Capability, Opportunity and Motivation of pregnant women to enact social distancing behaviour in the Covid-19 pandemic in the UK: A qualitative interview study

Capability, Opportunity and Motivation of pregnant women to enact social distancing behaviour in the Covid-19 pandemic in the UK: A qualitative interview study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Capability, Opportunity and Motivation of pregnant women to enact social distancing behaviour in the Covid-19 pandemic in the UK: A qualitative interview study Emma Anderson, Amberly Brigden, Anna Davies, Emily Shepherd, Jenny Ingram This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-120182/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Covid-19 triggered the rapid roll-out of mass social distancing behavioural measures for infection control. Pregnant women were categorised as ‘at risk’ requiring extra vigilance with behavioural guidelines. Their understanding and ability to adhere to recommendations was unknown. Objectives To complete a behavioural analysis of the determinants of recommended social distancing behaviour in pregnant women, according to the ‘capability, opportunity, motivation and behaviour’ (‘COM-B’) model to inform the development of recommendations/materials to support pregnant women in understanding and adhering to behavioural guidelines. Design Qualitative interview study with pregnant women in the Bristol area (UK). Methods Semi-structured telephone/videoconference interviews were conducted following a topic guide informed by the COM-B model, transcribed verbatim and subjected to framework analysis. Infographic materials were iteratively produced with stakeholder consultation, to support pregnant women’s behaviour. Results Thirty-one women participated (selected for demographic range). Women reported adhering to social distancing recommendations and intended to continue. COM-B analysis identified gaps in understanding around risk, vulnerability, and the extent of required social distancing, as well as facilitators of social distancing behaviour (e.g. social support, motivation to stay safe, home environment/resources). Additional themes around detrimental mental health effects and changes to maternity healthcare from the social distancing measures were identified. Infographic resources (plus midwife report) addressing women’s key concerns were produced and disseminated. Conclusions The COM-B model provided useful details of determinants of pregnant women’s adherence to social distancing behaviours. The confusion of what being ‘at risk’ meant and varying interpretation of what was expected indicates a need for greater clarity around categories and guidance. The loss of maternity care and negative mental health effects of social distancing suggests a growing area of unmet health needs to be addressed in future. Health Economics & Outcomes Research Coronavirus Pandemics Covid-19 Pregnant women Social distance Infection control Qualitative research Behavioral research Health-related behavior Maternal health services Figures Figure 1 Figure 1 Background Covid-19 and social distancing The coronavirus disease 2019 (Covid­19) outbreak was declared a public health emergency by the World Health Organization in January 2020 ( 1 ), and a global pandemic in March 2020 ( 2 ), due to the highly infectious nature of the disease and related risk of mortality. In the absence of pharmaceutical interventions, key strategies to prevent/limit the spread were mass behavioural measures for infection control ( 3 ). These measures focused on social distancing behaviours as well as screening/isolation of positive cases and increased hygiene (e.g. handwashing). The United Kingdom (UK) government provided such advice to its citizens, and in February gave strong social distancing behavioural advice for everyone to limit travel and contact with others and work from home if possible, though on a voluntary basis. The rapidly changing pandemic context led to the UK government implementing a nationwide social distancing ‘lockdown’ strategy on 23 March 2020 with the message “Stay Home, Protect the NHS [National Health Service], Save lives” ( 4 ). The guidance stated that all members of the public should stay at home. Leaving the house was permitted for only four main reasons: shopping for necessities like food and medicine (limited frequency encouraged), to take exercise once per day only, for medical reasons (though people were asked to use telephone/online services where possible) or for essential work or where working from home was not possible (though many workplaces were closed). Social gatherings were not permitted, and when outside, people were to keep at least two metres apart from anyone not in their household. The guidance became law, with police given powers to ensure people followed the rules. Risk categories and pregnancy In mid-March, the government classified pregnant women, along with people aged over 70 years and those with certain health conditions as ‘clinically vulnerable’ or ‘at risk’ of being more seriously affected by Covid-19, advising them to be particularly strict with following the social distancing behavioural guidelines. The government also classified those with specific medical issues into a further category of ‘extremely clinically vulnerable’ or ‘very high risk’, which included recipients of organ transplants, certain cancers, respiratory illnesses, and pregnant women with heart problems. This latter group were contacted by their General Practitioner (GP) from 23 March 2020 advising them to shield (not leave the house for any reason) for 12 weeks and they gained priority in online supermarket shopping delivery arrangements and volunteer support arrangements. The social distancing guidance required unprecedented mass behaviour change, with advice shifting quickly as the pandemic situation progressed. The guidance specifically singled out pregnant women as an at-risk group in this context. To our knowledge, there is no existing research exploring pregnant women’s understanding of, and factors related to, the enaction of social distancing behaviours and no interventions designed to support these behaviours in this group. The COM-B model The British Psychological Society’s Behavioural Science and Disease Prevention Taskforce advises using the Capability, Opportunity, Motivation- Behaviour (COM-B) model of behaviour change ( 5 ) to understand and facilitate the enactment of preventative behaviours in the context of the pandemic ( 6 ). The COM-B model proposes that an individual must have sufficient capability, opportunity and motivation in order to enact a behaviour. Capability can be psychological (e.g. knowledge) or physical (e.g. skills); opportunity can be social (e.g. societal norms) or physical (e.g. environmental resources); motivation can be automatic (e.g. emotional and habitual) or reflective (e.g. beliefs and intentions). A COM-B analysis of determinants of behaviour can be used to diagnose deficient components to identify intervention targets to improve adherence to behavioural guidance. COM-B has been successfully used in comparable research to explore the determinants of exercise uptake in new mothers to produce recommendations for how to improve physical activity ( 7 ), and in the context of the Covid-19 pandemic for exploring determinants of hand-washing behaviour in the general population to inform intervention development ( 8 ). Aims This project aimed to explore pregnant women’s understanding of the behavioural restrictions and their perceived ability to comply, as well as the most concerning impacts of the measures. The overall aim was to develop and disseminate recommendations/materials to help pregnant women understand and adhere to the social distancing guidance. Methods Phase 1: COM-B analysis Design This was a qualitative interview study informed by the COM-B model ( 5 ), designed to explore pregnant women’s perceived capability, opportunity and motivation to follow the guidance on social distancing behaviours, and to identify barriers to, and facilitators of, these behaviours. Recruitment and sampling Women were invited opportunistically to express interest in taking part via The Bristol Post (local news media), university communications team, social media (Twitter and Facebook) and via local radio feature. In an attempt to increase ethnic diversity in the sample, Ujima Radio was targeted (a station for African-Caribbean and other BME communities) for study promotion, as well as community groups for Black, Asian and minority ethnic (BAME) groups on Twitter (e.g. Barton Hill/ Wellspring settlement, Ujima radio Twitter group). A statement was added to the study website to encourage women from BAME groups to participate in the study. Participants were directed to the participant information sheet and an online expression of interest form, hosted on a study website ( 9 ). Respondents were asked to provide their contact details and demographic characteristics for eligibility checking and sampling (see Additional file 1 ) and consent for a researcher to contact them to discuss the study. This form was captured on the Research Electronic Data capture (REDCap) system ( 10 ), a secure online data capture system designed exclusively for research studies. Information included the offer of £10 online shopping voucher for participating. Table 1 Inclusion and exclusion criteria Inclusion Exclusion Pregnant women (any stage of pregnancy) No longer pregnant at time of interview Access to telephone/ videocall facility and internet (for expression of interest form and receipt of online consent form) No access to telephone/videocall facility/ internet Home address in Bristol or immediate surrounding counties (North Somerset/West Wiltshire/South Gloucester) Home address outside Bristol/immediate surrounding counties. Aged at least 18 years Aged less than 18 years English-speaking Unable to speak/understand English.* Provision of informed consent Women lacking capacity to provide informed consent (determined during phone/videocall prior to interview) * While it would have been preferable to have an option to include non-English speakers, limited resources and rapid timeline prevented us from offering translation services. Eligible participants were pregnant women of any gestation, living in Bristol and the surrounding area, aged 18 or above (for full eligibility criteria see Table 1 ). Purposive sampling was applied to the pool of potentially eligible women who completed an expression of interest form, aiming for maximum diversity according to participant age, ethnicity, Index of Multiple Deprivation (IMD) by home postcode, gestation, and avoiding over-representation of those with medical/nursing training. Those selected were contacted by email, provided with a participant information sheet and invited to a research interview. A telephone/video call (depending on preference) was arranged for women wishing to participate, who were sent a link to an online consent form (captured on REDCap). At the start of each interview, the interviewer provided verbal information about the study, answered questions, and made final eligibility checks, ensuring informed consent was complete before proceeding to interview. The aim was to recruit 30 pregnant women, aiming for data saturation of key COM-B model themes to answer the research question ( 11 ). All methods were carried out in accordance with relevant guidelines and regulations. Data collection Qualitative interviews followed a topic guide structured around the COM-B model (See Additional file 2 ). Additional questions (outside of the COM-B model) asked participants: ‘What information would you find helpful and who would you like to hear it from?’ and; ‘Are there some other comments you would like to make on what we have talked about today?’. Interviews were conducted by all five authors, who have expertise in qualitative research, a background/interest in health psychology and interventions and an understanding of the COM-B model of behaviour change. Interviews were designed to last 30 minutes and were audio-recorded. Detailed interview notes were taken during or immediately after interviews using a structured template. On interview completion, participants were provided with emailed links to up-to-date social distancing guidelines ( 12 , 13 ) and a £10 online shopping voucher. Audio-recordings were professionally transcribed verbatim, and transcripts were pseudonymised before full analysis. Analysis Framework analysis was applied to the data, following the seven steps outlined in Gale et al ( 14 ), which began with a rapid analysis of main themes (concurrent with data collection) prior to detailed analysis, as described in Table 2 . Framework analysis was appropriate as the aim was specifically to identify subthemes within the COM-B model as a diagnostic framework to generate recommendations to help pregnant women follow government advice on social distancing behaviours. All transcripts were independently double-coded (by EA and AB) to ensure reliability, and discrepancies were resolved through discussion. Table 2 Framework Analysis (seven step) method Stage 1. Transcription : Audio recordings were transcribed verbatim and pseudonymised. Detailed notes were taken by each interviewer (all authors), structured around the COM-B framework and additional questions. Stage 2. Familiarisation with the interview : Two authors (EA and AB) familiarised themselves with each interview by reviewing the detailed interview notes, and full transcript when available. Stage 3. Coding : EA and AB developed a matrix in an excel file, with columns representing each component of the COM-B framework plus the extra questions, and rows representing each participant. The initial rapid coding process involved systematically reading (and re-reading) the interview notes (and full transcripts where available) for each participant, assigning data to the relevant COM-B and extra question headings and identifying key subthemes within each component. Notes were made on relevant data which did not fit into the COM-B framework as potential inductive themes. Stage 4. Developing a working analytical framework : EA and AB met on two occasions to discuss in detail the findings for each participant (row) and the themes identified (column) as enabled by the framework analysis matrix, to agree the key themes, and produced a report of the initial findings. Stage 5. Applying the analytical framework : All full transcripts were imported into NVivo and the nodes function was used to set up the analytical framework established in step 4. Each transcript was coded by systematically assigning data to a node in the analytical framework. Authors swapped transcripts for coding so that all interviews were double coded. Stage 6. Charting data : Drawing on the full analysis in NVivo, EA created a table of the key themes with illustrative quotes, and reviewed it with all authors. Stage 7. Interpreting the data : During regular team meetings (10 meetings over the analysis phase), and via circulation of written materials, impressions and interpretations of the data, coding and the analytical framework were discussed and agreed. Rather