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Abstract Background The delivery of high-quality services in chronically underfunded social or long-term care systems is a major challenge internationally. National guidelines, developed by the National Institute for Health and Care Excellence, set out how local authorities in England and Wales should fund and provide care based on best available evidence. Theoretical and participatory approaches can usefully inform the design and evaluation of implementation strategies for guidelines. The aim of the study is to develop a Theory-of-Change for how the implementation of these guidelines is expected to lead to impacts from a local authority perspective. Methods As part of a comparative case study (The ‘Valuing Care Guidelines’ study; February 2022 to April 2024) with three local authority sites in England and Wales, we involved altogether 17 participants in two Theory-of-Change online workshops per site, each of 2 hours. Additional data gathered from the same participants as part of the overall study were used to conceptualise and enrich information from the workshops. Results Participants described the Theory-of-Change map as follows: A wide range of activities (categorised in stages of ‘pre-implementation’, ‘implementation’, ‘sustainment and scaling’) and skills were required to implement guidelines, and achieve long-term organisational sustainability and service delivery outcomes, leading to final impacts for service users and carers. Participants described a co-creation implementation model, led by ‘Implementation Support Practitioners’, who utilised relational skills to achieve motivation, trust, and confidence at different organisational levels, addressing contextual barriers such as inadequate staffing, lack of resources and of organisational support systems. Consistent use of guidelines by frontline staff could only be achieved if the value of guideline implementation was promoted widely, and if consideration was given to the roles of stakeholders, such as the inspection body, local health care providers, users and carers. Conclusions Our study is the first to investigate the implementation of national social care guidelines by local authorities in England and Wales. It generates insights that can guide implementation practice as well as inform the evaluation of future implementation strategies.

