Experiences of lockdown during the Covid-19 pandemic: descriptive findings from a survey of families in the Born in Bradford study [version 1; peer review: 1 approved, 1 approved with reservations]

Background: Lockdown measures implemented to contain the Covid19 virus may be increasing health inequalities, with families from deprived and ethnically diverse backgrounds most likely to be adversely affected. This paper presents findings of the experiences of the Covid-19 lockdown on families living in the multi-ethnic and deprived city of Bradford, England. Methods: Questionnaire surveys were sent during the Covid-19 UK lockdown (10th April to 30th June 2020) to parents in two prospective birth cohort studies. Cross tabulations explored variation by ethnicity and employment status. Text from open questions were analysed using thematic analysis. Results: Of 7,652 families invited, 2,144 (28%) participated. Ethnicity of respondents was: 957 (47%) Pakistani heritage, 715 (35%) White British and 356 (18%) other. 971 (46%) live in the most deprived decile of material deprivation in England. 2,043 (95%) were mothers and 101 Open Peer Review

were partners. The results summarised below are based on the mothers' responses. Many families live in poor quality (N=574, 28%), and overcrowded (N=364, 19%) housing; this was more common in families of Pakistani heritage and other ethnicities. Financial (N=738 (37%), food (N=396, 20%), employment (N=728, 37%) and housing (N=204, 10%) insecurities were common, particularly in those who were furloughed, self-employed not working or unemployed. Clinically significant depression and anxiety symptoms were reported by 372 (19%) and 318 (16%) of the mothers and were more common in White British mothers and those with economic insecurity. Open text responses corroborated these findings and highlighted high levels of anxiety about becoming ill or dying from Covid-19. Conclusions: The experiences of the Covid-19 lockdown in this ethnically diverse and deprived population highlight a large number of families living in poor housing conditions, suffering from economic insecurity and poor mental health. There is a need for policy makers and commissioners to better support these families.

Introduction
In response to the Covid-19 pandemic, the UK government, like many others internationally, implemented a stringent lockdown to stop the spread of the virus 1 . This included the closure of all schools, non-essential shops and businesses, reduced health and social care provision and restrictions on daily activities. These measures, implemented from March 23 rd , aimed to limit the number of deaths, severe Covid-19 cases and consequent pressures on the National Health Service (NHS) 2 . However, there is a growing recognition that the measures have had a negative impact on mental health 3,4 and economic insecurity 5,6 , with the greatest impact most likely to be on those in society who are already vulnerable [7][8][9] .
This paper presents descriptive findings of the immediate health, social and economic status during the Covid-19 lockdown of families living in the ethnically diverse and deprived city of Bradford, England.
The Born in Bradford (BiB) research programme has been following the health and wellbeing of over 36,000 Bradford residents since 2007. Bradford is the fifth largest metropolitan district in England, situated in the North of England and has a young, ethnically diverse population with high levels of deprivation and health inequalities 10 . BiB is host to three family cohort studies, which have in-depth information on the demographics of participants and consent to contact participants for new research studies [11][12][13] . We were therefore in a unique position to be able to study the impact of the Covid-19 virus and lockdown response on families with pre-school, primary and/or secondary school aged children living in a highly deprived and ethnically diverse city. This research infrastructure is being harnessed as part of a mixed-methods, longitudinal adaptive research study to provide actionable intelligence to local decision makers about how best to minimise health inequalities and aid the City's recovery. Our approach can be read in more detail here 10 . This paper reports an overview of findings from the quantitative survey of BiB parents undertaken during the Covid-19 UK lockdown, with the following objectives: • To describe the demographic, socio-economic and living circumstances; financial, food and employment insecurity; and physical and mental health of parents during lockdown, by ethnicity, in order to identify research questions for further in-depth quantitative analysis.
• To explore responses to open-ended questions about worries, challenges and any positive experiences during lockdown, in order to corroborate the survey findings and identify any other areas of concern for future research questions.
• To inform areas of interest, including health and socioeconomic issues, for repeated longitudinal waves of data collection throughout the pandemic.