than being a final stage, this process was ongoing throughout the analysis process. Phase 2: Developing outputs A report from our initial rapid analysis (stage 4, Table 2 ) identified key themes that were important to address in output/materials that could be used to support pregnant women during the pandemic. The stages outlined below were carried out with the aim of establishing what materials were needed, to whom they should be directed, and the appropriate delivery format/mode. Design and refinement of materials followed an iterative process involving stakeholders (community midwives, pregnant women, graphic designer). Stage 1: Consultation with expert group The team consulted the University of Bristol’s Health Psychology and Interventions Group (HPIG) ( 15 ), presenting the initial findings and discussing next steps for informational output. Stage 2: Establishing outputs and delivery format A single online meeting was conducted between study team members and two community midwifery staff from one NHS trust. A community midwife from a second NHS trust was separately consulted via email. This pragmatic approach was taken due to difficulties in convening staff during a busy period involving unusual working practices. Midwives were presented with the brief report of interview findings and were asked for their views about how the findings could be usefully conveyed to support women and midwives, and to whom those materials should be targeted (staff vs. women). Midwives were offered suggestions of mode of delivery of information including written materials, materials for a website and/or a video. Stage 2: Iterative design process Following identification of the most appropriate target and modes of information delivery, the planned materials were developed iteratively with the assistance of a graphic designer (Oakshed.co.uk). Feedback was gained electronically from two pregnant women who had participated in the interviews, and community midwifery staff. Materials were checked for utility, clarity, content, format, layout, and colours used. Further iterations were reviewed by the research team in collaboration with the graphic designer to optimise appearance and functionality of the materials. Results Sample: Ninety-five women expressed an interest in participation, of whom 83 were eligible and 31 were selectively sampled (aiming for demographic diversity) and interviewed between 24 April–4 May 2020. Participant characteristics are presented in Table 3 , which includes information on parity collected within interviews. Of the 31 women in the sample, 20 were primiparous; the age range was 24–48 years (mean 33), at the time of interview parity ranged from 10–39 weeks (mean 24). Every IMD level ( 1 – 10 ) was represented and the ethnicity of our sample was: 24 White British, 1 White European, 2 Asian, 1 Black, 3 mixed. Two had medical/nursing training. Table 3 Participant characteristics Consent ID IMD (from home post-code) Gestation at time of interview* (weeks) Current age* (years) Ethnicity Do you have children already?** 01 9 25–27 30–34 White No 03 3 16–18 35–39 White No 05 1 28–31 30–34 Black No 06 10 32–35 30–34 White No 09 7 10–12 35–39 White Yes 11 5 22–24 25–30 White No 13 6 28–31 30–34 White No 14 1 28–31 20–24 White No 17 2 36+ 25–29 White No 18 8 36+ 35–39 White Yes 19 4 19–21 25–32 White No 20 7 16–18 30–34 Asian No 21 5 36+ 30–34 White No 24 4 32–35 35–39 White Yes 25 2 22–24 30–34 White Yes 31 4 28–31 40+ White Yes 32 5 13–15 35–39 White Yes 37 3 19–21 25–33 White No 39 7 10–12 35–39 Mixed Yes 40 9 10–12 20–24 White No 41 4 32–35 25–34 White No 45 2 14–20 30–34 White Yes 46 5 28–31 30–34 White No 53 2 19–21 40+ White Yes 54 4 32–35 30–34 White No 60 7 16–18 25–31 White No 62 6 10–12 35–39 White No 79 2 32–35 40+ Mixed Yes 82 2 22–24 30–34 White Yes 83 7 14–20 35–39 Mixed No 85 1 22–24 30–34 Asian No * Participant data presented as a range to preserve anonymity **information collected during interview. All other demographic information in this table was collected within the expression of interest form to inform sample selection. The rapid analysis and team discussions during data collection indicated that reasonable data saturation for the COM-B framework themes was reached in our sample, as well as for the main additional themes, indicating that our sample was adequate and further recruitment was unnecessary. Phase 1: Qualitative interviews: COM-B analysis and main themes An overview of the main themes identified are presented in Table 4 . For the full analysis table with supporting quotations, see Additional file 3. Table 4 Overview of thematic analysis according to the COM-B model COM-B category Themes identified BEHAVIOUR Social distancing (in accordance with guidelines) Adhering More extreme Slight deviations CAPABLITY – The individual’s physical and psychological capability to engage in the behaviour(s) Psychological capability (understanding/ mental processes) Knowledge and understanding of guidance around social distancing behaviours Confidence in ability to enact social distancing behaviours Physical capability Physical capability had little impact on social distancing behaviour OPPORTUNITY – Environmental factors influencing the behaviour(s) Social opportunity Social norms to comply with social distancing Household composition impacts on ability to enact social distancing Social distancing compromised by strangers in public spaces Physical opportunity Impacts of home environment and resources Work environment/ ability to work from home Shopping for essentials including preparation for the baby Healthcare appointments MOTIVATION – Individual internal factors that direct the behaviour(s) Reflexive motivation Motivated to adhere to social distancing guidelines Establishment of routines to enable social distancing Intentions to continue to adhere to guidelines Risks and balance of risks to determine behaviour Automatic motivation Emotional drivers of social distancing Automatic behaviours Beyond COM-B: cross-cutting themes Isolation, mental health, and loss of maternity care Isolation and mental health impacts Loss of maternity care – communication issues Loss of maternity care Behaviour Women reported that they were adhering to the social distancing guidance to the best of their abilities, describing staying home as much as possible, limiting shopping trips, not allowing others in the house, going outside no more than once per day and staying at least two metres away from others when out. Many were taking extra precautions such as limiting their healthcare appointments and engaging in other behaviours that did not relate to social distancing but that aimed to reduce risk of exposure to Covid 19. These included washing and quarantining shopping, quarantining post or asking partners to do this before items came into the house. Six women in our sample were shielding (not leaving the house at all): one due to extra health issues that increased her risk from Covid-19 (though she had not received a letter from her GP to facilitate her ‘extremely clinically vulnerable’ status); one to protect a member of her household who was in the ‘extremely clinically vulnerable’ category due to health issues; three others were shielding believing this was the requirement when pregnant. Women reported few instances of breaching the social distancing rules, and breaches were minimal and carefully considered, for example one woman drove a short distance to take exercise safely, one reported her parents and her households went into isolation for safety prior to moving in together for support. Psychological Capability Women reported making efforts to access “credible” and “reputable” sources for information. These included: government advice, BBC (British Broadcasting Corporation) news, Royal College of Obstetricians and Gynaecologists (RCOG)/ midwives, NHS, pregnancy apps/emails (e.g. Bounty), Tommy’s (online), some social media groups, select social contacts, scientific sources, and newspapers. While the women in our sample mainly reported feeling able and confident that they could adhere to the guidelines and showed good understanding about what was expected of them, women reported a lack of clarity about what it meant to be in an “at risk” category, or why pregnant women were placed in it. Some women felt it was a precaution and many wanted more information about the rationale and what it meant. Uncertainty around the risk category was evident in women’s different interpretations of what was expected of them: some interpreted it as requiring them to shield due to the ‘at risk’ status of being pregnant, while others stated that the guidance was no different for pregnant women from the rest of the population. Many women felt the advice was confusing at first, though seemed clearer by the time of interview. Some details of the behavioural recommendations remained unclear, such as how to handle shared parenting between households, how to stay safe at work for those not working from home/ furloughed and whether to attend healthcare appointments for minor issues. One aspect of psychological capability was the emotional ability to adhere to social distancing. While some women reported positive experiences about lockdown (e.g. enjoying extra time at home with their family), many reported feeling isolated, low, and suffering loss of joy, which impacted on their perceived ability to sustain the behaviour. This was particularly acute when living alone and fully shielding. Physical Capability Personal physical abilities had little relevance to adhering to social distancing recommendations. Interviews revealed only one example (a woman reported that due to being pregnant she struggled to lift her toddler to stop the child running close to others when outside). Social Opportunity Women in our sample reported strong support from their immediate social circle to adhere to the social distancing guidelines, citing examples of friends, family and partners being strict about keeping them safe, particularly because of being pregnant. Women also described general social norms with ‘everyone’ adhering to the social distancing guidelines, or people generally expecting them to stay away (e.g. from work) due to being pregnant, with several reporting gaining priority in their organisation’s home working or furlough schemes. By contrast some women reported a minority of friends or family who did not adhere to the rules, though this did not seem to influence their own social distancing behaviours. Women chose to reaffirm and explain the rules or keep a distance, with one participant reporting losing friends over this. The household composition had a significant impact on women’s ability to maintain social distance. Many reported having supportive partners who were taking care of practical tasks to keep them safe, or other family members in the house who upheld social distancing practices. Others’ household composition brought added risks or challenges, such as co-parenting teenagers across two households, having to take small children to nursery, coping with the risks of other household members going out to work, or living alone, which made social distancing challenging both emotionally and practically. While women reported being mindful of staying at least two metres away from others when out of the house, many commented on not being able to control other people when outside, giving examples of people coming too close, with some women wishing for a visible sign that they were ‘at risk’ to warn people to stay away. Physical Opportunity There were multiple physical opportunity determinants of social distancing behaviour reported in our sample. Home environment and access to resources had a key impact on women’s ability to maintain social distancing. Participants recognised how lucky they were for the resources they had, for example access to a garden or local green space, exercise equipment at home, a car to avoid public transport, or for digital technology to enable them to stay in contact with people. Those in small flats or without gardens commented on how challenging it was to maintain social distancing and these women were hugely limiting their lives to adhere to the guidance and suffering negative mental health effects. The ability to work from home enabled many women in our sample to maintain social distancing. Most felt these arrangements had been prioritised for them due to being pregnant. By contrast, one woman employed by the NHS reported having to push for changes to their work environment and responsibilities to reduce her contact with patients, and some chose to continue going to work if they could not work from home and judged the risk to be relatively low. Several women worried about future relaxing of the guidance (lockdown ending) meaning they may be expected to return to the workplace. Some women who were unable to work from home chose to leave work, taking sick leave or early maternity leave to enable them to stay at home. These women reported potentially facing financial consequences rather than put themselves at risk, though mortgage holidays, furlough schemes and workplace financial support made these decisions easier. Shopping for essentials was an important behaviour for which it was challenging for women to adhere to social distancing behaviours. Many commented on being unable to gain online shopping slots. Many relied on their partner or family members to do regular food shopping or reported having to go themselves, which made them feel unsafe. Though one woman, who expressed less anxiety than most, reported that going out for the weekly shopping was the highlight of her week. One woman who was single and shielding reported that she was growing her own vegetables due to difficulties getting fresh food. Several women mentioned the difficulty with preparing for the coming baby – being unable to buy baby items from shops, online shops being out of stock, and having to consider how to manage handover of baby items from family members in a socially distanced way. Healthcare appointments were also a key source of concern when it came to social distancing. Women worried about whether they would be able to maintain distance when attending clinics and some chose to limit visits. Labour itself was a source of concern in this context, with women knowing that they would be unable to maintain social distancing and worrying about it, with single women needing someone to take them to hospital. Some reported that antenatal appointments were the only times they had contact with other people and felt that their social distancing abilities were compromised by needing to attend appointments. For women with other children they had to consider how to manage childcare, with one commenting that she would ask a relative to shield for two weeks prior to her maternity appointment to facilitate childcare. Most participants acknowledged that changes to maternity care had been put in place to enable social distancing, mentioning more telephone consultations, limited face-to-face time, staff wearing personal protective equipment (e.g. masks), spacing out waiting areas or enabling women to wait in their car to be called in to their