Health Service Users Research Articles

Evaluation of the causal effect of maternal education on the utilisation of maternal health services in Bangladesh using an observational study - a comparison of different propensity score methods and covariate adjustment

BackgroundAssessing maternal health care utilisation is imperative for the health of both mother and her child. Maternal education is an important determinant in subsequent maternal health care usage, according to research. There is a dearth of research on the causal relationship between maternal education and maternal health services as well as examining the performance of different propensity score methods for estimating absolute effects. Therefore, this study aims to estimate the effect of maternal education on usage of maternal health services minimising the confounding effect and to compare different propensity score approaches to estimate absolute effects of maternal education on usage of maternal health services.MethodsWe used data from a cross-sectional study conducted by icddr,b in Bangladesh. A total of 1300 recently delivered mothers were included in this study. We used different propensity score (PS) methods to estimate the causal effect of maternal education on receiving maternal health services, including PS matching, PS weighting, covariate adjustment using PS, as well as used modified log-Poisson regression with and without multiple covariates.ResultsThe study revealed highly imbalanced possible confounding factors for mother's educational level, which might lead to erroneous estimates. All methods indicated a significant effect of higher maternal education, whether measured as a continuous scale or a binary variable (secondary or higher vs. below secondary) on maternal health services, significantly increased the likelihood of receiving four or more ANC, delivered at facility, PNC within 42 days and receiving all maternal health services compared to the mothers with lower level of education. The PS weighting provided precise estimates with a low range of confidence interval.ConclusionsThe results provided important insights on how well these techniques worked to reduce effect of confounding variables and achieve precise estimates. Propensity score weighting method performed better in terms of providing more precise estimates with a narrower range of confidence intervals, indicating that this method may be a reliable approach for estimating the causal effect of maternal education on maternal health service utilisation. However, careful consideration should be given to selecting the most appropriate method.

Machine learning insights into regional dynamics and prevalence of COVID-19 variants in US health and human services regions

BackgroundThe COVID-19 pandemic arising from the emergence of SARS-CoV-2 in late 2019 has led to global devastation with millions of lives lost by January 2024. Despite the WHO’s declaration of the end of the global health emergency in May 2023, the virus persists, propelled by mutations. Variants continue to challenge vaccination efforts, underscoring the necessity for ongoing vigilance. This study aimed at contributing to a more data-driven approach to pandemic management by employing random forest regression to analyze regional variant prevalence.MethodsThis study utilized data from various sources including National COVID Cohort Collaborative database, Bureau of Transportation Statistics, World Weather Online, EPA, and US Census. Key variables include pollution, weather, travel patterns, and demographics. Preprocessing steps involved merging and normalization of datasets. Training data spanned from January 2021 to February 2023. The Random Forest (RF) Regressor was chosen for its accuracy in modeling. To prevent data leakage, time series splits were employed. Model performance was evaluated using metrics such as MSE and R-squared.ResultsThe Alpha variant was predominant in the Southeast, with less than 80% share even at its peak. Delta surged initially in Kansas City and maintained dominance there for over 5 months. Omicron subvariant BA.5 spread nationwide, becoming predominant across all Health and Human Services regions simultaneously, with New York seeing the earliest and fastest decline in its share. Variant XBB.1.5 concentrated more in the Northeast, but limited data hindered full analysis. Using RF Regressor, key features affecting spread patterns were identified, with high predictive accuracy. Each variant showed specific environmental correlations; for instance, Alpha with air quality index, Delta with ozone density, BA.5 with UV index, and XBB.1.5 with land area and income. Correlation analysis further highlighted variant-specific associations.ConclusionsThis research provides a comprehensive analysis of the regional distribution of COVID-19 variants, offering critical insights for devising targeted public health strategies. By utilizing machine learning, the study uncovers the complex factors contributing to variant spread and reveals how specific factors contribute to variant prevalence, offering insights crucial for pandemic management.

Mental health disorders before, during and after the COVID-19 pandemic: a nationwide study.

