To burn or not to burn: governance of wildfires in Australia.

Globally, wildfires are increasing in extent, frequency, and severity. Although global climate change is a major driver and large-scale governance interventions are essential, focusing on governance at smaller scales is of great importance for fostering resilience to wildfires. Inherent tensions in managing wildfire risk are evident at such scales, as objectives and mandates may conflict, and trade-offs and impacts vary across ecosystems and communities. Our study feeds into debates about how to manage wildfire risk to life and property in a way that does not undermine biodiversity and amenity values in social-ecological systems. Here, we describe a case study where features of adaptive governance emerged organically from a dedicated planning process for wildfire governance in Australia. We found that a governance process that is context specific, allows for dialogue about risk, benefits, and trade-offs, and allows for responsibility and risk to be distributed amongst many different actors, can provide the conditions needed to break down rigidity traps that constrain adaptation. The process enabled actors to question whether the default risk management option (in this case, prescribed burning) is aligned with place-based risks and values so they could make an informed choice, built from their participation in the governance process. Ultimately, the community supported a move away from prescribed burning in favor of other wildfire risk management strategies. We found that the emergent governance system has many features of adaptive governance, even though higher level governance has remained resistant to change. Our study offers positive insights for other governments around the world interested in pursuing alternative strategies to confronting wildfire risk.

Protons as second messenger regulators of G protein signaling.

In response to environmental stress, cells often generate pH signals that serve to protect vital cellular components and reprogram gene expression for survival. A major barrier to our understanding of this process has been the identification of signaling proteins that detect changes in intracellular pH. To identify candidate pH sensors, we developed a computer algorithm that searches proteins for networks of proton-binding sidechains. This analysis indicates that Gα subunits, the principal transducers of G protein-coupled receptor (GPCR) signals, are pH sensors. Our structure-based calculations and biophysical investigations reveal that Gα subunits contain networks of pH-sensing sidechains buried between their Ras and helical domains. Further, we show that proton binding induces changes in conformation that promote Gα phosphorylation and suppress receptor-initiated signaling. Together, our computational, biophysical, and cellular analyses reveal an unexpected function for G proteins as mediators of stress-response signaling.

Using a resilience thinking approach to improve coastal governance responses to complexity and uncertainty: a Tasmanian case study, Australia.

Conventional approaches to environmental governance and management are limited in their responses to uncertainty and complexity of social-ecological system (SES) change. Prevailing neoliberal and efficiency-based mindsets tend to focus on avoiding risk and creating "fail-safe" systems. In the last decade, resilience thinking has emerged as a means to transition from risk-averse, and command-and-control governance approaches towards those that are more adaptive, innovative and collaborative. To examine the practical usefulness of a resilience thinking approach, we used a complex, multi-layered case study of Tasmanian coastal governance. Drawing on the diverse expertise and a variety of key governance actors, we identified crucial problems being experienced with the Tasmanian coastal governance regime and discussed potential contributions of resilience thinking to address them. Thematic analysis of the results revealed three major contributions: resilience thinking (1) provides a way to think about change and uncertainty; (2) is compatible with proactive and entrepreneurial leadership; and (3) effectively considers issues of scale in the decision-making process. We conclude by offering practical suggestions towards devolved leadership and improved cross-scale collaboration, and consider the possibility of a hybrid resilience and risk-based approach to coastal management and governance.

A systematic review of qualitative studies of adults' experiences of being assessed for psychological therapies.

