments), caregivers provided consent. In these cases, attempts were made to still seek input from participants directly where possible and relevant as in the cases of children aged 10 years and above. Proxy interviews were still needed for younger children and adults who had severe difficulties communicating with available support. Using simplified information sheets, assent from the participants aged 10–18 years was sought, following the same protocols for consent such as oral or emailed for phone interviews and written if the interview was conducted in person.
Adaptations were put in place to support the participation of people with different impairments. For example, people with profound hearing impairment could participate using sign language interpretation and through written responses over email and/or WhatsApp. Simplified interview schedules were used for people with cognitive and/or intellectual impairments and younger children. Job Access with Speech (JAWs), a screen reader, was installed on Q.E.S.’s computer. This was available to read information sheets and consent forms by participants with visual impairments if they wished. Personal assistants, although nonparticipants, were also allowed during interview. Some participants with visual impairments opted to read information sheets from their own smartphones and laptops. Referral services were identified and available if participants reported severe distress.
A female PhD student, Q.E.S., led this study and has a background in development studies and public health, with more than 16 years of experience in the coordination of multisectoral response to human immunodeficiency virus (HIV) at the district level. In this study, Q.E.S. took an emic position. Ontologically, the emic account refers to an insider’s perspective (Markee
The research team had no prior relationship with participants. Q.E.S. took time to share the research objectives and ensure that they knew about the interviewer. C.K. (Public Health Undergraduate), M.M. (experienced in qualitative research) and V.K. (Public Relations Undergraduate) helped to set up interviews with participants and recordings. When Q.E.S. travelled out of the district, she was accompanied by a caregiver whose role was to help her navigate inaccessible physical environment and was not part of the interview session.
Participants were nearly equally divided by gender and ranged in age from 10 to 74 years (mean age being 36 years;
To frame the analysis, it is important to note that most participants were living in difficult socioeconomic situations. Most participants reported that their households often had to make tough economic choices between buying the basics (e.g. food, utilities) and purchasing airtime, internet bundles and television subscriptions to stay abreast of COVID-19; this task became difficult during the pandemic. While peri-urban and urban residents had electricity connections, they experienced load shedding and high electricity tariffs. In rural areas, access to adequate water and sanitation was limited. Most participants were not receiving social welfare benefits from government because the criteria were to include people with ‘severe’ impairments, and this tends to leave out people with mild and moderate disabilities who may need welfare support. However, many received material support from religious organisations and organisations of people with disabilities. Most of the adult participants were unemployed or in informal work either in self-employment or part of cooperatives.
This section presents findings on the in-depth interviews conducted with people with disabilities.
Key themes and subthemes.
| Key themes | Subthemes |
|---|---|
Awareness and Experience of Public Health Measures on COVID-19 among People with disabilities |
Awareness of COVID-19 and accompanying public health measures among People with disabilities Challenges of access to COVID-19 information Practicalities of following the five golden rules on COVID-19 prevention |
Experience of Othering and Stigmatisation as people with disability during the COVID-19 pandemic |
Disability, COVID-19 stigmatisation Being labelled as ‘the one spreading COVID-19’ Neglect, driving COVID-19 risk |
Experience of COVID-19 symptoms and having COVID-19 among People with Disabilities |
Rationing of test kits and access to testing for COVID-19 Experiences with home management of COVID-19 infection Navigating unresponsive healthcare |
By November 2022, most people with disabilities knew about COVID-19 broadly as a disease and could explain some of its basic features. This awareness was demonstrated in knowledge about origin and symptoms (including most commonly coughing and sneezing identified by most respondents), as well as transmission modes. Regarding awareness of the methods of preventing COVID-19, a few participants with hearing and speech impairments and most participants with physical, visual and other impairments not affecting communication also knew the methods of preventing COVID-19, under the buzzword of ‘five golden rules’. Additionally, when COVID-19 vaccines were rolled out in Zambia, most respondents with disabilities were aware of COVID-19 vaccines as a prevention measure, being available in the country:
‘Yes, I know about this terrible disease, it has taken a lot of lives around the world.’ (IDI 34, male, 58, physical and mild psychosocial impairment)
