There is emerging evidence of the detrimental impact of the pandemic andassociated restrictions on young people’s mental health in the UK but to date,these data have been largely quantitative. The aim of the current study was togain a deeper understanding of young people’s experiences in relation to theirmental health and wellbeing during the pandemic. Seventeen young people, aged 11to 16 years, sampled for diverse characteristics, and living in the UK, wereinterviewed virtually between December 2020 and February 2021. Reflexivethematic analysis was carried out by the research team, which included two youngpeople, and five themes were developed: (1) positives; (2) worries and anxiety;(3) sadness and anger about losses; (4) mental exhaustion; and (5) support fromothers. Aspects of young people’s individual circumstances  appeared to play a role in their experiences. Continued measurementof young people’s mental health, initiatives to identify young people who havebeen struggling and the provision of support (including evidence-based andaccessible interventions) will be important for protecting young people fromfuture adversities as we emerge from the pandemic. The restrictions put in place to mitigate the impact of COVID-19 have causedsignificant disruption to the lives of young people, despite the lower risk ofsevere health consequences resulting from COVID-19 for young people, relative toother groups. There is emerging evidence of the detrimental impact of the pandemicand these restrictions on young people’s mental health in the UK .HoweverReports suggest that in broad terms, the COVID-19 pandemic has had an adverse effecton the mental health of children and young people in the UK. Data from the NHSDigital Survey of children and young people’s mental health in England in July 2020showed a 16% increase in probable mental health disorders, compared to 2017 . TheCOVNonetheless, there is evidence that many young people did not experience high levelsof distress and that some groups experienced improvements in their mental healthduring the pandemic. For example, over the course of the first national UK lockdown,This variability in experience and coping can be understood in terms of risk andresilience factors. Young people’s ability to adapt in adverse circumstances appearsto relate to a range of factors associated with the child or young person, theirfamilies, and characteristics of their wider social environments .These fQualitative research on the experiences of children and adolescents during  the pandemic in the UK and other countries has highlighted theemotional impact of the pandemic on young people . IncreasYoung people interviewed in qualitative studies also commonly discussed changes tosocial relationships and feelings of loneliness and isolation during the pandemic.Some found it difficult to adapt to and maintain social relationships online , and repDespite this emerging evidence, there are gaps in our understanding of theexperiences of young people in the UK. Two studies come froConsequently, the aim of this study was to address these limitations by exploring theexperiences of young people aged 11 to 16 years, in relation to their mental healthand wellbeing and how they coped during the COVID-19 pandemic in the UK. Inparticular, it set out to investigate young people’s experiences of nationallockdowns , with interviews taking place duringa unique period of easing and tightening of restrictions (December 2020–February2021). The study purposively sampled for young people across the UK from a range ofbackgrounds, including those who may be at increased risk of mental healthdifficulties, such as those with a pre-existing mental health difficulty, specialeducational needs, and neurodevelopmental disorders.The study’s research questions were:(1) What were the experiences of young people aged 11 to 16 years, inrelation to their mental health and wellbeing and how they coped during theCOVID-19 pandemic in the UK?(2) What were the experiences at different time points  and over time as the pandemic progressed?The present study was part of a wider mixed-methods research study (Co-SPACE),tracking the mental health of children, young people, and their families during theCOVID-19 pandemic. Ethical approval for the study was granted by the Oxford CentralUniversity Research Ethics Committee .The research team consisted of researchers with an interest in mental health inchildren and young people, particularly in relation to understanding what causesand maintains mental health difficulties and the development of psychologicalinterventions. As a group, we were largely psychologists by training. Twomembers of the team (LB and MK) undertook this research as part of theirundergraduate (psychology) degrees. PL and PW were both trained clinicalpsychologists, as well as being parents. ES and MS were young people aged 15 to16 years, involved as lived experiences researchers. Both young people wereinterested in young people’s mental health and potentially pursuing a degree inpsychology. They were recruited via the Co-SPACE patient and public involvementand engagement (PPIE) group and were involved in the current study to givebetter representation and understanding of adolescents’ experiences in theanalysis. They were not participants in the study. They were involved inanalysis of the data and reviewing the final manuscript to ensure that itaccurately reflected young people’s experiences. They were financiallyreimbursed for their work in line with NIHR agreed payment and reimbursementrates for involvement . Three oTo be included in the study, participants were required to be living in the UKand be a young person aged 11 to 16 years. Participants were selectively sampledbased on demographic data provided as part of the Co-SPACE survey or via theexpression of interest form for external participants. As is typical inqualitative research, we adopted purposive sampling by selecting participantswho would be likely to provide information-rich data to analyze , rather https://osf.io/8zx2y/), twothrough involvement in PPIE activities and one through contact with fosteragencies. A summary of participants’ characteristics can be found in The participants for this study were 17 adolescents aged between 11 and 16 years.Fourteen of the participants were recruited through the Co-SPACE survey,completed by their parent/carer  to complete an expression of interest form.Parents/carers from a first round of recruitment were initially contacted basedon specific characteristics for which we were purposively sampling. Followinglow uptake, however, all who had expressed an interest were then contacted. Asecond round of recruitment was then conducted, and participants were contactedpurposively from those who had expressed an interest. In total, 142parents/carers indicated that their child would be interested in participatingand 35 responded to invites to interview. Of these, 20 completed and returnedconsent forms. All adolescents whose parent/carer had provided written consentwere sent information about the study and invited to take part. Nineteenprovided written assent and 17 were interviewed. Those who were not interviewedeither did not respond to email invitations for an interview or could not fitthe interview into their schedule.Interviews were conducted between December 2020 and March 2021. During this time,the UK had experienced two national lockdowns . During these lockdowns, schools were closed tomost children and young people. While at a national level, schools were openfrom September to December 2020, high levels of restrictions remained in place and locallockdowns were in place in some areas of the UK where infection levels werehigh. Prior to the interview, participants were sent a visual timeline ofpandemic-related lockdowns/restrictions and other key events (specific to thedevolved nation in which they were residing) to aid discussion.The first 10 interviews were conducted by a third-year undergraduate psychologystudent (LB), and a further seven interviews were conducted by a graduateresearch assistant (AS). Both interviewers identified as women; LB was from aWhite ethnic background and AS was from an Asian ethnic background. Interviewersreceived ongoing training and supervision throughout the interview process fromclinical research psychologists (PW and PL) and a post-doctoral researcher (SP),experienced in qualitative methods. Participants had not met the interviewersbefore the interview.n = 13), or with no video via Microsoft Teams(n = 2), or over the phone (n = 2). At thebeginning of the interview, parents/carers and young people gave verbalconsent/assent to participate. The interviewer then explained that the purposeof the study was to supplement knowledge from the wider Co-SPACE study and tolearn about people’s experiences in greater depth than the survey allowed . Subsequently, parents/carers were invited to leave theroom but asked to remain nearby in the case of distress; as such, mostinterviews were conducted with the adolescent alone, except where participantsopted to have a parent/carer present (n = 2), or if theinterview was conducted in an area where others were in the background(n = 4).Interviews were conducted on a video call via Microsoft Teams. At the beginning of the interview,participants were reminded that they did not have to answer questions if theypreferred not to and that they could request to stop the interview at any pointwithout having to give a reason. At the end, all participants receivedinformation about appropriate sources of support and resources that they couldaccess. If any concerns arose in relation to risk/safeguarding, interviewerswere required to discuss this with PW, a qualified clinical psychologist, andlocal safeguarding procedures were followed.Interviews began with a broad question around how things had been during thepandemic, before moving on to questions around their experiences at times ofhigh restrictions/lockdown and less restrictions  andthe impact on their wellbeing. A topic guide was used flexibly to provideprompts throughout the subsequent discussion (see n = 2), these were usedfor analysis in place of the original transcripts. Field notes were also kept byall interviewers, reflecting their thoughts and observations following eachinterview to provide additional context where needed during analysis.Interviews lasted between 33 and 57 minutes. Following the interview,participants were emailed a £30 gift voucher to reimburse them for their time.Interviews were recorded and transcribed through Microsoft Teams. Back uprecordings were made on an external audio recording device. Transcripts werechecked for accuracy, amended, and anonymized by the interviewer, as well assent to participants for confirmation of accuracy. Where transcripts werereturned by participants with edits (Data were managed in Nvivo (for Mac and PC) and analyzed using an inductiveapproach to reflexive thematic analysis, following Braun and Clarke’s six phasemethodology , includiInitial themes and subthemes were developed from the initial 10 interviews  by organizing codes into coherent groups. Following furtherinterviews and resulting new codes, the thematic structure was reviewed anddeveloped iteratively by the study team over