Smartphone-based ecological momentary assessment reveals mental health benefits of birdlife | Scientific Reports - Nature.com

A increasing assemblage of empirical grounds is revealing the benefits of quality for intelligence health, including higher intelligence wellbeing and little hazard of intelligence illness¹. The immense bulk of the lit has focussed connected the worth of regular interaction with greenish spaces including forests, parks, gardens and trees². A smaller information of the lit has investigated the worth of bluish spaces, including disposable bodies of h2o specified arsenic lakes, rivers, canals, ponds and seas². While these studies person led to increasing appreciation of the intelligence wellness benefits of quality successful general, we cognize small astir the circumstantial features wrong greenish and bluish spaces which are driving these benefits. The contiguous probe focuses connected a diagnostic of the earthy situation which has captivated humans implicit the centuries and yet has received precise small technological attention: birdlife.

In the United Kingdom, our captivation with birds is underlined by the information that implicit 1.3 cardinal radical are members of the Royal Society for the Protection of Birds (more than the members of each governmental parties combined). Interest successful birds is not a uniquely British phenomenon. In the United States, for example, implicit 70 cardinal radical are funny successful birdwatching, making this 1 of the astir fashionable nature-based recreational activities³. Birdwatching societies are not a improvement unsocial to the occidental satellite but are contiguous worldwide, including countries with precise antithetic traditions and cultures. Despite the quality fascination with birdlife, fewer studies person specifically examined the interaction of encountering birds arsenic portion of mundane beingness connected our intelligence health.

Using semi-structured interviews, Ratcliffe and colleagues reported that astir radical acquisition birdsong arsenic restorative from intelligence accent and attentional fatigue⁴. In a follow-up probe utilizing quantitative measures, the aforesaid authors reported that circumstantial qualities of vertebrate sounds specified arsenic perceived familiarity, complexity and signifier are predictive of perceived restorative potential⁵. Our encounters with birdlife, however, are multi-sensory experiences, typically involving some auditory and ocular modalities successful assorted degrees. It follows that some modalities request to beryllium considered erstwhile assessing the imaginable benefits of birdlife for intelligence health. Consistent with this idea, a caller probe showed that the perceived restorative imaginable of earthy features specified arsenic wetland paths are enhanced by the beingness of birdsong⁶.

The existing lit connected the benefits of birdlife for intelligence health, however, is hindered by a fig of methodological limitations. The bulk of studies utilized surveys oregon questionnaires requiring participants to recollect past experiences⁷. We cognize that specified method of probe is susceptible to callback bias, particularly successful the lawsuit of radical with intelligence illness⁸. The remainder of the studies utilized an artificial set-up which progressive the presumption of images oregon sounds of birds to radical sitting successful beforehand of a machine screen. This is susceptible to generating information with small ecological validity, making it hard to estimation the intelligence wellness benefits of seeing oregon proceeding birds successful real-life. A further regulation of the studies published truthful acold is the constricted illustration size, with the immense bulk of studies recruiting up to 30 participants.

To flooded the limitations of the existing literature, we assessed the relation betwixt seeing oregon proceeding birds and self-reported intelligence wellbeing, a beardown predictor of intelligence wellness successful the wide population⁹, utilizing a smartphone-based exertion which we person developed¹⁰. The Urban Mind exertion (https://www.urbanmind.info/) uses Ecological Momentary Assessment (EMA), a methodology which involves sampling people’s experiences successful real-time and successful real-world contexts¹¹. This methodology allowed america to research the narration betwixt the acquisition of seeing oregon proceeding birds and intelligence wellbeing portion minimising the hazard of callback bias. The Urban Mind exertion besides collected elaborate accusation connected the participants, allowing america to research however the interaction of seeing oregon proceeding birds connected intelligence wellbeing depends connected idiosyncratic characteristics specified arsenic age, sex and having a diagnosis of intelligence illness. In peculiar we focussed connected depression, which is the astir communal intelligence unwellness crossed the satellite and is predicted to go the archetypal origin of planetary load of illness by 2030¹². Previous studies utilizing surveys oregon questionnaires person reported a protective effect of greenish spaces connected beingness hazard of depression^13,14. However, nary erstwhile probe has examined the intelligence wellness benefits of mundane encounters with birdlife successful radical with a diagnosis of depression. A amended knowing of the effects of idiosyncratic characteristics specified arsenic age, sex and having a communal intelligence unwellness is captious for readying and designing municipality and agrarian environments which enactment intelligence wellbeing successful each citizens.

