Communication skills training for family caregivers of people living with dementia: the experiences of peer facilitators and course attendees

ABSTRACT

Family caregivers of people with dementia can find the impairments in their relative’s ability to communicate an enormous challenge. Peer facilitated educational interventions are a potentially efficient and effective way to address these complex communication issues. This paper examines the processes required to support the development of peer educators and the impact this has had on facilitators and course attendees. Semi-structured interviews with six participants who facilitated Empowered Conversations (EC) a communication skills educational program for caregivers of people with dementia and 28 participants who attended the program. A qualitative thematic analysis approach identified emergent themes within the data. Three broad findings are reported: first the support that is needed for peer facilitators; second, the impact of the course reported by facilitators and course attendees; and third, suggestions for improvements. The content of the EC program is strong and the reflective cycle encouraged via support mechanisms prior to, during and following the delivery of sessions is effective for supporting facilitators. When upscaling the program it was important to enhance the support structures for new peer facilitators. Introducing a support session focusing on examples of logistical issues experienced and how these could be addressed would be a useful addition to the support mechanisms already devised. Attendees reported positively on participation in the course, particularly valuing the input from facilitators with experience of caregiving. Suggested improvements related to better information about the course and a settling in period, with some specific individual suggestions for content relating to their personal experiences.

Introduction

The benefits of training intended to support those providing care for a family member living with dementia have been reported as limited (Morris et al., 2017), but when available sustained benefits have been found (Hsu et al., 2017). Peer support and education has been recognized as being valuable for a range of social and health issues (Graham & Rutherford, 2016). Peer support is an area that has been highlighted as being of increasing importance when it comes to initiatives for carers of people with dementia (Smith et al., 2018) and to support older people in different settings (Jin et al., 2019; Stewart & Lovely, 2017). A recent review of peer support for carers of people living with dementia (Carter et al., 2020) found that more research is required as to how to design and evaluate interventions that provide such peer support, this includes educational as well as other forms of interventions such as befriending. Peer delivered educational interventions are a potentially efficient and effective means of improving health and social care outcomes (Burmeister et al., 2016; Khong et al., 2015; Ogrin et al., 2017).

As well as helping to bridge the gaps in under-resourced areas, such as dementia care, there is evidence to show that structured educational interventions with a sound theoretical and empirical basis delivered by people who are experts by experience (Russell, 2020) may be more effective than the same program delivered by healthcare professionals (Dennis, 2003). This may be because peer educators are able to draw upon their lived experience when delivering the training, their enthusiasm for the training and their empathy with their peers (Jin et al., 2019). However, there are also risks associated with the potential for emotional over involvement, which may lead the peer educator to assume that other experiences are more similar to their own than they are, unrealistically high expectations of the trainees or using the training to work through personal issues that the peer educators have not come to terms with themselves. To mitigate these risks, effective recruitment, supervision, and quality control measures may need to be in place.

This paper reports on the peer delivery of a training program designed to address the communication challenges of dementia. The “Empowered Conversations” (EC) course was developed for care partners of people living with dementia (Morris et al., 2020). The EC runs weekly for 4-weeks (each session lasts 2.5 hours and includes a break) and is a community based, group-training course. It is based on the Communication Empowerment Framework (CEF), which is an integrative theoretical framework and addresses the specific psychological, relationship and communication needs of dementia caregivers (Morris et al., 2017). This paper contributes to the literature around how to support facilitators to deliver peer led education and the benefit to both themselves and participants attending a peer led course.

Participants

Participants consisted of six facilitators who had been regularly delivering or supporting the delivery of the Empowered Conversations course (see Table 1). One participant was also the project manager of the Empowered Conversations course. Four participants had initially attended the course as group attendees and the fifth had become interested in the course through their role as a health-care professional. Twenty-eight care partners from the 159 who attended the EC program agreed to be interviewed about their experiences of attending the training, 20 were self-selecting and eight were purposively selected to capture the views of community members who were not well represented.

Table 1. Care partner course attendee participant characteristics

	Number [out of 28 unless specified]
Gender, number female	19	9 male
Ethnicity (number W. British)	25	2 Asian British; 1 Italian British
Caring for:
Parents	14
Spousal	11
Long-term partner (never cohabited)	1
Sister	1
At time of interview not carer (previously had been)	1
Age	Mean 61	Range 32–81

Facilitator participants were accessed via the project manager who introduced the researcher to all facilitators who were invited to take part via an e-mail from the researcher with an information sheet and consent form. All consented to participate. Three participants were interviewed in a community setting and three via telephone.