several meetings. SP and PW furtherrefined the thematic structure between meetings. The lived experienceresearchers (MS and ES) were actively involved in research group meetings todevelop themes and subthemes. ES and MS had met some members of the researchgroup before the data analysis meetings. Prior to the meetings, they were giventhe opportunity to speak with SP and were also emailed slides that providedbackground information about the project and the process of qualitative researchmore broadly. The materials explained that their role in the meetings was toconsider the data from their perspective as a young people. This was alsoemphasized within the meetings, and they were actively encouraged to give theirthoughts and opinions throughout.The current analysis focused on young people’s experiences across the pandemic, witha particular focus on their mental health and wellbeing, and how they coped. Theirexperiences were developed into five themes: (1) positives; (2) worries and anxiety;(3) sadness and anger about losses; (4) mental exhaustion; and (5) support fromothers. The themes and subthemes are presented in Positive experiences described by young people were often focused on theearly part of the pandemic and related to the consequences of schoolclosures, such as a release from the stress of exams. They described thefirst lockdown as “a break”  from the pressures of school. Theearly stages of lockdown also brought about increased independence andautonomy over how to use their time.Just focusing on me and what I need to do. I liked working at my own pace and I liked not having to speak toanybody. Many of the young people pointed out that they had a “lot more time free tolike do [their] own things”  in the early part of the pandemicas school, clubs and organized activities came to an abrupt halt. This wasseen positively by those who described the first lockdown “like a reallylong holiday” , with many young people seeing it as anopportunity to do “something new that [they had] never [done]” , such as growing vegetables in the garden.For some young people, they were able to use this time for their hobbies andinterests and this gave them something else to focus on other than thepandemic, helping them to connect with friends, or making things feel morenormal.I did lots of online courses and kept myself occupied. . . .most helpful thing to me is being able to read and play computergames and play guitar. Just carry on with my hobbies which I wasdoing before lockdown. Being able to use this time to focus on themselves without having to“accommodate to other people”  was particularly valued bythose with pre-existing mental health or physical health difficulties. Inaddition, there was a sense that more time spent as a family could sometimeslead family members to feel better or become “closer” .It was, like, pretty much at least four times a week that we would dosomething altogether. Like all five of us as sisters.. . .and thosedays where we didn’t do anything, those days were kind of, like,low. In some instances, there were less arguments than normal, “because everyoneis a bit less stressed because they’re not really working that much”.Nevertheless, young people described feeling uneasy about the constantchanges that were happening throughout the pandemic, such as rules aroundbeing able to see other people, schools closing and re-opening, and examsbeing canceled. They described feeling a sense of inner conflict; theyeither felt confused about the situation and government response or couldunderstand different perspectives and felt conflicted about which to follow.Young people described feeling unsure whether seeing friends or taking partin activities was “the right thing”  to do, given the risksof catching COVID.It was mixed feelings because yes, it was nice socializing. But thenit’s kind of selfish, isn’t it? Er, a bit stressed like it kind of it wasn’t, like I didn’t feel likereally stressed, but I mean it was kind of, on my mind and still islike a bit. . . Ruminating and worrying about events that had already occurred that day, orduring increased periods of free time was common, with young peopledescribing “sitting around on [their] own getting stressed about work andthings like that” . For young people without a history ofmental health difficulties and/or SEN/ND, the experience of “not knowingwhat’s happening with, like all sorts of things”  wasdescribed in ways that implied that the level of stress was manageable. For example:Not knowing when this lockdown was gonna end was horrible. Like evennow when they you know say ‘oh, there’s a new tier, or there’s a newadded bit to lockdown and now you can only meet this number ofpeople’ like that still gives me panic attacks. . . However, those with pre-existing mental health difficulties and/or SEN/NDdescribed these changes having a serious impact on feelings of anxiety:Young people described remaining concerned about their own and other’s safetyas restrictions lifted. Two young people from the north of England (whereinfection rates tended to be relatively high compared to the rest of the UK)who also had SEN/ND reported that, despite the measures in place, “it doesfeel unsafe” , especially in crowded areas where theywould “end up getting quite stressed” . Some young people“became more worried for my grandparents than for me”  andfelt a responsibility for keeping others safe.I’m thinking about something goes wrong and it’s my fault that peoplein my house end up with this virus. So I was quite stressed outabout that. With the closures of school to most young people extending from March toSeptember 2020, there were mixed feelings about the return to school. Someyoung people described how much they missed the school environment and as aresult felt “scared that [they] won’t be able to go to school for a longtime” .the workload and having to see people when you haven’t seen peoplefor so long. .However, there was a recognition of the challenges of the school environmentand young people, especially those who had pre-existing mental healthdifficulties or had experienced abuse or bullying at school, had oftenlegitimate concerns about the return to school. Bridget reported that she“really did not want to” go back to school and was very anxious aboutreturning. This related to:Jiro (aged 14) had experienced COVID-related racist abuse early in thepandemic before the first lockdown and described how he “didn’t want to beforeign,” and was very worried about going back to school and the abusereoccurring.At home its harder to learn, but it’s not as much stress from otherpeople. I got a bit like paranoid about like touching stuff . . . so it kindof, at the same time as being really good, it was quite stressful.Some were anxious or stressed about catching COVID in the school environmentand potentially inadvertently infecting others:As young people returned to school at the start of the new academic year,many returned to a changed environment from the one they had left. For thosewho had remained at school throughout lockdown, the once quiet environmentbecame “hectic” and “loud”  as other students began toreturn. For others, the restrictions that had been introduced  were described as “allvery confusing”  by young people.Many young people reported feeling worried about their future. Some reportedfeeling worried “that it stays like this. . .not seeing people and having anormal life” .Worries about the impact on their education were common across the age rangebut it was noticeable that older individuals had concerns around “how myfuture is going to be”  and preparation for GCSE exams,taken at the end of compulsory education.I just wish that I could be able to know now. . . I feel confused bynot knowing what like I’m prepared, I’m preparing for. I mean, it is quite stressful to know how many exams I’ve got to getthrough, left when I’ve missed like 3, 4 months of school. Whereas for younger children, worries about the future appeared to be morebroadly about not attending school.I won’t be able to go to school for a long time. But apart from that,not really’ .Young people experienced multiple losses in their lives throughout thepandemic, from everyday routines and activities to significant life events, particularly in times of full lockdown. The loss ofroutine and events often left them feeling “bored, so I get upset. . .daysjust seem very long” , with some reporting that they “kindof spiral into depression because you don’t know what to do with yourself”. Not being able to go outside very much or exercise as partof hobbies made it “harder to get to sleep at night”  and“really, really sucked” .While there were positives for some in spending more time with family, youngpeople also found this hard, feeling trapped with no escape or outlet forbuilt-up frustrations which led to an increase in emotional distress andirritability. Families “argued quite a bit more than usual” and young people also reported that they had a shorter temper than usual inlockdown.I mean everything I could possibly be angry with, I was kind of angrywith at some point. Erm. My parents, the government, coronavirus ingeneral, yeah. One important loss for young people was not being able to spend time withfriends and family out of the house. Young people felt they had “lost touch” with school and friends, causing them to feel sociallyisolated and described feeling “panic”  about this. Theisolation was particularly difficult for those who “don’t have a phone thatcan text or anything” . Many felt that “it’s really suckednot being able to see [family]”  beyond those in thehousehold, such as cousins and grandparents; causing them to feel “sad” or“depressed.” One of the interviewees described feeling “very, very upset” about not being able to see her divorced parent.The loss of face-to-face school was particularly isolating for many youngpeople. They described it being “just stressful ‘cause . . .teachers find itharder to explain things over the internet to us”  or thatthere “wasn’t a lot of interaction”  when they wanted toask a question. However, even when back at school with restrictions, therewere elements of this that young people described as “horrible” because theyhad been placed in bubbles and could not mix these to spend time with theirfriends.Staying in touch with friends via technology during lockdown and the returnto hobbies, school, and other events were ultimately described as“frustrating” . For example, although they appreciatedtechnology allowing them to see and interact with people, they alsoexplained that “it’s not really the same” , which theyfound “really, really sad and really upsetting” . It alsofelt much harder to communicate remotely than in person, finding texting“tedious ‘cause you can’t, you’ve got to try and, like, put everything intowords and then you’ve got to try and like, it never seems to flow as well”.When hobbies and outdoors social interaction were allowed, young peopledescribed it being not quite the same as it had been before.Having to social distance . . .and like not being able to do half thestuff that you would be able to is sad. . . .during the start [of lockdown], I think most of us kind ofthought ‘oh it’s, it’s going to, kind of, be almost a holiday,’ butdidn’t end up being like that. . . Young