Study design
Adult participants from two prospective family cohort studies were asked to complete a survey of their experiences during the full lockdown response to the Covid-19 pandemic between 10th April and 30 th June 2020.

Mode of delivery and data collection
We used multiple methods -a combination of emails, text and phone with a follow-up postal survey in order to facilitate a rapid response. Participants were recruited in their main language wherever possible.

Consent
Participants had previously consented to be a part of Born in Bradford and for their research and routine health and education data to be used for research. For this survey, and as approved by the HRA and Bradford/Leeds research ethics committee, verbal consent was taken for questionnaires completed over the phone and logged in the questionnaire database, implied consent was assumed for all questionnaires completed via post or online. Informed consent for publication of the participants' details was obtained from the participants.

Measures
Key questionnaire domains for the survey were co-produced with the Bradford Institute for Health Research Covid-19 Scientific Advisory Group 14 and key policy and decision makers within Bradford, based upon hypothesised areas of impact for vulnerable families and their likely mediators. Questions were selected from validated questionnaires, from previous Born in Bradford questionnaires or were devised specifically for this survey. The full questionnaire is available on our website 14 and as Extended data 15 , key domains were: • Household Circumstances: number of children, adults and bedrooms in the house; housing tenure 16 , quality of housing; clinical vulnerability to, and self-isolation due to Covid-19 17 .
• Family relationships and social support: partner relationship 18 , parenting competency 19 , social support, and loneliness 20 .
• Physical Health 23 and health anxiety 24 ; smoking, alcohol and physical activity.
• Main worries, challenges and any positive aspects of lockdown: open ended questions.

Statistical analysis
Descriptive statistics are presented for each of the survey domains. We used cross tabulations (proportions and 95% confidence intervals) to explore differences in outcomes (e.g. forms of economic insecurity and mental health outcomes) by ethnicity and current employment status. For depression we used total scores on the PHQ8 and also standard categorisations (0 to 4 no depression, 5 to 9 mild depression, 10 to 14 moderate depression, 15 to 19 moderately severe depression and 20 to 24 severe depression) 25 . Similarly, for anxiety we employed total scores on the GAD7 and standard categorisations (0 to 4 no anxiety, 5 to 9 mild anxiety, 10 to 14 moderate anxiety and 15 to 21 severe anxiety 26 ).
The majority of respondents (95%) were mothers, with the remaining 5% being partners. As most partners lived in the same households as the mothers, we completed analyses using the mothers' response to avoid duplicate responses on household questions. Cross tabulations of partners responses were completed to look for differences in outcomes of partners compared to mothers. All statistical analyses were carried out using Stata 15 28 .
Text responses to the open questions were explored by thematic analysis 29 . The first 100 responses were analysed by one researcher (BL), employing an inductive approach where coding and theme development were driven by the content of the responses. Two codebooks were developed, one for the questions on the three biggest worries and recent challenges during lockdown and another smaller codebook for the question on what had been made more enjoyable and easier during lockdown. The remaining responses were then coded by three different researchers in order to test the strength and validity of the codebooks. Through frequent discussion between the researchers about this process, adjustments were made to the original codebooks so that they were reflective of the total responses.

Ethics
This research was approved by the HRA and Bradford/Leeds research ethics committee (BiB Growing Up study 16/YH/0320; BiBBS study 15/YH/0455).

Results
Out of a total of 7,652 eligible participants, 2,144 (28%) participated in the study between 10th April and 30 th June 2020. 2,043 were mothers and 101 partners, of whom 64 were from the same household as a mother in the sample. 1,581 (74%) were from the BiBGU cohort and 563 (26%) from the BiBBS cohort (see Figure 1).
The participants were broadly representative of the BiB and BiBBS cohorts (see Table 1): they had a mean age of 38 years   Table 2 shows the household circumstances of families. A large proportion of families live in poor quality and overcrowded housing with damp/mould (N=574, 28%), vermin problems (N=347, 17%), major repairs needed (N= 262, 13%) and 364 (19%) reporting two or more people per bedroom. Poor quality housing was most common in families of Pakistani heritage.

