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. 2023 Sep 29;29(2):661–673. doi: 10.1177/13591045231204073

Evaluating end of treatment care of young people with cancer

Eve Twivy 1,*,✉, Helen Griffiths 2,**, Matthew TD Knight 1
PMCID: PMC10945980  PMID: 37773596

Abstract

Background

Existing literature implies there may be gaps in post-treatment support for young people with cancer. This service evaluation explored the needs and experiences of young people when ending cancer treatment in a UK children’s hospital to inform service provisions.

Methods

Semi-structured interviews were conducted with nine young people, aged 13–18 years, who had finished active cancer treatment and were receiving follow-up care. The data was analysed using thematic analysis.

Results

Four main themes were developed: being in the dark (i.e. limited awareness of what happens when treatment ends); separation from the hospital (i.e. the loss of valued support from staff); consequences of cancer (i.e. managing ongoing psychological and physical effects); and getting back to normal life (i.e. shifting from hospital to everyday life).

Conclusions

Recommendations for improving clinical practice were made. Greater preparedness for ending treatment could be achieved by clearly setting out ongoing care arrangements, providing resource packs, having opportunities to mark the end of treatment, and offering peer support. To identify specific post-treatment needs, there should be an end of treatment multidisciplinary review and space for young people to share how they are feeling in follow-up medical appointments.

Keywords: Cancer, adolescent, end of treatment, qualitative, service evaluation

Introduction

Young People (YP) with cancer have unique care needs due to the rapid developmental changes that occur during adolescence (Docherty et al., 2015; Marshall et al., 2019). The five-year survival rate of 0–24 year olds with cancer in the UK has recently increased to 86% (Public Health England, 2021). In part, this has been attributed to the development of more specialised and age-appropriate services (Mayor, 2019; Public Health England, 2021). With these promising advances in curative care, there is a greater need to support YP in life beyond treatment (Galán et al., 2018). Increased understanding of the experiences of adolescents when ending active treatment (i.e. the end of curative cancer treatment) and starting follow-up care is needed (Lea et al., 2018).

The Biographical Disruption framework was developed to understand experiences and responses to chronic health conditions (Bury, 1982, 1991). Biographical disruption is a process by which a significant event alters one’s life path as well as how one views oneself, the world, and the future (Bury, 1982; Pranka, 2018). Cancer can cause biographical disruption given the long-term impact it can have on people’s lives and identities (Balmer et al., 2015; Grinyer, 2007; Hubbard & Forbat, 2012). This may be especially pertinent for adolescents, as according to psychosocial theory, this is a critical time for developing identity i.e. one’s sense of self (Erikson, 1994; Grinyer, 2007). Cancer can disrupt developmental tasks that support self-exploration, such as gaining independence and building peer relationships (Docherty et al., 2015). To minimise the life disruptions caused by cancer, it is important to consider how YP can be supported with ‘getting back on track’ when treatment ends.

The model of post-traumatic stress disorder (PTSD) also highlights the need to attend to the long-term impact of cancer in YP. Traumatic events that occur during cancer diagnosis and treatment can lead to Paediatric Medical Traumatic Stress (PMTS: Kassam-Adams & Butler, 2017). This includes PTSD symptoms, such as re-experiencing medical events and avoiding reminders of them. A meta-analysis found 11.5% of YP with chronic physical conditions have PTSD (Pinquart, 2020). YP can therefore continue to feel under threat from cancer after successful treatment.

Current research indicates that the end of treatment can be a challenging time for YP and families due to the ongoing physical and psychosocial impact of cancer (Bessell, 2001; Choquette et al., 2016; Galán et al., 2018; Lea, Martins, Fern, et al., 2020) i.e. “the end of treatment is not the end” (McKenzie & Curle, 2012, p. 649). A study found that young adults, aged 19–26 years, did not feel prepared for managing difficulties encountered post-treatment (Lea, Martins, Cable, et al., 2020). Furthermore, 73% of YP and parents do not think there is adequate access to post-treatment support across physical, social and psychological domains (All Party Parliamentary Group on Children Teenagers and Young Adults with Cancer [APPG CTYAC] 2018). Thus, existing patient experience data indicates that improvements in end of treatment care are required. Indeed, there is a recognised need for greater commissioning of services in England to support people in their recovery beyond cancer treatment (Independent Cancer Taskforce, 2015). Furthermore, the National Institute for Health and Care Excellence (NICE, 2014) identifies follow-up care as a priority area for improvement in cancer services for YP (see ‘Quality statement 6’). It proposes the implementation of end of treatment summaries so that YP receive information about their cancer and treatment, the long-term impact, and ongoing care arrangements. NICE (2014) also recommends having a psychosocial assessment at the end of treatment, which covers diverse needs from educational to spiritual (see ‘Quality statement 4’).