people described feeling caught in a loop of initially feelingoptimistic, but as time went on, they felt fed up and lost hope:It’s never really going to end. We’re always gonna have to be morecareful than we were before. Along the way, events, such as the roll-out of the vaccination program, madesome feel “a lot more hopeful”  and restrictions beinglifted made others feel “happy when everything opened up a bit, because,like, there was hope. . .” . However, repeated lockdowns andrestrictions caused young people to lose that hope, worry, and to have toprepare themselves for things not returning to normal:Young people reported that they felt tired and exhausted throughout thepandemic.. . .it was really wearing, and it was extremely tiring at the startof the pandemic ‘cause I just didn’t have enough energy to, like, doanything, ‘cause, like, my brain was just scrambled. Young people commonly found each of the two national lockdowns more and more“tiring” . They felt too tired to keep in touch with friends,which seemed to take more energy than it did before; finding that they“didn’t message anyone back for, like, a few months because it was just toomuch to face” . Balancing academic work and other demandscould be difficult, particularly for those with extra responsibilities athome.I’m trying to attend every live lesson. . .and mum is disabled andstruggles to get around. . . now dad is at work, it’s more, I’mhelping out mum. . .I’m having a big dip in energy Many found the move to home learning during the first lockdown difficult.Young people themselves found it stressful trying to do schoolwork in theirhome environment, which had not been designed as an environment for learningand where they often lacked resources and space. The requirement to organizetheir own work without the support of teachers was “a bit of a shock atfirst” , which made it hard to then work effectively.I felt like it was, it was quite hard to get the work done. I’ve gota lot of distractions around me. My school didn’t have online lessons, they kind of sent work home,but it was, I couldn’t get it done, like motivating yourself to getlike through a whole pile of papers was not really too fun so Ididn’t really get any work done for like 6 months. I literally just get upset for no reason. Well not for no reason,because the teachers always set so much work. And I just feel reallyoverwhelmed. During the second national lockdown, the workload felt heavier for some:In addition, the increased effort needed to maintain concentration forteaching when delivered online was overwhelming and described as “a lot moretiring because it’s so easy to just drift off an online lesson” .It cause disruptions because I was sent home, in the September toDecember time, I was sent home twice and each time it was for twoweeks. Once lockdowns were lifted and schools re-opened, there was further stressfor those who were unable to attend school in person due to the requirementto self-isolate:Young people were generally positive about the support they received fromtheir families in relation to understanding and coping with COVID. They feltthat it was “better hearing [COVID information] from [mum] because she’smore reassuring” . Many young people felt grateful forbeing able to talk to their parent or carer about how they were feeling andcoping.I can be open with my mum, but not many other people .Some also found the presence of their siblings “helps immensely” to copethrough lockdown, speculating that their absence would have caused them to“feel alone” .Young people also felt conflicted between feeling “concerned for everyone” in their family, but also wanting or needed support fromtheir family.I mean, I know it’s difficult when they’re feeling stressed too. Butwhen they can, I mean, I always get support if I’m feeling bad aboutsomething. Nevertheless, for some young people, there were limits to the support parentsor carers could provide.We just don’t really click on that level with mental health, which isno problem ‘cause, you know, not everyone is going to understand.I talk about different things with my friends than I would with myparents. It is being able to discuss stuff with my friends that’s,it’s a good way to, like, stay mentally calm. For most young people, being able to talk to friends and keep in contact wasdescribed as a “lifesaver” . They found that talking tofriends about their emotions and about how to deal with the pandemicrestrictions was “something that helped me cope” :However, there were some young people who reported “not really”  talking to their friends much about how they were feeling about thepandemic and that talking to friends “would[n’t] have made a difference” or that their friends wouldn’t “be of use” .I talk to my friends but they’re the same age as me so they can’treally do much to help me. For those attending school through lockdown, a major benefit of this wasbeing able to spend time with and gain support from their friends in person.Once schools reopened after periods of lockdown, some young people describedfeeling “happy because you got to, like, see everyone again” .Young people’s feelings about the support they received from school wereoften mixed. Whilst some felt grateful for the educational or mental healthsupport that school provided, others felt that school could have done moreto support them, especially in the first lockdown. Some felt abandoned byschool in relation to support around the young person’s wellbeing and theprovision of resources to be able to learn at home.They didn’t really care what was properly going on. . .[they couldhave]. . .Given me a laptop to use. . .they could’ve phoned up moreand said, what’s happening. Most felt that by the second national lockdown, this support had improved.This appeared to relate to greater opportunity for regular interactions withteachers through online lessons or, for some, because they were able toattend school in person.I think ‘cause I’m going into school now, they they definitely makesure I’m OK. For those who required professional support, accessing mental health serviceswas helpful, even if they were initially reluctant. However, as servicesmoved to online provision, especially early in the pandemic, this was notalways well received.It was really helpful and now I’m doing a lot better and I can stillsee her now in person ‘cause it’s a medical appointment. So that’sreally really helpful and important like I would have struggled ifthat went online. When we did have a meeting it would be online, making it difficult,even more difficult than it normally is, to explain how I feel inreal life when I’m there . . . I didn’t really feel it was, I don’t know, confidential. ..just doesn’t feel like I can be as open. The present study sought to qualitatively explore the experiences of 17 young people,aged 11 to 16 years, in relation to their mental health and wellbeing and how theycoped during the COVID-19 pandemic within the UK. Through thematic analysis of youngpeople’s interviews, we developed five themes; (1) positives , such as a release from social and educational pressures, as well asmore time to spend on things they enjoyed and with family; (2) worries and anxiety,including feelings of uneasiness about doing the right thing, safety, attending (ornot attending) school in person, and worries about the future, (3) sadness and angerabout losses, including the loss of events and routines, not seeing others, andthings not being the same; (4) mental exhaustion, due to a continuous cycle of hopeand hopelessness, and home learning feeling overwhelming and exhausting; and (5)support from family, friends, school, and services. Within each theme, young peopleidentified factors that related to themselves, their family, and the widerenvironment that had both positive and negative effects on their wellbeing andability to cope.The young people in this study identified a range of factors that appeared tofacilitate resilience over the course of the pandemic, relating to them as anindividual, their family, the environment, and school/support services . During Nevertheless, at this point in the pandemic, young people in this study describedstruggling emotionally, with feelings of worry/anxiety, sadness, and anger. This isconsistent with previous findings from both quantitative and qualitative research. For exaIn our study, young people’s background characteristics appeared to play a role intheir experiences, consistent with previous quantitative literature. The youngpeople in the sample with pre-existing mental health difficulties, specialeducational needs, and neurodevelopmental disorders appeared to find uncertainty andchange, such as an increase in restrictions or the return to school after lockdown,particularly challenging. In some cases, they made direct links between recallingevents related to the pandemic, such as increased restrictions, and emotionaldistress, such as experiencing a panic attack. This is consistent with survey datathat have shown elevated patterns of mental health difficulties during the pandemicin young people with special educational needs and neurodevelopmental disorders. Scott eIt was notable that our findings around young people feeling mentally exhausted andexperiencing a cycle of hope and hopelessness have not been identified in previousstudies. Young people described difficulty trying to make decisions around their ownwants and needs in relation to socializing, whilst being aware this could haverepercussions for the safety of others. Given that adolescence involves an increasedneed for social connection, peer acceptance and belonging , and greOur findings suggested that during this period, young people found support frommultiple sources, including parents/carers, siblings, friends, school, and mentalhealth services, but that this was not always sufficient. Young people varied in whothey sought support from, and in their ability to access support (and other people’sability to successfully provide support). Our finding that there were gaps in theprovision of support from schools, especially early in the pandemic, and that theonline support provided by mental health services could be problematic for someyoung people replicates findings from other studies; for example, Clearly the picture is still developing in terms of the consequences of thepandemic for young people. While the purpose of this qualitative study was toprovide an in-depth understanding of the experiences of the young people ratherthan generalizable findings, there is a great deal of consistency with thebroader literature. Thus, there are several potential implications. It isimportant that parents/carers and schools recognize the emotional impact thepandemic and associated restrictions had on young people and to look for ways tominimize this going forward. Academic pressure and worries around workloads werecommon and so initiatives to address gaps in learning will need to be sensitiveto these concerns without creating additional stress. To ensure equity of accessto education if there are future episodes of home-schooling, it will beimportant that there is a reliable technological infrastructure available forsuccessful blended/online learning  and thatThis study benefits from several strengths; interviews explored