The impact of Chatbot-Assisted Self Assessment (CASA) on intentions for sexual health screening in people from minoritised ethnic groups at risk of sexually transmitted infections.

Background Sexually transmitted infections (STIs) present a significant global public health issue, with disparities in STI rates often observed across ethnic groups. The study investigates the impact of Chatbot-Assisted Self Assessment (CASA) on the intentions for sexual health screening within minoritised ethnic groups (MEGs) at risk of STIs as well as the subsequent use of a chatbot for booking STI screening. Methods A simulation within-subject design was utilised to evaluate the effect of CASA on intentions for STI/HIV screening, concern about STIs, and attitudes towards STI screening. Screening intentions served as the dependent variable, while demographic and behavioural factors related to STI/HIV risk were the independent variables. ANCOVA tests were conducted to measure the impact of CASA on these perceptions. Results Involving 548 participants (54% women, 66% black, average age=30years), the study found that CASA positively influenced screening intentions t (547)=-10.3, P t (544)=-4.96, P t (543)=-4.36, P Conclusion CASA increased motivations for STI screening intentions among ethnically diverse communities. The intervention's non-judgemental nature and the chatbot's ability to emulate sexual history-taking were critical in fostering an environment conducive to behavioural intention change. The study's high acceptability indicates the potential for broader application in digital health interventions. However, the limitation of not tracking actual post-intervention behaviour warrants further investigation into CASA's real-world efficacy.

'It depends on where you were born here in the North East, there's not really many job opportunities compared to in the South': young people's perspectives on a North-South health divide and its drivers in England, UK.

BACKGROUND: Improving the public's understanding of how regional and socioeconomic inequalities create and perpetuate inequalities in health, is argued to be necessary for building support for policies geared towards creating a more equal society. However, research exploring public perceptions of health inequalities, and how they are generated, is limited. This is particularly so for young people. Our study sought to explore young people's lived experiences and understandings of health inequalities. METHODS: We carried out focus group discussions (n = 18) with 42 young people, aged 13-21, recruited from six youth organisations in England in 2021. The organisations were located in areas of high deprivation in South Yorkshire, the North East and London. Young people from each organisation took part in three interlinked focus group discussions designed to explore their (i) perceptions of factors impacting their health in their local area, (ii) understandings of health inequalities and (iii) priorities for change. Due to the Covid-19 pandemic, most discussions took place online (n = 15). However, with one group in the North East, we carried out discussions face-to-face (n = 3). Data were analysed thematically and we used NVivo-12 software to facilitate data management. RESULTS: Young people from all groups demonstrated an awareness of a North-South divide in England, UK. They described how disparities in local economies and employment landscapes between the North and the South led to tangible differences in everyday living and working conditions. They clearly articulated how these differences ultimately led to inequalities in people's health and wellbeing, such as linking poverty and employment precarity to chronic stress. Young people did not believe these inequalities were inevitable. They described the Conservative government as prioritising the South and thus perpetuating inequalities through uneven investment. CONCLUSIONS: Our study affords important insights into young people's perceptions of how wider determinants can help explain the North-South health divide in England. It demonstrates young people's contextualised understandings of the interplay between spatial, social and health inequalities. Our findings support calls for pro-equity policies to address the structural causes of regional divides in health. Further research, engaging young people in deliberative policy analysis, could build on this work.

Achieving health equity through conversational AI: A roadmap for design and implementation of inclusive chatbots in healthcare.

BACKGROUND: The rapid evolution of conversational and generative artificial intelligence (AI) has led to the increased deployment of AI tools in healthcare settings. While these conversational AI tools promise efficiency and expanded access to healthcare services, there are growing concerns ethically, practically and in terms of inclusivity. This study aimed to identify activities which reduce bias in conversational AI and make their designs and implementation more equitable. METHODS: A qualitative research approach was employed to develop an analytical framework based on the content analysis of 17 guidelines about AI use in clinical settings. A stakeholder consultation was subsequently conducted with a total of 33 ethnically diverse community members, AI designers, industry experts and relevant health professionals to further develop a roadmap for equitable design and implementation of conversational AI in healthcare. Framework analysis was conducted on the interview data. RESULTS: A 10-stage roadmap was developed to outline activities relevant to equitable conversational AI design and implementation phases: 1) Conception and planning, 2) Diversity and collaboration, 3) Preliminary research, 4) Co-production, 5) Safety measures, 6) Preliminary testing, 7) Healthcare integration, 8) Service evaluation and auditing, 9) Maintenance, and 10) Termination. DISCUSSION: We have made specific recommendations to increase conversational AI's equity as part of healthcare services. These emphasise the importance of a collaborative approach and the involvement of patient groups in navigating the rapid evolution of conversational AI technologies. Further research must assess the impact of recommended activities on chatbots' fairness and their ability to reduce health inequalities.

