Alcohol use disorders (AUD) are among the most highly stigmatized medical conditions. Only a minority of individuals with AUD seek treatment, and stigma is one of the most prominent barriers to treatment-seeking. However, there is a lack of knowledge about the associations between stigma and preferences for help-seeking, and the associations between stigma and preferences for treatment seeking.to investigate the associations between stigma and preferences for where to seek help and treatment for AUD. As sub-analyses, associations between stigma, level of alcohol use and preferences for help-seeking and treatment preferences will be analyzed.n = 3037 participants aged 30 – 65 years, living in Denmark. Data: In 2020, an online questionnaire was administered by a market research company. The questionnaire covered demographics, preferences for help-seeking and treatment for AUD, stigma measured with the Difference, Disdain & Blame Scales for Public Stigma, and alcohol use measured with the Alcohol Use Disorder Test (AUDIT). Analyses: restricted cubic spline models were applied to model outcomes. Odds ratios were calculated.Cross-sectional design, including A lower level of stigma was associated with a higher probability of preferring formal and informal help-seeking for AUD. Both high and low levels of stigma were associated with a higher probability of preferring to consult general practitioners. Stigma was not associated with other preferences for treatment-seeking, nor trying to change oneself or a passive strategy. The sub-analyses, grouped by level of alcohol use, showed similar results.Stigma is associated with lower preferences for formal and informal help-seeking, however not type of treatment preferred. Future studies should address stigma in relation to other factors of the treatment-seeking process.The online version contains supplementary material available at 10.1186/s12913-023-09037-y. Public stigma and self-stigma are two different aspects of health-related stigma . Public Alcohol use disorders (AUD) are among the most highly stigmatized medical conditions in the Western world . IndividEven though AUD is associated with great harm such as diseases and injuries , it has It is well established that the stigma associated with AUD, is one of the most prominent barriers to treatment-seeking –20. PrevThe overall aim of this study is to investigate the associations between stigma, preferences for where and how to seek help, and treatment for AUD in the general population.stigma and preferences for help-seeking;stigma and treatment preferences;Specifically, the study will investigate associations between:3)stigma and preferences for help-seeking differ by level of alcohol use,4)stigma and treatment preferences differ by level of alcohol use,The analyses will take demographic factors, age, sex, education, having children, and previously having alcohol problems into consideration. As sub-analyses, the study will investigate whether associations betweenThis will be analyzed in a subsample of participants who completed the AUDIT.Cross-sectional studyThe participants were recruited by a market research company with access to a panel consisting of adults from all regions in Denmark. Between June and October 2020, a representative group of adults aged 30 – 65 years was asked to participate in an online questionnaire. The topic of the survey was not known to the participants beforehand. It is not known how large proportion of those asked that opened the survey. The proportion of participants that dropped out before completing the survey was slightly higher compared to similar surveys on other topics: 8.5% compared to normally 5—6%. In total, 3037 individuals participated.There are two outcome measures: 1) preferences for help-seeking for AUD and 2) treatment preferences for AUD.Preferences for help-seeking were measured with the question: “What would you do if you developed alcohol problems?”. The participants were presented with the following items, which were examined as separate binary outcomes, and answered yes or no to each: “Try to change it myself”, “Seek professional help”, “Ask those closest to me for help”, “Wait for others to help me”, “Put it off until I found a solution”, or “I would not do anything”. The last three: “Wait for others to help me”, “Put it off until I found a solution”, and “I would not do anything” were grouped together in the analyses and named “Passive strategy”. Treatment preferences were measured with the question: “Who would you contact first if you felt the need to discuss your alcohol use?”. The following alternatives were given, which also were examined as separate binary outcomes, and the participants answered yes or no to each: “General practitioner” (“GP”), “Seek alcohol treatment at the social services”, “Seek advice on the Internet”, and “Call a helpline”.How different do you think a person with an alcohol problem is, compared to everyone else in the general population?”), disdain  and blame . The participants rate a total of nine items on a scale from 1  to 9 (Very much). The score on each item is summed to a total score, the minimum score being 9 and maximum 81, where a higher score indicate a higher level of stigma. Two items were reverse scored before summary. The questionnaire was translated from English to Danish, backtranslated and finalized for the purpose of this study.The online questionnaire covered demographic data on sex, age category, education, and offspring. Experience of AUD was measured with the question:”Have you previously had alcohol problems?”, which could be answered yes or no. Stigma was measured with the Difference, Disdain & Blame Scales for Public Stigma; a questionnaire measuring key aspects of public stigma associated with mental illness. Versions of this questionnaire have been used in previous studies , 24. Forn = 1594 participants who also completed the Alcohol Use Disorder Test (AUDIT), a 10-item questionnaire [The level of alcohol use and related problems were assessed in a subsample of ionnaire . Please th, 50th, and 90th percentile, corresponding to the following scores: 26, 41 and 52. The reference value was for visualization placed at the stigma value 45, allowing for nine evenly spaced out points on the x axis, with the reference centered. Odds ratios (OR) were calculated with 95% confidence intervals (CI). Cronbachs alpha for the stigma questionnaire was 0.74.Each item describing preferences for help-seeking and treatment was examined as a separate binary outcome, except for “Passive strategy”, which was a combination of three items. After describing the sample, logistic regression, utilizing restricted cubic splines with three knots, was performed in order to model the associations between the continuous exposure variable, i.e., the total stigma score, and the dichotomous outcomes . This aln = 1594). These analyses were performed in three steps. First, the sample was divided into two categories; low-risk alcohol use, defined as AUDIT score 0 to 6 for women, and 0 to 8 for men, and hazardous alcohol use, defined as AUDIT score 7 and above for women, and 9 and above for men [The primary analyses were performed in two steps. First, the crude associations between public stigma and the outcome measures were calculated. Next, all analyses were adjusted for sex, age category, education, having children, and previous experience of AUD. Sub-analyses were performed in the subsample where data on alcohol use and related problems were available  stigma and preferences for type of help-seeking; 2) stigma and preferences for types of treatment; 3) stigma, preferences for types of help-seeking, grouped by level of alcohol use; 4) stigma and preferences for type of treatment, grouped by level of alcohol use. We found that perceived stigma was related to preferences for where to seek help and treatment, and that the individual’s level of alcohol use also had an impact. Our findings will be discussed in detail below.professional help and a higher probability of stating a preference for asking someone close for help. Sub-analyses, where the participants were grouped by level of alcohol use, still identified an association between lower stigma and a higher probability of a preference for seeking professional help, but not an association with a preference for asking those closest to me for help. These results indicate that willingness to seek professional help is closely related to stigma, and that a high level of stigma may contribute to a reluctance to, and lower preference for, seeking professional treatment. This is in line with the research on barriers to treatment, which shows that the stigma associated with AUD is an important barrier to treatment-seeking [In our study, based on a survey performed among the general population, a lower perceived stigma was associated with a higher probability of stating a preference for seeking -seeking –19. Thus-seeking , 29. How-seeking . There i-seeking .Stigma may have different mechanisms and impose different types of barriers to help-seeking depending on the type of help – e.g., seeking professional treatment or informal support from the social network. Regarding stigma and its association with seeking informal support, it is known that health-related stigma in general, but not specifically for AUD, is associated with not telling others and fear of social rejection and judgment . MoreoveA preference for avoiding help or treatment from the outside, and rather trying to change on one’s own, was not associated with the level of stigma nor seemingly affected by one’s own alcohol use, which may not be surprising. Epidemiological studies show that many with AUD recover without seeking help , althougRegarding preferences for where to seek treatment, the results of the present study showed that both lower and higher stigma scores were associated with a higher probability of a preference for consulting a GP for treatment. In the sub-analyses, when alcohol use was also adjusted for, the association between lower stigma and a higher probability of a preference for consulting a GP was also found. These findings emphasize the crucial role that GP’s and primary care play as a cornerstone in Danish health care . It alsowhere to seek treatment is secondary to the decision to seek treatment. Future studies should investigate this further.There were no associations between stigma and preferences for seeking treatment through social services, the Internet and by telephone, even when the level of alcohol use was taken into consideration. This is surprising, considering that a previous study on treatment preferences showed that Internet support and telephone helplines were preferred alternatives for assessment and guidance to treatment . MoreoveAn important limitation is the use of self-report measures on topics such as stigma and alcohol-related questions, which can be perceived as sensitive by the participants. Sensitive topics pose an increased risk for giving socially desirable answers. In order to reduce the risk of bias, stigma was measured with a questionnaire that emphasizes differentness, which is considered to impose less risk for biased answers compared to other measures of stigma , 49. HowAnother limitation is that the current study only measured preferences for different treatment settings. It is possible that factors other than the setting are important, such availability, or messages about treatment goals – reduced alcohol use, or abstention only.AUD, stigma and help-seeking are complex phenomena, where synergistic effects between these and factors such as socioeconomic position, gender, and age are to be expected. Moreover, previous studies have shown that individuals familiar with AUD, and individuals with lived experience of AUD, are less likely to endorse stigmatizing attitudes towards others with AUD . A strenStigma is associated with a lower probability of a preference for seeking both professional help and informal help-seeking. Both lower and higher stigma was associated with a higher probability of a preference for consulting a GP, emphasizing the important role of primary care in addressing and treating AUD. However, stigma was not associated with other treatment preferences. Future studies should address stigma in relation to other factors of the treatment-seeking process for AUD, such as the understanding of AUD, the decision to seek treatment, and specific messaging characteristics around the treatment settings.Additional file 1.Additional file 2.


