Applying co-production principles in research: reflections from young people and academics.

Co-production, a form of collaborative working, is guided by principles including valuing all participants, building on individual strengths, blurring distinctions between roles, delivering benefits for all participants, building support networks and supporting people to deliver work themselves. This article explores how co-production is understood by young people and researchers and how co-production principles can be applied within a research context. We identify challenges of implementing existing co-production frameworks in research and key areas to consider for future work.

Effect of the COVID-19 pandemic on incidence of long-term conditions in Welsh residents: a population linkage study.

BACKGROUND: The COVID-19 pandemic had direct and indirect effects on health. Indirect effects on long term medical conditions (LTCs) are unclear. We examined trends in recorded incidences of LTCs and quantified differences between expected rates and observed rates from 2020 onwards. METHODS: This is a population data linkage study using primary and secondary care data within the Secure Anonymised Information Linkage Databank. We included data of Welsh residents diagnosed with any of 17 identified LTCs for the first time between Jan 1, 2000, and Dec 31, 2021. LTC's include mental health conditions, respiratory diseases, and heart conditions among others, generally chosen in line with the Quality and Outcomes Framework. The primary outcome was incidence rates (monthly number of new cases per 100 000 population). For each LTC, we did interrupted time series analysis of incidence rates from 2015 to 2021. Expected rates from between Jan 1, 2020, to Dec 31, 2021, were predicted using overall trends and seasonal patterns from the preceding 5 years and compared with observed rates. FINDINGS: We included 5 476 012 diagnoses from 2 257 992 individuals diagnosed with at least one LTC between Jan 1, 2000, to Dec 31, 2021. Across multiple long-term conditions, there was an abrupt reduction in observed incidence of new diagnoses from March to April 2020, followed by a general increase in incidence towards prepandemic rates. The conditions with the largest percentage difference between the observed and expected incidence rates in 2020 and 2021 were chronic obstructive pulmonary disease (38·4% lower than expected), depression (28·3% lower), hypertension (25·5% lower), and anxiety disorders (24·9% lower). The condition with the largest absolute difference between observed and expected incidence rates was anxiety disorders, with 830 per 100 000 less in 2020 and 2021 compared with observed rates. INTERPRETATION: The reduction in incidence rates of LTCs suggests an underreporting of LTCs, especially during 2020 and early 2021. The emergence of these yet undiagnosed cases could result in a surge of new patients in the near future. FUNDING: This work was supported by the Wales COVID-19 Evidence Centre, funded by Health and Care Research Wales.

A cost-effectiveness analysis of patiromer in the UK: evaluation of hyperkalaemia treatment and lifelong RAASi maintenance in chronic kidney disease patients with and without heart failure.

BACKGROUND: Chronic kidney disease (CKD) patients with and without heart failure (HF) often present with hyperkalaemia (HK) leading to increased risk of hospitalisations, cardiovascular related events and cardiovascular-related mortality. Renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, the mainstay treatment in CKD management, provides significant cardiovascular and renal protection. Nevertheless, its use in the clinic is often suboptimal and treatment is frequently discontinued due to its association with HK. We evaluated the cost-effectiveness of patiromer, a treatment known to reduce potassium levels and increase cardiorenal protection in patients receiving RAASi, in the UK healthcare setting. METHODS: A Markov cohort model was generated to assess the pharmacoeconomic impact of patiromer treatment in regulating HK in patients with advanced CKD with and without HF. The model was generated to predict the natural history of both CKD and HF and quantify the costs and clinical benefits associated with the use of patiromer for HK management from a healthcare payer's perspective in the UK. RESULTS: Economic evaluation of patiromer use compared to standard of care (SoC) resulted in increased discounted life years (8.93 versus 8.67) and increased discounted quality-adjusted life years (QALYs) (6.36 versus 6.16). Furthermore, patiromer use resulted in incremental discounted cost of £2,973 per patient and an incremental cost-effectiveness ratio (ICER) of £14,816 per QALY gained. On average, patients remained on patiromer therapy for 7.7 months, and treatment associated with a decrease in overall clinical event incidence and delayed CKD progression. Compared to SoC, patiromer use resulted in 218 fewer HK events per 1,000 patients, when evaluating potassium levels at the 5.5-6 mmol/l; 165 fewer RAASi discontinuation episodes; and 64 fewer RAASi down-titration episodes. In the UK, patiromer treatment was predicted to have a 94.5% and 100% chance of cost-effectiveness at willingness-to-pay thresholds (WTP) of £20,000/QALY and £30,000/QALY, respectively. CONCLUSION: This study highlights the value of both HK normalisation and RAASi maintenance in CKD patients with and without HF. Results support the guidelines which recommend HK treatment, e.g., patiromer, as a strategy to enable the continuation of RAASi therapy and improve clinical outcomes in CKD patients with and without HF.