The effectiveness of sexual assault referral centres with regard to mental health and substance use: a national mixed-methods study - the MiMoS Study.

Background: Sexual assault referral centres have been established to provide an integrated service that includes forensic examination, health interventions and emotional support. However, it is unclear how the mental health and substance use needs are being addressed. Aim: To identify what works for whom under what circumstances for people with mental health or substance use issues who attend sexual assault referral centres. Setting and sample: Staff and adult survivors in English sexual assault referral centres and partner agency staff. Design: A mixed-method multistage study using realist methodology comprising five work packages. This consisted of a systematic review and realist synthesis (work package 1); a national audit of sexual assault referral centres (work package 2); a cross-sectional prevalence study of mental health and drug and alcohol needs (work package 3); case studies in six sexual assault referral centre settings (work package 4), partner agencies and survivors; and secondary data analysis of outcomes of therapy for sexual assault survivors (work package 5). Findings: There is a paucity of evidence identified in the review to support specific ways of addressing mental health and substance use. There is limited mental health expertise in sexual assault referral centres and limited use of screening tools based on the audit. In the prevalence study, participants (n = 78) reported high levels of psychological distress one to six weeks after sexual assault referral centre attendance (94% of people had symptoms of post-traumatic stress disorder). From work package 4 qualitative analysis, survivors identified how trauma-informed care potentially reduced risk of re-traumatisation. Sexual assault referral centre staff found having someone with mental health expertise in the team helpful not only in helping plan onward referrals but also in supporting staff. Both sexual assault referral centre staff and survivors highlighted challenges in onward referral, particularly to NHS mental health care, including gaps in provision and long waiting times. Work package 5 analysis demonstrated that people with recorded sexual assault had higher levels of baseline psychological distress and received more therapy but their average change scores at end point were similar to those without sexual trauma. Limitations: The study was adversely affected by the pandemic. The data were collected during successive lockdowns when services were not operating as usual, as well as the overlay of anxiety and isolation due to the pandemic. Conclusions: People who attend sexual assault centres have significant mental health and substance use needs. However, sexual assault referral centres vary in how they address these issues. Access to follow-up support from mental health services needs to be improved (especially for those deemed to have 'complex' needs) and there is some indication that co-located psychological therapies provision improves the survivor experience. Routine data analysis demonstrated that those with sexual assault can benefit from therapy but require more intensity than those without sexual assault. Future work: Further research is needed to evaluate the effectiveness and cost-effectiveness of providing co-located psychological therapy in the sexual assault referral centres, as well as evaluating the long-term needs and outcomes of people who attend these centres. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (16/117/03) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 21. Trial registration: This trial is registered as PROSPERO 2018 CRD42018119706 and ISRCTN 18208347.

We undertook several studies including: Searching and examining published research (review). A survey that asked sexual assault referral centres how mental health and substance use are addressed. Questionnaires: survivors who had recently attended a sexual assault referral centre completed questionnaires on mental health, alcohol and drugs, and quality of life. Interviews with staff at sexual assault referral centres and survivors of assualts. Routine data: we analysed anonymous data from mental health services to compare how those with sexual assault benefit from psychological therapy. We combined the findings from all the aspects of the study to conclude that most people who attend sexual assault referral centres have significant mental health needs; however, the response to these needs is variable within sexual assault referral centres. Survivors report that the sexual assault referral centres offer a caring and supportive service, but many also reported difficulties in accessing the right support afterwards. Where there was co-located psychological therapy, there were benefits for both survivors and the wider team. We also showed that, despite high needs, people surviving sexual assault can benefit from therapies but may need more therapy than those who have not experienced sexual assault.

"But can chatbots understand sex?" Attitudes towards artificial intelligence chatbots amongst sexual and reproductive health professionals: An exploratory mixed-methods study.

