Living with a genetic, undiagnosed or rare disease: A longitudinal journalling study through the COVID‐19 pandemic

Abstract Introduction COVID‐19 changed the way we lived with uncertainty from the outset as the pandemic impacted every aspect of our lives from well‐being, socializing to accessing healthcare. For people in vulnerable populations, such as those with genetic, undiagnosed and rare disorders, the experience was heightened. Aim The aim of this study was to identify how the rapidly changing COVID‐19 environment impacted the lives of the Genetic, Undiagnosed and Rare Disease community. Methods From June 2020 to May 2021, we collected monthly open‐ended journals from people living in Australia with genetic, undiagnosed and rare disorders. Data analysis was deductive, using the Resilience Scale for Adults, and inductive using thematic analysis. Results We recruited 29 people (average of n = 9.7 submissions each month). Responses changed over the year, with initial journals focusing on the importance of developing new structures for day‐to‐day lives, while later journals started to focus on mental well‐being. Throughout the project, participants reported challenges in accessing health and social care that was compounded by fear and concern over being exposed to the virus. Later journals highlight inconsistent messaging for vaccinations for this vulnerable community. Discussion/Conclusion In parallel with the waves of the COVID‐19 pandemic, there need to be waves of targeted support for vulnerable communities. The first support wave needs to focus on facilitating the identification of new frameworks to structure day‐to‐day lives. A later second wave needs to focus on mental well‐being and coping with isolation, while consistent communication relating to health and social care throughout was essential. Patient/Public Contribution This study was co‐designed, co‐led and analysed with a patient support network.


| INTRODUCTION
Genetic, Undiagnosed and Rare Diseases (GUaRDs) individually present infrequently, but are collectively common. In Australia, 'rare diseases' affect approximately 6%-8% of the population, impacting an estimated 1,574,000-2,063,200 people and their families. 1 People with GUaRDs are a vulnerable population, facing challenges in their search for a diagnosis, often referred to as the diagnostic odyssey, with multiple expensive and invasive investigations. 2 In addition, their day-to-day lives are impacted by multisystemic chronic illness, frequently with acute exacerbations. 3 Furthermore, those in the GUaRD community can face difficulty in connecting with peers and integrating seamlessly into the population whether through mainstream education or employment. 3 The lived experiences of the GUaRD community commonly centre on one patient group for example, fragile X 4 and epidermolysis bullosa 5 ; however, it is important to understand the experiences of the whole community. 6 As such, the Australian Federal Government has recognized the vulnerability and previous lack of focus on the GUaRD community and developed a National Strategic Action Plan with three pillars: (1) awareness and education, (2) care and support and (3) research and data aimed at promoting the 'best possible health and wellbeing outcomes' for this community. 7(p5) The COVID-19 pandemic has impacted all Australians, 8 though it has disproportionately affected vulnerable communities internationally with increased shielding and challenges with access to essential health and social care services. 9,10 The lived experiences of people with GUaRD, their carers and the support sector during this time of upheaval provided a unique opportunity to gather an understanding of how COVID-19 has affected their lives (both positively and negatively) and how this will shape their needs in the future. When faced with unprecedented circumstances, how this vulnerable community would respond to the uncertainty of a global pandemic and enforced restrictions is not known. Resilience has been defined as 'the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of stress'. 11(para4) However, resilience is not static and is known to exist on a continuum requiring a range of coping strategies to be deployed at different times. 12 For the purposes of this study, we define resilience as the dynamic ability to maintain/restore relatively stable functioning, which will ebb and flow, when confronted with stressful life events and adversity.
The need for resilience is not confined to vulnerable communities.
However, even before the pandemic, the GUaRD community had to draw on their personal strengths to overcome adversity to cope with the day-to-day challenges that present from living with a chronic illness. 13 The use of coping strategies has been associated with better quality of life for those with chronic illness 14 and their carers, 15 though the nature of a crisis, for example, the cause of the crisis, duration and extent of resource loss, is known to influence the efficacy of the mechanisms used. Previous pandemics, such as Ebola and Severe Acute Respiratory Syndrome (SARS), provide some learning on chronic illness, resilience and crisis situations. Though not linked to chronic illness, the International Medical Corp 16 reported an increase in mental health and psychosocial problems during the Ebola virus in Sierra Leone in 2014/15. In particular, they noted several factors linked to mental well-being such as, fear, stress and isolation. During the SARS outbreak in Hong Kong in 2003, Lau et al. 17 and others 18 observed that the subjective well-being of the elderly population was lowered, while young adults maintained their well-being within normative levels.
Keeping a journal is a commonly used approach to data collection in health services research, 19,20 though typically addressed at symptom management. 21,22 The use of journalling allows the capture of day-to-day activities alongside emotion and self-reflection. 23 As a research method, journalling permits the collection of longitudinal experiences and allows participants to be at ease with their level of self-disclosure. 23 However, there appears to be a paucity of studies using journalling for data collection relating to people with a chronic illness that explore the lived experience, beyond immediate health presentations, with a methodological preference for semistructured interviews to gather lived experiences, for example. 24,25 By contrast, this study looks to use journal keeping as a mechanism to capture longitudinal changes in the lives of the GUaRD community.
The aim of this study was to investigate how the rapidly changing COVID-19 environment influenced the lives of the GUaRDs community. In particular, we ask, (1) How has the COVID-19 pandemic impacted the well-being and resilience of people in the GUaRD community and what coping mechanisms have they used?
(2) How has the COVID-19 pandemic affected access to health and social care services?
(3) What lessons can be learnt for future health and social care service provision for people in the GUaRD community?

