Reflections, resilience and recovery: a qualitative study of Covid-19’s impact on an international adult population’s mental health and priorities for support

The impact of the coronavirus 2019 (Covid-19) pandemic on different countries and populations is well documented in quantitative studies, with some studies showing stable mental health symptoms and others showing fluctuating symptoms. However, the reasons behind why some symptoms are stable and others change are under-explored, which in turn makes identifying the types of support needed by participants themselves challenging. To address these gaps, this study thematically analysed 925 qualitative responses from five open-ended responses collected in the UCL-Penn Global COVID Study between 17 April and 31 July 2021 (Wave 3). Three key themes that comprised 13 codes were reported by participants across countries and ages regarding the impact of Covid-19 on their health, both mental and physical, and livelihoods. These include: (1) Outlook on self/life, (2) Self-improvement, and (3) Loved ones (friends and family). In terms of support, while 2.91% did not require additional support, 91% wanted support beyond financial support. Other unexpected new themes were also discussed regarding vulnerable populations suffering disproportionately. The pandemic has brought into sharp focus various changes in people’s mental health, physical health and relationships. Greater policy considerations should be given to supporting citizens’ continued access to mental health when considering pandemic recovery.


Introduction
We are not all in the same boat. We are all in the same storm. Some are on super-yachts. Some have just the one oar.
-Damian Barr (2020) The novel coronavirus 2019 (Covid-19) pandemic took the world by surprise in early 2020 [1], forcing many of us to reassess our priorities and rethink the future. It did not take long for countries and individuals to learn that we are in the same storm but indeed, not in the same boat. The Covid-19 pandemic has brought into sharp focus society's disparities at all levels. Health has become a key topic of everyday conversations as we grapple with the precarity of 'good health'both physical and mental health. Pandemic policies, restrictions and repeated lockdownsalthough varying in length and severity by country -have undoubtedly impacted people's livelihoods and outlook on life, some for the short-term, others for much longer [2][3][4][5][6]. Rippling effects are still being observed at the global economic level and in key sectors such as healthcare and education arguably for years to come [7]. The last two years have seen an ever-widening gap between the developing and developed world in access to vaccines, contrasts between governments' action and inaction and the rising global death toll. To overcome this pandemic -and future pandemics to come -the international community must come together in solidarity to fight this virus.
One way of coming to a shared resolution is to understand the impact of the pandemic on people's lives and the support they might need. At the time of writing this article, international media coverage has primarily focused on the economic and financial costs brought on by the Covid-19 pandemic. Whether this is a key focus on people's minds is less clear. At the time of writing this article, additional European lockdowns over the winter of 2021 are being put in place (e.g., Austria, Germany, the Netherlands) and the UK has reinstated mandatory face masks in shops and public transport. The costs of partial and full lockdowns on businesses as well as the rapid circulation of the Omicron variant has also meant that countries such as New Zealand, which has maintained a 'zero covid policy', have had to also accept that Covid-19 is here to stay. Parts of Asia which rely heavily on tourism have been rebuked for their long and stringent quarantine rules (21 days to 1 month), yet have maintained their stance in slowly imported cases. And as the world rolls-out potential Covid-19 antiviral pills, clinical trials on needle-less vaccines, and booster jabs for the population -still, less than half of the world is currently vaccinated (42.4%), with only 6% of the African population having received the first dose. As policymakers worldwide continue to react to, rather than staying on top of new variants, the pandemic by prioritising the financial and economic gains over more punitive public health safety measures, scientific evidence and data are becoming increasingly vital in informing current and future public health policy and recovery strategies.
In particular, research on the impacts of Covid-19 on mental health since the start of the pandemic has seen exponential growth. Numerous quantitative studies from different countries have reported on the impacts of the Covid-19 pandemic on the general population's mental health [8][9][10] but many more studies have focused on specific populations including: healthcare professionals and providers [11,12], educational professionals [13], patients with existing mental health conditions [14], young children and adolescents [15][16][17] and young adults and undergraduates [18,19] to name a few. While most studies are cross-sectional or focused on the first 12-18 months of the pandemic [20], a handful of studies have also continued beyond that to report on the longer-term health impacts of the Covid-19 pandemic on health [21]. Studies on the stability and changes in rates of mental health symptoms while informative do not by design offer insight into the underlying reasons for the stability and change as well as potential solutions in the way that is captured by qualitative studies. As such, qualitative studies are immensely valuable in generating a more in-depth understanding of how populations are faring during the pandemic where the day-to-day environment in which they live has changed greatly.