experiencesincluding two periods of national lockdowns/tightened restrictions, andpurposive sampling was used to recruit a diverse sample of adolescents from avariety of locations and backgrounds across the UK. The study was conducted witha high level of rigor and credibility and benefited from the inclusion of youngpeople as members of the research team who were involved in the analysis andwrite-up. However, there are limitations to this study that should beconsidered. We were not able to capture experiences of young people from groupswho were not represented in the study . We did not obtain information about some characteristics . Further research is needed togain a greater understanding of the experiences of young people from these andother groups. We did not find gender to be associated with experiences but didnot explicitly ask about this and therefore the lack of findings may reflectwhat was covered in the interviews. While we sought to gain a broad perspectiveon young peoples’ experiences at a critical time point, there may be advantagesto recruiting more homogenous samples to provide more in-depth andcontextualized findings, particularly where there were relatively few youngpeople in the sample with a particular characteristic. Despite the explorationof experiences across the multiple lockdowns being an advantage of this study,it also meant a reliance on memory of experiences from up to 1 year prior. Twoof the young people chose to have a parent/carer present for the interview andfour of the young people were interviewed in an area where other family memberswere present in the background; although these young people talked openly abouttheir experiences, inevitably the presence of family members is likely to haveinfluenced what was said. Finally, participants were interviewed betweenDecember 2020  and February 2021 , within which times the current pandemic situation was very different.Although participants interviewed earlier did not appear to provide morepositive views than those interviewed later, the timings of the interviews mayhave impacted the way participants described their experiences. As we approachdifferences phases of the pandemic, it will be important to continue to capturethe voices of young people through further research.To conclude, this study sheds an important light on the experiences of young people’semotional wellbeing, mental health, and coping during a global pandemic. Consistentwith other studies, we found that young people experienced some positives early inthe pandemic but overall, feelings of worry and anxiety, sadness, and anger aboutlosses were common. Notably, we also found that by this point of the pandemic, youngpeople felt mentally exhausted due to a continuous cycle of hope and hopelessnessand that young people’s experiences appeared to vary according to key backgroundcharacteristics. Young people received support in multiple ways but there could bebarriers to successfully accessing support, such as feeling too exhausted to reachout to friends, or concerns about receiving online support from services. Movingforward, it will be crucial for those supporting young people to recognize theemotional impact of the pandemic on young people, provide opportunities for them toreconnect with others and engage in hobbies and interests, and help them to managethe uncertainty as we move to new phases of the pandemic. Continued measurement ofyoung people’s emotional wellbeing and mental health, initiatives to identify youngpeople who have been struggling and the provision of support (includingevidence-based and accessible interventions) will be important for protecting youngpeople from future adversities as we emerge from the pandemic.Click here for additional data file.sj-docx-1-jar-10.1177_07435584231151902 for How the COVID-19 Pandemic AffectedYoung People’s Mental Health and Wellbeing in the UK: A Qualitative Study bySamantha Pearcey, Lowrie Burgess, Adrienne Shum, Eshal Sajid, Milly Sargent,Marie-Louise Klampe, Peter J. Lawrence and Polly Waite in Journal of AdolescentResearch


End-of-life decisions present challenges in both human and veterinary medicine. Legally, the options are clearly defined in the respective fields. The legal differences, however, are not necessarily mirrored in personal judgements by different stakeholder groups involved in the decision-making processes. In this study, veterinary and medical professionals as well as a control group of laypersons were asked to choose treatment options in six different fictional end-of-life scenarios for human and for animal patients, differing in age, gender, and, in case of the human patients, in terms of their state of consciousness. Interesting differences and congruencies—within and between stakeholders but also animal and human patients—can be found in the results, especially with regard to the reasons study participants gave for their choices.Veterinary and human medicine share the challenges of end-of-life decisions. While there are legal and practical differences, there might be parallels and convergences regarding decision-making criteria and reasoning patterns in the two disciplines. In this online survey, six variants of a fictitious thought experiment aimed at pointing out crucial criteria relevant for decision-making within and across both professional fields. The six variants introduced four human and two animal patients with the same disease but differing in age, gender and, in case of the human patients, in terms of their state of consciousness. Participants could choose between four different treatment options: euthanasia, continuous sedation, a potentially curative treatment with severe side effects and no intervention. Study participants were human and veterinary medical professionals and an additional control group of lay people. Decisions and justifications for the six variants differed but the three groups of participants answered rather homogeneously. Besides the patient’s “suffering” as a main criterion, “age”, “autonomy” and, to a lesser extent, “species” were identified as important criteria for decision-making in all three groups. The unexpected convergences as well as subtle differences in argumentation patterns give rise to more in-depth research in this cross-disciplinary field. Kira is sick. She suffers from a serious lung disease that will eventually make her suffocate if not treated. Her doctors inform you about her options: They could administer a tablet A that will end her life immediately and painlessly. They could give Kira a different tablet B that would sedate her so that she would fall asleep and die painlessly from her disease within the next two weeks. Tablet C has a 70% chance of curing Kira. However, she would suffer from the side effects of that treatment for a period of 6 months, including nausea, vomiting, and pain. What do you consider the best option for Kira?It depends, you might answer. It depends on several context-specific aspects we did not give you here. Our study focused on some of those very aspects that might make a difference for people’s decisions and explanations. Who is Kira? Does it, for example, matter, if Kira is young or old? Would it be different if Kira was Tom? Is it relevant for your decision to which extent Kira is autonomous? And does your decision depend on whether Kira is a human patient or, let’s say, a dog? Besides, it might be important who you are. Are you someone who professionally decides on therapy limitations or companion animal euthanasia on a regular basis? Or are you any other citizen who might have been personally involved in care for someone in their final days of life?In this study, we want to tackle the vibrant discourse on ethical aspects in end-of-life decisions (EOLD), empirically and from an unconventional angle. We are interested in convergences and divergences regarding the ethics of EOLD in human and companion animal medicine. Legally, the framework for decision-making differs substantially between human and veterinary practice and, besides, from country to country. A recent court ruling of the German Federal Constitutional Court initiated a new debate on physician-assisted suicide in Germany  which haWithin this framework, physicians as well as veterinarians counsel patients, patient owners and family members in EOLD and decide on therapy options. In veterinary practice, euthanasia is an established and fundamentally unquestioned means to end a patient’s suffering if other options are ruled out, or if it is impossible to administer the adequate therapy to the patient . Human pIn this study, we wanted to shed light on precisely these decision-making criteria in EOLD in veterinary and human medical practice and also in comparison to the public perspective on this matter. Therefore, we designed the thought experiment briefly introduced above with six variations concerning patient properties, including the patient being a dog or a human, being young or old , female or male and, in case of the human patient, one variation with the patient being in a coma. In offering four treatment options—no treatment, euthanasia, continuous sedation and a potentially healing treatment with serious side effects—we mixed alternatives that are actually available in human and/or veterinary medicine and thereby took away the legal and practical restrictions that exist in real life. We recruited participants from the veterinary and human medical field and added a control group without a background in (veterinary) medicine. By parallelizing the cases of human and nonhuman patients and ascribing the same disease, we wanted to explore those characteristics that make the cases different for our participants and identify potential thresholds in the assessment of these situations. In addition to their choices, we asked for their criteria and explanations.(1)The species of the patient . Despite the explicit hint that all options are legally and technically possible in our hypothetical scenario, we expected participants to differentiate between an animal and a human patient in EOLD. That difference can be expected in all three groups, assuming the fundamental human habit of differentiating between ending animal and ending human life. More specifically, though, one research question would be to determine whether all three groups perceive this difference as equally important and whether the (pattern of) reasons participants mention for their decisions is similar between the three groups.(2)The patient’s age. There are—at least—three separate dimensions of the factor “age” that may come into play in EOLD. First, an elderly patient might not be able to compensate for certain side effects as well as a younger one. She might suffer more, take longer to recover, or have disadvantages due to comorbidities. Participants might not want to put an elderly patient though the suffering (from the side effects of the treatment) and therefore would rather let them go (from here: the “putting-through dimension”).Depending on the factors specified in our thought experiment, we expected to find differences regarding:The second dimension is a calculation of a measure’s effectiveness, known from medical ethics as “QALY”, quality-adjusted life years . The maiA third argument referring to age is known as “fair innings”, which has recently gained attention again when deliberating decision-making during a pandemic. The basic idea “reflects the feeling that everyone is entitled to some ‘normal’ span of health (…) and anyone failing to achieve this has been cheated, whilst anyone getting more than this is ‘living on borrowed time’”  (p.117).To what extent all of these arguments are presented for animals and humans and used by all groups is the main research question regarding “age”.