key: cord-0989565-8cw0gwyn
authors: Hodson, A.; Woodland, L.; Smith, L. E.; Rubin, J.
title: Parental perceptions of COVID-19-like illness in their children
date: 2020-11-06
journal: nan
DOI: 10.1101/2020.11.05.20226480
sha: b7ece25ff449b087e885fde5982537944047e8f3
doc_id: 989565
cord_uid: 8cw0gwyn

Objectives To explore parental perceptions of COVID-19-like symptoms in their child and attitudes towards isolating from others in the household when unwell. Study Design Qualitative, semi-structured interviews. Methods 30 semi-structured telephone interviews with parents of children between 4 and 18 years. Results We found four themes relating to symptom attribution (normalising symptoms, err on the side of caution, experience of temperature, symptoms not normal for us). In general, parents were more likely to attribute symptoms to COVID-19 if a temperature was present or the symptoms were perceived as unusual for their family. Four themes relating to self-isolation (difficult to prevent contact with children, isolation would be no different to lockdown life, ability to get food and supplies, limited space). Parents believed they would find isolation within the household difficult or impossible if they had dependent children, had limited space or could not shop for groceries. Conclusions The findings highlight complexities in symptom perception, attribution, and household isolation. We suggest that they can be overcome by a) providing better guidance on what symptoms require action, b) providing guidance as to how to prevent infection within the household, and c) by supporting families with grocery shopping through a potential second or third wave.

impossible if they had dependent children, had limited space or could not shop for groceries. Conclusions The findings highlight complexities in symptom perception, attribution, and household isolation. We suggest that they can be overcome by a) providing better guidance on what symptoms require action, b) providing guidance as to how to prevent infection within the household, and c) by supporting families with grocery shopping through a potential second or third wave.

Children can spread certain illnesses readily at school and, in order to prevent outbreaks, are encouraged to stay at home when ill or until they are no longer infectious (1) . How thoroughly children and parents adhere to the rules around sickness absence is unclear. In England, schools were closed nationally from 23 rd March 2020, to prevent the spread of COVID-19 (2) and re-opened to all children in September. There have been concerns that some parents may continue to send children to school when experiencing the symptoms of COVID-19, which include fever and cough (3) .

Sending a child to school while symptomatic, rather than keeping them at home and arranging a test for COVID-19 as recommended by national guidance, may depend partly on how parents interpret their child's symptoms (4) and partly on whether the parent is willing and able to keep the child off school. This in turn may require the parent to take time off work and affect the child's education. However, little is known about factors that are at play in this decisionmaking process.

In this paper, we use data from interviews that explored parents' perceptions of COVID-19like symptoms in their child and attitudes towards isolating from others in the household when unwell.

Two interviewers conducted semi-structured telephone interviews lasting approximately 75 minutes between 15th and 21st April 2020 (n = 30, female = 20). All participants were aged 18 years or over and were the primary caregiver to a child who, from March 23rd, 2020 was not attending pre-school or school in England because of COVID-19. At the time of data collection, the recognised symptoms of COVID-19 were a new, continuous cough and fever. Loss of sense of smell or taste was added on May 18 th , 2020 (5) . At the time of interviewing, guidance stated that individuals who suspected they had symptoms should isolate as best they could from others in the household (6) .

A broad discussion guide was used, covering psychological wellbeing, educational activity while at home and adherence to social distancing guidance. Results for these aspects of the interviews will be reported elsewhere. In this manuscript, we focus on responses relating to symptom perception, attribution, and how parents thought they would react to the presence of symptoms among their children. In our interview schedule, we asked parents whether their child had had "coronavirus or coronavirus symptoms, either a high temperature or new continuous cough?". We also asked a set of questions about whether the parent or child would find it difficult to self-isolate and how they would cope with self-isolation.