Sexting among British adults: a qualitative analysis of sexting as emotion work governed by 'feeling rules'.

Sexting has generated considerable public and professional interest with concerns centring on young people, and potential harms to mental and sexual health. Little research thus far has explored the practice among adults and none has focused on the cultural norms relating to the emotional experience of sexting across different ages and genders. We conducted 40 semi-structured interviews with a diverse sample of adults aged 18-59 years in Britain on the role of digital technologies in participants' sexual lives. In this paper, we draw on the accounts of 34 people with experience of sexting. We identified three main themes in participants' accounts related to the emotional aspects of sexting: (1) trust, (2) desire/intimacy and (3) shame. Under each theme, we identified motivations, 'feeling rules', and examples of 'emotion work' relating to the self, the other and the dyad. We conclude that there are shared cultural norms that constitute what appropriate sexting should feel like. Interventions aiming to minimise harms arising from sexting need to build on commonly held cultural conventions regarding the 'rules of the game' concerning feelings as well as behaviours.

Defining research priorities for youth public mental health: reflections on a coproduction approach to transdisciplinary working.

BACKGROUND: With most mental health problems established during childhood/adolescence, young people must be a key focus of public mental health approaches. Despite the range of factors known to influence mental health, evidence for effective interventions is lacking for this age group. This study aimed to define priorities for future public health intervention-focused research to support youth mental health by engaging with transdisciplinary stakeholder groups. METHODS: Our coproduction approach involved priority-setting workshops with young people, researchers, practitioners and policy-makers. Each workshop focused on three thematic areas: social connections and relationships; schools and other education settings; and key groups at greater risk of mental ill-health, specifically LGBTQ+ and care-experienced young people. Workshop outputs were synthesized to define research priorities. RESULTS: This paper presents the research priorities that were defined through the priority-setting workshops, and our reflections on the coproduction approach to guide future similar activities undertaken by others. Ten priorities for youth public mental health research were defined, covering the following areas: building supportive relationships; whole system approaches; social media; support at times of transition; improving links between different services; development and training for those who support young people; staff mental health; engaging with families; awareness of and access to services; and out-of-school and community settings. CONCLUSIONS: These research priorities can inform future intervention development to support youth public mental health. Our transdisciplinary approach means the identified research priorities are likely to be relevant to young people's experiences and needs, and to fit with the needs of those working in practice and policy to support young people.

Complement activation in polycystic ovary syndrome occurs in the postprandial and fasted state and is influenced by obesity and insulin sensitivity.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is associated with metabolic risk. Complement proteins regulate inflammation and lipid clearance but their role in PCOS-associated metabolic risk is unclear. We sought to establish whether the complement system is activated in PCOS in the fasting and postprandial state. DESIGN: Case-control study. PATIENTS: Fasting complement levels were measured in 84 women with PCOS and 95 healthy controls. Complement activation post-oral fat tolerance test (OFTT) was compared in 40 additional subjects (20 PCOS, 20 controls). MEASUREMENTS: Activation pathway (C3, C4, C3a(desArg), factor B, factor H, properdin, Factor D) and terminal pathway (C5, C5a, terminal complement complex [TCC]) proteins were measured by commercial or in-house assays. RESULTS: Fasting C3, C3a(desArg) and TCC concentrations were increased in insulin-resistant (adjusted differences: C3 0.13 g/L [95%CI 0-0.25]; C3a(desArg) 319.2 ng/mL [19.5-619]; TCC 0.66 µg/mL [0.04-1.28]) but not in insulin-sensitive women with PCOS. C3 and factor H levels increased with obesity. Post-OFTT, C3 and C4 levels increased to a similar extent in PCOS subjects and controls, whist factor H levels increased more in women with PCOS compared to controls (adjusted differences (area under the curve): 12 167 µg min/mL [4942-19 392]), particularly in the presence of concomitant obesity. CONCLUSIONS: Activation and terminal complement pathway components are elevated in patients with PCOS, especially in the presence of insulin resistance and obesity.