OBJECTIVE: To synthesize the qualitative literature on adults' experiences of psychological therapy assessments. The review was led by people with experience of undergoing assessments, with high levels of client involvement throughout. SEARCH STRATEGY: A comprehensive search of electronic databases was undertaken, with additional search strategies employed to locate further literature. INCLUSION CRITERIA: Studies were included that qualitatively explored the experiences of people aged 16+ who had been assessed for psychological therapy services. Assessments could be structured or unstructured. Qualitative was defined as any analysed account of people's experiences, including qualitative survey data. DATA EXTRACTION AND SYNTHESIS: Literature quality was appraised using the Critical Appraisal Skills Program checklist, modified to include client involvement and intersectionalities. Following data extraction, thematic synthesis was used to synthesize findings across studies. RESULTS: Of 12 743 titles were screened, with 13 studies relevant to the review. Themes and subthemes were identified at three stages of the assessment process: the journey to the assessment, at the assessment, and after the assessment. Findings highlighted the emotional impact of assessments, collaboration, intersectionalities, rights, pathologization, socioeconomic restrictions, and information and support needs. Implications and limitations were indicated. DISCUSSION AND CONCLUSIONS: Findings were situated within the trauma-informed (TIA) literature. Trauma-informed assessment principles, including collaborative assessments, may be fruitful means of improving people's experiences. Whilst the benefits of collaboration appear self-evident, explicitly collaborative approaches were not the norm, nor were studies conducted independently. Further service user research is needed. A greater understanding of the experience of minority groups is also needed.

Investigating the Extent to Which Patients Should Control Access to Patient Records for Research: A Deliberative Process Using Citizens' Juries.

BACKGROUND: The secondary use of health data for research raises complex questions of privacy and governance. Such questions are ill-suited to opinion polling where citizens must choose quickly between multiple-choice answers based on little information. OBJECTIVE: The aim of this project was to extend knowledge about what control informed citizens would seek over the use of health records for research after participating in a deliberative process using citizens' juries. METHODS: Two 3-day citizens' juries, of 17 citizens each, were convened to reflect UK national demographics from 355 eligible applicants. Each jury addressed the mission "To what extent should patients control access to patient records for secondary use?" Jurors heard from and questioned 5 expert witnesses (chosen either to inform the jury, or to argue for and against the secondary use of data), interspersed with structured opportunities to deliberate among themselves, including discussion and role-play. Jurors voted on a series of questions associated with the jury mission, giving their rationale. Individual views were polled using questionnaires at the beginning and at end of the process. RESULTS: At the end of the process, 33 out of 34 jurors voted in support of the secondary use of data for research, with 24 wanting individuals to be able to opt out, 6 favoring opt in, and 3 voting that all records should be available without any consent process. When considering who should get access to data, both juries had very similar rationales. Both thought that public benefit was a key justification for access. Jury 1 was more strongly supportive of sharing patient records for public benefit, whereas jury 2 was more cautious and sought to give patients more control. Many jurors changed their opinion about who should get access to health records: 17 people became more willing to support wider information sharing of health data for public benefit, whereas 2 moved toward more patient control over patient records. CONCLUSIONS: The findings highlight that, when informed of both risks and opportunities associated with data sharing, citizens believe an individual's right to privacy should not prevent research that can benefit the general public. The juries also concluded that patients should be notified of any such scheme and have the right to opt out if they so choose. Many jurors changed their minds about this complex policy question when they became more informed. Many, but not all, jurors became less skeptical about health data sharing, as they became better informed of its benefits and risks.

Novel ecosystems: Governance and conservation in the age of the Anthropocene.

Meeting conservation objectives in an era of global environmental change has precipitated debate about where and how to intervene. Ecological and social values of novel ecosystems are particularly contested. Governance has a role to play, but this role is underexplored. Here, we critically review the novel ecosystems literature to identify challenges that fall within the realm of governance. Using a conceptual framework for analysing adaptive governance, we consider how governance could help address five challenges. Specifically, we argue that reforming governance can support the re-framing of policy objectives for ecosystems where transformation is likely, and in doing so, it could highlight the tensions between the emergence of novel ecosystems on the one hand and cultural expectations about how ecosystems should look on the other. We discuss the influence of power, authority and administrative competence on conservation efforts in times of environmental change. We consider how buffering can address translational mismatch between conventional conservation policy and modern ecological reality. This review provides insights into how governance reform could enable more adaptive responses to transformative changes, such as novel ecosystems, while remaining committed to achieving conservation outcomes. Indeed, at their best, adaptive responses would encompass the reality of ecological transformation while being sympathetic to concerns about undesirable outcomes. Connections between researchers in the fields of governance, ecology and conservation could help to achieve these twin aims. We provide examples of governance and policy-making techniques that can support context-specific governance reform that supports more effective conservation in the Anthropocene.