Using smartphone-based EMA, we carried retired a national subject survey which aimed to reply the pursuing questions:

1. 1.

   Are encounters with birds arsenic portion of mundane beingness associated with higher intelligence wellbeing?

2. 2.

   Is the beneficial interaction of mundane encounters with birds connected intelligence wellbeing time-lasting?

3. 3.

   Does the beneficial interaction of mundane encounters with birds connected intelligence wellbeing disagree betwixt radical with a diagnosis of slump and radical without a intelligence wellness condition?

We hypothesised that mundane encounters with birds would beryllium associated with higher intelligence wellbeing (hypothesis 1), and that this effect would inactive beryllium evident aft the brushwood has taken spot (hypothesis 2) and would beryllium replicated successful radical with a diagnosis of slump and radical without a intelligence wellness information (hypothesis 3).

The existent survey received organization reappraisal committee (IRB) support from the Psychiatry, Nursing and Midwifery Research Ethics Subcommittee astatine King’s College London (LRS-17/18-6905). All probe was performed successful accordance with applicable guidelines and regulations.

Design

Observational survey utilizing ecological momentary assessments successful a smartphone application.

Urban Mind app

The contiguous survey was conducted utilizing information collected from the Urban Mind smartphone application¹⁰ a smartphone-based EMA instrumentality disposable for some Apple iPhone and Android devices. The app was developed arsenic portion of the Urban Mind probe project—a collaboration betwixt King’s College London, scenery architects J&L Gibbons and arts instauration Nomad Projects. Participants were recruited globally implicit a play of 42 months (April 2018–October 2021) utilizing assorted societal media platforms, the project-related website, and connection of mouth. Participation successful the survey was self-selected and anonymous. Once an idiosyncratic downloaded and installed the app, they were presented with accusation astir the study, including the privateness argumentation astir however their information would beryllium utilized and were asked to supply informed consent. After consent was provided, participants were requested to implicit a baseline assessment. This baseline appraisal collected accusation regarding demographics (e.g. age, gender, ethnicity), socioeconomics (e.g. education, occupation), sleeping patterns (e.g. accustomed aftermath and slumber times) and self-reported intelligence wellness past (e.g. existent and past intelligence wellness diagnoses). Following the baseline assessment, the exertion scheduled a full of 42 ecological momentary assessments during the pursuing 14 days (3 assessments per day). As portion of the baseline assessment, each subordinate was asked astir their emblematic slumber pattern. The timeframe erstwhile they were awake was past divided into 3 adjacent windows, and the assessments were randomly scheduled wrong each window. Once an appraisal was available, the app would punctual a subordinate to respond wrong 1 hour earlier the appraisal was marked arsenic incomplete. This allowed users to implicit the appraisal arsenic they spell astir their regular lives, portion minimising interruptions to immoderate activities they were engaged in. Each EMA collected accusation astir an individual’s perceived natural, built and societal situation and their momentary intelligence wellbeing. The Urban Mind app is disposable successful 8 languages including English, Cantonese, Mandarin, German, French, Spanish, Italian and Portuguese. Iconography is utilized heavy passim the interface to amended engagement and easiness of usage (Fig. 1).

Figure 1

Screenshots of the Urban Mind app interface.

Participants

A full of 1292 participants were included successful our investigation. All participants completed astatine slightest 25% of the assessments (a minimum of 11 retired of 42 assessments), 593 participants completed astatine slightest 50% of the assessments (21 retired of 42 assessments), and 196 participants completed astatine slightest 75% of the assessments (32 retired of the 42 assessments). A full of 2245 participants were excluded from the statistical analyses due to the fact that they completed little than 25% of the ecological momentary assessments (fewer than 11 retired of 42 assessments). Participants were based crossed the world, with the bulk of them located successful the United Kingdom (46%), the European Union (16%), the United States of America (8%), China (4%), and Australia (2%).

Measures

Participant characteristics

Demographic characteristics were measured by asking participants the pursuing questions: ‘How aged are you?’, ‘What is your gender?’, ‘What is your ethnicity?’, ‘What is your highest level of education?’, and ‘What is your occupation?’. The beingness of a diagnosis of slump was assessed by asking participants whether a doc had ever diagnosed them with a intelligence wellness condition. When participants responded “Yes”, they were asked to bespeak the circumstantial diagnosis from a database of imaginable intelligence illnesses.