Results were analysed using an inductive approach to thematic analysis (7) . We found four themes relating to symptom attribution and four themes relating to self-isolation. These are described in Table 1 with supporting quotes. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 6, 2020. ; Normalising symptoms "I've not done night shift work before, there's times where I've felt a bit odd, and I've thought … 'Are these symptoms?' 'Am I showing symptoms of corona?' But then you think, 'Actually, no I'm just tired,' and, 'Actually, I've got a bit of a sore throat, because-'" (P27) "my five-year-old did have cough, but then he gets cough around that time anyway … cough is one of those things, you know if you get dust in the house, if it gets dusty or hay fever or whatever" (P22) "a cough … it only lasted a day … she didn't have any other symptoms [and] she has suffered with a cough since she was young" (P2) "It was … 24, 48 hours of this horrible tickly cough that wouldn't go away but it wasn't continual and there was no other symptoms. Neither of the kids picked it up. So, I can only assume it was something more likely linked to hay fever or a cold" (P26)

Err on the side of caution "you can carry [COVID-19], but you don't have it yourself … I just wouldn't wanna be responsible for anyone's illness" (P13) "if we thought we had any symptoms we'd be protecting ourselves" (P24) "as soon as they get a cold or a cough, you're thinking, 'Is this the coronavirus?' And I know that's a bit paranoid, but…" (P15) "definitely have to stay in if they were showing symptoms" (P4) "I'll just keep her in to be safe … and err on the side of caution for once." (P5) "I was definitely self-isolating … because I didn't want to pass it to my nana and because I know that that's the best thing to do, with any virus. Even regardless of coronavirus" (P11) Experience of temperature "Before I was a oh-just-suck-it-up, he'll-be-fine, kind of mum. Unless there was a temperature" (P11) "Well if she didn't have a temperature, she had a cough … or a bit of a cold, then I'd send her in, yeah" (P1) "Of course, we're concerned, because obviously I had temperature" (P14) "He got a temperature for about 24 hours. I had a temperature, a sore throat and a headache for about two days. Possibly, we could have had mild symptoms. But I don't know, without being tested we won't know" (P23)

Symptoms not normal for us "we know each other, we'll know if something gets to that stage, we would go and get tested" (P10) "everyone was so tired. I mean so tired, they couldn't watch telly, they couldn't do anything … that was what was weird" (P8 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 6, 2020. We could just shut ourselves away, but if the kids got it, that would be different, and I think we'd almost certainly catch it from them" (P8) "I think we just accept the fact that we wouldn't be able to do that … if one goes down, probably all of us would go down" (P9) "I have been panicking, which is why I've been staying in and extra precautions, because I feel if I was to get ill, I don't know how he'd cope looking after me and the kids" (P30) "it would be basically impossible to. Especially my one-year-old and twoyear-old. The one-year-old, the two-year-old, the four-year-old, they're constantly wanting to be with me … And he's breastfeeding as well" (P22) "My little girl, she wouldn't understand it at all. It's no good having the conversation with her 'cause she just won't understand it" (P10) "they wouldn't understand 'no, you can't go and see mummy' or 'no you can't go and talk to daddy'. I think that would be quite hard" (P9) "that's a real worry for me because if I was ill, it's just me and the children, that is a real worry" (P29) "being ill on my own with the kids … was a bit of a pest. So, it was Mr YouTube had to look after them" (P23) "it would be hard for anyone to look after a kid or kids on their own whilst they're also trying to look after [others in the household]" (P7)

Isolation would be no different to lockdown life "Well apart from going to the park or … shopping, very similar … So yeah, I'd adapt to it. Plus I'd adapt to it even more because it's your life" (P28) "we're not going anywhere; it's going to be very difficult for them to catch anything. We're just at home" (P18) "they're that much self-isolated anyway" (P6) "It would be easy, we've done it for six weeks. Another 14 days wouldn't do anything, would it?" (P30)

Ability to get food and supplies "there's big network in my town, so if anyone is having to self-isolate, you can contact the [local] Coronavirus Project" (P19) "because occasionally we can get Tesco's slots" (P9) "the only thing I found really difficult [about self-isolation] was, I hated having to ask someone else to go and buy me food" (P23) "I think then we'd struggle because apart from anything, you can't get online deliveries and that at the moment" (P12)

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is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 6, 2020. ;

"I had to get a friend to do all my shopping for me. But thankfully I'd stocked up quite a lot of food, anyway, so it was all right. No, I didn't panic buy, I always have loads of food in anyway" (P23)

