Non-binary people may face specific challenges in psychological settings. Psychotherapists often display a lack of preparation for non-binary gender identities, resulting in overt or subtle forms of prejudice that compromise the therapeutic alliance. The present study aimed to provide data on non-binary clients’ positive and negative experiences within therapeutic relationships. Twenty-five interviews were conducted with non-binary people in the age range of 19–35. Using codebook thematic analysis, the researchers identified three main themes: (1) the self of the psychotherapist, consisting of the impact of the therapist’s personal  and professional  characteristics on the therapeutic experience; (2) the practice of the psychotherapist, emerging as affirmative  or negative  approaches toward non-binary identities; (3) the therapeutic relationship, referring to the alliance, rupture, and reparation based on the therapists’ openness toward non-binary identities. To provide a safer setting for non-binary clients, psychotherapists should incorporate issues related to gender minority identities in their training, acknowledge clinical errors when they occur and adopt an active predisposition to learn through the client’s experience, giving value to their unique contribution. Non-binary is an umbrella term to refer to those people who perceive their gender as falling outside the binary construct of “man” or “woman”. There is evidence that non-binary people are less likely to access competent psychological care than binary transgender (or trans) and cisgender (or cis) people. Non-binary people may face specific challenges when dealing with healthcare providers, such as psychotherapists, who often display a lack of preparation resulting in overt or subtle forms of prejudice . The preThe experience of gender among non-binary individuals varies and may include identifying with both male/female genders , a third gender, no gender , or moving between binary genders . Conceptually, non-binary identities fall under the transgender umbrella since their gender differs (at least partly) from their sex assigned at birth. However, not all non-binary people consider themselves transgender, as the clear distinction between trans and cis identities can be perceived as an additional limiting dichotomy .Historically, Western societies’ psychological and scientific communities have denied, denigrated, and pathologized all people that do not align with their assigned gender at birth, incorporating a systemic ideology named “cisgenderism” . CisgendThe non-binary erasure reflects the absence of alternatives other than the male/female options in official documents, public bathrooms, and locker rooms, as well as within broader social beliefs, which expose non-binary people to the risk of being non-affirmed by others and/or in the condition of educating them, thus receiving less support from significant others and health and social care providers . There iThe lack of preparation of psychotherapists results in overt or subtle forms of prejudice concerning non-binary people, such as non-binary negativity, microaggressions, and unfamiliarity with non-binary issues ,16,17. NA growing number of people, especially among youth, self-identify as non-binary ,26. The Due to social stigma and erasure, such a population presents elevated adverse mental health outcomes and may need increased access to psychotherapy. Previous studies involving gender minority individuals documented that negative experiences occurring in mental health settings damage the therapeutic alliance and, consequently, the therapeutic outcomes ,30,31. TThe different steps of the research  were guided by the authors, who are researchers and psychologists directly engaged in the clinical work with non-binary clients. The research members embodied different positionalities concerning their academic role, age, gender identity, and sexual orientation . All the interviews were conducted by trained students and researchers, some of whom had a non-binary gender identity and/or a queer/lesbian sexual orientation.The interviewers were open about their gender identity and sexual orientation to let participants feel free to choose with whom to interact during the interview. Therefore, the interview setting was perceived as less at risk of cisnormative practices, thus enhancing participants’ motivation and openness to participate in the study. During the recruitment phase, participants were informed about the general content and the average time required for the interview (30 min). Before starting the data collection, they were asked to sign their consent to proceed. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Department of Developmental and Social l Psychology, Sapienza University of Rome .Data were collected using a brief questionnaire for demographic and gender identity-related information, followed by a semi-structured interview. Demographic information included age, nationality, sex assigned at birth (with the option of not declaring it), education level, socioeconomic status, employment status, and living and relationship conditions. The Gender Diversity Questionnaire (GDQ) ,32 was uThe interview protocol was developed ad hoc by the research team. Given the lack of previous research on non-binary clients’ psychotherapy experiences, questions were designed based on the research team’s personal and professional experiences, as well as on the existing literature on broader Lesbian, Gay, Bisexual, Trans, Queer, Intersex, and Asexual (LGBTQIA+) clients’ psychotherapy experiences. The interview protocol allowed obtaining in-depth information relating to the following thematic areas: (a) the centrality of gender identity in psychotherapy ; (b) the impact of the psychotherapist’s identity  on the client’s choice and evolution of therapy ; (c) the psychotherapist’s attitude towards non-binary gender identities ; (d) the psychotherapist’s use of the client’s chosen name and pronouns ; (e) the psychotherapist’s reactions toward the client’s coming out ; (f) episodes of alliance, ruptures and potential repair . The interview protocol will be made available upon request to the corresponding author.M = 27.44; SD = 4.31) participated in the study. All participants were White and Italian. Most of them (n = 21) were assigned female at birth. Some participants used additional categories to describe their gender identity: “genderqueer” (n = 2), “genderfluid” (n = 3), “agender” (n = 3), “bigender” (n = 1), and “demigirl” (n = 1)  are filtered from my gender identity, and if the person in front of me is uninformed or unqualified, they will handle these problems in the wrong way and will not actually help me to deal with them.However, finding a non-binary therapist is extremely difficult in Italy, so the second choice fell on cis women that were preferred to cis men, regardless of sexual orientation:I don’t care about sexual orientation. Regarding gender, I would like a non-binary therapist, but I don’t think there are many [laughs]. So, everything is fine as long as it is not a cis man because I feel he couldn’t fully understand. I believe that a woman can be more open to the question [of non-binary gender identity and sexuality], and, obviously, someone who is not cis, would understand it perfectly.Other participants did not consider the therapist’s sexual orientation and gender identity as factors impacting the therapist’s ability:In my opinion, it is not important information, also because it is an extremely personal matter. I may be dealing with a male therapist who is cis but who still has a whole range of skills and openings.A few participants also reported negative experiences related to a non-binary therapist. Indeed, sharing a gender minority identity may have some benefits and stimulate unique resonances in both clients and therapists. In the case of clients, they may desire being validated and/or perceive being under evaluation:Having a non-binary trans person in front of you can also be a problem in terms of being validated […] If I sit in front of you and you tell me “Ah, I’ve lived it too” I can say to myself “Okay, then I am” […] and if I start to think that it is you who must tell me how much trans or non-binary I am, you have a weapon in your hand that you have to know how to manage.Moreover, since the queer communities are often relatively small, non-binary psychotherapists and clients may share the same community and encounter relevant ethical dilemmas. One participant reported negative and confusing feelings due to unclear boundaries with their therapist:My last therapist was queer and non-binary. She wasn’t professional because she took care of me even though we had a series of common relationships and political spaces. She didn’t put the right distances […] and so let’s say she has me… I felt a little manipulated because then I discovered things about her […] it was very traumatic as an end like I don’t know, for me it was helpful in its way, but it was not professional in my opinion.The therapist’s knowledge and competence in non-binary identities was a crucial topic in the participants’ narratives. Most of the therapists were described as not trained and/or unprepared, and several participants believed that it was quite impossible to find a therapist who was already prepared and competent on non-binary issues. As B. stated, “I think no one has good enough training on this stuff” (30 years). Others performed intensive research to ensure they did not find themselves in uncomfortable settings:I made careful research as I thought that I could not go there to explain everything. And so, I found my therapist who deals with, let’s say, “queer issues” and I read a couple of papers she wrote, and I liked them, and so I said, “oh well, she seems to be the right person”.The issue of having to educate one’s therapist was central in participants’ narratives: My therapist had never had anyone before who described themselves as I do. He is open-minded and ready to listen, but I had to explain a lot of things to him, sensations, emotions, what makes me uncomfortable, and so on. All these things must be explained in more detail since they don’t have an idea and there are no cultural references [of non-binarism].In some cases, participants reported having perceived that, for their therapist, having a non-binary client was an opportunity for training or “a particular case study”, as stated by F. (28 years). Such participants do not seem to be annoyed but, instead, they positively interpret the dynamic:In my opinion, he did “mmm, very well, there is something for my studies” [laughs]. I think I’m an asset to him.This