This service evaluation set out to explore the needs and experiences of YP when ending active cancer treatment at a Principal Treatment Centre (PTC) for children and YP (≤18 years old) in England. The PTC had identified a need to review their end of treatment processes due to a lack of service standards. Based on informal patient feedback, the hospital was considering setting up an end of treatment day for YP focused on coping with life after treatment. Existing provision included end of treatment medical summaries and medical follow-up clinics. Referrals to psychology were made by doctors or nurses reviewing YP in these clinics. By interviewing YP, this project aimed to evaluate service provisions and make patient-centred recommendations regarding end of treatment care.

Methods

Approvals

This project was classed as a ‘service evaluation’ and was therefore reviewed via the appropriate internal route at the PTC. The project received approval from the local Clinical Audit team (reference: 6417). Prior to participation, informed verbal consent was obtained for YP ≥16 years old and parents of YP <16 years old. Assent was obtained for YP <16 years old.

Participants

The inclusion criteria were YP aged 11–18 years, who had completed active cancer treatment within the past 5 years, and were attending follow-up clinics at the PTC or shared care centres. A further criterion was completion of active treatment prior to March 2020 to minimise the impact of the COVID-19 pandemic on experiences of care. This decision was guided by preferences of hospital staff, to ensure that care received was representative of typical service provision and therefore informative for improvements. Potential participants, and their parents, were asked during follow-up clinics whether they were happy to be contacted about the project.

Interviews took place between November 2020 and February 2021. There were nine participants (6 female, 3 male), all White British. At the time of participation, age ranged from 13–18 years (M = 16.3), with length of time off-treatment ranging from one year to three and a half years. Age at the end of treatment ranged from 11 to 16 years (M = 14.4). Five YP had Acute Lymphoblastic Leukaemia, two had Hodgkin Lymphoma, and two had an ovarian tumour. All YP had undergone chemotherapy, and two also had surgery. Length of active treatment ranged from a few months to a few years.

Semi-structured interview

A semi-structured interview schedule was developed (see Supplementary Material). This was informed by the biographical disruption theory of cancer (Grinyer, 2007), existing literature on the challenges YP can face at the end of treatment (Lea et al., 2018; Lea, Martins, Fern, et al., 2020), and feedback from hospital staff and a children’s patient experience group. The questions covered experiences of healthcare during treatment, at the end of treatment, and during early follow-up care. The questions also explored any difficulties that YP faced when ending treatment and gained their perspective on what helped them, or might have helped them, to cope.

Interviews were conducted individually with YP using Microsoft Teams video calls. One participant had their parent present during the interview. Interviews lasted between 45 min and 80 min and were audio recorded. Prompts were used to gain additional information or clarify understanding.

Design and analysis

This qualitative project adopted a critical realist stance. The data was analysed using thematic analysis (Braun & Clarke, 2006). This method is suited to understanding people’s experiences and views, developing themes shared across participants, and informing implications for healthcare practice (Braun & Clarke, 2014, 2020).

The interview recordings were transcribed, and familiarisation notes were made whilst reading and re-reading the transcripts. NVivo software was used for data management and coding. Initial coding was performed using an inductive and semantic approach. Subsequently, the codes were collated to develop initial themes, which were meaningful to the project aims (i.e. inform clinical practice). The initial themes were reviewed by determining whether the coded quotations matched each theme, and whether the themes were representative of the dataset. As part of this process, the initial themes were refined to develop the final themes and sub-themes, which were named and defined.

Project team and reflexivity

The data collection and analysis was performed by Eve Twivy, a female trainee clinical psychologist in her twenties. She previously worked in a paediatric psycho-oncology team and had people in her personal life who had cancer. A bracketing interview was completed by Eve to increase self-awareness of her experiences, assumptions and values that may impact data collection or analysis. Transcripts of the first two interviews were reviewed by Matthew Knight, a clinical psychologist identifying with a critical realist position, who has expertise in qualitative methodology, and lived experience of multiple episodes of cancer with treatment thereof. Reviewing and refining the themes took place in consultation with Matthew. The implications of the analysis were discussed with Helen Griffiths, a consultant clinical psychologist who has expertise in paediatric psycho-oncology.

