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How can UK public health initiatives support each other to improve the maintenance of physical activity? Evidence from a cross-sectional survey of runners who move from Couch-to-5k to parkrunPhysical activity improves physical and mental well-being and reduces mortality risk. However, only a quarter of adults globally meet recommended physical activity levels for health. Two common initiatives in the UK are Couch-to-5k (an app-assisted 9-week walk/run programme) and parkrun (a free, weekly, timed 5-km walk/run). It is not known how these initiatives are linked, how Couch-to-5k parkrunners compare to parkrunners, and the extent to which this influences their parkrun performance. The aims were to compare the characteristics and motives and to compare physical activity levels, parkrun performance and the impact of parkrun between Couch-to-5k parkrunners and parkrunners. Three thousand two hundred and ninety six Couch-to-5k parkrunners were compared to 55,923 parkrunners to explore age, sex, ethnicity, employment status, neighbourhood deprivation, motives, physical activity levels, parkrun performance and the impact of parkrun. Couch-to-5k parkrunners were slightly older, more likely to be female and work part-time, but similar in ethnicity, and neighbourhood deprivation compared with other parkrunners. Couch-to-5k parkrunners had different motives for participation and reported high levels of physical activity at registration, which remained to the point of survey completion. This group had slower parkrun times but, when registered for a year, completed a similar number of runs (11) per year. Larger proportions of Couch-to-5k parkrunners perceived positive impacts compared with other parkrunners and 65% of Couch-to-5k parkrunners reported improvements to their lifestyle. parkrun appears to be an effective pathway for those on the Couch-to-5k programme, and the promising positive association between the two initiatives may be effective in assisting previously inactive participants to take part in weekly physical activity.
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What are the roots of the nation’s poor health and widening health inequalities? Rethinking economic growth for a fairer and healthier futureHealth inequalities are differences in health between groups in society. Despite them being preventable they persist on a grand scale. At the beginning of 2024, the Institute of Health Equity revealed in their report titled: Health Inequalities, Lives Cut Short, that health inequalities caused 1 million early deaths in England over the past decade. While the number of studies on the prevalence of health inequalities in the UK has burgeoned, limited emphasis has been given to exploring the factors contributing to these (widening) health inequalities. In this commentary article I will describe how the Government's relentless pursuit of economic growth and their failure to implement the necessary regulatory policies to mitigate against the insecurity and health effects neoliberal free market capitalism (referred to as capitalism herein) causes in pursuit of innovation, productivity and growth (economic dynamism) is one key driver underpinning this social injustice. I contend that if the priority really is to tackle health inequalities and ensure health for all then there is an imperative need to move beyond regulation alone to mitigate the worst effects of capitalist production; the goal of the economy has to change to fully restore the balance between economic growth and public health.
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Addressing the elephant in the room: Economic growth and the nation’s poor health – changing the economy’s goal for a healthier futureThis opinion piece focuses on how in order to improve the nation's poor health, the government needs to place more value on social justice and wellbeing as well as the use of regulation to positively change culture and health behaviour.
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“The want for independence!”: Factors influencing care preferences for older people living in a local authority in northwest EnglandThis paper reports a project evaluating public opinions regarding factors determining preferred place and type of care in older age. Design/methodology/approach: A service evaluation utilising appreciative inquiry and co-creation was conducted. Participants were recruited via convenience sampling from public places and care/support facilities. Data were captured utilising five methods: four innovative, creative approaches (Snap Judgement, 3-Word elicitation, Ideas Board, Scenarios) and a survey. Results were analysed thematically. Findings: There were 126 participants, in the study; the majority expressed a preference for care in their own home. Closeness to family and friends was the most important factor in choice, followed by cost. A wide variety of sources were identified to gain information about care. A desire was expressed for local community-based care options. Research limitations/implications: Findings suggest most people may prefer to remain at home as they age, emphasising importance of domiciliary care in maximising independence. Leveraging technology could aid this goal. Further application of the creative methods used is essential to determine their effectiveness and validity. Practical implications: Unless individuals plan for their care arrangements in older age, the location and type of care may be determined at point of need, with minimal or no input from individuals involved. This may result in people not receiving their preferred mode of care. Originality/value: Assisted by the local authority’s proactiveness in commissioning the project, researchers actively engaged with the public in a variety of settings. Innovative data collection methods enabled capture of rich data and data triangulation strengthened trustworthiness.