client’s positive interpretation was likely verified when the therapist’s lack of knowledge was associated with positive variables, such as open-mindedness and motivation to train themselves on non-binary issues:I really appreciate her openness; she told me that during this year of therapy with me, she trained herself, both during the sessions with me and on her own, by studying and reading stuff to be able to understand and support me.However, the therapist’s openness to non-binary issues was insufficient to make a suitable intervention. As stated by one participant, the risk is that the therapist overemphasizes gender issues while remaining superficial on other meaningful aspects for the client:It seems like he remains a bit superficial about the rest because he sees me as someone who has already faced many things. This likely depends on the fact that for him, it is incredible that someone could have gone through such an experience and understand a whole series of things on their own. On the other hand, I had the impression that he did not examine in depth some aspects of my life.Some participants reported having ended their therapy out of excessive frustration due to the idea of being “the expert” that trains the therapist on non-binary issues:I’m in a bit of a crisis because I just left the therapist. After all, she didn’t have enough awareness of trans issues. I had to explain too many things, from my personal and intimate issues to social issues, right? Something that for me are totally connected, and she didn’t understand, and therefore I had to explain, and this made me angry.Finally, when participants encountered a therapist that was trained and engaged in trans issues/communities, their experience appeared empowered, and the therapeutic relationship could more easily benefit from trust:She is trained, she is prepared, and she already knew non-binarism, gender fluidity, and so on. She told me that she had concrete experience with other trans patients […] I introduced myself to her, saying that something was happening to me in terms of identity, and the first things she said to me were about her experiences. She told me that she did her dissertation on trans issues, worked with trans women in prison and fought for them since they were put in jails with men. So, I said, “Well, top!”The therapist’s practice was characterized by verbal and non-verbal communication that strongly influenced the participants’ sense of comfort and safety. Participants’ description of the affirmative approach included the therapist’s act of seeing their authentic gender:I’ve always had anxiety associated with the idea of starting the [medical] path because I think, “If I don’t take hormones, I’m not female enough, I’m not woman enough, I’m just a man with makeup” […], and she always told me “The hormones, the surgery, these are not things that make you more or less a woman, you are already yourself. Inside, you are already yourself and I can see you”. And this speech saved me.Another way through which participants felt affirmed consisted in their therapist’s acknowledgment of social oppressions affecting non-binary identities:At that moment, he did something I needed; that is, he recognized how difficult this path had been and how good I had been in getting this far on my own […] He sees how difficult the [non-binary] condition is and how it is socially oppressed.Microaffirmations mainly consisted in verbal and non-verbal acts that gave value to participants’ gender and coming out:I shared with my therapist about the struggle in using public restrooms, and then when I came back the following time, I saw that there were “gender-free toilet” signals attached to the toilet door of the office. And I also discovered that she had a meeting with other colleagues to discuss it and put it in the other studios.Another key topic of microaffirmations concerns the correct use of names and pronouns. Participants were positively surprised when their therapists asked about their names and pronouns without them having to express such requests:At one point, she asked me, “Ok, so what pronouns do you want me to use”? To me, this thing was like… like I thought “Ah wow, you know I’m wondering about this thing”? And I said, “Masculine pronoun”, and then she asked me about my name. And from that moment, she used my correct name and pronoun.Negative practices ranged on a continuum from the open rejection of non-binary gender identity to more subtle forms of microaggressions. Some participants reported severe negative interventions acted by their therapist, such as more or less explicit attempts to change their gender identity through invalidation, pathologization, and a conscious refusal to utilize the correct name and pronouns:Maybe he didn’t have the training to deal with it… Perhaps he didn’t care, or he really didn’t understand. He opposed my gender identity because he invalidated me every time… insistently. He corrected me for using the feminine pronoun each time I used the masculine.Interviewer: Did your therapist ever want to change your gender identity?Participant: But emm, since when I started therapy, I was questioning, it happened that I told her, “You know, in certain moments, I feel like I wanted to be a man”, and she answered me, “But what are you saying, you are not a man!” And since I also went there for some dissociation issue, I felt that my therapist thought my doubt about gender identity was due to a form of dissociation.Other cases were characterized by a manifest aggressive behavior of the therapist as a response to the participant’s attempt to talk about their gender identity:I tried to say that I felt this gender ambivalence, I asked her if she had ever heard about non-binary and genderqueer identities, but she immediately reacted and criticized me. She thought I wanted to talk about politics and the current debate about gender identity, a construct she is very critical about. Actually, I just wanted to talk about myself. So, the following time I was much more introverted, a little uncomfortable, right? And she told me that I was regressing in therapy as if I had made progress up to that point, and then sharing this experience was, in her opinion, a sign of regression. When I raise these issues, she often says that this is connected to my problems, in that I am hypersensitive to the subject and very reactive to the question, that this is my stuff, a negative transference.The most common negative interventions reported by participants were microaggressions. In many cases, microaggressions occurred within a positive therapeutic relationship. For that reason, and given the subtle nature of microaggressions, sometimes participants struggled to recognize them as negative practices. For instance, some participants tended to interpret as positive or natural the absence of reaction from their therapist:Interviewer: How did your therapist react when you came out as non-binary?Participant: As if nothing happened. I think that for her, it is a normal thing that does not require to be investigated as if I told her my date of birth. She doesn’t care. There has not been a change, like “let’s talk more about this”.Others noticed that their therapist avoided talking about gender-related issues:It’s weird because at the beginning, I remember that when […] I referred to gender dysphoria, as well as to my relationship with my sexual orientation, or gender identity, and my relationship with my sexual orientation, or gender identity, it was a bit like if she did… not properly ignoring it, but she didn’t say like “Ah okay, fine, let’s talk about this”. She instead said something like, “ah let’s talk about your family”.Another example of microaggressions occurred when the therapist invalidated the gender identity experience of participants using stereotypical images associated with non-binarism:The problem is that people think that [gender] fluidity is an absence of definition or that it depends on a trend of the moment. And this thing, of course, when it is said by your therapist—even in a good way, talking about many other things—is sad, and you don’t always have the strength to say, “No, man, that’s not how it works”.Finally, a common microaggression consisted of the therapist’s difficulty in using the correct pronouns. The incorrect use may manifest through misgendering, as well as through awkwardness when using the correct pronouns:I don’t like that every time that my therapist uses feminine pronouns, it creates ridiculous or embarrassing situations. It seems that she just can’t use it, like if it was an effort or if she was reluctant.A good alliance emerged when participants reported positive feelings associated with the therapeutic relationship. The setting was described as comfortable, and the therapist was perceived as engaged and supportive:I see that my therapist believes in what she does, and that makes me trust her. She seems to believe in it that people may be non-binary. I think she really understands all my needs.In this scenario, participants felt comfortable coming out, and the therapist was able to understand and accompany the awareness process:I noticed that when I spoke to her, she made research by herself [on non-binary issues] to have a dialogue with me in the right way, to be understanding, and I was pleased. Then […] she was able to talk about it better, and she accompanied me towards a better understanding of myself.The rupture of the alliance was characterized by a negative description of the therapeutic atmosphere. The climate of the setting was uncomfortable, so participants omitted important information up to the point of concealing their gender identity completely:No, I don’t feel comfortable talking about my intimate life. Because I’m afraid she can’t understand or that she can be judgmental. Because she often makes nasty comments. No, I don’t feel comfortable sharing certain things.When the therapist was not able to understand and repair the ongoing rupture, participants often abandoned the therapeutic path:I felt hostile with her at times, even a little angry […] After my coming out, I was very suffering, and it seemed to me that she didn’t deepen certain things so, after a while, it seemed to me that there was no longer a space for dialogue and so, at a certain point, I decided to stop.The reparation of alliance rupture occurs when the therapist tries to restore a positive balance following misunderstandings, disappointments, or breakups. Essential was the ability of the therapist to recognize microaggressions and apologize:Once she said something that it was better if she didn’t say. Since I was wondering about the possibility of going