(3)The patient’s autonomy. The reason for including an infant and a person in a coma was to point towards the so-called argument from marginal cases. While there are differences between most humans and most nonhuman animals, there are cases of certain humans—the “marginal” cases—who share morally relevant properties with certain nonhuman animals. This group consists, e.g., of infants and persons with dementia or other mental impairments. Like animals, they are not autonomous, meaning that they are not able to tell us their preferences and we are not able to explain future benefits from current treatments or actions to them. At the same time, they are able to suffer and clearly express suffering. In the study, the human patient in a coma, additionally, is never expected to gain autonomy again whereas the infant bears the potential to become an autonomous person later in her life and the 11-year old already is autonomous to a certain degree but still dependent on the decision-making of adults.Besides the debate on animal autonomy, there is the much less controversial attitude that experienced humans  are able to access (companion) animal preferences. Therefore, participants might be interested in the question as to which extent the animal patient in the given scenario expresses their preference to continue living or rather to end their life.The fictitious scenario was designed by the authors and pilot-tested among colleagues . According to their feedback, we adjusted wording and clarified ambiguities. The scenario reads as follows , Tablet B (from here “sedation tablet”), Tablet C (from here “curative tablet”) or no therapy. Afterwards, they were asked to explain their decision in a text box: “I made this choice because…”If tablet C is given, there is a 70% chance that his lung will be cured after 6 months. Tom will not feel the usual side effects such as nausea, dizziness and severe fatigue. There is a 30% chance that lung failure cannot be stopped this way.Wording was the same for a 70-year-old human, an 11-year-old human, and a 2-year-old Labrador Retriever. Wording differed for a 30-year-old human in an irreversible coma for tablet C because a coma patient is not expected to suffer from the listed side effects:Additionally, we adapted the description of the current state of the 6-month-old infant to make it plausible. The sentence “He has breathing difficulties, no longer eats and has little interest in everyday activities such as walks.” was replaced by “He has breathing difficulties, no longer drinks and has little interest in contact with his environment.”Half of the participants were assigned the questionnaire with the six different patients in this scenario called Tom. The other half got the same scenarios but with a female patient named Kira. The scenarios were displayed in randomized order to avoid framing effects.www.limesurvey.org, last accessed 7 January 2022) was used as a survey tool. The survey was started 6 May and finished on 25 August 2021 when a sufficient number of responses had been received.As representative of the ethics committee, the animal welfare officer of the Veterinary University Hannover approved the study in March 2020. Recruitment for the online survey took place between May and August 2021. We used social media groups  and email distribution lists for employees in human and veterinary hospitals to recruit participants from the three different groups. For the lay public group, we asked them to forward the emails and announcements in the social media groups to further acquaintances, neighbors, family members, etc. The aim was to reach at least 100 participants of each group . LimeSurvey  and IBM SPSS Statistics Professional. Quantitative analysis was performed by the first author and discussed with the other authors. The results were analyzed descriptively and checked for between-group differences among the answers for each scenario variant with a Chi-squared test. For the analysis of the open-ended responses, MAXQDA  was used to structure answering patterns and to obtain an overview regarding emerging themes and their frequencies. As the free texts were very short  it would not have been meaningful to conduct a thorough content analysis of qualitative research. However, explanation patterns were identified by going through the answers iteratively and ascribing codes in MAXQDA. The dominant explanations were expected to follow the study design, as the six vignettes differed most obviously regarding species of the patient, age and autonomy. However, the coding was done inductively and no codes or themes had been defined in advance.For the quantitative analysis and creation of the diagrams, we used Microsoftn = 113) of the participants were assigned to the group human medical professionals, from here “HumMed” group. 230 respondents identified as veterinarians and after adding animal caretakers (zoo), farmers, a lab worker, an animal physiotherapist and alternative animal health practitioners to the group, 36% (n = 244) formed the group of animal professionals, from here “VetMed” group. Again, the decision was made because those people potentially work with animals in end-of-life situations. The remaining 47% (n = 316) were the control group participants.Of 1096 participants who started the survey, 673 completed it (61%). Of those, 98 identified as human medical professionals and an additional 15 participants were added to this group based on their information regarding their profession . This decision was based on the most relevant criterion of being potentially involved in human end-of-life situations beyond private experience. In total, 17%  occurred in a Chi-squared test for the 11-year-old dog, in which case more than 53% of the VetMed group voted for the euthanasia tablet and ca. 23% each for sedation tablet and the curative tablet. The other groups chose the euthanasia tablet less frequently  and the sedation tablet more frequently . Similarly, in the scenario with the 70-year-old human patient, the HumMed and VetMed group answered significantly differently (p < 0. 05). While almost 70% of the VetMed group opted for the curative treatment , only 53% of the HumMed group chose that option . A third significant difference (p > 0.05) is displayed in the coma patient scenario, in which case human professionals opted for the sedation more often (45%) than the other two groups  and for the curative tablet less frequently . Significant between-group differences  decisions might help to identify the categories  which guided and motivated the decisions made. The texts varied in length and explanatory strength. Some participants only wrote one word picking up the demarcating fact of the specific scenario such as “young” or “coma”. Some explicitly wrote that they had been undecided considering two or more options. Others explained why they excluded some options and, consequently, voted for the remaining one. Additionally, participants referred to personal wishes and experiences. Before looking into the response patterns relating to the three research foci presented in the introduction, the authors give a brief overview of the most common explanations and reasons. It is worth noting that the most common reasons or justifications for choosing one of the four options were comparable throughout the scenarios and the three participant groups.Overall, most participants explained their decision for euthanasia tablet A or sedation tablet B by reduction of suffering for the patient, no matter if dog or human. Occasionally, participants specified “suffering” in terms of the potential side effects of the treatment (tablet C) or in terms of the pain and the imminent suffocation due to the lung disease. At the same time, most of them did not explain why they did not opt for one of the other two tablets, which would have also reduced suffering. If they did, they commonly mentioned the chance to say goodbye for a couple of days, which is implied in continuous sedation. For both options and both groups of patients, several participants stated that this was a good, pleasant or dignified way to die . Only VetMeds call option A “euthanasia” or “putting to sleep”. Complementary to this, human medical professionals talk about a “clear palliative situation” (coma patient scenario), and that “B is not active assisted dying but enables dying without suffering” (coma patient scenario) when administering sedation tablet B.Some HumMed participants choosing tablet A had different explanations, besides the main reasons, i.e., that there is no or too little chance of cure and too much suffering for the patient. For the coma patient, they state that, in their eyes, “it is undignified to delay death any longer”, “an irreversible coma is not a state worth living in—therefore, in the case of additional severe suffering, active assisted dying is also justified”, “life is so incredibly precious, but not at any cost” and, taking family members into consideration, “perhaps suffering and burden can be lifted from the family”.The vast majority of those who decided on curative tablet C explained their choice by good healing chances (70%).Occasionally, participants did not trust the description of the scenarios, called them unrealistic or medically wrong, or interpreted additional circumstances, such as this animal professional, choosing tablet A for the coma patient: “Tablet B will probably sedate Kira and take away her stress, but in the end she will probably suffocate, which is a cruel death in my eyes. Therefore, I have decided to use tablet A, which will relieve Kira of her suffering without any stress or pain”, or this human medical professional explaining why they chose sedation tablet B for the coma patient: “Hmm, actually, something like that  is more likely to be ended by withdrawing from therapy and not by giving a tablet (…)”.