Participants who attended the training from across Greater Manchester, a densely populated, predominantly urban geographical location in the north of England, were asked if they would be willing to participate in a follow-up interview. Twenty-eight agreed. Using a detailed semi-structured interview schedule, a researcher conducted interviews over the phone and in carers’ homes; two interviews were conducted in community locations. All the interviews were conducted over 4-months after the EC training.

Interview schedule and data collection

Facilitators: A semi-structured interview schedule was used to guide interview questions. The flexibility of this approach enabled the researcher to ask probe questions to further determine the experiences of facilitators on the Empowered Conversations course. Interviews lasted between 20 and 40 minutes and were digitally recorded.

EC course attendees: The length of the interviews ranged between around 30 and 60 minutes. In addition to the questions on the interview schedule, the interviewer asked prompt questions that were integral to the interview schedule. These were designed to encourage participants to elaborate on comments and to obtain a deeper understanding of their experience of the Empowered Conversations course and their perceptions of its impact on their ability to support the person living with dementia (anonymized).

All data from both facilitator and EC course attendee interviews were independently transcribed verbatim, and transcripts were produced.

Analytical strategy and procedure

A qualitative thematic analysis approach was used to identify emergent themes within the data (Braun & Clarke, 2006). The researchers who conducted the interviews familiarized themselves with the data through rereading transcripts and listening to the original audio recordings. A coding framework was then developed to organize the data. This was then examined by two further members of the team to ensure that the codes were appropriate and related to the research objectives. Once codes had been established, the data was coded line-by-line using the qualitative data management tool NVivo12. On reflection, some codes were then expanded or collapsed to create new codes. Once coding was complete, similarities and patterns were identified across the data set, and data was grouped to create themes that were relevant to the research question. Themes were identified by one researcher to ensure they were relevant, and they consisted of clear and robust data. These were then verified by two further researchers. Theme names were agreed upon by all three researchers involved in the analytical process to ensure they were informative but also encapsulated all the data. Ethics approval for the study was obtained by the authors of the Institutional Ethics Committee.

Findings

We report three broad findings. First support for facilitators; second, the impact of the course reported by facilitators and course attendees; and third, suggestions for improvements.

Support for facilitators

The primary theme that emerged involved the facilitators’ perspectives and experiences of the course trainingin particular, the self-reported support they had received before, during and after facilitating the EC program.

Course training consisted of a number of training workshops where facilitators observed the experienced project manager as she delivered different courses. As the facilitators’ confidence increased, they had the opportunity to take on more responsibility with the course facilitation until they felt comfortable to lead the course themselves.

All six facilitators positively commented on the step-by-step nature of the course facilitation training. The five facilitators who undertook the training all relayed how they felt that they were fully supported within the process. It wasn’t just a training course where you go out and try and do it … there was a pathway to it … It’s a difficult subject, it’s difficult on the impact on life …. So nurtured all the way through it, and I think that was fantastic. (F5)

The six facilitators specifically highlighted that the step-by-step nature of the training provided a supportive platform to engage and develop the course. This approach was valuable for the facilitators, and they could develop their skills until they felt ready to deliver a course independently. F1, who received this training described how they felt fully supported by this approach: And then you co-delivered a course. So you shared the delivery with someone who was already fully delivering, And then when you felt ready, you could co-deliver and lead deliver the course. So it felt very supported ….There was no sense of sort of having to jump off at the deep end … that was really helpful. (F1)

Providing support during the facilitation of the program related to facilitators’ perspectives on delivering in pairs, the role of their lived experience in delivering the course and the course handbook. Facilitating in pairs, with one facilitator taking a lead role and the other a support role was reported as successful by four facilitators:

F2 details the importance of the “co-facilitators” role: I think from my point of view, what works is having two facilitators doing it together … dynamics between the two facilitators means that the rest of the group are included … I think having a pair of facilitators enhances the ability of the group to be able to contribute and ideas to bounce more easily’. (F2)

Co-delivery of the program thus provided ongoing support to each individual involved in delivering the sessions.