Household circumstances
Overcrowding was most common in families of Pakistani heritage and other ethnic groups compared to White British families. 464 (23%) lived in a household with someone clinically vulnerable to Covid-19 (advised to shield, >70 or pregnant), this was more common in Pakistani heritage families than White British and other ethnic groups. 558 (28%) reported that their household had self-isolated at some point, there were no ethnic differences in self isolation.

Family relationships
The vast majority of mothers (N=1,770, 87%) were married or in a relationship. Most mothers reported an excellent or good relationship with their partner (N=1,537 90%); 180 (10%) reported their relationship as average/poor. An average/poor relationship was more likely in those struggling financially, in poor health and those with moderate/severe depression or moderate/severe anxiety (Table 3a). A lack of confidence in supporting home learning was reported by 414 (24%) mothers, this was more common in those with severe financial insecurity, very poor health, moderate-severe depression and anxiety (Table 3b).
Social support and isolation 607 (31%) mothers reported feeling lonely some of the time, and 199 (10%) reported feeling lonely most or all of the time.
White British mothers were more likely to feel lonely some of the time, but there were no ethnic differences in those feeling lonely most/all of the time (Table 4a). Loneliness (most/all of the time) was more common in those who were struggling financially, unemployed, in poor health, or had moderate/severe depression or anxiety. A minority of participants (N=264, 13%) said it was difficult to get practical help from friends, family or neighbours, if they needed it. This was most common in mothers from other ethnic groups, and in those who were financially insecure, unemployed, in poor health, and those with moderate-severe depression and anxiety (Table 4b).
Financial, food, employment and housing insecurity A high number of participants reported insecurities in finances, employment, housing and food (see Table 5a). When asked about financial security, 501 (25%) mothers said their family were just about getting by and 237 (12%) were finding it difficult or very difficult to manage. 627 (33%) said they were worse off during lockdown compared to three months previously and 88 (9%) were better off. Those families that reported just about getting by, or finding it difficult to manage, were more likely to report being worse off now than before lockdown. In contrast, those that were living comfortably were more likely to report being better off during lockdown (see Table 5b).
Food insecurity was also frequently reported with 396 (20%) mothers saying that their food often didn't last and they couldn't afford to buy more, and 180 (9%) having to regularly cut the size of, or skip meals because there wasn't enough money for food.
728 (37%) families were worried about the job security of the main earner. 228 (11%) of main earners within the household were self-employed and not working and 292 (15%) had been    furloughed. 204 (10%) of households were worried about losing their home (eviction/repossession).
Across financial, food and employment insecurity, White British families were more secure, and families of Pakistani heritage were the least secure (see Table 5a). White British families also had the least insecurity in housing, but the most insecurity was in the other ethnic group. Table 5c shows financial, food, employment and housing insecurity by the current employment status of the main earner in the household. Households where the main earner is self-employed and not working, furloughed, or unemployed were most likely to report financial, food, employment, and housing insecurity (see Figure 2). The most secure households were those where the main earner is employed and  still working. Table 5a shows that the current employment of the main earner differs by ethnicity suggesting that insecurities identified here may be explained by the type of employment held by the main earner in the household, rather than being directly related to ethnicity.

Physical health and health behaviours
A low percentage of mothers reported having poor general health (N=135, 7%) however this more than doubled in households that were financially insecure, unemployed, or living in poor housing conditions (Table 6a).
A large proportion of mothers who smoked (N=191, 9%) or drank alcohol (N=533, 26%) reported smoking more (N=70, 37%) and drinking more (N=164, 31%) during lockdown. Nearly half of mothers (N=832, 47%) reported doing less physical activity in lockdown than before. 118 (6%) reported that their children did no physical activity at all, 300 (15%) did exercise 1-2 times a week. Mothers of Pakistani heritage were most likely to do no physical activity as were those who were financially insecure, in poor health or had severe depression or anxiety (Table 6b). 341 (17%) of mothers reported worrying about their health most or all of the time. This was more common in those who were financially insecure, unemployed, living in poor quality housing, and in those who had someone in the home who was clinically vulnerable to Covid-19 and/or if the household had self-isolated at some point (Table 6c).