Background Many children and young people in England provide support to family members who are disabled, have mental or physical ill health, or misuse drugs or alcohol. Providing care can negatively impact children and young people’s education, employment, health and social participation, with associated costs. Support is needed to prevent and reduce these negative impacts. The study sought to provide new knowledge and address prior research gaps regarding how best to support young carers from their perspective and that of the people they care for. Objectives To address the following questions: What types, components or features of services and other support are seen as helpful, valued, and acceptable to young people who look after someone at home and the people they support? Conversely, what is found to be less or unhelpful? What additional support is perceived as needed? What are the barriers experienced by young and young adult carers in seeking and accessing services for themselves or the person they support? What are the barriers and facilitators for practitioners in providing support and services perceived as valued, helpful and needed by young and young adult carers and the people they support? Design and setting In-depth qualitative methodology using focus groups, in-depth semistructured interviews and workshops in four localities in England. Participants One hundred and thirty-three carers aged 9–25 years with a range of caring and life circumstances and sociodemographic characteristics. Seventeen adult care recipients (parents) with a range of physical and/or mental healthcare and support needs. Nineteen practitioners from schools, colleges, young carers organisations, voluntary sector services, mental health services, the National Health Service, adult social care and local authority adult and children’s social care commissioners. Results The types and aspects of support that young carers and their families need, and value when received, include: support that reduces or removes their practical and emotional caring responsibilities; support to mitigate the negative impacts of care and help with other life issues; information and advice about services and wider resources and support; someone trusted available to talk to; greater awareness, recognition and understanding; and choice, flexibility, and co-development of plans and solutions. We found a great deal of unmet need for support, and variation in type and quality of support received, including geographically. Limitations Potential limitations are that we were not able to engage with, or recruit, young carers from some intended subgroups, meaning some perspectives are missing. Partly because of COVID-19 measures during the study, we mainly recruited through young carers organisations and their family projects, although this was balanced by recruitment through schools and extensive outreach and engagement by the collaborating organisations prior to the project starting. Conclusions Action is now needed to consistently and sustainably implement the types of support that young carers and the people they care for say they need and value. Future work Future work should include more research from the perspectives of young carers and the people they care for, especially from particularly marginalised groups; and research to understand what works and how to improve implementation of the support needed and valued. Study registration This study is registered as Current Controlled Trials ISRCTN13478876. https://doi.org/10.1186/ISRCTN13478876 Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129645) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 36. See the NIHR Funding and Awards website for further award information. Plain language summary Many children and young people in England provide support to family members who are disabled, have mental or physical ill health, or misuse drugs or alcohol. They are sometimes called young or young adult carers. Providing care often brings satisfaction and a sense of pride but can also have negative effects on young people’s lives. The study aimed to find out their views about what would best support them and the people they care for. The study asked two important questions: (1) What are the difficulties faced by young carers and the people they support in seeking, accessing and receiving the right type of support at the right times? (2) What services and support do they find helpful, what support would they like, and what needs would it meet? To answer these questions, we held group discussions (focus groups) and in-depth interviews with 133 young carers with a range of caring and life circumstances and 17 parents receiving help from a young carer. We also held workshops with 19 practitioners who are involved in identifying, supporting and funding services for young carers and their families. They told us that the types of support that they and their families need, and value when received, include: support for the people they care for, so they are providing less practical and emotional care support to help with any negative impacts of providing care and with other life issues information and advice about services, wider resources and support someone trusted to talk to greater awareness, recognition and understanding choice, flexibility and working together to develop plans and solutions We found a great deal of unmet need for support, and variation in the type and quality of support received, including across geographical areas. Action is now needed to consistently and sustainably implement the types of support that young carers and their families say they need and value. Scientific summary Background Providing care can negatively impact children and young people’s education, employment, health and social participation, with associated costs to individuals and the government. Transition to adulthood can be particularly challenging. Recent years have seen improved legal rights for young carers, aiming to increase support provided and avoiding excessive or inappropriate care that might risk their emotional or physical health or life chances. However, there are substantial knowledge gaps regarding how best to support young carers in the current service and rights context and from the perspective of young carers and the people they care for. Objectives To explore the following questions: What types, components or features of services and other support are seen as helpful, valued and acceptable to young people who look after someone at home and the people they support? Conversely, what is found to be less or unhelpful? What additional support is perceived as needed? What are the barriers experienced by young and young adult carers in seeking and accessing services for themselves or the person they support? What are the barriers and facilitators for practitioners in providing support and services perceived as valued, helpful and needed by young and young adult carers and the people they support? Methods The study used in-depth qualitative methods including focus groups and semistructured interviews with young and young adult carers aged 9–25 years and parent care recipients and workshops with practitioners. Data collection methods in focus groups included group and paired discussions, use of flipchart and stickers, drawing, writing and annotation. Focus groups and interviews were structured around topic guides to explore perceptions of: what is helpful, unhelpful or could be improved about existing services; what additional support is needed and what needs would it cover; and barriers to accessing support. We recruited participants in four localities in England, representing different young carer and marginalised groups and different geographical and sociodemographic areas. The inclusion criteria for young carers were that they be aged between 9 and 25 years and providing unpaid care and, for care recipients, that they be aged 16 years or older and cared for by a young carer (not necessarily a young carer involved in the study). Participants were recruited through young carers organisations, schools and colleges in the four localities. Workshops were held with practitioners from each locality, recruited through partner organisations and their networks. Workshops were informed by preliminary findings from the focus groups and interviews and structured around key findings and questions about barriers and facilitators to their implementation. Data included transcripts, fieldnotes and other written and drawn material and annotations. Data were analysed using deductive and inductive thematic analysis with the aid of NVivo 12 (QSR International, Warrington, UK) software. We set out with particular research questions, seeking to discover what acceptable intervention or support looked like, and for whom, how this related to what was currently on offer and what the barriers to access were perceived to be. Initial codes and themes were also informed by the theoretical frameworks and existing literature described elsewhere in this report. Coding also took place inductively, with categories not pre-set but drawn from the data, allowing the development of unanticipated themes. Analysis of the focus groups and interviews with carers and care recipients took place prior to the practitioner workshops, so that preliminary results could be discussed with the advisory groups and used to inform workshop discussions. Results The study sample was 150 participants of which 17 were care recipients. Young carer participants had varied caring and life circumstances and sociodemographic characteristics. Care recipients were parents with a range of physical and/or mental care and support needs. We found seven key areas of support and services that were perceived by young carers and the people they care for as needed, valued when received, but often lacking. Young carers and the people they care for valued having someone they trust to talk to. This person would listen, understand and be non-judgemental and would not share private information inappropriately and without consulting with them first. Trusted relationships were highly valued where they occurred. The trusted person could be a named person or named role in school or college or a school counsellor; a key worker in a young carers organisation; a social worker or family support worker; or their general practitioner. Young carers and their families also wanted clear, early, accessible information about what to expect and not expect from a service or person. This might include information about the length of the waiting list for that service; how a service or person can and cannot help; expected number of sessions; and when and why information might need to be shared with others. Being transparent, and consulting with the young person about the sharing of information, helped build trust. Clear and well-managed endings mattered, including clarity about why support was ending, what would happen next and where to go should similar help be needed in future. Linking to other support, or new workers when existing staff leave, was also needed, and valued when received. A wide range of support might be required. Accessible and multiformat information and advice about wider resources, and formal and informal support that might be available, were therefore needed. However, information alone was rarely enough. Support to access services was sometimes perceived as needed and valued by young carers and care recipients when received. Practitioners felt that linking to other services by an already-trusted practitioner could increase likelihood of take-up and engagement. Valued practice included helping with introductions, attending sessions or appointments with the young carer or care recipient, and checking in after first sessions to address barriers and concerns. Specific or generalised information about the care recipient’s health conditions and treatment was also valued by young carers, although care recipients in the study did not always want this information shared. The heterogeneity of the young carer population and their caring experiences means that support needed and valued will vary. Choice, flexibility and co-development of plans and solutions are key. This entails involving young carers in decisions and plans; a flexible approach to support; and allowing young carers and their families repeated chances to accept support from services. Timing is important to the young carers and their families; they are not always ready to access support when it is offered, or they need to return to support as circumstances or life stage changed. Support that reduces young people’s practical and emotional caring responsibilities was needed. It was valued when received, but was often absent or insufficient, resulting in considerable unmet need. Reduced caring responsibilities would enable young people to have more time for other things in their lives, such as education, social participation and hobbies, and to have less stress and sense of responsibility. In some cases, it was also perceived that support provided by others would improve the health, happiness and independence of the care recipient. Support needed varied but could come, it was felt, from paid caregivers, adult mental health services, other family members, community groups, social connections and activities or aids and adaptations. It could involve long-term reductions, short breaks and/or emergency or crisis support for the person with care needs. Support to reduce the need for children and young people to provide excessive or inappropriate care by providing more support for the person they care for should consider the whole family. While practitioners recognised the value of whole-family working, both practitioners and young people felt effective support could be given working with specific individuals only, and some young people valued having a practitioner who was ‘just for them’. Practitioners also recognised the challenges involved in providing support for the whole family, such as eligibility criteria mismatches, differences of opinion within the family and different commissioning systems for children’s and adult services. In the absence of support that reduced or removed caring responsibilities, or in addition to it, support that helps with impacts of caring and/or young carers’ other life issues was identified as needed and was valued when received. This included timely, helpful, accessible and young carer-aware mental health support and greater understanding at school, such as flexibility of deadlines for schoolwork and homework, although there was a recognition of the difficult balance between making allowances for the home situation and supporting the young person’s educational progress. Opportunities to take a break at school were valued, as were systems where breaks could be taken without publicly having to give an explanation. Peer support from other young carers was usually valued, along with activities that were ‘fun’ and gave them a break, which were often provided by young carers organisations or sometimes young carer clubs in schools. Greater awareness, recognition and understanding of young carers, what young carers do, and about disability and mental and physical illness, would be helpful to young carers. Although there were some examples where schools, particular school staff, or other students, had shown good awareness and understanding, this was often felt to be lacking. Children’s mental health services needed to be more understanding of the interaction between mental ill health and caring responsibilities. Young carers and the people they care for expressed numerous barriers to accessing the support they needed and valued: the support needed may not have been available and/or services were sometimes not accessible or approachable; there may not have been enough information about a service and how it worked and/or information may not have been communicated in accessible, user-friendly formats. Other perceived barriers identified in the study were service boundaries and lack of links between services. Young carers’ and care recipients’ lack of time and competing priorities such as school or caring responsibilities (for the young carers) and their mental or physical health could get in the way of support. Feelings of fear, mistrust, nervousness, embarrassment, fear of judgement or lack of confidence in seeking help were further barriers and ones that services could help overcome. Lack of transport prevented some carers and care recipients from accessing services, exacerbated by centralised, rather than local, hubs. The findings have economic implications. Provision of care by young adult carers aged 16–25 years costs the state an estimated £1B annually. Recent, relevant and high-quality economic evidence on interventions supporting young carers, and which might alleviate impacts, is limited. In the extant studies found ion the scoping review, estimated costs of interventions per person ranged widely from £121 to £778 for co-developed support planning and review; £1200 to more than £15,000 for family interventions; £265 to £385 for social prescribing; and £1100 for having a designated person at school. Return-on-investment estimates [calculated by dividing estimated benefits (‘returns’) by the cost of the intervention or support provided] ranged from £5 to £91 per £1 spent on whole-family approaches; and £8 per £1 spent for a designated person at school. Most of the ‘returns’ related to a societal perspective, including benefits to the government and to individuals (such as in the form of income gains). Conclusions In-depth listening to young and young adult carers and their families has shown the types, aspects and range of support that young and young adult carers need, and value when received. The study shows much unmet need for support, and variation in type and quality of support received, including geographically. Many of the valued and needed aspects of support are already recognised and embedded in current legislation. Action is now needed to implement this legislation and to sustain and extend the areas of good practice that currently exist. Other aspects of good and needed support we identified are not currently reflected in legal rights, and are not consistently reflected in commissioning, service tenders or practice. Implications for social care commissioners, practitioners and policy-makers There needs to be more funding overall, and more targeted funding and allocation of resources nationally and locally, for adult social care and mental health services to fulfil the requirements of the 2014 Care Act, to prevent children undertaking inappropriate or excessive caring roles, which impact young carers’ wellbeing, education and life prospects. Funding needs to be directed at practitioners and organisations working with young carers and the people they care for to have time to provide the support young carers say they need and value and to allow time for building trusting relationships. Commissioning of services and support in schools, adult and children’s social care, young carers organisations and mental health services could be done in ways that enable continuity of valued support; flexibility of support is needed that responds to changes in needs and strengths over time, and as people’s readiness to access support, and their circumstances, change. There should be wider implementation of whole-family agreements, assessment and practice across and within adult and children’s social care, mental health and the voluntary and community sector. Policy or guidance should recommend a designated person(s) available in schools for young carers to talk to about their caring situation or if they are in need of extra help. Wider roll-out of good practice is needed. Greater use should be made of active linking to wider support, such as accompanying people to meetings or appointments. More, and more accessible and multiformat, information about remit, eligibility, nature and how to access the support available needs to be provided. Advocacy to help people negotiate the system might be beneficial, but better communication is key. Young carers are young people first and the impacts of the care they provide, the context in which they provide it, and the support they need and value varies; their views and individual experiences need to be taken into account. Recommendations for research (numbered in priority order) More research is needed from the perspectives of young and young adult carers and the people they care for, including those from marginalised groups of young and young adult carers, such as those from Roma and Traveller communities and refugee and migrant communities. There are key roles for peer researchers in this type of research. Research is needed to identify and understand the good practice that exists, and how to improve wider implementation of the support needed and valued by young carers and the people they care for. Future research could also valuably include economic evaluation of the support needed set against the costs of not providing it. Study registration This study is registered as Current Controlled Trials ISRCTN13478876. https://doi.org/10.1186/ISRCTN13478876 Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129645) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 36. See the NIHR Funding and Awards website for further award information.

