COVID-19 Pandemic & My NIHR SPARC Placement

Moral injury prevention and intervention

Background: Those working in high-risk occupations may often face ethical dilemmas that violate their moral code which can lead to moral injury (MI). While research into the impact of MI is growing, evidence for effective treatment interventions and prevention approaches remains limited. Objective: To review recent developments in treatment and prevention approaches for MI-related mental health difficulties. Method: We synthesised emerging treatments, including trauma focused therapies and spiritual approaches, as well as possible prevention strategies. Results: Conventional treatments for post-traumatic stress disorder (PTSD) (e.g. prolonged exposure) often inadequately address MI and may exacerbate symptoms. Adapted or novel approaches, including Impact of Killing, Adaptive Disclosure, and Restore and Rebuild, show promise, particularly when co-produced with patients and clinicians. Spiritual interventions demonstrate mixed outcomes. Prevention research remains very limited but highlights the potential of systemic reforms, leadership fostering psychological safety, preparedness training, structured reflection, and peer support. Evidence remains constrained by small samples, military-focused populations, and inconsistent measurement of MI. Conclusions: While no gold-standard intervention exists, values-based and compassion-focused approaches appear promising. Prevention strategies targeting organisational culture and fostering preparedness are urgently needed, particularly for civilian and diverse occupational groups, to better support and protect those exposed to potentially morally injurious events.

Predicting hypotension, syncope, and fracture risk in patients indicated for antihypertensive treatment: the STRATIFY models

Abstract Antihypertensives are associated with increased risk of syncope, hypotension, and fractures, but the highest-risk individuals are unclear. This study aimed to develop and validate three models to predict these outcomes in patients with an indication for antihypertensive treatment. A cohort study was conducted using data from Clinical Practice Research Datalink (CPRD). Patients aged 40+ with systolic blood pressure 130-179 mmHg were included. Outcomes were first hypotension, syncope, or fracture leading to hospitalization or death within 10 years. Models were derived from CPRD GOLD data (n = 1,773,224) and validated with CPRD Aurum data (n = 3,805,366). Each model had 31-37 predictors. Validation demonstrated strong discriminative ability (10-year C-statistic: hypotension 0.824; syncope 0.819; fracture 0.790), with close agreement between predicted and observed risks for the hypotension and syncope models. Some underprediction was observed for the fracture model. These models could be used to help reassure patients about the relatively low risk of harm from antihypertensive treatment, or identify the small number of individuals with a higher risk where additional monitoring may be indicated.

Practitioners’ views on the measurement and management of postural hypotension in general practice: a qualitative inquiry

Background Postural hypotension is associated with cognitive decline, falls, and all-cause mortality, representing a substantial burden on the NHS. Postural hypotension is often asymptomatic, making detection and treatment difficult. Currently, there is no systematic approach to measuring and managing postural hypotension in UK general practice. Aim To explore barriers to and facilitators of improving postural hypotension measurement and management. Design and setting This was a qualitative interview study with healthcare practitioners (HCPs) in general practices in England. Method Individual, remote, semi-structured interviews were conducted with a range of HCPs who measure blood pressure in general practice to explore their views and experiences of measuring and managing postural hypotension. Participants were identified from expressions of interest during a national survey. Interviews were video- and audio-recorded, transcribed verbatim, and analysed thematically. Results In total, 26 HCPs in 24 practices across nine clinical research networks in England were interviewed between March and July 2023. HCPs checked for postural hypotension when patients were older, reported dizziness, fatigue, or had chronic conditions. Despite awareness of clinical guidelines, various diagnostic definitions were provided and measurement protocols varied between participants. Sit-to-stand rather than supine-to-stand measurements were considered more feasible owing to time constraints and patient mobility. Education and training, as well as incentives and specialist clinics, were suggested as methods to improve postural hypotension measurement and management. Conclusion This is the first study, to our knowledge, to explore barriers to and facilitators of postural hypotension measurement in English general practice. Findings suggest a more systematic approach to measurement is needed to improve detection and management of postural hypotension in general practice.