Another important factor was the lived experience of caring for a person living with dementia. Four facilitators attended the course as participants. It was evident that through this experience, these four facilitators felt passionate about the course and its ability to improve the lives of carers: I really feel the course is so valuable (F1)

All four facilitators who directly cared for a family member living with dementia described how their experiences had helped them to empathize with participants of the course and build stronger relationships: They are living in hell … we know what it’s like, because we’ve all had some experience of living with someone with Dementia or caring for someone with Dementia, so we know what they’re going through. (F4)

F6 a facilitator who has also co-developed the course, detailed how the lived experience was an important attribute for facilitators contributing to the success and impact of the course: Having lived experience people actually on there … not acting it out, so it’s just absolutely real … I think it just adds a whole level … it strengthens what we do. (F6)

Thus, participants felt that their caregiving experiences were of direct benefit to their ability to deliver the program as they could both empathize and share their own personal experiences.

Five of the facilitators described how they used the handbook as a framework to help them understand and then deliver the courses, with F6, who co-developed the handbook, commenting: You’ve got that there as a security so you can look at it, you can refer to it and you could run an exercise, you could have it in your hand and run an exercise.

Four facilitators discussed their contribution to shaping the handbook as the course developed. This was reported as being a positive attribute to the course development: It made sense in an applied sort of way. You try something and you think … it would be better this way around and then the manual evolves to encompass it. (F2)

Only one participant, F3, commented that they found the organization and structure of the manual challenging to refer to when undertaking the course training and delivering sessions: The only thing I would say is the handbook does my head in. The way it’s organized … I’ve organized it because they’ve got all the lesson plans at the front and then all the support information comes after all the lesson plans. (F3)

Overall, the handbook provided a clear frame of reference for facilitators and that the evolving nature of it encouraged best practice and the sharing of ideas based on their lived experiences.

Facilitators described how they were supported after they had delivered a session or course. One valued way was a one-to-one telephone meeting with another team member, F6, and also one supervision meeting per course (four sessions) with external support. All five facilitators described how they felt that the one-to-one telephone meetings with F6 were helpful and made them feel supported: We can chat through things that went well, or things that didn’t go so well, situations maybe within the group, things that I want a bit of support on how maybe we can best support this participant … So we have that, which is really useful. (F4)

F6 who provided this support, reported that the structure of having a one-to-one after every session meant that she was able to keep in regular contact with other facilitators.

Telephone debriefs helped facilitators with difficulties that arose within the session. For example, F1 highlighted that the debriefs provided her with reassurance that if a safeguarding issue was to occur, she would have the right-support mechanisms in place to deal with it effectively.

Two participants reported using the one-to-one sessions to feedback their perspectives on the content of the sessions and develop the course: We’ve always got that one-to-one … so you’re able to talk through things that have gone well, things that have gone difficult, things that you might do differently week on week, So you’re always actually feeling you’re in the evolution of the course (F5).

All five participants, who were supported by F6 reported that the debrief encouraged them to reflect on the session they had been involved in: The debriefs with [F6] are useful … I think because she often reflects on an aspect, which isn’t necessarily the angle you were coming from, so you get another angle to look at something which is really useful. (F2)

Although all participants reflected positively on the one-to-one debriefs, two participants described how they had found some elements challenging but could understand the reasons behind why it had been organized. Both participants stated that they sometimes found it challenging to provide feedback information within the debrief as nothing had seemed particularly challenging or remarkable within the session. However, they still felt that it was important to have the debriefs should support be required: So that’s the only part that’s difficult, I know I’ve got to do a debrief, so sometimes if nothing sort of major has. gone wrong … it sometimes becomes a little bit of a tick box … But I suppose it’s about making sure that you’re supported and have been able to feedback main issues (F1)

Three facilitators reported that the team aspect of supervision was important to them and that it gave them the opportunity to hear other perspectives and ideas: I think with so many people involved and so many ways of looking at things, it then means that the changes are far higher of the course being approachable and understandable by the people who come on it. Because, they’re also diverse, aren’t they(F2).

The debrief supervision also received critique. Two facilitators reported that they felt the 2-hour session was too long: I just find it too long, if we haven’t got a course and we haven’t had a course since the last time we saw him … there’s nothing we can really discuss. (F4)

Another facilitator described some of the logistical difficulties with attending supervision after delivering a course session: Some people have missed supervision because they literally can’t get back [to office] after a course. (F1).