Results

Four main themes and six sub-themes were developed. These are presented below with supporting quotations. Each YP was assigned a pseudonym.

Theme 1: Being in the dark

This theme describes YP’s awareness of what happens when cancer treatment ends. Most described being in the dark about aspects of this. There were two sub-themes: preparedness for ending and peer guidance.

Preparedness for ending

Most YP didn’t feel prepared for what life would be like or how they would feel when treatment ended. YP generally expected it would be a joyous and easy time, but the reality was different for most: “I thought it was just kind of gonna go back to normal and I was gonna be able to do everything again but it wasn’t, it was very difficult” (Cameron); “I thought that I’d feel a lot happier” (Kerry).

YP reported receiving varying levels of information from the hospital about the end of treatment. Information that was received had a predominantly practical focus around ongoing medical care. YP appreciated when care arrangements were clearly set out. Roughly half of YP described not knowing how to adjust back to everyday life, and would have liked more guidance around “what actually happens like with your life and how it changes, like and if there any ways that they could help” (Rory). Awareness of the hospital support available to YP post-treatment also varied: “they did make it really clear that I could always get the support if I needed it” (Erin); “I feel like there wasn’t really an option, like I didn’t really know who to go to” (Cameron). To increase preparedness for ending treatment, some YP highlighted the need for age-appropriate sharing of information. Ideas included giving YP information as well as parents, and having videos in addition to writtenmaterial.

Peer guidance

To help navigate the uncertainty of life after treatment, YP felt they would have benefitted from peer guidance. Eight YP described wanting to connect with other adolescents who had experienced cancer. This appeared to be partly driven by a desire to feel understood and less alone: “I don’t know anyone who has been through something that I’ve been through…I don’t have anyone that I know of who is like me” (Sam). Additionally, YP spoke about wanting to learn from peers about how they coped with the return to everyday life: “I think it would be nice to talk to someone about how they found the end of treatment and how they coped with it and just like get advice from them” (Riley).

Most YP described having minimal opportunities to build up peer support networks during treatment, largely due to being an older patient in a paediatric ward. YP expressed positivity about the hospital setting up an end of treatment day for YP who are a similar age. They felt this would be a good opportunity to meet peers who they could relate to and build friendships: “I think it’s definitely good for like kids to meet other kids that have been through like the same and that are gonna go through the same” (Rory). It was felt that centring the day around an activity, such as having food or going on a trip out, would make it easier to socialise:

I feel, if, if you just put a load of sort of like teenagers into a room and asked them to talk, talk to each other about their feelings, I feel like there would be a deep silence there [both laugh] so, maybe to arrange it around some sort of activity, or something to break the ice, something to get people talking. (Sam)

Theme 2: Separation from the hospital

This theme describes YP’s experiences of separation from the hospital when ending treatment. This theme had two sub-themes: bonds with the hospital and coping on your own.

Bonds with the hospital

The hospital was described as a secure base for YP whilst having treatment: a place where they felt welcomed, supported, and comforted by staff. As one YP explained: “I did really feel like I was cared for properly. And like they all genuinely actually did care about me” (Erin). At the end of treatment, most YP expressed sadness, anxiety, or frustration around suddenly losing staff relationships: “it was kind of like more separation from the hospital itself, which was more scary in a way, because I wasn’t having that comfort from them” (Alex). YP that saw familiar staff at post-treatment appointments generally valued opportunities to catch-up and receive reassurance: “I think it was just nice to like be checked in on again, just like they know that I’m still there, I still might need help” (P4). Roughly half of YP expressed a desire to stay more connected to staff post-treatment: “because I had a, such a relationship with the nurses, I kind of completely stopped seeing them all of a sudden, and like I wish there was something like I could see them maybe once or twice” (Alex).

Coping on your own

Most YP shared experiences of coping independently from the hospital after ending treatment. Some YP did not feel the need for ongoing support: “I didn’t feel like I needed um to have the support like because I was fine…nothing really affected me at the time” (Noah). Others felt they were required to manage alone, due to less frequent contact with staff: “it wasn’t necessarily that they said it as that, but it was more that you kind of just knew in the way that it was like you kind of just have to figure things out on your own” (Kerry). The reported reduction in support from staff was challenging for some: “I think my mum found it quite difficult…she’s the one that had to like chasing up everything and like all the appointments because, yeah it’s just ‘do it yourself’ basically, which is really hard” (Riley).