Evidence for effective interventions to reduce mental-health-related stigma and discrimination.

Stigma and discrimination in relation to mental illnesses have been described as having worse consequences than the conditions themselves. Most medical literature in this area of research has been descriptive and has focused on attitudes towards people with mental illness rather than on interventions to reduce stigma. In this narrative Review, we summarise what is known globally from published systematic reviews and primary data on effective interventions intended to reduce mental-illness-related stigma or discrimination. The main findings emerging from this narrative overview are that: (1) at the population level there is a fairly consistent pattern of short-term benefits for positive attitude change, and some lesser evidence for knowledge improvement; (2) for people with mental illness, some group-level anti-stigma inventions show promise and merit further assessment; (3) for specific target groups, such as students, social-contact-based interventions usually achieve short-term (but less clearly long-term) attitudinal improvements, and less often produce knowledge gains; (4) this is a heterogeneous field of study with few strong study designs with large sample sizes; (5) research from low-income and middle-income countries is conspicuous by its relative absence; (6) caution needs to be exercised in not overgeneralising lessons from one target group to another; (7) there is a clear need for studies with longer-term follow-up to assess whether initial gains are sustained or attenuated, and whether booster doses of the intervention are needed to maintain progress; (8) few studies in any part of the world have focused on either the service user's perspective of stigma and discrimination or on the behaviour domain of behavioural change, either by people with or without mental illness in the complex processes of stigmatisation. We found that social contact is the most effective type of intervention to improve stigma-related knowledge and attitudes in the short term. However, the evidence for longer-term benefit of such social contact to reduce stigma is weak. In view of the magnitude of challenges that result from mental health stigma and discrimination, a concerted effort is needed to fund methodologically strong research that will provide robust evidence to support decisions on investment in interventions to reduce stigma.

Accelerating Progress: A New Era of Research on Character Development.

Adolescent character development is a high priority for educators, policymakers, and front-line youth workers. To meet this growing demand, and as exemplified in the five articles in this special section, character development scholars are drawing from a range of academic disciplines to push beyond the traditional boundaries of the science of character development. These articles highlight important trends in character research, including the co-development of a subset of character strengths, the articulation of developmental trajectories of character, the use of advanced methodological approaches, and the implications for education. Studies such as these are critically important for establishing the research base that will be used to design the character development programs of tomorrow.

Defining continuity of care from the perspectives of mental health service users and professionals: an exploratory, comparative study.

BACKGROUND: Continuity of care (COC) is central to the organization and delivery of mental health services. Traditional definitions have excluded service users, and this lack of involvement has been linked to poor conceptual clarity surrounding the term. Consequently, very little is known about the differences and similarities in the conceptualization of COC by mental health service users and professionals. OBJECTIVE: To explore and compare mental health service users' and professionals' definitions of COC. METHODS: Using an exploratory, qualitative design, five focus groups with 32 service users each met twice. Data were analysed thematically to generate a service user-defined model of COC. In a cross-sectional survey, health and social care professionals (n = 184) defined COC; responses were analysed thematically. Service user and professional definitions were conceptually mapped and compared to identify similarities and differences. RESULTS: There was crossover between the service user and professional derived models of COC. Both contained temporal, quality, systemic, staff, hospital and needs-related elements of COC. Service users prioritized access, information, peer support and avoiding services; health professionals most frequently referred to staff, cross-sectional and temporal COC. Service users alone identified service avoidance, peer support and day centres as COC elements; professionals alone identified cross-sectional working. CONCLUSIONS: Important similarities and differences exist in service user and professional conceptualizations of COC. Further research is necessary to explore these differences, prior to integrating service user and professional perspectives in a validated COC framework which could enable the development and evaluation of interventions to improve COC, informing policy and practice.

Influences on uptake of cancer screening in mental health service users: a qualitative study.