The governance of pharmaceutical medicines entails complex ethical decisions that should, in theory, be the responsibility of democratically accountable government agencies. However, in many Low- and Middle-Income Countries (LMICs), regulatory and health systems constraints mean that many people still lack access to safe, appropriate and affordable medication, posing significant ethical challenges for those working on the “front line”. Drawing on 18 months of fieldwork in Ghana, we present three detailed case studies of individuals in this position: an urban retail pharmacist, a rural over-the-counter medicine retailer, and a local inspector. Through these case studies, we consider the significant burden of “ethical labour” borne by those operating “on the ground”, who navigate complex moral, legal and business imperatives in real time and with very real consequences for those they serve. The paper ends with a reflection on the tensions between abstract, generalised ethical frameworks based on high-level principles, and a pragmatic, contingent ethics-in-practice that foregrounds immediate individual needs – a tension rooted in the gap between the theory and the reality of pharmaceutical governance that shifts the burden of ethical labour downwards and perpetuates long-term public health risks. For example, in England and Wales, NICE  makes decisions about how to allocate finite resources between competing demands and priorities, with controversies often arising about the value of expensive medications; for example, end-of-life cancer drugs, which can offer patients a few extra months of life at costs of tens of thousands of pounds ,Ravinetto et al concluded thatexceptional and temporary circumstances, if based on a meaningful quality risk assessment, guided by a rigorous ethical framework built on the principles of independence, technical competence, transparency, and accountability” . They propose that “an international group of experts in quality assurance/regulatory affairs and health ethicists” be established to oversee and formulate appropriate ethical responses. While it is difficult to argue against this conclusion, the ideal of an “international group of experts” making well-informed, independent assessments is a far cry from the current reality of over-stretched, under-resourced regulatory agencies typical of many LMIC contexts  a gap between what they Wendland  describeWendland , recountWendland  have draon the ground and in the moment. Writing about a medical research institution in Western Kenya, Kingori . However, it is clear that, particularly in LMICs settings, there are significant challenges in high-level pharmaceutical governance that expose patients to multiple risks. In this paper, we describe and reflect on the resulting “ethical labour” that is transferred to those involved in the day-to-day business of buying, selling and regulating medicines lower down the supply chain in Ghana: a West African country with relatively well-functioning regulatory authorities.The paper proceeds as follows. After a brief description of the study context and methods, we outline the practices and challenges inherent in pharmaceutical governance in Ghana, focussing on three main areas: distribution and supply, regulation of drug quality and safety, and regulation of professional practice. As we will show, despite relatively robust institutional frameworks, those inside the system recognised significant challenges. We then present three detailed case studies of individuals operating lower down the supply chains: an urban retail pharmacist, a rural over-the-counter medicine retailer, and a local inspector, who must navigate complex moral, legal and business imperatives in real time and with very real consequences for those they serve. The paper ends with a reflection on the tensions between abstract, generalised ethical frameworks based on high-level principles, and a pragmatic, contingent ethics-in-practice that foregrounds immediate individual needs – a tension rooted in the gap between the theory and the reality of pharmaceutical governance that shifts the burden of ethical labour downwards and perpetuates long-term public health risks.2.This paper draws on 18 months of ethnographic fieldwork undertaken in Ghana (2016–17) by the authors and research assistants as part of the “Trust in Medicines” (TrustMed) project, funded by the Wellcome Trust. Ethical clearance was granted by IRBs at the Universities of Cape Coast, Durham and Oxford.Ghana represents an interesting case study for this work. It is the second largest manufacturer of pharmaceutical medicines in West Africa (after Nigeria), with over 30 licensed manufacturers, supplying around 30% of medicines in the country. The remaining 70% are imported, mostly from Asia  and Europe, with smaller quantities coming from elsewhere in Africa. Ghana’s regulatory authorities are regarded as among the most effective in Africa PMQ, ; as noteFieldwork for this study was conducted in Greater Accra  and in Central Region . Over 200 interviews and accompanying ethnographic observations were conducted with individuals and organisations operating at different points in pharmaceutical supply, retail and regulation in the country . In this paper, we draw specifically on our interactions with licenced retail pharmacists (N = 25) and licenced over-the-counter (OTC) medicine retailers (N = 40) based in Greater Accra and Central Region , plus 20 key informant interviews with national- and regional-level representatives of organisations involved with pharmaceutical governance in Ghana .undesirable behaviours but potentially incriminating illegal activities. However, the vast majority of our study participants appeared to be remarkably open and frank in our discussion. Indeed, many seemed to find some relief in sharing their experiences in a confidential forum.Interviews were conducted in either English or Twi, according to participants’ preference; they were wide-ranging, loosely structured around themes of medicine quality, distribution and regulation, allowing interviewees considerable scope to direct the conversation. As in any study based on self-reporting, we recognise the risk of “social desirability bias” , the second largest healthcare provider in Ghana, with nearly 350 facilities serving the most remote rural areas.While representatives of these organisations were generally keen to showcase good practice, almost all acknowledged significant challenges, leading to some concerns about the availability, safety and/or appropriateness of medicines reaching patients. We elaborate on each of these below.3.1open market” through an expedited process with less stringent controls: “We go shopping”, he put it. Similar concerns were expressed by a representative of a voluntary-sector organisation also supplied by Regional Medical Stores:We cannot avoid sourcing from the open market if RMS has stock-out. […] Regulation of the open market is a big challenge. […] It’s very difficult to check the registration status of suppliers, especially if you’re in a hurry because you’re in need.”“The Ghana Health Service is responsible for ensuring the supply of medicines on the National Drugs List to all public-sector facilities across the country. In theory, Regional Medical Stores (RMS) are supplied by the National Medical Store (NMS) and, in turn, they supply facilities in their region. However, according to one study participant, chronic shortage in official supplies often forces Regional Stores to source medicines directly from the “Nothing is adequate. We are constrained. We have to admit it.” Some also blamed alleged “leakages” of government-purchased medicines which found their way into private retail outlets; a practice reported elsewhere in West Africa, driven by shortages, low wages and poor governance . Some also cast doubt on the moral integrity of importers who were, they believed, “only interested in making money”. A couple of interviewees even mentioned the possibility of collusion between overseas manufacturers and Ghanaian importers to reduce costs by reducing the amount of active ingredient (API) in certain products.Another reported the recent interception of a truck from Togo carrying an “The FDA do a good job on testing the quality of products when first imported but their ability to do PMS [Post-Market Surveillance] is limited,”, or the capacity of the FDA to ensure Good Manufacturing Practice in overseas facilities: “The biggest problem by far is imported generics. They get a 3-year licence from FDA, with very little checking after the preliminary samples. The FDA are completely overwhelmed by PMS […] They really don’t have the capacity.” Similar concerns were raised about enforcement agencies, including the Ghana Revenue Authority and the Ghana Police, reinforcing the perception that those breaching regulations were rarely caught or faced penalties.Given this context, it was widely acknowledged that, however well-intentioned, regulatory agencies lacked the capacity  to do a comprehensive job. One study participant was frank in his view that, despite rigorous protocols, the FDA’s drug enforcement team was simply too small for the work required. Others pointed to perceived gaps in other areas, including post-market surveillance (PMS): “3.3competent pharmaceutical care providers who practice with agreed standards are accessible to the whole population”  freely admitted that financial, technical and human resource constraints limited what they could realistically achieve. In this context, individuals operating further down the supply chains must make some difficult decisions, as we show through the following case studies.4.4.1Joseph proudly showed us into his pharmacy: a large, newly-constructed building in a suburb of Accra. Inside, it was strikingly empty. A modest array of medicines were arranged neatly on shelves. Behind was a small “consultation room” with a blood pressure monitor sitting on a small table. Joseph explained that he was just starting up; he had ambitious plans to expand if things went well.Joseph grew up in Ghana, but had spent most of his adult life in Europe, where he trained and then worked as a hospital pharmacist. However, his “life-long dream”, he said, was to return “home” to set up his own pharmacy in Ghana. For the last three years he had travelled between Europe and Ghana, overseeing construction of the premises on a plot of land he had bought for the purpose. Upon retirement (three months prior to our interview), he moved to Accra to “get the business going”, leaving his wife and children in Europe. However, “getting going” was proving more difficult than anticipated. Trade was slow; in the two hours we spent there, not a single customer came by. Joseph talked despondently about the competition from a new pharmacy just down the road.It’s very difficult to identify genuine items. The issue of sourcing medicines here is very complex because there are no specific supply chains. There are so many wholesalers.