The COVID-19 pandemic and lockdowns prompted a major concern for mental health effects. Comprehensive nationwide studies are lacking on the indirect effect of the COVID-19 pandemic on the population's mental health. We aimed to determine whether the COVID-19 pandemic and lockdowns affected mental health service usage, suicide attempts, and suicides. This comprehensive nationwide register-linked study followed all individuals in Denmark from 1990. The main outcomes were rates of psychiatric admissions, use of psychotropic medication, suicide attempts, suicides, patients in community-based private psychiatry or psychology practices, and referrals to psychiatric hospitals. The impact of the pandemic (March 11, 2020-June 30, 2023) and lockdowns was assessed with log-normal models adjusted for pre-pandemic trends (January 1, 2017-March 10, 2020). We reported Rate Ratios (RR) of the observed and counterfactual rates. We identified the 5 807 714 (50.3% females) individuals living in Denmark on March 1, 2020. The rates of psychiatric admissions (RR: 0.95, 95% Confidence Interval (CI): 0.91 to 0.99, p-value: 0.017) and suicide attempts (RR: 0.85, 95% CI: 0.76 to 0.95, p-value: 0.007) were lower during the pandemic compared to the pre-pandemic trend. The rates of suicides (RR: 0.89, 95% CI: 0.75-1.05, p-value: 0.173), patients in private practices (RR: 1.00, 95% CI: 0.96-1.04, p-value: 0.986), and referrals (RR: 1.06, 95% CI: 0.95-1.18, p-value: 0.307) were not significantly different during the pandemic compared to the pre-pandemic trend. During the first lockdown, rates were lower for psychiatric admissions (RR: 0.85, 95% CI: 0.80 to 0.90, p-value <0.001), suicide attempts (RR: 0.80, 95% CI: 0.69 to 0.94, p-value: 0.007), suicides (RR: 0.67, 95% CI: 0.52 to 0.86, p-value: 0.002), patients in private practices (RR: 0.88, 95% CI: 0.82 to 0.93, p-value <0.001), and referrals (RR: 0.69, 95% CI: 0.60 to 0.81, p-value < 0.001) compared to the pre-pandemic trend. However, during the pandemic, the rate of psychotropic medication users increased by 6% compared to the pre-pandemic trend (RR: 1.06, 95% CI: 1.05 to 1.06, p-value < 0.001). The COVID-19 pandemic and lockdowns did not severely influence pre-pandemic trends of the mental health burden in Denmark's population on a nationwide level.

Patients’ trust in health information sources as an antecedent of novel healthcare technology usage

Abstract Background As professional health information sources, healthcare maintenance organizations (HMOs) need to convince patients of the necessity, efficiency, and reliability of technology-based services to increase and optimize their usage. It raises the question of whether patients’ trust in health information sources shapes the use of technology-based services and, in return, increases their willingness to use novel healthcare services in the future. Methods Data were collected through an online close-ended survey among 668 adult Israeli citizens insured with Israeli health insurance (85% of them Jewish, 52.5% female, and in their early 40s, with half holding an academic degree). The survey explored actual use and willingness to use innovative healthcare technologies and the trust respondents attributed to various sources of health information. Data were analyzed by SPSS 28. Results Participants generally use healthcare technology primarily to schedule appointments, search for medical information, and make health-related requests. To quite an extent, they are willing to be treated with innovative healthcare technologies (e.g., for radiological purposes and personally tailored medication). Preliminary results suggest that trust in the measured formal health information sources (i.e., formal health providers, HMO, HMO online services) was positively associated with technology-based healthcare services usage (r=.14 - .20, p&amp;lt;.001). A positive association also emerged between the current use of healthcare technology and the willingness to use innovative medical technologies in the future (r=.23, p&amp;lt;.001). Conclusions HMOs, as key players, have the power to maximize the usage of advanced health services by establishing trusting relationships with their patients. This will increase the usage of healthcare technology-based services and generate positive patient experiences, which will result in the willingness to experience novel types of health services in the future. Key messages • Encouraging patients to use technology-based health services will maximize the potential inherent in the use of innovative health services and treatments in the future. • Nurturing trusting relationships with patients at any level in the health system will increase their compliance with health providers’ recommendations to use advanced health services.