(1)Species: To what extent do explanations refer to the patient’s species?The authors’ research focus was on the factors laid out in the introduction:Despite species being an obvious difference between the patients in the scenarios, it was not a factor the participants frequently explicitly mentioned in their reasoning. Rather, participants referred to those animal properties they do not share with (most) human patients: nonhuman animals do not understand the purpose of a long-lasting treatment; they are not able to tell us their preferences; we might not be able to estimate the extent of their suffering, etc. Those criteria, however, were also true for the 6-month-old or the comatose human patient, which is why, at least for the infant, participants argued similarly when explaining their decisions (see aspect 3. “Autonomy”). Particularly in the answers of the control group to the animal patient scenarios, there are a few explicit references regarding differences between nonhuman animals  and humans. From the short statement that “he is a dog”  or, similarly, the insight that “he is 11 years old and an animal is not a human”  to the more elaborate view that “half a year with side effects is too long for an animal” , participants offered justifications for immediately putting the animal to sleep. Human medical professionals referred to the animal’s lack of ability to say goodbye  or the inability to communicate suffering . Some participants of the animal group, in contrast, presented the minority opinion that the treatment tablet would be the right choice as “animals don’t ask whether something is ‘worth it’, they accept things as they are. That’s why he survives the half year” , or, emphasising the emotional state of the patient’s family, “you also don’t suffer as much regarding the side effects as you do with a child” . Apparently struggling with a decision, an animal group participant choosing C admits that “6 months is an eternity even for a 2-year-old dog, but I think I would want to give it a try”.Participants mention the species in the free-text answers to the human patient scenarios even less frequently. One VetMed participant states that there is a “small difference between humans and animals. Euthanasia critical issue” when arguing for their decision to administer sedation tablet B to the 70-year-old patient. Strikingly, a HumMed participant opting for tablet A answers that the 6-month-old human is “too young to actively say goodbye”, implicitly referring to a parallel with animal patients. The idea that “every human has the right to a dignified and painless death”,  is not mentioned for the animal scenarios.(2)Age: Do the participants elaborate their understanding of the relevance of age ?Putting-Through DimensionAge is one of the most-mentioned reasons in the free text answers for the elderly, but also for the explicitly young patients. Besides vague statements like “because of the age” or “because she is old,” participants elaborate in several ways to what extent the factor is relevant for their decision-making. The statements suggest that all three dimensions of age come into play in the participants’ reasoning:Participants argued from both angles: for choosing treatment tablet C, such as “a young body can take more” , or for letting the patient go, because “Kira is already elderly, I wouldn’t want to put her through the strain” . The wording was often similar for human and animal patients: “Since the dog has reached a fairly advanced age of 11 years, you don’t want to put the old guy through a torturous therapy but rather let him ‘go’ peacefully” . Some participants explicitly compared the two different ages concluding that “here the decision is different, because at 2 years old (…) the body might be able to cope better” .QALY DimensionThe basic idea that the quality time gained should be weighed against the duration of the suffering while undergoing the treatment was brought up frequently. However, the argument was used for different decision outcomes, depending on (a) the knowledge regarding life expectancy and, (b) the judgement regarding how much potential good-quality time would be worth the sacrifice of—at least—half a year of bad-quality time. “I have no idea whether 11 years is a high age in dogs. If it is and her lifetime is almost at the end anyway, I would have chosen A.” “Despite the high age, there is a high chance of recovery after 6 months. However, tablet A would also be justified.” “70% survival rate worth the side effects.” “Labrador is at the target age (10–12 years), no further problems mentioned. Tablet C offers only 0% quality time and 70% quality time for half of the time in the last year of life, but on average only a 35% chance—in other words, a little more than 2 months. This is better than B with 2 weeks.”  The knowledge regarding life expectancy of dogs in general and Labrador Retrievers in particular was rather heterogeneous among the groups of participants according to the estimations within the free-text answers. In the control group, 14, 15 or 16 years were mentioned, whereas the VetMed group brought up the specific life expectancy quite frequently between 10 and 14, mostly 12 years. Consequently, those participants evaluated the question of the ratio between the expected life years with a good quality and the comparably short time of suffering differently for the elderly dog: However, there were participants who seemed to judge the 6 months period with severe side effects to be too much for an animal per se, because “proportionally, the animal suffers for an unnecessarily long time” .In contrast to that: “The 70% chance of recovery justifies the 6 months of side effects for me, as the animal is at the beginning of its life and could easily live another 10 years” . Another veterinarian states that, “we treat diseases with a worse prognosis!” .Fair Innings Dimension“Tom has already had a relatively long life (…). Through Tablet B, Tom can spend his last weeks peacefully and with dignity, have his family around him one last time and everyone can say goodbye and prepare for the inevitable.” “The good man has lived his life.” “Life expectancy at the end.” “11 years is a noble age for a  Labrador. But I wouldn’t want him to suffer.” A VetMed group participant admitted: “I am struggling a lot with my answer, as age should not be a reason that influences the decision” . Nevertheless, the perspective that the elderly patient, be it human or dog, has already lived a complete life came up in many statements, especially when opting for the sedation tablet B:The general problem of age comparability in humans and companion animals was at least touched on in passing, e.g., when a HumMed participant elaborated regarding the 70-year-old human patient: “It’s difficult, his general condition would be interesting. Age 70 is theoretically no longer as old as it used to be”; or when a VetMed participant voting for B for the 11-year-old dog states: “Half a year with the side effects mentioned is a very long time in relation to the average life expectancy of the Labrador .”(3)Autonomy: To what extent is it relevant for the participants’ choices if the patient is, has been, or will be autonomous?“Because for me a baby can as little communicate as an animal and I don’t want to inflict unnecessary pain.” “The baby doesn’t understand what’s happening to him”  “Probably, I’ll get in trouble now because I let everyone die, but for me this would be the same as for the dog.” The most relevant explanations with regard to autonomy belong to the answers in the scenarios with non-autonomous patients. On the one hand, for the infant, several participants explicitly or at least implicitly emphasize commonalities between non-autonomous animals and humans:On the other hand, HumMeds opting for A or B in the coma patients hardly ever refer to the fact that the patient is not/no longer autonomous. Only one participant asks if there was an advance directive, giving credit to the patient’s choice. One control group participant explains their choice for “B” with an unusual ascription of autonomy, though: “(…) If the body cannot do it without outside help, one should not prolong the suffering, but give the soul the opportunity to choose the time—free of pain—itself.”The control group members opting for A or B in the coma patient rather refer to their own experiences with death/dying , or to their own preferences , besides the most commonly mentioned factors that the patient is in a coma, suffering and the chances of cure are too low. One participant excludes the other options: “Has no desire (for) B, and no benefit from C”. Another one adds “if it was allowed” when choosing A, showing their awareness of the legal situation regarding killing on demand. Several participants refer to a potential advance directive and a few mention the option to donate organs as a reason for choosing A.Among the veterinarians, too, we find an answer explicitly including the patient’s preferences: “For me, an irreversible coma is already sufficient reason for euthanasia, regardless of the lung problem. Of course, it would be nice to have a living will. If it was clear from this that the patient would prefer to continue living, I would be in favor of Tablet C.” At the same time, this answer suggests that for this vet it does not make a medical difference that the patient is human, as they state that the diagnosis would be sufficient for euthanasia . Similarly, a veterinarian explains her choice for A in the human coma patient directly referring to her profession: “I am a veterinarian and I make these decisions for my patients every day.”In the scenarios with the autonomous human patients, there is strong emphasis on human autonomy, e.g., by this veterinarian choosing B for the 70-year-old patient: “Actually, I would like to leave the choice to the patient. It is not for me to decide”, or this control group participant choosing C for the 11-year-old child: “I would only decide this way if he wanted it himself. If he no longer wants to live, I would choose tablet A immediately.” Quite a few statements clearly expressed that any paternalistic choice would be wrong and they would opt for “none of the answers. I would discuss this with Tom and respect his will—no matter what that looks like” . Some participants explicitly demarcate their decision from those in the other scenarios with non-autonomous animal patients: “In contrast to the dog, Kira can decide for herself. Therefore, all other answers could also be considered” . Stressing their communication habits, a human medical professional opting for B in the 70-year-old patient claims: “I talked to Kira. She wanted it that way.” This participant even invented a dialogue with Kira to highlight the self-evidence of asking the patient.When discussing between-group differences for the decision results, it must be kept in mind that even in cases with significant differences the overall decision patterns in the scenarios are similar for all three groups. Even if, for example, significantly more veterinarians opted for a treatment tablet C in the 70-year-old patient, most participants of the other two groups also chose tablet C. Therefore, the differences between the three groups are addressed subordinately when discussing the overall decision-making patterns and criteria. The fracture lines regarding the decisions for one of the four options can be drawn, on the one hand, between older and younger patients. Other things being equal, participants suggest different treatments for the older human and the older canine patient compared to the younger ones. The difference is, however, much more pronounced for the animal than for the human scenarios: Most participants suggest euthanizing the older but treating the younger dog, whereas in all three, for the young and the elderly human patients, most participants considered treatment tablet C the best option. Belonging to the human species, though, does not present a sufficient criterion to be kept alive under all circumstances. For the human coma patient, most participants suggested the euthanasia tablet A. Analyzing these patterns thus allows for the conclusion