BACKGROUND: Artificial Intelligence (AI)-enabled chatbots can offer anonymous education about sexual and reproductive health (SRH). Understanding chatbot acceptability and feasibility allows the identification of barriers to the design and implementation. METHODS: In 2020, we conducted an online survey and qualitative interviews with SRH professionals recruited online to explore the views on AI, automation and chatbots. Qualitative data were analysed thematically. RESULTS: Amongst 150 respondents (48% specialist doctor/consultant), only 22% perceived chatbots as effective and 24% saw them as ineffective for SRH advice [Mean = 2.91, SD = 0.98, range: 1-5]. Overall, there were mixed attitudes towards SRH chatbots [Mean = 4.03, SD = 0.87, range: 1-7]. Chatbots were most acceptable for appointment booking, general sexual health advice and signposting, but not acceptable for safeguarding, virtual diagnosis, and emotional support. Three themes were identified: "Moving towards a 'digital' age'", "AI improving access and service efficacy", and "Hesitancy towards AI". CONCLUSIONS: Half of SRH professionals were hesitant about the use of chatbots in SRH services, attributed to concerns about patient safety, and lack of familiarity with this technology. Future studies should explore the role of AI chatbots as supplementary tools for SRH promotion. Chatbot designers need to address the concerns of health professionals to increase acceptability and engagement with AI-enabled services.

Exploring young people's perspectives on mental health support: A qualitative study across three geographical areas in England, UK.

Improving young people's (YP) mental health and well-being is a global public health priority. Despite continued commitment within the UK policy agenda to improve the mental health and well-being of YP, the incidence of mental health issues continues to rise. This has been further compounded by the outbreak of COVID-19 which has disproportionately affected YP in the most socioeconomically disadvantaged areas. Understanding YP's perspectives on what supports their mental health is important to develop policies that meet their needs. We conducted focus groups (n = 18 with 42 YP aged 13-21) in three geographical areas with high levels of deprivation in England, UK. Recruited through six local youth organisations, each group of YP took part in three interlinked focus groups designed to explore their perceptions of what impacts their health in their local area, and their understandings of health inequalities through participatory methods. Throughout their discussions, YP foregrounded the significance of mental health and mental health support structures. YP perceived challenges to accessing mental health provision and an unmet need for support within their local communities. Alongside this, YP consistently highlighted the importance of youth groups for promoting good mental health and mitigating challenges to poor mental health. However, ongoing cuts to the voluntary sector and universal services continue to impact areas and individuals in the greatest need. In the face of deficits in formal mental health support, our findings highlight the pressing need for increased investment in services focused on prevention (such as youth groups) in areas of high deprivation.

Why does early childhood deprivation increase the risk for depression and anxiety in adulthood? A developmental cascade model.

BACKGROUND: Using data from the English & Romanian Adoptees (ERA) study, we recently reported that early time-limited exposure to severe institutional deprivation is associated with early-onset and persistent neurodevelopmental problems and later-onset emotional problems. Here, we examine possible reasons for the late emergence of emotional problems in this cohort. Our main focus is on testing a developmental cascade mediated via the functional impact of early-appearing neurodevelopmental problems on late adolescent functioning. We also explore a second putative pathway via sensitization to stress. METHODS: The ERA study includes 165 Romanian individuals who spent their early lives in grossly depriving institutions and were subsequently adopted into UK families, along with 52 UK adoptees with no history of deprivation. Age six years symptoms of neurodevelopmental problems and age 15 anxiety/depression symptoms were assessed via parental reports. Young adult symptoms of depression and anxiety were assessed by both parent and self-reports; young adults also completed measures of stress reactivity, exposure to adverse life events, and functioning in work and interpersonal relationships. RESULTS: The path between early institutional deprivation and adult emotional problems was mediated via the impact of early neurodevelopmental problems on unemployment and poor friendship functioning during the transition to adulthood. The findings with regard to early deprivation, later life stress reactivity, and emotional problems were inconclusive. CONCLUSIONS: Our analysis suggests that the risk for adult depression and anxiety following extreme institutional deprivation is explained through the effects of early neurodevelopmental problems on later social and vocational functioning. Future research should more fully examine the role of stress susceptibility in this model.

Adoptees' responses to separation from, and reunion with, their adoptive parent at age 4 years is associated with long-term persistence of autism symptoms following early severe institutional deprivation.