It is estimated that one out of three individuals will experience a mental illness at some point in their lives. Parenting with a mental illness can be particularly challenging and often requires additional support and resources to navigate through it. One of the challenges is accessing mental healthcare while also having parenting responsibilities. This study aims to explore how mothers with a mental illness in Tyrol, Austria, experience the impact of their parenting responsibilities in terms of accessing mental healthcare, and which processes contribute to such challenges. We draw from 20 semi-narrative interviews with mothers with a mental illness which were conducted in the context of a larger research project, focusing on developing and evaluating support for families with a parent with a mental illness. We identified three main findings affecting access to mental healthcare services: (1) organisational issues with mental healthcare services, (2) socio-cultural norms around family and care work, and (3) identity-related expectation of being a ‘good mother’ who is always there for her children. The concern for the children's wellbeing was also closely linked to these aspects. It is important, however, to consider the ways in which these findings are interwoven, and that social support could mitigate challenges. The findings of this study contribute to understanding childcare responsibility as a significant challenge to accessing mental healthcare for mothers with a mental illness and recognising it as a structural, socio-cultural, and identity-related phenomenon.

This study sought to develop a user-friendly decision-making tool to explore country-specific estimates for costs and economic consequences of different options for scaling screening and psychosocial interventions for women with common perinatal mental health problems in Malawi. We developed a simple simulation model using a structure and parameter estimates that were established iteratively with experts, based on published trials, international databases and resources, statistical data, best practice guidance and intervention manuals. The model projects annual costs and returns to investment from 2022 to 2026. The study perspective is societal, including health expenditure and productivity losses. Outcomes in the form of health-related quality of life are measured in Disability Adjusted Life Years, which were converted into monetary values. Economic consequences include those that occur in the year in which the intervention takes place. Results suggest that the net benefit is relatively small at the beginning but increases over time as learning effects lead to a higher number of women being identified and receiving (cost‑)effective treatment. For a scenario in which screening is first provided by health professionals (such as midwives) and a second screening and the intervention are provided by trained and supervised volunteers to equal proportions in group and individual sessions, as well as in clinic versus community setting, total costs in 2022 amount to US$ 0.66 million and health benefits to US$ 0.36 million. Costs increase to US$ 1.03 million and health benefits to US$ 0.93 million in 2026. Net benefits increase from US$ 35,000 in 2022 to US$ 0.52 million in 2026, and return-on-investment ratios from 1.05 to 1.45. Results from sensitivity analysis suggest that positive net benefit results are highly sensitive to an increase in staff salaries. This study demonstrates the feasibility of developing an economic decision-making tool that can be used by local policy makers and influencers to inform investments in maternal mental health.