that species, age and autonomy are intertwined criteria in the decision-making process.The given circumstances in the scenario present a stark contrast to usual procedures in both human and companion animal medicine in several aspects. First, therapies with severe side effects are commonly not applied in companion animal practice even if that means accepting a shortened life of the patient. Chemotherapy is a prominent example. Veterinarians are advised to discontinue chemotherapy if the animal patient shows substantial side effects  and overSecond, tablet A obviously represents a choice that is not available in human medicine (in Germany) while describing a standard procedure in veterinary medicine. This difference was, however, picked up remarkably rarely in the free-text answers. Some participants in the animal professional group clearly identified the procedure as euthanasia. In all groups, some participants stated that they would opt for this if they or close family members were in a similar situation, mirroring the ongoing debate on assisted dying. As laid out in the introduction and confirmed by several above-mentioned participant statements, veterinarians’ professional habits can lead to a rather pragmatic and matter-of-fact attitude towards euthanasia that is by definition  not as acquainted to human medical professionals. Stripped of the usual legal and social constraints and also of the explicit expression “euthanasia”  the fictional text led nevertheless to a considerable proportion of all participant groups administering euthanasia tablet A to a human coma patient. Third, continuous palliative sedation as presented in tablet B is not a common practice in veterinary medicine in Germany but is part of the human medical toolbox in EOLD. This is underlined by the fact that participants in the human medical professional group opted for tablet B more often than the other two groups in all but those scenarios involving human children. With the changing role of companion animals who are increasingly perceived as family members, the demand for treatments from animal owners who are familiar with human medicine is growing. That includes procedures at the end-of-life situations. In a recent qualitative study veterinarians report an increasing number of clients asking for alternatives to euthanasia (see ) and theOverall, the difference in species seems to have played an implicit role in the decision-making, as both the choices and the explanations in the animal patient scenarios display less ambivalence in the participants’ reasoning. However, the difference is only gradual as argumentative patterns for human and animal patients overlap to a large extent.A study limitation that is true for all aspects becomes evident for the research focus “age”. The free-text question allowed for exploratory rather than hypothesis-driven research questions making it difficult (a) to quantify and (b) compare argumentation patterns. Apparently, the three introduced dimensions of “age” are represented in those participants’ statements that refer to age, besides the frequent mentioning of “age” lacking further differentiation.In all three groups, there are participants bringing up the thought that they do not want to put an elderly patient  through the six month of stress and suffering because the patient “cannot take it” anymore. In addition, they infer that the younger patient’s body will be able to tolerate the procedure better. Given that, at least in several cases, this is the foremost or the only reason participants mention for their choice, the perspective seems rather reductionist as (a) a patient is generally considered to comprise more than his body and (b) the context of patient owners/family members is excluded in this argument. Even more striking, however, are the statements representing the QALY-dimension of age. Given the specifics of commonly tolerated side effects of a veterinary treatment, as elaborated above, the weighing process of the six months with extremely bad quality of life against the  healthy years that follow seems to be a human medical calculation that, in cases like that, would just not be played through in veterinary medicine. Nevertheless, a clear majority of all three groups was willing to put the younger dog through the treatment C procedure as the healing chances were estimated as sufficiently high, and about a fifth of all participants even opted for this in the scenario with the elderly dog. After all, one of the ethical justifications for performing euthanasia in severely ill animals is the basic assumption that, for them, the current suffering outweighs future potential happiness after a time-consuming treatment . An ordeAgainst this background, the findings on the fair-innings-dimension were equally surprising. In contrast to the statements of other participants that  a 70-year-old person can be expected to have at least ca. 10 more years of life, quite a few participants stated that this patient had lived his life and might as well die peacefully, now. Giving credence to the fact that a huge proportion of all participants stated they would ask the patient or try to learn about their preferences, the minority opinion that a paternalistic decision would be acceptable must be acknowledged. Again, this result can potentially be attributed to the study design, as participants were asked which option they considered to be the best, including a forced decision that intentionally excluded the patient’s perspective. There is the viewpoint, most certainly also a minority opinion, that, to quote one of its most prominent advocates, “living too long is also a loss” . EmanuelFinally, despite comparable decision patterns see , age repAutonomy can be understood as a graded property. With different accounts of autonomy described in the literature ,20,21 anunderstand decision-relevant facts, consequences and risks of, e.g., a treatmentapply the relevant information to their own situationweigh arguments for and against different options in the light of their own values and attitudesmake a decision based on that weighing processcommunicate that decision.Kira and Tom, as an infant, comatose or dog patient, undoubtedly do not fulfill those requirements. That is why in those cases the necessity to make a decision for them is more obvious than in case of the 11-year-old child or the 70-year-old adult. The hesitation when being forced to decide for these two patients is displayed in several evasive participant answers who would have liked to include the patient’s will, too, independent of their choices for Tablets A, B, or C. Several statements indicated a cascade from talking directly to the patient, looking for an advance directive, to asking family and friends in order to respect the patient’s autonomy. Interestingly, despite the clear difference in (current) autonomy, the decision-making for the infant and the 11-year-old was almost exactly the same. Here, the combination of a long life expectancy and the chances of being healed were judged to be most relevant.Dealing with non-autonomous patients presented fewer difficulties for the participants according to the free-text answers. The paternalistic act of deciding for tablet A or B was, in line with Jox’s above-mentioned criteria, frequently justified by the incapability of the animal to understand the purpose of a therapy (tablet C) or to express their current level of suffering . Arguably, this challenge could equally be attributed to a human deficit in precisely perceiving the animals’ suffering, rather than to the animals’ deficit in communicating their physical and mental state. Several times, respect was paid to the (autonomous) animal owner’s preferences when choosing tablet B to say goodbye rather than to the presumed preferences of the animal patient. In the non-autonomous coma patient, participants did not mention autonomy as an influential factor, in contrast to the patient’s prospective quality of life (see above). Methodologically speaking, the obtained data support the thought experiment’s success. Participants were able and willing to distance themselves from constraints and frameworks they experience in their everyday life and to get involved in the scenario. Intentionally, the authors did not ask the participants for a personal choice if they were in the patient’s, the family’s, or advising physician’s situation but for their judgement on the best option in the case as an observer. However, the very vague wording, “Which option do you consider to be right?” left room for the participants to pick a role, either as patient, family member, or, especially in case of the human medical and veterinary professionals, as treating doctors. The spectrum of answers underlines the process some participants have gone through; first deciding on a role or perspective  treat such cases…”, “I would want that for my dog” etc.) and then on one of the four options.This was also the aspect most clearly distinguishing professional and private experiences of the three study groups, underlining the slight differences in the answering patterns. Veterinarians who regularly euthanize patients referred to that habit and corresponding justifications whereas human medical professionals, being used to palliative treatment options, elaborated on that decision in a professional, habitual way, and the control group rather fell back on examples from their private life.At the same time, despite the careful phrasing, the question might have suggested that there is, objectively, a “right” choice, leading the participants to pick and mention potential objective criteria for supporting their choices. To be more thorough, a further question in the study might have pointed out more clearly to what extent participants are convinced that there is a right answer  in this matter. A further obstacle in the free-text analysis occurred when participants kept referring to their former answers without being precise . With the randomized order of the scenarios, the analysis of those statements would have been at least very cumbersome if not speculative. Another phenomenon worth discussing is the non-completion rate of almost 40%. Even though there is no consensus in the literature on what percentage constitutes an acceptable completion rate in web surveys , the autSome participants, expecting to be exposed to a wider range of end-of-life situations, might have been “disappointed” relatively quickly. Others may have felt uneasy or even exposed when learning that their moral intuitions to treat certain patients differently or similarly might be incompatible with their ability to give moral reasons to do so in their free-text answers. It is also possible that respondents might have evaluated the described patients or situations to be not so different from one another  so that they simply lost patience. All these experiences may have led participants to discontinue the survey at some point. Of course, these possibilities are mere speculations—nonetheless it may be promising to research these hypothetical conjectures in the future.In a follow-up study, instead of asking for free-text explanation a list of factors extracted from the exploratory results discussed here could be displayed to the