Encounters with birds

Within each EMA, encounters with birds arsenic portion of mundane beingness were assessed utilizing a azygous item: “Can you spot oregon perceive birds close now?”. Participants could respond with either “No”, “Not sure” oregon “Yes”. The answers were recoded arsenic a binary adaptable wrong the statistical analyses, with “No” and “Not sure” combined into a azygous class and “Yes” arsenic the different category. This attack was followed owed to the precise tiny fig of “Not sure” responses and was accordant with erstwhile studies¹⁰.

Mental wellbeing

Current intelligence wellbeing was measured utilizing 10 questions with 5-point Likert standard (Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree). Five questions referred to affirmative intelligence wellbeing: I americium feeling confident/ relaxed/ happy/ connected to different people/ energetic. Five questions referred to antagonistic intelligence wellbeing: I americium feeling anxious/ stressed/ down/ lonely/ tired. Questions referring to antagonistic intelligence wellbeing were reverse-scored and added to the affirmative intelligence wellbeing scores, summing to a full intelligence wellbeing people betwixt 10 (minimum) and 50 (maximum).

Statistical analysis

All statistical analyses were performed with STATA/MP 16. Longitudinal associations betwixt seeing / proceeding birds and intelligence wellbeing were investigated utilizing random intercept multilevel regression models, arsenic due for hierarchical longitudinal data. These longitudinal associations were expressed arsenic mean quality (MD) and 95% assurance intervals (CI) of intelligence wellbeing. All models were adjusted for the pursuing imaginable confounders: age, gender, ethnicity, level of education, occupational status, whether a subordinate could spot trees, plants, and spot oregon perceive water. Due to tiny compartment numbers, for the intent of the statistical analysis, taste categories were collapsed into White, Asian (including Bangladeshi, Chinese, Indian, Pakistani, Japanese, Taiwanese, and Other Asian), and Other (Black, Caribbean, Latino oregon Hispanic, Indigenous, Arab, Other People of Colour and Mixed).

The main statistical investigation focused connected individuals who had completed astatine slightest 50% of the assessments (n = 593), with sensitivity analyses connected antithetic priori-defined samples involving participants who had completed astatine slightest 25% of the assessments (n = 1,292) and those who completed astatine slightest 75% of the assessments (n = 196). The analyses were tally arsenic univariate models unadjusted for confounders and again arsenic multivariate models adjusted for confounding variables. All models were rerun with the pursuing modifications: (1) inclusion of the random slopes of the predictor adaptable and (2) within-subject centering of the predictor variables successful enactment with champion signifier for multilevel models¹⁵. The results of these sensitivity analyses were past compared with the results of the main statistical analysis. Furthermore, successful bid to code missing information issues owed to skipped assessments, each models were rerun utilizing the STATA crystal routine, an implementation of the Multiple Imputations with Chained Equations (MICE) procedure¹⁶. While this does not summation the tested illustration sizes, this allowed america to impute the missing assessments from our samples. Our results utilizing the MICE process were past compared with our results with the archetypal investigation nether the missing astatine random (MAR) assumption¹⁷, which assumes that the probability of missing assessments whitethorn disagree betwixt participants owed to observed variables. Interaction effects betwixt encounters with birds and diagnosis of slump connected intelligence wellbeing was assessed by including enactment presumption successful the models. All results were considered important if p < 0.05.

Participant characteristics

Our full illustration of 1292 participants included 912 (71%) females, 367 (28%) males, 11 (1%) other, and 2 preferred not to disclose, with an mean property of 34.5 years (age range: 16–80). The sociodemographic characteristics of participants are presented successful Table 1. The main statistical investigation focused connected individuals who had completed astatine slightest 50% of the assessments (n = 593). This illustration included 421 (71%) females, 168 (28%) males, 2 (0.3%) different and 2 who had preferred to not disclose their gender, with an mean of 35.5 years (age range: 16–73). The sociodemographic characteristics of this illustration and our 2 sensitivity samples are presented successful Table 1.

Are encounters with birds arsenic portion of mundane beingness associated with higher intelligence wellbeing?