‘Through wearing a mask, handwashing or sanitising, coughing in elbow, avoiding crowded places and doing social distance.’ (IDI 09, male, 25, hearing impaired)
‘I heard about corona virus and people [
As mentioned earlier, the majority of participants were living in challenging financial circumstances. Young people with disabilities expressed difficulty in getting funds for internet access because the costs exceeded their ‘pocket money’. They also faced limited opportunities to secure part-time jobs to earn their own income, often relying on male relatives for financial support. Here we found intersections (de Beco
‘
The Ministry of Health often disseminated standard text messages with up-to-date information on COVID-19 through phones. Additionally, some people, such as people with vision impairment, required phones with accessibility features, which are often smartphones. However, most participants, particularly those in rural areas, did not own smartphones. A grade 6 boy with vision impairment said:
‘I don’t have a smartphone.’ (IDI 15, male, 15, vision impairment)
‘Bafunika kupunzhila sign language. Ba usinga sign language ya kumunzhi [
People with hearing impairment had a history of interactions with health and health promotion services which were largely not respectful of the deaf culture and did not provide sign language interpretation, leading to doubts whether COVID-19 information they received was up-to-date and trustworthy. With so much information and misinformation (infodemic) during the COVID-19 pandemic, participants felt the need to be cautious and expressed the need to have adequate, truthful information on the pandemic, delivered by staff accredited through Organisations of People with Disabilities and professional bodies, who knew both English and Zambian sign language. For instance, a woman who lived in an unplanned settlement with her brother and worked as a volunteer at a local health centre in the city said:
‘I am concerned that the information I have about COVID-19 is not enough. As Deaf people we are sidelined [
‘Many materials in Braille were needed. There is specific software [
‘No, I do not think that he can understand anything on his own.’ (IDI 18, father, 60, of 25 year old male with multiple impairments)
‘No, she doesn’t talk, and l am not sure she is able to understand, although she hears when people are speaking. She also watches TV. It is ok for me.’ (IDI 07, mother, 53, of 10 year old female with multiple impairments)
Additionally, although they were required to safeguard their children and young adults with severe impairments from getting COVID-19 infection, there were little or no guidelines adapted for the carers in the early part of the COVID-19 pandemic. The absence of adapted guidelines for use was experienced as disempowering, given that COVID-19 was a new disease. Although guidelines were developed later through the association of parents with disabilities, they were not widely circulated to end users:
‘The association [
‘The challenge with COVID keeping a metre apart was that people with disabilities always needed a helping hand. Like in my case … and at times because some people would want to follow those rules critically before doing anything or touching their relatives, so it was a very big challenge for a person with a disability to get help on time.’ (IDI 22, female, 23, cerebral palsy and physical disability)
‘I do not have a [
‘We were supposed to sit one meter away, when you want to sit on a bench or even on the bus. But for us blind people this was a challenge because we could not be one meter apart when you need help for [keeping] the same distance.’ (IDI 27, female, 49, visual disability)
A few people with visual impairments did not adopt mask wearing, because of physical discomfort or they had difficulty breathing:
‘I have failed to get used to wearing of masks as it makes me very uncomfortable. If there was a way to have them develop those masks which can cover the whole face [
In some parts of the world, opaque face masks were aimed at making it easier for people who do lip reading to communicate. However, only cloth and medical face masks were often distributed, by both the public and private sectors, during COVID-19 prevention interventions in Zambia. Some participants with hearing impairments who require lip reading to understand what is being communicated could not always wear these cloth and medical face masks. They took risks in public places like schools, hospitals and marketplaces by uncovering their faces. Sometimes, they left their mask hanging below the chin. Most of these participants said they abandoned wearing a mask altogether during a conversation. To highlight this, a male teacher with hearing impairment said:
‘I have no problem wearing a facemask. Every time I go out [
‘I was pressed so I called someone to help me. The person guarding the hospital first asked mum to sanitise herself before touching me. After that I had to wash my hands so that there was no barrier when getting help. I couldn’t even reach the wash basin from my wheelchair.’ (IDI 22, female, 23, cerebral palsy and physical disability)
Most participants were not able to wash their hands as often as possible during the COVID-19 pandemic, and owing to cost, some washed their hands with water only.