Abstract Background Evidence on the negative outcomes of untreated mental disorders during pregnancy and in the first year after childbirth on women’s and children’s health has stimulated interest in how to develop and sustain high-quality mental health care during the perinatal period. In Italy, there is a lack of knowledge about how mental health services support women with perinatal mental disorders (PMDs). This study aims to describe the adoption of good practices for the prevention and care of PMDs by the Italian mental health departments (MHDs). Methods This is a nationwide cross-sectional survey conducted online using LimeSurvey. Starting from the Ministry of Health Registry’s 127 MHDs were invited to participate between February and March, 2023. Characteristics of the participating MHDs were reported as descriptive statistics. Results One hundred nineteen MHDs participated, with a response rate of 93.7%. Regarding the prevention of PMDs, 69 (58.0%) MHDs offer preconception counseling, whereas only 6 (5.0%) have information material for this purpose. Written integrated care pathways for PMDs are not available in 94 (79.7%) MHDs. A reference professional for psychopharmacological treatment during pregnancy or breastfeeding is available in 55 (46.2%) MHDs, while a specific treatment plan for women with PMDs is adopted by 27 (22.7%) MHDs. Thirty-four (28.6%) MHDs have established an outpatient clinic for PMDs, whereas there are no inpatient psychiatric facilities designed for mothers and infants (mother-baby units). Conclusions There is a need to improve the care of women with PMDs in Italy. The provision of pre-conception counseling, integrated care pathways, and specialist skills and facilities for PMDs should be prioritized.

There are many pressing questions about how to deliver adult social care services. Where research evidence exists to address these questions, there is often limited use by social care commissioners, providers and the workforce. Sometimes this is attributed to the lack of perceived relevance and accessibility of the research itself, at other times it is considered to be a matter of individual and organizational capacity. As things stand, there is a gap between social care research and practice. Improving interaction between different stakeholders in the research process is a contemporary mechanism for promoting the production of research that is useful, usable and used. This paper describes one collaborative approach called Research Practice Partnerships (RPPs). These partnerships share the goal of benefit for all partners and are supported by a growing international evidence base. This paper summarizes some of the key literature from different countries and contexts where the approach has been tried. It highlights the main features of RPPs, introduces a project setting up three new partnerships in the care home sector in England and highlights aspects of the theory of change that will guide the evaluation of the partnerships. In doing so, the paper introduces a promising collaborative approach to a social care audience and considers whether RPPs have the potential to achieve meaningful and impactful research in social care contexts.

ObjectiveHER2 status in breast cancer is an essential parameter in individual therapeutic decision-making and is routinely assessed in primary tumors in accordance with international recommendations. Reports of HER2 heterogeneity raise the question of basing treatment decisions on HER2 status in metastases, if present. We investigated the degree and clinical implications of HER2 heterogeneity in lymph node–positive breast cancer. Because of recent recognition of therapeutic opportunities in this group of tumors, we especially focused on cases involving low-level HER2 expression.MethodsThe HER2 status of primary tumors and of corresponding lymph node metastases was determined in archived material at the protein and gene levels using the gene– protein assay and interpreted in accordance with 2018 ASCO/CAP criteria. HER2-low status was defined as protein expression levels 1+ or 2+ with negative amplification status.ResultsWe analyzed a series of 43 cases of primary infiltrating breast cancer, each with at least two axillary nodes harboring macrometastases (>2 mm), in total 206 such nodes. In 7% of cases, we detected intertumoral HER2 heterogeneity. Three of nine HER2-positive primary tumors were associated with HER2-negative metastases. No cases with HER2-negative primary tumors had HER2-positive metastases, but 55% (6/11) of HER2 0 primary tumors had HER2 1+ and/or 2+ metastases, and 19% (3/16) HER2 1+ cases had exclusively HER2 0 metastases. All metastases in HER2 2+ cases showed HER2-low protein expression levels. Internodal HER2 heterogeneity at low protein expression levels (presence of HER2 0, HER2 1+, and/or HER2 2+ metastatic deposits within the same axilla) was seen in 40% (17/43) of cases. We found no statistically significant association between HER2 heterogeneity and other tumor-related parameters. Survival data indicated worse outcomes in the HER2-low group compared with the rest of the cohort.ConclusionOur results indicate a substantial instability of HER2 protein expression, leading to considerable intertumoral and internodal HER2 heterogeneity in lymph node–positive breast carcinomas. This heterogeneity is particularly relevant in HER2-low tumors in which the corrective effects of HER2 gene copy number analysis definitionally is absent. Our findings suggest that determining HER2 status in metastatic lymph nodes may generate relevant information for therapeutic decision-making.

Abstract Background Perinatal mental health problems, defined as mental health problems occurring from the start of pregnancy to one year after birth, substantially affect women's and children's quality of life in low- and middle-income countries. In South Africa, despite high prevalence and documented negative impacts, most women do not receive any care. Methods A modelling study examined the costs of perinatal mental health problems, namely depression and anxiety, for a hypothetical cohort of women and their children in South Africa over part of their life course (10 years for women, 40 years for children). In sensitivity analysis, additional impacts of post-traumatic stress disorder (PTSD) and completed suicide were included. Data sources were published findings from cohort studies, as well as epidemiological and economic data from South Africa. Data from international studies were considered where no data from South Africa were available. Results Lifetime costs of perinatal depression and anxiety in South Africa amount to USD 2.8 billion per annual cohort of births. If the impacts of PTSD and suicide are included, costs increase to USD 2.9 billion. This includes costs linked to losses in quality of life (USD 1.8 billion), losses in income (USD 1.1 billion) and public sector costs (USD 3.5 million). Conclusions Whilst important progress has been made in South Africa with regards to mental health policies and interventions that include assessment and management of perinatal mental health problems, substantial underinvestment prevents progress. Findings from this study strengthen the economic case for investing in perinatal mental health care.