Limited space "we live in a three-bedroom bungalow … it would be virtually impossible. Especially if more than one person had it, which it's likely to happen, in a house of six people" (P8) "it would be a challenge if [self-isolation] had happened. It's a relatively small house, it's got three bedrooms" (P21) When reporting quotes, 'PX' corresponds to participant number

In terms of symptom attribution, parents appeared to go through a process of finding the most likely reason for the experience of symptoms, discounting COVID-19 if a more likely explanation was apparent ("normalising symptoms"). Symptoms were often normalised in dayto-day terms that reduced the perceived risk and thus the intention to isolate. Particularly if symptoms were transitory or mild, this reduced worry and increased the likelihood of attribution to a non-COVID explanation. Conversely some participants expressed a view that "any symptoms" should be treated as if they were COVID-19 related ("err on the side of caution"). Given the context of the pandemic, they would isolate if they or a household member experienced either a cough or fever, to be on the safe side.

Some parents indicated that they would be more likely to attribute high temperature than a cough to COVID-19 ("experience of temperature"). While a cough could be put down to a sore throat or common cold, parents appeared more cautious about a temperature.

There was a sense among some participants that unexpected or unusual symptoms would be a particular cause for concern ("symptoms not normal for us"). Annual or seasonal experience of symptoms (e.g. hay fever) reduced parental concerns about whether symptoms were due to COVID-19 or not, as well as the experience of symptoms 'normal' to their household. Conversely, symptoms that were "weird" or unusual for the person were "a key indicator if something is wrong."

Parents had varied beliefs about their ability to isolate from others in the home and particularly the difficulty of isolating from children ("difficult to prevent contact with children"). Across interviews, parents expressed that this was related to their child's age and their understanding of the virus, i.e. younger children do not understand boundaries or reasons why they cannot be close to their parents. A common, fatalistic sentiment was that if one member of their household presented symptoms of COVID-19, then the whole household would catch it. Single parents relied on novel sources of care when they themselves became illfor example, increased dependence on online resources, such as gaming and YouTube videos. When having to isolate due to symptoms, one parent stated they sent their child to their grandparent's house so that they could get sufficient rest to recover.

At the time of data collection, people could only leave home for very limited reasons (for example, shopping as infrequently as possible and a daily walk or exercise). Some parents noted that it would be easy to isolate the entire household as it would be no different to how they were already living during lockdown ("isolation would be no different to lockdown life"). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 6, 2020. ;  Access to additional help or available resources was identified as impacting parents' ability to isolate. It would appear that ability to self-isolate was facilitated by connectedness to other members of the community and access to local shops ("ability to get food and supplies"); lack of this may make parents believe that they are not able to isolate. Some parents identified that the size of the home would be an additional challenge during self-isolation ("limited space").

Although rules and context have changed since the data were collected early in the pandemic, the findings highlight several key areas worthy of further exploration and quantification. We believe that there are two main implications.

First, parents' perceptions of whether a given symptom is a possible indicator of COVID-19 do not match the official guidance. Symptoms are often not attributed to COVID-19 unless a temperature is present. Data from a national UK study suggests that amongst under 18s, 48% of those who tested positive for COVID-19 reported having a temperature in the first 7 days of the illness (8). Since parents who identified "not normal" symptoms or a temperature in themselves or their child were more inclined to attribute them to COVID-19, communications may benefit from highlighting that the presence of even one of the identified symptomsi.e. a cough alonenecessitates self-isolation or request of a test, even if that symptom is mild (6) .

Second, isolation is seen as difficult by many parents. Given the guidance at the time of interviewing, parents ideally should have isolated from their children to the best of their ability. Many parents identified that this would be difficult or "impossible". Our findings also suggest that larger families and those living in smaller homes may find it particularly difficult to isolate. Indeed, research suggests that households with dependent children are less likely to adhere to self-isolation than those without children (9) . Those who perceived household isolation to be easier were those who said it would be no different to their life in lockdown and would isolate even if they were not sure their or their child's symptoms were due to COVID-19. Parents who reported that they could rely on someone for help with food shopping were more likely to think they could isolate. This is in line with previous research (10) . We suggest that aiding families with grocery shopping may be a practical route to facilitating adherence to isolation. While it might be impractical for supermarkets to do this, grassroots organisations played a key role in the first wave and could mobilise again in the second wave.

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