[…] The wholesalers come round, and the packaging looks perfect but packaging alone is not enough to distinguish a genuine medicine. […] The lack of regulation makes it more or less impossible to be sure about medicine quality.”“Conversation turned to the issue of medicine quality and the difficulties of sourcing trustworthy products. Joseph explained:Sometimes I would just go for price – I would take the cheapest one, because there is actually no way to tell which medicines are the quality ones. Even if it’s just 20 pesawascheaper than the other one, it means I can pass the savings onto the customer and they will start coming to me.”“Initially, Joseph opted for the lower-cost products, reasoning that, in the absence of other information, at least his medicines would be more affordable:It should be a powder but it had solidified into a solid lump, like a stone. Anyone taking that medicine could not get cured. I reported it to the wholesaler and, when we checked, we found the whole consignment was the same.”“However, a particular incident changed his views. One day, a customer complained that his flucloxacillin capsules were not working. When Joseph opened a capsule, he was shocked:The wholesaler then became angry and threatening.Now I only buy the UK brands of flucloxacillin, even though it is much more expensive: GHS 25 rather than GHS 5 for a 7-day course. The problem is people don’t want to spend that much money, so they just go to a different place [waves his arm towards the nearby pharmacy].”“Moreover, he is still reliant on buying from local wholesalers whom he trusts less and less:I’ve heard that some of these people can go to India and negotiate with manufacturers to supply them with different qualities of drugs depending on what money they have. So, if they go with less money, they can negotiate to buy low-quality medicines with less active ingredient. The government doesn’t have a good means of checking.”“Shaken by this episode, Joseph decided to switch to the UK brands he knew and trusted. However, these were unaffordable for many customers:The only way to be one hundred per cent sure is to import directly from the UK.” To do this legally, however, is expensive and requires “a lot of bureaucracy”. Instead, he opts to bring what he can in his suitcase. Price remains an issue:The one I bring from UK may cost GHS 35 [c. GBP 7], but the customer comes with only 1 GHS and cannot pay any more. So, I give them the Ghanaian medicine, which is very cheap, but I feel very uncomfortable because I don’t really know how good it is.”“The other option is importing directly, as Joseph explained: “Joseph’s dilemmas were shared by other pharmacists we interviewed, who struggled to reconcile customers’ need for efficacious medicine with their inability to pay for (supposedly) higher-quality products, combined with the uncertainties of an under-regulated supply chain. Losing customers to competitors represented both a financial risk and a moral risk. Joseph reasoned that, if the other pharmacy was selling cut-price medicines, they were unlikely to be of good quality. It was only by carefully balancing pricing, legality and following his “hunches” that Joseph tried to protect both his business and his customers’ health.You lose customers by trying to help them. It is very difficult in this business if you want to have a good conscience.”Towards the end of our interview, Joseph brought out two bottles of a UK-branded “tonic”: he had purchased one from a local wholesaler; the other he had brought from the UK. The packaging was very similar but not identical. There were small differences in the size and position of the logo, which made him wonder: had the manufacturers simply changed the packaging or had he been sold a “fake”? Should he take it up with the wholesaler? Based on his previous experiences, they were unlikely to respond sympathetically. Should he alert the authorities? He had no “insider connections” and very little confidence that they would take it seriously. He also feared the reputational damage if word got round, undermining his  client base and perhaps bringing repercussions from wholesalers who may not be willing to deal with him again. Should he dispose of the locally-purchased batch and sell only those he had brought directly from the UK? What about customers who couldn’t afford the UK-purchased ones? And what to do when they ran out? There were limits to how often he could travel to the UK and how much he could fit in his suitcase, apart from the dangers of getting stopped at customs. Such quandaries weighed heavily on Joseph. He sighed, “4.2Isaac’s small over-the-counter (OTC) medicine shop in a remote village in Central Region was a far-cry from Joseph’s up-market urban venture. Isaac had started out some 30 years previously as an itinerant medicine vendor, buying from a large retail pharmacy and re-selling (without a licence) in rural settlements. After several years, he was offered a position dispensing medicines at the pharmacy, where he learned a lot “on the job”. Eventually, he saved enough money to establish his own small OTC shop in a village where his brother, the Assemblyman , helped him with the necessary paperwork and up-front registration costs. Business was slow, however, and he relied on farming to supplement his income. Five years before our interview, he moved to his current location, where the farming was more profitable. It was relatively easy, he said, to get his business established in the new setting because people remembered and trusted him from his time as an itinerant seller.When Isaac first set up the shop in the village, there was no other licensed medicine outlet. Since then, a small government clinic  was established. However, according to Isaac, the clinic rarely has adequate medicine supplies; instead, patients are given a prescription to fill elsewhere. The nearest pharmacy is an hour’s drive down a heavily pot-holed dirt road: an expensive journey on infrequent public transport and often impassable in the rainy season. Isaac therefore has a steady stream of patients turning up with prescriptions for antibiotics and other medicines that he is not permitted to stock under terms of his OTC licence.they can just run away” if things go wrong. Eventually, he used his “connections” to purchase and stock a small range of prescription-only antibiotics for common skin and respiratory infections, risking legal penalties in order (as he saw it) to protect both his business and his customers’ health. During our interview, a young woman arrived at the shop with a large, suppurating wound on her arm. She handed a prescription to Isaac, for flucloxacillin, paracetamol and vitamin C tablets. He dispensed all three products, explaining carefully – and accurately – what each was for and how it should be taken.At first, Isaac explained, he would take his customers’ prescriptions to fill on their behalf in town. However, this strategy quickly became untenable: either patients would have to wait several days until he was going to town, or he would have to make a special trip, which was expensive (he could not pass the extra cost onto the customer) and meant leaving his shop unattended. Isaac saw that some customers began resorting instead to itinerant peddlers who undercut his prices and whom he saw as unreliable: “In the year or so prior to our interview, two new OTCs have opened in the village, further compelling Isaac to meet customer demand for prescription medicines: if he doesn’t supply them, his competitors will.4.3promote the rational use of properly registered medicines” and to “curb the menace” of unlicensed vendors. In his role as an inspector, Mensah regularly visited pharmacies and OTC retailers in his catchment area, checking licences and ensuring that medicines for sale complied with regulations . Occasionally, he would also be involved in “swoop operations” targeting unlicensed vendors.In a small district office, Mensah told us about his work, supporting the Pharmacy Council’s mandate to “Mensah described the penalties for regulatory infringements, ranging from fines to temporary or even permanent closure for more significant breaches. However, this left Mensah with a quandary. As a local resident himself, he recognised the constraints that many small-scale retailers were operating under, which could make it difficult to comply fully with regulations. For example, he knew that the process of obtaining and maintaining a licence could be lengthy and expensive, particularly for those without the “right connections”. And he understood why OTC retailers might sometimes be tempted to stock prescription-only medicines or sell individual doses to customers who are unable to afford a full course.balance strategically” (as Mensah put it) the healthcare needs of a community with regulatory requirements. In some cases, the decision was straightforward. For example, Mensah had had few qualms about ordering the temporary closure of an OTC outlet in an urban area staffed only by a 14-year-old boy:In that case, it was not safe to have a boy in charge, and because it is a town with other retailers nearby, it would not be detrimental to the community to shut this one down temporarily.”“It was thus important to “If the medicine seller is operating in a rural community, where there is nowhere else for people to buy medicines, it is better not to arrest them but to work with them to get them properly certified. Otherwise, you may have a community of 1000 people with no way of buying any medicines.”“When other options were not available, however, it could be a different matter:If a village ends up not having an approved medicine outlet, then more people will end up getting drugs from peddlers,” he explained, acknowledging this sometimes meant turning a blind eye to some infringements indefinitely.Timing was everything in such cases. Rather than order the closure of an outlet pending training or proper certification, Mensah was often inclined to support shop-keepers to remain open for business while they (hopefully) got their papers in order, to avoid people going without medicines at all or turning to riskier sources. “5.On the face of it, the challenges and dilemmas experienced by Joseph and Isaac are typical of those faced by any other small-scale business owners operating on tight margins in a difficult, uncertain and under-regulated market. However, unlike sellers of leather belts, stereo systems and other goods, medicine retailers in our study were acutely aware that the decisions they made could have very serious, even existential, consequences for their customers, many of whom they knew personally as friends and neighbours. Similar considerations applied to Mensah and other local inspectors, who often had long-standing relationships with the communities they worked in and were acutely aware that, especially in rural areas, making the wrong decision could deprive a whole village of access to medicines.practical and immediate outcomes of their actions in specific situations. Drawing on a deep (often embodied) contextual understanding, they were able to act on “hunches” and intuitions on a case-by-case basis .The experiences of Joseph, Isaac, Mensah and others were far removed from the ideal set out by Ravinetto et al. , p. 81, just ethically motivated. As business owners and employees, they had to try to reconcile and somehow balance the urgent health needs of those around them with their professional and legal obligations, their personal business interests, and their own “consciences” (as Joseph put it). Sometimes, these moral, legal and business imperatives might align; for example, when Mensah closed down the urban pharmacy staffed by a young boy, he was acting both legally and morally . Oftentimes, however, they come into direct conflict with one another, with individuals breaking the law in various ways  in order to keep their businesses afloat and to serve (as they saw it) the needs of their communities. There are also many “grey areas”, where the blurred line between commercial interests and ethical concerns could potentially generate what Feldman and Halali . Perhaps more significant, though, is the burden of ethical labour, borne disproportionately by those “on the ground”  in the interests of those in their communities by maintaining access to less risky medicine sources, collectively, their actions may serve to undermine the integrity of pharmaceutical supply chains and confound regulatory efforts. The aggregated actions of decisions that may be reasonable  at the individual level can have seriously detrimental systemic effects, as complex systems modellers have shown  for SF medical products, coupled with substantial scaling up of investment in health systems and NMRAs to narrow the gap between demand and supply of quality-assured essential medicines. This is no small task but the alternative is the continued delegation of ethical responsibility to those working on the “front line” and a tacit acceptance of “different [ethical] standards for the advantaged and the disadvantaged” (Farmer & Gastineau,