Protocolizing social prescribing in mental health and addiction services: barriers and opportunities

Abstract Issue Social Prescribing (SP) is a structured approach where health professionals recommend community activities to enhance well-being. Starting in Catalonia in 2012, it expanded to the entire primary care network by 2016. By 2023, 23,338 patients received SP, showing a 2.3-fold increase from 2022. Two-thirds experienced improvement in mental well-being. Now, efforts focus on applying SP to mental health and addiction services (MHAS), where SP can be used for restoring health and well-being. Description A literature review was conducted and a working group was initiated with MHAS professionals was initiated to exchange experiences and identify needs and best practices. This was done in preparation for designing a pilot experience, which will include a qualitative study through focus groups to validate the action plan and determine barriers and facilitators in MHAS. The groups will be segmented into MHAS users and frontline professionals. Results The results of the review process and the working group sessions demonstrated that SP can be useful and beneficial for the health MHAS users. However, barriers and opportunities were identified. The main barriers detected include: the need for strong support during referrals to community activities; increased awareness of addiction among activity providers to reduce stigmatization; define inclusion and exclusion criteria; determining monitoring and evaluation tools; and mapping and updating community assets. Regarding opportunities, the following were highligthed: the interest of MHAS professionals in promoting and implementing a SP program in this area; the existence of organizations already conducting community activities focused MHAS users; and political prioritization of this issue. Lessons The implementation of a SP program protocol in MHAS is considered beneficial. It is necessary to analyse barriers to effectively address them and to identify opportunities to leverage them. Key messages • Social Prescribing has significantly enhanced mental health outcomes in Primary Care, which can imply a potential improvement in well-being of mental health and addiction services users. • Implementing Social Prescribing in mental health and addiction services offers promising integrated care opportunities, requiring barriers resolution and maximizing existing prospects.

Dis-continuity in Continuity-of-Care: a pathway for more equal access to mental health care services?

Abstract Background Access to healthcare is core to achieving universal health coverage. Reaching and obtaining appropriate health care services requires engagement by health care organizations and users. For people with mental illness, access emerges as a continuous process, reflecting oscillating health conditions. This challenges aspirations of continuity of care (COC), but we know little about the experiences of users. Methods We carried out observations of interactions between professionals and users (n = 18) and semi-structured interviews with users, professionals, and managers (n = 33) in the specialised mental health services in Central Denmark Region and FACT-inspired teams in three municipalities. We also conducted 3 focus groups with regional and municipal professionals from these teams. Data was analysed through a qualitative thematic analysis. Results From the perspective of users, COC builds on the acknowledgment of their entire life situation. For users, this is about making connections between their past, present and future lives. Past experience affect their present abilities to follow treatment and influence future hopes and expectations. The acknowledgment of these connections often translates into spaces of discontinuity in continuity, where users need occasional breaks from treatment but worry about being excluded from treatment. Crucially, the organization of the FACT-inspired teams allows for flexibility in the intensity of visits and treatment. The norms of professionals also support users’ perspectives on COC, as the norms focus on building trust in the relations between users and professionals. Conclusions One important step to achieve more equal access is to integrate the social world of users. This requires organizational and professional approaches that allow for user needs for dis-continuity in COC. Key messages • For mental health service users, continuity-of-care includes breaks from treatment (discontinuity). • More equal health access requires adapting continuity-of-care to needs as perceived by users.

Defining digital health literacy profiles in Spanish adults: a latent class analysis

Abstract Background According to different reports, Spain is among the European countries that use digital health technologies the most. However, to develop inclusive and fair digital health services, there is the need to feature digital health knowledge, skills, confidence, and a positive attitude about their significance. This work aims to draw a picture of digital health literacy levels in Spain. Methods A stratified sample of the Spanish population regarding gender, age group and area of residence was used. Participants were recruited from an online panel and by direct approach to balance quotas. Between May 2021- May 2022, participants filled a self-administered online survey, including the Spanish version of the eHealth Literacy Questionnaire (eHLQ) and the eHealth Literacy Scale (eHEALS). Results Digital health literacy showed similar mean scores, between 2.6-2.7 out of 5 with similar SD on each of the 7 dimensions of the eHLQ. The highest scores were related to knowledge about filling data in digital health services and knowledge about health and how the body works, and feelings about the usefulness of digital technology for health. In contrast, lower scores were related to sharing health information by technology, thinking that using technology gives access to better health services, and the possibility to contact usual health professionals with technology. Latent profile analysis identified 5 user profiles. Significant differences were found according to age, inhabitants per municipality, technology use, self-perceived health status, educational level, socioeconomic index and eHEALS scores; not by gender. Conclusions As the scores are similar in the different subscales, competencies, attitudes and confidence in digital health that they measure are balanced. However, the main challenge appears in granting users access to digital services that work, which involves the definition and monitoring of strategies until the final implementation. Key messages • Digital Health literacy in Spain differs according to different aspects, not only age, educational or socioeconomic level. • Confidence in usefulness is a common denominator among the five digital health service user profiles identified.