Overall, participants reported feeling supported when facilitating the EC program. The initial preparation phase led to confidence in feeling able to run the program sessions. The one-to-one sessions and supervisions provided opportunities for the facilitators to reflect and develop new collaborative approaches to the development of the course after they had facilitated the program, and the support of their co-facilitator and the written materials provided support during the delivery periods.

Impact of the course

Facilitators

All six facilitators reported that the content of the course was effective in conveying the different points relating to communicating with a person living with dementia. Facilitators described different situations where they had witnessed participants engaging with the content and developing their own skills: In terms of the course, I think what they get out, what a lot of people really get out of it is just sharing with each other, and I think that’s where the course is good, because it’s really open to that, and I always think a course has gone really well when we don’t do much talking. And that’s when I really think, oh you know what we’ve cracked this. (F4)

The ongoing development of the course was important to all six facilitators. Each facilitator described how, through using their experiences from facilitation, they had regular opportunities to personalize the course: It feels like you’re actually growing the course or you’re helping to shape it, so your views are really taken on board … I feel like we all do have quite a lot of input into it. (F1)

Alongside the overall development of the course, all facilitators reported that they were able to be flexible when delivering the course content and make judgments about what course content would be most beneficial to each individual group. This is the material, you take it and make it your own, which is really good (F3)

Facilitators therefore took ownership of the materials they delivered and could adapt the course content to fit the context of their course attendees. This was possible due to both their personal experiences and skills but also the way the materials had been developed in that they did not need to follow a fixed pattern.

The five facilitators who had undertaken the course training all reported that they had enjoyed their facilitator role. All five facilitators commented on how they felt part of a team and enjoyed working with their facilitators: I think the course has brought us together as a group of facilitators, and there’s a really strong bond between us. (F1)

Five facilitators also described how they found facilitating the course rewarding: I think it’s a privilege … it’s a privilege to be able to do it, I love it, Its so rewarding. I feel really honored to be part of the team. (F5)

Specific examples of this related to seeing how the course positively impacted the participants in the group. For example, when discussing how a group attendee had fed back how much her relationship with her father had improved through using techniques she had learnt on the course, F3 stated: And when you see that sort of thing happening, it’s just so heart-warming, it’s wonderful. (F3)

Although the majority of experiences that were articulated were positive, two facilitators described how they sympathized with some of the difficulties that the participants on the course were facing. However, both facilitators highlighted that although some of the situations with participants were difficult, the course still had a positive impact on them: The example with Richard was sad, I thought, Oh my god the sudden realization that his wife of 50+ years isn’t going to get better. But … the positive is, he can now take that and make the rest of it still much better, rather than anger and frustration. (F5)

Participants voiced numerous positive experiences of their role as a facilitator. Strong friendships developed and individuals reported satisfaction in their roles.

Course attendees

The positive experiences of the facilitators were reflected in the positive feedback of course attendees. Attendees commented on the content and format of EC, as well as the facilitators. The themes identified within participant comments were: Course format; Care partner attendees’ perspective on facilitators and Suggestions for Improvements (both facilitators and care partner attendees identified areas for improvement).

Course format

Participants described generally appreciating the course both in terms of how the material was delivered and what material was delivered. They articulated their opinions regarding the length of sessions within the Empowered Conversations courses. Eighteen participants found the 2.5-h sessions an appropriate length for all necessary information to be adequately addressed: Yeah, I think about the right time … It stops people from getting a bit bored, doesn’t it, if that’s the right word to use (Bill).

Two participants mentioned that due to caring and working responsibilities, a longer session duration would pose difficulties due to individual’s current situations: Anything longer than that could have maybe been a bit awkward for me, but the two hour one was just perfect for my situation (Jane).