to XXX [gender-affirming clinic’s name], and she told me, “I don’t recommend it because you look too feminine”. […] Then she apologized, and she explained that she did it to protect me as she knew the type of narrative they require in that clinic. She was afraid that they would tell me things that would hurt me.The person experiences reparations as events that resolve ruptures and improve trust and the therapeutic alliance.In recent years, an increasing number of people self-identify as non-binary ,25,26. NThe professionals’ lack of competence on this topic significantly impacts the non-binary clients’ perception of psychotherapy, and they may experience negative feelings, therapeutic dropout, and avoidance of mental health services . Given tThe therapist’s self is concerned with how personal and professional aspects are actively and purposefully used to promote the aims of therapy . To “useFindings from this study showed that non-binary people often prefer to know the therapist’s sexual orientation and gender identity. Some participants reported the desire to engage a non-binary and/or queer therapist to increase the likelihood of feeling understood and minimize the risk of stigma within the clinical setting ,47. SincOn the other hand, having a non-binary therapist was reported by some participants as an additional challenge in defining boundaries, especially when they shared the same queer community . Given tMost therapists were described as not trained and/or unprepared for non-binary issues. As found in previous research involving transgender clients, participants in this study reconducted the negative experiences with psychotherapy to their therapists’ lack of preparation ,50. In sThe therapist’s practice consisted of verbal and non-verbal communication that influenced the participants’ experience of the setting. We categorized the therapist’s practice into non-binary affirmative or negative approaches . AffirmaThe negative approach manifested when the psychotherapist reproduced, both consciously and unconsciously, cisnormative attitudes toward the client. Specifically, cisnormative attitudes and beliefs manifested when the therapist assumed that the client was cisgender, leaving little room for coming out; or when, despite the client’s coming out, the therapist did not respect their chosen name and pronouns and/or referred to the client’s gender identity as something that requires to be treated. Examples of negative and cisnormative approaches consisted of explicit attacks on participants’ gender identity, a pathologizing attitude toward non-binarism, and microaggressions. The most damaging practice was characterized by the therapist’s attempt to change the client’s gender identity by responding to cisnormative pressures . Gender Additional negative practices included the therapists’ aggressive response when participants came out as non-binary or tried to discuss gender identity issues. Manifest aggressions were characterized by rigid and manipulative attitudes, pathologizing interpretations of non-binary identities, and verbal aggressions. More subtle forms of negative approach were microaggressions that mainly occurred when the therapist: overemphasized or minimized the role of the client’s gender identity; avoided talking about themes related to gender identity, such as life challenges and coming out; adopted a cisnormative perspective on the client’s experiences and relationships; stereotypically considered non-binarism as a temporary phase, a trend, or confusion towards one’s gender identity; assumed that a non-binary gender identity necessarily leads to negative feelings and needs to be psychologically treated ,30,55,56The quality of the interaction significantly impacted the therapeutic alliance. As found in previous studies, when the therapist was able to affirm the non-binary client identity, the therapeutic connection increased, whereas when they adopted a negative approach, the alliance weakened . A good Finally, episodes of alliance rupture characterized both positive and negative therapeutic relationships. Indeed, ruptures and mistakes occur regardless of a therapist’s attitude and intention . What maLooking at the frequency of each sub-theme , sexual The findings of the present research have important implications for clinical practice. Thanks to participants’ narratives, we identified those factors that are part of a negative or, instead, an affirmative practice with non-binary clients. We noticed that the therapist’s self, in terms of their sexual identity and professional competence, has an impact on the therapeutic process, even before the process starts . Non-binWe also found that clinical mistakes, especially microaggressions, are common, even because they can be unintentional and unconscious, thus resulting also in positive therapeutic relationships. Given the cisgenderist norms that prevail in our societies, it is almost inevitable that therapists internalize and make clinical errors that hurt the client. Moreover, some good practices, such as using chosen names and pronouns correctly, are relatively new and unfamiliar to practitioners approaching clinical work with non-binary clients. However, microaggressions may lead to alliance rupture and therapeutic dropout, especially if the therapist does not efficiently address them.Mental health professionals should incorporate issues related to gender minority identities in their clinical training to provide a welcoming and comfortable setting to non-binary people who require their support. Moreover, it is fundamental to recognize and deconstruct the internalized gender biases and, when clinical errors occur, acknowledge and use them to increase connection with their client. Finally, to embrace an affirmative approach with non-binary clients, it is also necessary to adopt active listening, open-mindedness, and an overall predisposition to learn through the client’s experience giving value to their precious contribution.The present study is not exempt from limitations which must be considered for the generalizability of the findings to the entire non-binary population. First, all participants were White and Italian; thus, we were not able to consider the role of ethnicity as a potential additional factor influencing the experience of psychotherapy. We acknowledge that racialized people are underrepresented in psychological research and invisibilized in the public discourse on sexual and gender minorities. Future research should address this gap, giving voice to those subjectivities incorporating multiple oppressions and identifying their unique experiences of psychological settings.Moreover, qualitative research is increasingly recognized as fundamental to addressing life experiences’ complexity. However, qualitative methods require a great amount of energy for a relatively small group of participants, limiting the generalizability of the results. The present study could inspire the construction of quantitative measures that might be distributed to a larger sample of participants.Finally, we focused on participants’ narratives of psychotherapy, that is, their perception of the setting and the therapist’s attitudes. Consequently, we cannot assume the objectivity of information emerging from the interviews, as they might be influenced by participants’ feelings associated with transfer and projections. Nevertheless, the client’s feelings about the clinical setting have a concrete impact on the therapeutic alliance and adherence to the psychotherapy. We invite future studies to assess the therapists’ experience of their work with non-binary clients to expand knowledge on the therapists’ attitudes, awareness, competence, and sense of efficacy when dealing with non-binary clients.There is evidence that sexual and gender minority people present worse mental health conditions if compared to the general population ,61. TherDespite the limitations, the present study provides interesting information for the clinical practice with non-binary clients. In recent years, many people have identified beyond the gender binary, especially among youth ,26, and Episodes of aggression and microaggression in clinical settings increase the stigma-related effects on mental health ,30. On t


There are concerns that the economic impacts of the COVID-19 pandemic, including employment inactivity and job loss, will have consequences for the UK population's health and wellbeing. However, there is limited qualitative research into how financial adversity contributes to poor health outcomes in this context. This study aimed to explore forms of financial adversity experienced during the pandemic and their subsequent impacts for health and wellbeing.Qualitative semi-structured interviews with 20 people who experienced a form of financial adversity during the pandemic and six service providers employed in social welfare support services. Data were analysed using reflexive thematic analysis.Two main sources of financial adversity were identified: reductions in household incomes and increased living costs which engendered emotional and physical burdens. Coping strategies included increased financial borrowing, support from informal and formal networks and cutting back on energy use, food and non-essential items.Our study highlighted exposure to multiple financial adversities because of the pandemic and how these experiences led to poor mental and physical health. The findings underline the importance of measures attending to the immediate needs of individuals, including accessible, co-located financial and psychological services, as well as broader measures that seek to reduce social and economic inequalities. Indeed,The pathways through which financial adversity undermine health and wellbeing are thought to be driven by a number of psychosocial and behavioural mechanisms. Common consequences of financial adversity, including financial hardship , have been found to engender psychosocial responses. This includes feelings of uncertainty, lack of control, stigma, shame and personal failure , that seThus far, international data has shown considerable impacts on mental health and wellbeing as a result of job loss, workload declines and worries relating to finance during the COVID-19 pandemic . Wright International data have shown how those from lower socioeconomic and racially minoritized groups were disproportionally exposed to unemployment and job loss during this period , with siMany low-income families have also had to navigate financial adversity in the context of reduced face-to-face service provision, which has interrupted access to services such as debt and financial advice charities, local