Multilevel regression analyses showed important affirmative associations betwixt seeing oregon proceeding birds and intelligence wellbeing. The mean differences (MD) successful the intelligence wellbeing scores were 1.72 (95% CI 1.53, 1.91) wrong our main sample, 1.53 (95% CI 1.37, 1.68) and 1.72 (95% CI 1.42, 2.02) astatine the sensitivity 25% and 75% effect rates. The associations remained important aft adjusting for imaginable confounders (age, gender, ethnicity, education, occupation, whether a subordinate could spot trees, plants, and spot oregon perceive h2o astatine the clip of the assessment), aft within-subject centering and including random slopes for the predictor variable, and aft implementing the MICE process to code missing information (see Table 2, Supplementary Tables S1, S4, and S5).

Is the beneficial interaction of mundane encounters with birds connected intelligence wellbeing time-lasting?

Using time-lagged random intercept regression models, we recovered a affirmative relation betwixt seeing oregon proceeding birds and momentary intelligence wellbeing during the consequent appraisal (_L1MD: 0.69; 95% CI 0.42, 0.96). While the affirmative relation betwixt intelligence wellbeing and seeing oregon proceeding birds remained during the consequent appraisal (L1), the effect was little than astatine the clip of exposure. The time-lasting effect was not evident during the 2nd consequent appraisal (L2). These results were accordant crossed our sensitivity samples, erstwhile adjusting for imaginable confounders, erstwhile within-subject centering the predictor variable, erstwhile implementing the MICE procedures to code missing data, and erstwhile adjusting for the autoregressive effects of latent mean centered intelligence wellbeing astatine the anterior timepoint (see Fig. 2, Supplementary Tables S2, S3, S4, and S9).

Figure 2

Time-lagged associations of momentary intelligence wellbeing scores successful narration to seeing oregon proceeding birds. Associations are shown unadjusted and adjusted for age, gender, education, occupational status, ethnicity, whether participants could spot trees, plants, and spot oregon perceive water, and with the implementation of the MICE procedure. The vertical axis represents the mean quality (MD) and 95% assurance intervals (95% CI) of intelligence wellbeing people erstwhile seeing oregon proceeding birds. The horizontal axis represents the assessments lagged from 0 to 2. L0 indicates the interaction of seeing oregon proceeding birds connected intelligence wellbeing astatine the clip of the assessment. L1 indicates the interaction of seeing oregon proceeding birds connected intelligence wellbeing during the consequent assessment. L2 indicates the interaction of seeing oregon proceeding birds connected intelligence wellbeing successful the 2nd consequent assessment.

Does the beneficial interaction of mundane encounters with birds connected intelligence wellbeing disagree betwixt radical with and without a diagnosis of depression?

In bid to trial whether the affirmative effect of mundane encounters with birds connected intelligence wellbeing differs betwixt radical with a diagnosis of slump and radical without a intelligence wellness condition, we included an enactment word into our multilevel regression models. When adjusting for age, gender, ethnicity, education, occupational status, whether a subordinate could spot trees, plants, and spot oregon perceive h2o astatine the clip of the assessments, having a diagnosis of slump did not interact with the relation betwixt seeing oregon proceeding birds and intelligence wellbeing (p > 0.05) (See Table 2). This suggests that the affirmative effect of encounters with birds connected intelligence wellbeing was remained accordant successful radical without a intelligence wellness information and those who with a diagnosis of depression. Further subgroup analyses showed that the affirmative effect was evident successful some radical with slump and radical without a intelligence wellness information (See Fig. 3).

Figure 3

Associations of momentary intelligence wellbeing scores successful narration to seeing oregon proceeding birds successful participants with nary diagnosis of intelligence wellness information and those with a diagnosis of depression. Associations are shown unadjusted and adjusted for age, gender, education, occupational status, ethnicity, whether participants could spot trees, plants, and spot oregon perceive water. The vertical axis represents the mean quality (MD) and 95% assurance intervals (95% CI) of intelligence wellbeing people erstwhile seeing oregon proceeding birds. The horizontal axis represents the assessments lagged from 0 to 2. L0 indicates the interaction of seeing oregon proceeding birds connected intelligence wellbeing astatine the clip of the assessment. L1 indicates the interaction of seeing oregon proceeding birds connected intelligence wellbeing during the consequent assessment. L2 indicates the interaction of seeing oregon proceeding birds connected intelligence wellbeing successful the 2nd consequent assessment.

The main purpose of the contiguous survey was to analyse the intelligence wellness benefits of encountering birds arsenic portion of mundane life. This was achieved utilizing smartphone-based EMA, which allowed america to illustration people’s experiences successful real-time and real-world contexts.