Mental health
Reports of depression and anxiety symptoms were high with 838 (43%) mothers reporting depression, 19% of whom had clinically significant (moderate/severe) symptoms. 762 (39%) mothers reported anxiety, 16% of whom had clinically significant (moderate/severe) symptoms. White British participants were most likely to be moderate/severely depressed but there were no ethnic differences in moderate/severe anxiety. Moderate/Severe depression and moderate/severe anxiety were associated with financial insecurity, unemployment, poor quality housing (see Table 7a and Table 7b; Figure 3a and Figure 3b).
The experiences of partners 101 (5% of all responses) partners completed the survey making it difficult to generalize from their responses. Partners who responded were more likely to be White British (N= 38, 58%) and were more financially secure (N=34, 34% were living comfortably) than the mothers overall, but showed little difference to the mother's responses for all other measures, see Supplementary Table 8 (Extended data) 29 .

The lived experiences of participants
We asked participants to tell us their biggest three worries at the moment, a challenge they have faced in the last two weeks, and whether anything had been made easier or more enjoyable in lockdown. Some of the most commonly reported worries reflected those captured in the survey including financial insecurity and mental health concerns; other reported worries reflected concerns and challenges specific to Covid-19 including health anxieties, caring for or educating their children at home, seeing and supporting their family and friends, bereavement and wider fears about the impact of Covid-19 on society.
Health anxieties. The most commonly reported worry was that themselves, their children and/or wider family members might catch the coronavirus and become seriously ill or die. Participants were particularly concerned if they perceived themselves  Respondents also often reported worrying about not seeing wider family and friends and being unable to help loved ones, especially if they lived far away or in another country.

'Not being able to physically be there for my parents, dad very elderly and vulnerable and worrying if they died in these circumstances not being able to see them'
Some were experiencing recent bereavement of friends or family members, both Covid-19 and non-Covid 19 deaths, and were sad and distressed about being unable to attend their funerals and gather with loved ones for support. Financial insecurity. The second most commonly reported worry was around financial, housing and employment insecurity. Some respondents reported that either they and/or their  partner had already lost their job as a direct result of coronavirus and the lockdown, and many more were worried about this eventuality. It was clear, even from these brief responses, that for many participants, any change to income was a serious concern because they were only just managing to get by before the pandemic. For families already reliant on credit cards and overdrafts to get by, Covid-19 and lockdown measures had pushed them into deeper and longer-term debt. Positive aspects of lockdown.
One of the open-ended questions did enable people to report some positive aspects of the lockdown. When asked if there was anything that had become easier or more enjoyable since lockdown, some participants reported that nothing had improved, with many more reporting some positive consequences. These included getting to spend more quality time with their children, enjoying a slower pace of life, a more relaxed routine and spending less time driving and commuting. With less rushing to get to and from school, work and extracurricular activities, a number of participants reported that they were sleeping better, taking more time to cook meals and eating together as a family.