Implementing trauma-informed practice across services to support people experiencing multiple disadvantage: a mixed method study

Background People facing multiple disadvantage have often experienced extensive trauma. Changing Futures Bristol was part of a national programme to improve outcomes for people who face multiple disadvantage, such as combinations of homelessness, substance misuse, mental ill-health, domestic violence and abuse or contact with the criminal justice system. Aims were to understand how services could be improved, with more trauma-informed approaches at individual, service and system levels. An in-depth mixed method evaluation of Changing Futures Bristol examined how trauma-informed approaches were implemented and linked across services supporting people experiencing multiple disadvantage. Methods The study followed a participatory action research approach, involving research conducted in collaboration with people who have experienced multiple disadvantage, and staff partners. Collaborators actively contributed to securing funding, research design, data analysis, and write-up. A staff survey was conducted using existing measures and some tailored questions, to assess perceptions of trauma-informed approaches, equality, diversity and inclusion, and co-production. One hundred and seventeen staff responded, with 30 staff completing the survey again after one year to track any changes. Twenty-three staff members were interviewed. Qualitative data were analysed thematically, guided by trauma-informed principles and implementation domains. Results Movement toward more trauma-informed approaches was detected, although these changes were not found to be statistically significant after one year. Barriers included short-term funding and commissioning cycles and difficulties in staff retention, due to short-term contracts, vicarious trauma, stress and pressures of the job. Managers had to hold contradicting drivers to deliver targets and manage finances whilst creating space for relational support and trauma-informed practice. To create psychological safety, staff needed to feel trust and transparency. 73% of staff reported lived experience of at least one domain of multiple disadvantage or trauma. Support for staff is needed at all levels of the organisation. Conclusions A long-term, collaborative, and trauma-informed approach is needed at all levels, including leaders, managers, policymakers, and central government. Government and public service reforms that focus on cross-sector collaboration and devolution of power will support trauma-informed practices. Stable, long-term funding and planning will help create a motivated, skilled workforce that can build on existing good practice.

Distribution and quality of privately-funded general practices in England: a cross-sectional analysis

Abstract Background Public surveys indicate demand for privately-funded general practice services in England has increased. However, little is known regarding the number, location and quality of private general practices. Aim To examine: 1) the geographical distribution of private general practices across England; 2) the relationships between access, continuity of care and funding of NHS general practices with nearby private practices; and 3) the quality ratings of NHS and private general practices. Design & setting Cross-sectional analysis of NHS and private general practices in England as of April 2024. Method We used the Care Quality Commission (CQC) Primary Medical Services Inspectorate to identify all private general practices in England. We used multilevel logistic regression to examine associations between NHS practice characteristics and the presence of a private general practice nearby. We then compared available CQC ratings. Results As of April 2024, England had 358 private and 5,976 NHS practices. Private general practices are primarily in London and other urban areas. NHS practices with higher patient satisfaction with waits for appointments (odds ratio 1.08 (95% CI: 1.03–1.13)) and more GPs per 10,000 patients (1.04 (1.01–1.06)) were more likely to have a private practice nearby. There was no association with continuity of care or funding. Quality ratings were similar, although 44% of private practices were unrated by the CQC. Conclusion Private general practices are more common in London, as well as areas with better access to NHS GPs. The growth in private general practices may have widened inequalities in access to primary care.