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Refugees: An examination of the Post-Traumatic Stress Disorder NICE guidelinesThe aim of this review is to consider whether the NICE guidelines for Post-Traumatic Stress Disorder (PTSD) can appropriately guide professionals in meeting the needs of refugees, through evaluation, assessment and treatment. In particular, the limited consideration for culture within the guidelines is explored. Of key importance is that the NICE guidelines are based on the diagnostic model of PTSD, which may fail to appreciate the broader ways in which refugees may understand their traumatic experiences, and wish to address the impacts. Furthermore, there is a clear gap in literature concerning PTSD treatment for refugees (Lee & Bowles, 2023). Arguably, this brings into question the validity of the treatment recommendations within the NICE guidelines, for refugees. More broadly, within the global context, the application of western-based mental disorders has been disputed based on the cultural, and philosophical differences, varying interpretations of life and different traditions in relation to expressing distress and seeking support (Summerfield, 2013). This paper suggests that the NICE guidelines fail to consider the depth and complexity of the role of culture within trauma and recommend insufficient flexibility with regards to the mode of treatment delivery, including a lack of consideration for native and culturally grounded methods of intervention.
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Utilizing a Delphi Panel Approach to co-create the PROTECtoolkit designed to safeguard care home staff and residents during pandemicsCONTEXT: The COVID-19 pandemic resulted in upward of seven million deaths worldwide. In the United Kingdom, the Government was unprepared for the pandemic, which was especially evident in the care home sector, where thousands of residents lost their lives. AIMS: This research addressed the need for care homes to have robust, user-friendly solutions to planning for, and reacting to, infectious disease outbreaks. The intention was to develop a toolkit to safeguard residents, staff, and others visiting care homes. DESIGN AND METHODS: The research adopted an appreciative inquiry approach that involved working collaboratively with stakeholders. A scoping review identified relevant information and informed the development of the Toolkit. A Delphi panel of relevant experts was established to co-create and develop the PROTECToolkit. An online survey captured the experience of nurses working in care homes during the pandemic. The prototype toolkit was feasibility tested by care home staff. RESULTS: In addition to refining the content of the Toolkit, the scoping review demonstrated that co-creation in the care sector improves safety and quality of care. The survey revealed how care homes strengthened infection prevention and control and addressed challenges. The Delphi panel quickly reached a consensus on the online survey and Toolkit contents, with feasibility testing confirming the Toolkit content while highlighting issues regarding completion. CONCLUSIONS: The collaborative approach to developing the Toolkit resulted in a user-friendly instrument that is relevant to practice. The Toolkit offers an adaptable framework for use alongside existing safety and quality metrics to plan for, and address, infectious disease outbreaks in care homes. The Toolkit also empowers nurses working in care homes to identify good practices and where improvements are needed.
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The Mental Health Bill (2025) for England and Wales: Professional and carer consensus statement summarising concerns and unintended consequences from proposed changes to autism and learning disabilityThe Mental Health Bill, 2025, proposes to remove autism and learning disability from the scope of Section 3 of the Mental Health Act, 1983 (MHA). The present article represents a professional and carer consensus statement that raises concerns and identifies probable unintended consequences if this proposal becomes law. Our concerns relate to the lack of clear mandate for such proposals, conceptual inconsistency when considering other conditions that might give rise to a need for detention and the inconsistency in applying such changes to Part II of the MHA but not Part III. If the proposed changes become law, we anticipate that detentions would instead occur under the less safeguarded Deprivation of Liberty Safeguards framework, and that unmanaged risks will eventuate in behavioural consequences that will lead to more autistic people or those with a learning disability being sent to prison. Additionally, there is a concern that the proposed definitional breadth of autism and learning disability gives rise to a risk that people with other conditions may unintentionally be unable to be detained. We strongly urge the UK Parliament to amend this portion of the Bill prior to it becoming law.