BACKGROUND: Cancers are a leading cause of death worldwide. People with mental illness are 30 % more likely to die from cancer than the general population. One reason for this may be low uptake of nationally offered cancer screening tests by people with mental illness. We aimed to identify barriers and facilitators for breast, cervical and bowel cancer screening uptake by people with mental illness in order to inform interventions to promote equal access. METHODS: The interview study was conducted in both urban and rural settings. The study was informed by the Theoretical Domains Framework, using framework analysis and triangulation across participant groups. Participants included 45 mental health service users (service users) eligible for cancer screening, 29 mental health professionals and 11 professionals involved in cancer screening. RESULTS: Themes emerging from the data that affected uptake included knowledge of screening programmes by both service users and healthcare providers; knowledge of, and attitudes towards, mental illness; health service-delivery factors; service users' beliefs and concerns about cancer screening, and practical issues. These are relevant to different stages of the screening process. Service users do not receive invitations to screening or cancer testing kits if they are admitted to hospital. They are not routinely invited for screening if they are not registered with a general practitioner (GP). Lack of integrated care means that mental health staff do not know if someone is overdue for a test and cancer screening is often not considered during health promotion. Barriers including information processing problems, the extent to which the screening process aggravates symptoms, poor staff client relationships and travel difficulties vary between individuals. Screening professionals are motivated to help, but may lack time or training to manage mental health needs. Reactive measures are available, but service users must request help which they may find difficult. CONCLUSIONS: There are specific barriers to cancer screening uptake for mental health service users that prevent equality of care. Interventions that can be personalised are needed at individual, policy and service-delivery levels. Primary and secondary care staff and policy-makers should work together to develop an integrated approach to cancer screening in this population.

Scenario analysis for biodiversity conservation: a social-ecological system approach in the Australian Alps.

Current policy interventions are having limited success in addressing the ongoing decline in global biodiversity. In part, this is attributable to insufficient attention being paid to the social and governance processes that drive decisions and can undermine their implementation. Scenario planning that draws on social-ecological systems (SES) analysis provides a useful means to systematically explore and anticipate future uncertainties regarding the interaction between humans and biodiversity outcomes. However, the effective application of SES models has been limited by the insufficient attention given to governance influences. Understanding the influence governance attributes have on the future trajectory of SES is likely to assist choice of effective interventions, as well as needs and opportunities for governance reform. In a case study in the Australian Alps, we explore the potential of joint SES and scenario analyses to identify how governance influences landscape-scale biodiversity outcomes. Novel aspects of our application of these methods were the specification of the focal system's governance attributes according to requirements for adaptive capacity, and constraining scenarios according to the current governance settings while varying key social and biophysical drivers. This approach allowed us to identify how current governance arrangements influence landscape-scale biodiversity outcomes, and establishes a baseline from which the potential benefits of governance reform can be assessed.

High prevalence of early hypothalamic-pituitary damage in childhood brain tumor survivors: need for standardized follow-up programs.

INTRODUCTION: Childhood brain tumor survivors (CBTS) are at increased risk to develop endocrine disorders. Alerted by two cases who experienced delay in diagnosis of endocrine deficiencies within the first 5 years after brain tumor diagnosis, our aim was to investigate the current screening strategy and the prevalence of endocrine disorders in survivors of a childhood brain tumor outside of the hypothalamic-pituitary region, within the first 5 years after diagnosis. PROCEDURES: Firstly, we performed a retrospective study of 47 CBTS treated in our center, diagnosed between 2008 and 2012. Secondly, the literature was reviewed for the prevalence of endocrine disorders in CBTS within the first 5 years after diagnosis. RESULTS: Of 47 CBTS eligible for evaluation, in 34% no endocrine parameters had been documented at all during follow up. In the other 66%, endocrine parameters had been inconsistently checked, with different parameters at different time intervals. In 19% of patients an endocrine disorder was found. At literature review 22 studies were identified. The most common reported endocrine disorder within the first 5 years after diagnosis was growth hormone deficiency (13-100%), followed by primary gonadal dysfunction (0-91%) central hypothyroidism (0-67%) and primary/subclinical hypothyroidism (range 0-64%). CONCLUSION: Endocrine disorders are frequently seen within the first 5 years after diagnosis of a childhood brain tumor outside of the hypothalamic-pituitary region. Inconsistent endocrine follow up leads to unnecessary delay in diagnosis and treatment. Endocrine care for this specific population should be improved and standardized. Therefore, high-quality studies and evidence based guidelines are warranted.