welfare and social security agencies and foodbanks . FoodbanDespite this emerging body of research, there is relatively little qualitative research into how specific forms of financial adversity, including loss of work, furlough and reduced hours, impacted the health and wellbeing of individuals during the pandemic. Understanding these mechanisms are crucial to the design of effective policies to mitigate harms stemming from financial strain, particular for those disproportionally at risk of unemployment and job loss during this period. Of further interest is how welfare providers are continuing to respond to these adversities in this context, including any adaptations to support measures implemented during this period. Understanding these experiences can help shape future responses to financial adversity in periods of economic instability.To these ends, this study aimed to qualitatively explore factors affecting financial adversity and subsequent health and wellbeing of UK adults during the COVID-19 pandemic.2This study formed part of the University College London (UCL) COVID-19 Social Study , which e2.1Participants and service providers were recruited purposively via social media and the UCL COVID-19 Social Study (including its newsletter and website) . Communi2.2Interviews were conducted by TM (research fellow), AM (research fellow) and AB (senior research fellow) via telephone or video call. Interviews lasted an average of 49 minutes (range 27–75 minutes) and followed a semi-structured topic guide. This enabled data collection on the factors affecting the financial situation, mental health and wellbeing of people experiencing financial adversity during the COVID-19 pandemic ; half were male and five were White British.3.1.3Four primary themes were identified: (1) Impact of COVID-19 restrictions on financial adversity, (2) Strategies for dealing with financial adversity, (3) Impact of financial adversities on mental health, physical health and wellbeing and (4) A change in delivery of formal support services. Themes are shown in 3.23.2.1I feel it’s been harder for me to find a job … maybe, there’s more people looking for work right now, so, that’s why I think it’s harder … and I guess I look for online work as well and I’ve had no luck from there either … obviously, I think that has even more competition. Although some participants reported pre-existing financial adversity due to unemployment or low incomes, others noted how the pandemic had triggered an immediate reduction in their income. This was often due to the loss of work - either for themselves or another household member (e.g. their partner) - or an acceptance of shorter hours or lower pay in new jobs following redundancy. Some also described being unable to find new employment, because they were burdened by additional responsibilities such as childcare or because of a lack of employment opportunities during this period:3.5.3.Challenges to providing remote debt and financial advice). Following assessment, some also discovered that their claims were subject to caps or deductions or affected by other household earnings (e.g. that of a partner), which decreased their entitlement. For instance, the fact that UC considers joint household income as part of its conditions, significantly reduced the amount some claimants were entitled to, especially if only one member of the household had been subject to job loss during this period. One participant described difficulties in paying for their rent as a result of this condition:We signed up to Universal Credit, but because we live together, and because we’re in a relationship, my income was counted as part of our joint household income. So, again, [that] took the proportions of what he would be able to do. So it also meant that we didn’t really get anything from that. We are on Universal Credit, but it was going to be £30 for the month or something, which is not enough, also, for rent. In response to substantial decreases in household incomes, some participants applied for and claimed Universal Credit (UC) during this period. New claimants with little knowledge of the benefits system reported initial confusion regarding eligibility, and difficulties navigating the application process, an issue compounded by a lack of face-to-face contact .The inadequacy of UC payments was a common theme among participants. Indeed, those who had been subject to sudden job loss reported how a transition to UC represented a substantial decrease in income. Despite a £20 increase in the UC standard allowance to support claimants during the pandemic period, concerns about the impending removal of this temporary uplift in October 2021 were reported, particularly as many already faced difficulties living within their existing UC budgets: 3.2.2It’s made the situation worse in that people are sitting in their house 24 seven a lot of the time. And you’re using more electricity that you used. You’ll probably be eating more than you used to. You know. And trying to fill that time up. That ends up costing people money. If not through directly buying stuff, just through using electricity, gas. Many participants reported how extended periods spent inside the home during lockdown contributed to increased energy costs and food consumption. Service providers also reported client experiences of increased costs due to spending more time at home:I’d say probably on everything at the moment, probably [an increase in costs of] about an extra £40 to £50 a month, which doesn’t sound a lot. But you times that by 15 months and that is quite a lot of money basically. One participant suggested how even small increases in monthly payments represented a significant additional cost given their tight monthly budget:3.3As well as attempting to deal individually with financial burdens during the pandemic through cutting back on spending and non-essential items, participants also reported the use of formal and informal support networks to assist during this period including accessing foodbanks and help from friends or family.3.3.1[I'm] on Universal Credit but it’s very difficult to manage. I receive it on a monthly basis, but the income doesn’t allow me to pay for all my needs. So as a result the income lasts for two weeks, and then after two weeks I just have to lend ideally from my mum. Participants described the importance of informal support provided by friends, family and the community during this period. Some reported difficulties managing financially and described borrowing from family members to meet daily needs:3.4.Impact of financial adversities on mental health, physical health and wellbeing), they still functioned as important sources of emotional and practical support. Some participants described how prior to the pandemic these networks would often provide help with food or childcare that helped alleviate some aspects of financial difficulty. Emotional support was also beneficial in buffering the emotional strain of living in hardship.Although some participants expressed emotional shame at disclosing their financial precariousness to friends and family . Participants also reported reducing expenditure on daily activities to help cope with increased living costs during the pandemic, which often meant they were unable to see family or friends during the lockdown period:I haven’t really been organising social stuff, as such, because it’s hard when you haven’t really got the funds. And I’m very much like I’d rather not do it if I’m going to be watching the money. The advent of social distancing regulations, however, restricted the ability to access and engage with these networks. Some participants also grieved the closure of social spaces, including libraries and community centres, that offered practical assistance and help with job searches and benefit applications. One participant described attending the library prior to the pandemic “3.3.2I think people that were self-employed especially who almost seem to live on zero income so they’ll be behind with their mortgage and all of their bills and they will have had to take out additional borrowing and their credit rating probably wasn’t great because they are already in problem debt so they’d been getting these credit cards with really high rates of interest. Some people have been doing it to pay the mortgage, borrowing from a credit card. Many participants reported increased financial borrowing - either through increased spending on credit cards or overdrafts, or loans from friends or family - to help ease financial strains during the pandemic. Service providers also described accounts from service users using additional borrowing and credit to pay for daily essentials, such as mortgage repayments and bills. This method was especially prominent among study participants who reported being particularly hard hit financially by the pandemic, and service providers observed self-employed workers being particularly affected:It’s like a juggling act, so I think my mum has a saying, robbing Peter to pay Paul, and I feel like I’m doing that half the time, because I don’t have enough money in the current account, so I’ll put it on the credit card. So, I don’t go without the food, but actually, I’m not sticking to the budgets half the time. Some described how the continual process of borrowing and repaying money was challenging, especially as many had experienced reductions in their income. The increased reliance on loans and credit cards therefore required constant management and planning in attempts to pay for necessities such as food:So, my mum and her partner did start to issue me M&S vouchers. It could have been somewhere cheaper, but they did do Tesco vouchers as well, but they did three of these. A £50 voucher for Tesco or M&S, which did help. The same with my dad, he would say, oh, please let me know if you’re in financial difficulty. A further method of financial borrowing among participants was asking for help from friends or family. This often involved being given money, vouchers, or increased contributions toward daily living from spouses:3.3.3There were some months having to try and manage, and then being like okay, well today I might only be able to have one meal a day” .The increased costs associated with more time being spent at home meant participants often enacted a range of strategies to help them cope with the additional financial burden during this period. The most common of these were a transition to cheaper and non-branded/supermarket own brand products and a reduction in food purchasing, consumption or skipping meals entirely as described by a single parent: ““During the pandemic, I would always do handwashing, I