Calcium and Albumin Blood Tests, Ethnicity, and Cancer Incidence in Primary Care in the UK

Simple Summary For many common blood tests, typical values differ for patients from different ethnic groups. Although it is known that albumin and calcium tests may be useful in identifying patients with a higher-than-average cancer risk, the evidence is limited and does not take into account patient ethnicity. Examining the blood test results in a large English primary care dataset demonstrated that having either low albumin or high calcium was predictive of cancer risk, and more specifically risk of myeloma. Having low albumin was also predictive of liver cancer. There were no differences in how effective these blood tests are at estimating cancer risk for patients from different ethnic groups. Abstract Objectives: This study aimed to assess any ethnic differences in blood calcium and albumin levels for patients receiving these tests in primary care, and to investigate how this affects the use of these markers in assessing cancer risk. Methods: The analysis was based on a primary care dataset comprising patients in England. Multilevel logistic regression was used to investigate the relationship between blood test results and cancer risk by ethnic group. Results: A total of 4,632,856 patients were eligible for the albumin analysis, and 1,979,763 for the calcium analysis. Raised calcium levels were indicative of an increased risk of cancer, with diagnostic odds ratios (ORs) ranging from 2.0 to 2.7 for the different ethnic groups. ORs for myeloma were between 6.6 and 13.6. Similarly, low albumin was associated with an increased risk of cancer with an OR of between 3.2 and 3.8, myeloma (OR between 8.7 and 10.0), and liver cancer (OR between 9.2 and 15.7). Conclusions: Albumin and corrected calcium were effective indicators of cancer risk, and more specifically of risk of myeloma. Albumin levels were also linked with liver cancer risk. While there are some differences in typical corrected calcium and albumin levels between ethnic groups, there was no evidence that this had an effect on the usefulness of these markers to infer cancer risk.

Understanding and improving compound pressures in general practice: a realist review protocol

Abstract Background Compound Pressures (CP) significantly impact the role of General Practice (GP) in supporting human health. These pressures include climate change, pandemics, and financial crises. CP can be predictable, pre-determined, or unpredictable in nature and scope. Strategies to address the demands arising from CP range from short-term initiatives to buffering existing GP systems to ensure flexible and agile resources. Interventions designed to prevent, identify, and manage CP may result in both intended and unintended outcomes. Aim To conduct a realist appreciative inquiry, realist review, and three embedded studies within a review (SWAR) about CP affecting GP and the delivery of effective, equitable patient care. Design & setting Realist appreciative inquiry, realist review, and three SWARS. Method We will conduct a realist appreciative inquiry facilitating patient and stakeholder input into the review scope, focus, and initial programme theory development. This approach emphasises the identification of assets, successes, hopes, and aspirations to enable positive change. Based on these insights, we will conduct a realist review of empirical and grey literature. This project includes three elements of methodological innovation (SWARs). First, evaluation of how appreciative inquiry can inform initial programme theory development. Two further SWARs will examine how artificial intelligence might a) support the identification of relevant resources at title and abstract, and full-text stages, and b) support data extraction and analysis in future realist reviews. Conclusion Our research aims to understand the effects of CP on GP, supporting preparation and solutions that can inform future policies, interventions, and support systems.

Regression towards the mean—a plea for civility in peer review

Peer review is integral to the ongoing publication of high quality research. In pursuit of this aim, reviewers are expected to provide constructive feedback that helps authors improve their manuscripts. All too often, however, peer reviewers fall into the trap of harsh criticism rather than critical evaluation. Common pitfalls include reviews that are overly negative or incredibly brief, give little acknowledgment of the strengths of the manuscript, and use an unfriendly or insulting tone

Social prescribing for children and young people

Mental ill health in children and young people is a global problem. In 2019, one in seven children and young people had diagnosed mental health conditions. The drivers for this high burden are complex and include home-based and school-based risks, lifestyle factors, and vulnerabilities due to disability, discrimination, and socioeconomic circumstances.