Another factor contributing to experiences of coping alone was the perceived barrier to seeking hospital support. A key reason was YP feeling less deserving of support given they had completed treatment:

Everyone on the ward is just like always so busy, like it’s always jam packed…and I just don’t wanna be like an extra thing for them to like worry about because like you’ve gone through treatment, like you’re done, kind of thing, it’s like the next child’s opportunity. (Riley)

Another key barrier reported was the lack of space to talk about feelings or ask for support in medical appointments: “they’ll like check me up, make sure nothing’s come back and there’s nothing wrong with me, like nothing to do with like mental health and how I’m like feeling” (Cameron). Some YP spoke about needing support to ask for support as it felt daunting. Ideas included having a mental health professional at the final treatment session, having time alone from parents at appointments, and asking specific questions about how YP are coping with the changes associated with ending treatment.

Theme 3: Consequences of cancer

This theme describes the experience and management of the physical and psychological consequences of cancer. YP described how the impact of cancer and side effects of treatment persisted beyond the end of treatment: “I finished treatment but there was still a lot, like I still wasn’t well in myself, I didn’t really feel myself and I didn’t feel like I looked like myself” (Alex).

Most YP reported physical difficulties when ending treatment, mostly related to fatigue, being overweight, and ongoing vulnerability to infections: “I had an infection in the side of my face…and then, I had [pause] um shingles” (Jamie). This led to ongoing restrictions in activities for some, such as sports. YP talked about the availability of hospital support if they were physically unwell, but some felt they would have benefitted from more input in getting back into healthy patterns of exercising and eating.

Most YP reported psychological difficulties after ending treatment, including anxiety and mood changes. Concerns about appearance and weight were common, and were linked to a loss of confidence for some: “because I put on so much weight, I kind of became obsessed with like trying to lose weight, um, and yeah just I, I suffered from that quite badly” (Alex). Some YP also struggled with difficult memories of treatment: “I only remember like extremely traumatic things…so I remember like certain bits very vividly, like just like things that are very difficult to think about” (Cameron).

To help cope, some YP talked about gaining emotional support from family, friends and dogs. Roughly half of YP mentioned receiving psychology support from the hospital post-treatment, with some reporting this being a positive experience: “it was fantastic, and it was extended as an offer to, to all my family so they could all get the support that they needed” (Sam). Others felt that there were unhelpful aspects, such as being suited to younger children, not feeling understood, and having infrequent support: “it wasn’t really that helpful in a way, because they wouldn’t come in that much, so you didn’t get to know that person a lot” (Kerry).

Theme 4: Getting back to normal life

This theme describes the process of shifting from hospital life to normal everyday life. There were two sub-themes: ending as a process and the shift to everyday life.

Ending as a process

YP described ending treatment as a process of recovery, given the abovementioned ongoing difficulties faced:

The end of treatment is actually, you know, you could argue a year long process where you sort of [laughs] try and get back to the person you were before or the person that you want to be going forwards, um, so you can’t pinpoint really that finish to, to a single day. (Sam)

YP had varied responses to this process, with some expressing frustration about the long recovery period: “I had to just sit around and wait for my immunity to get back, um, so that’s a bit annoying, um, and I was…still quite restricted from quite a few things” (Rory). Some noted the benefits of pacing themselves when returning to activities, and appreciated when this was recognised by others.

Some of the YP who underwent maintenance chemotherapy described a somewhat different recovery process. Some spoke about returning to normal activities, such as school, during maintenance treatment, thus they felt adjusted to normal life by the time treatment ended:

Throughout the entire thing of maintenance, I sort of forgot that I had it because, it, it’s like yeah, I had to take tablets every day but it was normal, and coming out of that I didn’t really notice much difference. (Noah)

The shift to everyday life

Roughly half of YP spoke about hospital life dominating during treatment, and how this became their new normal: “I had periods where there was like one day in a few weeks that I didn’t actually have to go to the hospital so it just became part of life” (Jamie). Most YP described happiness and relief when treatment ended, and some welcomed the freedom of normal life: “It’s just not having to think about it all the time and just be able to do things without second thoughts is like the main thing” (Erin).