To date, qualitative studies examining the impact of the Covid-19 pandemic on sub-populations' mental health have uncovered a variety of experiences. In one semi-structured telephone and video interview study of older adults in the UK aged 70 years and above (n = 20) conducted between May and September 2020, researchers found that 'fears for mortality', 'grieving normal life' and 'concerns for the future' were identified as potential threats to this group's mental well-being [22]. Participants spoke about coping activities and behaviours including 'adopting a slower pace of life', 'maintaining routine', 'socialising' and 'using past coping skills' as protective factors of mental health. Unsurprisingly, participants also drew on personal experience to manage the fear and uncertainty brought on by the pandemic and used the lockdown to reflect or organise end-of-life affairs. These themes were consistent with another study of a geriatric population (60+ years) in Buenos Aires conducted during a similar period (April-July 2020), where distress, anxiety, anger, uncertainty, exhaustion and expressed fear of contagion from themselves and their loved ones were also key themes [23]. In addition, this study identified individuals who lived alone, lived in small and closed environments, with weak relational networks, or limited access to technologies were more vulnerable.
In other qualitative studies of young children and families, Sullivan et al. [24] interviewed Irish families (n = 48) and found clear negative impacts of Covid-19 restrictions on young people's mental well-being. These included negative feelings of social isolation, depression, anxiety and increased maladaptive behavioural changes, such as clinginess in younger children, were common. Families with children with autism spectrum disorders (ASD) in particular, reported increased mental health difficulties. These findings are consistent with quantitative studies of UK families with special education needs children and disabilities in the UK [25] and families even with typically developing children [17]. Drawing on these studies, it is evident that people who live alone and those with different family structures should be taken into consideration when developing appropriate support.
Studies of individuals living with pre-existing mental health conditions paint a similar picture. Taking a co-production participatory approach, Gillard et al. [26] conducted an online video interview study between 18 May and 8 July 2020 and found that mental health difficulties were further exacerbated in those with pre-existing mental health conditions. Specifically, some people struggled with staying connected and accessing mental health support and services, while others found new ways to cope and stay connected with the community. For some people, access to mental health care through technology was possible, but for others, there were substantial barriers. Specifically, individuals from black and minority ethnic groups reported heightened pandemic-related anxiety, stigma and racism that further impacted their mental health. These contrasting experiences highlight the need for a better understanding of providing targeted and effective support for subgroups in the population.
Global studies of healthcare professionals and medical staff are also fairly consistent. In a semistructured interview study of Iranian healthcare professionals (n = 97) conducted between 10 March and 4 July 2020, four themes were highlighted by this group: 'Working in the pandemic era', 'Changes in personal life and enhanced negative affect', 'Gaining experience, normalisation and adaptation to the pandemic' and 'Mental health considerations' [27]. Similar themes were reported by Swedish frontline doctors (n = 20) working in intensive care units (ICU) during Spring 2020: 'Professionalism in work-life' (adaption, the patient's welfare, insecurity and security), 'Community spirit' (responsibility and contribution), and 'Institutional organisation' (the role of management, loss of freedom and information) [28]. This is not dissimilar to the reports of Italian healthcare professionals (n = 19), where individual motivations/ethics, interpersonal relationships and support, and work/organisational leadership and messaging were identified as risk and protective factors during the pandemic [29]. Although individuals from the same occupation group were being interviewed, the resultant themes from different countries were more similar than different, suggesting that the impacts of the global pandemic may be more universal for some groups than country specific. However, as interview questions may differ across studies and with a focus on just one small group of individuals absent of comparison groups, these data are limited in that comparisons on qualitative experiences across different occupational groups or countries are not possible.
The current qualitative study aims to understand the positive and negative impacts of the Covid-19 pandemic on people's experiences, perspectives and livelihoods. A key question is to identify whether there are country-specific and/or universal themes that people have raised and how they may inform international policies in pandemic recovery plans. To the best of our knowledge, few existing studies have looked at the varying socioeconomic and emotional impacts of Covid-19 across multiple countries, and even fewer studies have aimed to understand country similarities and contrasts in people's perceptions and need for support post-pandemic. Should individuals voice the same needs regardless of whether they are in the same country, this would suggest that universal strategies are needed, while country-specific needs may better serve country-specific recovery plans. As such, our study tests three main hypotheses and one open-ended hypothesis: 1. How has people's health (mental and physical) and livelihoods been negatively impacted by the Covid-19 pandemic? We hypothesise that the impacts of the pandemic have primarily been negative (e.g., Covid-19-related anxiety, staying connected, mental health access) with some positive impacts as well.
2. How do the above effects differ by country, gender, age and socioeconomic status?
3. What support do people need? We hypothesise that there will be country-specific and universal needs, and different needs for different groups of participants.
4. We also predict there will be differences in experiences and solutions, hence unexpected themes may also be generated and shed light on future research directions where people's environmental conditions have changes.