The Health and Healthcare Outcomes of Trans and/or Non-Binary Adults in England: Protocol for an Analysis of Responses to the 2021 GP Patient Survey

Abstract Background: The large-scale quantitative evidence base to understand and improve health and healthcare outcomes for people who are trans and/or non-binary is still developing, although what research there is suggests that risk of poor health is high, and experiences of healthcare services are often poor. In 2021 the GP Patient Survey, which is carried out annually to measure patient experience in primary care in England, added inclusive questions about gender identity and trans status for the first time. Methods: This protocol paper pre-registers the methods that we will use for this work for a secondary analysis of these data, including both the statistical analysis protocol and early patient and public involvement work, to answer the following three research questions: (1) What are the (a) demographic characteristics, (b) health conditions, and (c) healthcare experiences of trans and/or non-binary adults in England? (2) Was there any difference in whether people who are trans and/or non-binary had been asked to shield during the COVID-19 pandemic or not compared with all other survey responders? (3) Does the relationship between being trans and/or non-binary, and self-reported long-term mental health problems, autism and autistic spectrum disorder and learning disability vary by age, gender, ethnicity, deprivation, sexual orientation or region? Keywords: trans; transgender; patient experience; primary care; healthcare outcomes; health

Antipsychotic prescriptions in people with dementia in primary care: a cohort study investigating adherence of dose and duration to UK clinical guidelines

Background In the UK, it is recommended by the National Institute for Health and Care Excellence (NICE) that if antipsychotics are initiated in people living with dementia, treatment should be at the lowest dose for the shortest time possible (1–3 months). In this study, we aimed to investigate how dose and duration of antipsychotic medication adhere to UK clinical guidelines and explore treatment restart details in those who stop treatment. Methods We did a retrospective cohort study using longitudinal UK primary care data from the IQVIA Medical Research Database. We included people living with dementia aged 60–85 years who received their first antipsychotic prescription between Jan 1, 2000, and Dec 31, 2023. Individuals with any previous antipsychotic prescriptions in their records more than 1 year before a dementia diagnosis and those who had missing social deprivation information were excluded from the study. Duration of first and subsequent antipsychotic treatment episodes, medication dosage, and treatment discontinuation and reinitiation rates were investigated. Duration and discontinuation were defined by grouping consecutive prescriptions into treatment episodes using the waiting time distribution method (80% inter-arrival density, 59 days). Daily doses were derived from strength and frequency information and categorised as low or moderate or high based on established minimum effective dose equivalences. People with lived experience of dementia care contributed throughout this project, shaping the research question and advising on interpretation and dissemination strategies. Findings In our dataset search, we identified 108 910 people with a record indicating dementia at any time. In total, 99 091 cases were excluded (ie, individuals with no antipsychotic prescription between the ages of 60 and 85 years between 2000 and 2023, a previous history of antipsychotics, missing deprivation information, or only one eligible prescription). We included 9819 people living with dementia aged 60–85 years who received their first antipsychotic prescription between 2000 and 2023 in the study. 5310 (54·1%) were female and 4509 (45·9%) were male, with a mean age of 77·1 years (SD 5·6 years), and ethnicity data were not available. The first treatment episode lasted a median of 7 months (IQR 6·6–8·7), exceeding NICE guidelines of 1–3 months and 18·1% [95% CI 17·4–18·9]) were initiated on a prescription above the minimum effective dose (ie, low dose). Of the 1781 participants who started on a moderate or high dose, 519 (29·1%) had a moderate or high dose in all quarters of the first year of treatment. 1 year after treatment initiation, 5136 (78·3%) of 6559 eligible individuals remained on medication (48·9% [95% CI 47·7–50·1] on low dose, 14·8% [13·9–15·6] on moderate or high dose of haloperidol, olanzapine, quetiapine or risperidone; and 14·6% [13·8–15·5] on other antipsychotics). Of the 5547 individuals eligible to restart treatment after initial discontinuation, 3106 (56%) restarted with a median treatment duration of 2·6 months (IQR 0·0–9·9). Interpretation This study highlights how antipsychotic prescribing in dementia is discordant with current NICE guidelines on both duration and dose. More than half of those who discontinued their treatment then restarted treatment. These findings emphasise a persistent gap between clinical guidelines and real-world prescribing, underscoring the need for interventions that prioritise safety and person-centred dementia care.