However, most YP also described difficulties when returning to everyday life. YP spoke about missing out on socialising with friends during treatment, and subsequently struggling with social reintegration post-treatment: “whilst you’re having your treatment…you just get to talk to your friends like every now and then so yeah, so when you actually kind of stop treatment, you didn’t, you weren’t really knowing of things as much” (Kerry). Additionally, returning to school was challenging given that YP were behind their peers academically: “by the time I got back to school I was so behind and it was GCSE year, as well, so um, it was very, it was very difficult going back to school” (Rory). YP had varying experiences of school support post-treatment. Most YP had positive school adjustments, but some felt teachers lacked understanding of ongoing difficulties. When the hospital liaised with school post-treatment this was deemed beneficial: “I had to join like a pre-16 programme at a college, um and that helped a lot, um they worked really closely with people from the hospital to kind of like liaise with them” (Riley).

As part of their transition from hospital life to everyday life, YP spoke about valuing opportunities to celebrate the end of treatment with family and friends. Roughly half of YP also expressed a desire to mark the end of treatment with the hospital, with some suggesting this might have helped them to move on: “I would’ve loved to ring a bell, to mark the end of treatment…it’s just the final verification of you’re leaving the hospital now, your journey’s over, if that makes sense, the battle is won and you get to leave” (Jamie).

Discussion

This project explored the needs and experiences of YP when ending cancer treatment at a PTC to inform service provisions. YP were very complimentary about the care received during treatment, whilst post-treatment care experiences were mixed. YP described experiencing varying physical, psychological, and social difficulties at the end of treatment, which they generally did not feel prepared for. Some symptoms can be understood in the context of PMTS. YP sometimes felt alone in managing these difficulties due to the separation from hospital staff, and not knowing other YP who had experienced cancer. Most YP felt they would have benefitted from more information and support.

These findings are consistent with existing literature, which indicates that YP have unmet needs when ending cancer treatment (APPG CTYAC, 2018; Lea et al., 2018; Lea, Martins, Fern, et al., 2020). Comparable themes were obtained in a study with young adults (Lea, Martins, Cable, et al., 2020). Both projects had themes relating to the insecurity arising from losing valued staff support. Another similar finding was the mismatch between expectations that life would go back to normal and the reality of managing ongoing difficulties. However, YP faced distinct difficulties in the current study, such as returning to school, owing to life stage differences (Grinyer, 2007). Thus, this study adds to existing findings by sharing the voices of YP in early to mid-adolescence (i.e. aged 11–16 years at the end of treatment), who are less represented in patient experience literature (APPG CTYAC, 2018).

The needs of YP in this study can be understood within the context of the psychosocial theory of identity development (Erikson, 1994). For example, concerns related to appearance post-treatment were common, which may have been exacerbated by the heightened self-consciousness and high levels of peer comparison among adolescents (Grinyer, 2007; Rapee et al., 2019). Additionally, the importance of peer relationships and belonging during adolescence (Rapee et al., 2019) may have contributed to the strong desire for peer support. Furthermore, YP highlighted the need for age-appropriate care of adolescents treated in a paediatric setting. To support YP’s growing autonomy, it is important to directly involve them in their care (Duncan & Sawyer, 2010). Overall, this study highlights the need to attend to developmental stage when supporting young cancer survivors.

Recommendations for clinical practice

The below recommendations for clinical practice are based on the areas of improvement identified in this service evaluation. Whilst the recommendations are for the PTC concerned, they may have some transferability to other similar paediatric hospital settings. This would be determined through a large-scale research study. Overall, a more consistent approach to providing information and assessing needs at the end of treatment is needed.

  • • As recommended in NICE (2014) standards, provide end of treatment summaries and care plans to YP and parents, which clearly set out ongoing care arrangements, and information on accessing support for longer term medical and psychological needs. This should include an accessible explanation of PMTS and how to recognise the symptoms of PTSD, given the elevated prevalence in this population.

  • • Prior to ending treatment, provide YP with resource packs with guidance around adjusting to everyday life, and signposting to other resources (e.g. charity websites). Use of videos and incorporation of lived experience could help to ensure that the information is accessible and engaging for adolescents.

  • • Liaise with schools at the end of treatment to aid understanding of ongoing needs and ensure any necessary adjustments are made.

  • • Conduct a multidisciplinary review at the end of treatment, which assesses biopsychosocial needs. This could ensure that consistent topics are covered with each family, specific needs are identified, and individualised care is provided. The latter may include onward psychology referral. Screening questionnaires could support this process. In particular, a child PTSD interview, such as the CPSS-5 (Foa et al., 2018), is recommended.