appointment. Women also reported that partners were not permitted to attend appointments as a social distancing measure and antenatal classes had been cancelled for the same reason. Some women sought alternatives online. Reflexive Motivation Despite some of the challenges identified above, there was strong motivation to adhere to social distancing guidelines in our sample, with women adhering closely to the behavioural restrictions and many taking extra precautions. Women cited the safety of themselves and their baby as motivating factors as well as social responsibility motives around protecting others, protecting the NHS and stopping the spread of the virus. Some women talked about having a lower immune system during pregnancy which makes them more susceptible to infections; many expressed particularly high motivation to avoid the virus near the birth. Some women mentioned their own higher risk status, such as a higher risk ethnicity or having comorbidities which made it even more important to adhere to the rules. No-one reported being motivated by the law or police sanctions. Many women talked about having consciously established routines to enable the maintenance of the new social distancing lifestyle as well as to maintain sanity during lockdown. When asked about their intentions to continue with social distancing behaviours, most women in our sample described their plans to continue with adhering to the behavioural advice, some wanting to continue with the current stringent measures if the lockdown was to ease, especially when nearing the time of birth. The birth event itself was pivotal, with some wanting to continue to maintain social distance afterwards to protect their new-born baby, and others expressing a need to ‘break the rules’ to gain support with the new-born baby or see people, weighing up the relative risks of this decision. Decision-making and planning around social distancing behaviours often involved weighing up relative risks. Women described difficult decisional processes such as being unsure whether it was safer to attend the midwife appointment or avoid it, or whether risks of exposure outweighed the mental and physical health effects of outdoor exercise. This was compounded by a lack of understanding around the reasons for being in the ‘at risk’ group (as described in psychological capability, above). Planning arrangements around the birth were particularly fraught in this respect as women grappled with how to plan for a parent to come and help look after their existing children when they went into labour or to support them with the new-born after the birth, or if their partner became ill. Automatic Motivation Fear was identified throughout interviews as a motivating factor for adhering to social distancing guidance. Fears focused on worries about catching Covid-19 near the birth date, or the partner becoming ill, as well as general risk to self and baby. Other emotional drivers of social distancing included guilt or an anticipated guilt of catching the virus due to going out, especially compounded by a sense that women felt capable of adhering to the rules. Conversely, the sadness and low mood some women experienced from their social isolation posed a challenge to adherence. Unconscious processes and automatic behaviours are difficult to assess in a reflective interview, though some women reported that they were now automatically enacting social distancing and other protective behaviours (e.g. keeping away from strangers, handwashing and washing shopping). Beyond COM-B: Isolation, mental health and loss of maternity care: While some positive aspects of following the social distancing guidance were identified by women in our sample, such as spending more time with their immediate family or enjoying working from home, there were significant negative impacts, mainly the social isolation and negative mental health, which came out strongly across interviews. Pregnant women living alone (or only with small children) were particularly vulnerable to isolation and mental health effects. Pregnancy was seen as a time when women would normally seek out connection with others (friends, family, other pregnant women). In this context, the isolation and loss of social contact during pregnancy was experienced as an acute loss. A major concern for most of our participants was the loss of maternity care, and while they recognised that midwives were doing their best in a very difficult situation, many had experienced not only a loss of care, but a lack of communication about the changes to their healthcare, with some reporting that midwives have been ‘hard to get hold of’. The loss was particularly acute for women in their first pregnancy, who did not know what they were missing out on. While some women felt well supported by their midwives, many reported cancelled appointments and classes, face-to-face appointments feeling rushed and stressed and feeling unable to ask questions or share positive emotions. Telephone appointments felt less personal, more removed. Women were particularly troubled that partners were not able to come to the scan appointments, experiencing this as an acute loss, with one worrying about the impact on partner-child bonding. They also felt acutely the loss of antenatal classes – for the important information they were missing out on and the chance to meet other pregnant women. Women wanted ways of replacing these losses, with some mentioning paying for digital antenatal classes, while others simply had no access. Many women were acutely worried about what the birth would be like, and whether their partner could be with them. These concerns about maternity care were stronger than concerns about Covid-19 itself for many of the women in our sample. What information did women want? While recognising that services were doing their best in a difficult time, women expressed a need for more time, support and reassurance from midwives. Women wanted to know more information about their Covid-19 related risk during pregnancy (e.g. why were they in the vulnerable category, what relative risk was associated with each trimester, what is the evidence), their personal risk factors (e.g. comorbidities, ethnicity), clarity on aspects of the guidelines and clarity on changes to their maternity care. Women wanted written information from credible sources, with clear messages presented in an accessible format. Some women reported a desire for lots of detail, while some were experiencing information overload. Phase 2: output development Consultation with HPIG confirmed the authors’ plans to approach midwives with initial findings to gain their input with producing resources to support pregnant women. Midwives were provided with a summary report to guide the consultation process. Midwives agreed that an infographic or brief video would be acceptable for midwives to share, though recognised that as information was changing rapidly, video or written materials could become out-of-date quickly, recommending links to up-to-date information sources. They also recommended producing printable, as well as online, resources to share with women without smartphones/internet access, or for those with limited English who could then access help to read them. The midwives agreed that a more detailed report aimed at midwives would be useful to understand the context of the materials produced. As a result, we distilled women’s main concerns from our findings to enable us to produce materials that could be shared with pregnant women. The aim was to help answer key questions, direct women to credible, up-to-date information resources and to facilitate conversations with midwives, recognising that communication had suffered due to the pandemic impact. The government, NHS and RCOG websites ( 4 , 13 , 16 ) informed the content, and were included as clickable links for women to access as these were trustworthy information sources that were regularly updated as guidance evolved. We took the following main headings based on our rapid analysis and initial report as a basis for an infographic resource and added summary information for each: Why am I clinically vulnerable? What is my risk? Should I go to work? Seeing family and friends? Exercise and going shopping? Are there any antenatal classes? What about my antenatal care? What will happen at the birth? Working iteratively with a graphic designer and consultation with two midwives and two interview participants to refine the content, design and format, we produced an online sharable PDF infographic ( 17 ) – see Fig. 1 , as well as a printable leaflet and poster version and a moving Graphics Interchange Format (GIF) image of the main questions that linked to the online infographic. We also adapted our initial summary into a report for midwives ( 18 ) – see Additional file 4 – to give more context and to communicate the findings that midwives may be able to act on or help with. We circulated the infographic versions and midwife report via email to the maternity services at two local NHS trusts as well as providing printed posters for them to display. We gained feedback that these were well received and were shared across teams. We also shared the infographic with all the women who had expressed an interest in taking part (as well as those who actually took part) in our study and we shared the GIF image and link to the online infographic via social media (Twitter and Facebook) and made these available online ( 19 ). Discussion Summary of findings in the context of literature This study is novel in exploring social distancing behaviour in relation to the Covid-19 pandemic in pregnant women, and is the first to apply the COM-B model ( 5 ) to assess the determinants of this behaviour in this group. We found that women were adhering well to the social distancing guidance, with many going beyond the recommendations to remain safe. Facilitators of social distancing behaviour were women’s perceived ability to adhere to guidelines (psychological capability), strong conscious desire to stay safe and intentions to continue to comply to mitigate risk (reflexive motivation) with fear as a key driver (automatic motivation). Prevailing strong social attitudes and support helped pregnant women enact social distancing (social opportunity), while work support for furlough/home working and home environmental resources, such as access to a garden and nearby open space were reported as helpful (physical opportunity). There was a lack of clarity around the ‘at risk’ category and what it meant which led some to interpret the guidelines to mean they must shield completely, as well as a lack of clarity around relative risk by trimester (psychological capability). This needed to be addressed to help women understand and adhere to what was expected of them, and was included in the infographic we produced (Fig. 1). The strong reflexive motivation to adhere to the guidance and avoid risk in this group is consistent with findings that reflexive motivation was driving Covid-19-related hygiene behaviour in a general UK population ( 8 ). Women experienced a burden of decision-making, balancing relative risks of exposure to Covid-19 against their needs (e.g. getting fresh air/exercise/attending maternity appointments/support needs around labour). A similar quandary existed in grey areas around the guidance; women wanted to adhere to the rules though uncertainty led to risk-based decisions (e.g. whether to go to work/shared parenting management/gaining essential items for the baby). This mirrors recent research showing people are experiencing psychological conflict “between the urge to stay safe and the desire to maintain a normal, pleasurable life” ( 20 ), though for pregnant women, the conflict is more between an urge to stay safe (likely to be stronger than in the general population) and meeting essential needs rather than pleasure, which is a more severe predicament. Several factors made social distancing more challenging. These included lack of access to outdoor space, being unable to access online shopping delivery slots and living alone. Pregnant women in our sample tended to respond by further restricting their lives and suffering the consequences – largely negative mental health effects, which was a cross-cutting theme in our interviews. This adds to the burgeoning literature showing the impact of the pandemic and related policies on the mental health of pregnant women and new mothers ( 21 – 23 ) Beyond the COM-B model, women spontaneously expressed that the loss of maternity care and their anxieties about the birth were their most pressing concerns. UK research ( 24 ) confirms that maternity services have been modified substantially in response to the pandemic with major reduction of services and shifts to remote methods, changes to screening pathways and birth arrangements, calling for more research to understand the impact of these. Concern has been raised about the drastic changes to maternity services to mitigate viral transmission and the resultant reduced capacity of care causing moral injury and impacting the mental health of maternity staff ( 25 ). European research ( 26 ) also highlights the rapid changes to maternity care and calls for research to understand its impact on pregnant women. Our study adds new information about the impact on women of changes to their maternity care, as well as trying to address this issue by providing resources to facilitate midwife-patient conversations and to address women’s key concerns. Strengths and limitations A strength of our study was that it led to practical outputs (infographic and midwife report), developed iteratively with stakeholder input. The outputs were designed to address women’s main concerns identified in our data (clarifying the guidance, addressing risk, maternity care changes, enabling planning and support) and to facilitate conversations between midwives and patients. These gained positive feedback when shared with local maternity services. Other strengths include the diverse sample, robust data collection and analysis procedures and grounding in behaviour change theory (COM-B). This was a rigorous approach to explore the many determinants of social distancing behaviours in pregnant women in the pandemic context, with the COM-B model providing a framework for the themes identified. During data collection and analysis, we deliberately allowed flexibility so that the findings were not constrained by the COM-B model and were therefore able to identify pertinent data-driven themes (e.g. impact on mental health, concerns about loss of maternity care). We had a robust, systematic process for analysis, following framework analysis methods; all interviews were double coded plus codes and themes were checked during regular consultation with the wider team, which included experienced qualitative researchers and health psychologists. Work-related comments within interview data suggested that the sample may have had an overrepresentation of university employees which is a potential limitation. We did not capture occupation on the sampling form, and doing so would have allowed us to sample for a diverse employment range, though several different occupations