Institutionally deprived young children often display distinctive patterns of attachment, classified as insecure/other (INS/OTH), with their adoptive parents. The associations between INS/OTH and developmental trajectories of mental health and neurodevelopmental symptoms were examined. Age 4 attachment status was determined for 97 Romanian adoptees exposed to up to 24 months of deprivation in Romanian orphanages and 49 nondeprived UK adoptees. Autism, inattention/overactivity and disinhibited-social-engagement symptoms, emotional problems, and IQ were measured at 4, 6, 11, and 15 years and in young adulthood. Romanian adoptees with over 6 months deprivation (Rom>6) were more often classified as INS/OTH than UK and Romanian adoptees with less than 6 months deprivation combined. INS/OTH was associated with cognitive impairment at age 4 years. The interaction between deprivation, attachment status, and age for autism spectrum disorder assessment was significant, with greater symptom persistence in Rom>6 INS/OTH(+) than other groups. This effect was reduced when IQ at age 4 was controlled for. Age 4 INS/OTH in Rom>6 was associated with worse autism spectrum disorder outcomes up to two decades later. Its association with cognitive impairment at age 4 is consistent with INS/OTH being an early marker of this negative developmental trajectory, rather than its cause.

HPA axis dysregulation in adult adoptees twenty years after severe institutional deprivation in childhood.

Hypothalamic-pituitary-adrenal (HPA) axis function is disrupted in institutionally-deprived children - reduced morning cortisol, flattened diurnal slope and blunted reactivity persist even after successful adoption into positive family environments. Here we test whether such effects persist into adulthood. Cortisol release across the day (sampled at awakening, 30 and 45min later, and at four points across the day) was investigated in young adult adoptees who had lived in severe deprivation for up to 43 months in early childhood in Ceaușescu's Romanian orphanages and a comparison group of non-deprived UK adoptees (Total N=57; mean age=24±0.9years). The mediating role of cortisol levels on adult mental health was examined using data from standardized clinical assessments. Cortisol profiles were disrupted in the Romanian adoptees who experienced more than 6 months deprivation marked by a striking absence of the cortisol awakening response (CAR) and a significantly flatter cortisol curve until 1h 15min after awakening. Whereas institutional deprivation was associated with both cortisol secretion and emergence of emotional problems in young adulthood, path analysis revealed no evidence for a mediating role of CAR disruption in the sub-sample studied here. The results are in line with findings of HPA axis hypo-functionality following early adverse experience and provide strong evidence for long-term programming effects of HPA axis function through experience of institutional deprivation.

Adult disinhibited social engagement in adoptees exposed to extreme institutional deprivation: examination of its clinical status and functional impact.

BackgroundEarly-life institutional deprivation produces disinhibited social engagement (DSE). Portrayed as a childhood condition, little is known about the persistence of DSE-type behaviours into, presentation during, and their impact on, functioning in adulthood.AimsWe examine these issues in the young adult follow-up of the English and Romanian Adoptees study.MethodA total of 122 of the original 165 Romanian adoptees who had spent up to 43 months as children in Ceausescu's Romanian orphanages and 42 UK adoptees were assessed for DSE behaviours, neurodevelopmental and mental health problems, and impairment between ages 2 and 25 years.ResultsYoung adult DSE behaviour was strongly associated with early childhood deprivation, with a sixfold increase for those who spent more than 6 months in institutions. However, although DSE overlapped with autism spectrum disorder and attention-deficit hyperactivity disorder symptoms it was not, in itself, related to broader patterns of mental health problems or impairments in daily functioning in young adulthood.ConclusionsDSE behaviour remained a prominent, but largely clinically benign, young adult feature of some adoptees who experienced early deprivation.

Child-to-adult neurodevelopmental and mental health trajectories after early life deprivation: the young adult follow-up of the longitudinal English and Romanian Adoptees study.