Consistent with our archetypal hypothesis, we recovered that participants’ intelligence wellbeing was importantly amended erstwhile seeing oregon proceeding birds compared to erstwhile not seeing oregon proceeding birds. The effect was robust and observed astatine each 3 completion complaint thresholds arsenic good arsenic aft adjusting for imaginable sociodemographic confounders including age, gender, ethnicity, acquisition and occupation. Interestingly, we recovered that the affirmative effect of seeing oregon proceeding birds connected intelligence wellbeing was much pronounced erstwhile individuals were outdoors (see Supplementary Table S8). People are astir apt to spot oregon perceive birds successful the discourse of greenish spaces, raising the anticipation that the relation betwixt birdlife and intelligence wellbeing mightiness successful information bespeak an wide effect of quality connected intelligence wellbeing. In bid to minimise specified possibility, we modelled seeing trees, plants, and seeing oregon proceeding h2o arsenic further confounding variables. Critically, the results were inactive significant, providing enactment to a circumstantial payment of birdlife connected intelligence wellbeing, supra and beyond the well-established effect of greenish spaces.

Consistent with our 2nd hypothesis, we recovered that the beneficial effect connected intelligence wellbeing is inactive important aft the brushwood with birds has taken place. This is accordant with our earlier probe connected the benefits of green¹⁰ and blue¹⁸ spaces which demonstrated time-lasting benefits for intelligence health. Perhaps unsurprisingly, the beneficial effect of seeing oregon proceeding birds connected intelligence wellbeing does wane implicit time. Specifically, it is reduced astatine the clip of the archetypal consequent appraisal pursuing the brushwood and is nary longer important astatine the clip of the 2nd consequent appraisal pursuing the encounter. The usage of an observational plan meant that we were incapable to found causality successful our findings. Nevertheless, we recovered that the relation betwixt seeing oregon proceeding birds and intelligence wellbeing was inactive evident successful the consequent assessment, whereas intelligence wellbeing astatine a fixed timepoint did not summation the likelihood of seeing oregon proceeding birds astatine consequent timepoints (see Supplementary Tables S6, S7). This signifier of results could beryllium an denotation of a imaginable causal nexus effect of birdlife connected intelligence wellbeing.

Consistent with our 3rd hypothesis, the beneficial interaction of mundane acquisition of birds connected intelligence wellbeing was evident successful some radical with slump and radical without a intelligence wellness condition. Once again, this uncovering was observed astatine each 3 completion complaint thresholds arsenic good arsenic aft adjusting for imaginable sociodemographic confounders including age, gender, ethnicity, education, occupation, seeing trees, plants and seeing oregon proceeding h2o astatine the clip of the assessment. Depression is the starring origin of disablement and sick permission globally¹⁹, affecting an estimated 350 cardinal people²⁰. While antidepressant medicine tin pb to a important simplification of symptoms¹², determination is an urgent request for non-pharmacological interventions to enactment intelligence wellness successful radical who person developed this illness. The existent grounds for intelligence wellness benefits of greenish spaces successful radical with slump is mixed, with immoderate studies reporting important effects^21,22,23 and different suggesting reduced benefits comparative to steadfast individuals^24,25. Our probe extends this existing lit by demonstrating that mundane acquisition of birdlife has beneficial effects not lone successful steadfast individuals but besides successful radical with a diagnosis of depression.

The imaginable argumentation implications of the contiguous survey are two-fold. First, the findings person implications for biology and wildlife extortion policy. The past fewer decades person seen a gradual but changeless diminution successful biodiversity. A caller European study has revealed that determination are 247 cardinal less location sparrows and that 1 successful six vertebrate taxon person disappeared since the 1980s²⁶. The reasons for this diminution are complex. In agrarian areas, cultivation intensification and farming with chemicals are causing situation nonaccomplishment and the disappearance of insects that provender birds; whereas successful municipality areas, vertebrate colonisation is falling owed to a operation of trends including shortages of food, situation loss, summation successful diseases specified arsenic avian malaria and raising levels of aerial pollution. Our probe provides enactment to the instauration of biology and wildlife extortion policies which promote biodiverse habitats successful urban, suburban and agrarian areas (e.g. permaculture farming, wilding initiatives, hedgerow and meadow enhancement, municipality forestry). Second, the findings person implications for intelligence healthcare policy. In caller years societal prescribing of nature-based activities, besides known arsenic “green prescribing”, has go progressively fashionable to enactment individuals with intelligence unwellness including depression^27,28. Our probe supports the conception that visits to habitats with a precocious grade of birdlife, specified arsenic parks and canals, whitethorn beryllium encouraged arsenic portion of greenish prescribing efforts.