were mentioned within interviews and we had a good demographic range. The sample was self-selecting, so it is possible that the types of individuals keen to participate in a Covid-19 research study may be more engaged or keen to adhere to guidelines than the population at large. We reached saturation on the main themes, though we may not have reached saturation for the range of issues experienced by sub-groups of participants, e.g. those with a chronic health condition or different ethnicities. Understanding the experiences of pregnant women in these more vulnerable categories would be worth exploring further. Conclusions (Implications for policy and practice) The confusion of what being ‘at risk’ meant and the varying interpretation of what was expected indicated that there needs to be greater clarity around the categories and guidance. Clarity of policy is especially important given the negative mental health effects of isolation, the extra challenges when pregnant, the psychological burden of risk-related decision-making and potential loss of employment in favour of safety. The loss of maternity care is a major concern for women (and the health care professionals that care for them). When combined with the negative mental health impacts of the pandemic and social isolation, there is likely to be a growing area of unmet health needs which will need to be addressed in future – both around the physical health of the mother and baby during pregnancy and in longer-term maternal mental health. While a Lancet paper states that “political leaders must enact quarantine and social distancing policies that do not bias against any population group” ( 27 ), it seems pregnant women are disproportionately affected by social distancing policy, and more resources need to be employed to protect the health and needs of this vulnerable group. Abbreviations BAME Black, Asian and minority ethnic COM-B Capability, Opportunity, Motivation and Behaviour GP General Practitioner HPIG Health Psychology and Interventions Group IMD Index of Multiple Deprivation NHS National Health Service REDCap Research Electronic Data capture RCOG Royal College of Obstetricians and Gynaecologists UK United Kingdom Declarations Ethics approval The study was reviewed and approved (16/04/2020) by the Faculty of Health Sciences Research Ethics Committee at the University of Bristol (reference: 102642). Consent for publication Not applicable Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This work was supported by the Elizabeth Blackwell Institute, University of Bristol, the Wellcome Trust ISSF3 grant 204813/Z/16/Z and the Economic and Social Research Council ES/T501840/1. The funders were not directly involved in the design of the study, the collection, analysis and interpretation of data nor in writing the manuscript. Authors' contributions EA led the study as Principal Investigator. EA, AB, AD and JI conceived the idea for the study. Ethics approval was sought by AB with support from EA, AD and JI. AD led the topic guide development, with support from EA, AD and JI. Data were collected by EA, AB, AD, JI and ES. Analyses were undertaken by EA and AB, and data were interpreted with the support of all authors. AD, EA and JI sought midwife and participant input for infographic development. EA led the manuscript drafting and all authors commented on and approved of the manuscript. Acknowledgements The authors would like to thank the pregnant women who agreed to be interviewed for this study and who contributed to the infographic development. We would also like to thank the midwives at North Bristol NHS Trust and University Hospital Bristol for their contributions to the infographic development and dissemination. Transcription services were provided by Adrienne Dunn. REDCap support was provided by Alison Horne, University of Bristol. Infographic development was provided by Hannah Oakes from Oakshed. References World Health Organization. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) 2020 [updated 30/01/2020. Available from: https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov) . World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19-11 March 2020. 2020. Hsiang S, Allen D, Annan-Phan S, Bell K, Bolliger I, Chong T, et al. The effect of large-scale anti-contagion policies on the COVID-19 pandemic. Nature. 2020;584(7820):262–7. Gov.UK. Coronavirus: stay at home, protect the NHS, save lives 2020 [updated 15/04/2020. Available from: https://www.gov.uk/government/publications/coronavirus-covid-19-information-leaflet/coronavirus-stay-at-home-protect-the-nhs-save-lives-web-version . Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science. 2011;6(1):42. Chater AM, Arden M, Armitage C, Byrne-Davis L, Chadwick P, Drury J, et al., editors. Behavioural science and disease prevention: psychological guidance2020: British Psychological Society. Ellis K, Pears S, Sutton S. Behavioural analysis of postnatal physical activity in the UK according to the COM-B model: a multi-methods study. BMJ open. 2019;9(8):e028682. Gibson Miller J, Hartman TK, Levita L, Martinez AP, Mason L, McBride O, et al. Capability, opportunity, and motivation to enact hygienic practices in the early stages of the COVID-19 outbreak in the United Kingdom. British Journal of Health Psychology. 2020. Centre for Academic Child Health UoB. Pregnant in a Pandemic: The PiP Study 2020 [Available from: http://www.bristol.ac.uk/academic-child-health/research/research/maternal-health/pip-study/ . Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of biomedical informatics. 2009;42(2):377–81. Shaw RL, Bishop FL, Horwood J, Chilcot J, Arden MA. Enhancing the quality and transparency of qualitative research methods in health psychology. British journal of health psychology. 2019;24(4):739–45. Public Health England. Guidance on social distancing for everyone in the UK: Gov.uk; 2020 [Available from: https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults . Royal College of Obstetricians and Gynaecologists. Coronavirus infection and pregnancy 2020 [Available from: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/ . Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC medical research methodology. 2013;13(1):117. University of Bristol. Health Psychology and Interventions Group (HPIG) 2020 [Available from: http://www.bristol.ac.uk/population-health-sciences/research/groups/hpig/ . NHS. Pregnancy and coronavirus 2020 [updated 16 October 2020. Available from: https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/pregnancy-and-coronavirus/ . Pregnant in a Pandemic (Pip) Study team. QUESTIONS ABOUT THE COVID-19 PANDEMIC THAT WORRY PREGNANT WOMEN University of Bristol2020 [Available from: http://www.bristol.ac.uk/media-library/sites/ccah/documents/PDF-pregnant-in-a-pandemic-infographic-uob.pdf . Anderson E, Brigden A, Davies A, Shepherd E, Ingram J. Pregnant in a Pandemic: Summary report for midwives. unpublished (shared via email): University of Bristol; 2020. Anderson E. Pregnant in a Pandemic: The PiP Study: University of Bristol; 2020 [updated 17/09/2020. Available from: . Bacon AM, Corr PJ. Coronavirus (COVID-19) in the United Kingdom: A personality‐based perspective on concerns and intention to self‐isolate. British Journal of Health Psychology. 2020. Dib S, Rougeaux E, Vázquez-Vázquez A, Wells JC, Fewtrell M. The impact of the COVID-19 lockdown on maternal mental health and coping in the UK: Data from the COVID-19 New Mum Study. medRxiv. 2020. Singh P, Goyal M, Singh K, Misra S. COVID-19 and Pregnancy: A Review. Annals of the National Academy of Medical Sciences (India). 2020. Davenport MH, Meyer S, Meah VL, Strynadka MC, Khurana R. Moms are not ok: COVID-19 and maternal mental health. Frontiers in Global Women's Health. 2020;1:1. Jardine J, Relph S, Magee LA, von Dadelszen P, Morris E, Ross-Davie M, et al. Maternity services in the UK during the COVID‐19 pandemic: a national survey of modifications to standard care. BJOG: An International Journal of Obstetrics & Gynaecology. 2020. Horsch A, Lalor J, Downe S. Moral and mental health challenges faced by maternity staff during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy. 2020. Coxon K, Turienzo CF, Kweekel L, Goodarzi B, Brigante L, Simon A, et al. The impact of the Coronavirus (COVID-19) pandemic on maternity care in Europe. Midwifery. 2020. Lewnard JA, Lo NC. Scientific and ethical basis for social-distancing interventions against COVID-19. The Lancet Infectious diseases. 2020;20(6):631. Supplementary Files Additionalfile1Expressionofinterestform.docx Expression of interest form: Form for prospective participants to fill in prior to selection for interview Additionalfile1Expressionofinterestform.docx Expression of interest form: Form for prospective participants to fill in prior to selection for interview Additionalfile2Topicguide.docx Topic guide: Questions to guide semi-structured interviews Additionalfile2Topicguide.docx Topic guide: Questions to guide semi-structured interviews Additionalfile3COMBanalysistablewithquotations.docx Thematic analysis according to the COM-B model (as table 4) with supporting quotations: Table of themes from full analysis including supporting quotations Additionalfile3COMBanalysistablewithquotations.docx Thematic analysis according to the COM-B model (as table 4) with supporting quotations: Table of themes from full analysis including supporting quotations Additionalfile4Summaryreportformidwivesnologo.pdf Pregnant in a Pandemic: Summary report for midwives: Report from initial rapid analysis, produced for maternity staff to accompany dissemination of infographic to two local maternity teams. Additionalfile4Summaryreportformidwivesnologo.pdf Pregnant in a Pandemic: Summary report for midwives: Report from initial rapid analysis, produced for maternity staff to accompany dissemination of infographic to two local maternity teams. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 02 Mar, 2021 Reviewers agreed at journal 07 Jan, 2021 Reviews received at journal 05 Jan, 2021 Reviewers agreed at journal 04 Jan, 2021 Reviewers agreed at journal 04 Jan, 2021 Reviewers agreed at journal 15 Dec, 2020 Reviewers invited by journal 15 Dec, 2020 Editor assigned by journal 15 Dec, 2020 Editor invited by journal 14 Dec, 2020 Submission checks completed at journal 14 Dec, 2020 First submitted to journal 02 Dec, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), and a global pandemic in March 2020 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), due to the highly infectious nature of the disease and related risk of mortality. In the absence of pharmaceutical interventions, key strategies to prevent/limit the spread were mass behavioural measures for infection control (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These measures focused on social distancing behaviours as well as screening/isolation of positive cases and increased hygiene (e.g. handwashing).\u003c/p\u003e \u003cp\u003eThe United Kingdom (UK) government provided such advice to its citizens, and in February gave strong social distancing behavioural advice for everyone to limit travel and contact with others and work from home if possible, though on a voluntary basis. The rapidly changing pandemic context led to the UK government implementing a nationwide social distancing \u0026lsquo;lockdown\u0026rsquo; strategy on 23 March 2020 with the message \u0026ldquo;Stay Home, Protect the NHS [National Health Service], Save lives\u0026rdquo; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The guidance stated that all members of the public should stay at home. Leaving the house was permitted for only four main reasons: shopping for necessities like food and medicine (limited frequency encouraged), to take exercise once per day only, for medical reasons (though people were asked to use telephone/online services where possible) or for essential work or where working from home was not possible (though many workplaces were closed). Social gatherings were not permitted, and when outside, people were to keep at least two metres apart from anyone not in their household. The guidance became law, with police given powers to ensure people followed the rules.\u003c/p\u003e \u003cp\u003eRisk categories and pregnancy\u003c/p\u003e \u003cp\u003eIn mid-March, the government classified pregnant women, along with people aged over 70\u0026nbsp;years and those with certain health conditions as \u0026lsquo;clinically vulnerable\u0026rsquo; or \u0026lsquo;at risk\u0026rsquo; of being more seriously affected by Covid-19, advising them to be particularly strict with following the social distancing behavioural guidelines. The government also classified those with specific medical issues into a further category of \u0026lsquo;extremely clinically vulnerable\u0026rsquo; or \u0026lsquo;very high risk\u0026rsquo;, which included recipients of organ transplants, certain cancers, respiratory illnesses, and pregnant women with heart problems. This latter group were contacted by their General Practitioner (GP) from 23 March 2020 advising them to shield (not leave the house for any reason) for 12 weeks and they gained priority in online supermarket shopping delivery arrangements and volunteer support arrangements.\u003c/p\u003e \u003cp\u003eThe social distancing guidance required unprecedented mass behaviour change, with advice shifting quickly as the pandemic situation progressed. The guidance specifically singled out pregnant women as an at-risk group in this context. To our knowledge, there is no existing research exploring pregnant women\u0026rsquo;s understanding of, and factors related to, the enaction of social distancing behaviours and no interventions designed to support these behaviours in this group.\u003c/p\u003e \u003cp\u003eThe COM-B model\u003c/p\u003e \u003cp\u003eThe British Psychological Society\u0026rsquo;s Behavioural Science and Disease Prevention Taskforce advises using the Capability, Opportunity, Motivation- Behaviour (COM-B) model of behaviour change (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) to understand and facilitate the enactment of preventative behaviours in the context of the pandemic (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The COM-B model proposes that an individual must have sufficient capability, opportunity and motivation in order to enact a behaviour. Capability can be psychological (e.g. knowledge) or physical (e.g. skills); opportunity can be social (e.g. societal norms) or physical (e.g. environmental resources); motivation can be automatic (e.g. emotional and habitual) or reflective (e.g. beliefs and intentions). A COM-B analysis of determinants of behaviour can be used to diagnose deficient components to identify intervention targets to improve adherence to behavioural guidance.