Discussion
This cross-sectional study describes some of the key short-term experiences of families living in the deprived and ethnically diverse city of Bradford during the Covid-19 pandemic lockdown (April-June 2020). The findings have highlighted inequalities in living circumstances with a large proportion of ethnic minority families having endured the pandemic in poor and overcrowded housing conditions. Economic insecurities were frequently reported with more than one-third reporting financial insecurity, and one-in-ten reporting serious economic difficulties such as having to regularly skip meals and serious concerns about being evicted or having their home repossessed. In particular, many families who have lost income due to being selfemployed and not able to work, being furloughed, or recently unemployed, now find themselves in perilous financial, food and employment insecurity. Whilst the furlough scheme and support to self-employed workers has been designed to provide support during this difficult time, our findings suggest that the loss of 20% of a low income wage may be enough to tip families into financial difficulty, and potentially further exacerbate health inequalities. These findings reflect other research that has highlighted ethnically diverse and deprived families as high risk of financial and food insecurities 5,6 .
Another major concern uncovered in the survey was the mental health of mothers, with 18% reporting clinically significant depression symptoms and 16% clinically significant anxiety symptoms. Many participants also raised concerns about the mental health of their children. These findings reflect depression and anxiety prevalence rates reported in other lockdown surveys 3,4 . Depression was associated with White British ethnicity and both depression and anxiety were associated with financial insecurity. Further exploration of this finding is planned to understand the underlying causes of increased poor mental health and the potential ethnic differences.
Policy makers and commissioners must intervene quickly and provide greater support to these families. Families need support to enable them to manage financially and stop them becoming homeless and living in food poverty. Increasing access to support for mental wellbeing is also critical at this time. Whilst specialist services should focus on treating those with moderate to severe depression and anxiety, commissioners and policy makers must also consider broader, population-based preventative measures for those with mild symptoms.
Whilst the physical health of families was overall good, participants who smoked or drank alcohol often reported smoking/ drinking more during lockdown and a large number reported doing less, or no exercise. Poor housing and lack of access to outdoor space were also common in this population. The increase of negative health behaviours in addition to living in poor housing conditions with a lack of access to safe green space puts people at risk of developing, or exacerbating, non-communicable diseases and co-morbidities such as diabetes, hypertension and respiratory illnesses, conditions that in turn increase risk of worse outcomes of the Covid-19 virus.
More than one quarter of families had a person vulnerable to Covid-19 living in their household. Our open ended questions identified that health anxieties about catching the Covid-19 virus and becoming severely ill or dying was the most commonly reported worry and had a negative impact on behaviors such as exercise. There has been concern across the UK about the dramatic drop in use of health services, and a lack of uptake of school places, especially for vulnerable children during lockdown. Given the high anxiety of being exposed to Covid-19, particularly in families living with a vulnerable person, methods to reassure and encourage vulnerable families to access critical services, return to work and school and engage in exercise needs to be considered extremely carefully and sensitively.

Strengths and limitations
These findings demonstrate a host of negative experiences during the Covid-19 lockdown for families living in the ethnically diverse and deprived city of Bradford. We used multiple methods to obtain a high response in a timely way, but acknowledge that the overall low response may have introduced selection bias. Comparing results with other studies of similar and differing populations will be important to gain a fuller picture of the impact of the pandemic and its management on social and health inequalities. The longitudinal nature of the BiB cohorts will allow us to look for change over time and we will continue to follow our families over a one year period from April 2020 to March 2021 so that we can look at trajectories of change overtime, adding more value to this research.

Conclusion
The effect of the pandemic and lockdown may be socially patterned, with the most vulnerable in society bearing the brunt. Vulnerable families could be pushed into poverty and worsening mental ill health. There is a need for policy makers and commissioners to consider how to better support vulnerable families to enable them to manage financially and avoid them becoming homeless and living in debt and food poverty. There is also a need to provide support for a significant proportion of people who are now suffering from depression and anxiety, enabling services for severe cases and preventative interventions for those with mild symptoms to stop these getting worse. There is also a need to develop methods to reassure and encourage vulnerable families to access health and education services with immediate effect to stop these health inequalities becoming even worse. • If your request is approved we will ask you to sign a collaboration agreement and if your request involves biological samples we will ask you to complete a material transfer agreement. Thank you for the opportunity to review this paper which was a pleasure to read. The results from this survey demonstrate firstly that, as we have always known, the social determinants continue to be the source of inequity for families and their children regardless of the pandemic. Both BBGU and BiBBS have a long history of exploring these issues. The authors have presented wide ranging data from a survey in these 2 existing cohorts in Bradford, UK. These cohorts are known for their ethnic diversity and general disadvantage. The cohorts are more or less concurrent but with different child ages. The authors have surveyed these families using a phone/postal survey in April-June 2020 which overlapped with the first wave and lockdown in response to COVID-19 in the UK. While the descriptive data are interesting, the volume of tables and lack of comparison to previous "states" means that it is difficult to both get a sense of the overall picture (too many tables) and to really understand the impact of the lockdown as opposed to the previous conditions and outcomes for these families. A potential reframe might be to focus on (1) where there are data to note the impact of the lockdown and pandemic using data that had questions focussed on "compared to" e.g. smoking or where there are data that are specific to the pandemic e.g. children learning from home or potentially those being furloughed and change in financial status and then (2) note that there is a substantial burden of disadvantage for these families that will inevitably worsen during the 2 waves of the pandemic (international data are already showing this) with COVID-19 exposing the inequity gaps in our systems. Further details are outlined below.