Anticipated and experienced discrimination amongst people with schizophrenia, bipolar disorder and major depressive disorder: a cross sectional study.

BACKGROUND: The unfair treatment of individuals with severe mental illness has been linked to poorer physical and mental health outcomes. Additionally, anticipation of discrimination may lead some individuals to avoid participation in particular life areas, leading to greater isolation and social marginalisation. This study aimed to establish the levels and clinical and socio-demographic associations of anticipated and experienced discrimination amongst those diagnosed with a schizophrenia and comparator severe mental illnesses (bipolar and major depressive disorders). METHODS: This study was a cross-sectional analysis of anticipated and experienced discrimination from 202 individuals in South London (47% with schizophrenia, 32% with depression and 20% with bipolar disorder). RESULTS: 93% of the sample anticipated discrimination and 87% of participants had experienced discrimination in at least one area of life in the previous year. There was a significant association between the anticipation and the experience of discrimination. Higher levels of experienced discrimination were reported by those of a mixed ethnicity, and those with higher levels of education. Women anticipated more discrimination than men. Neither diagnosis nor levels of functioning were associated with the extent of discrimination. Clinical symptoms of anxiety, depression and suspiciousness were associated with more experienced and anticipated discrimination respectively. CONCLUSIONS: The unfair treatment of individuals with severe mental illnesses remains unacceptably common. Population level interventions are needed to reduce levels of discrimination and to safeguard individuals. Interventions are also required to assist those with severe mental illness to reduce internalised stigma and social avoidance.

Stigma and disclosing one's mental illness to family and friends.

PURPOSE: People with mental illness face the dilemma whether or not to disclose their condition. We examined stigma variables and their relationship with comfort disclosing. METHODS: Comfort with disclosure, well-being, symptoms and aspects of experiencing and reacting to stigma were assessed among 202 individuals with mental illness. RESULTS: Controlling for symptoms, greater comfort disclosing one's mental illness was associated with lower anticipated discrimination and lower stigma stress; more comfort disclosing was related to greater well-being. CONCLUSIONS: Anticipated discrimination as an external threat and stigma-related stress as an internal process may reduce comfort with disclosure and could be targeted in interventions.

Incorporating sense of place into the management of social-ecological systems: The researchers' perspectives.

As the world around us changes, so too do the bonds that people have with their environment. These environmental bonds, or Senses of Place (SoP), are a key component of social-ecological systems (SESs). SoP has social, psychological and economic value, it impacts how people use and behave in an environment and how they respond to changes such as those caused by anthropogenic pressures. Despite this connection, the consideration and application of SoP in the management of SESs remains relatively under explored. This study takes the first step in addressing that gap by investigating the perceptions of researchers in the field. We achieve this by interviewing SoP researchers from around the globe to elucidate whether they see SoP as valuable for the management of SES. We also identify their perspectives on the barriers to, and enablers of, incorporating SoP into policy and management. Results show while researchers do see the value in incorporating SoP into policy, there are a range of barriers that impact this, most notably, the intangible nature of the phenomena and shortcomings of current governance systems. Results also identify a range of enablers that could improve the incorporation of SoP into policy-particularly through improved engagement and communication between stakeholders. These findings represent a first step in the formal inclusion of this social value into the management of SES.

How resilience is framed matters for governance of coastal social-ecological systems.