Seven participants reported that they would like longer sessions. Feelings around this largely related to participants wanting to discuss topics further: There were times when we could have spent more time talking about what was going on (Helen)

Only one participant stated that they would have preferred a shorter session: I thought they were a bit long, I felt probably two hours would have been better. (Jess)

The EC course comprised four sessions and participants had varying perspectives as to whether this was an appropriate number. Twelve of the 28 participants stated that they felt that four sessions were an adequate amount: I think if you’d have had it any longer, I think it would have lost its impact. (Sally)

While 12 participants said they would like more sessions: Sometimes it wasn’t long enough. You’d be getting really interested and the session ended. (John)

A couple more participants made mixed comments relating to whether they would like more sessions in the course. Both acknowledged that more sessions could have been good, but both also felt fine with the amount they learnt within the time frame: If there is more to learn and more sessions could be put on, fine, but for what we learned it was probably the right number of sessions. Sometimes I felt we could do more, but we were never rushed, and everything was done thoroughly. (Suzie)

Twenty-one participants reported that they felt happy with the weekly structure: It actually gave you time to put into context or practice something that you had spoken about that particular week, that worked well for me. (Claire)

Participants articulated general positive comments relating to the content delivered within the course. Nine participants relayed that they had found the animation films particularly useful and that they had helped them to gain a deeper insight into dementia and the associated issues: The animations are very good for making a point very sharply and quickly (Rosie).

Twenty-three participants described how they enjoyed the group aspect of the course. Reasons for this were identified as opportunities to make connections between one another and participants feeling supported and listened to: You were talking to a small group of people that you bonded with (Ivan)

Nine participants reported that the diverse nature of the group was important to them and that they enjoyed listening to the experiences and feelings of others within the group: Just speaking to other people that actually lived with people with dementia, and again learning that everyone is so different, it is not like everybody does the same things … it was really good speaking to other people. (Claire)

Six participants specifically described how the course provided them with a secure and open environment to openly discuss their experiences and perspectives: It was a really nice group of people where we felt quite safe and relaxed … I found it was part of my healing process. (Amanda)

Care partner attendees’ perspective on facilitators

Positive perspectives of facilitators were reported with nine participants specifically commenting on their positive experiences relating to this. It appeared to be particularly poignant for participants that the facilitators had their own lived experience of caring for someone with dementia as this created mutual understanding: They were very open and transparent and willing to share their own experiences (Rosie)

Participants felt welcomed and looked after by the facilitators and this enhanced their overall experience of the course: I felt as though you were looked after (Amanda). With the safe and secure environment of the course leading to confidence in sharing experiences: To create that kind of environment where you felt comfortable in sharing was also a testament really to the facilitators (Sally)

Suggestions for improvements

Although the majority of topics discussed were positive, both the facilitators and attendees also provided insights into how they felt the Empowered Conversations course could be improved. First, the facilitator improvements are discussed.

Five facilitators reported that their main difficulties when facilitating the course were regarding the logistics of the venues. This included not knowing which room they were facilitating in how they would set up the I.T equipment and how the sound works within the room: The only things that don’t go well are connected to the physical angles of the course. So sometimes room booking, type of room, I.T facilities and the physicality’.(F5)

Five facilitators also relayed that they thought the marketing of the course could be improved. Four facilitators highlighted that they wanted more marketing resources to be developed to ensure that the course reached a wider audience and accessed more people.

A specific example of this includes how one facilitator statement relating to how the course should be marketed to health-care professionals: I think every health professional ought to know about it, basically. Because it undoubtedly works. (F3)

Another facilitator outlined that they thought the course marketing needs to be more explicit in that the course provides support but does not provide answers for carers of people living with dementia: I think that’s the most difficult bit actually. So it’s not so much where it doesn’t go well, but it’s where maybe we need to be even more explicit that we are not here to give answers. (F4)

Only one facilitator commented on the research aspect of the course and described how sometimes asking people to fill in a questionnaire proved challenging as attendees of the group were not always willing to share some of their more personal emotions. When referring to an attendee of the group, the facilitator said: We had one family group and one of the children went, I don’t want to do this, I don’t want to answer questions about how I’m feeling, it’s not about me, it’s about my dad’. (F4)

However, the facilitator also acknowledged that they could not find any other solutions as to how to capture the data: I don’t know any other way of doing it, because I don’t think, if we emailed that before they came, I don’t think they’d fill it out. But that’s a difficult aspect of the course’. (F4)

F6 highlighted some of the challenges associated with accessing care partners. She acknowledged that it was difficult at times to work with dementia support services and local councils. However, she described how this could be overcome with more resources and time at the beginning of the project: I think just having that ramp up time when you start a new project is really important and not underestimating the amount of time it takes to go out, to do the footwork, to build up the signposting, to find the venues, that is really time consuming. (F6)

Participants reflected on how the course could be improved in the future and made several recommendations. This is largely related to further consideration of the logistical elements of facilitating a course, improved marketing and more effort and resources into course set up and development.