‘It is just that the cost of soap, hand sanitizer and other alternative to such are costly these days. When there is no soap at home, there is nothing I can do. I wash hands with water that’s all.’ (IDI 33, male, 31, visual impairment)
‘We have a big problem with the water. There is water rationing. We just have water on some days of the week. We draw water in our buckets and store for the period we will not have the running water. For emergencies like cooking beans, we ask from our people [
Vaccines were a later addition to the guidelines on COVID-19 prevention. Vaccine acceptability and adoption by study participants varied. Among a few adult participants, who had some level of education, this intervention was a welcome measure. However, a common pattern was not getting much information about the side effects. A man with visual impairment explained his experience:
‘… one thing they did not explain the side effects associated with vaccination. After the vaccine, I was in pain because the site of injection was sore. I felt ill but I did not return to the clinic.’ (IDI 01, male, 52, visual impairment)
Others were reluctant to vaccinate because of past negative experiences, such as attributing disability causation to past vaccination experience and coercion from significant others. For instance, a woman attributed the onset of hip joint problems to a vaccine injection during her childhood observed:
‘I followed all the golden rules except for one, vaccination. I have phobia of injections. When I was young, the [
People with disabilities and their families reported that they had already experienced disability-related stigmatisation prior to COVID-19. Contracting COVID-19 or being in a household with someone who had COVID-19 could then lead to additional stigma and exclusion. Some participants reported being shunned by neighbours in these circumstances. One participant was accused of using COVID-19 as a way to ‘get rid of their problem’ namely a child with severe impairments. She said:
‘It [
In ordinary times, most adults with disabilities experienced intersecting identities that created spaces of marginalisation and stigmatisation, compared to people without disabilities (Yoshida et al.
‘
Most young people with severe mobility restrictions and all participants with multiple impairments needed physical care from others to function in their daily lives and this involved unavoidable close contact with other human beings. In this study, most of the young people with disabilities had no designated carer and household members took turns to provide such care. A few young people with disability also experienced negative judgements and discriminatory attitudes from other household members because they were seen to be typical of persons likely to spread COVID-19. For instance, a young woman participant said:
‘Before COVID-19 came, people [
Participants who became disabled as adults rejected the risk designation based on their personal experience, claiming it put them in a marginalised group deserving of pity. Instead, they emphasised external factors that included government indifference and imposed participation restrictions on people with disabilities, before and during the COVID-19 pandemic. However, they were afraid to voice their concern. As an illustration, a man physically impaired by a traffic accident who worked for an international organisation said:
‘Yes, we were at risk of COVID-19 infection although we were neglected but still, we cannot say that to the government. We only complain in private or when we are with people whom we trust that they cannot report us [
Among COVID-19 guidelines was instruction to seek healthcare if experiencing symptoms of COVID-19, and testing services were typically provided at health centres around the country. In some instances, younger participants did not access testing services because health centres had few testing resources and were reserving them for severe cases. For instance, a few participants said they were not tested for COVID-19 when they presented to the clinic with symptoms of COVID-19:
‘I drunk warm water and rushed to the clinic when I had strong [
Besides ensuring their own safety, a few people with disabilities had responsibilities as carers of their own adult children with confirmed COVID-19, placed under home management. Their experiences as contacts of confirmed home management cases of COVID-19 were stressful. As a man from a rural town reflected on his experiences, all members of his household had severe symptoms of COVID, although he said only his daughter tested positive for COVID-19:
‘We were all sick at home and had to be in bedrooms. it was emotionally stressing because you have to see to it that, that person [
Apart from the occasional phone call, participants said there was little support for most cases of COVID-19 placed under home management, and they often had to buy medications and use alternative remedies. Most often cited were steaming with eucalyptus leaves, drinking ginger and lemon tea.
Different influences shaped people with disabilities’ interaction with the health system. These cases highlight gaps between what was also expected and what services they received, given their health needs as people with disabilities. Six out of the 40 participants tested positive for COVID-19. Most of them said it was easy to go to the clinic. For those who required hospitalisation, they reported poor experiences such as lack of prompt attention and inaccessible health services, bringing to the fore how the health system during crisis times provides inappropriate services to persons with disabilities. Participants said services were unresponsive to their treatment needs.