Effective governance of social-ecological systems (SES) is an enduring challenge, especially in coastal environments where accelerating impacts of climate change are increasing pressure on already stressed systems. While resilience is often proposed as a suitable framing to re-orient governance and management, the literature includes many different, and sometimes conflicting, definitions and ideas that influence how the concept is applied, especially in coastal environments. This study combines discourse analysis of the coastal governance literature and key informant interviews in Tasmania, Australia, demonstrating inconsistencies and confusion in the way that resilience is framed in coastal governance research and practice. We find that resilience is most often framed as (1) a rate of recovery from disturbance or (2) the process of acting in response to, or anticipation of, a disturbance. A third framing considers resilience as an emergent property of SESs. This framing, social-ecological resilience, accounts for multiple configurations of SES, which necessitates adaptation and transformation strategies to address changes across temporal and spatial scales. Coastal managers recognised the value of this third framing for governing coastal SESs, yet the confusion and inconsistency in the literature was also evident in how they understood and applied resilience in practice. Expanding the use of social-ecological resilience is essential for more effective coastal governance, given the dynamics of coastal SESs and the intensity of social, economic, and environmental drivers of change these systems face. However, this requires addressing the unclear, confused, and superficial use of resilience-oriented concepts in research and policy discourse.

The Definition of Recurrence of Differentiated Thyroid Cancer: A Systematic Review of the Literature.

Background: Recurrence is a key outcome to evaluate the treatment effect of differentiated thyroid carcinoma (DTC). However, no consistent definition of recurrence is available in current literature or international guidelines. Therefore, the primary aim of this systematic review was to delineate the definitions of recurrence of DTC, categorized by total thyroidectomy with radioactive iodine ablation (RAI), total thyroidectomy without RAI and lobectomy, to assess if there is a generally accepted definition among these categories. Methods: This study adhered to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. In December 2023, a systematic literature search in MEDLINE and EMBASE was performed for studies reporting on the recurrence of DTC, from January 2018 to December 2023. Studies that did not provide a definition were excluded. Primary outcome was the definition of recurrence of DTC. Secondary outcome was whether studies differentiated between recurrence and persistent disease. Two independent investigators screened the titles and abstracts, followed by full-text assessment and data extraction. The study protocol was registered in PROSPERO, CRD42021291753. Results: In total, 1450 studies were identified. Seventy studies met the inclusion criteria, including 69 retrospective studies and 1 randomised controlled trial (RCT). Median number of patients in the included studies was 438 (range 25-2297). In total, 17 studies (24.3%) reported on lobectomy, 4 studies (5.7%) on total thyroidectomy without RAI, and 49 studies (70.0%) with RAI. All studies defined recurrence using one or a combination of four diagnostic modalities cytology/pathology, imaging studies, thyroglobulin (-antibodies), and a predetermined minimum tumor-free time span. The most common definition of recurrence following lobectomy was cytology/pathology-proven recurrence (47.1% of this subgroup), following total thyroidectomy with RAI was cytology/pathology-proven recurrence and/or anomalies detected on imaging studies (22.4% of this subgroup). No consistent definition was found following total thyroidectomy without RAI. Nine studies (12.9%) differentiated between recurrence and persistent disease. Conclusion: Our main finding is that there is no universally accepted definition for recurrence of DTC in the current studies across any of the treatment categories. The findings of this study will provide the basis for a future, international Delphi-based proposal to establish a universally accepted definition of recurrence of DTC. A uniform definition could facilitate global discussion and enhance the assessment of treatment outcomes regarding recurrence of DTC.

Decision aid on disclosure of mental health status to an employer: feasibility and outcomes of a randomised controlled trial.

BACKGROUND: Many mental health service users delay or avoid disclosing their condition to employers because of experience, or anticipation, of discrimination. However, non-disclosure precludes the ability to request 'reasonable adjustments'. There have been no intervention studies to support decision-making about disclosure to an employer. AIMS: To determine whether the decision aid has an effect that is sustained beyond its immediate impact; to determine whether a large-scale trial is feasible; and to optimise the designs of a larger trial and of the decision aid. METHOD: In this exploratory randomised controlled trial (RCT) in London, participants were randomly assigned to use of a decision aid plus usual care or usual care alone. Follow-up was at 3 months. Primary outcomes were: (a) stage of decision-making; (b) decisional conflict; and (c) employment-related outcomes (trial registration number: NCT01379014). RESULTS: We recruited 80 participants and interventions were completed for 36 out of 40 in the intervention group; in total 71 participants were followed up. Intention-to-treat analysis showed that reduction in decisional conflict was significantly greater in the intervention group than among controls (mean improvement -22.7 (s.d. = 15.2) v. -11.2 (s.d. = 18.1), P = 0.005). More of the intervention group than controls were in full-time employment at follow-up (P = 0.03). CONCLUSIONS: The observed reduction in decisional conflict regarding disclosure has a number of potential benefits which next need to be tested in a definitive trial.