An inductive thematic approach was adopted for the data analysis, and four main themes emerged: commensality; elevated place of food in the home; snacking; and food shopping. Study findings highlighted several changes: some related to increased snacking and more takeaway food; others were more favorable, including spending more time together, increased home cooking, more efficient shopping practices and reduced food waste. Overall, an elevation of the place of food within the home was apparent, alongside enhanced food literacy, and some evidence of the relocalisation of food. This study contributes to the international literature on the impact of COVID-19 and national lockdowns on family lifestyle behaviors, specifically food choice and dietary habits; further research into the longer-term effects of COVID-19 on family food practices is required.COVID-19 changed the way families in the UK live, with as yet uncertain impacts to food choice and dietary habits. This study sought to explore food-related experiences and changes to behavior of families with children, during the pandemic. Semi-structured one-to-one interviews with parents ( The World Health Organization characterized COVID-19 as a pandemic on 12 March 2020  and schoThe UK government announced that a phased reopening of schools could begin in June . HoweverThe lockdown measures are likely to have had considerable impact on the nation's day-to-day lives. Similar enforced restrictions in other countries have resulted in changes including those associated with unhealthy lifestyle behaviors in families. A cross-sectional survey of 254 families in Canada reported that families with young children experienced increased snacking, decreased physical activity and increased screen time in both parents and children . InteresInternationally, much of the research into the impact of COVID-19 on dietary habits has been through cross-sectional questionnaires. Few qualitative studies have explored families' experiences; one Californian study involving 48 parents of children (5 to 18 years) found changes in eating habits, increased snacking and more family connectedness at mealtimes . AnotherDuring the first national lockdown in the UK, children were at home with their family for a sustained period; the changes to their diet and food habits is not known. For example, the effects of changes to shopping, as well as spending more time within the home food environment, and with family members, is unclear. It is also important to note that children ordinarily spend a large proportion of the year in school, and school meals can make an important contribution to children's diets. Weight gain in children has been associated with school holiday periods , 16–and Food choice is multifaceted, complex, and dynamic. Given the multiple changes accompanying the national lockdown, changes to family food habits and food choice may be anticipated. Socioecological theory suggests that health-related behaviors such as food choice are influenced by factors both intrinsic and extrinsic to the individual . Levels An important consideration in this is the home food environment, which is a series of interactive overlapping domains, relevant to dietary behavior . InfluenWe need to understand how COVID-19 and the restrictions of lockdown impacted families' food practices and food choice–in order to consider the implications and inform support for families post COVID-19. This study aimed to explore the food-related experiences and perspectives of families with primary school-aged children during the COVID-19 pandemic and the national lockdown.A qualitative methodology was chosen based on the study's emphasis on families' individual experiences, their household activities and how and why they behave in specific ways. This can enable a focus on participants' everyday life experience , and proOne-to-one interviews were chosen as they provide more detailed insight into participant experiences and a better understanding of their behavior, than focus groups . Semi-stAn inductive approach for the data analysis was chosen to allow findings to emerge from the data's frequent or dominant themes . ReflexiParent-child pairs were recruited through purposive sampling; parents were required to have spent the first lockdown at home, either working or not, with at least one child  who was not at school between 23 March and 8 September 2020. This age group was chosen as these children were not included in the phased reopening of schools in June 2020  and therTwo interview schedules were developed: one for parents and one for children. The questions and associated prompts focused on families' experiences around food during COVID-19 and the first national lockdown period. Both the parent and child schedules explored food practices and dietary behaviors; questions related to topics, such as food choice, food shopping and preparation, food practices in the home, and food from outside the home. The questions were developed to be open, and non-leading, with particular attention paid to age-appropriate wording for the child interview schedule, e.g., Can you tell me what you remember about the first national lockdown when your school closed? What about food during lockdown, what do you remember about that? A final question gave participants the opportunity to introduce any information they thought was relevant but which had not come up. The interview schedules were reviewed by an expert panel of academics and public health practitioners who provided feedback on content, appropriateness of topics and the language use. Six pilot interviews were conducted with three parent-child pairs, and the interview schedule was refined to allow for more relevant discussion and to improve the question order. The interview schedules are available from the corresponding author upon request.Semi-structured interviews were conducted in November and December 2020 . In total, 40 interviews were conducted, each with one parent or child from parent-child dyads, except for two interviews involving two siblings in the same household fitting the eligibility criteria. Interviews with parents and children lasted on average of 26 and 15 mins, respectively. Informed consent was gained and interviews were conducted remotely using video conferencing software (Microsoft Teams), with participants in their home. A researcher led the interviews using the interview schedule; however, this was flexible and depended upon the direction of discussions and topics arising. During each interview, the researcher noted non-verbal observations, salient points, and initial thoughts for inclusion in data analysis. Immediately following the interview, parents completed a short online questionnaire to collect demographic characteristics. Recruitment and interview of dyads was conducted until it was felt that data saturation had been reached, and there were no further issues or insights arising from the data.Interviews were video recorded with the participants' consent, and then transcribed to a protocol using a denaturalised approach removing interview noise such as stutters and mannerisms . TranscrCoding was conducted to capture participants' attitudes, perceptions, and experiences related to food. This was an iterative process, and once all data had been initially coded, researchers reviewed and discussed the coding, before beginning another iteration. In all, four iterations of coding took place, with coding reviewed and refined with each successive iteration. Themes were identified from main concepts that appeared across multiple interviews and significantly contributed to understanding the research topic.A total of 20 parents  and 22 children participated in the study. Parents were aged 26–50 years, with the majority over 36 years. Children were aged 8–10 years, with most aged 8 years. All but one parent and child pair were white British, and all households were two-parent families, with most having two children. Participants lived in areas with an IMD decile 4–10 (10 being the least deprived), with 70% of participants living in areas with an IMD decile six or above, indicating lower deprivation levels , and fouData analysis provided four themes: commensality, elevated place of food in the home, snacking, and food shopping. Themes and associated sub-themes are presented in Many participants reported changes relating to commensality [a concept to describe eating with others ] during Children and parents alike recognized that they were spending more time eating together and enjoyed this. Sitting to eat together more regularly became important, and many reported mealtimes at home as a more social occasion.... in lockdown: breakfast, lunch and tea, it was all [of us eating] together–we made a point that no electronics [were out]... we're going to just sit and have this time... we might not ever get the time like this again, really (P13).I think we probably ate more together as a family because obviously we weren't... we're normally all here, there, and everywhere, and I think it probably meant that we actually spent more time eating as a family (P16).It [eating together] felt a bit more happy, happier than usual because we get to, we got to talk about, we got to talk about things and our worries (C1).It was nice to be with my dad... It was different because [usually] he works on weekends, and we're off. He doesn't work on a week, and we're at school. We don't really get to see him that much. I'm really glad that we get to see him more than we used to do before lockdown (C14).Changes to mealtimes, often with parents eating their evening meal earlier than pre-lockdown, enabled families to eat together and was possible because after-school activities and work were no longer barriers. For children, large lunches (in school) and small convenient evening meals were replaced by smaller snack-type lunches and large, social evening meals. Interestingly, participants reported continuing post-lockdown to try to eat together as often as possible.Normally we would eat separate to the kids, just through work patterns and time I get home and stuff, but we were sitting down as a family and eating more together (P17).I think food