Methods Participants
Over 2300 adult volunteers took part in a 30-minute online survey in Wave 1 (April-July 2020), 1806 in Wave 2 (October 2020-January 2021) and 925 in Wave 3 (April-July 2021). Participants were recruited via online advertising of the study, university lists, charity lists, LinkedIn, Twitter, Instagram and word-ofmouth. All adults aged 18 years and above with access to the study website GlobalCOVIDStudy.com could take part.  Appendix 1). Additional participant information can be found in Table 1.

Design
The current qualitative study is based on five open-ended questions embedded in a larger battery of questionnaires administered as part of the UCL-Penn Global COVID Study [1]. This study was conducted and reported in line with the Consolidated Criteria for Reporting Qualitative Research (COREQ) where appropriate. All questions gauged the impact of the Covid-19 pandemic on the general population's mental health, livelihoods, and need for future support as of 17 April to 31 July 2021.

Measures
The five open-ended qualitative questions asked to better understand the impact of the Covid-19 pandemic on people's lifestyle, behaviours and mindset and, importantly, potential support that individuals and families would need in the next 6 months were: Covid-19's impact on an international adult population's mental health and priorities for support

Data analysis
Braun and Clark's [30] six-step thematic analysis were conducted on our qualitative data. Three researchers (KW, KM, KL) independently conducted the steps to minimise bias as best as possible and met as a team when discussing discrepancies in coding. The following steps were conducted in an iterative manner:  Covid-19's impact on an international adult population's mental health and priorities for support

Establishing inter-rater reliability
To ensure that all coders were consistent in applying the same codes across all responses, data were first reviewed independently by each researcher to identify example quotes and respective codes and repeated through subsequent iterative meetings. Inter-rater reliability (IRR) checks were conducted between researchers KL and KM with KW providing a third-party opinion, first on responses from Q52 to develop a set of 13 refined codes (see Appendix 3 for detailed IRR process and notes).
Briefly, 13 initial codes were established after all three coders independently reviewed the data: mental health, outlook on life, loved ones, sedentary behaviour, self-improvement, loss of motivation, optimism about the future, financial security, Covid-19 policy, access to services, loss, virtual living, frustration towards others, distrust in media/government and does not need support (see Table 2). Next, KL and KM coded Q52 independently against the 13 initial codes and took notes after each round of independent coding to document potential issues for group discussion. Aiming for an IRR above 80%, a random number generator identifying 10% of coded responses in Q52 resulted in a low IRR threshold in the first meeting (64%) and second meeting (75%), but a high reliability by the third meeting, (81.2%). At each iteration, discordant codes were discussed between researchers and addressed in subsequent iterations. After the third meeting, the team coded the rest of the responses in the dataset. Non-English responses (e.g., Italian, French, Greek) were translated through Google Translate, taking care that translations of smaller chunks of inputted text resulted in more accurate translations.

Results
Thematic analysis across our dataset revealed three key themes comprising 13 codes of varying degrees of overlap: (1) Outlook on self/life, (2) Self-improvement, and (3) Loved ones (friends and family). See example quotes in Table 3 and a visual representation of overlap themes across questions in Figure 1.
To investigate which codes had the greatest proportional overlap with one another, descriptive tables were generated for all five questions and yielded a total of 488 unique combinations of codes (e.g., codes 1, 2, 3). The following table shows the distribution of codes for each question (see Appendix 4 for example codes) and the percentage of overlap between codes across the five questions (Table 4). Many participants reported a general lack of motivation and concentration due to isolation and having to adapt to a changed balance in the environment including spending more time at home. Covid-19's impact on an international adult population's mental health and priorities for support Many also reported being more negative when it came to feelings about the future, ranging from 'feeling optimistic about the future to ambivalent at best'. This sentiment often presented alongside a change in work environment or work-life balance, and even annoyance in the mundane space and environment where the line for work-and-play is blurred, 'getting so bored working from home'.
Another theme centred on how the Covid-19 pandemic impacted participants' finances, work and studies. Many participants spoke of how changes to the work environment and workload have negatively or positively impacted their livelihoods. Participants reported widespread issues including worries about long-term job security, such as worries about 'teaching contract[s] not being extended', and the impact of drastic increases in workload since working from home (e.g., 'work-life balance has decreased significantly'; 'My workload has increased a lot last year and I have job insecurities'; 'My work has been moved primarily online … which has resulted in my workload increasing by at least 50% in terms of effort and time'). For some participants, these issues were further compounded by pre-existing financial struggles, and they reported a desperate