Illustration on navigating unresponsive healthcare.
| Case | Description | Comment |
|---|---|---|
| Case 1: 27 years old, female, speech impairment | A 27-year-old woman from southern province presented to the general hospital with severe fever following COVID-19 infection. She was treated at the said hospital, and 3 days later, the young lady showed remarked reduction of fever. Given the improvement, she was discharged from the hospital. At the time of the interview – months later – complete resolution of symptoms was noted. She returned to her house in her mother’s compound in a separate small dwelling with her 2-year-old. However, nobody explained to her or her elderly mother why and how she might have gotten COVID-19, what measures to take in future. It remains a puzzle to her. | This case suggests a possible therapeutic success for COVID-19 treatment, but for disability inclusion, this highlights challenges in reasonable accommodations to improve the participation of people with disabilities in their care and achieve good experiences. Part of patient-centred care is explaining probable causes, reassuring clients, and explaining how the medication given to them will work. None of these were explained to her. Treatment without addressing the concerns of this woman may have led to increased likelihood of anxiety. |
| Case 2: 25 years old, male, intellectual impairments | A 25-year-old male from an urban area was taken to a public hospital. His family felt the public healthcare system was unresponsive to their son’s needs because he was doing poorly but they had to wait 3–4 h ‘just like everyone else’. They attributed this to the limited awareness and the poor judgement of health workers to interpret the seriousness of his condition, hence long hours to receive a diagnosis. After a positive COVID-19 test, his carers switched to private care to ensure he had access to Intensive Care Unit services needed. They incurred a lot of expenses and had to use their savings because the breadwinner’s salary was reduced during the pandemic. He recovered days later and went home. | The case shows how some people with disabilities struggled to get adequate care in an emergency during the pandemic. It is not known whether someone without a disability with similar severity would have had to wait as long as this person. However, deprioritising care for people with disabilities has been commonly reported either because of discrimination or lack of understanding of the seriousness of someone’s symptoms when they cannot communicate themselves. Healthcare workers may need training to better recognise symptoms and their severity in patients who face difficulties communicating (Hashemi et al. |
Note: Please see the full reference list of the article, Seketi, Q.E., Menon, J.A., Michelo, C., Banks, L.M. & Bond, V., 2024, ‘At risk but not adequately included: People with disabilities’ experience of COVID-19 in Zambia’,
The experience of people with disabilities was that they were aware of the COVID-19 pandemic as a disease and its associated prevention measures. However, this study also established that people with disabilities faced barriers of access to health information. Using the guidelines themselves presented issues without reasonable accommodations – a missed opportunity to meet their needs. People with disabilities continued to experience othering and stigmatisation during the COVID-19 pandemic and this led to, for instance, being portrayed as the ones spreading COVID-19. The study also found that healthcare needs for COVID-19-related care were not adequately met. Our findings situate how the COVID-19 measures were experienced by people with disabilities. The measures were experienced as barriers in the environment, which often interacted with people’s impairments and health conditions, restricted further their participation in preventative, treatment and care situations, and raised risks of infection and severe disease for people with disabilities. We now discuss these observations, largely focussing on the disabling environments and interaction of contextual factors in these pandemic experiences, which were, largely, exclusion experiences. This discussion is structured around the three themes that arose from the analysis of in-depth interviews of people with disabilities from districts, and the meanings the participants assigned to these experiences.
Firstly, this study found people with disabilities generally had adequate awareness of COVID-19, although many still reported challenges with getting up-to-date information in accessible formats. This is similar to another research in South Africa (Wickenden et al.
Secondly, people with disabilities were expected to follow largely generic prevention rules (the ‘five golden rules’). These rules were not adapted to individual circumstances such as for people who require caregiving support and could not social distance; opaque masks were not introduced for people who require lip reading and did not factor in poverty contexts and in an unaccommodating environment. For example, some people with disabilities were unable to undertake frequent handwashing because of inaccessible WASH and because soap and other materials were expensive. This finding mirrored other research from before COVID-19 (Wilbur et al.