Pathways to help-seeking for sexual difficulties in older adults: qualitative findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

BACKGROUND: Older adults are at an increased risk of sexual difficulties due to ageing and chronic health conditions. While they experience barriers to seeking and receiving help for sexual difficulties there is a dearth of research about the help-seeking journey. OBJECTIVE: To explore decision-making in context; particularly, the reasons why older adults do, or do not, seek help for sexual difficulties. METHODS: Semi-structured interviews were conducted with 11 men and 12 women aged 58-75 who reported having a health condition, disability or medication that had affected their sex life in the last year. Participants were part of the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Data were analysed thematically. RESULTS: Help-seeking was rarely a predictable or linear process. Participants tended to wait and see if the sexual difficulty got better on its own or improved as a result of lifestyle changes. An often-lengthy period of thinking, researching and planning could end with a decision to seek professional help, to not seek help, or do nothing for now. A significant barrier was concern about the interaction of medicines prescribed for the sexual difficulty with those already taken for chronic health conditions. Patient fear of not being taken seriously and doctor reticence to ask thwarted potential conversations. Help-seeking journeys often ended without resolution, even when professional help was sought. CONCLUSIONS: To give patients and practitioners permission to raise the topic, suggestions include providing patients with a pre-consultation card which lists topics they would like to talk about, including sexual issues.

Navigating new sexual partnerships in midlife: a socioecological perspective on factors shaping STI risk perceptions and practices.

OBJECTIVE: Despite increases in STIs among those over 40, little is known about the social context of STI transmission among people experiencing relationship transition in midlife, and few sexual health promotion initiatives are targeted at this group. This study sought to identify factors shaping STI risk perceptions and practices among midlife individuals either contemplating or having sex with new partners following the end of a long-term relationship. METHODS: Participants were purposively selected from respondents to Britain's third National Survey of Sexual Attitudes and Lifestyles, using three eligibility criteria: aged 40-59, reported experience of the end of a marital or cohabiting relationship with an opposite-sex partner in the past 5 years, and willingness to participate in a qualitative interview. Qualitative data were generated via face-to-face interviews with 10 women and 9 men and analysed inductively using thematic analysis, with themes then organised using a socioecological framework. RESULTS: Participants' accounts of new sexual partnerships in midlife indicate that STI risk perceptions and practices are shaped by factors operating at multiple levels across the socioecological arena (individual, partnership, peers and communities, societal). Constraints on, and resources for, the navigation of sexual safety include self-perceived STI risk rooted in past rather than present circumstances; legacies of mistrust within former relationships; intersecting gender-age dynamics in negotiation of risk prevention strategies with new partners; peers and younger relatives' influences on understandings of sexual risk and safety; postrelationship change in social networks that increase or mitigate vulnerability to sexual risk; age-related barriers to accessing condoms; and disconnection from safer sex messaging and services culturally coded as for the young. CONCLUSIONS: Improving sexual health among midlife adults requires age-sensitive interventions designed to address multilevel constraints, and harness positive influences, on the navigation of sexual safety at this stage of life.

Development, validation and effectiveness of diagnostic prediction tools for colorectal cancer in primary care: a systematic review.