Figure 1
Visual summary showing the relationship between the 13 codes and the extent of overlapping themes across the data set. The size of the circles is relative to their prevalence rates in the dataset, whereby a larger circle represents higher prevalence (e.g., the relative size of the circles was made by setting the length and width of the circles equivalent to their prevalence rate). need for a steady cash flow just to get by. The impact of an increase in workload and work-related stressors further impacted participants' relationships (e.g., wanting 'a workload that isn't crippling so I can spend more time with my son'). Furthermore, participants also voiced their frustrations about not being able to see family due to tighter restrictions and, for some, not being able to grieve over the loss of their loved ones. Whilst staying socially connected with others has been proven difficult during Covid-19, the responses further highlighted the impact of lockdown restrictions on people's access to services such as mental health support, including the pandemic being a stimulus to starting therapy or counselling sessions for those who can afford it (e.g., 'I started online therapy … knowing that this was going to be a rough ride'; 'I learned how to deal with trauma memories … [after] attempted suicide in February'; 'starting to attend trauma therapy').
People's attitudes toward themselves and others have changed for the better and worse The pandemic prompted significant changes in people's outlook on life and this theme appears to be the most prominent (37.7% of all responses). This included significant changes in participants' attitudes toward others. Firstly, participants reported less trust towards governments due to their response to the pandemic, as shown in policymaking. Some participants described their government as 'selfish', 'corrupt' or 'self-serving'. Dissatisfaction with governments' Covid-19 response also included 'vaccine role out', 'financial cuts' and not being able to 'keep infections under control'. There was an overarching sense that what participants wanted was 'a government that is focused on supporting people rather than pandering to their financial backers', and for governments to focus on implementing evidence-based support systems to local communities.
Secondly, participants had reported feeling 'angry', 'frustrated' and 'depressed' about the spreading of Covid-19 misinformation 'shared… [on] social media'. Thirdly, frustration towards others over differences in opinion on how strongly one should adhere to Covid-19 policies (e.g., social distancing or getting vaccinated) was observed. Participants commented on how 'lots of people don't care about others', and how the pandemic has shown them just 'how selfish some people are' and how some people are 'unwilling to make sacrifices to protect other(s)'. Lastly, mixed impressions towards friends and family were reported. While some participants were 'more appreciative of their friends and family', others commented they have learned 'who their real friends are', suggesting that reduced social contact with loved ones has prompted periods of introspection and reassessment. Emotions were mixed for some participants who moved back in with their families to weather out the pandemic, including feeling 'more irritable', 'more frustrated', 'more thankful' and that 'talking [to them] helped them cope and validate their feelings'.
Thirdly, the Covid-19 pandemic has also changed participants' attitudes toward themselves, providing 'more time to understand their jobs', 'find new opportunities after they finish [their] studies', and made them 'excited' to 'reconnect with friends and family'. Some expressed how the pandemic has prompted them to rethink their current priorities in life, bringing about 'significant changes in terms of their lifestyle, behaviour and thinking'. Others have found the pandemic to be a transformative experience of 'learning', 'realisation' and 'rediscovery', afforded in the changed 'single' environment in which they are forced to dwell, learn, and work in, prompting self-reflection on the areas of their life, which perhaps is not unlikely pre-pandemic times when an individual may have had to actively seek refuge and solace in their own private space due to too much social interactions with others. During the pandemic, changes in an individual's outlook on life and on themselves have therefore encouraged many participants to be more motivated and optimistic for their future.
People's mental and physical health have been primarily negatively impacted by the Covid-19 pandemic with some positive impacts Many participants reported how their mental health was negatively impacted by the pandemic. Participants who were living alone during lockdown largely reported feeling lonely and missing social contact from their loved ones. Participants further expressed feeling 'more anxious', 'constant anxiety' or worried about 'being around other people', and some expressed that they would rather be on their own to minimise the risk of contracting Covid-19. Participants reported mixed success in how they have coped with Covid-19, with some feeling 'more resilient' and others that their mental health was the worst it has ever been (e.g., 'all time low'; 'rock bottom').
Participants' physical health was also negatively impacted by the pandemic. Unsurprisingly, many participants spoke about reduced physical exercise and social activities with others, in line with the Covid-19 restrictions, which have prevented people from 'visit(ing) friends and family abroad' and has contributed to more sedentary behaviours such as staying indoors and at home for longer periods of time. Some participants recounted poorer physical health due to increases in alcohol consumption (e.g., 'drinking more alcohol'; 'worse alcohol intake'; 'drink more, put on weight'), drug usage (e.g., 'doing cocaine again'; 'relapsed into smoking/vaping') or 'addiction to social media'. For other participants, such behaviours resulted in stronger 'reluctance to leave home' for exercise or social contact. These experiences are perhaps not unlikely the experiences of individuals who even pre-pandemic times have had to live with health vulnerabilities (e.g., asthma, ageing populations with reduced access outdoors due to high pollution levels, individuals with reduced mobility) and restricted environments (e.g., curfew, parole, elderly home).
Even so, some participants also described an increase in coping behaviours. Examples included making more effort to stay in touch with friends and family virtually (e.g., 'increased socialisation through social means') and practicing meditation and mindfulness (e.g., 'sustained a meditation regime'; 'meditation, reflecting, prayer').
Overall, while the impacts of Covid-19 were largely negative, certain individuals were finding ways to cope.