9.D. Practice session: Luton, a Marmot town – Lessons from using a whole-system approach to tackle health equity

Abstract Objective To share learnings from our Health Equity Town journey, including opportunities and challenges. To allow stimulating discussion on whole system approaches to health inequalities and the social determinants of health. To include discussion on where and how public health influences or leads, the importance of impact measures, and of shared vision. Added value Luton’s 2040 strategy, and being a health equity town, are long term visions. It has been 18 months since we launched Luton’s health equity ambition, and during that time we have taken great strides forward in how we deliver against the Marmot principles and create a movement around health equity in Luton. Organisations nationally and internationally are grappling with approaches to doing this. This workshop will provide an opportunity to discuss some of the key learnings, challenges and opportunities so far in taking this approach, and how to continue to maintain momentum and buy in across sectors at local level. The workshop will include discussion on the following: 1. Taking a whole-system approach to health inequalities - working across system leaders and strategic partners including health, care, voluntary sector, businesses, housing, police and others, as well as across the local authority departments. This takes clear articulation of the problem and actions, as well as clarity on where public health professionals are most effective to support, influence, and lead. 2. There is increasing recognition of the building blocks of health and the importance of ensuring action to improve health outcomes is taken across the whole system to tackle health inequalities - including employment, education, and housing. Discussion on specific actions being taken in some of these areas to tackle health inequalities as part of the health equity town approach. 3. Working with the community to understand health inequalities. 4. How we will measure progress. 5. The concept of proportionate universalism is now well known, however making this a reality is a challenge. 6. East London Foundation Trust, the mental health provider in Luton, is also embedding Marmot Policy objectives across the Trust, and is a key partner in Luton. Work is underway to establish projects with joint aims such as skills passport to increase employment in mental health service users. Format Presentation followed by opportunity for question and answer and discussion with panel. Key messages • Whole system approaches to tackling health equity are possible through shared vision and coordinated approach. • Action across the building blocks of health is vital, the complex and long term nature is challenging.

Stressors and symptoms explaining sexual orientation inequalities in mental health services usage: A longitudinal study with young adults

Abstract Background Sexual minority (i.e., lesbian, gay, and bisexual [LGB], and other non-heterosexual) individuals are more likely to use mental health services than heterosexuals; however, evidence is scarce about factors contributing to this difference. Methods This study uses longitudinal data from a population-based sample of young adults (aged 18- 36) in Sweden (N = 1,137). We use mediation analysis to examine whether common mental health symptoms (i.e., depressive, anxiety and social anxiety symptoms, suicidality, and alcohol use) mediate sexual orientation differences in mental health services use; and to understand whether adding general stressors (i.e., low social support, loneliness, and perceived stress) to these models increases the total effect explained. Afterwards, we use logistic regression models to understand how minority-specific stressors (e.g., family reaction and dimensions of sexual minority identity) predict mental health service use among sexual minority individuals (N = 498), adjusting for common mental health symptoms. Results Common mental health symptoms only partially mediate the associations and the direct effect for sexual orientation remain significant (β = 0.11, p &amp;lt; 0.01). Adding general stressors to these models only slightly increase the total effect explained and the direct effect remained significant (β = 0.11, p &amp;lt; 0.01). Among sexual minority individuals, after adjusting for common mental health symptoms, a difficult process of coming out (β = 0.12, p &amp;lt; 0.05) and negative family reaction towards one’s sexual orientation (β = 0.15, p &amp;lt; 0.05) predicted use of mental health services. Conclusions Overall, these results show that minority-specific stressors contribute to help-seeking behaviours among sexual minority individuals, regardless of psychiatric morbidity, highlighting the potential role of mental health services empowering sexual minority individuals to cope with minority stress.