Primary care practitioners’ and patients’ views on the benefits and challenges of remote consulting for anxiety and depression in UK general practice: a qualitative interview study

Abstract Objective To explore primary care patients’ and practitioners’ views and experiences of remote consulting for common mental disorders (CMDs), to optimise their management in primary care. Design Qualitative study using in-depth interviews and thematic analysis. A topic guide was used to ensure consistency across interviews. The interviews were audio-recorded, transcribed verbatim and analysed thematically. There was patient and public input throughout. Setting Participants were recruited from general practices. Interviews were held by telephone or videocall between March 2023 and October 2023. Participants We interviewed 20 practitioners and 21 patients. Results Interviewees suggested benefits included convenience, increased anonymity and were easier for those feeling very low or anxious. Challenges included practitioners finding it hard to assess risk, which lengthened consultation duration or led to further contact, increasing practice workload and patients feeling anxious waiting for the practitioner to call. In-person appointments were viewed as important for initial consultations and providing a safe space. Continuity of care and practitioner training were identified as facilitators for telephone consultations, and both patients and practitioners identified training needs around how to deliver mental healthcare remotely. Conclusions Practitioners should aim to offer continuity of care and in-person appointments when patients initially seek help. Remote consultations may not be more time or cost-efficient for individuals with CMDs as risk is harder to assess. There is a need to evaluate existing training on delivering remote consultations to identify whether remote mental healthcare is included or should be incorporated in the future.

Cost-effectiveness of CA125- and age-informed risk-based triage for ovarian cancer detection in primary care

Abstract Background In England, current practice is cancer antigen 125 (CA125) testing with pelvic ultrasound scan (USS) if CA125 is ≥35 U/mL for triage of women with suspected ovarian cancer (OC) in primary care. However, OC risk varies with CA125 level and age. The Ovatools model predicts OC risk based on age and CA125 levels to support primary care triage. Method We evaluated five alternative triage pathways for suspected OC in primary care, using a decision model. Two CA125-USS sequential pathways used Ovatools risk: 1-3% (subsequent USS) and ≥3% (urgent referral), or age-adjusted CA125 thresholds equivalent to Ovatools risks. Three pathways involved concurrent CA125-USS testing, with referral if abnormal USS or one of the following: (1) Ovatools risk ≥3%, (2) CA125 above the equivalent age-adjusted threshold or (3) CA125 ≥35U/mL. Clinical and cost-effectiveness was compared against current practice for women over and under 50 years of age. Results All alternative pathways increased benefits at age ≥50 years, at additional cost. The incremental cost-effectiveness ratios for CA125-USS sequential pathways were below 30,000 British pounds, dropping below 20,000 British pounds if the Ovatools threshold for USS was increased to 1.2-1.4% risk. Discussion For women ≥50 years, the Ovatools and equivalent age-adjusted threshold sequential pathways are cost-effective compared to current practice.

Improving healthcare information for young people with ADHD in general practice: a qualitative study

Abstract Background Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder that can have poor long-term outcomes when unmanaged. Young people aged 16–25 years with ADHD are often unable to access specialist health care as recommended by UK guidelines because of gaps in services, poor transitional support between child and adult services, and long waiting lists. Healthcare information, which is important for condition management, may help mitigate service gaps and support thriving in people with ADHD; however, little is known about provision via primary care. Aim To investigate experiences of information provision supporting management of young people with ADHD in general practice and explore the potential of digital resources. Design and setting This qualitative study comprised interviews with young people with ADHD, their supporters, and primary healthcare professionals from sites across England. Method Participants were recruited from five purposively sampled general practices, varying by local area characteristics. Semi-structured interviews included questions about information provision, healthcare information needs, and digital resources. Themes were generated using reflexive thematic analysis, within a critical realist framework. Results In total, 20 participants were recruited (11 healthcare professionals and nine people with lived experience). Four themes were generated: lack of ADHD-specific resources, supporting patients with condition management, dedicated resources for clinicians, and digital resources enhancing care. Conclusion People with lived experience and healthcare professionals want better healthcare information about ADHD in general practice, including co-produced resources to support understanding and self-management. Digital resources represent a potentially cost-effective and accessible solution that is currently underutilised.