couldn't afford washing” . Some reported denying themselves non-essential items in attempts to save money: “We couldn't afford the little treats that you buy every now and again. And things like that were having to stop” . One participant reported how her efforts to remain within financial budgets often came at the expense of other luxuries which, at times, put additional strain on participant relationships:There would be situations where my partner would say oh, shall we get a takeaway this weekend? I would want one, and then I would look up and be like no, we can’t, because we can’t afford it. We’ll have to wait until I get paid, and then you can have it. The money hasn’t gone through yet. So it ended up being a really strange power dynamic where he, as a grown man, would have to ask me for takeaway and for food and stuff. And I’d have to say no, which we both hated and we’re both pretty aware it’s not what we want. Several participants also reported reducing frequency of laundry or washing, often choosing to wear unclean clothes or wash items by more burdensome methods to save money 3.3.4It was people who had worked in hospitality cleaning, etcetera, and weren’t furloughed, either couldn’t claim benefits or didn’t know anything about the benefit system. Foodbanks reported a major increase in demand during the pandemic, often linked to a range of pandemic specific problems, including immediate and sudden job losses, limited availability of low-cost food and other goods due to people stockpiling items, and inadequate financial and social protection:it was increasing credit, not being able to go to the supermarket and get stuff. And, yes, I found these foodbanks, who do food parcels, they were really, really supportive through COVID” , whilst others viewed them as a resource though which to subsidise increased costs such as heating bills during this period:So in terms of foodbanks, I’ve had to visit them because they’re the priority where there’s not enough income to subsidise that, so you have to find out initiatives and other programmes where you cansavecosts, you can benefit. So the foodbank has been helpful in enabling me to get access to resources. Similar to service provider accounts, some participants reported an increased reliance on foodbanks during this period compared to previously. Reasons for doing so were varied, with some using them in direct response to COVID initiated adversity, including loss of employment, income loss, rising living costs and the closure of supermarkets “3.4Participants described both the mental and physical health toll of the financial adversities they were experiencing, as well as the negative impact of some of the strategies they were using to cope on their health and wellbeing.3.4.1just like pure boredom” , and a lack of routine and purpose: “not having work, on top of that there are no routines, and then I feel like what is my sense of purpose?” , the financial consequences appeared to have the greatest bearing on wellbeing. Many participants had worries about how reductions in income would lead to difficulties to support oneself: “Well, if I run out of money, I won't be able to get food”  and the ability to stick within pre-existing household budgets: “We were both really stressed and worried about this. We'd go to bed every night, really worrying about our budget and looking at the budget every single day of whether we could afford things” . The emotional burden of a reduction in household income often manifested itself through feelings of stress and anxiety as described by a participant who was furloughed during the pandemic:I still feel stressed, to be honest with you. I’m stressed because of the fact of the money, and I know that we’re not getting on top of that. It’s still going to be a long time before we do get on top of it. So, that stresses me out. Participant narratives highlighted how the immediate loss of employment was a stressful and worrying experience, which impacted on their mental and physical health. Whilst some described how employment inactivity led to “And I used to lie in bed, and then have a thought about some sort of figure in our bank account or our budget or whatever, and then have to look it up on my phone in the middle of the night. Otherwise, I definitely couldn’t get it out of my head. So I think, definitely, in terms of physical manifestations, yes, lack of sleep. But yes, I used to sit feeling, especially at my lowest point, on edge the whole time, not feeling very present with chatting to friends and stuff as well. If I had a Zoom call with friends, not feeling like I can focus on them. Several participants described how they or their partner had lost work, with the subsequent reduction in income triggering periods of excessive rumination and worry. For some, this often led to physical symptoms such as sleep problems and a sense of detachment that impacted on their daily life:So, there’s a semi-permanent worry, at the minute, about what we do in the longer term … I don’t know what the winter looks like, I don’t know what next year looks like, I don’t know if we’ll be able to go back to our lifestyle, I just don’t know what will happen. And I think that uncertainty is the biggest problem at the moment. Others reported how the severity of COVID-19 restrictions and a perceived lack of control over the situation contributed to feelings of uncertainty. This was often linked to worries about the long-term consequences of reductions in household income and how this might affect plans for the future:3.4.2Yes, we don’t have all the right nutrients, vitamins, all the rest of it, we’re more tired. I think we’re more anxious, we don’t really go anywhere, do anything. We’re housebound a lot, that sort of thing. Imagine living off cans constantly. That’s your only choice, we can’t really afford to buy all the stuff. Whilst reducing the consumption and purchase of food eased financial burdens, many participants described how such behaviours often had direct implications for physical health. A greater reliance on cheaper, tinned food, for example, made maintaining a healthy diet challenging:And I felt it. To be honest with you, I have a stomach ulcer, and so, I must be careful what I eat. And I was buying exceedingly inferior food I know I shouldn’t be eating … [it] meant that eventually I did lose a considerable amount of weight ….it was down to bananas and crisps, to be frank. Some, particularly those with pre-existing health conditions, reported deteriorations in their health or an exacerbation of conditions in response to consuming poor quality or a limited range of food:We’re grateful, I’m not going to lie, but at the same time we’re not really grateful because, no offence, it’s kind of white people’s things and it’s not really catering to our needs. Let me explain something. So we’re from [Asian] background and they just give us cans all the time … cans of stuff, half of it we can’t eat, it’s different tastes to our needs. Despite being grateful for the food they were provided with by foodbanks, some participants noted a lack of nutritious and culturally appropriate food, meaning they instead had to rely on suboptimal alternatives:“building debt” weighing heavily on them. Worries relating to increased debt were often exacerbated by feelings of being ‘trapped’ in perpetual borrowing cycles that characterised periods of indebtedness. Some participants described how increases in debt and spending of savings were experienced as overwhelming and contributed to emotional and psychological pain. This also led to some participant's engaging in behaviours such as taking more drugs and spending more money to cope with these negative feelings:So as of a couple of months ago there wasn’t any more savings. And the text from the bank that says, you have gone into your unplanned overdraft is what’s been happening. And I’ve got really depressed and sad and emotional and took more drugs because … yes. You kind of go, oh for fuck’s sake, what’s the point? Participants also detailed how increased financial borrowing and the accrued debt they generated, was often a stressful and burdensome experience, with descriptions of During lockdown there’d been three or four occasions where I’ve got really, really short of money and had to borrow. And if I borrow from these people, the minute I get any money again, it could be my UC . They see a credit go in and rather than just taking like a £100, if I owed £400, as soon as my UC went in, they would take the full amount back … I would then have to borrow that money back again …. But there have been times where it’s got to a point where the money’s gone. And it’s about three or four days until I get my next lot of money through. So, I just find myself not eating properly, just snacking on stuff. The challenge of repaying loans often contributed to behaviours that were likely to be detrimental to physical health and wellbeing. One participant making use of a high-interest, payday loan service described how the structuring of the loan left him short of money once he had paid off the borrowed credit. This resulted in him being unable to afford sufficient amounts of food during these periods, which led to him skipping meals:“on edge” :Because what was happening was the seconds were turning into minutes, the minutes into hours and hours into weeks. And so, every time the phone rang, you expected the worst. In other words, is it going to be a bailiff … Was it going to be a debt collector? Was it going to be this? Was it going to be that? Am I going to sleep in the street tonight? Deferring payment of bills to save money during this period helped alleviate short term concerns and allowed money to be redirected elsewhere, however participants expected future consequences. Heightened anxiety about potential consequences were widespread in participant narratives. Fears of potential debt collection left people feeling 3.4.3I feel really, really bad asking people to help me out” . Others, particularly those who had been financially comfortable prior to the pandemic, found the experience of asking and receiving financial support particularly uncomfortable given the perceived relative status of their financial position in comparison to others:I feel really awkward saying that I am in that position, particularly for like, I have a smart phone, and I speak to people, when I do the mutual aid stuff, who are really in financial difficulty, and we’re experiencing different types of financial insecurity, and I just don’t think it’s ethical for me to say that I’m in a relative position to those types of people. Whilst receiving financial support from family or friends