Users' Experience of Treatment and Coercion in an Inpatient Medium-Stay Psychiatric Rehabilitation Unit: A Mixed Methods Study.

Coercion influences mental health services users' experience of care and can hinder their recovery process, so it is essential to understand how it is perceived in rehabilitation settings oriented towards recovery. To describe and measure users' experience of coercion and explore their perception of the treatment received in an inpatient medium-stay psychiatric rehabilitation unit (IMSPRU). This study, in which 75 service users participated, used a mixed methods approach. Twenty participants were administered a semistructured interview and completed quantitative measures for coercion and 55 additional service users completed the quantitative measurements only. The perception of coercion was measured using the Coercion Experience Scale. The content analysis of qualitative data resulted in two main themes: treatment received and experience of coercion in the IMSPRU. The participants made a distinction between good treatment and mistreatment or unfair treatment. Experience of coercion in the IMSPRU included the feeling of freedom or lack thereof in the unit, forms of formal and informal coercion, and the positive or negative impact of rules on the unit. The quantitative data revealed a low perception of formal coercion among the users. Individuals had different views of what it meant to be treated well, but all agreed on the importance of communication and the need to feel respected. Informal coercion was the most frequent type of coercion identified, but users were often unaware of its existence. Knowledge of how IMSPRU users experience the treatment received from nursing staff and how they perceive coercive situations will help to lay the foundations of a system of care oriented towards good treatment and noncoercive practices.

Exploring mental health experiences and supports among international engineering undergraduate students – insights to inform university support

ABSTRACT This study explores the mental health perceptions, expectations for mental healthcare, and use of existing mental health services among international engineering students at a Western Canadian university. Employing a phenomenological qualitative approach, semi-structured interviews were conducted with 18 international undergraduate engineering students to understand their mental health challenges and service usage. The thematic analysis revealed three significant themes: students’ understanding of mental health; their experiences within the engineering programme, and recommendations to enhance and facilitate a positive mental health experience at the university. Findings suggest that mental healthcare for international engineering students should be responsive to the students’ unique needs, providing support and accessible services during their transition from their home countries and recognising the impact of the environmental and cultural factors on their experiences as members of the Faculty of Engineering and the broader university community.

Palliative rehabilitation and quality of life: systematic review and meta-analysis

ImportanceInternational guidelines recommend the integration of multidisciplinary rehabilitation into palliative care services but its impact on quality of life across disease types is not well understood.ObjectiveTo determine the effect of...

A qualitative study exploring mental health professionals' perspectives, opinions, and attitudes on the state of service users' rights.

The rights of mental health service users are a subject of profound debate. In this article, we aim to examine mental health professionals' perspectives, opinions, and attitudes on the state of service users' rights. We conducted a thematic analysis of eleven focus groups involving mental health professionals. Through this process, we identified two main meta-themes that shed light on the challenges faced by mental health service users: 'Transforming the therapeutic relationship' and 'Societal determinants of service users' rights'. Within the former meta-theme, we identified the following themes: 'Diversifying mental health knowledge', 'Risk-protection tensions', and 'Being (ir)responsible'. Within the latter meta-theme we identified 'Determinants inside the clinics' and 'Determinants outside the clinics.' Reflecting on these themes could potentially encourage new strategies to support professionals in overcoming the subjective barriers that prevent their adherence to rights-based mental health care models.

Psychological, psychosocial and physical barriers preventing nature-based intervention participation in adults with mental health disorders: A scoping review.