has remained a social thing, in that it's what the four of us do, to have a focus point of the day and to sit down together (P11).As well as eating together as a family more, parents acknowledged missing eating with others, particularly extended family and friends.That [food] completely changed because on weekends [before lockdown], we were basically spending most of our time with friends. We were always eating out or eating at someone's house or someone was coming over to ours (P13).I missed the family, eating with the family. That was the biggest thing for me (P15).In parallel, children enjoyed more family meals but missed their friends and missed eating with friends during the “noisy” social school lunch.It was quite weird: normally, I'm crowded with people around me... while I eat (C18).I missed having a really good chat. I always miss... seeing my friends, just seeing everyone eating and hearing the chatter of other people around me (C16).I was sad that I didn't get to see my friends because of lockdown. That made me sad, that I didn't get to see my friends. Also... I miss talking to them in the dinner hall (C14).allowed to move to where your friends are sitting”.Interestingly, children also referred to returning to school post-lockdown, and having to eat lunch in the classroom rather than the dining hall and still not being “During the interviews, parents referred to spending more time on food-related activities, e.g., meal planning, shopping, preparing, cooking, as well as making food more “special” and using food as a source of enjoyment. Some parents recognized that they were becoming fatigued with the situation–and looked to “nicer food” and takeaways to try to alleviate the food monotony. Children also had more involvement in food preparation and expressed their opinions over food choice more often. Overall, it was apparent that food had acquired an elevated place within the home.Children were more involved in cooking and baking; parents explained this as an activity to do while children were spending more time at home.I think a lot of the activities we did, looking back, revolved around food, even making it, or playing with it, or preparing it (P15).We did lots and lots of cooking. We cooked cakes and baked cakes... We'd make a lot of cakes, and we made… I remember we made loads of cheesecakes (C12).I think I did a bit more [cooking] because I didn't really have much time when it was not in lockdown, to bake because I only really had weekends off and so there's not really much time after school. So I think I did a bit more (C16).Parents also spoke of children being more involved and wanting “to have a bit more of an input” in what they were eating, and playing a more central role in food decisions, with more freedom to choose. Children also reported this increased input into their food choice.I mean she [daughter] got a bit more picky about what she wanted. It was alwaysthiscereal bar, then she was like, “Oh, I want a fresh fruit salad” and, “I want this” and, “I want that”, and she was more specific about what she wanted (P3).It went from having some Weetabix before he [son] went to school to, “Well, I'll just have some boiled eggs on toast”, and “I'll just have some chopped up fruit while I'm waiting”, and “I'll just have this, and I'll just have that” (P4).He [son] had a lot more freedom with it [food] as well, because he'll just go and get something from the fridge (P8).Some days they'll [children] come up to me before I even start cooking and they were like, “Can we have this tonight?” or they knew if I was going shopping, they'd ask for a specific thing (P3).A popular meal for children during lockdown was a “snacky lunch”, a variety of  cold foods such as boiled egg, sliced meats, sliced/cream cheese and vegetables slices . For some children, snacky lunches were introduced during lockdown; for others already familiar with snacky lunches, these were eaten more often.At lunchtime, her [daughter] and Evelyn [other daughter] developed a meal called “Scraps and Pieces”, which sounds ridiculous, but basically, it was things like carrots, cucumber, houmous, celery, ham, all on a plate with different vegetables. That was their favorite thing and that's what they ate pretty much all of lockdown (P16).For lunch, we would probably have... a snacky lunch, where we would have, maybe a bit of ham, a bit of cheese, a bit of cucumber, a bit of tomato, and maybe a boiled egg (C19).Interestingly, once lockdown ended and schools reopened, it emerged that more children took packed lunches than before. Children felt that packed lunches gave them more input into their food, or felt that it was easier than consuming school lunches in the classroom (which was the practice when they returned to school post-lockdown).I can choose what I put in [my packed lunch], instead of having the same thing (C2).She [daughter] wants to be independent... that's why she wants to take her lunch with her (P15).Since she's been back she's opted for packed lunches only now, because she hates having to go carry the tray back [to the classroom], because she's afraid she'll drop it (P10).It became evident that food became a primary source of enjoyment for many participants, who acknowledged it was one thing they could still influence and choose to enjoy.It [lockdown] was just so boring and so mundane that we needed something to look forward to. You look forward to food because... we enjoy it; our family, we enjoy food. It was something to be excited about… like, look forward to, during the day (P13).It was one of the main purposes of the day sometimes, which sounds ridiculous, doesn't it? But it was that one thing of... we'll get to sit down together tonight and eat a really nice meal (P11).Parents reported enjoying spending more time cooking and preparing family meals from scratch, explaining that they did not have time to do this pre-lockdown. Interestingly, parents felt that their children tried more new food, and that generally, there was more variety in what was eaten by the family, with different recipes and new foods.I think the main thing for me has been just having that time now to be able to prepare food, nice meals for them, rather than always thinking, “Oh, God, they're eating crap all week!” (P17).I was cooking more like my mum used to cook, or my grandma used to cook (P13).I think I put a lot more thought into trying new foods and different recipes that we hadn't done yet (P9).Overall, parents and children felt that the family was eating healthier meals, with less eating out, fewer convenience foods as well as more cooking from scratch. Many parents acknowledged feeling good about this, satisfied to be providing “better” family food.We cooked more healthy things. In our curries, we normally have loads of meat–but during lockdown, we had lots of vegetables (C13b).We couldn't go out to restaurants, so we had to eat inside, and I think we ate healthier snacks (C19).I made sure that we had plenty of fruit in and that the meals were healthy and they were cooked from scratch rather than convenience food and things like that (P11).I have got that bit more time to meal plan, and make sure they're getting a probably more balanced range of meals... than they were before (P17).Some participants also reported that some of these changes had persisted post-lockdown, and for example, felt like they were still eating healthier meals compared to pre-lockdown.We still do meal plan, and we do still try to have a healthy tea as such, with vegetables. We're still making things pretty much from scratch, when it comes to certain meals (P7).In lockdown we did try and make foods that we really enjoy. We've been trying to get those recipes back and trying them again (C13b).Food became a focal point in the home, and parents reported spending more money on food and buying nicer food and treats. This was explained by not being able to eat out, having nothing else to do or to spend money on during lockdown.The one enjoyment was: let's plan a really nice meal, that's healthy, that's really tasty but guilt-free and we can all sit down and enjoy that meal (P11).Just trying to think of different recipes to cook and things that were, maybe a little bit more special and to make you feel like you had... a change of the routine (P20).fed up of thinking and having to organize something every mealtime”–opting for more takeaways, premium foods and eating outside to make mealtimes more interesting. Children recognized these changes too.Parents acknowledged that, over time, food in the home became monotonous; and they were “I think the longer that [lockdown] went on, it became a bit... frustrating, because we were just constantly having to cook and that probably also impacted on our creativity because we just got bored with it (P19).We stopped really eating out because everywhere was shut, but we had takeaways and brought them home, so that was good (C16).I mean, we had a lot of fast food in lockdown, we didn't have a lot before (C4).The girls quite liked having a picnic outside on the grass; even though it's just in the back garden, it felt like it was a bit special (P16).We let the kids eat outside a lot more. I think that was just a combination of trying to get them outside and a bit of fresh air–also, just a different location to eat (P19).In the summer we ate quite a lot of meals outside on an evening. We spent a lot of time in the garden (C11).According to parents, premium foods and takeaways also endured post-lockdown, displacing eating out to some extent.We still don't eat out, still can't get my head round eating out very often. I don't like it, although we've done it a couple of times. We do now get takeaway. We probably now have takeaway once or twice a week (P18).It's [takeaway] like us treat for the week, and it's something to look forward to. Frankie [son] absolutely loves it, so I've just carried on, and it's easier as well; I don't have to start cooking then [...] We're still getting us takeaways really. It's as if it's like your bit of enjoyment of the week as well (P8).Parents felt that they and their children snacked more. Increased snacking was also recognized by children in this study, and parents looked to implement strategies to control the number of snacks eaten by children.Parents felt that children ate more snacks and talked about their children being hungry and asking for more food. The emphasis was on the requests for more food, rather than specific types of food, although common foods mentioned by parents included crisps, biscuits and fruit. Parents also commented that this was not “real” hunger, but instead, driven by boredom and availability of food in the home.Yes, they had a lot of snacks [in lockdown]... I think they were hungry all the time. I don't think they actually were hungry; I think they were just bored (P16).The thing with him [son] was that he was constantly saying that he was hungry. I think that's by being at home and knowing that there's a cupboard there that's full of food, that he can just nip in and get something (P6).snacking a bit more” during lockdown.Children also recognized that they were “Maybe, [snacked more] just because we didn't have to sit and just do our work, because if we were at school… and we had more freedom to go to the toilet more often and... to waste school time [laughs]. Olivia [sister] definitely snacked a lot more (C11).Well, I would have more time to have them [snacks] because I wouldn't be at school or at gymnastics. Also, [pre-lockdown] I would be at school a lot, so I wouldn't have time to eat lots of things... except dinner at school (C14).During the discussions, it was evident that most “snacks” were foods that were high in fat, sugar