Introduction:
While noting that the aim was to describe the various outcomes for these families, it may be more helpful to have a sense of what the authors might hypothesise here in terms of the differential impact of the lockdown.

Methods
The descriptive methods here are quite straightforward.

Introduction
We have added clarity to the introduction regarding our hypothesis -that health inequalities are likely to have worsened during the pandemic and we intend to look at differential impacts based on ethnicity and current financial insecurity.

○
We have clarified the intentions of the wider programme of research in the introduction: ○ a) That this paper reports the participant characteristics and the immediate health, social and economic status (by ethnicity and financial insecurity) during the first survey of BiB parents undertaken during April -June 2020. One of our underlying aims of this paper was to make our Covid-19 survey findings widely available to researchers and policy makers as quickly as possible.
○ b) That future plans are in place to use longitudinal data from before the pandemic, and from future surveys during the pandemic, to describe the trajectories, and identify the long-term consequences, of the pandemic on vulnerable populations.

Results
The majority of the detailed tables are now supplementary tables, and we have used figures to more easily describe the data.

○
As above, the results section is now hooked onto the hypothesis regarding differential impacts for ethnic minorities and those experiencing current financial insecurity. Other associations found are then described where relevant ○

Discussion / Conclusion
We have added in references to recent papers that show similar findings to ours within England, further elaborated on the strengths / limitations section, and added in more about future research questions. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Malavika Subramanyam
Social Epidemiology, Indian Institute of Technology Gandhinagar, Gandhinagar, India This study describes the findings from a detailed survey of living conditions, psychological wellbeing, stresses, and lived experiences of a multi-ethnic socioeconomically disadvantaged subsample of the Born in Bradford cohorts during the Covid-19 lockdown. Unsurprisingly, the authors find that substantial proportions of the analytical sample lives in poor quality housing, has economic, housing, and food insecurities. Moreover, it was the socioeconomically disadvantaged sub-groups that reported greater proportions of depression and anxiety symptoms. The study underscores the burden of housing, economic, and psychological health issues in this population.
An international audience would benefit from a brief comparison of the socioeconomic profile of the final analytical sample with those of Bradford and other major urban areas in England. A note on the unique contribution of the current study, beyond providing data to policy-makers interested specifically in Bradford, would also be helpful.
The reader would also benefit from seeing a comparison of these lockdown prevalences of mental health outcomes with pre-pandemic prevalences in the same population. Similarly, it would be helpful to identify how the prevalence of the outcomes in this study compare with similar figures from the rest of England (or at least samples similar to the general English population).
One stated goal of the study was the "identify any other areas of concern for future research questions". It would have been helpful if the authors had expanded more on this point. The freetext responses to the open-ended questions appear to have provided rich data. Perhaps those responses lead to interesting questions for the future?
A few clarifications will further strengthen this excellent and detailed descriptive study. For instance, the abstract could clarify that a mix of telephonic, online, and paper-based surveys were used. And on a related note, a clarification could be added to the main text about any differences in the pattern of answers by the mode of survey data collection Finally, the authors are requested to highlight a key finding which is specific and policy-relevant in the "conclusions" section of the abstract. For instance, perhaps they could offer a comparison with other cities/sub-groups or comment on the policies/programs in place which may need to be tweaked on the basis of these findings?

Is the study design appropriate and is the work technically sound? Yes
Are sufficient details of methods and analysis provided to allow replication by others?