Using guidelines on COVID-19 was difficult for people with disabilities because the COVID-19 measures required additional resources that were not always within reach. For instance, actual unmet material and financial needs were behind inability to afford or access basics such as electricity, phones, data bundles and facemasks and hand sanitizers. These barriers, around poverty and material deprivation, which negatively impact lived experiences of people with disabilities, were well researched before the COVID-19 pandemic (Trani & Mitchel
Experiences accessing care for COVID-19 symptoms and infection also demonstrated health sector challenges, including long wait times, supply shortages and challenges in meeting the needs of individuals with disabilities. Examples of the latter included lack of training of healthcare workers. Many struggled to get a proper diagnosis because of shortages in test kits, which has been reported also for the general population in LMICs because of inequities in global supply chains (Boro & Stoll
This research carries several implications for policy and practice. Government should ensure that multisectoral response measures to future pandemics and other crises are disability inclusive (WHO
Further research is needed. Through the National Health Research Institute and ethics bodies, researchers should be encouraged to collect data, which is inclusive of disability indicators. For instance, in quantitative research, researchers should use appropriate tools such as the Washington group short set of questions in surveys because this inclusion enables analysis of disability as a predictor of health outcomes, and/or measures effects of other phenomena on disability. This is needed to address other gaps in disability-specific data, required to provide more evidence on health inequities, thereby contributing to reduction of risks of infection during pandemics and leave no one behind. In qualitative research, there is need to also explore disability inclusion in policies and strategies, to improve health outcomes for people with disabilities in LMICs like Zambia during crisis times. Additionally, further research is needed on measures that address social determinants of health such as chronic material poverty and deprivation, stigma and intersectionality. Lastly, researchers should engage in implementation research to learn more about barrier removal and conduct research on feasibility of disability-inclusive measures such as harmonising the sign language needs and cultural needs for people with hearing impairments. Implementation research should also study adoption, reach and effectiveness of interventions meant to improve access to health services for different impairment groups and marginalised populations during pandemics and other public health crises.
This study has several strengths like the recruitment of a diverse pool of participants across geographical locations, impairment types and gender. Still, there are some limitations to consider. To begin with, our research was conducted in only 11 of 116 districts in Zambia. Most participants were recruited purposively through OPDs – often those affiliated with OPDs are very engaged in the disability community and may have received support during COVID-19 from these organisations. We did include some participants through snowball sampling who were not part of the OPDs, which may have minimised this issue.
In conclusion, we note that in this population, COVID-19 interventions were largely unresponsive to the needs of people with disabilities, exacerbating the risk of exposure to infection, stigma and discrimination and other disadvantages like unmet triple health needs. The lack of adaptations to deal with the increased risk of COVID-19 infection and serious illness for people with disabilities indicates a need for disability inclusion using both targeted and mainstreaming strategies (twin-track approach) in multisectoral response during pandemics. In future pandemic control, interventions should be based on the lived reality of people with disabilities and adapted to their requirements. Hence, most of the response and prevention methods should have appropriate adaptations like emergency risk communication in braille, audio formats, sign language interpretation to ensure their usability, and target barriers of access to services could potentially contribute to a more disability-inclusive response. Further studies are needed to quantify the gaps in access to health and to explore policies and strategies to improve health outcomes for people with disabilities in LMICs like Zambia, thereby contributing to the reduction of health inequities during crises and promoting the achievement of the larger sustainable development goals.
The authors would like to thank the participants who took time to take part. A warm thank you to the Organisations of People with Disabilities for supporting the recruitment, Zambart staff for arranging logistics of travel, Chanda Kaoma for supporting my local trips, Vincent Kauseni and Mambwe Muchelle for supporting the data collection, and all who supported Q.E.S. Thanks to the ICED directors, Hannah Kuper and Tom Shakespeare. This study was supported by PENDA at LSHTM. However, the views presented in the article are solely the authors’ views.
This article is partially based on the author’s thesis entitled ‘Disability Inclusiveness of the Multisectoral Responce to Crises’ for the degree of Doctor of Philosophy in Public Health at the University of Zambia, with primary supervisor Virginia Bond and secondary supervisor Morgon Banks.
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
All authors, Q.E.S., J.A.M., C.M., L.M.B. and V.B., contributed to the conceptualisation and design of the study; Q.E.S. led the data collection process, Q.E.S. led the formal analysis with oversight from L.M.B. and V.B. and Q.E.S. drafted the first draft. Various versions were reviewed by Q.E.S., J.A.M., C.M., L.M.B. and V.B., and the final manuscript was accepted by all authors.
All relevant data generated or analysed during this study are included in this published article.
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.