and salt, although some parents and children also reporting eating more fruit as a snack.I've never bought so much stuff for them [children] to snack on. I've had a chocolate sweet tub which I've never had before (P7).We ate a lot more fruits. Sometimes, we'd have a little snack in the sweet cupboard; apart from that, it was mainly fruits (C13).Boredom was reported as a driver for increased snacking amongst parents, alongside wanting to treat themselves. For some, this was explained as a coping strategy for the ongoing stress and worry caused by the pandemic. For some parents, alcohol consumption increased for the same reasons.Probably a little bit panicked about everything, so I'd probably just ate out of... emotion. I don't know, it were just a strange time (P14).I think that [stress and anxiety] had a part to play, and I think as well, it was boredom. Knowing that we were having some treats that night or sharing a bottle of wine and some dips and crisps was like the highlight of the day (P15).Parents acknowledged implementing strategies in response to their children's increased snacking. These included straightforward steps such as hiding the snacks away and offering healthier alternatives, as well as other ideas they had found online, such as putting out snack boxes or devising “price lists” to limit the amount eaten. Snacks were also used in some instances by parents, to incentivise children to complete tasks during the day.I became a lot more aware of the amount of snacks the kids were having. I looked for tips, from other parents as to how they were doing it [limiting snacks] (P15).I made a shop menu board, so they had to–each snack had a value, a price value–they had a pound a day to spend on snacks. Once that pound went, then they had no more snacks (P7).Once Mummy made a massive price list and we had to pay for our sweets (C7).Sometimes I did use it [snacks] as an incentive as well. If he [son] asked for some food, I would say, “Well, just do this piece of writing, and then you can have a snack” (P20).Parents acknowledged that concern over their child's reduced physical activity and potential weight gain during lockdown, partly drove their desire to try to control their increased food intake.So I'm never concerned about what she [daughter] eats because she does lots of sports, in and out of school. But during lockdown again she seems to have quite healthy appetite and I did sort of think, “Oh, how will this work, with her not exercising as much?” (P1).As well as altered food habits at home, shopping habits and routines also changed, with families introducing new and more efficient shopping. Participants' attitudes toward food shopping adjusted, in part, because of the changes to the retail food environment.Parents spoke about the importance of planning meals and avoiding having to shop too often, and no longer 'nipping' to the shops. Families stopped shopping together for food and it became the exclusive responsibility of one member of the household, with children no longer accompanying them. Many of these changes were due to the restrictions in place, as well as fear and minimizing risk.Typically, we'd sometimes go to the shop to pick up different bits and pieces during the week, but we stopped doing that (P19).I was really conscious: we really must try and get everything in this one shop, to reduce, really, the risk of going out and being with anybody else. I really try to get everything on that Tuesday morning shop (P5).Mum usually got really big shops, so it lasts quite a few weeks. It makes sure that we also have enough to last a couple of weeks, so we don't have to do a big shop the next day (C14).My mum might have been scared that if I went inside, I might catch Corona because of all the people (C19).Participants also adapted their shopping; many tried food deliveries for the first time and those who struggled to get delivery slots at supermarkets looked to local shops that had introduced deliveries during lockdown. Participants also shopped locally because they wanted to support their local economy, it was easier, and they had more time.I think there was a couple of key things that changed after lockdown. I think one of the things was that we started ordering most of our food online. We stopped going to the shops just because of the risk factor (P19).It did [shopping changed] a lot because we started getting just a click and collect once every week, and normally, before it was like, we'd go into the shop and... go around more and... things like that (C11).One thing, actually, that we did do because we've had the time to do it, was to go to the local veg shops. I was buying more fresh fruit and veg (P6).the queues to get in [the supermarkets] were huge, and the whole rigmarole, the one-way systems, queuing at the checkouts, and things like that; it was just easier to go local (P17).…Interestingly, participants reported a reduction in food waste, explained primarily through increased food planning, and because using up all of the food within the home became more important as participants tried to avoid shopping.I'd started having to get a bit creative of what we had left, like, “Oh, what can I put with this old spinach and this half of butternut squash?” or whatever (P5).By Friday, there's not a lot in except what we're going to be making maybe on the Saturday, and then we go shopping again. I think that our food waste has gone down quite a bit (P13).Post lockdown, many participants reported resuming their usual shopping practices, e.g., nipping to the shops more, no longer shopping online–however, some continued shopping more locally as they felt the food quality was better, it was more reliable, or they wanted to continue to support local businesses.During the interviews, it emerged that shopping was no longer enjoyable for some participants due to the restrictions and also reactions from fellow shoppers. Participants acknowledged feeling guilty and embarrassed when they thought they were being judged for purchasing too much food.It [shopping] were just hard work, harder work than [pre-COVID]... It was an event in your life, rather than you just going and getting what you needed (P14).Everybody looked really angry, and quite aggressive. I couldn't get out of there fast enough. It was really depressing (P15).I was embarrassed as well... I kept saying, ”I'm not panic buying. It's just there's five of us. We're home all the time” (P5).However, for some participants, shopping was a means of escape, somewhere they could leave the house for.Back then, it was a highlight because it got you out of the house, a bit of peace and quiet as well (P10).It was one of the few things, again, that you could do, wasn't it? I wasn't one of these people who avoided going to shops or supermarkets, for fear of catching COVID (P17).This study revealed the food-related experiences and behaviors of families with primary school-aged children, during COVID-19 and the first national lockdown. As the government's policies restricted usual activities, families spent more time together over food, enjoying family meals, cooking more meals from scratch and involving children in cooking. The place of food within the home was elevated as it became a source of enjoyment, entertainment, and comfort in uncertain times. Food choice was less focused on convenience, and participants spent more time on food, e.g., planning, shopping, preparing, cooking, as well as buying more premium foods and making food more special.It was evident that there were changes in commensality; parents and children ate together more often, and there was a shift in food routines, with more quality family time during meals. Eating together as a family also adjusted the food and meals eaten by participants with, for example a more substantial and leisurely evening meal. Increased commensality corresponds with a Canadian study (conducted in April-May 2020) of families with 4–8-year-olds, where parents ate together more with their children since COVID-19 . Other sAs well as favorable changes such as spending more time cooking and preparing meals from scratch, unfavorable changes also emerged. These included increased snacking. This has been reported previously in adults –47 and cSome parents attributed their own increased snacking to pandemic-related anxiety or worry. A study from New Zealand  highlighInterestingly, many parents in the present study attempted different strategies to control children's snacking, including restriction, providing healthier alternatives, and other means such as a snack menu board with limited “money” to spend. Parents also reported using food as an incentive or to control behavior. Previous research from the US reported various parenting practices during the pandemic, such as more snack planning and more emotion-based snack feeding, and exerting more control when experiencing high-stress levels . FurtherIn this study, parents recognized children's increased food choice autonomy; children chose their own and their family's food more often and were more involved in food preparation. The parents in this study also reported involving their children in meal preparation more, which children enjoyed. It is interesting to note that some of the changes arising out of lockdown, for example, child involvement in meal preparation, which has been associated with healthier diet consumption , have thFood became more important to families in this study, and parents spent more time planning and preparing meals (including from scratch) and sought new recipes; they also gained satisfaction in spending time providing “healthier” meals to the family. Increased planning and preparation of home-cooked meals and cooking from scratch , 60–62 aOver time however, food preparation became monotonous, and for a break from the usual routine and to make mealtimes more enjoyable, participants bought more premium foods and had takeaways more often. Increased takeaways during lockdown due to boredom with your own home-prepared food has been reported elsewhere . This diAs the pandemic continued and food businesses reopened, participants did not resume their pre-lockdown rates of eating out, and instead focused on takeaways. Parents felt it was not as safe or as pleasant to eat out due to the restrictions in place. This corresponds to findings from a US survey (administered in October 2020) of families  reportinIn the present study, parents reported using online shopping and deliveries because of changes in the retail food environment and government restrictions. In the UK, reduced food availability in shops influenced food choice during the pandemic, and food systems were initially put under pressure as consumer purchasing habits changed . PeriodsAs well as shopping more locally, participants shopped as infrequently as possible, discarding the usual “nipping to the shops”. This was driven by fear of visiting shops too often, and similar findings were reported in an Australian study . AvoidanInterestingly, many of this study's insights suggest that the stay-at-home policies in place during the national lockdown may have provided the opportunity for improved food literacy. Many changes reported by participants  point to spending more time with food, becoming more skilled in food preparation, and gaining more knowledge about food. Likewise, a greater ownership of food and feeling good about providing healthier meals for the family, as well as more localized food shopping may propagate a deeper understanding of the importance of food and its role in social relationships with others and thinking about where food comes from, when considering supporting the local economy. Many of these relate to the components