Abstract Aims Depression and anxiety are the leading contributors to the global burden of disease among young people, accounting for over a third (34.8%) of years lived with disability. Yet there is limited evidence for interventions that prevent adolescent depression and anxiety in low- and middle-income countries (LMICs), where 90% of adolescents live. This article introduces the ‘Improving Adolescent mentaL health by reducing the Impact of poVErty (ALIVE)’ study, its conceptual framework, objectives, methods and expected outcomes. The aim of the ALIVE study is to develop and pilot-test an intervention that combines poverty reduction with strengthening self-regulation to prevent depression and anxiety among adolescents living in urban poverty in Colombia, Nepal and South Africa. Methods This aim will be achieved by addressing four objectives: (1) develop a conceptual framework that identifies the causal mechanisms linking poverty, self-regulation and depression and anxiety; (2) develop a multi-component selective prevention intervention targeting self-regulation and poverty among adolescents at high risk of developing depression or anxiety; (3) adapt and validate instruments to measure incidence of depression and anxiety, mediators and implementation parameters of the prevention intervention; and (4) undertake a four-arm pilot cluster randomised controlled trial to assess the feasibility, acceptability and cost of the selective prevention intervention in the three study sites. Results The contributions of this study include the active engagement and participation of adolescents in the research process; a focus on the causal mechanisms of the intervention; building an evidence base for prevention interventions in LMICs; and the use of an interdisciplinary approach. Conclusions By developing and evaluating an intervention that addresses multidimensional poverty and self-regulation, ALIVE can make contributions to evidence on the integration of mental health into broader development policy and practice.

Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and caregivers will be closely involved throughout to ensure that the interventions are shaped by the communities concerned. The effect of the interventions will be assessed with a quasi-experimental sequential implementation in three regions, in terms of DUP reduction, symptom remission, functional recovery and PWLE / caregiver impact, with quality of life as the primary outcome. As the study team is focused on long-term impact, we recognise the importance of having embedded, robust evaluation of the programme as a whole. We will therefore evaluate implementation processes and outcomes, and cost-effectiveness, to demonstrate the value of this approach to the Ministry of Health, and to encourage longer-term adoption across Malawi.

Mental health is inextricably linked to both poverty and future life chances such as education, skills, labour market attachment and social function. Poverty can lead to poorer mental health, which reduces opportunities and increases the risk of lifetime poverty. Cash transfer programmes are one of the most common strategies to reduce poverty and now reach substantial proportions of populations living in low- and middle-income countries. Because of their rapid expansion in response to the COVID-19 pandemic, they have recently gained even more importance. Recently, there have been suggestions that these cash transfers might improve youth mental health, disrupting the cycle of disadvantage at a critical period of life. Here, we present a conceptual framework describing potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people. Furthermore, we explore how theories from behavioural economics and cognitive psychology could be used to more specifically target these mechanisms and optimise the impact of cash transfers on youth mental health and life chances. Based on this, we identify several lines of enquiry and action for future research and policy.

Introduction Research–practice partnerships (RPPs) are long-term collaborations between research and practice that aim to conduct research that can be used to make practice-based improvements. They intentionally bring together diverse experience in decision making and seek to shift power dynamics so that all partners have a say. The Creating Care Partnerships project aims to explore whether the RPP approach developed within the US educational context can be successfully applied to the English care home context. The project involves a programme of codesign, implementation and evaluation within three case study sites. This protocol set outs the aims, research design and governance of the evaluation.Methods and analysis The evaluation takes a theory-based approach to explore how, why and in what circumstances RPPs in the care home context contribute to enhancing research and research use in local care homes and informing wider improvement efforts. A mixed-methods design will be used for each case study, including semistructured interviews, observations of RPP events and meetings, an online survey, activity diary and review of local data and documents. Data collection will proceed in waves, with the theory of change (ToC) being continually refined and used to guide further data collection and analysis. Insights will be drawn using Contribution Analysis, Realist Evaluation and systems perspectives to assess the contribution made by the case study sites to achieving outcomes and the influence of contextual factors. Economic consequences will be identified through the ToC, using a narrative economic analysis to assess costs, consequences and value for money.Ethics and dissemination The study has undergone ethics review by HRA Research Ethics Committee. It does not pose major ethical issues. A final report will be published and articles will be submitted to international journals.

Stigma can have devastating health and wellbeing impacts, not just on people with mental health problems, but on people associated with the stigmatized person. This is called stigma-by-association. Children whose parents have mental health problems are a particularly vulnerable group, and stigma acts as a mechanism, contributing to the transgenerational transmission of mental disorders. The current study is a systematic mixed studies review, synthesizing knowledge about how this group of children experience stigma-by-association. Overall, 32 studies were included, after a systematic search including quantitative, qualitatative, and mixed methods studies. The methodological quality was assessed and qualitative content analysis undertaken. We grouped children's stigma experiences into four dimensions, i.e., experienced stigma, anticipated stigma, internalized stigma, and structural discrimination. Results show that stigma is an important factor in those children's lives, and needs further investigation in qualitative and quantitative research. The current study emphasizes the importance of anti-stigma interventions and campaigns.

Providing support to parents and their children to help address the cycle of intergenerational impacts of mental illness and reduce the negative consequences for children is a key focus of selective prevention approaches in public mental health. However, a key issue for children of parents with a mental illness is the lack of access to early intervention and prevention support when needed. They are not easily identifiable (until presenting with significant mental health issues of their own) and not easily accessing the necessary support that address the complex interplay of parental mental illness within families. There are significant barriers to the early identification of these children, particularly for mental health care. Furthermore, there is a lack of collaborative care that might enhance identification as well as offer services and support for these families. The “It takes a Village” project seeks to improve mental health outcomes for children through the co-development, implementation and evaluation of an approach to collaborative practice concerned with the identification of families where a parent has a mental illness, and establishing a service model to promote child-focused support networks in Austria. Here we describe the development of service delivery approach for the “It takes a Village” project that aims to improve identification and support of these children within enhancements of the existing service systems and informal supports. The paper describes the use of codesign and other implementation strategies, applied to a research setting, with the aim of impacting the sustainability of workforce reform to achieve lasting social impact. Results highlight the steps involved in translating evidence-based components, local practice wisdom and lived experience into the “It takes a Village” practice model for Tyrol, Austria. We highlight through this paper how regional context-specific solutions are essential in the redesign of care models that meet the complex needs of children of parents with a mental illness. Service system and policy formation with local and experienced stakeholders are also vital to ensure the solutions are implementation-ready, particularly when introducing new practice models that rely on organizational change and new ways of practice with vulnerable families. This also creates a solid foundation for the evaluation of the “It take a Village” approach for children of parents with a mental illness in Austria.