BACKGROUND: Tools based on diagnostic prediction models are available to help general practitioners (GP) diagnose colorectal cancer. It is unclear how well they perform and whether they lead to increased or quicker diagnoses and ultimately impact on patient quality of life and/or survival. The aim of this systematic review is to evaluate the development, validation, effectiveness, and cost-effectiveness, of cancer diagnostic tools for colorectal cancer in primary care. METHODS: Electronic databases including Medline and Web of Science were searched in May 2017 (updated October 2019). Two reviewers independently screened titles, abstracts and full-texts. Studies were included if they reported the development, validation or accuracy of a prediction model, or assessed the effectiveness or cost-effectiveness of diagnostic tools based on prediction models to aid GP decision-making for symptomatic patients presenting with features potentially indicative of colorectal cancer. Data extraction and risk of bias were completed by one reviewer and checked by a second. A narrative synthesis was conducted. RESULTS: Eleven thousand one hundred thirteen records were screened and 23 studies met the inclusion criteria. Twenty-studies reported on the development, validation and/or accuracy of 13 prediction models: eight for colorectal cancer, five for cancer areas/types that include colorectal cancer. The Qcancer models were generally the best performing. Three impact studies met the inclusion criteria. Two (an RCT and a pre-post study) assessed tools based on the RAT prediction model. The third study looked at the impact of GP practices having access to RAT or Qcancer. Although the pre-post study reported a positive impact of the tools on outcomes, the results of the RCT and cross-sectional survey found no evidence that use of, or access to, the tools was associated with better outcomes. No study evaluated cost effectiveness. CONCLUSIONS: Many prediction models have been developed but none have been fully validated. Evidence demonstrating improved patient outcome of introducing the tools is the main deficiency and is essential given the imperfect classification achieved by all tools. This need is emphasised by the equivocal results of the small number of impact studies done so far.

Engaging parents in digital sexual and reproductive health education: evidence from the JACK trial.

BACKGROUND: Research evidence and international policy highlight the central role that parents play in promoting positive sexual behaviour and outcomes in their children, however they can be difficult to engage in sexual and reproductive health (SRH) education programmes. Digital health promotion that uses online and mobile technologies (OMTs) to promote parent-child communication may offer an innovative solution to reach parents, however, few programmes have used OMTs to involve parents in SRH, and none have reported lessons learned in relation to optimising engagement. This study addresses this gap in the literature by reporting acceptability and feasibility of using OMTs to engage parents in SRH education. Findings will be relevant for those wishing to develop and implement digital SRH programmes with parents internationally. METHODS: The Jack Trial is a UK-wide cluster randomised controlled trial recruiting over 8000 adolescents from 66 socially and religiously diverse post-primary schools. An embedded mixed-methods process evaluation explored user engagement with parent components of the If I Were Jack SRH education programme, which include online animated films and a parent-teen homework exercise. RESULTS: A total of 109 adolescents, teachers, parents and SRH policy experts took part in semi-structured interviews and focus groups, 134 parents responded to an online survey, and 3179 adolescents completed a programme engagement and satisfaction questionnaire. Parents who accessed the materials were positive about them; 87% rated them as 'good or excellent' and 67% said they helped them have conversations with their child about SRH. Web analytics revealed that 27% of contacted parents accessed the digital materials, with 9% viewing the animated films. Only 38% of teachers implemented the homework exercise, mainly because they assumed that students would not complete it or it might result in backlash from parents. CONCLUSIONS: While digital parental materials show promise for engaging parents in SRH education, this study suggests that in order to optimise engagement, parental components that give parents the necessary skills to have conversations with their children about sex should be coupled with efforts to increase school and teacher confidence to communicate with parents on sensitive topics. TRIAL REGISTRATION: ISRCTN99459996 .

Dating and relationship violence among 16-19 year olds in England and Wales: a cross-sectional study of victimization.