of food literacy, such as the planning and management, selection, preparation, and eating of food , and fooCOVID-19 restrictions presented challenges to participants' usual food-related practices. Closure of food service outlets  emphasized food preparation and consumption at home. Shortages of certain foods and changes to the retail food environment contributed to the adoption of new shopping behaviors. Participants recognized increased snacking for themselves and their children, attributing the latter to boredom or food availability at home. Government restrictions removed social interaction over food with, for example friends, peers, colleagues and extended family. The various influences on participants' behavior correspond to different levels of the socioecological model , for exaThe study's strength comes from incorporating both parent and child perspectives and experiences during lockdown, providing a rich picture of the home food environment at this unique time. Using remote video interviews widened participation to individuals who may have otherwise had time or place constraints. Conversely, it may have inadvertently excluded participants with limited access to the technology or competency required to participate . FurtherThe limitations of this study should be acknowledged, and these include sample bias, e.g., potentially higher response rate from families interested in food or with healthier eating habits. The study data is derived from participants' recollections of lockdown and could be subject to recall bias. This bias may be more pronounced with child participants whose recollection of lockdown was not as clear as parents. Further, researcher-led interviews may have led to social desirability bias with participants saying what they think the interviewer wanted to hear.In considering this study's findings attention should be given to the demographic characteristics of the sample population, which was almost exclusively mothers (95%), white British (95%), and educated to degree level (75%). Although there was a range of household incomes, half of households were earning £75,000 plus, i.e., at least twice the average household income in the UK. This is particularly relevant, given for example, better education levels and higher household income have been shown to be relevant to better food literacy skills , 86. FurThe potential impacts of changes on nutritional status, for example cooking from scratch, snacking, should be explored. Greater understanding of both favorable and unfavorable shifts to dietary behaviors will be valuable in informing public health interventions targeting families. Special consideration should be given to how lockdown may have impacted food literacy, and if learnings can be applied beyond the pandemic to improve food literacy and nutrition status for families. Incorporating, for example, food skills, cooking confidence and nutrition education, within efforts to support individuals to implement or develop some of the positive aspects seen in this study, is worthy of further examination.It is unclear whether the effect of further lockdowns and the continuing pandemic will result in longer term shifts in behavior, and for example more reliance on the local food retail sector may persist. It may be that some of the changes  initially driven by fear, apparently subside with usual habits returning. Further research, including across socioeconomic groups, is necessary to ascertain the longevity of changes and to understand any lasting shifts in behavior. This is particularly relevant given the nutritional implication of some changes  and the possibility of working from home and flexible working in the future.To conclude, this study has revealed how, as the government's lockdown policies restricted usual activities, families spent more time together over food, enjoyed eating family meals together, cooked more meals from scratch and involved children in cooking more. As well as favorable changes reported by parents and children , unfavorable changes also emerged including increased snacking. The place of food was elevated in families' homes and overall, findings point to improvements in food literacy. The longevity of changes should be investigated, particularly given the potential implication on the nutritional status of families.The datasets presented in this article are not readily available because of ethical restrictions.Ethical approval for this study was granted through the Faculty Research Ethics Committee. Parents provided their written informed consent to participate in this study, and for their children to participate in this study.HE conceived the study. LS wrote the original manuscript. HE and LS designed the study, conducted the data collection, analysis, reviewed, and approved the final manuscript. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Communication is central to the implementation and effectiveness of public health measures. Informed by theories of good governance, COVID-19 pandemic public health messaging in 3 Canadian provinces is assessed for its potential to encourage or undermine public trust and adherence.This study employed a mixed-methods constant comparative approach to triangulate epidemiological COVID-19 data and qualitative data from news releases, press briefings, and key informant interviews. Communications were analyzed from January 2020 to October 2021 in Nova Scotia, Ontario, and Alberta. Interview data came from 34 semi-structured key informant interviews with public health actors across Canada. Team-based coding and thematic analysis were conducted to analyze communications and interview transcripts.Four main themes emerged as integral to good communication: transparency, promptness, clarity, and engagement of diverse communities. Our data indicate that a lack of transparency surrounding evidence and public health decision-making, delays in public health communications, unclear and inconsistent terminology and activities within and across jurisdictions, and communications that did not consider or engage diverse communities’ perspectives may have decreased the effectiveness of public health communications and adherence to public health measures throughout the COVID-19 pandemic.This study suggests that increased federal guidance with wider jurisdictional collaboration backed by transparent evidence could improve the effectiveness of communication practices by instilling public trust and adherence with public health measures. Effective communication should be transparent, supported by reliable evidence, prompt, clear, consistent, and sensitive to diverse values. Improved communication training, established engagement infrastructure, and increased collaborations and diversity of decision-makers and communicators are recommended. As the COVID-19 pandemic unfolded across Canada in 2020, public health officials gained prominence, even centre stage. Amid scientific uncertainty, initial communication focused on public health measures (PHMs) undertaken by ordinary citizens , then turned to encouraging vaccination as vaccines became available. While Canada outperformed most G10 countries in terms of fewer COVID-related infections and deaths, and higher vaccination uptake . Participants represent one or more of four cohorts: public health officials, frontline healthcare workers, health scholars , and healthcare worker union leaders.Constant comparison of critical incidents across data sources point to four conditions that may improve public health communication: transparency, promptness, clarity, and engagement.We’re following data, we’re following evidence. People who are hounding us to shut down restaurants—Why? Because they want us to, quote, do something when our data indicates that 0.7% of identifiable transmission has occurred in restaurants and similar businesses? Transparency is a complex condition of communication that involves evidence and disclosure of interests and processes. In a pandemic where information, misinformation, disinformation, and conspiracy theories circulate, scientific evidence is instrumental in countering skepticism, justifying PHMs, and fostering public trust in those PHMs. Throughout the pandemic, public health officials attempted to justify actions with information to gain public trust and compliance with PHMs, but efforts were uneven at best. During autumn 2020 in Alberta, Premier Jason Kenney cited evidence to support his decision to keep restaurants open:During summer 2021, Chief Medical Officer of Health (CMOH) Dr. Kieran Moore (ON) addressed fertility concerns related to COVID-19 vaccines, saying that officials were paying ‘close attention’ to a study following 40,000 pregnant women in Ontario, all of whom had been vaccinated safely without complications .People […] like to ‘do their research.’ And that can be a problem because they go to deep corners of the internet, and they get wrong information […]. And so, it’s important to emphasize strategies that provide them with information that is correct […] so that, they can make the right decisions. And in providing them with correct information, coming up with different strategies but also connecting them with […] different pathways of information.Participants spoke about challenges addressing false information. FL5, an infectious disease paediatrician, stated:Anti-vaxxers are using fear tactics and they don’t have to say things that are true. But they can say things that are scary or completely biased. And so, it’s not a fair game. […] I think we need to beef up our capacity to deal with things like that. So, that might be a reform in the sense of paying more attention to it, supporting it more using evidence in terms of what works, from a public perspective, a broad perspective, in terms of messaging, and how do you modify people’s understanding […] to align […] their beliefs and their thinking […] with accurate information. And I think that’s […] one of the big challenges.Directing hesitant individuals to reliable, trustworthy sources to enable informed choices regarding immunization is particularly critical as PH8, a provincial health officer, acknowledged:Doctors and public health professionals are up here all the time, talking about efficacy. I had a client talk to me at one of the vaccine clinics, and she said, “I’m so glad to hear the vaccine has an 80% efficacy rate. It’s just such a shame that 20% of the people will die.” Like, that was the way that the information was being read […]. Efficacy [is] a tough mathematical idea to understand.Sharing reliable, evidence-based information through diverse media can help reach multiple communities and dispel inaccurate information circulating online. This requires awareness of where misinformation comes from, and emotions, such as fear, associated with immunization decisions. Reliable information must be conveyed clearly, and in ways that are understood. FL8, an Alberta healthcare worker, warned that purely scientific data without integrating social factors, including health literacy, can harm public understanding:We’re really not giving people who have not been vaccinated a chance to feel good about getting vaccinated. We’ve already moved, like, fully into the shame mode, right? And that’s going to be hard for some people to walk back if they’ve got any kind of pride. So, you can try to force them with vaccine passports. But you know, they’re going to be resistant. So, we haven’t gotten that piece right.Vaccine communication is most persuasive when it is reliable, evidence-based, and clear about risk, and avoids blame and stigma-generation  announced that the benefits of COVID-19 vaccines ‘far outweigh’ the potential risk of myocarditis or pericarditis, and emphasized the need to make informed decisions, although he did not identify where trustworthy information could be found . CMOH Moore (ON) urged those who were hesitant to speak to trusted healthcare providers , a point emphasized by eight interviewees, including S4:They need to have a better understanding of where misinformation comes from and why people believe it. I think that’s been a […] really unique challenge to this vaccination campaign […] To use a pre-COVID example, if you say to a family, “Vaccines don’t cause autism. We have studies.” That’s true. But why do they think that? And what other beliefs have led them to this place? You can’t just say, “That’s not true.” Because that’s not emotionally compelling. It’s not persuasive. […] In terms of public health messaging, I think there have been some emotionally compelling things about “We’re all going to get back to doing things we love.” […] And I think in some cases, that’s been effective.As noted, officials occupy a competitive informational space that requires acknowledging and countering the information quagmire. CMOH Strang remarked, “No matter how many YouTube videos or conspiracy theories from so-called experts that you send to me, we will not agree. [...] Please, please, get vaccinated” . CMOH Moore, responding to concerns about vaccines on fertility, drew on evidence from consultations with the Society of Obstetricians & Gynecologists . FL8 suggested that knowing the audience and tending to emotional aspects can be effective:Ultimately, to achieve transparency, communication should be evidence-based, reliable, and tailored through wide engagement with diverse communities.