A deep eutectic solvent (DES) is a eutectic system consisting of hydrogen bond donor and acceptor has been suggested as a promising formulation strategy for poorly soluble drugs. A DES consisting of choline chloride and levulinic acid in a 1:2 molar ratio was used to formulate a liquid solution of the model drug aprepitant. This formulation was tested in vitro (drug release and permeability) and in vivo (rat model) and compared with the performance of amorphous aprepitant and the commercial aprepitant nanocrystalline formulation. In this study a DES formulation is compared for the first time directly to other established enabling formulations. The in vitro drug release study demonstrated that the DES formulation and the amorphous form both were able to induce an apparent supersaturation followed by subsequent drug precipitation. To mitigate the risk of precipitation, HPMC was predissolved in the dissolution medium, which successfully reduced the degree of precipitation. In line with the results from the release study, an in vitro permeation study showed superior permeation of the drug from the DES formulation and from the amorphous form compared to the nanocrystalline formulation. However, the promising in vitro findings could not be directly translated into an increased in vivo performance in rats compared to the nanocrystalline formulation. Whilst the DES formulation (34 ± 4%) showed a higher oral bioavailability compared to amorphous aprepitant (20 ± 4%), it was on par with the oral bioavailability obtained from the nanocrystalline formulation (36 ± 2%).

Objectives: In several high-income countries, family-focused practice programs have been introduced in adult mental health care settings to identify and support children whose parents live with mental health problems. Whilst their common goal is to reduce the impact of parental mental illness on children, the mechanisms by which they improve outcomes in different systems and settings are less well known. This kind of knowledge can importantly contribute to ensuring that practice programs achieve pre-defined impacts.Methods: The aim of this study was to develop knowledge about relationships between contextual factors, mechanisms and impact that could inform a program theory for developing, implementing, and evaluating family-focused practice. Principles of a realist evaluation approach and complex system thinking were used to conceptualize the design of semi-structured in-depth interviews with individuals who led the implementation of programs. Seventeen individuals from eight countries participated in the study.Results: Interviewees provided rich accounts of the components that programs should include, contextual factors in which they operated, as well as the behavior changes in practitioners that programs needed to achieve. Together with information from the literature, we developed an initial program theory, which illustrates the interconnectedness between changes that need to co-occur in practitioners, parents, and children, many of which related to a more open communication about parental mental health problems. Stigma, risk-focused and fragmented health systems, and a lack of management commitment were the root causes explaining, for example, why conversations about parents' mental illness did not take place, or not in a way that they could help children. Enabling practitioners to focus on parents' strengths was assumed to trigger changes in knowledge, emotions and behaviors in parents that would subsequently benefit children, by reducing feelings of guilt and improving self-esteem.Conclusion: To our knowledge, this is the first research, which synthesizes knowledge about how family-focused practice programs works in a way that it can inform the design, implementation, and evaluation of programs. Stakeholder, who fund, design, implement or evaluate programs should start co-developing and using program theories like the one presented in this paper to strengthen the design and delivery of family-focused practice.

In England, the National Institute for Health and Care Excellence (NICE) has been responsible for developing social care guidelines since 2012. Internationally, it is the first health technology assessment and guideline agency that specifically includes social care. As is the case for NICE’s clinical and public health guidance, social care guidelines comprise recommendations based on the best available evidence of effectiveness and cost-effectiveness. This paper provides an overview of how economic evidence is used within social care guideline development. Firstly, the paper describes the guideline development and quality assurance process, in addition to the roles and responsibilities of the technical team and guideline committee members. Secondly, the paper summarises how economic evidence is reviewed, generated, and used to inform recommendations, with examples given to highlight some of the challenges and opportunities that can be encountered. The paper culminates with proposals for the use of economic evidence in social care in England going forward and makes recommendations for further research in this area. The paper posits that guidelines are an important vehicle for supporting evidence-based practice in social care and that economic evidence is a critical kind of evidence to include. As economic evidence in social care becomes more widely available, it can be increasingly used to produce useful and accessible information for decision makers. Further research is needed to understand the impact of implementing economic evidence-based recommendations in social care practice.

Abstract Background Whilst people with intellectual disability grow older, evidence has emerged internationally about the largely unmet health needs of this specific ageing population. Health checks have been implemented in some countries to address those health inequalities. Evaluations have focused on measuring process outcomes due to challenges measuring quality of life outcomes. In addition, the cost-effectiveness is currently unknown. As part of a national guideline for this population we sought to explore the likely cost-effectiveness of annual health checks in England. Methods Decision-analytical Markov modelling was used to estimate the cost-effectiveness of a strategy, in which health checks were provided for older people with intellectual disability, when compared with standard care. The approach we took was explorative. Individual models were developed for a selected range of health conditions, which had an expected high economic impact and for which sufficient evidence was available for the modelling. In each of the models, hypothetical cohorts were followed from 40 yrs. of age until death. The outcome measure was cost per quality-adjusted life-year (QALY) gained. Incremental cost-effectiveness ratios (ICER) were calculated. Costs were assessed from a health provider perspective and expressed in 2016 GBP. Costs and QALYs were discounted at 3.5%. We carried out probabilistic sensitivity analysis. Data from published studies as well as expert opinion informed parameters. Results Health checks led to a mean QALY gain of 0.074 (95% CI 0.072 to 0.119); and mean incremental costs of £4787 (CI 95% 4773 to 5017). For a threshold of £30,000 per QALY, health checks were not cost-effective (mean ICER £85,632; 95% CI 82,762 to 131,944). Costs of intervention needed to reduce from £258 to under £100 per year in order for health checks to be cost-effective. Conclusion Whilst findings need to be considered with caution as the model was exploratory in that it was based on assumptions to overcome evidence gaps, they suggest that the way health systems deliver care for vulnerable populations might need to be re-examined. The work was carried out as part of a national guideline and informed recommendations about system changes to achieve more equal health care provisions.