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“It’s just not something we do at school”. Adolescent boys’ understanding, perceptions, and experiences of muscular fitness activityBACKGROUND: English youth typically do not sufficiently engage in the types and intensities of physical activity that develop muscular fitness. The aim of this study was to use a combination of qualitative techniques to explore adolescent boys' understanding, perceptions, and experiences of physical activity and the role muscular fitness plays within boys' physically active lifestyles. METHODS: Focus group interviews with a write, draw, show, and tell activity were conducted with 32 adolescent boys aged 14-16 years from 3 secondary schools. Three separate sources of data (frequency counts, verbatim transcripts, and visual data) were generated and were pooled together and triangulated. Data were analysed deductively, first using the Youth Physical Activity Promotion model as a thematic framework, and then inductively. RESULTS: Physical activity was frequently associated with organised sport, and most boys were unaware of current UK physical activity guidelines. Co-participation was frequently reported as a reinforcing factor to physical activity. CONCLUSIONS: There was a perceived lack of opportunity to participate in muscular fitness activities, particularly in school, and knowledge of how to conduct muscular fitness activities was limited. The contribution of physical education was highlighted as being key to facilitating exposure to muscular fitness activities.
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The influence of adolescent sport participation on Body Mass Index tracking and the association between Body Mass Index and self-esteem over a three-year periodThis study aimed to (1) investigate gender-specific characteristics associated with low sport participation among UK adolescents, and (2) assess gender-specific BMI tracking, and gender-specific associations between BMI and self-esteem based on different levels of adolescent sport participation. Participants were 9046 (4523 female) UK adolescents. At 11- and 14 years self-esteem was self-reported and BMI was calculated from objectively measured height and weight. At 11- years sport participation was parent-reported. Gender-specific sport participation quartile cut-off values categorised boys and girls separately into four graded groups. Gender-specific χ<sup>2</sup> and independent samples t tests assessed differences in measured variables between the lowest (Q1) and highest (Q4) sport participation quartiles. Adjusted linear regression analyses examined BMI tracking and associations between BMI and self-esteem scores. Gender-specific analyses were conducted separately for sport participation quartiles. Compared to Q4 boys and girls, Q1 boys and girls were more likely to be non-White, low family income, have overweight/obesity at 11 years and report lower self-esteem at 11 years and 14 years. BMI at 11 years was positively associated with BMI at 14 years for boys and girls across sport participation quartiles. BMI at 11 years was inversely associated with self-esteem scores at 11 years for Q1 and Q2 boys, and Q1 and Q4 girls. BMI at 11 years was inversely associated with self-esteem scores at 14 years for Q1, Q3 and Q4 boys, and Q1, Q2, Q3 and Q4 girls. Gender and sport participation influence BMI tracking and the BMI and self-esteem association among adolescents.
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The feasibility and acceptability of an online CPD programme to enhance PE teachers’ knowledge of muscular fitness activitySchools provide an opportunity to enhance muscular fitness of English youth during physical education (PE). Continued professional development (CPD) among teachers may improve muscular fitness activity delivery in schools. This study sought to assess the feasibility and acceptability of an online CPD programme to enhance PE teachers' knowledge of muscular fitness activity. METHODS: Co-production of an online CPD platform was undertaken with five secondary school PE teachers. A quasi-experimental pre-post control group design for the CPD was adopted (CPD group <i>n</i> = 76, control <i>n</i> = 32). Upon CPD completion feedback was solicited for qualitative analysis. RESULTS: Pre-and-post CPD knowledge quiz data were available from 65 participants (55.4% male). The median knowledge quiz change score was significantly higher in the CPD group than in the wait list control group (CPD score vs. control score; U =37, z = -5.96, <i>p</i> < 0.01). Three primary themes reflecting factors associated with the acceptability and feasibility were (1) practical application, (2) support and resources, and (3) knowledge and confidence. CONCLUSIONS: Co-production of an online CPD programme can improve knowledge and affect practice. PE teachers that completed the CPD reported the online platform was beneficial to overcoming the limitations of face-to-face CPD such as time and financial constraints and suggested the content covered was beneficial and appropriate to their teaching. Future work is required to establish links between teachers' learning following CPD, the translation into PE practice and student MF outcomes.