helped alleviate feelings of financial pressure, having to ask for help often prompted feelings of shame and guilt. For some, asking for financial help and therefore disclosing being in a position of financial hardship prompted these feelings. Such sentiments were widespread in participant narratives, with one participant describing how “I went to the one which was 15, 20 minutes away and I stood in the queue … And you felt belittled. You felt this is not what I expected … I felt sad that I had got to that position.Some participants had worries about the social stigma of foodbank use, which often made it hard for them to accept help. This was most noticeable among those who were using services for the first time, who described a reluctance and hesitancy to enter foodbank settings due to a sense of shame and failure:3.4.4The pandemic has created some mental health difficulties where I’ve had to think twice, it’s put me on edge to some extent. Where I was working before I could pay out my rent, I was living comfortably.But now I’ve had to claim Universal Credit welfare assistance where it’s placing an impact on my mental health. Because I’m not able to meet friends, or go out for that meal, or go places outside, go on a holiday, it’s just not possible anymore. Financial adversity coupled with social distancing restrictions meant a loss of social networks and a reduction in practical and emotional support. Having to limit social activities impacted mental health and wellbeing through feelings of loneliness and isolation due to not being able to connect with friends:I felt really, really isolated. And I’ve noticed a drop in my mood. And back in March, my doctor had to increase my antidepressants, because I was really, really struggling with lockdown ….It was the financial strain, not seeing people, not being able to meet up with people as well. And I just felt really, really isolated. Isolation was felt particularly strongly among those with pre-existing mental health conditions, which were often exacerbated by both financial adversity and the conditions of the pandemic:3.5Participants described accessing a range of support and services during the pandemic to assist with the financial and mental health implications of lockdown including debt advice charities, mental health support and community hubs. Service provision changed from predominantly in-person to remote delivery and these changes were sometimes experienced as challenging by both participants and service providers.3.5.124-hourservice, rather than nine to five” , telephone services and dedicated COVID-19 hotlines that increased service user connectivity. One foodbank worker reported how remote service provision also facilitated greater possibilities for multi-agency working. This enabled service users to be referred to services that could respond to specific challenges, for example when service providers had concerns about a service user's mental health:So these two Covid helplines or referral helplines is what we gave to everyone, and they were really helpful in keeping people connected. The local one … it wasn’t just with foodbank referrals, but it was also arranging a volunteer who would go and get your medication, or a personal shopping service, or a befriender, and just connecting people withother support like mental health support andso on, so that’s been a really good thing that has come out of the crisis that we’ve now got this telephone line which is quite well used actually. That was really important, and it was really important as well in getting key organisations in < area> talking to each other and trying to problem solve together.The pandemic had a major impact on the way that many financial support services were delivered. While some forms of telephone advice were available prior to the pandemic, many services, particularly those providing financial advice, responded to social distancing measures by transitioning to remote-only operations, including telephone or video calls for assessments and support. In a context of limited face-to-face services, providers felt that such methods offered unique forms of support that were particularly beneficial during this period. Indeed, some services described expanding their operations, including providing “3.5.2some people were really wanting to talk as well, you could tell from these long conversations, some people really needed some contact” . In response, some service providers described offering more informal support over the phone during this period:I did feel a bit more during lockdown obviously especially elderly people are quite isolated and lonely so you would feel people did want to keep you on the phone and have a chat, that’s fine. Sometimes I wanted to keep them on the phone for a chat … so you’d have more of a chat with people, you pick up on that, people are just needing a bit of a chat. Service providers described various pandemic-related problems that altered the type of support they offered during this period. Some observed an increase in isolation and loneliness among service users, which necessitated nuanced and more considered responses. For instance, one service provider described how “the two run together, so they get foodbank and things like shower gel, shampoo, stuff for the washing machine, washing up liquid, loo roll” , additional measures attending to the drivers of financial hardship  were also considered. One foodbank worker described how these issues were now being catered to through increased financial support services in foodbank settings, which were delivered in a context of reduced availability of more conventional financial support services during this period:I think the big thing at the beginning was sort of in April, May last year was accessing Citizens Advice service, that was really overrun … We’ve now got advice workers in our centres, and when we say to people, “Go and deal with your debt, there’s an advice worker just sitting there, go and have a conversation,” people say, “Oh, I wish you’d told me that months ago.” I think there has been an almost giving up on seeking help and advice, and people have got into a deeper rut. Service providers noted how their work had become more reactive and were now offering forms of support and assistance that were responsive to the issues reported by service users. Whilst this included initiatives serving the immediate needs of service users such as provision of household items, clothes and hygiene products “In March last year, we had to close our buildings because our collection centres tended to be in church buildings, they suddenly closed, so we did some mobile foodbanks on the street outside, and then from April until September last year, we were just delivering food.Foodbank workers also described setting up mobile services either outside of buildings that were closed to the public or by offering food delivery services to people's homes to avoid the spread of COVID-19:I found the best way, then, to contact them, was to let them have my mobile number and they could text me. They found it easier to send me a message saying, have you got any food this week, or, I’ve run out of nappies or whatever, than me ringing them and saying, what would you like? They find it very hard to articulate that, and that works much better. Others employed alternative methods to foster levels of trust and reduce stigma among new service users. One foodbank worker described how she would allow service users to contact her directly and then deliver foodbank packages to them herself:The Latin American community, at the beginning we found out they didn’t want to give their details. There was a kind of fear of authorities and what would be done with the information, so some people didn’t want to give their names and addresses, so we set up an informal foodbank where people could just give their name as unknown or address as unknown or something, and then our worker has over a period of months built up the confidence and the trust of those people so that they will give their details and they understand that nothing is going to happen to their details, we’re not going to pass it on to any authorities, and it’s basically safe. There was a whole relationship building, trust building exercise that had to go on with some people in that community as well. Another foodbank worker described how pre-existing mistrust of authorities meant some communities were hesitant to attend foodbank settings where they were required to leave their details. As a result, anonymous collections were permitted to increase accessibility:3.5.3I’ve had service users … who do have letters they don’t understand, letters they struggle to read whether because they’re dyslexic, just don’t read well or don’t read English well. If you’re trying to do an interpreting service, you know, if you’ve got somebody who speaks no English and are doing it through an interpreter, that’s fine, until you get to the point where you say “you got that letter, what does it say?” And then you’re a bit stuck ….I mean you can if service users have e-mail access you can ask them to take a photo and send it in. They often don’t do that. Or they send the first page and you need more than that, so you have to create the back and forth that takes quite a bit of time … so that means the advice that I’m giving is based on a lot less certain information than it should be. Despite the reported benefits of remote service provision, several challenges were noted for both service users and providers. Firstly, a lack of face-to-face services made it difficult for service providers to respond to the often complex and multi-dimensional nature of service user issues. This was a particular problem for those with specific needs, including learning difficulties, language barriers or hearing impairments:Honestly, there's so much red tape around it but it's so frustrating. So, I've spent the last four weeks stressing about all this and having so many conversations” , an occurrence which was made even more difficult given the lack of face-to-face support.Similar issues were often felt most among those participants who had found themselves in hardship for the first time and with limited knowledge of what support was available. Some participants described application processes for UC as convoluted and overly bureaucratic: “I think there’s a type of person who wants to look them in the eye and get that rapport. I can think of a couple of service users who I did have an initial appointment with in-person. After that we did everything by phone, but they really wanted that first appointment to be in person so they could assess what I was like, whether