Aspects that could be improved from the attendee perspective

Sixteen participants expressed aspects of the course that could have been improved or additions that could have been made, 11 of these comments related to content covered in the group or its format. Five comments related to the dynamics of the group, with five participants expressing that at times they felt that these proved challenging. This is largely related to participants feeling that certain members dominated some of the exercises and that this prevented other members from having equal input. For example, It became an offloading session …. (Rebecca); and Some things were over-talked (Florence).

One participant commented that it would have been better if the group size had been bigger to gain the benefit of wider perspectives: It would have been nice to have other people’s perspective as well I think …. Three’s a bit small, six would have been a good size, or possibly eight at the most (Rosie).

Another participant felt the first arrival to the course was intimidating and a way to combat this would be to have an allotted slot of time where participants could informally get to know each other: But it’s that first bit of when you walk in the room, is just perhaps just to mingle a little bit at first, rather than just coming in and sitting straight down into the circle (Celia)

Further comments related to specific exercises within the course e.g.: The one where the carer sat back to back, I didn’t agree with that one (John)

Or to specific suggestions about the content of the course: It would be nice to know a bit more about the different types of dementia and how to deal with patients and what’s the signs to look out for early detection, (Aisha). However, this participant was also working professionally with people living with dementia and acknowledged that it was in this role that such information would have been particularly helpful.

Discussion

Careful consideration about how to support those facilitating the EC course was evident in the findings relating to the different time periods each facilitator received support, both before delivering a course, during the course facilitation period, and after the course had ended. In this way, each facilitator was offered a regular opportunity to reflect on the process and content of the EC course. This reflective cycle (Kolb, 1984) not only offered multiple opportunities for each facilitator to reflect on their experiences of delivering the course but promoted a sense of wellbeing and confidence in taking their roles forward to the next session or course. In this way, a reflective practitioner model was encouraged and supported (Schon, 1983) contributing to the positive impacts reported by the facilitators on themselves and their perceptions of the impact on course attendees. Suggestions for improvements in the course from participants and facilitators related largely to logistics (attendee pre-course information and settling in period and how facilitators organized the groups) rather than content. Suggestions on content were largely related to individual circumstances, for example, professional roles and the age range of a person living with dementia, rather than missing topics. These positive findings reflect the process of development of the EC approach and the support for the facilitators, and the value of the lived experiences of caregiving of facilitators on their credibility with course attendees.

High levels of support were reported before, during and after the delivery of the program by facilitators promoting a reflective cycle for each individual facilitator that promoted confidence in the delivery of the program. Suggestions for improvements related to logistical issues rather than the content of the program which facilitators reported on positively as they were relevant and appropriate for delivery to the course attendees. This reflects the process of developing the materials and then adapting for use with care partners of people living with dementia.

Implications

Peer-led education has been reported as beneficial in other studies due to the empathic relationships between facilitators and learners based on shared experiences (Jin et al., 2019). Therefore, the implications of providing support to peer facilitators to enable them to provide a high-quality learning experience is a key implication for others seeking to develop peer facilitated education from our research. Our research also reinforces the importance of co-creating learning and support experiences with and for peer educators (Ogrin et al., 2017) to enable a positive outcome for both the facilitator and those attending a course.

Conclusions

The content of the EC program is strong and the reflective cycle for facilitators encouraged via support mechanisms prior to, during and following the delivery of sessions is effective. Upon upscaling this work, it is important that these support structures are maintained and adapted for new facilitators. Facilitators were less confident around logistical issues that emerged when delivering the program, and the most commonly described improvements from attendees' perspectives were: more course sessions and better management of group dynamics when one member of the group dominated. Introducing a support session focussing on examples of logistical issues experienced and how these can be addressed most effectively would be a useful addition to the support mechanism already devised for facilitators. Participants who had attended the EC program valued facilitators sharing their lived experiences and the overall format of the course largely suited their personal circumstances and could be applied to their day-to-day caregiving. Thus, the EC program had a positive self-reported impact on both our participants who were facilitators and who were course attendees.

Ethics statement

This work received ethics approval from the University of Salford, Health, and Society ethics committee approval number: HSR1617-176

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the National Lottery [grant number 10010293441].