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Prevalence of perceived discrimination and associations with mental health inequalities in the UK during 2019–2020: A cross-sectional studyExperiencing discrimination is associated with poorer mental health and the demographic patterning of discrimination may explain social inequalities in mental health. The present research examined prevalence of perceived discrimination in the UK and associations with social inequalities in mental health. Data were taken from the UK Household Longitudinal Study (n = 32,003). Population subgroups (sex, age, ethnicity, health, religiousness, income, education, and occupation), perceived personal discrimination (personal experience) and perceived belonging to a discriminated group (identified as belonging to a group discriminated against in this country), and probable mental health problems (GHQ-12 assessed, cut off 4+) were reported on in 2019/2020. Nineteen percent of participants perceived personal discrimination in the last year, 9% perceived belonging to a discriminated group, and 22% had probable mental health problems. There were significant inequalities in both perceived discrimination and mental health. Being a younger adult, of mixed ethnicity, having health problems, having a university degree, and being unemployed increased risk of mental health problems and these associations were partially explained by perceived discrimination being more common among these groups. Perceived discrimination is common among UK adults, but prevalence differs by population subgroup. Perceived discrimination may contribute to social inequalities in mental health.
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The Physical Behaviour Intensity Spectrum and Body Mass Index in school-aged youth: A compositional analysis of pooled individual participant dataWe examined the compositional associations between the intensity spectrum derived from incremental acceleration intensity bands and the body mass index (BMI) z-score in youth, and investigated the estimated differences in BMI z-score following time reallocations between intensity bands. School-aged youth from 63 schools wore wrist accelerometers, and data of 1453 participants (57.5% girls) were analysed. Nine acceleration intensity bands (range: 0−50 mg to ≥700 mg) were used to generate time-use compositions. Multivariate regression assessed the associations between intensity band compositions and BMI z-scores. Compositional isotemporal substitution estimated the differences in BMI z-score following time reallocations between intensity bands. The ≥700 mg intensity bandwas strongly and inversely associated with BMI z-score (p < 0.001). The estimated differences in BMI z-score when 5 min were reallocated to and from the ≥700 mg band and reallocated equally among the remaining bands were −0.28 and 0.44, respectively (boys), and −0.39 and 1.06, respectively (girls). The time in the ≥700 mg intensity band was significantly associated with BMI z-score, irrespective of sex. When even modest durations of time in this band were reallocated, the asymmetrical estimated differences in BMI z-score were clinically meaningful. The findings highlight the utility of the full physical activity intensity spectrum over a priori-determined absolute intensity cut-point approaches.
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Changes in the prevalence of perceived discrimination and associations with probable mental health problems in the UK from 2015 to 2020: A repeated cross-sectional analysis of the UK Household Longitudinal StudyBackground: Significant social and political changes occurred in the UK between 2015 and 2020. Few studies have examined population level trends in experiencing discrimination and mental health problems during this period. Aims: To determine prevalence trends in perceived discrimination and probable mental health problems amongst UK adults during 2015-2020. Method: Repeated cross-sectional data from the UK Household Longitudinal Study was used to estimate nationally representative trends in perceived discrimination and probable mental health problems (GHQ-12; 4+ threshold) among adults between 2015/2016-2019/2020 (25,756 observations). Weighted logistic regression models with post-estimation margins commands determined changes between survey waves controlling for sociodemographic characteristics. Mediation models explored whether changes in perceived discrimination prevalence trends explained trends in probable mental health problems. Results: From 2015/2016 to 2019/2020 perceived discrimination and probable mental health problems increased significantly by 6·1% (95% CI: 3·4-8·8, <i>p</i> <·001) and 4·5% (95% CI: 1·3-7·7, <i>p</i> = ·006), respectively. These changes did not tend to reliably differ by sociodemographic grouping. Increased prevalence of probable mental health problems from 2015/2016 to 2019/2020 was partially explained (15·2% of association mediated) by the increase in perceived discrimination observed during the same time period. Conclusions: Amongst UK adults, the prevalence of perceived discrimination and probable mental health problems increased between 2015/2016 to 2019/2020. Increases in perceived discrimination partially explained increases in probable mental health problems. National measures designed to reduce both discrimination and mental health problems have potential to make substantial improvements to public health and should be prioritised in the UK.