Group differences on the Covid-19 experience
Many people expressed the need for more support as part of the post-Covid-19 recovery. Support that extends beyond solely financial support was preferrable (e.g., 'better access to physical and mental health support and if necessary, treatment, would be of huge impact to me and my family'). To identify potential group differences in the frequency of codes, independent t-tests were conducted on gender, country, age and income groups. There were significant group differences in participants aged above and below 38 years for all codes except for code 9 (Loss/bereavement Out of all the countries, Italy and UK participants reported significantly more Covid-19 induced changes in their outlook towards life and themselves (see Table 5 Covid-19's impact on an international adult population's mental health and priorities for support   Participants from the UK reported having the most optimism for the future, with many participants expressing their excitement for 'things to return to normal', 'moving freely in society' and 'travelling abroad'. In addition, participants from the UK spoke significantly more than those in other countries about their experiences with work, studies and financial disruptions and silver linings that arose from the pandemic. There were mixed feelings about 'working from home' but employees wanted 'more flexibility' when returning to the work force.
Participants found technology to be a saving grace and a hindrance to their work and social lives, with participants from the UK reporting significantly more that 'online support groups', 'online workshops' and 'Zoom calls' were the most popular way for participants to stay connected with friends and family and to work with colleagues from home. Some participants spoke about 'online lectures' and 'online teaching'. In particular, participants from Greece found that 'online lectures were less effective compared to those with physical presence', but overall there was a sense that Covid-19 enabled participants from all countries to get 'used to online teaching and learning'.
Participants from the US and the UK reported significantly more frustration towards others, 'people are selfish' and that Covid-19 has revealed 'how unkind and insensitive most people are' and in some cases, deteriorating relationships with loved ones, led people having to move houses. Frustration towards others also extend to governments and news outlets. Participants' sentiments towards the US and UK administration have been emphasised to be worsening: 'the pandemic has taught me just how little this government cares about the everyday person and important issues'. Participants expressed their 'trust in government has deteriorated' and that they 'feel much worse about the state of our country'. The media was found to be a key source of stress Covid-19's impact on an international adult population's mental health and priorities for support for all participants, but particularly in the US and the UK where participants expressed that they 'hate reading the news because it always makes me sad' and that sometimes the 'anger of the state of the world would consume me'.
In terms of gender, although there were significant differences in the frequency of some codes between male and female participants (see Table 6), participant's responses were not qualitatively different. Both men and women spoke about changes in lifestyle as a result of Covid-19 where they had to remind themselves 'not rushing around and trying to do too much' or to 'prioritise myself more and stick to my boundaries. Exercise more. Eat better'. Some participants gained insight about themselves even though they did not think they would cope, 'that I am comfortable with my own company' and that it was possible to 'set short term goals and take my health into my own hands'.
When comparing groups earning more or less than £40,000 per year to see whether they cared about different things, although there were significant differences in the frequency of codes for some codes, their responses were not qualitatively different (see Table 7). Many respondents spoke about having, 'little faith in the process of government in getting vaccines to people or managing lockdowns or crisis situations'. Some spoke about the need for the government to be held responsible for their poor handling of the pandemic, 'for the government to be held to account for their horrific failings to relieve the sense of injustice I feel'. Still, others spoke about their resilience and lessons learned from the pandemic, 'Yes, that I can cope with a sedentary lifestyle reasonably well; and those others are more prone to stress than I thought', missing interactions with colleagues, 'Not seeing coworkers is not great. I miss them', and friends, 'I miss seeing people more than I thought I would'. No real differences in content were observed between groups.  Covid-19's impact on an international adult population's mental health and priorities for support