‘In It From the Beginning’: How Do Young Men and Boys Explain Their Entry Into Criminal Gangs?

Abstract This article reports on a qualitative study exploring the intersection of mental health, exclusion from school and entry into criminal gangs. It seeks to strengthen the young person’s perspective in the literature. It examines social and psychological mechanisms implicated in the process of joining and staying in gangs. Young people who have experienced exclusion from multiple services reported that, cash earned through illicit drug deals was a key driver to gang membership, enabling them to achieve independence and status. This appeared, at times, more central to their accounts than the search for belonging often cited as a motivator for gang membership.

The impacts of Liverpool Citizen's Advice on Prescription (CAP) on mental health outcomes– an Instrumental Variable (IV) approach

Highlights • Citizens Advice on Prescription provides advice/support via health services to reduce financial insecurity. • The intervention included a quick referral process with proactive follow-up by case workers. • It led to fewer antidepressant prescriptions and mental health emergencies. • It reduces mental health-related GP consultations and A&E attendances. • Citizens advice on prescription likely improves mental health and is cost-saving to the health service.

Exploring perinatal loneliness as a key social determinant of perinatal mental ill health in the UK: findings from a multidisciplinary consensus statement exercise that mapped knowledge about measurement, prevalence, antecedents, impacts and interventions, and agreed future priorities for research, policy and practice

Abstract Objectives: New parents are at increased risk of loneliness, which adversely affects parental and infant health and well-being and has been linked to an increased likelihood of parental mental illness. In the UK, perinatal mental illness is estimated to cost £8.1bn a year, predominantly due to lasting poor health and developmental consequences for children. The purpose of this consensus statement is to determine the state of this research field, highlighting key issues for researchers, policymakers and those responsible for perinatal mental health services and interventions. We will also highlight knowledge gaps to be addressed in future perinatal loneliness research. Design, setting and participants: The Parental Loneliness Research Group held six online meetings between October 2023 and May 2024, attended by academics and practitioners from the UK and USA. Attendees conducted a mapping exercise by appraising published, unpublished and ongoing perinatal loneliness research. The findings were shared with advisory groups, including parents with lived experience of loneliness. A consensus statement was then drafted, reflecting existing knowledge and gaps in the current evidence about the experience of perinatal loneliness in the first 1001 days. Results: A consensus about the definitions, measurement, prevalence, antecedents, impacts and interventions relevant to perinatal loneliness is outlined. Gaps in the literature are highlighted. Conclusions: Despite emerging research into perinatal loneliness, it is hard to determine prevalence due to limited analyses of national survey data. Recommendations for future research include secondary data analysis; prioritising equality, diversity and inclusion; reconsidering solutions to perinatal loneliness through a social justice lens; co-producing interventions, and rigorous evaluation of existing interventions.

Social Return on Investment (SROI) Evaluation of Citizens Advice on Prescription: A Whole-Systems Approach to Mitigating Poverty and Improving Wellbeing