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Adolescent time use and mental health: a cross-sectional, compositional analysis in the Millennium Cohort StudyOBJECTIVE: To examine the association of 24-hour time-use compositions with mental health in a large, geographically diverse sample of UK adolescents. DESIGN: Cross-sectional, secondary data analysis. SETTING: Millennium Cohort Study (sixth survey), a UK-based prospective birth cohort. PARTICIPANTS: Data were available from 4642 adolescents aged 14 years. Analytical samples for weekday and weekend analyses were n=3485 and n=3468, respectively (45% boys, 85% white ethnicity). PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome measures were the Strengths and Difficulties Questionnaire (SDQ, socioemotional behaviour), Mood and Feelings Questionnaire (MFQ, depressive symptoms) and Rosenberg Self-Esteem Scale (RSE, self-esteem). Behavioural exposure data were derived from 24-hour time-use diaries. RESULTS: On weekdays, participants spent approximately 54% of their time in sleep, 3% in physical activity, 9% in school-related activities, 6% in hobbies, 11% using electronic media and 16% in domestic activities. Predicted differences in SDQ, MFQ and RSE were statistically significant for all models (weekday and weekend) that simulated the addition or removal of 15 min physical activity, with an increase in activity being associated with improved mental health and vice versa. Predicted differences in RSE were also significant for simulated changes in electronic media use; an increase in electronic media use was associated with reduced self-esteem. CONCLUSION: Small but consistent associations were observed between physical activity, electronic media use and selected markers of mental health. Findings support the delivery of physical activity interventions to promote mental health during adolescence, without the need to specifically target or protect time spent in other activities.
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Reference values for wrist-worn accelerometer physical activity metrics in England children and adolescentsBackground: Over the last decade use of raw acceleration metrics to assess physical activity has increased. Metrics such as Euclidean Norm Minus One (ENMO), and Mean Amplitude Deviation (MAD) can be used to generate metrics which describe physical activity volume (average acceleration), intensity distribution (intensity gradient), and intensity of the most active periods (MX metrics) of the day. Presently, relatively little comparative data for these metrics exists in youth. To address this need, this study presents age- and sex-specific reference percentile values in England youth and compares physical activity volume and intensity profiles by age and sex. Methods: Wrist-worn accelerometer data from 10 studies involving youth aged 5 to 15 y were pooled. Weekday and weekend waking hours were first calculated for youth in school Years (Y) 1&2, Y4&5, Y6&7, and Y8&9 to determine waking hours durations by age-groups and day types. A valid waking hours day was defined as accelerometer wear for ≥ 600 min·d−1 and participants with ≥ 3 valid weekdays and ≥ 1 valid weekend day were included. Mean ENMO- and MAD-generated average acceleration, intensity gradient, and MX metrics were calculated and summarised as weighted week averages. Sex-specific smoothed percentile curves were generated for each metric using Generalized Additive Models for Location Scale and Shape. Linear mixed models examined age and sex differences. Results: The analytical sample included 1250 participants. Physical activity peaked between ages 6.5–10.5 y, depending on metric. For all metrics the highest activity levels occurred in less active participants (3rd-50th percentile) and girls, 0.5 to 1.5 y earlier than more active peers, and boys, respectively. Irrespective of metric, boys were more active than girls (p < .001) and physical activity was lowest in the Y8&9 group, particularly when compared to the Y1&2 group (p < .001). Conclusions: Percentile reference values for average acceleration, intensity gradient, and MX metrics have utility in describing age- and sex-specific values for physical activity volume and intensity in youth. There is a need to generate nationally-representative wrist-acceleration population-referenced norms for these metrics to further facilitate health-related physical activity research and promotion.
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An ethnographic study of multidisciplinary collaboration: the role of psychological safety at a high secure forensic inpatient hospital in GermanyPurpose: This study aims to provide an in-depth understanding of staff perspectives of enablers and barriers to multidisciplinary team (MDT) collaboration and the role of psychological safety (PS) within a high secure forensic inpatient hospital. Design/methodology/approach: A qualitative ethnographic design was adopted. Data were sourced for thematic analysis from 10 observations of treatment meetings, 13 in-depth interviews, and informal conversations among 49 professionals belonging to seven professions, between March 2017 and June 2018. Findings: Four central themes were discovered: a shared approach to care, informal relationships, leadership–power–hierarchy, and PS – influenced by all and influencing all. The absence of a shared approach to care, informal relationships, inclusive leadership, construction of meetings, perceived equality between professions, and feelings of belonging and value to the MDT exert the greatest influence on PS and MDT collaboration. Practical implications: Leaders and knowledgeable staff are advised to: - adopt an inclusive leadership style, - give meeting ownership and chairing to professions low in the hierarchy – design a multidisciplinary concept of treatment with informal relationships, and establish clear roles/responsibilities that enhance equality, value, and belonging to promote PS and diminish perceived power distance between professions. Originality/value: MDT collaboration that aims to socially construct knowledge and share information about patients through communication in meetings is not possible without first consciously creating a safe organisational culture and local context that enables staff to overcome the perceived power distance between professions.