Nature-based interventions (NBIs) are becoming a common mental health care referral option; however, little is known about the barriers to participation. Research reveals a concentration of evidence on the practical barriers with a paucity of guidance on the personal barriers as experienced by service users. This review explores what is known on the psychological, psychosocial and physical barriers as disclosed by adult mental health service users and the various stakeholders involved in NBI. Nine of the 104 articles screened met the inclusion criteria. The review identified a total of 47 barriers in which the majority were standalone barriers unique to the individual article or participant that generated them. However, other barriers suggest a level of universality with the greatest array of barriers identified in the psychosocial category. The review highlights an urgent need for further research on the psychological, psychosocial and physical barriers to NBI participation.

Development of a culturally safe recovery-oriented mental health practice

ABSTRACT This paper provides a comprehensive perspective on recovery, highlighting the significance of cultural awareness and the use of intersectionality theory to further the understanding of the influence of diverse identities on the recovery journey. A conceptual model is being introduced for culturally safe recovery-oriented practices, encompassing key domains: ways of knowing, presence, doing, and operating. Social workers are urged to lead the adoption of these practices, addressing service delivery gaps and promoting cultural safety for mental health service users. The model encourages mental health practitioners to engage in self-reflexivity, challenge power structures, and dismantle social inequities that hinder mental health recovery. The holistic embrace of all four practice domains can enhance service delivery and foster cultural safety for service users in recovery.

Learning About Mental Health Lived Experience in Social Work Education

ABSTRACT Lived experience education occupies an increasingly important space in mental health education for social workers. Despite being plagued by practices that continue to be discriminating and exclusionary, the mental health policy and practice context demand robust attention to the meaningful inclusion of service users and their families to achieve genuine partnership, reciprocity, and equality in mental health service provision. For social work educators, lived experience education is now an indispensable component of a critically informed mental health curriculum and pedagogy. Framed within an appeal for epistemic justice, this article reports on qualitative survey data from social work students who experienced teaching from people with lived experience. Findings show that students greatly valued lived experience education, as it created opportunities for authentic and more diverse understandings of mental health that fostered critical reflection. A curriculum that supports epistemic equality and a social justice agenda would help scaffold lived experience expertise for student learning. IMPLICATIONS Mental health lived experience education positively impacts social work students’ values and attitudes towards mental health service users. Lived experience education supports social work students to expand their understandings of mental health and recovery beyond dominant biomedical perspectives. Genuine valuing of lived experience knowledge and expertise in social work education helps address epistemic injustice.

Barriers and enablers to a coordinated MHPSS response in Lebanon: A case study of the MHPSS Taskforce

During humanitarian crises, under-resourced and overstretched health systems may not be able to fully meet mental health and psychosocial support (MHPSS) needs of affected populations, including refugees, internally displaced persons and host communities. Health system governance is vital to humanitarian health response, but there has been little research on this, particularly for MHPSS. We present a case study of a national MHPSS coordination mechanism (the MHPSS Taskforce) in Lebanon, a country which has experienced multiple crises and hosts over 2 million refugees. The aim was to explore the barriers and enablers facing the MHPSS Taskforce in responding to the needs of displaced and host populations in Lebanon. Interviews were conducted with 34 key stakeholders, including Taskforce members, representatives from non-governmental organisations, United Nations agencies, and government Ministries. Our findings show that the positioning of MHPSS within the humanitarian cluster system acts as a barrier to mounting an effective response, with the MHPSS Taskforce sometimes siloed rather than integrated across clusters. Coordination within the Taskforce was reported to be effective in some respects, but limited by a lack of clarity about its decision-making processes, affiliation, mandate, and inclusion of regional perspectives and key groups such as mental health services users in Lebanon. While the technical capacity of the Taskforce is strong, limited funding and staffing were seen to impact its capacity to effectively oversee the MHPSS response in Lebanon. Key recommendations include: the need for stronger mechanisms and operating procedures for interagency and inter-sectoral collaboration on MHPSS within the humanitarian cluster system; greater clarity on the role of the Taskforce and key Taskforce actors, streamlined reporting channels and greater inclusion of diverse perspectives, particularly mental health service users; and greater financial and human resources within coordination mechanisms to support the national MHPSS response in Lebanon.

Breaking the Silence: Addressing Domestic Abuse in Mental Health Settings-Identification, Screening, and Responding.