\u003c/p\u003e \u003cp\u003eCOM-B has been successfully used in comparable research to explore the determinants of exercise uptake in new mothers to produce recommendations for how to improve physical activity (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), and in the context of the Covid-19 pandemic for exploring determinants of hand-washing behaviour in the general population to inform intervention development (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAims\u003c/p\u003e \u003cp\u003eThis project aimed to explore pregnant women\u0026rsquo;s understanding of the behavioural restrictions and their perceived ability to comply, as well as the most concerning impacts of the measures. The overall aim was to develop and disseminate recommendations/materials to help pregnant women understand and adhere to the social distancing guidance.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003ePhase 1: COM-B analysis\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis was a qualitative interview study informed by the COM-B model (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), designed to explore pregnant women\u0026rsquo;s perceived capability, opportunity and motivation to follow the guidance on social distancing behaviours, and to identify barriers to, and facilitators of, these behaviours.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment and sampling\u003c/h2\u003e \u003cp\u003eWomen were invited opportunistically to express interest in taking part via The Bristol Post (local news media), university communications team, social media (Twitter and Facebook) and via local radio feature. In an attempt to increase ethnic diversity in the sample, Ujima Radio was targeted (a station for African-Caribbean and other BME communities) for study promotion, as well as community groups for Black, Asian and minority ethnic (BAME) groups on Twitter (e.g. Barton Hill/ Wellspring settlement, Ujima radio Twitter group). A statement was added to the study website to encourage women from BAME groups to participate in the study.\u003c/p\u003e \u003cp\u003eParticipants were directed to the participant information sheet and an online expression of interest form, hosted on a study website (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Respondents were asked to provide their contact details and demographic characteristics for eligibility checking and sampling (see \u003cem\u003eAdditional file 1\u003c/em\u003e) and consent for a researcher to contact them to discuss the study. This form was captured on the Research Electronic Data capture (REDCap) system (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), a secure online data capture system designed exclusively for research studies. Information included the offer of \u0026pound;10 online shopping voucher for participating.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInclusion and exclusion criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInclusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExclusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnant women (any stage of pregnancy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo longer pregnant at time of interview\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccess to telephone/ videocall facility and internet (for expression of interest form and receipt of online consent form)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo access to telephone/videocall facility/ internet\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome address in Bristol or immediate surrounding counties (North Somerset/West Wiltshire/South Gloucester)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome address outside Bristol/immediate surrounding counties.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAged at least 18\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAged less than 18\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnglish-speaking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnable to speak/understand English.*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProvision of informed consent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen lacking capacity to provide informed consent (determined during phone/videocall prior to interview)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003e* While it would have been preferable to have an option to include non-English speakers, limited resources and rapid timeline prevented us from offering translation services.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEligible participants were pregnant women of any gestation, living in Bristol and the surrounding area, aged 18 or above (for full eligibility criteria see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Purposive sampling was applied to the pool of potentially eligible women who completed an expression of interest form, aiming for maximum diversity according to participant age, ethnicity, Index of Multiple Deprivation (IMD) by home postcode, gestation, and avoiding over-representation of those with medical/nursing training. Those selected were contacted by email, provided with a participant information sheet and invited to a research interview. A telephone/video call (depending on preference) was arranged for women wishing to participate, who were sent a link to an online consent form (captured on REDCap). At the start of each interview, the interviewer provided verbal information about the study, answered questions, and made final eligibility checks, ensuring informed consent was complete before proceeding to interview.\u003c/p\u003e \u003cp\u003eThe aim was to recruit 30 pregnant women, aiming for data saturation of key COM-B model themes to answer the research question (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eQualitative interviews followed a topic guide structured around the COM-B model (See \u003cem\u003eAdditional file 2\u003c/em\u003e). Additional questions (outside of the COM-B model) asked participants: \u0026lsquo;What information would you find helpful and who would you like to hear it from?\u0026rsquo; and; \u0026lsquo;Are there some other comments you would like to make on what we have talked about today?\u0026rsquo;. Interviews were conducted by all five authors, who have expertise in qualitative research, a background/interest in health psychology and interventions and an understanding of the COM-B model of behaviour change. Interviews were designed to last 30 minutes and were audio-recorded. Detailed interview notes were taken during or immediately after interviews using a structured template. On interview completion, participants were provided with emailed links to up-to-date social distancing guidelines (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and a \u0026pound;10 online shopping voucher. Audio-recordings were professionally transcribed verbatim, and transcripts were pseudonymised before full analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eFramework analysis was applied to the data, following the seven steps outlined in Gale \u003cem\u003eet al\u003c/em\u003e (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), which began with a rapid analysis of main themes (concurrent with data collection) prior to detailed analysis, as described in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Framework analysis was appropriate as the aim was specifically to identify subthemes within the COM-B model as a diagnostic framework to generate recommendations to help pregnant women follow government advice on social distancing behaviours. All transcripts were independently double-coded (by EA and AB) to ensure reliability, and discrepancies were resolved through discussion.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFramework Analysis (seven step) method\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 1.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTranscription\u003c/span\u003e: Audio recordings were transcribed verbatim and pseudonymised. Detailed notes were taken by each interviewer (all authors), structured around the COM-B framework and additional questions.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFamiliarisation with the interview\u003c/span\u003e: Two authors (EA and AB) familiarised themselves with each interview by reviewing the detailed interview notes, and full transcript when available.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 3.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCoding\u003c/span\u003e: EA and AB developed a matrix in an excel file, with columns representing each component of the COM-B framework plus the extra questions, and rows representing each participant. The initial rapid coding process involved systematically reading (and re-reading) the interview notes (and full transcripts where available) for each participant, assigning data to the relevant COM-B and extra question headings and identifying key subthemes within each component. Notes were made on relevant data which did not fit into the COM-B framework as potential inductive themes.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 4.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDeveloping a working analytical framework\u003c/span\u003e: EA and AB met on two occasions to discuss in detail the findings for each participant (row) and the themes identified (column) as enabled by the framework analysis matrix, to agree the key themes, and produced a report of the initial findings.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 5.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eApplying the analytical framework\u003c/span\u003e: All full transcripts were imported into NVivo and the nodes function was used to set up the analytical framework established in step 4. Each transcript was coded by systematically assigning data to a node in the analytical framework. Authors swapped transcripts for coding so that all interviews were double coded.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 6.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCharting data\u003c/span\u003e: Drawing on the full analysis in NVivo, EA created a table of the key themes with illustrative quotes, and reviewed it with all authors.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 7.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eInterpreting the data\u003c/span\u003e: During regular team meetings (10 meetings over the analysis phase), and via circulation of written materials, impressions and interpretations of the data, coding and the analytical framework were discussed and agreed. Rather than being a final stage, this process was ongoing throughout the analysis process.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePhase 2: Developing outputs\u003c/p\u003e \u003cp\u003eA report from our initial rapid analysis (stage 4, Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) identified key themes that were important to address in output/materials that could be used to support pregnant women during the pandemic. The stages outlined below were carried out with the aim of establishing what materials were needed, to whom they should be directed, and the appropriate delivery format/mode. Design and refinement of materials followed an iterative process involving stakeholders (community midwives, pregnant women, graphic designer).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStage 1: Consultation with expert group\u003c/h2\u003e \u003cp\u003eThe team consulted the University of Bristol\u0026rsquo;s Health Psychology and Interventions Group (HPIG) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), presenting the initial findings and discussing next steps for informational output.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStage 2: Establishing outputs and delivery format\u003c/h2\u003e \u003cp\u003eA single online meeting was conducted between study team members and two community midwifery staff from one NHS trust. A community midwife from a second NHS trust was separately consulted via email. This pragmatic approach was taken due to difficulties in convening staff during a busy period involving unusual working practices. Midwives were presented with the brief report of interview findings and were asked for their views about how the findings could be usefully conveyed to support women and midwives, and to whom those materials should be targeted (staff vs. women). Midwives were offered suggestions of mode of delivery of information including written materials, materials for a website and/or a video.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStage 2: Iterative design process\u003c/h2\u003e \u003cp\u003eFollowing identification of the most appropriate target and modes of information delivery, the planned materials were developed iteratively with the assistance of a graphic designer (Oakshed.co.uk). Feedback was gained electronically from two pregnant women who had participated in the interviews, and community midwifery staff. Materials were checked for utility, clarity, content, format, layout, and colours used. Further iterations were reviewed by the research team in collaboration with the graphic designer to optimise appearance and functionality of the materials.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003eNinety-five women expressed an interest in participation, of whom 83 were eligible and 31 were selectively sampled (aiming for demographic diversity) and interviewed between 24 April\u0026ndash;4 May 2020. Participant characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, which includes information on parity collected within interviews. Of the 31 women in the sample, 20 were primiparous; the age range was 24\u0026ndash;48\u0026nbsp;years (mean 33), at the time of interview parity ranged from 10\u0026ndash;39 weeks (mean 24). Every IMD level (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) was represented and the ethnicity of our sample was: 24 White British, 1 White European, 2 Asian, 1 Black, 3 mixed. Two had medical/nursing training.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsent ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIMD \u003c/p\u003e \u003cp\u003e(from home post-code)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGestation at time of interview* (weeks)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCurrent age*\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eDo you have children already?**\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026ndash;27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u0026ndash;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u0026ndash;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u0026ndash;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u0026ndash;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u0026ndash;32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u0026ndash;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u0026ndash;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u0026ndash;33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u0026ndash;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u0026ndash;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u0026ndash;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003e* Participant data presented as a range to preserve anonymity\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003e**information collected during interview. All other demographic information in this table was collected within the expression of interest form to inform sample selection.