they trusted me, which is fair enough. Difficulties establishing emotional connections were also described by both participants and service providers, which made such methods limited in comparison to previous physical interactions and support:People who don’t have access to, that is another thing as well. I lost my Wi-Fi, couldn’t afford to pay the Wi-Fi, halfway through lockdown … there’s [also] a huge balcony above me which messes with my signal. So I have no signal now. The costs of electronic equipment and phone/internet bills presented a further barrier to receiving help and support. Participants previously reliant on community centres or hubs for internet use reported access issues, especially if they were unable to afford, or had difficulties accessing, wi-fi at home. This often acted as a barrier to accessing help and support:4This study provides new qualitative insights into the impact of different forms of financial adversity on the health and wellbeing of people during the COVID-19 pandemic in the UK. This includes how the pandemic has exacerbated pre-existing financial stressors, and why they are detrimental to physical and mental health. Our study compliments and supports existing quantitative literature documenting how worries about finance and financial adversities directly caused by the pandemic – including income reduction and loss of paid work – are closely related to poor mental health outcomes, including anxiety and stress . This isOur work also adds to a growing body of qualitative evidence from the UK documenting the experiences of those living on a low-income during the pandemic . HoweverExtended periods spent inside the home during lockdown contributed to increased expenditure on energy and food consumption, which prompted additional ‘squeezes’ on finances. Whilst there is evidence that some households were able to save money during the pandemic , the expThe study also adds to the growing literature on how people are navigating financial adversity through increasingly harmful means , which hOur findings also provide some evidence of the pathways through which financial adversities impact physical health, specifically, by altering the ability to care for oneself and maintain a healthy lifestyle. For instance, some participants described how food budgets were often deprioritised due to its greater flexibility within tight budgets compared with other expenditures (e.g. housing and fuel) . Often, Finally, some participants reported challenges to accessing financial support and practical advice. Access to financial support measures, including UC, has long been considered a complex, confusing and frustrating experience for claimants  and the This study does have several limitations. First, the sample may be biased in favour of participants motivated or willing/able to participate. It is possible that the findings presented in this paper are therefore missing the views of individuals most acutely impacted by financial adversity including those who may not have the resources to contact the study team or conduct remote telephone/video interviews. Remote interviews also have some limitations over in-person interactions, for example we did experience some connectivity issues and it can be more difficult to pick up non-verbal cues. Second, our study sample is predominantly white British, despite efforts to recruit a broad and inclusive sample. This omission means our sample only includes limited insights from Black, Asian and minority ethnic populations who are disproportionally affected by socioeconomic and health inequalities, and whose experiences of financial adversity during the pandemic may vary in ways that are not fully captured in this research. Third, the study team experienced difficulties recruiting service providers to take part, which may be due, in part, to their increased workload during this period. It is possible that a larger sample of this population would have resulted in additional insights and experiences. Fourth, we did not collect standardised objective measures on the types of financial adversity people were experiencing and whether these experiences pre-dated the pandemic. Finally, interviews were conducted between May–December 2021, a period where the most restrictive COVID-19 restrictions in the UK were not in place. This included the removal of social distancing and social contact limits and the reopening of businesses. Therefore, the timing of interviews requires consideration when interpreting the findings, although participants did recount retrospective experiences during periods when more restrictive social distancing measures were in place (e.g. stay at home orders).Nevertheless, our study has some important implications for policy and organisational practices. First, we identified increased forms of financial adversity and subsequent reliance on strategies  that have previously been identified as risk factors for and exacerbators of psychological distress . This hiFinally, our finding that many participants experienced difficulties  living on UC during this period adds to previous research highlighting the challenges of living on benefit payments, including the detrimental impacts this has on mental health and wellbeing . That ma5This study highlights financial adversities during the COVID-19 pandemic in the UK and the subsequent impacts on mental health and wellbeing. Participants reported being exposed to multiple and intersecting financial burdens during this period - including the permanent or temporary loss of employment and elevated living costs and expenditure - that functioned as pathways through which financial adversity impacted on health and wellbeing. These factors also induced behaviour changes that are predictive of poor health, including the increased use of credit and financial borrowing, and foregoing food. Therefore, this study contributes to understanding financial insecurity as a social determinant of health, specifically within the context of the COVID-19 pandemic, with financial stressors acting as risk factors for poor health. These findings underline the importance of measures attending to the immediate needs of individuals, including accessible, co-located financial and psychological services, as well as broader measures that seek to reduce social and economic inequalities. These are especially important given the potentially lasting financial impacts of the COVID-19 pandemic on people's health and wellbeing.10.13039/501100000279Nuffield Foundation (WEL/FR-000022583), but the views expressed here are those of the authors. The study was also supported by the MARCH Mental Health Network funded by the Cross Disciplinary Mental Health Network Plus initiative supported by 10.13039/100014013UK Research and Innovation (ES /S002588/1) and by the 10.13039/100010269Wellcome Trust (221400/Z/20/Z). DF was funded by the 10.13039/100010269Wellcome Trust (205407/Z/16/Z).The COVID-19 Social Study was funded by the AB and DF contributed to the conception and design of the study. TM was responsible for data collection and wrote the first draft of the manuscript. TM and HA performed the formal data analysis. AB, DF, and HA assisted with review and editing. All authors contributed to manuscript revision, read, and approved the submitted version.d.fancourt@ucl.ac.uk.The data presented in this article are not readily available because they contain information that could compromise the privacy of research participants. Requests to access the data should be directed to Ethical approval to conduct the study was provided by University College London research ethics committee [Project ID 6357/002].All study participants provided written informed consent to take part in the study.Dr Mandy Cheetham, Northumbria University: m.cheetham@tees.ac.uk Research specialities: qualitative research methods, place-based and community-led approaches to addressing inequalities in health, and the health and social impacts of welfare reform, including Universal Credit.D.Edmiston@leeds.ac.uk Research specialities: poverty and inequality; welfare; citizenship; social security and activation policy; public service reform; social innovation; social impact investment.Dr Daniel Edmiston, University of Leeds: Dr Shamini Gnani, Imperial College London: s.gnani@imperial.ac.uk Research specialities: primary care, public mental health, quality improvement and health inequalities.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Background: Health and behavioural outcomes of adolescents have been shown to be related to school pressure, demands or unfavourable relationships with classmates or teachers. These associations may relate to school satisfaction, but evidence on this is lacking. Therefore, our aim is to explore the associations of school satisfaction with hopelessness, health complaints, fighting and truancy. Methods: Data come from the cross-sectional Health Behaviour in School-aged Children study collected in 2018 from Slovak 15-year-old adolescents . School satisfaction was measured by school engagement and attitudes towards education, grouped as: satisfied (both positive), inconsistent  and indifferent (both negative). Hopelessness, health complaints, fighting and truancy were measured using self-report questionnaires. Logistic regression models were used to explore the associations of school satisfaction with hopelessness, health complaints, fighting and truancy separately. Results: Indifferent adolescents were more likely to feel hopeless, to frequently experience two or more health complaints, to be involved in a fight and to skip school  than satisfied adolescents. Inconsistent adolescents were more likely to frequently experience two or more health complaints than satisfied adolescents (1.72/1.05–5.79). Conclusions: School satisfaction affects adolescents’ health and social behaviour and may threaten their healthy development. Education is one of the most important tools for gaining the skills necessary for an individual’s contribution to society and for improving young people’s development and health ,2,3. LeaCompared to other European countries, adolescents in Slovakia have been low-ranking in terms of liking school for up to a decade now, but even so, many adolescents still value the education they will pursue . Such a On top of that, negative school experiences may negatively affect adolescents’ social behaviour and school performance with long-term consequences. Negative experiences at school may lead to a decreased motivation and further result in deteriorated academic progress, achievement and learning outcomes of adolescents . DissatiPrevious research has shown that experiencing dissatisfaction