Children's perspectives and experiences of the COVID‐19 pandemic and UK public health measures

Abstract Background The COVID‐19 pandemic has had profound impacts on how we live our lives; yet, the implications for children and the effects on children's everyday lives have been relatively underacknowledged. Understanding children's views on COVID‐19 and related restrictions on their lives provides an important opportunity to understand how children have responded to the pandemic, including the impacts on their social and emotional well‐being. Objective This study explored the experiences and perspectives of children in relation to the COVID‐19 pandemic and related restrictions on everyday life. Method A qualitative study using semistructured online interviews with participatory drawings was undertaken between May and July 2020. Eighteen children from England and Wales, aged 7–11 years, participated in interviews. Findings Themes included children's reflections on (1) COVID‐19 as a deadly contagion; (2) fears and sadness and (3) social responsibility and opportunities to respond positively. Conclusions Young children offer insightful reflections on their experiences during the first wave of the COVID‐19 pandemic in the United Kingdom. Children and young people's perspectives must be considered in future public health discourse. Patient or Public Contribution This work was informed by conversations with my own three primary school‐aged children and the children of friends. A formal Patient and Public Involvement (PPI) group was not established due to the speed with which the project was undertaken. Any future research in this area would benefit from formal PPI in the design, methods and questions.


| INTRODUCTION
Across the globe, the COVID-19 pandemic has profoundly affected the ways in which we all live our lives. In the United Kingdom, and other many other countries, much of the political and public health response has been adult-centric, with the roles and perspectives of children on the pandemic and how best to respond to this less well considered. Rather, children and young people have been differentially positioned as either 'resilient', able to simply and unproblematically 'bounce back' from the pandemic, or as 'deviant' and largely culpable for (ongoing) transmission of the virus because of their 'failure' to adhere to public health guidance and maintain social distancing. The relative absence of children's perspectives within the development of public health strategies not only serves to downplay the impacts that COVID-19 has, and continues to have, on young lives but also runs the risk of failing to engage sensitively and meaningfully with the different ways in which children understand and respond to the pandemic, including what this might mean for their engagement with public health advice.
Drawing on a qualitative study with 18 children in England and Wales, this paper explores children's understandings of, and reflections on, COVID-19 and the related political and public health responses to the pandemic. The findings reported here highlight children's thoughts and fears about the scale and impacts of the pandemic, and explore how they have taken up key public health messages to protect themselves and others. The findings also highlight the importance of reframing health promotion messages to better capture children's own perspectives on, and roles within, public health responses to the pandemic. We begin by foregrounding children's contributions to health promotion and the value of attending to these perspectives within the development of public health programmes, before detailing the study and its main findings.

| CHILDREN'S PERSPECTIVES AND THE DEVELOPMENT OF PUBLIC HEALTH PRIORITIES
The development of public health priorities is usually underpinned by an assessment of epidemiological measures including morbidity and mortality rates, and related indicators of health practices or individual risk behaviours (e.g., smoking, exercise, diet, alcohol use). Dominant forms of health promotion thus aim to educate people about the risks tied to harmful health practices and encourage them to adhere to official health advice. These traditional forms of health education typically depict an uncritical, compliant health consumer who engages in proscribed behaviour change, often without due regard to the (differing) meanings attached to health and related health practices. 1,2 Health education with children has followed these models, adopting a didactic approach to providing formal health knowledge.
Children are expected (uncritically) to follow instructions and modify their behaviours accordingly. 3 These approaches position children as 'empty vessels' to be 'filled' with 'appropriate' health information to make expert-defined 'right' choices. 1,4 Children's 'failure' to follow such advice is often attributed to assumptions about their lack of knowledge, 'immaturity' and inabilities to know what is best for them and their health. 2 Because of this, adult frames of reference often define the forms of health promotion deemed most appropriate for children. Not only do such approaches downplay children and young people's own understandings of health and health promotion 1,5 but they also neglect the relevance of the context in which health is experienced and enacted.
Critiques of adult-centric health promotion agendas have emerged in recent times. 5 10,11 Despite the increasing recognition of the importance of eliciting children and young people's views on topical health concerns and public health priorities, there has been a notable absence and failure to engage with children's perspectives on COVID-19 within political and public health decision-making (The New Zealand Prime Minister, Jacinda Arden, offers an exception to this and held briefings and conversations with children at the beginning of the pandemic 12 ). The impacts of COVID-19 on children's present and future lives in terms of their socio-emotional and mental health, their education and future career prospects are beginning to emerge. [13][14][15] Indeed, children (increasingly termed the COVID generation) are likely to experience the impacts and consequences of the pandemic for many years to come and as education and career prospects are compromised and reconsidered. To address the absence of young perspectives in the pandemic discourse, we undertook a qualitative study with young children in England and Wales during the first wave of the pandemic to better understand their experiences of COVID-19 and how these perspectives may help to inform future health promotion strategies.