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe rapid analysis and team discussions during data collection indicated that reasonable data saturation for the COM-B framework themes was reached in our sample, as well as for the main additional themes, indicating that our sample was adequate and further recruitment was unnecessary.\u003c/p\u003e \u003cp\u003ePhase 1: Qualitative interviews: COM-B analysis and main themes\u003c/p\u003e \u003cp\u003eAn overview of the main themes identified are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. For the full analysis table with supporting quotations, see \u003cem\u003eAdditional file 3.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of thematic analysis according to the COM-B model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOM-B category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThemes identified\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eBEHAVIOUR\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSocial distancing\u003c/p\u003e \u003cp\u003e(in accordance with guidelines)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdhering\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore extreme\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSlight deviations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eCAPABLITY \u0026ndash; The individual\u0026rsquo;s physical and psychological capability to engage in the behaviour(s)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePsychological capability\u003c/p\u003e \u003cp\u003e(understanding/ mental processes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge and understanding of guidance around social distancing behaviours\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfidence in ability to enact social distancing behaviours\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical capability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical capability had little impact on social distancing behaviour\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eOPPORTUNITY \u0026ndash; Environmental factors influencing the behaviour(s)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSocial opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial norms to comply with social distancing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousehold composition impacts on ability to enact social distancing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial distancing compromised by strangers in public spaces\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePhysical opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImpacts of home environment and resources\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWork environment/ ability to work from home\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShopping for essentials including preparation for the baby\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthcare appointments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eMOTIVATION \u0026ndash; Individual internal factors that direct the behaviour(s)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eReflexive motivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMotivated to adhere to social distancing guidelines\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstablishment of routines to enable social distancing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntentions to continue to adhere to guidelines\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisks and balance of risks to determine behaviour\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAutomatic motivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional drivers of social distancing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutomatic behaviours\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eBeyond COM-B: cross-cutting themes\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIsolation, mental health, and loss of maternity care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIsolation and mental health impacts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLoss of maternity care \u0026ndash; communication issues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLoss of maternity care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBehaviour\u003c/h2\u003e \u003cp\u003eWomen reported that they were adhering to the social distancing guidance to the best of their abilities, describing staying home as much as possible, limiting shopping trips, not allowing others in the house, going outside no more than once per day and staying at least two metres away from others when out. Many were taking extra precautions such as limiting their healthcare appointments and engaging in other behaviours that did not relate to social distancing but that aimed to reduce risk of exposure to Covid 19. These included washing and quarantining shopping, quarantining post or asking partners to do this before items came into the house. Six women in our sample were shielding (not leaving the house at all): one due to extra health issues that increased her risk from Covid-19 (though she had not received a letter from her GP to facilitate her \u0026lsquo;extremely clinically vulnerable\u0026rsquo; status); one to protect a member of her household who was in the \u0026lsquo;extremely clinically vulnerable\u0026rsquo; category due to health issues; three others were shielding believing this was the requirement when pregnant. Women reported few instances of breaching the social distancing rules, and breaches were minimal and carefully considered, for example one woman drove a short distance to take exercise safely, one reported her parents and her households went into isolation for safety prior to moving in together for support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePsychological Capability\u003c/h2\u003e \u003cp\u003eWomen reported making efforts to access \u0026ldquo;credible\u0026rdquo; and \u0026ldquo;reputable\u0026rdquo; sources for information. These included: government advice, BBC (British Broadcasting Corporation) news, Royal College of Obstetricians and Gynaecologists (RCOG)/ midwives, NHS, pregnancy apps/emails (e.g. Bounty), Tommy\u0026rsquo;s (online), some social media groups, select social contacts, scientific sources, and newspapers.\u003c/p\u003e \u003cp\u003eWhile the women in our sample mainly reported feeling able and confident that they could adhere to the guidelines and showed good understanding about what was expected of them, women reported a lack of clarity about what it meant to be in an \u0026ldquo;at risk\u0026rdquo; category, or why pregnant women were placed in it. Some women felt it was a precaution and many wanted more information about the rationale and what it meant. Uncertainty around the risk category was evident in women\u0026rsquo;s different interpretations of what was expected of them: some interpreted it as requiring them to shield due to the \u0026lsquo;at risk\u0026rsquo; status of being pregnant, while others stated that the guidance was no different for pregnant women from the rest of the population. Many women felt the advice was confusing at first, though seemed clearer by the time of interview. Some details of the behavioural recommendations remained unclear, such as how to handle shared parenting between households, how to stay safe at work for those not working from home/ furloughed and whether to attend healthcare appointments for minor issues.\u003c/p\u003e \u003cp\u003eOne aspect of psychological capability was the emotional ability to adhere to social distancing. While some women reported positive experiences about lockdown (e.g. enjoying extra time at home with their family), many reported feeling isolated, low, and suffering loss of joy, which impacted on their perceived ability to sustain the behaviour. This was particularly acute when living alone and fully shielding.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePhysical Capability\u003c/h2\u003e \u003cp\u003ePersonal physical abilities had little relevance to adhering to social distancing recommendations. Interviews revealed only one example (a woman reported that due to being pregnant she struggled to lift her toddler to stop the child running close to others when outside).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSocial Opportunity\u003c/h2\u003e \u003cp\u003eWomen in our sample reported strong support from their immediate social circle to adhere to the social distancing guidelines, citing examples of friends, family and partners being strict about keeping them safe, particularly because of being pregnant. Women also described general social norms with \u0026lsquo;everyone\u0026rsquo; adhering to the social distancing guidelines, or people generally expecting them to stay away (e.g. from work) due to being pregnant, with several reporting gaining priority in their organisation\u0026rsquo;s home working or furlough schemes. By contrast some women reported a minority of friends or family who did not adhere to the rules, though this did not seem to influence their own social distancing behaviours. Women chose to reaffirm and explain the rules or keep a distance, with one participant reporting losing friends over this.\u003c/p\u003e \u003cp\u003eThe household composition had a significant impact on women\u0026rsquo;s ability to maintain social distance. Many reported having supportive partners who were taking care of practical tasks to keep them safe, or other family members in the house who upheld social distancing practices. Others\u0026rsquo; household composition brought added risks or challenges, such as co-parenting teenagers across two households, having to take small children to nursery, coping with the risks of other household members going out to work, or living alone, which made social distancing challenging both emotionally and practically.\u003c/p\u003e \u003cp\u003eWhile women reported being mindful of staying at least two metres away from others when out of the house, many commented on not being able to control other people when outside, giving examples of people coming too close, with some women wishing for a visible sign that they were \u0026lsquo;at risk\u0026rsquo; to warn people to stay away.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePhysical Opportunity\u003c/h2\u003e \u003cp\u003eThere were multiple physical opportunity determinants of social distancing behaviour reported in our sample. Home environment and access to resources had a key impact on women\u0026rsquo;s ability to maintain social distancing. Participants recognised how lucky they were for the resources they had, for example access to a garden or local green space, exercise equipment at home, a car to avoid public transport, or for digital technology to enable them to stay in contact with people. Those in small flats or without gardens commented on how challenging it was to maintain social distancing and these women were hugely limiting their lives to adhere to the guidance and suffering negative mental health effects.\u003c/p\u003e \u003cp\u003eThe ability to work from home enabled many women in our sample to maintain social distancing. Most felt these arrangements had been prioritised for them due to being pregnant. By contrast, one woman employed by the NHS reported having to push for changes to their work environment and responsibilities to reduce her contact with patients, and some chose to continue going to work if they could not work from home and judged the risk to be relatively low. Several women worried about future relaxing of the guidance (lockdown ending) meaning they may be expected to return to the workplace. Some women who were unable to work from home chose to leave work, taking sick leave or early maternity leave to enable them to stay at home. These women reported potentially facing financial consequences rather than put themselves at risk, though mortgage holidays, furlough schemes and workplace financial support made these decisions easier.\u003c/p\u003e \u003cp\u003eShopping for essentials was an important behaviour for which it was challenging for women to adhere to social distancing behaviours. Many commented on being unable to gain online shopping slots. Many relied on their partner or family members to do regular food shopping or reported having to go themselves, which made them feel unsafe. Though one woman, who expressed less anxiety than most, reported that going out for the weekly shopping was the highlight of her week. One woman who was single and shielding reported that she was growing her own vegetables due to difficulties getting fresh food. Several women mentioned the difficulty with preparing for the coming baby \u0026ndash; being unable to buy baby items from shops, online shops being out of stock, and having to consider how to manage handover of baby items from family members in a socially distanced way.\u003c/p\u003e \u003cp\u003eHealthcare appointments were also a key source of concern when it came to social distancing. Women worried about whether they would be able to maintain distance when attending clinics and some chose to limit visits. Labour itself was a source of concern in this context, with women knowing that they would be unable to maintain social distancing and worrying about it, with single women needing someone to take them to hospital. Some reported that antenatal appointments were the only times they had contact with other people and felt that their social distancing abilities were compromised by needing to attend appointments. For women with other children they had to consider how to manage childcare, with one commenting that she would ask a relative to shield for two weeks prior to her maternity appointment to facilitate childcare. Most participants acknowledged that changes to maternity care had been put in place to enable social distancing, mentioning more telephone consultations, limited face-to-face time, staff wearing personal protective equipment (e.g. masks), spacing out waiting areas or enabling women to wait in their car to be called in to their appointment. Women also reported that partners were not permitted to attend appointments as a social distancing measure and antenatal classes had been cancelled for the same reason. Some women sought alternatives online.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eReflexive Motivation\u003c/h2\u003e \u003cp\u003eDespite some of the challenges identified above, there was strong motivation to adhere to social distancing guidelines in our sample, with women adhering closely to the behavioural restrictions and many taking extra precautions. Women cited the safety of themselves and their baby as motivating factors as well as social responsibility motives around protecting others, protecting the NHS and stopping the spread of the virus. Some women talked about having a lower immune system during pregnancy which makes them more susceptible to infections; many expressed particularly high motivation to avoid the virus near the birth. Some women mentioned their own higher risk status, such as a higher risk ethnicity or having comorbidities which made it even more important to adhere to the rules. No-one reported being motivated by the law or police sanctions. Many women talked about having consciously established routines to enable the maintenance of the new social distancing lifestyle as well as to maintain sanity during lockdown.