Group differences on support
When asked what type of support people wanted, there were no particularly stark contrasts in their view of support across countries, age, gender and income.
Both men and women spoke about the return to pre-pandemic environmental conditions in which they lived with the possibility and hope that Covid-19 vaccines can bring about an ending to the pandemic, 'vaccines, money, ability to travel again (international family)' and how they would want travel restrictions to be lifted to allow everyone to reunite with distant families again, 'permission to travel to see family, efficient vaccines'. Participants aged above and below 38 both spoke about the pandemic having a toll on their mental health, some feeling 'an all time low' and others feeling 'more resilient and stronger than they think', as well as 'missing friends', 'family' and 'colleagues'. Participants from various income groups spoke about feeling frustrated that they 'can't host large gatherings' and working in Covid-19 times has been 'more challenging', whether working from home or in face-to-face professions. Income was not a predictor of whether participants needed significantly different kinds of support, as some participants regardless of income reported 'nothing comes to mind', 'nothing' or 'we're doing fine'.

Other relevant themes
From our data, we also identified a small but specific vulnerable population who spoke about having suffered disproportionately throughout the pandemic. These populations include single Table 7. Analysis of code frequencies between participants with a higher income of £40,000 per year (I 1 ) and participants with a lower income of £40,000 per year (I 2 ) Code Significance 1: Mental health (cognitions, feelings, perceptions) I 1 = I 2 z = 0.6, P = 0.483 2: Outlook on life/self I 1 = I 2 z = −1.7, P = 0.081 3: Loved ones (friends and family) I 1 > I 2 Z = −2.5, P = 0.012 4+: Self-improvement (active, increase in behaviors) I 1 < I 2 z = NaN, P < 0. Covid-19's impact on an international adult population's mental health and priorities for support parents who described having 'struggle[s] with childcare, [and had] started therapy [and even] started therapy for [their] kids'. Another group identified is individuals trapped in unstable and unsafe relationships, where some participants reported needing to move out of their homes due to relationship conflict and breakdown (e.g., 'I need to buy a house real quick so I can move out … I have no support from anyone').

Main findings
The aim of this study was to explore the impact of the Covid-19 pandemic on people's experiences, perspectives and livelihoods. To the best of our knowledge, this is the first study to examine a range of socioeconomic, behavioural and mental health impacts of the Covid-19 pandemic across countries in a large sample of over 900 participants. Each of our study findings are discussed in turn.

Theme 1: Covid-19 restrictions such as social distancing and travel restrictions, have negatively impacted people's livelihoods
With regard to our first hypothesis, our study has uncovered three main themes comprised of 13 codes capturing the wide ranging positive and negative impacts of the pandemic on different populations. It is clear that Covid-19 lockdown restrictions have led to decreased motivation and concentration, increased workload and worries relating to long-term job security, and distrust towards government policy and action -similar to experiences reported by individuals working in healthcare [11,12,27], young adults in school [18,19] and education [13]. Restrictions also preceded the increased use of mental health services -for those who were able to access free counselling or those who had the financial capital to afford private services -yet highlighting those who were not able to have continued access or afford mental health and healthcare support during the pandemic. These findings were consistent with past studies uncovering difficulties in mental health access [26] from those with existing mental health conditions [14] and families with young children and children with special education needs [15][16][17]19].
Covid-19 restrictions, such as social distancing and travel restrictions, significantly contributed to a negative impact on livelihoods across the world. Many participants reported feeling despondent and reduced motivation and concentration from needing to spend more time at home. Finances, work and studies (Code 6) was particularly prevalent, with participants reporting struggles with long-term job security and stable funding, which is consistent with past studies. This has further implications for their ability to afford healthcare and essentials, as shown in past studies [19], identifying a potential vulnerable group that deserves further support and attention.