Background: Dating and relationship violence (DRV) is under-researched in the UK, especially among Further Education (FE) students. This study examines the association between DRV victimization and socio-demographic characteristics, sexual identity and dating and relationship behaviours among 16-19 year olds FE students. Methods: Cross-sectional self-report data were collected from 1751 students aged 16-19 at six FE settings in England and Wales. Factor analysis examined the structure of DRV victimization by gender. Multilevel logistic regression examined the odds ratios of DRV victimization according to socio-demographics, sexual identity and dating behaviours. Results: DRV victimization clusters into two categories for females, and three for males. Among females, 46.1% experienced controlling behaviours and 31.6% threatening behaviours; 49.9% of males experienced controlling behaviours, 27.1% threatening behaviours and 5.8% online sexual violence. The odds of DRV victimization were 2-8 times greater for males and 2-4 times greater for females who had ever sent a sexually explicit image. No consistent association was found between DRV and age, spending money per week, educational attainment or meeting partners online. Conclusions: The high prevalence, absence of gender differences and social patterning, suggests DRV victimization may be becoming normalized and is of significant public health importance for young people in England and Wales.

Patient and public views about the security and privacy of Electronic Health Records (EHRs) in the UK: results from a mixed methods study.

BACKGROUND: Although policy discourses frame integrated Electronic Health Records (EHRs) as essential for contemporary healthcare systems, increased information sharing often raises concerns among patients and the public. This paper examines patient and public views about the security and privacy of EHRs used for health provision, research and policy in the UK. METHODS: Sequential mixed methods study with a cross-sectional survey (in 2011) followed by focus group discussions (in 2012-2013). Survey participants (N = 5331) were recruited from primary and secondary care settings in West London (UK). Complete data for 2761 (51.8 %) participants were included in the final analysis for this paper. The survey results were discussed in 13 focus groups with people living with a range of different health conditions, and in 4 mixed focus groups with patients, health professionals and researchers (total N = 120). Qualitative data were analysed thematically. RESULTS: In the survey, 79 % of participants reported that they would worry about the security of their record if this was part of a national EHR system and 71 % thought the National Health Service (NHS) was unable to guarantee EHR safety at the time this work was carried out. Almost half (47 %) responded that EHRs would be less secure compared with the way their health record was held at the time of the survey. Of those who reported being worried about EHR security, many would nevertheless support their development (55 %), while 12 % would not support national EHRs and a sizeable proportion (33 %) were undecided. There were also variations by age, ethnicity and education. In focus group discussions participants weighed up perceived benefits against potential security and privacy threats from wider sharing of information, as well as discussing other perceived risks: commercial exploitation, lack of accountability, data inaccuracies, prejudice and inequalities in health provision. CONCLUSIONS: Patient and public worries about the security risks associated with integrated EHRs highlight the need for intensive public awareness and engagement initiatives, together with the establishment of trustworthy security and privacy mechanisms for health information sharing.

Urbanicity, persecutory delusions, and clinical intervention: the development of a brief CBT module for helping patients with persecutory delusions enter social urban environments.

BACKGROUND: Substantial epidemiological research has shown that psychotic experiences are more common in densely populated areas. Many patients with persecutory delusions find it difficult to enter busy social urban settings. The stress and anxiety caused by being outside lead many patients to remain in-doors. We therefore developed a brief CBT intervention, based upon a formulation of the way urban environments cause stress and anxiety, to help patients with paranoid thoughts to feel less distressed when outside in busy streets. AIMS: The aim was to pilot the new intervention for feasibility and acceptability and gather preliminary outcome data. METHOD: Fifteen patients with persecutory delusions in the context of a schizophrenia diagnosis took part. All patients first went outside to test their reactions, received the intervention, and then went outside again. RESULTS: The intervention was considered useful by the patients. There was evidence that going outside after the intervention led to less paranoid responses than the initial exposure, but this was only statistically significant for levels of distress. CONCLUSIONS: Initial evidence was obtained that a brief CBT module specifically focused on helping patients with paranoia go outside is feasible, acceptable, and may have clinical benefits. However, it could not be determined from this small feasibility study that any observed improvements were due to the CBT intervention. Challenges in this area and future work required are outlined.

Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal).