\u003c/p\u003e \u003cp\u003eWhen asked about their intentions to continue with social distancing behaviours, most women in our sample described their plans to continue with adhering to the behavioural advice, some wanting to continue with the current stringent measures if the lockdown was to ease, especially when nearing the time of birth. The birth event itself was pivotal, with some wanting to continue to maintain social distance afterwards to protect their new-born baby, and others expressing a need to \u0026lsquo;break the rules\u0026rsquo; to gain support with the new-born baby or see people, weighing up the relative risks of this decision.\u003c/p\u003e \u003cp\u003eDecision-making and planning around social distancing behaviours often involved weighing up relative risks. Women described difficult decisional processes such as being unsure whether it was safer to attend the midwife appointment or avoid it, or whether risks of exposure outweighed the mental and physical health effects of outdoor exercise. This was compounded by a lack of understanding around the reasons for being in the \u0026lsquo;at risk\u0026rsquo; group (as described in psychological capability, above). Planning arrangements around the birth were particularly fraught in this respect as women grappled with how to plan for a parent to come and help look after their existing children when they went into labour or to support them with the new-born after the birth, or if their partner became ill.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eAutomatic Motivation\u003c/h2\u003e \u003cp\u003eFear was identified throughout interviews as a motivating factor for adhering to social distancing guidance. Fears focused on worries about catching Covid-19 near the birth date, or the partner becoming ill, as well as general risk to self and baby. Other emotional drivers of social distancing included guilt or an anticipated guilt of catching the virus due to going out, especially compounded by a sense that women felt capable of adhering to the rules. Conversely, the sadness and low mood some women experienced from their social isolation posed a challenge to adherence.\u003c/p\u003e \u003cp\u003eUnconscious processes and automatic behaviours are difficult to assess in a reflective interview, though some women reported that they were now automatically enacting social distancing and other protective behaviours (e.g. keeping away from strangers, handwashing and washing shopping).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eBeyond COM-B: Isolation, mental health and loss of maternity care:\u003c/h2\u003e \u003cp\u003eWhile some positive aspects of following the social distancing guidance were identified by women in our sample, such as spending more time with their immediate family or enjoying working from home, there were significant negative impacts, mainly the social isolation and negative mental health, which came out strongly across interviews. Pregnant women living alone (or only with small children) were particularly vulnerable to isolation and mental health effects. Pregnancy was seen as a time when women would normally seek out connection with others (friends, family, other pregnant women). In this context, the isolation and loss of social contact during pregnancy was experienced as an acute loss.\u003c/p\u003e \u003cp\u003eA major concern for most of our participants was the loss of maternity care, and while they recognised that midwives were doing their best in a very difficult situation, many had experienced not only a loss of care, but a lack of communication about the changes to their healthcare, with some reporting that midwives have been \u0026lsquo;hard to get hold of\u0026rsquo;. The loss was particularly acute for women in their first pregnancy, who did not know what they were missing out on.\u003c/p\u003e \u003cp\u003eWhile some women felt well supported by their midwives, many reported cancelled appointments and classes, face-to-face appointments feeling rushed and stressed and feeling unable to ask questions or share positive emotions. Telephone appointments felt less personal, more removed. Women were particularly troubled that partners were not able to come to the scan appointments, experiencing this as an acute loss, with one worrying about the impact on partner-child bonding. They also felt acutely the loss of antenatal classes \u0026ndash; for the important information they were missing out on and the chance to meet other pregnant women. Women wanted ways of replacing these losses, with some mentioning paying for digital antenatal classes, while others simply had no access.\u003c/p\u003e \u003cp\u003eMany women were acutely worried about what the birth would be like, and whether their partner could be with them. These concerns about maternity care were stronger than concerns about Covid-19 itself for many of the women in our sample.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eWhat information did women want?\u003c/h2\u003e \u003cp\u003eWhile recognising that services were doing their best in a difficult time, women expressed a need for more time, support and reassurance from midwives. Women wanted to know more information about their Covid-19 related risk during pregnancy (e.g. why were they in the vulnerable category, what relative risk was associated with each trimester, what is the evidence), their personal risk factors (e.g. comorbidities, ethnicity), clarity on aspects of the guidelines and clarity on changes to their maternity care. Women wanted written information from credible sources, with clear messages presented in an accessible format. Some women reported a desire for lots of detail, while some were experiencing information overload.\u003c/p\u003e \u003cp\u003ePhase 2: output development\u003c/p\u003e \u003cp\u003eConsultation with HPIG confirmed the authors\u0026rsquo; plans to approach midwives with initial findings to gain their input with producing resources to support pregnant women. Midwives were provided with a summary report to guide the consultation process. Midwives agreed that an infographic or brief video would be acceptable for midwives to share, though recognised that as information was changing rapidly, video or written materials could become out-of-date quickly, recommending links to up-to-date information sources. They also recommended producing printable, as well as online, resources to share with women without smartphones/internet access, or for those with limited English who could then access help to read them. The midwives agreed that a more detailed report aimed at midwives would be useful to understand the context of the materials produced.\u003c/p\u003e \u003cp\u003eAs a result, we distilled women\u0026rsquo;s main concerns from our findings to enable us to produce materials that could be shared with pregnant women. The aim was to help answer key questions, direct women to credible, up-to-date information resources and to facilitate conversations with midwives, recognising that communication had suffered due to the pandemic impact. The government, NHS and RCOG websites (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) informed the content, and were included as clickable links for women to access as these were trustworthy information sources that were regularly updated as guidance evolved. We took the following main headings based on our rapid analysis and initial report as a basis for an infographic resource and added summary information for each: \u003cem\u003eWhy am I clinically vulnerable? What is my risk? Should I go to work? Seeing family and friends? Exercise and going shopping? Are there any antenatal classes? What about my antenatal care? What will happen at the birth?\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWorking iteratively with a graphic designer and consultation with two midwives and two interview participants to refine the content, design and format, we produced an online sharable PDF infographic (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) \u0026ndash; see \u003cem\u003eFig.\u0026nbsp;1\u003c/em\u003e, as well as a printable leaflet and poster version and a moving Graphics Interchange Format (GIF) image of the main questions that linked to the online infographic. We also adapted our initial summary into a report for midwives (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) \u0026ndash; see \u003cem\u003eAdditional file 4\u003c/em\u003e \u0026ndash; to give more context and to communicate the findings that midwives may be able to act on or help with. We circulated the infographic versions and midwife report via email to the maternity services at two local NHS trusts as well as providing printed posters for them to display. We gained feedback that these were well received and were shared across teams. We also shared the infographic with all the women who had expressed an interest in taking part (as well as those who actually took part) in our study and we shared the GIF image and link to the online infographic via social media (Twitter and Facebook) and made these available online (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSummary of findings in the context of literature\u003c/p\u003e \u003cp\u003eThis study is novel in exploring social distancing behaviour in relation to the Covid-19 pandemic in pregnant women, and is the first to apply the COM-B model (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) to assess the determinants of this behaviour in this group. We found that women were adhering well to the social distancing guidance, with many going beyond the recommendations to remain safe. Facilitators of social distancing behaviour were women\u0026rsquo;s perceived ability to adhere to guidelines (psychological capability), strong conscious desire to stay safe and intentions to continue to comply to mitigate risk (reflexive motivation) with fear as a key driver (automatic motivation). Prevailing strong social attitudes and support helped pregnant women enact social distancing (social opportunity), while work support for furlough/home working and home environmental resources, such as access to a garden and nearby open space were reported as helpful (physical opportunity). There was a lack of clarity around the \u0026lsquo;at risk\u0026rsquo; category and what it meant which led some to interpret the guidelines to mean they must shield completely, as well as a lack of clarity around relative risk by trimester (psychological capability). This needed to be addressed to help women understand and adhere to what was expected of them, and was included in the infographic we produced (Fig.\u0026nbsp;1). The strong reflexive motivation to adhere to the guidance and avoid risk in this group is consistent with findings that reflexive motivation was driving Covid-19-related hygiene behaviour in a general UK population (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWomen experienced a burden of decision-making, balancing relative risks of exposure to Covid-19 against their needs (e.g. getting fresh air/exercise/attending maternity appointments/support needs around labour). A similar quandary existed in grey areas around the guidance; women wanted to adhere to the rules though uncertainty led to risk-based decisions (e.g. whether to go to work/shared parenting management/gaining essential items for the baby). This mirrors recent research showing people are experiencing psychological conflict \u0026ldquo;between the urge to stay safe and the desire to maintain a normal, pleasurable life\u0026rdquo; (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), though for pregnant women, the conflict is more between an urge to stay safe (likely to be stronger than in the general population) and meeting \u003cem\u003eessential needs\u003c/em\u003e rather than pleasure, which is a more severe predicament.\u003c/p\u003e \u003cp\u003eSeveral factors made social distancing more challenging. These included lack of access to outdoor space, being unable to access online shopping delivery slots and living alone. Pregnant women in our sample tended to respond by further restricting their lives and suffering the consequences \u0026ndash; largely negative mental health effects, which was a cross-cutting theme in our interviews. This adds to the burgeoning literature showing the impact of the pandemic and related policies on the mental health of pregnant women and new mothers (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBeyond the COM-B model, women spontaneously expressed that the loss of maternity care and their anxieties about the birth were their most pressing concerns. UK research (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) confirms that maternity services have been modified substantially in response to the pandemic with major reduction of services and shifts to remote methods, changes to screening pathways and birth arrangements, calling for more research to understand the impact of these. Concern has been raised about the drastic changes to maternity services to mitigate viral transmission and the resultant reduced capacity of care causing moral injury and impacting the mental health of maternity staff (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). European research (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) also highlights the rapid changes to maternity care and calls for research to understand its impact on pregnant women. Our study adds new information about the impact on women of changes to their maternity care, as well as trying to address this issue by providing resources to facilitate midwife-patient conversations and to address women\u0026rsquo;s key concerns.\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eA strength of our study was that it led to practical outputs (infographic and midwife report), developed iteratively with stakeholder input. The outputs were designed to address women\u0026rsquo;s main concerns identified in our data (clarifying the guidance, addressing risk, maternity care changes, enabling planning and support) and to facilitate conversations between midwives and patients. These gained positive feedback when shared with local maternity services. Other strengths include the diverse sample, robust data collection and analysis procedures and grounding in behaviour change theory (COM-B). This was a rigorous approach to explore the many determinants of social distancing behaviours in pregnant women in the pandemic context, with the COM-B model providing a framework for the themes identified. During data collection and analysis, we deliberately allowed flexibility so that the findings were not constrained by the COM-B model and were therefore able to identify pertinent data-driven themes (e.g. impact on mental health, concerns about loss of maternity care). We had a robust, systematic process for analysis, following framework analysis methods; all interviews were double coded plus codes and themes were checked during regular consultation with the wider team, which included experienced qualitative researchers and health psychologists.