| METHODS
A qualitative study with 18 children (9 boys and 11 girls) aged 7-11 years in England and Wales was conducted between May and July 2020. During this period, most children in England and Wales were experiencing a prolonged period of home schooling as part of a national lockdown, with schools having been closed since late March 2020. None of the children involved in the study were currently attending school in person due to the national lockdown.

| Recruitment and sampling
The study was advertised on two parent support groups on the social media platform, Facebook. Interested parents were encouraged to contact the researcher, J. T., via email. Following contact, an information sheet and consent form were emailed to parents. All those who expressed an interest in the study were interviewed.

| Data collection
Twelve semistructured online interviews with participatory drawings were conducted with 18 participants (six paired interviews were conducted, with siblings being interviewed at the same time). This method has been successfully used in other research exploring children's understandings of health. [16][17][18] Drawings encourage children to share their thoughts to some initial questions in a visual format. In practice, some children in this study were more enthusiastic about drawing than others, with some children simply preferring to talk about their experiences. Difficulties were experi- Interviews were conducted by J. T. and lasted between 30 min and 1 h. Some parents remained present during the interviews, with some actively contributing to discussions (the implications and impacts of this are discussed later in the paper). Others left their children, enabling them to talk privately to the researcher. All interviews were audio-recorded with participants' consent (and their parents').
Following the interviews, parents were asked to email photographs of their children's drawings to J. T.

| Data analysis
Interviews were transcribed verbatim by a professional transcription company. Transcripts were fully anonymized, and participants were given pseudonyms (some were the child's own choice) and thematically analysed. 19 First, transcripts were (re)read and descriptive codes were attached to the data by J. T. Codes were then discussed and cross-checked with G. S. and P. C. to enable alternative 'readings' of the data. Descriptive codes were then scrutinized, refined and grouped by J. T. and P. C. to identify topical categories emerging from the data. Categories were then compared within and across transcripts to identify synergies and departures. Topical categories were developed into core thematic areas. The drawings were analysed alongside the children's transcripts and to reflect the specific issues that the children were discussing at the time.

| Ethical considerations
Ethical approval for the study was received from the Health Sciences  Reports about losing the people they love highlighted some of the worrying and unintended impacts that dominant public health narratives may have on children's mental well-being. Along with concerns about virus risk for family members and friends, children's accounts also reflected their sadness about the things that they missed due to COVID-19 restrictions. They described how they longed for physical contact with others, along with missing out on sports and extracurricular activities or key school events, such as their final year of primary school and residential trips. For example, Rose spoke about her sadness following the abrupt end to her primary education and how she missed out on important opportunities that would aid her transition to secondary school: When I last went to school, I was really sad that we were going to have to go and then when I didn't know that school was going to close, I was really excited to have a leavers' assembly and leavers' jumpers and my SATS. But obviously when I found out that I couldn't have leavers' jumpers or assembly, I was really upset. I'm not really excited that much to go to high school because it's a bit too  I'm happy that we're all safe and that we're all working together to stop it …I just feel so proud that everyone's working together…and we're all doing our bit. (Eva, ages 9) Many participants spoke fondly about lockdown, including opportunities to spend more time with family. When asked about the things that made her happy during this time, Laura (aged 9) said: Spending more time with my mum and dad because at school we are away from them for at least 7hours because we have to get collected by someone else, so it's nice to get a full day with them.
Children also described the benefits of spending more time outdoors, playing in their gardens, riding their bikes or taking walks with their family, often discovering new outdoor spaces. There was a clear sense that many children enjoyed the freedoms afforded to them by not being in school and the opportunities to fill their own time.
I like that we're still allowed to walk outside, and like have some fresh air and explore new places. (Eva, aged 9) We have quite a big garden and we own part of a field and so we've been going outside a lot, which is really fun. health and well-being. However, over 30 years since its inception, Article 12 of the UNCRC is still not enforceable in UK courts. 21,22 Clearly, much work remains to be undertaken to ensure that children's views on all aspects of their lives are given the prominence that they deserve.
Throughout the COVID-19 pandemic, the measures used to 'protect' the nation have impacted significantly on children's health and well-being 23 and arguably will have a continued impact throughout many children's lives in terms of missed education and opportunities. 24  pandemic and thus reflects the state of the pandemic and the related responses during that time. We appreciate that it has been a continuously evolving situation and that public health discourses and responses may have shifted since we collected our data. Second, the children drawn on for this study clearly did not reflect a diverse group, especially those children who come from more marginalized and vulnerable circumstances and who are likely to experience more significant (adverse) impacts as a result of the pandemic. Second, the necessary use of technology for children to take in the study sometimes hindered the potential to develop rapport with children and also limited the potential to engage with the drawing method. Further, the presence and/or proximity of parents within some interviews could have impacted on some children's responses. We are reflecting on these and broader methodological and ethical issues of conducting online research with children during a pandemic in a forthcoming paper. Despite these shortcomings, the findings from this study highlight the importance of creating opportunities to harness children's perspectives and engage them in debates about contemporary global challenges that directly impact on their lives.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.