BACKGROUND: Sexual behaviour and relationships are key components of wellbeing and are affected by social norms, attitudes, and health. We present data on sexual behaviours and attitudes in Britain (England, Scotland, and Wales) from the three National Surveys of Sexual Attitudes and Lifestyles (Natsal). METHODS: We used a multistage, clustered, and stratified probability sample design. Within each of the 1727 sampled postcode sectors for Natsal-3, 30 or 36 addresses were randomly selected and then assigned to interviewers. To oversample individuals aged 16-34 years, we randomly allocated addresses to either the core sample (in which individuals aged 16-74 years were eligible) or the boost sample (in which only individuals aged 16-34 years were eligible). Interviewers visited all sampled addresses between Sept 6, 2010, and Aug 31, 2012, and randomly selected one eligible individual from each household to be invited to participate. Participants completed the survey in their own homes through computer-assisted face-to-face interviews and self-interview. We analysed data from this survey, weighted to account for unequal selection probabilities and non-response to correct for differences in sex, age group, and region according to 2011 Census figures. We then compared data from participants aged 16-44 years from Natsal-1 (1990-91), Natsal-2 (1999-2001), and Natsal-3. FINDINGS: Interviews were completed with 15,162 participants (6293 men, 8869 women) from 26,274 eligible addresses (57·7%). 82·1% (95% CI 81·0-83·1%) of men and 77·7% (76·7-78·7%) of women reported at least one sexual partner of the opposite sex in the past year. The proportion generally decreased with age, as did the range of sexual practices with partners of the opposite sex, especially in women. The increased sexual activity and diversity reported in Natsal-2 in individuals aged 16-44 years when compared with Natsal-1 has generally been sustained in Natsal-3, but in men has generally not risen further. However, in women, the number of male sexual partners over the lifetime (age-adjusted odds ratio 1·18, 95% CI 1·08-1·28), proportion reporting ever having had a sexual experience with genital contact with another woman (1·69, 1·43-2·00), and proportion reporting at least one female sexual partner in the past 5 years (2·00, 1·59-2·51) increased in Natsal-3 compared with Natsal-2. While reported number of occasions of heterosexual intercourse in the past 4 weeks had reduced since Natsal-2, we recorded an expansion of heterosexual repertoires--particularly in oral and anal sex--over time. Acceptance of same-sex partnerships and intolerance of non-exclusivity in marriage increased in men and women in Natsal-3. INTERPRETATION: Sexual lifestyles in Britain have changed substantially in the past 60 years, with changes in behaviour seeming greater in women than men. The continuation of sexual activity into later life--albeit reduced in range and frequency--emphasises that attention to sexual health and wellbeing is needed throughout the life course. FUNDING: Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health.

Lifetime prevalence, associated factors, and circumstances of non-volitional sex in women and men in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

BACKGROUND: Sexual violence is increasingly recognised as a public health issue. Information about prevalence, associated factors, and consequences for health in the population of Britain (England, Scotland, and Wales) is scarce. The third National Survey of Sexual Health Attitudes and Lifestyles (Natsal-3) is the first of the Natsal surveys to include questions about sexual violence and the first population-based survey in Britain to explore the issue outside the context of crime. METHODS: Between Sept 6, 2010, and Aug 31, 2012, we did a probability sample survey of women and men aged 16-74 years living in Britain. We asked participants about their experience of sex against their will since age 13 years and the circumstances surrounding the most recent occurrence. We explored associations between ever experiencing non-volitional sex and a range of sociodemographic, health, and behavioural factors. We used logistic regression to estimate age-adjusted odds ratios to analyse factors associated with the occurrence of completed non-volitional sex in women and men. FINDINGS: We interviewed 15,162 people. Completed non-volitional sex was reported by 9·8% (95% CI 9·0-10·5) of women and 1·4% (1·1-1·7) of men. Median age (interdecile range) at most recent occurrence was 18 years (14-32) for women and 16 years (13-30) for men. Completed non-volitional sex varied by family structure and, in women, by age, education, and area-level deprivation. It was associated with poor health, longstanding illness or disability, and treatment for mental health conditions, smoking, and use of non-prescription drugs in the past year in both sexes, and with binge drinking in women. Completed non-volitional sex was also associated with reporting of first heterosexual intercourse before 16 years of age, same-sex experience, more lifetime sexual partners, ever being diagnosed with a sexually transmitted infection, and low sexual function in both sexes, and, in women, with abortion and pregnancy outcome before 18 years of age. In most cases, the person responsible was known to the individual, although the nature of the relationship differed by age at most recent occurrence. Participants who were younger at interview were more likely to have told someone about the event and to have reported it to the police than were older participants. INTERPRETATION: These data provide the first population prevalence estimates of non-volitional sex in Britain. We showed it to be mainly an experience of young age and strongly associated with a range of adverse health outcomes in both women and men. FUNDING: Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health.