with school increases among boys who come from low affluence families . MoreoveWe conducted an online cross-sectional questionnaire-based survey on health and health-related behaviour in a nationally representative sample consisting of 11- to 15-year-old school-aged children. For the purpose of this study we used items on attitude towards education that were only asked to 15-years old adolescents. The younger participating children were assumed to not be able to answer this question due to the underdeveloped required ability to think hypothetically and contemplate possible future outcomes .p > 0.05) and school satisfaction . There were differences between excluded and included respondents with regards to gender  with more boys with missing responses (62.3% vs. 49.8%).We used data from the Health Behaviour in School-aged Children (HBSC) study conducted in 2018 in Slovakia. This regards a population-representative sample obtained via two-step sampling. In the first step, 140 larger and smaller elementary schools from rural and urban areas from all regions of Slovakia were asked to participate. These were randomly selected from a list of all eligible schools in Slovakia obtained from the Slovak Institute of Information and Prognosis for Education. In the end, 109 schools agreed to participate in our survey (77.9%). In the second step, we obtained data from 8405 adolescents from the fifth to ninth grades of these elementary schools, aged 11 to 15 years old  ,33. In tThe study was approved by the Ethics Committee of the Medical Faculty at P.J. Safarik University in Kosice (16N/2017). Procedure of approvement included the assessment of the HBSC study protocol which contains the information about the passive consent procedure. Parents were informed about the study via the school administration and could opt out if they disagreed with their child’s participation.School satisfaction regarded school engagement and attitudes towards education. School engagement was measured using the item: “How do you feel about school at present?”, with four-point Likert-type responses . Attitudes towards education were measured using the item “Do you care what kind of education you will have?”, with three-point Likert-type responses . Both variables were dichotomized into two categories. Next, we created a composite variable of school satisfaction by grouping into three groups: (1) indifferent—adolescents who do not like school a lot and do not care about their education a lot, (2) inconsistent—adolescents who do not like school a lot and care about their education a lot or adolescents who like school a lot and do not care a lot about their education, and (3) satisfied—adolescents who like school a lot and care about their education a lot [on a lot ,33.Hopelessness was measured using five items: “All I see ahead of me are bad things, not good things”; “There’s no use in really trying to get something I want because I probably won’t get it”; “I might as well give up because I can’t make things better for myself”; “I don’t have good luck now and there’s no reason to think I will when I get older”; “I never get what I want, so it’s dumb to want anything” with two response options: “I agree” and “I don’t agree” (Cronbach’s α = 0.78). Responses were summed and dichotomized to get two groups of adolescents: those who expressed hopelessness in at least one item and those who did not [ did not .Health complaints were measured using the HBSC-Symptom Checklist, which assesses the occurrence of eight subjective psychosomatic health complaints, including: headache, stomach ache, backache, feeling low, irritability and bad temper, feeling nervous, sleeping difficulties and feeling dizzy  were dichotomized into those who skipped school at least once in the last 12 months and others [Socioeconomic status (SES) was measured using the Family Affluence Scale III (FAS-III), which consists of six questions: “Does your family own a car, van or truck?” , “Do you have your own bedroom for yourself?” (Yes/No), “How many computers does your family own?” (None/One/Two/More than two), “How many bathrooms (room with a bath/shower or both) are in your home?” (None/One/Two/More than two), “Does your family have a dishwasher at home?” (Yes/No), “How many times did you and your family travel out of your country for a holiday/vacation last year?” . The sum score was converted into a ridit score ranging from 0 to 1 with the mean (0.5) in the middle of the distribution. Next, we created three tertiles: low (0 to 0.333), medium (0.334 to 0.666) and high (0.667 to 1) socioeconomic position [position .First, we described the baseline characteristics of the sample using descriptive statistics. Next, we assessed the associations of school satisfaction (independent variable) with hopelessness, health complaints, fighting and truancy (dependent variables), first nod-adjusted and then adjusted to gender and SES using binomial logistic regression models. All analyses were performed using IBM SPSS Statistics 23 for Windows.The results of the regression analyses showed that adolescents who reported feeling indifferent towards school and education were more likely to feel hopeless, to experience two or more health complaints at least once a week, to be involved in a fight and to skip school compared to the adolescents who feel satisfied . MoreoveThe aim of this study was to explore the associations of school satisfaction with hopelessness, health complaints, fighting and truancy. We found that indifferent adolescents were more likely to feel hopeless, to experience two or more health complaints at least once a week, to be involved in a fight and to skip school in comparison with the satisfied ones. Moreover, inconsistent adolescents were more likely to experience two or more health complaints at least once a week than the satisfied ones. Our results are consistent with our hypothesis.We also found that indifferent adolescents, i.e., those who do not like school and do not value education were more likely to feel hopeless and to frequently experience two or more health complaints compared to adolescents who feel satisfied. These findings are compliant with our hypothesis and previous research suggesting that negative experiences at school are associated with generalized states of unhappiness, dysphoric moods and frequent occurrence of compromised health, including anxiety, depression, nervousness or headache and stomach ache ,16,38. AMoreover, we found that indifferent adolescents were more likely to be involved in fights and skip school as opposed to satisfied adolscents. This is in line with our hypothesis and it confirms previous research indicating that negative experiences at school are linked to truancy and violent behaviour ,21. An eWe found that the adolescents who felt inconsistent, i. e. those who do not like school but value their education, were more likely to frequently experience two or more health complaints than satisfied adolescents. These findings partially confirm our hypothesis and previous research concerning the associations of negative school experience and health outcomes. An explanation may be that these adolescents experience continuous tension because of the incongruence between their attitudes towards school and education, and that this tension may lead to psychosomatic problems, such as nervousness, anxiety, headaches or sleep difficulties ,41. HoweThe strengths of this study include the use of a relatively large and representative sample of 15-year-old adolescents and following the Health Behaviour of School-aged children (HBSC) survey protocol, which enables comparison across countries. Next, we used validated and reliable measures allowing for an international comparison.Some limitations need to be mentioned as well. A first limitation is the relatively large number of excluded respondents due to the missing responses (N = 477). We found differences between excluded and included respondents with regards to gender with more boys with missing responses. We do not, however, expect these gender differences resulting in significant bias, e.g., overestimating of our findings. Second, the study design is cross-sectional which does not allow for the exploration of causality nor reversed causality; using a longitudinal study design might be useful for confirmation. Third, we only explore school satisfaction as a determinant of adolescents’ health issues and other factors affecting health issues need to be considered as well. Finally, we used self-reported questionnaires, which means that responses may have been influenced by social desirability, but we tried to moderate this by using validated measures and administering them in an anonymous environment.The results from this study contribute to the knowledge of school satisfaction and its consequences on health and behaviour in adolescence, showing that indifferent adolescents seem to be particularly vulnerable and may require more attention and a thorough screening of their health. For practice, it could be worth focusing on the attitudes towards school and education of 15-year-old adolescents, in particular in case of mental health difficulties. Specific attention for mental and psychosomatic symptoms among adolescents should also be considered for those who seem to be more prone to feel indifferent, i.e., boys experiencing learning difficulties or disruption in the social context and living in a low affluence family, as was shown in a previous study . PracticFuture research may employ other indicators of school satisfaction such as satisfaction with other classmates, school grades, school experience, and relationships with teachers, and might include other factors that contribute to (dis)satisfaction with school. Moreover, it should focus on ways to reduce the negative outcomes of school dissatisfaction on adolescents’ health and behaviour. Additionally, considering that the situation of the adolescents who are inconsistent in their attitudes towards school and education is a unique one, further research in this area may add new knowledge. A qualitative approach may help to better understand coping mechanisms and resources as a basis for targeting preventive interventions. This could, e.g., include individual or group interviews with adolescents about their perception and attitudes towards school and education as well as adolescents’ own experiences at school.The experienced dissatisfaction at school resulting from the negative or incongruent attitudes towards school and education significantly affects adolescents’ health and behaviour and may later compromise their healthy development and academic and professional journey.