| Context
The global COVID-19 pandemic has been affecting countries worldwide at different times and with different intensities, with various governments enacting varying policies to manage the health of their populations. In Australia, COVID-19 has affected the various states of Australia in different ways. Figure 1 shows how Victoria endured the most extensive restrictions with 9 months of mask wearing and 8 months of restrictions related to leaving the house. In contrast, the Northern Territories have experienced no mask wearing and only 2 months of restrictions related to leaving the house. Additionally, Victoria is the only state to have imposed an extra restriction, limiting residents to stay within 5 km of their home.
The Genetic Support Network Victoria (GSNV) (https://www. gsnv.org.au/), a statewide organization focused on supporting people living with GUaRD and those who support them, and Australian Genomics (https://www.australiangenomics.org.au/), a research funded network supporting implementation of genomic medicine collaborated to codesign and deliver the study.

| Research design
This phenomenological, longitudinal, qualitative research study utilized open prompted journals to capture the lived experience of individuals with a GUaRD, their carers and support groups. Participants of the study were asked to keep a journal in any form they preferred (e.g., digital text, handwritten) in their preferred format (e.g., text, pictures) to share their lived experiences during the COVID-19 pandemic.

| Participants and recruitment
Individuals, older than 18 years of age, with a GUaRD, their carers or support group leaders living in Australia were eligible. Recruitment into the study was conducted through patient support group websites and their social media streams (e.g., Instagram). Potential participants were invited to contact the research team directly to obtain more information about the study. Participants who were interested were emailed a participant information sheet, written consent form, demographics form and the invitation to ask any questions. The recruitment period was through May 2020. Once participants returned the written consent and demographics form, they were considered as an enrolled participant for the study and sent the User Guide (File S2).

| Data collection
Participant journals were open-ended, and participants were free to share as much or as little as they preferred. Journals were collected via email each month from July 2020 until May 2021. Participants were informed each month, by email from the study admin lead, that the journals were due, in any format. There was no obligation to send in a journal and participants could opt out of the study whenever they wished. Regular study updates were provided via the GSNV newsletter. Each participant was given a number, and their journals including visual submissions were filed via a Virtual Private Network by month and participant number.

| Data analysis
We adopted a five-step approach to the longitudinal data analysis. 26 (1) Consider the analysis approach: The team discussed the potential for different approaches to analysis as the journals were being submitted over the first few months. Initially, we selected a deductive approach to help identify findings in relation to resilience theory. 27 (2) Setting up an analytic roadmap: To respond to the research questions, data were initially analysed using a resilience scale. Numerous resilience scales exist including some relating to genetic conditions (e.g., the Psychological Adaptation Scale). 28 However, these frameworks did not take into account the impact of unforeseen events for example, an international health crisis. As such, we looked to the broader resilience literature and identified the Resilience Scale for Adults (RSA). 29 This validated scale has been used in a range of settings and found to be responsive to users' experiences of resilience in crisis environments. 30,31 The RSA has five constructs, which include the perception of self, social competence, structured style, family cohesion and social resources (Table 1).

| Familiarization and coding
Journals were cleared of any personal identifiers and replaced with pronouns or pseudonyms to maintain confidentiality among the participants. Each participant was given an interviewee number for example, 1, 2, 3 and so forth location by state (QLD-Queensland, F I G U R E 1 Comparison of COVID-19 restrictions by state, March 2020 to March 2021. Sources: State Departments of Health and news agencies (detail in File S1) NSW-New South Wales, VIC-Victoria, WA-Western Australia), their role (e.g., carer) and age group. Each RSA division was used as a code for the data. The first month's journal submissions were coded independently (M. B. and S. B.) before gathering together to discuss how entries were categorized. On familiarizing ourselves with the journals, the coders (M. B. and S. B.) identified additional potential codes in the journals. The need to evolve the approach to data analysis is common in longitudinal qualitative research, 27 and we supplemented the deductive data analysis using thematic analysis. 32 Additional thematic codes included the direct impact of COVID-19 on health and social care services, turning points and coping strategies related to the pandemic ( Table 2). The coding was then completed by one author (M. B.) with fortnightly meetings to continue to discuss and resolve challenging coding. Visual submissions (photographs) were tied (M. B. and S. B.) to RSA codes or inductive codes where possible. (4) Describing cross-sectional data: Data analysis began as cross-sectional analysis, describing the findings month by month. Once over 6 months of data had been collected, the research team regularly reviewed the monthly analysis to identify potential longitudinal patterns in the coding. 33 Finally, (5) Exploring longitudinal data: After all the data had been collected, we adopted a trajectory approach to analyse our findings, to identify how experiences had changed over time. 34

| RESULTS
First, we present the characteristics of the participants and their journals before outlining the findings from the written text journals.
Themes from the journals relate to the RSA and additional thematic analysis (see File S3 for additional data from the journals supporting the RSA and thematic analysis).