Fear, "Discomfort," Anger, and Shame in the Night-Time Economy: Women's Responses to Unwanted Sexual Intrusions.

Despite a surge of attention to gender-based violence (GBV), research about the night-time economy (NTE) as a site of gendered violence is limited. Even less research examines women's emotional responses to "unwanted sexual intrusions" (USI) in the NTE. Analyzing women's emotional responses can generate deeper understanding of social phenomena, power and its operation, and is in keeping with feminist theorizing that uses a victim-survivor-centered approach. Analysis of qualitative data, from a survey we conducted in the United Kingdom, reveals women experience USI in the NTE as a frightening, shameful injustice. The article discusses these emotions in light of the changing "emotional climate" about GBV.

Potential types of bias when estimating causal effects in environmental research and how to interpret them.

To inform environmental policy and practice, researchers estimate effects of interventions/exposures by conducting primary research (e.g., impact evaluations) or secondary research (e.g., evidence reviews). If these estimates are derived from poorly conducted/reported research, then they could misinform policy and practice by providing biased estimates. Many types of bias have been described, especially in health and medical sciences. We aimed to map all types of bias from the literature that are relevant to estimating causal effects in the environmental sector. All the types of bias were initially identified by using the Catalogue of Bias (catalogofbias.org) and reviewing key publications (n = 11) that previously collated and described biases. We identified 121 (out of 206) types of bias that were relevant to estimating causal effects in the environmental sector. We provide a general interpretation of every relevant type of bias covered by seven risk-of-bias domains for primary research: risk of confounding biases; risk of post-intervention/exposure selection biases; risk of misclassified/mismeasured comparison biases; risk of performance biases; risk of detection biases; risk of outcome reporting biases; risk of outcome assessment biases, and four domains for secondary research: risk of searching biases; risk of screening biases; risk of study appraisal and data coding/extraction biases; risk of data synthesis biases. Our collation should help scientists and decision makers in the environmental sector be better aware of the nature of bias in estimation of causal effects. Future research is needed to formalise the definitions of the collated types of bias such as through decomposition using mathematical formulae.

Seeking support for abortion online: a qualitative study of women's experiences.

INTRODUCTION: Social support can mitigate the impact of stress and stigma before or after an abortion. However, stigma anticipation can limit access to in-person support. Informal online spaces can offer opportunities to address unmet support needs including supplementing in-person support lacking within stigmatised contexts. While earlier studies have explored content of posts comprising personal accounts of abortion, little is known about the nuances of how and to what end online spaces are navigated. METHODS: Semi-structured interviews were conducted remotely (online or by telephone) with 23 women living in Scotland (aged 20-54 years) recruited through social media and online advertisements. Reflexive thematic analysis was supported by NVivo12 software. RESULTS: Key themes: obtaining support that was unavailable from in-person networks; preparation for abortion; reducing feelings of isolation. The majority of participants independently searched online for accounts of abortion, with only three receiving any signposting to specific resources. Without guidance, finding relevant, supportive content was not straightforward. The search process was additionally complicated by the prevalence of abortion stigma online, which generated an additional burden at a potentially challenging time. Those who received direction towards particular resources reported primarily positive online experiences. CONCLUSIONS: While online content could address perceived in-person support gaps, the process of finding supportive content without guidance can be complex. Online searching may also expose women to stigmatising material and interactions. Signposting by abortion services towards well-moderated and trustworthy online resources could be constructive in limiting exposure to stigma and misinformation, while allowing those seeking it to access better support.