BACKGROUND: Time-limited, early-life exposures to institutional deprivation are associated with disorders in childhood, but it is unknown whether effects persist into adulthood. We used data from the English and Romanian Adoptees study to assess whether deprivation-associated adverse neurodevelopmental and mental health outcomes persist into young adulthood. METHODS: The English and Romanian Adoptees study is a longitudinal, natural experiment investigation into the long-term outcomes of individuals who spent from soon after birth to up to 43 months in severe deprivation in Romanian institutions before being adopted into the UK. We used developmentally appropriate standard questionnaires, interviews completed by parents and adoptees, and direct measures of IQ to measure symptoms of autism spectrum disorder, inattention and overactivity, disinhibited social engagement, conduct or emotional problems, and cognitive impairment (IQ score <80) during childhood (ages 6, 11, and 15 years) and in young adulthood (22-25 years). For analysis, Romanian adoptees were split into those who spent less than 6 months in an institution and those who spent more than 6 months in an institution. We used a comparison group of UK adoptees who did not experience deprivation. We used mixed-effects regression models for ordered-categorical outcome variables to compare symptom levels and trends between groups. FINDINGS: Romanian adoptees who experienced less than 6 months in an institution (n=67 at ages 6 years; n=50 at young adulthood) and UK controls (n=52 at age 6 years; n=39 at young adulthood) had similarly low levels of symptoms across most ages and outcomes. By contrast, Romanian adoptees exposed to more than 6 months in an institution (n=98 at ages 6 years; n=72 at young adulthood) had persistently higher rates than UK controls of symptoms of autism spectrum disorder, disinhibited social engagement, and inattention and overactivity through to young adulthood (pooled p<0·0001 for all). Cognitive impairment in the group who spent more than 6 months in an institution remitted from markedly higher rates at ages 6 years (p=0·0001) and 11 years (p=0·0016) compared with UK controls, to normal rates at young adulthood (p=0·76). By contrast, self-rated emotional symptoms showed a late-onset pattern with minimal differences versus UK controls at ages 11 years (p=0·0449) and 15 years (p=0·17), and then marked increases by young adulthood (p=0·0005), with similar effects seen for parent ratings. The high deprivation group also had a higher proportion of people with low educational achievement (p=0·0195), unemployment (p=0·0124), and mental health service use (p=0·0120, p=0·0032, and p=0·0003 for use when aged <11 years, 11-14 years, and 15-23 years, respectively) than the UK control group. A fifth (n=15) of individuals who spent more than 6 months in an institution were problem-free at all assessments. INTERPRETATION: Notwithstanding the resilience shown by some adoptees and the adult remission of cognitive impairment, extended early deprivation was associated with long-term deleterious effects on wellbeing that seem insusceptible to years of nurturance and support in adoptive families. FUNDING: Economic and Social Research Council, Medical Research Council, Department of Health, Jacobs Foundation, Nuffield Foundation.

Early severe institutional deprivation is associated with a persistent variant of adult attention-deficit/hyperactivity disorder: clinical presentation, developmental continuities and life circumstances in the English and Romanian Adoptees study.

BACKGROUND: Early-life institutional deprivation is associated with attention-deficit/hyperactivity disorder (ADHD) later in childhood and adolescence. In this article, we examine, for the first time, the persistence of deprivation-related ADHD into young adulthood in a sample of individuals adopted as young children by UK families after periods in extremely depriving Romanian orphanages. METHODS: We estimated rates of ADHD at age 15 years and in young adulthood (ages 22-25 years) in individuals at low (LoDep; nondeprived UK adoptees and Romanian adoptees with less than 6-month institutional exposure) and high deprivation-related risk (HiDep; Romanian adoptees with more than 6-month exposure). Estimates were based on parent report using DSM-5 childhood symptom and impairment criteria. At age 15, data were available for 108 LoDep and 86 HiDep cases, while in young adulthood, the numbers were 83 and 60, respectively. Data on education and employment status, IQ, co-occurring symptoms of young adult disinhibited social engagement (DSE), autism spectrum disorder (ASD), cognitive impairment, conduct disorder (CD), callous-unemotional (CU) traits, anxiety, depression and quality of life (QoL) were also collected. RESULTS: ADHD rates in the LoDep group were similar to the general population in adolescence (5.6%) and adulthood (3.8%). HiDep individuals were, respectively, nearly four (19%) and over seven (29.3%) times more likely to meet criteria, than LoDep. Nine 'onset' young adult cases emerged, but these had a prior childhood history of elevated ADHD behaviours at ages 6, 11 and 15 years. Young adult ADHD was equally common in males and females, was predominantly inattentive in presentation and co-occurred with high levels of ASD, DSE and CU features. ADHD was associated with high unemployment and low educational attainment. CONCLUSION: We provide the first evidence of a strong persistence into adulthood of a distinctively complex and impairing deprivation-related variant of ADHD. Our results confirm the powerful association of early experience with later development in a way that suggests a role for deep-seated alterations to brain structure and function.