\u003c/p\u003e \u003cp\u003eWork-related comments within interview data suggested that the sample may have had an overrepresentation of university employees which is a potential limitation. We did not capture occupation on the sampling form, and doing so would have allowed us to sample for a diverse employment range, though several different occupations were mentioned within interviews and we had a good demographic range. The sample was self-selecting, so it is possible that the types of individuals keen to participate in a Covid-19 research study may be more engaged or keen to adhere to guidelines than the population at large. We reached saturation on the main themes, though we may not have reached saturation for the range of issues experienced by sub-groups of participants, e.g. those with a chronic health condition or different ethnicities. Understanding the experiences of pregnant women in these more vulnerable categories would be worth exploring further.\u003c/p\u003e "},{"header":"Conclusions","content":"\u003cp\u003e(Implications for policy and practice)\u003c/p\u003e \u003cp\u003eThe confusion of what being \u0026lsquo;at risk\u0026rsquo; meant and the varying interpretation of what was expected indicated that there needs to be greater clarity around the categories and guidance. Clarity of policy is especially important given the negative mental health effects of isolation, the extra challenges when pregnant, the psychological burden of risk-related decision-making and potential loss of employment in favour of safety. The loss of maternity care is a major concern for women (and the health care professionals that care for them). When combined with the negative mental health impacts of the pandemic and social isolation, there is likely to be a growing area of unmet health needs which will need to be addressed in future \u0026ndash; both around the physical health of the mother and baby during pregnancy and in longer-term maternal mental health. While a \u003cem\u003eLancet\u003c/em\u003e paper states that \u0026ldquo;political leaders must enact quarantine and social distancing policies that do not bias against any population group\u0026rdquo; (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), it seems pregnant women are disproportionately affected by social distancing policy, and more resources need to be employed to protect the health and needs of this vulnerable group.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eBAME Black, Asian and minority ethnic\u003c/p\u003e \u003cp\u003eCOM-B Capability, Opportunity, Motivation and Behaviour\u003c/p\u003e \u003cp\u003eGP General Practitioner\u003c/p\u003e \u003cp\u003eHPIG Health Psychology and Interventions Group\u003c/p\u003e \u003cp\u003eIMD Index of Multiple Deprivation\u003c/p\u003e \u003cp\u003eNHS National Health Service\u003c/p\u003e \u003cp\u003eREDCap Research Electronic Data capture\u003c/p\u003e \u003cp\u003eRCOG Royal College of Obstetricians and Gynaecologists\u003c/p\u003e \u003cp\u003eUK United Kingdom\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch3\u003eEthics approval\u003c/h3\u003e\n\u003ch3\u003eThe study was reviewed and approved (16/04/2020) by the Faculty of Health Sciences Research Ethics Committee at the University of Bristol (reference: 102642).\u003c/h3\u003e\n\u003ch3\u003e\u0026nbsp;\u003c/h3\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThis work was supported by the Elizabeth Blackwell Institute, University of Bristol, the Wellcome Trust ISSF3 grant\u0026nbsp;204813/Z/16/Z and\u0026nbsp;the Economic and Social Research Council ES/T501840/1. The funders were not directly involved in the design of the study, the collection, analysis and interpretation of data nor in writing the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAuthors' contributions\u003c/h3\u003e\n\u003cp\u003eEA led the study as Principal Investigator. EA, AB, AD and JI conceived the idea for the study. Ethics approval was sought by AB with support from EA, AD and JI.\u0026nbsp; AD led the topic guide development, with support from EA, AD and JI. Data were collected by EA, AB, AD, JI and ES. Analyses were undertaken by EA and AB, and data were interpreted with the support of all authors. AD, EA and JI sought midwife and participant input for infographic development. EA led the manuscript drafting and all authors commented on and approved of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThe authors would like to thank the pregnant women who agreed to be interviewed for this study and who contributed to the infographic development. We would also like to thank the midwives at North Bristol NHS Trust and University Hospital Bristol for their contributions to the infographic development and dissemination.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTranscription services were provided by Adrienne Dunn. REDCap support was provided by Alison Horne, University of Bristol. Infographic development was provided by Hannah Oakes from Oakshed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) 2020 [updated 30/01/2020. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19-11 March 2020. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsiang S, Allen D, Annan-Phan S, Bell K, Bolliger I, Chong T, et al. The effect of large-scale anti-contagion policies on the COVID-19 pandemic. Nature. 2020;584(7820):262\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGov.UK. Coronavirus: stay at home, protect the NHS, save lives 2020 [updated 15/04/2020. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.uk/government/publications/coronavirus-covid-19-information-leaflet/coronavirus-stay-at-home-protect-the-nhs-save-lives-web-version\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMichie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science. 2011;6(1):42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChater AM, Arden M, Armitage C, Byrne-Davis L, Chadwick P, Drury J, et al., editors. Behavioural science and disease prevention: psychological guidance2020: British Psychological Society.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEllis K, Pears S, Sutton S. Behavioural analysis of postnatal physical activity in the UK according to the COM-B model: a multi-methods study. BMJ open. 2019;9(8):e028682.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGibson Miller J, Hartman TK, Levita L, Martinez AP, Mason L, McBride O, et al. Capability, opportunity, and motivation to enact hygienic practices in the early stages of the COVID-19 outbreak in the United Kingdom. British Journal of Health Psychology. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCentre for Academic Child Health UoB. Pregnant in a Pandemic: The PiP Study 2020 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.bristol.ac.uk/academic-child-health/research/research/maternal-health/pip-study/\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)\u0026mdash;a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of biomedical informatics. 2009;42(2):377\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaw RL, Bishop FL, Horwood J, Chilcot J, Arden MA. Enhancing the quality and transparency of qualitative research methods in health psychology. British journal of health psychology. 2019;24(4):739\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePublic Health England. Guidance on social distancing for everyone in the UK: Gov.uk; 2020 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoyal College of Obstetricians and Gynaecologists. Coronavirus infection and pregnancy 2020 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC medical research methodology. 2013;13(1):117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUniversity of Bristol. Health Psychology and Interventions Group (HPIG) 2020 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.bristol.ac.uk/population-health-sciences/research/groups/hpig/\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS. Pregnancy and coronavirus 2020 [updated 16 October 2020. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/pregnancy-and-coronavirus/\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePregnant in a Pandemic (Pip) Study team. QUESTIONS ABOUT THE COVID-19 PANDEMIC THAT WORRY PREGNANT WOMEN University of Bristol2020 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.bristol.ac.uk/media-library/sites/ccah/documents/PDF-pregnant-in-a-pandemic-infographic-uob.pdf\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson E, Brigden A, Davies A, Shepherd E, Ingram J. Pregnant in a Pandemic: Summary report for midwives. unpublished (shared via email): University of Bristol; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson E. Pregnant in a Pandemic: The PiP Study: University of Bristol; 2020 [updated 17/09/2020. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBacon AM, Corr PJ. Coronavirus (COVID-19) in the United Kingdom: A personality‐based perspective on concerns and intention to self‐isolate. British Journal of Health Psychology. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDib S, Rougeaux E, V\u0026aacute;zquez-V\u0026aacute;zquez A, Wells JC, Fewtrell M. The impact of the COVID-19 lockdown on maternal mental health and coping in the UK: Data from the COVID-19 New Mum Study. medRxiv. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh P, Goyal M, Singh K, Misra S. COVID-19 and Pregnancy: A Review. Annals of the National Academy of Medical Sciences (India). 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavenport MH, Meyer S, Meah VL, Strynadka MC, Khurana R. Moms are not ok: COVID-19 and maternal mental health. Frontiers in Global Women's Health. 2020;1:1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJardine J, Relph S, Magee LA, von Dadelszen P, Morris E, Ross-Davie M, et al. Maternity services in the UK during the COVID‐19 pandemic: a national survey of modifications to standard care. BJOG: An International Journal of Obstetrics \u0026amp; Gynaecology. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHorsch A, Lalor J, Downe S. Moral and mental health challenges faced by maternity staff during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoxon K, Turienzo CF, Kweekel L, Goodarzi B, Brigante L, Simon A, et al. The impact of the Coronavirus (COVID-19) pandemic on maternity care in Europe. Midwifery. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewnard JA, Lo NC. Scientific and ethical basis for social-distancing interventions against COVID-19. The Lancet Infectious diseases. 2020;20(6):631.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Coronavirus, Pandemics, Covid-19, Pregnant women, Social distance, Infection control, Qualitative research, Behavioral research, Health-related behavior, Maternal health services","lastPublishedDoi":"10.21203/rs.3.rs-120182/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-120182/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e Covid-19 triggered the rapid roll-out of mass social distancing behavioural measures for infection control. Pregnant women were categorised as ‘at risk’ requiring extra vigilance with behavioural guidelines. Their understanding and ability to adhere to recommendations was unknown.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eObjectives \u003c/strong\u003eTo complete a behavioural analysis of the determinants of recommended social distancing behaviour in pregnant women, according to the ‘capability, opportunity, motivation and behaviour’ (‘COM-B’) model to inform the development of recommendations/materials to support pregnant women in understanding and adhering to behavioural guidelines.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDesign \u003c/strong\u003eQualitative interview study with pregnant women in the Bristol area (UK).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eSemi-structured telephone/videoconference interviews were conducted following a topic guide informed by the COM-B model, transcribed verbatim and subjected to framework analysis. Infographic materials were iteratively produced with stakeholder consultation, to support pregnant women’s behaviour.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThirty-one women participated (selected for demographic range). Women reported adhering to social distancing recommendations and intended to continue. COM-B analysis identified gaps in understanding around risk, vulnerability, and the extent of required social distancing, as well as facilitators of social distancing behaviour (e.g. social support, motivation to stay safe, home environment/resources). Additional themes around detrimental mental health effects and changes to maternity healthcare from the social distancing measures were identified. Infographic resources (plus midwife report) addressing women’s key concerns were produced and disseminated.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions \u003c/strong\u003eThe COM-B model provided useful details of determinants of pregnant women’s adherence to social distancing behaviours. The confusion of what being ‘at risk’ meant and varying interpretation of what was expected indicates a need for greater clarity around categories and guidance. The loss of maternity care and negative mental health effects of social distancing suggests a growing area of unmet health needs to be addressed in future.\u003c/p\u003e","manuscriptTitle":"Capability, Opportunity and Motivation of pregnant women to enact social distancing behaviour in the Covid-19 pandemic in the UK: A qualitative interview study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-12-15 20:38:12","doi":"10.21203/rs.3.rs-120182/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-03-02T10:34:54+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"7c458ab2-1e8c-4e07-9174-1f9b4dc92b1b","date":"2021-01-07T09:47:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-01-05T17:40:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"bef818a9-8611-44bc-bd2e-6b1efe3d401d","date":"2021-01-04T13:16:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e51c61b1-f5e1-4143-a0e8-322f2af1f758","date":"2021-01-04T07:43:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77dba7a0-3294-426f-a446-0bf5bccc7669","date":"2020-12-15T18:19:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-12-15T17:57:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-12-15T17:53:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-12-14T17:59:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-12-14T17:54:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2020-12-02T11:00:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e6bb2df1-95d6-4c47-ba6c-31729e24da9f","owner":[],"postedDate":"December 15th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":1492627,"name":"Health Economics \u0026 Outcomes Research"}],"tags":[],"updatedAt":"2021-05-24T05:44:08+00:00","versionOfRecord":[],"versionCreatedAt":"2020-12-15 20:38:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-120182","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-120182","identity":"rs-120182","version":["v1"]},"buildId":"pf3fE39SIOqb-0xH_OWvX","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}