[T]here just needs to be a lot of emphasis on our regulatory bodies, on Public Health Canada, on National Advisory Committees, on more timely advisories, more timely recommendations, better communication, whatever they need to do […] It needs to come quicker, faster and clearer than it is now […] Going forward [...], that is a big, big issue. So, for any new vaccines for that matter, recommendations need to come sooner.Rapid communication was prioritized in COVID-19 press briefings across jurisdictions, as well as among participants. PH5, a public health officer with provincial and federal expertise, stated:We were too slow off the mark. I think some of the anti-vaccine messages had already set in […] November, December of 2020. And for some people, it just became very entrenched […]. And I think that’s true to this day. […] A lot of people have moved, but for the ones in my practice, that 8%, they are now immovable. And I think we could have messaged earlier.FL4, an Ontario physician specializing in refugee health, emphasized timely communication in countering misinformation and anti-vaccination rhetoric:I am very sorry for the anxiety and confusion that this Order has sparked. This timing was not meant to hide information. Ironically, it was meant to be transparent. The intent was to ensure school authorities knew about the order, which codifies the guidance that has been online for weeks, before the order came into effect today. I understand the concerns, especially as we move forward quickly, and the need to ensure that Albertans have accurate information .In the summer of 2020, CMOH Dr. Deena Hinshaw, facing a backlash, apologized after Alberta issued Order 33-2020 regarding COVID-19 guidelines for schools without a public statement:This illustrates the critical nature of prompt/timely public health communication during a pandemic with rapidly changing conditions and guidelines, and is seen to be important for instilling trust in governmental decision-making.If we’re doing this again, we have to put way more responsibility on the politicians to articulate why they’re allowing things to happen and how that thing contributes or doesn’t contribute to the end goal. And they’ve got to define what that end goal is. It can’t simply be […] to maintain or to control the virus. That’s not the reason why a society exists, right? Or the reason why a government is there. The government is there to […] help produce other big goods that we can all benefit from.If people are to have confidence in the information they are receiving, it needs to be clear. That demands consistency in relation to common conditions. All four cohorts of participants emphasized the importance of consistent communication and commonality of core ideas. S4, a public policy scholar, emphasized the relationship between consistent messaging, public confusion, and trust, highlighting the need for justifications of PHMs:Press briefings were strikingly inconsistent and incoherent, particularly concerning vaccine quality, symptoms, adverse events following immunization, mixed dosing, and the fundamental matter of describing PHMs meant to interrupt virus transmission. Terms included ‘shutdown’, ‘lockdown’, ‘circuit-breaker’, and ‘stay-at-home order’ with variable and unclear meanings and significance. Bol et al.  define aNova Scotia implemented two circuit-breakers and one shutdown in early 2021. A circuit-breaker announced on February 23 was rescinded 1 week later with the justification by CMOH Strang that he would rather “under-promise and over-deliver” . While Premier Iain Rankin contended that safety is a priority, he acknowledged the negative impact of restrictions on businesses . After the rescission, active cases spiked. The next circuit-breaker was not implemented until after cases had already declined, and it transitioned to a province-wide shutdown in April 2021. The delay and discordance between case numbers and implementation of further restriction did not build public confidence.Ontario enacted one province-wide shutdown and two stay-at-home orders from December 2020 to April 2021, without articulating their differences. Public confusion around behavioural guidelines was ongoing, with uncertainty compounded by public officials failing to comply with their own guidelines . Reticence to name restrictions as lockdowns or shutdowns contributed to inconsistencies and ambiguity between provinces.The impact of communication—particularly risk communication—is not generated by raw data alone, but by the emotional involvement and sense-making of recipients  .Throughout the pandemic, values were suggested through political positioning, but they were rarely explicitly referenced, nor was recognition given to the range of communities’ values, so potentially competing values were hardly ever reconciled. Having said that, CMOH Strang did this overtly when he emphasized individual individual agency and personal empowerment. In early March 2020, she said, “We are all responsible for each other’s health,” and “We all have a responsibility to prevent the spread of this virus” . Later in March, she reiterated, “I want to stress overall that the future of this pandemic is in all of our hands. We have a say in how COVID-19 will impact our province” . Premier Kenny further underlined this notion by stating that the course of the pandemic will be decided by the choices individuals make . S2, an immunization expert, highlighted the utility of emphasizing responsibility within the context of infectious disease, saying that the consequences to family and others of not being immunized were not explained consistently or well. The right to refuse immunization if one has a medical contraindication can be properly circumscribed by the right of others not to be infected as a result.In Ontario in April 2020, CMOH Dr. David Williams highlighted the importance of wearing masks, not in fear of others but to protect them . Alberta CMOH Hinshaw took a slightly different tack; in an effort to encourage compliance with government recommendations, she emphasized There’s been colonization for Indigenous People. And there’s been experimentation […] without consent. So, there’s a lot of skepticism and distrust. [They wonder], “Hmm, is this another experiment?” Only, you know, when […] one involves the leaders of the community—the Elders in the Indigenous community context, or Indigenous doctors, nurses and other champions—they explain, “No, this is not that. COVID is a real danger. This is […] not someone trying to put microchips into our arms.” […] But that […] message would be much better received, if it’s coming [...] from the same community, leaders in the community. And that goes for other racialized marginalized groups as well.Local engagement facilitates practices that reflect community values. This is a particularly pressing and demanding requirement in Canada, with such diverse populations and experiences of government. Note should be taken of the legacy of dispossession, marginalization, and genocide experienced by Indigenous Peoples, their troubled history with Canadian institutions, and Indigenous-specific racism that persists in healthcare, all of which have left many Indigenous Peoples suspicious of healthcare workers and hesitant to accept vaccines , the public health communication setting would benefit from clear and compelling federal guidance on best practices. Federal guidance identifying general best practice in meeting the conditions of good communication might better harmonize practices, allay confusion, ease social exhaustion, decrease hesitancy, and improve compliance. An obvious short-term objective should be to develop a shared or common lexicon to guide reporting and discourse across the country. This would facilitate consistent and accurate communication and limit unjustified jurisdiction-specific differences. The provincial experience also speaks to the need for timely federal communication adopting a national perspective during issues of national importance. This would take pressure off provincial/territorial and local officials.Second, this  harmonization could probably only be achieved through improved collaboration between jurisdictions. Regular meetings between designated communicators at different levels of government to enhance consistency of messaging and facilitate the sharing of lessons learned would be beneficial, and again, federal authorities could (and should) take the lead in realizing this.Third, governments across Canada must take steps to better recognize the critical importance of communities to good health outcomes. This demands improved platforms for decision-makers, communicators, and communities to engage. Supportive courses of action include communicator training  and better development of engagement infrastructure .Fourth, steps need to be taken to increase the diversity and representativeness of public officials and communicators. Ensuring that official communicators and decision-makers reflect Canada’s diversity should facilitate a retreat from one-size-fits-all communication strategies  and policy options to pursue same.What does this study add to existing knowledge?Identification of a framework for communication that emphasizes transparency, promptness, and clarity/consistency of communication, while remaining attentive to diverse community values through direct engagement with local actors, which public health communicators should be aware of.Communicator training which addresses best practice in relation to all four conditions of good communication.The public health communication and intervention environment would benefit from increased federal leadership, especially around lexicon, standards, and information exchange.Public health communication and governance would benefit from increased cross-jurisdictional collaboration, from government/official engagement with local communities, and from improved diversity of decision-makers and communicators.What are the key implications for public health interventions, practice, or policy?