Strengths

Previous studies examined the imaginable intelligence wellness benefits of birdlife utilizing surveys oregon questionnaires requiring participants to recollect past experiences, oregon an artificial experimental mounting involving the presumption of bird-related images oregon sounds to radical sitting successful beforehand of a machine screen. In the contiguous study, the usage of EMAs allowed america to seizure dynamic changes successful the participants’ whereabouts and intelligence wellbeing successful real-time and successful real-world contexts. In peculiar we utilized smartphone-based EMAs, which supply much close and implicit measurements erstwhile compared to the accepted method of insubstantial diaries and stand-alone physics devices²⁹.

While the usage of an observational plan means that we cannot beryllium definite that the observed increases successful intelligence wellbeing are owed to seeing oregon proceeding birds alone, our analyses were adjusted for known sociodemographic confounders (age, gender, ethnicity, education, and occupation) arsenic good arsenic vulnerability to trees, plants, and h2o astatine the clip of the assessment. In addition, the information that the observed increases successful intelligence wellbeing are inactive evident aft the brushwood with birds has taken spot provides indirect enactment a imaginable causal link.

Limitations

The illustration successful this survey was self-selected, recruited done a constricted scope of societal media and websites. Furthermore, participants were alert of the information that the survey aimed to analyse the interaction of the societal and built situation connected intelligence wellbeing, which whitethorn person made them much conscious astir however they were feeling and bias their responses. While the 42-month recruitment timeframe allowed america to enlistee a ample sample, this occurred anterior to and during the Covid-19 pandemic, which whitethorn person changed people’s accent levels and effect to birdlife. Future studies should instrumentality imaginable effects of the pandemic into account. In addition, our illustration inactive consisted chiefly of white, assemblage educated individuals based successful the UK who were either successful employment oregon education. Caution should hence beryllium taken erstwhile applying the findings to the wide population. Additionally, participants were asked to self-report whether they had ever been diagnosed with a intelligence wellness condition, and to bespeak their diagnosis. Furthermore, portion participants were allowed to prime aggregate diagnoses, the imaginable effects of comorbid diagnoses were not taken into relationship successful the statistical analysis. Future studies would payment from the usage of validated objective instruments to measure existent symptoms and diagnosis, and the exploration of imaginable effects of comorbidity connected findings. Finally, since we asked participants if they could spot oregon perceive birds, we were incapable to dissociate betwixt the imaginable intelligence wellness benefits of “seeing” and “hearing” birdlife. Nevertheless, successful our encounters with birdlife, we bash not comprehend images and sounds of birds successful a vacuum but arsenic portion of our multi-sensory experience. Therefore, it whitethorn beryllium reductive to absorption connected ocular and auditory aspects erstwhile assessing the intelligence wellness benefits of birdlife successful real-time and real-world contexts. Consistent with this idea, a caller probe suggests that the restorative imaginable of quality is greater erstwhile considering ocular and auditory aspects unneurotic than erstwhile focussing connected either modality separately³⁰.

References

Authors and Affiliations

1. Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF, UK

   Ryan Hammoud, Stefania Tognin, Lucie Burgess, Nicol Bergou, Alia Afifi & Andrea Mechelli

2. Nomad Projects, Sunbury Workshops, 24, Swanfield St, London, E2 7LF, UK

   Michael Smythe

3. J&L Gibbons, 19 Swan Yard, London, N1 1SD, UK

   Johanna Gibbons & Neil Davidson

4. Health Services and Population Research Department, Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

   Ioannis Bakolis

5. Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

   Ioannis Bakolis

Contributions

R.H., S.T., M.S., J.G., N.D., A.A., I.B. and A.M contributed to the survey conception and design. R.H., S.T., M.S., J.G., N.D., L.B., N.B. and A.M contributed to information acquisition. Data investigation was performed by R.H. The archetypal draught of the manuscript was written by R.H. and A.M., and each authors commented connected erstwhile versions of the manuscript. All authors work and approved the last manuscript.

Corresponding author

Correspondence to Ryan Hammoud.

Competing interests

The authors state nary competing interests.

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