Theme 2: People's attitudes towards themselves and others have changed for the better and worse
Second, the pandemic has also caused changes in self-perception. Many reported introspective self-discoveries, such as knowing more about themselves. Often times, this was followed by greater optimism and motivation for the future that indicated significant personal growth, a more optimistic outlook when compared to studies of older age groups [22]. It was clear that greater time spent in isolation prompted episodes of self-revelation and discovery for many. We also received many responses indicating distrust in others due to the apparent lack of responsible action taken, which has also been found to be associated with poorer mental health [20] and adoption of health behaviours [31]. Varying attitudes towards how governments across the world have supported or unsupported their citizen's recovery from the pandemic were also observed. Some participants expressed frustration and having a lowered or lack of trust in their government. Covid-19's impact on an international adult population's mental health and priorities for support

Theme 3: People's mental and physical health have been primarily negatively impacted by the Covid-19 pandemic with some positive impacts
Third, people reported a toll on health -both mentally and physically. While the minority -2.91%reported minimal distress, coped adequately and/or reported improved mental health, an alarming number of responses illustrated deterioration of mental health and an inability to cope with significant life stressors, 66.85%. This was especially for those who lived alone and individuals who were already battling with pre-existing mental health difficulties, consistent with previous qualitative studies [23,26]. We know from past studies that mental health symptoms fluctuate throughout the pandemic lockdown periods for both adults and young children, thus more mental health support should be deployed for especially strict lockdown periods [2,3,17]. For this group, it seems that changes in lifestyle habits (e.g., social isolation, productivity and habits) became stressors for the onset of mental health problems including self-harm behaviours to ruminative thinking and symptoms of anxiety and depression, which has also been evidenced in past studies [20]. Our participants also spoke of worsening physical health, in the form of increased substance abuse and addictions (e.g., alcohol, food, social media) -a phenomenon observed in other studies showing increased risk for overdose during the pandemic [32] -and the reluctance to leave home to engage in social or physical activity [33,34]. However, 20.6% of participants also reported positive physical health outcomes due to an increased effort to exercise, practicing mindfulness and meditation or reducing their substance use.

Group comparisons on inequalities
By comparing data across country and income groups, significant differences in code frequencies were found for some country-pairs (in the case of UK-US, UK-Italy and UK-Greece) as well as between gender. No significant differences were found for age and income levels. Covid-19's impact on an international adult population's mental health and priorities for support took the time to exhaustively report their thoughts and feelings in the questionnaire highlights how many felt emotionally overwhelmed at the point of data collection. Due to the questionnaire being anonymous, perhaps participants felt more comfortable recounting exceedingly detailed information about their personal lives and experiences. Such detailed responses emphasise the strong desire for people to be heard in periods of crisis, especially having been isolated from social life for such an unprecedented period.
The questionnaire was successful in capturing the experiences from individuals in various populations considered vulnerable and those not so much affected. These responses presented a sharp contrast to those who reported not needing much support for post-pandemic recovery, highlighting the vast demographic disparities that have arisen or have been exacerbated by Covid-19. As Covid-19 restrictions have clearly affected individuals disproportionately, future research should explore the pandemic's unique impact on vulnerable populations, including single mothers and individuals who feel as though they are in an unstable or unsafe relationship, families seeking psychological support, and identify possible avenues for support for those who will need more than 6 months to recover from the pandemic.

What support do people need?
While many respondents reported that they did not need any form of support (2.41%), 24% of participants expressed that changes in work-related practices would help (e.g., ' [I] need my work to be understanding with childcare'; 'reduced workload'). In addition, 22% of participants expressed the need for either access to or continued 'mental health support' or 'therapy' (e.g., 'counselling or other mental health services to deal with the trauma of the past year'; 'I would appreciate … better access to mental health support because I am not a citizen, I do not qualify for mental health care'). Overall, there was a clear demand for support both at the individual (mental health, finances) and community level (workplace, local infrastructure). Of those who wanted more support, 91% of participants expressed that they needed more support for their post-Covid-19 recoverysupport that extends beyond financial support. And although our responses reveal no 'qualitative' differences between groups, people with existing conditions and fewer resources are likely to have experienced the impacts of the pandemic even more that may not necessarily be fully captured in our open-ended questions.
The findings from this study emphasises that global leaders and governments should prioritise their citizens' mental health, social relationships, and access to services, and that more funding and resources should be allocated to key organisations that serve their citizens.