Introduction Although cash transfer programmes are not explicitly designed to improve mental health, by reducing poverty and improving the life chances of children and young people, they may also improve their mental health. This systematic review and meta-analysis assessed the evidence on the effectiveness of cash transfers to improve the mental health of children and young people in low-income and middle-income countries.Methods We searched Pubmed, EBSCOhost, Scientific Electronic Library Online, ISI Web of Science and Social Sciences Citation Index and grey literature (from January 2000 to July 2020) for studies which quantitatively assessed the impact of cash transfers on mental health in young people (aged 0–24 years), using a design that incorporated a control group. We extracted Cohen’s d effects size and used a random-effects model for the meta-analysis on studies that measured depressive symptoms, I2 statistic and assessment of study quality.Results We identified 12 116 articles for screening, of which 12 were included in the systematic review (covering 13 interventions) and seven in the meta-analysis assessing impact on depressive symptoms specifically. There was high heterogeneity (I2=95.2) and a high risk of bias (0.38, 95% CIs: −5.08 to 5.85; p=0.86) across studies. Eleven interventions (85%) showed a significant positive impact of cash transfers on at least one mental health outcome in children and young people. However, no study found a positive effect on all mental health outcomes examined, and the meta-analysis showed no impact of cash transfers on depressive symptoms (0.02, 95% CIs: −0.19 to 0.23; p=0.85).Conclusion Cash transfers may have positive effects on some mental health outcomes for young people, with no negative effects identified. However, there is high heterogeneity across studies, with some interventions showing no effects. Our review highlights how the effect of cash transfers may vary by social and economic context, culture, design, conditionality and mental health outcome.

Social support is a well-recognised protective factor for children's mental health. Whilst many interventions exist that seek to mobilise social support to improve children's mental health, not much is known about how to best do this. We sought to generate knowledge about the ways in which social support can be mobilised to improve children's mental health. We conducted a systematic review, which followed the principles of a realist synthesis. The following databases were searched: PubMed, CINAHL, Ovid MEDLINE, PsychINFO, EMBASE, Child and Adolescent Studies, EconLit and SocINDEX. Studies were included if the age of participants was between 0 and 18 years and they evaluated or described programme theories of interventions that sought to improve children's mental health by mobilising social support. Relevance and quality of studies were assessed, and data were extracted and analysed narratively. Thirty-three articles were included. Studies varied substantially with regard to the detail in which they described the processes of mobilising social support and expected mechanisms to improve children's mental health. Those that provided this detail showed the following: Intervention components included explaining the benefits of social support and relationships to families and modelling friendly relationships to improve social skills. Pathways to improved outcomes reflected bi-directional and dynamic relationships between social support and mental health, and complex and long-term processes of establishing relationship qualities such as trust and reciprocity. Parents' ability to mobilise social support for themselves and on behalf of children was assumed to impact on their children's mental health, and (future) ability to mobilise social support. Although interventions were considered affordable, some required substantial human and financial resources from existing systems. Mobilising social support for vulnerable children can be a complex process that requires careful planning, and theory-informed evaluations can have an important role in increasing knowledge about how to best address social support and loneliness in children.

Various types of artificial biomimetic barriers are widely utilized as in vitro tools to predict the passive “transcellular” transport of drug compounds. The current study investigated if the sandwich barrier PermeaPad®, which is composed of tightly packed phospholipid vesicles enclosed between two support sheets, contributes to a transport mechanism that is paracellular-like, representing one of the alternative pathways of passive transport in vivo, primarily of relevance for hydrophilic drug compounds. To this end, we pretreated the commercial PermeaPad® barrier with NaCl solutions of either high or low osmolality prior to permeation experiments on reversed Franz cell setups with hydrophilic model compounds calcein and acyclovir and hydrophobic model compounds hydrocortisone and celecoxib. Our starting hypothesis was that the liposomes formed in the barrier during the hydration step should either shrink or swell upon contact with test media (drug solutions) due to osmotic pressure difference as compared to the pretreatment solutions. Apparent permeabilities for calcein and acyclovir across the PermeaPad® barrier were found to increase approximately 2.0 and 1.7 fold, respectively, upon hypo-osmotic pretreatment (soaking in hypotonic medium, while the permeation of hydrocortisone and celecoxib remained unchanged. A control experiment with lipid-free barriers (support sheets) indicated that the permeation of all the compounds was virtually unchanged upon hypo-osmotic pretreatment. In conclusion, soaking PermeaPad® in a medium of lower osmotic pressure than that used during the permeation study appears to induce the osmotic shrinking of the lipid vesicles in the barrier, leaving wider water channels between the vesicles and, thus, allowing hydrophilic compounds to pass the barrier in a paracellular-like manner.

Constrained social care resources mean that decision-makers must make difficult choices about how to allocate them to best effect. The EconomicS of Social carE CompEndium (ESSENCE) project aims to collate and build economic evidence on adult social care (including both cost and outcome data) and make it available to decision-makers, managers, practitioners and individuals who use or pay for services themselves. Searches for economic evidence were undertaken across a range of databases. The ESSENCE toolkit offers a comprehensive collection of relevant research and summarises it with individual case summaries and a searchable database. Seventeen case summaries and a database with 231 sources have been produced to date, published on the project website. Evidence is grouped into service categories, focussing primarily on interventions considered core to adult social care for which there are studies considered to be robust in terms of design, quality, consistency and setting. The toolkit also provides signposts to interventions where it is currently not possible to examine the economic case but which could be evaluated in future research.

Background: To investigate the potential synergistic effects of olive oil releasing 2-oleoylglycerol and hydrolyzed pine nut oil containing 20% pinolenic acid on GLP-1 secretion, glucose tolerance, insulin secretion and appetite in healthy individuals, when delivered to the small intestine as potential agonists of GPR119, FFA1 and FFA4. Methods: Nine overweight/obese individuals completed three 6-h oral glucose tolerance tests (OGTTs) in a crossover design. At −30 min, participants consumed either: no oil, 6 g of hydrolyzed pine nut oil (PNO-FFA), or a combination of 3 g hydrolyzed pine nut oil and 3 g olive oil (PNO-OO) in delayed-release capsules. Repeated measures of glucose, insulin, C-peptide, GLP-1, GIP, ghrelin, subjective appetite and gastrointestinal tolerability were done. Results: PNO-FFA augmented GLP-1 secretion from 0–360 min compared to no oil and PNO-OO (p < 0.01). GIP secretion was increased from 240–360 min after both PNO-FFA and PNO-OO versus no oil (p < 0.01). Both oil treatments suppressed subjective appetite by reducing hunger and prospective food consumption and increasing satiety (p < 0.05). Conclusions: In support of previous findings, 6 g of delayed-release hydrolyzed pine nut oil enhanced postprandial GLP-1 secretion and reduced appetite. However, no synergistic effect of combining hydrolyzed pine nut oil and olive oil on GLP-1 secretion was observed. These results need further evaluation in long-term studies including effects on bodyweight and insulin sensitivity.