Individuals experiencing domestic abuse (DA) struggle to disclose victimization, but as frequent users of mental health services, this is a pivotal setting for identification and addressing DA. This systematic review of 20 studies investigates DA identification, screening, and responses within mental health settings. Three databases were searched using these inclusion criteria: adults aged 18 and older accessing mental health services, samples comprising mental health professionals (or combination). No geographical restrictions were applied. All studies were peer-reviewed and published in English between January 2000 and December 2023. Studies had to incorporate screening for DA between (ex-)partners and/or response to disclosure within mental health settings. The findings revealed considerable variation in DA screening methods from direct screening tools to retrospective analyses of patient files. Professionals report barriers in identifying DA, including uncertainty about their role, time constraints, and the importance of building trust with service users. Nonetheless, many highlight the importance of routinely asking about DA. A small number of interventions have been effective in enhancing professionals' readiness to address DA, but it remains unclear what format of training is most effective. Service users report feelings of shame and fear of not being believed when disclosing DA, but are aided by therapeutic engagement and enhanced professional awareness. There is a lack of diverse inclusion in the research. In summary, there is considerable scope to develop good practice to support mental health professionals' ability to identify and respond to DA across assessment tool and training, but also in understanding what facilitates service users to disclose.

Exploring the determinants of online health service usage intentions under the threat of air pollution.

The rapid evolution of online health services (OHS) has significantly improved healthcare accessibility. However, the impact of air pollution on individuals' willingness to engage with OHS remains underexplored in the existing literature. This study addresses this gap by investigating how air pollution threats influence the intention to use OHS, grounded in Protection Motivation Theory (PMT) and Rational Choice Theory (RCT). Using cross-sectional survey data, a theoretical model was developed and tested to examine the relationships between threat appraisal, coping appraisal, perceived benefits, perceived costs, and OHS usage intentions. The findings indicate that threat appraisal, coping appraisal, and perceived benefits positively affect the intention to use OHS, while perceived costs negatively impact usage intention. Additionally, age significantly moderates the relationship between coping appraisal and the intention to use OHS. This study extends the application of PMT and RCT in the context of OHS. It provides valuable insights into the factors influencing users' intentions to utilize these services, with implications for improving OHS adoption in environments affected by air pollution.

Detection and Coil Embolisation of Pelvic Vein Incompetence for Chronic Pain in the Female Pelvis: A Development Phase Economic Analysis

Unexplained chronic pain in the female pelvis (CPFP) affects 7% of people indicating female sex in the UK. Evidence suggests that pelvic venous incompetence (PVI) could explain CPFP and that coil embolisation could provide relief. The aims of this study were to indicate (1) the cost effectiveness of detecting and treating PVI in people experiencing unexplained CPFP, and (2) the maximum value of further research, suggesting suitable areas. A decision tree compared standard care (regular prescribed analgesia) with an intervention comprising transvaginal duplex ultrasound to screen for PVI, venography to confirm the diagnosis, and coil embolisation treatment. The population was people experiencing unexplained CPFP. A UK National Health Service perspective and 2021 - 22 price year were used. Ten years of health costs and health related quality of life (HRQoL) effects for eligible 40 year olds were simulated. Evidence reviews informed diagnostic accuracy, health service usage, and unit costs. A single centre randomised controlled trial informed all other parameters. Probabilistic analysis incorporated parameter uncertainty in cost effectiveness estimates. Deterministic sensitivity analysis indicated drivers of uncertainty. Value of information methods measured the value of eliminating all relevant uncertainties, given uptake predictions. The main outcome measures were incremental cost and quality adjusted life years (QALYs) for the intervention compared with analgesia, the incremental cost effectiveness ratio (ICER), and expected value of perfect information. The mean ICER for the intervention was £4 558/QALY gained, and the probability that the ICER was within the UK cost effectiveness threshold (£20 000/QALY gained) was 90%. The expected value of perfect information about all model parameters was £46 M. All deterministic sensitivity analysis scenarios met the threshold, except the smallest plausible HRQoL effect of (resolving) CPFP. Detecting and treating PVI causing CPFP appears cost effective, but more primary research would be valuable to reduce decision uncertainty. Uncertainty in the HRQoL estimate for unexplained CPFP appeared to contribute most to decision uncertainty.