Strengths and limitations
This study is not without limitations. First, the lack of pre-pandemic data on participants' situation and health limited our ability to assess real change and impact beyond self-reported data, which will ultimately have a certain level of bias. Thus, future studies triangulating participant data across official clinical health database and self-report data will overcome this limitation.
Second, an openended survey from a global convenient sample does not allow follow-up elaborations and the translations of non-English responses, although fairly accurate, are both taken at face value and may not capture the nuances that some participants may have intended. Third, participants from different countries have experienced varying levels of Covid-19 restrictions and so the collected responses may reflect only those who have been most impacted in countries with strict lockdowns rather than less severe lockdowns (e.g., the UK had national lockdowns whilst most Asian countries did not have full national lockdowns). Hence, future qualitative studies from specific countries can help address this limitation.
Despite these limitations, this study has several noteworthy strengths. First, a key strength of this study is the large, cross-country sample representing a range of ages and socio-economic statues that has allowed testing for group differences. Second, thematic analysis was conducted blind to participants' demographic data, which minimised researcher bias on the impact of the pandemic, increasing the validity of our interpretations. Third and finally, the strongest aspects of this study were the long responses from the study participants. While participants were not paid (only entered into a prize raffle), the detailed responses reflected a highly motivated and willing group of participants who wished to share their insights with the study team. Covid-19's impact on an international adult population's mental health and priorities for support

Conclusion
The Covid-19 pandemic has fundamentally altered the environment in which people lived as a result of a range of controlled measures that are still being felt globally in different locally communities and globally. This study shows how this changed individuals' perceptions of themselves and the world, whilst also highlighting the substantial inequalities in support for the most vulnerable in times of crisis. This pandemic is a wake-up call for communities around the world to be better prepared for future pandemics to come. Whilst popular media coverage focuses on Covid-19 pandemic's impact on the global economy, our study findings contribute to the growing literature advocating for more consideration for the impact on individual's perceptions, behaviours and relationships. Lockdowns have clearly taken a toll on everyone, but particularly for vulnerable groups who find themselves isolating with limited support during these challenging times. Non-profits and third sectors working tirelessly to support vulnerable groups need additional funding to provide adequate support, not funding cuts. Local communities and authorities with potential to provide targeted support are lifelines to the population that can help bridge citizens' growing distrust and dissatisfaction toward governments and their pandemic policies. The time is now: Ahead of other pandemics to come, we need to mend relationships between individuals and governments globally, build resilient systems and motivate world leaders to work together to recover stronger from this pandemic.

Funding
This study was funded by the UCL Global Engagement Fund 563920.100.177785 and personal funds from KW. Covid-19's impact on an international adult population's mental health and priorities for support Appendix 2

Calibration meeting 1
In the first calibration meeting, the team found that code 2 ('outlook on life') was applied inconsistently. Its definition was subsequently revised to encompass only introspective responses. We also highlighted that codes 4+ ('doing more activities') and 4-('sedentary behaviours') were assigned to responses which were behavioural in nature. During this meeting, 37% of responses were blank, 29% of responses had a code match and 71% of responses did not have a code match. These responses were discussed, and discrepancies were addressed. In the second calibration meeting, 22  Covid-19's impact on an international adult population's mental health and priorities for support responses did not have a code match. These responses were discussed, and discrepancies were addressed.

Calibration meeting 2
After the second calibration meeting, the team came to a consensus to code responses mentioning an 'increase in social distancing' or 'keep(ing) distance' as (7,4-). While it was an increase in behaviour, the response was treated as a decrease in socialisation. It was also noted that any mention of money or finances was to be coded as 6. Responses that mentioned 'work from home' were also to be coded as 6. Responses that mentioned 'friends or family' were to be coded as 3.
Responses that mentioned 'studies' were also to be coded as 6. Two more codes were added to the coding scheme: '−999' (to denote responses scored neutrally as difficult to interpret e.g., 'not really', 'no', 'yes' with no further explanation) and '−99' (for blank responses). The team achieved an IRR of 75% by the third calibration meeting (see Table 2 for final code scheme), where the team evaluated 31 cases, of which 11 were blank and 5 were discussed.