Background: Children of parents with a mental illness (COPMI) are more likely to experience negative long-term adversities. However, interventions to support their needs early can significantly enhance adjustment and reduce negative outcomes. Approximately one in four children currently lives with a parent with mental illness worldwide. The lifelong impact for individuals, governments, and broader society is likely to be substantial. There are significant workforce barriers to the early identification of COPMI and addressing their needs, particularly within the adult mental health care system. The current study aims to reduce such barriers and to improve identification of COPMI in the current health care systems.Objectives: The project “The Village” is a multidisciplinary health and social care policy intervention and seeks to improve child development and well-being outcomes for children of parents with a diagnosed mental illness. This will be achieved through the co-development, implementation, and evaluation of a practice approach to the early identification and collaborative care for COPMI, through establishing child-focused support networks. This will be done with open innovation science (OIS) approaches engaging the public in Tyrol, a geographical region of Austria, throughout 4 years. As part of the co-development process, we will work with stakeholders to co-develop the practice approaches based on evidence-based approaches and determine the most appropriate study design to evaluate those, as well as the implementation processes we will undertake.Methods: The project is underpinned by theories from different disciplines (i.e., public health, psychology, sociology, linguistics, economic sciences) as well as drawing on different approaches (i.e., co-development, implementation science, symbolic interactionism, and realist evaluation). It is based on the seven content work packages (WPs): 1) management, 2) focusing on children and methods to understand their “voice,” 3) scoping, 4) co-development, 5) implementation, 6) evaluating the practice approaches, and 7) knowledge dissemination. “Scoping” will involve exploring the existing evidence, practice, and current state of identification and collaborative care in Tyrol, Austria. “Co-development” involves the co-design of practice approaches to identify and support children in partnership with key stakeholders and service providers working in Tyrol. The “implementation” of practice approaches will be based on the results of the co-development phase and will involve working with organizations to develop support strategies that draw on known organizational drivers from the field of implementation science to support the rollout of the practice approaches. In “Evaluation” we will follow principles of a realist approach; this includes developing program theories and logic models for the practice approaches. Those will set out the outcomes hypothesized to achieve and the processes that are expected to lead to those changes. This will refer to changes in children, parents, and practitioners. We expect that the main focus will be on measuring child quality of life and mental health outcomes, and outcomes that are on the path to those (such as social support needs, resilience, mental health literacy, stigma, and help-seeking behavior) as well as costs. The “child voice” WP focuses on children’s perceptions and needs as the importance of “assent” and support of children to develop their own “voice” in health care is increasingly recognized within child health research. The “dissemination” step focuses on reaching a broad public audience of different stakeholders, researchers, and families involved.Discussion: The research project aims to directly improve identification and support of vulnerable children across selected regions in Tyrol, Austria, and by doing so, improve the health and well-being of future generations, through breaking the cycle of intergenerational transfer of adverse childhood experiences.

Early formulation screening can alleviate development of advanced oral drug formulations, such as amorphous solid dispersions (ASDs). Traditionally, dissolution is used to predict ASD performance. Here, a high-throughput approach is described that simultaneously screens drug dissolution and permeation employing a two-compartment 96-well plate. Freeze-drying from hydro-alcoholic solutions was used to prepare amorphous formulations. The screening approach was tested on amorphous and crystalline tadalafil formulations with and without Soluplus®. The workflow consisted of: 1) dispersion of the formulations; 2) incubation within the two-compartment plate, where a dialysis membrane separated donor (dispersed formulation) and acceptor; 3) sampling (donor and acceptor), where donor samples were centrifuged to remove non-dissolved material; and 4) quantification by UHPLC-UV. To identify optimal screening conditions, the following parameters were varied: dispersion medium (buffer / biomimetic media), acceptor medium (buffer / surfactant solutions), and incubation time (1, 3, and 6 h). Surfactants (acceptor) increased tadalafil permeation. Biomimetic medium (donor) enhanced dissolution, but not permeation, except for freeze-dried tadalafil, for which the permeated amount increased. The predictiveness was evaluated by comparing dissolution-/permeation-results with in vivo bioavailability. In general, both dissolution and permeation reflected bioavailability, whereof the latter was a better predictor. High-throughput dissolution/permeation is regarded promising for formulation screening.

This study examines the contribution of a 3-D model in an early development of pectin tablets. The aim of this work was to extract as much information of the compression behavior from as few tablets as possible. Pectins with various degrees of methoxylation (DM) were studied (4%-72%). The compressibility was evaluated using classic “in-die” Heckel and Kawakita analyses in addition to the 3-D modeling. For validation purposes well-known reference materials were included. 3-D modeling applied to data of single tablets yielded some information on their compressibility. When several tablets with different maximum relative densities were included, no additional information was obtained through classic evaluation. However, the 3-D model provided additional information through the shape of the 3-D parameter plot. Pectins with a DM >= 25% consolidated predominantly by elastic deformation similarly to the 3-D parameter plot of pregelatinized starch (PGS). The 3-D analysis also suggests some degree of fragmentation and, for some of the low-methoxylated pectins (DM

This study examines the contribution of a 3-D model in an early development of pectin tablets. The aim of this work was to extract as much information of the compression behavior from as few tablets as possible. Pectins with various degrees of methoxylation (DM) were studied (4%-72%). The compressibility was evaluated using classic “in-die” Heckel and Kawakita analyses in addition to the 3-D modeling. For validation purposes well-known reference materials were included. 3-D modeling applied to data of single tablets yielded some information on their compressibility. When several tablets with different maximum relative densities were included, no additional information was obtained through classic evaluation. However, the 3-D model provided additional information through the shape of the 3-D parameter plot. Pectins with a DM >= 25% consolidated predominantly by elastic deformation similarly to the 3-D parameter plot of pregelatinized starch (PGS). The 3-D analysis also suggests some degree of fragmentation and, for some of the low-methoxylated pectins (DM