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What Aspects of Professional Socialisation Impact on UK Adult Student Nurses’ Future Career Aspirations? A Visual Methods StudyThere have been calls to strengthen the evidence base regarding how effective pre-registration nursing education is impacting upon improved healthcare outcomes. Whilst educating more student nurses is welcomed to meet the demands of the whole health and social care economy, there is deep concern that there is a lack of evidence to ensure that students are going into areas of clinical practice in which they are needed the most. The aim of this study was to critically investigate what aspects of professional socialisation impact on UK adult student nurses’ future career aspirations. Visual methods were selected as the methodological lens of enquiry, utilising photo elicitation to discover the characteristics and attributes that UK student nurses socially construct about registered nurses from their most and least desired areas of clinical practice post registration. The methods included eight semi-structured interviews from a third-year nursing student cohort from a university situated in the Northwest of the United Kingdom. Thematical analysis was employed to inform the findings of the study. A global theme of self-actualisation was established from student nurses describing their ‘ideal registered nurse’. This study presents new knowledge on the characteristics and attributes that student nurses perceive about registered nurses from different areas of adult clinical practice, which are socially constructed through themes of professional socialisation, professional evolution, care environments and mastery of skills and attributes. These findings suggest there is a dichotomy between socially constructed views held by student nurses and the reality of the registered nurse working in the least desirable area of clinical practice. The findings echo previous recommendations for approved educational institutions and practice learning partners to collaborate to ensure students experience a diverse range of clinical practice with greater preparation for learning opportunities with good role modelling. The findings also make new recommendations for nursing education and further research into the early evaluation of the effectiveness of the new NMC (2018;2023) standards. A student nurse career aspiration disk has also been created to support discussions with personal academic tutors and academic assessors.
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Perceptions of social careThe initial findings of a study evaluating the perspectives of learners and educators in higher education institutions (HEIs) in England.
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Common sense, clarity and a feel for the game: participation in child and family social work through a Bourdieusian lensIn child protection social work, children and their circumstances are unique, often lacking in clarity and requiring a subjective view. For social workers, the dominant discourse is safeguarding and, in certain circumstances, identifying, predicting and analysing risk of harm may be straightforward. Once established, social workers can offer appropriate support, money and access to services for the child and family. However, whilst social workers regularly assign ‘risk of harm’ as the dominant discourse, the deeper layers and lived experiences of children and families create alternative, competing discourses from a service user perspective, leading to a false clarity. With children and their parents often excluded from iterative participatory processes, their progression in the field of child protection is curtailed and their experiences and opinions unheard. Lack of clarity is then evident in what children and families do not know about their own child protection planning. Using Bourdieu’s (1990) concepts of social space (field) and illusio, this chapter will explore how ‘common sense’ and ‘clarity’ practice for social workers and related actors may be new and confusing to children and parents with no previous experience of social work. For children who may already have a ‘feel for the game’ (illusio), the “rhetoric of participation does not sit easily within statutory child protection services, particularly when the child is an involuntary high-risk client” (Dillon, Greenop and Hills, 2016:75). This chapter will therefore suggest creative ways in which children can gain clarity and meaningfully participate in their own child protection planning.
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Suicide in prison: The potentials and pitfalls of film-research collaborationsPrisoner suicide rates are consistently higher than rates among communities outside prisons. Between 2012 and 2016, England and Wales’s prison suicide rates more than doubled, hitting record numbers in 2016. Often those most invested in prison safety are those personally impacted, and campaigns by prisoners’ families can have material effects on imprisonment. This article critically reflects on a collaboration between an academic research team (who authored this article), a bereaved mother and a theatre company, which aimed to raise awareness of prison suicide through verbatim film. Drawing upon interviews with the filmmakers and audience surveys, we examine the potentials and challenges of such collaborations. We conclude that film can engage audiences within and beyond social science, making complex subjects accessible, humanising marginalised people and potentially inspiring social change, but a sustained ethic of care is required to mitigate harms and manage expectations, which may involve difficult decisions for researchers.