Abstract Citizens Advice on Prescription (CAP), a Liverpool (UK)-based service, provides welfare advice and link worker social prescription support to people experiencing and at risk of experiencing financial or social hardship. CAP, which receives referrals from healthcare and third-sector services, aims to improve service users’ financial security, health, and wellbeing. A mixed-methods social return on-investment (SROI) analysis was used to evaluate this service. Between May 2022 and November 2023, a subset of service users (n = 538) completed the Short Warwick–Edinburgh Mental Wellbeing Survey (SWEMWBS) at baseline and a 2-month follow-up. Supporting quantitative and qualitative economic data were also collected (February 2023–February 2024) through semi-structured interviews (n = 16). Changes in social value were determined by comparing pre- and post-SWEMWBS scores. These scores were then mapped to monetary values using the Mental Health Social Value Bank (MHSVB). SROI ratios were then calculated by dividing the change in social value by the associated service provision costs. The mean social value change per person ranged from GBP 505.70 to GBP 697.52, and the mean service provision cost was GBP 148.66 per person. The overall study reported a positive SROI return range of GBP 1: GBP 3.40–GBP 4.69. The results indicate that non-clinical support services, like CAP, may be an effective intervention for addressing the wider determinants of health and wellbeing.

The Effectiveness of Social Media Campaigns in Improving Knowledge and Attitudes Toward Mental Health and Help-Seeking in High-Income Countries: Scoping Review

Background: The prevalence of mental health problems is increasing, particularly among young people, making the prevention of mental health problems and improvements in care a public health priority. Social media, with its wide reach and low-cost information dissemination, has emerged as an important tool for public mental health campaigns in high-income countries. However, there is a limited understanding of the reach of public mental health social media campaigns and their impact on mental health knowledge, attitudes, stigma, and behaviors, such as help-seeking. Objective: This review aimed to assess the effectiveness of social media campaigns in high-income countries in improving knowledge and attitudes toward mental health, reducing stigma, promoting help-seeking behavior, and reaching underserved communities. Methods: A scoping review was conducted, involving a comprehensive search of 5 databases (MEDLINE, Embase, PsycINFO, Web of Science, and CINAHL) and gray literature from January 2004 to May 2024. We included quantitative evaluations of social media public mental health campaigns from high-income countries with comparable social media use and public health care systems. A narrative synthesis summarized the study characteristics, campaign exposure, reach, and effectiveness by outcomes. Results: The review included 26 studies for analysis. Less than half of the studies (11/26, 42%) reported on the reach of mental health campaigns, but for those that did, younger age groups and women were more likely to be aware of campaigns. The most frequently reported outcomes were attitudes about mental health (17/23, 74%) and stigma (17/23, 74%), followed by mental health knowledge (16/23, 70%) and behavior change (15/23, 65%), such as seeking help for a mental health condition. While stigma and attitudes showed the most improvement before and after the campaigns (5/11, 45%), behavior change showed the least positive change over time (1/8, 13%). However, behavior change was the most improved outcome for those who were campaign aware compared to those unaware (12/12, 100%), whereas positive attitudes often did not differ. In fact, some studies showed campaign awareness was associated with negative stereotypes. Conclusions: The evidence highlights the potential of social media campaigns in improving mental health knowledge, attitudes, stigma, and behavior change. However, due to the methodological limitations of these evaluations, it is challenging to determine if the positive changes in these outcomes are a result of the campaigns or other factors. Campaign awareness seems to be important for initiating behavior change, but these changes are often short-lived. Sustainable impact on mental health requires both individual behavior change and service improvements. Targeting more mental health campaigns at underserved groups could help to reduce stigma and raise awareness in these groups, which could lead to timelier access to services. Consistent measurement of campaign reach and behavior change outcomes could help to understand and maximize campaign impact.

Ethical challenges confronted in non-clinical, public health research with young people in England

Abstract This opinion piece emerged from a collaboration of mental health researchers working on the National Institute of Health Research 3-schools mental health programme in underserved communities. The aim is to encourage debate and reflection on the challenges encountered with university research ethics committees when undertaking qualitative research with vulnerable young people. We explore the tension between principles of safeguarding and protection of research participants, on the one hand, and the potential for this oversight to become obstructive and thus to effectively stifle the voices and experiences of an already marginalised population, on the other hand.

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