The development and validation of the Questionnaire on Anticipated Discrimination (QUAD).

BACKGROUND: The anticipation of mental health-related discrimination is common amongst people with mental health problems and can have serious adverse effects. This study aimed to develop and validate a measure assessing the extent to which people with mental health problems anticipate that they will personally experience discrimination across a range of contexts. METHODS: The items and format for the Questionnaire on Anticipated Discrimination (QUAD) were developed from previous versions of the Discrimination and Stigma Scale (DISC), focus groups and cognitive debriefing interviews which were used to further refine the content and format. The resulting provisional version of the QUAD was completed by 117 service users in an online survey and reliability, validity, precision and acceptability were assessed. A final version of the scale was agreed and analyses re-run using the online survey data and data from an independent sample to report the psychometric properties of the finalised scale. RESULTS: The provisional version of the QUAD had 17 items, good internal consistency (alpha = 0.86) and adequate convergent validity as supported by the significant positive correlations with the Stigma Scale (SS) (r = 0.40, p < 0.001) and the Internalised Stigma of Mental Illness Scale (ISMI) (r = 0.40, p < 0.001). Three items were removed due to low endorsements, high inter-correlation or conceptual concerns. The finalised 14 item QUAD had good internal consistency (alpha = 0.86), good test re-test reliability (ρ(c) = 0.81) and adequate convergent validity: correlations with the ISMI (r = 0.45, p < 0.001) and with the SS (r = 0.39, p < 0.001). Reading ease scores indicated good acceptability for general adult populations. Cross-replication in an independent sample further indicated good internal consistency (alpha = 0.88), adequate convergent validity and revealed two factors summarised by institutions/services and interpersonal/professional relationships. CONCLUSIONS: The QUAD expanded upon previous versions of the DISC. It is a reliable, valid and acceptable measure which can be used to identify key life areas in which people may personally anticipate discrimination, and an overall tendency to anticipate discrimination. It may also be useful in planning interventions aimed at reducing the stigma of mental illness.

Discrimination in relation to parenthood reported by community psychiatric service users in the UK: a framework analysis.

BACKGROUND: Experienced discrimination refers to an individual's perception that they have been treated unfairly due to an attribute and is an important recent focus within stigma research. A significant proportion of mental health service users report experiencing mental illness-based discrimination in relation to parenthood. Existing studies in this area have not gone beyond prevalence, therefore little is known about the nature of experienced discrimination in relation to parenthood, and how is it constituted. This study aims to generate a typology of community psychiatric service users' reports of mental illness-based discrimination in relation to becoming or being a parent. A secondary aim is to assess the prevalence of these types of experienced discrimination. METHODS: In a telephone survey 2026 community psychiatric service users in ten UK Mental Health service provider organisations (Trusts) were asked about discrimination experienced in the previous 12 months using the Discrimination and Stigma Scale (DISC). The sample were asked if, due to their mental health problem, they had been treated unfairly in starting a family, or in their role as a parent, and gave examples of this. Prevalence is reported and the examples of experienced discrimination in relation to parenthood were analysed using the framework method of qualitative analysis. RESULTS: Three hundred and four participants (73% female) reported experienced discrimination, with prevalences of 22.5% and 28.3% for starting a family and for the parenting role respectively. Participants gave 89 examples of discrimination about starting a family and 228 about parenting, and these occurred in social and professional contexts. Ten themes were identified. These related to being seen as an unfit parent; people not being understanding; being stopped from having children; not being allowed to see their children; not getting the support needed; children being affected; children avoiding their parents; children's difficulties being blamed on the parent's mental health problem; not being listened to; and being undermined as a parent. CONCLUSIONS: This research highlights the need for: greater support for parents with mental illness, those wishing to have children, and those who lose access or custody; services to better meet the needs of children with a mentally ill parent; training about discrimination for professionals; and parenting issues to be included in anti-stigma programmes.