  • • At follow-up appointments, continue to review unmet needs and help YP to voice any concerns. This could be achieved by normalising help-seeking post-treatment, allowing space for YP to talk about their emotions, asking specific questions about how they are coping, and giving them time alone from their parents. Given that YP built trusting relationships with hospital staff during treatment, it may be beneficial for conversations to be held with familiar staff.

  • • Set up a peer support programme. This could include an end of treatment day which is centred around a social activity. Peer support may reduce feelings of isolation and improve wellbeing (Campbell et al., 2004) and is suggested in NICE (2005) guidance.

  • • Provide opportunities to mark or celebrate the end of treatment in ways that are meaningful to YP. Additionally, give YP the opportunity to say goodbye to staff and be told how to keep in touch if they wish to.

  • • Consider whether any issues could be addressed whilst YP are having treatment, in order to minimise the difficulties experienced post-treatment. For example, supporting YP to keep in touch with friends.

Limitations

There were limitations to this project. Retrospective reporting of end of treatment experiences may have resulted in recall bias. Indeed, some YP noted that it was difficult to remember aspects of healthcare received or how they felt. Whilst the completeness of accounts was likely impacted by forgetting over time, accuracy of recalled information tends to remain high for personally experienced events (Diamond et al., 2020). Interviewing YP at the time of ending treatment may have been inappropriate given that recounting details can be difficult in the immediate aftermath of an emotional event (Van Giezen et al., 2005). Furthermore, a strength of retrospective reporting was the additional reflections on how end of treatment experiences impacted YP further down the line. However, this meant that perspectives on healthcare may have been viewed through the lens of adolescents at a later stage in biopsychosocial development compared to when they finished treatment.

Another limitation was the use of convenience sampling, which may have led to a biased sample. Whilst the somewhat homogeneous nature of participants aided the development of themes (Braun & Clarke, 2013), it limits the representativeness of the sample. Firstly, all participants were White British, thus reducing the transferability of the findings to other ethnic groups. This is pertinent given that ethnic minority groups have reported poorer experiences of cancer care in England (Independent Cancer Taskforce, 2015; Pinder et al., 2016). Thus, future studies should explore the post-treatment needs of YP from ethnic minority backgrounds and ascertain any recommendations for clinical practice beyond those indicated in the present study. Secondly, whilst the type of cancers in the sample are typical in YP, there was a fairly narrow range of diagnoses. Other common cancers in this age group, including brain and spinal cord tumours, skin cancer, and testicular cancer (Irvine, 2021), were not represented. There are preliminary indications (Ruccione et al., 2013) that type of cancer and treatment may influence post-treatment experiences. Future research could explore in-depth end of treatment experiences of specific types of cancer to inform more tailored service provision.

Conclusions

The findings of this study indicate that YP can face physical, psychological, and social challenges when ending cancer treatment. Therefore, YP would likely benefit from a biopsychosocial assessment of needs and provision of age-appropriate, tailored support at this stage of care. Recognition that some YP find it hard to ask for support should be considered when assessing needs. To increase confidence in managing any difficulties, there should be consistent provision of post-treatment information to YP, families, and schools. Additionally, opportunities for peer support may help YP feel less alone when navigating the transition back to everyday life.

Supplemental Material

Supplemental Material - Evaluating end of treatment care of young people with cancer
sj-pdf-1-ccp-10.1177_13591045231204073.pdf (91.4KB, pdf)

Supplemental Material for Evaluating end of treatment care of young people with cancer by Eve Twivy, Helen Griffiths, and Matthew TD Knight in Clinical Child Psychology and Psychiatry

Acknowledgments

The authors would like to thank the young people who generously took the time to participate in this study.

Author biographies

Eve Twivy is a Clinical Psychologist and Researcher with a particular interest in youth mental health and physical health.

Helen Griffiths is a Consultant Clinical Psychologist and Clinical Lead, working in paediatric settings.

Matthew TD Knight is a Consultant Clinical Psychologist and Senior Admissions Tutor; research interests include stigma, disclosure and qualitative methodologies.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was conducted as part of a Health Education England funded programme in clinical psychology.

Supplemental Material: Supplemental material for this article is available online.

ORCID iD

Eve Twivy https://orcid.org/0000-0001-6173-4153

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