| Response rates
In total, 27 people expressed an interest in taking part in the journalling project, completing the participant 'demographics' survey.
Seventeen journals were received at the first submission date in July 2020, and these 17 participants continued to contribute over the year. We subsequently received an average of 9.7 journals each month ( Figure 2).

| Characteristics of participants and journal submissions
Most participants were aged 46-59 years (n = 7), with six people daily rules/routines is made by the individual The continuation (or discontinuation) of daily rules/routines is influenced by an external factor (e.g., family members, doctors, etc.), not the individual The perception of self 'I know if I continue, I will succeed' The individual believes that they can continue on their path and achieve success The desire to continue and achieve success is mentally driven by the individual The desire to continue and achieve success is influenced by an external factor (e.g., family member, therapist, etc.)

| Characteristics of journals
Most participants (n = 10/17) solely used text using a word processor facility to record their journal. One participant hand wrote their journal and sent in photographs of their writing. Several participants (n = 5/17) submitted mixed media journals combining photographs, graphics and text. One participant sang their submission and sent it in as a video. The written journals varied in length from a few lines to several pages, with an average length of 5.5 pages, which remained fairly consistent over time.

| Themes
There was some variation in the themes identified by age group, The theme of structure was richly saturated at the outset of the project (July 2020 to September 2020), with many participants reporting the ways in which their usual routine was upset: The challenge now was to try and get back a sense of routine amongst the unpredictability of being in lock-

| Theme: Turning points
Turning points, as described in Table 2 Various other leisure activities also provided a mechanism to get out and enjoy the local community facilities (Figure 4). scenario, there is concern about the impact that this lack of care may have on longer-term physical and mental health for vulnerable groups. 8 The move to online services provided mixed experiences, with challenges with technology and connecting with health professionals.
Participants recorded a varied picture of health and social care information provision across the year. Most recently, this is typified by the discussion around vaccinations. Vaccine hesitancy in Australia is already higher than in many other countries. 36 Confused messages, misinformation, lack of information, fear and worry featured in journals as participants were unsure whether people with a GUaRD should access the vaccine due to their underlying condition. And if so, which one? The potential short-and long-term impacts of vaccination are particularly unclear for people with immunocompromising comorbidities. The need to provide clarity and consistency in health information is essential for vulnerable groups.

| Lessons for future crisis events
These findings are significant and provide lessons for future crisis events. Much as there have been waves of the COVID-19 virus, our participants identify that there need to be waves of different support offered at different times when people in the GUaRD community need it. The first support wave needs to be focused around helping the community adjust and recognize the importance of finding a new structure for their lives. This is likely to be an iterative process that the GUaRD community needs to be aware of. The subsequent support wave needs to include mental well-being support and finding a sense of self. While our journals suggest that this support is not needed immediately as a crisis occurs, as people are coping with the immediate effects of the pandemic and working out how it impacts them, it is clearly required a few months into the crisis. Our data also clearly indicate the need to support the younger population. Previous literature also suggests that this support will need to be continued once the crisis is alleviated. 18  benefits in empowering the participant, many of these features may be frustrating to the researcher, who may wish to delve deeper and be in control of data collection. 27 These concerns could be mitigated with follow-up interviews or focus groups to discuss the themes identified in the journals. Journalling provides an opportunity to gather longitudinal data, which aligns with capturing experiences during an ongoing global event. We started this project in June 2021, so missed experiences from the very early months of the COVID-19 pandemic. However, the study design ensured that we were able to gather the longitudinal experiences of this vulnerable group. Participation was voluntary and although we encouraged journal submissions in any format and length, due to the nature of journal writing, it is likely that we had a bias towards higher educated participants.

| CONCLUSION
This study supports the National Strategic Action Plan 7 in promoting awareness of the impact of GUaRD and has shown that the lives of the GUaRD community have been severely impacted by the COVID-19 pandemic. Timely support waves are required to ensure that this vulnerable community receives appropriate support when they need it including a first wave providing support to develop a day-to-day routine, consistency in health information and later, mental well-being guidance and direction. In line with these findings, further work is required to design, develop and test mechanisms to support people in the GUaRD community during challenging times.

ACKNOWLEDGEMENTS
We would like to thank all the participants who have contributed to this study. We would also like to thank Chloe Pike, who helped es-

CONFLICT OF INTERESTS
The author declares that there is no conflicts of interest.

ETHICS STATEMENT
Ethical oversight was provided by the Royal Childrens Hospital, Melbourne, Human Research Ethics Committee, with approval received on 15 May 2020.

DATA AVAILABILITY STATEMENT
The data for this study are not publicly available due to privacy and ethical restrictions.