study participants in order to select those that most influenced their choices. Alternatively, a qualitative interview study with participants from all three groups could more thoroughly shed light on their reasoning and explanations for their decisions.This study did not present different established professional attitudes and practices regarding EOLD in veterinary and human practice. That kind of research has been done before e.g., ,28) and  and 28])This thought experiment, however, succeeded in crossing disciplinary boundaries and, thereby, shedding light on more fundamental criteria of decision-making. With the difference in species being the most obvious between the scenarios and at the same time only a minor factor when making and reasoning about their decisions, the participants impressively demonstrated that there are more fine-grained criteria for both groups of patients, despite professional habits and familiarity with legal constraints. Besides the consistently mentioned criterion “suffering” that the participants ascribed to all patients and that they made the most basic reason for their decisions, the overarching criteria “age” and “autonomy”, in the above-described sense, explained most decision-patterns with “species” being a subordinate criterion, leading to a stronger tendency to kill the patient in case of doubt. The interesting findings that do not mirror the participants’ experiences in their actual life, i.e., palliative sedation of a dog, the aggressive treatment with long-lasting side effects for an elderly dog, euthanasia or aggressive treatment of a human coma patient, present cases of some disagreement in decision-making between the groups. This points towards interesting opportunities for both, human medical and veterinary medicine, to intensify their inter-professional dialogue on convergences and divergences and, based on that, to critically analyze their ethical reasoning and decision-making processes, and, potentially, to learn from the interdisciplinary exchange, that will in turn influence public policy making.


In this paper, the author specifically paid attention to China’s social class, a rarely discussed topic in China’s society. She also tried to listen to the voices of young people and schoolteachers and help them to be heard. By presenting the insights from schoolteachers, students, as well as the materials from a nationally approved textbook, the author conducted a thematic analysis about how social class influences young people’s sexuality education experiences in secondary education in China.The discussion of sexuality education has a long history in China since the onset of modernisation in the early 20th century. Sexuality education has also existed in China’s educational system for a long time but in various forms. However, the discussions regarding students’ experiences and the influence of social stratification in China’s particular social context are still limited. From March to September 2019, the author visited an academic high school ( Up to now, in the international arena, when academic researchers and the public talked about sexuality education, the mainstream discussions have focused mostly on the successful experiences of the European and American countries, such as the UK, the USA, the Netherlands, Germany, and Denmark. This has been evident across a series of handbooks and edited volumes about experiences of sexuality education throughout the world ,2,3,4. HComprehensive sexuality education, as a kind of evidence-based sexuality education, is now widely acknowledged as being the most effective and indispensable guide to help children and youth obtain systematic knowledge about sexuality ,6. StudiWhilst comprehensive sexuality education was first introduced in China in 2001, China has been largely underrepresented in academic discussion. Regarding the implementation of sexuality education in China, some scholars indicated that there was little sexuality education from 1949 to the late 1970s due to the strict political environment at that time ; yet, evEducation inequality is a long-lasting focus in China, typically the unequal distribution of educational resources is raising particular concerns amongst researchers and the public. Educational inequalities caused by geoeconomics and geopolitics throughout the country are the most notable issues regarding the unequal distribution of resources. Therefore, in many cases and related studies, when educational inequality is discussed, the debate is usually concentrated on the outcome of “economics” and “politics” in a broad sense. Regarding the capital theory raised by Bourdieu , it becopugao) and the vocational pathway (zhigao). In Woronov’s  I always try to deliver all important things mentioned in the text book to my students, but so rarely can I find students who listen to me carefully.Kangni’s observation was reflected through students’ accounts in the vocational high school. Amongst all of my student participants at the vocational school, none of the year-three students mentioned the Mental Health module during the interviews. Only some of the year-two students described their memories and experiences of it. Therefore, it is possible to make speculations based on students’ responses—the Mental Health module did not leave a deep impression on them.Jinru is another Mental Health teacher at the vocational high school, who had a bachelor’s degree in psychology. Moreover, she had less teaching experience than Kangni. She had less than two years’ teaching experience before fieldwork took place. She also shared her experiences of teaching the Mental Health module and some general feelings with me:Most of time, I do not feel so good, because I cannot feel any sense of achievement. You know students here basically do not listen to you during the classes. When I first came to this school, I felt so disappointed. For example, when I taught, students they were just on their phones. Then my senior colleagues told me to get used to it.With such ambition and expectation, Jinru said she did not enjoy her work so much, as she did not have enough subject-specific support. This is exemplified in the following quote:I sometimes do not know how to teach. I wanted to follow the teacher’s guidance book, but they did not offer anything useful. There were only some activities from the textbook. Basically, I had to teach without any clear instructions. […] I remember there was also something about reproduction hygiene, but it was too rough. There were no instructions. How could I teach with so little support?Both Jinru and Kangni emphasised their sense of powerlessness when they taught this Mental Health module. They were particularly unmotivated by students’ reactions. Especially under some strict restrictions due to political considerations, they could not use much information outside of the selected and censored teacher’s guidance book . Even ifEchoing Jinru’s interpretation, it is also necessary to see her students’ responses. Momo was one of my student participants and was in Jinru’s Mental Health class. Like Jinru, Momo also felt that the Mental Health class was not adequate for helping her obtain sexuality education . The module’s purpose was to enable students to have the capacity to deal with potential problems in their future lives. Momo’s quote is as follows:Researcher: How did Jinru teach your Mental Health class?Momo: She was really shy. When she taught, she was smiling timidly. I could imagine how embarrassed she was.Researcher: How about your classmates’ reflection?Momo: They were laughing. They did not do anything special. Anyway, we are not going to listen carefully in any class. That was all.Dantong was Momo’s classmate in the vocational school—she was a 16-year-old young woman from a working-class family background. Dantong, similar to all other five female student participants  who were interviewed at the vocational high school, explained that she did not have any strong impressions from their Mental Health module, even though Jinru delivered the class only a few weeks ago. As mentioned above, the Mental Health module did not leave a lasting impression amongst any of the student participants at the vocational high school. Even though Dantong and Momo shared their memories about the module, it was still mostly about the surrounding circumstance, such as teacher’s and classmates’ reactions, rather than the knowledge and content.Jinru admitted how timid she was. In the meantime, Momo noticed how embarrassed Jinru was. However, no one had tried to tell each other that this module was inadequate. The lack of impression and participation amongst students, referring to Jinru’s and Kangni’s description above, exposes the complexities in the classroom. Jinru’s and these young women’s experiences represent another common situation of sexuality education through schooling. In the end, students showed their displeasure at sexuality education experiences in schools. The insufficient communication between schoolteachers and students can deepen the schoolteacher’s misunderstanding of young people’s sexuality identity, practice, and relationships.Apart from this Mental Health module, all of my participants mentioned their biology class in the second year of their middle school, when I asked them about their sexuality education experiences. Through their accounts, that was the first ever and the most impressive experience learning about sexuality within schooling. However, what they learned was more than the human reproductive system itself. Similar to the Mental Health module, it was also about people’s, especially their biology teachers’ and classmates’, reactions. Hence, taking the biology class in middle school as an example, Weihang described his experience carefully to me as the following quote shows:When I was in middle school, the biology teacher taught about humans’ reproductive system. All of my classmates were very shy, so they, including me, laughed a lot. I did not listen to my teacher carefully. It was not that engaging. The teacher was very severe.Through the similarities and differences between the biology class in compulsory middle school education and the Mental Health class in the vocational high school, people’s reactions and values regarding sexuality would play a more significant role than the knowledge in influencing young people’s experiences with sexuality education. Therefore, it is not surprising to see how sexuality education exists everywhere in young people’s lives and how institutional factors should be discussed with regard to young people’s sexuality education experiences.Learning to Labour, through an in-depth ethnographical investigation of a group of working-class young men in a secondary school in England, illustrated that youth’s values and expectations are strongly affected by their social class. Likewise, the discussion about value and expectation among youth has also been increasingly popular in Chinese academia. For example, Fong . Besides, it might also endanger their safety. What if they get pregnant or make others pregnant? How could we explain to their parents?Since the economic reforms in 1978, sexuality education has been officially promoted and non-officially advocated through various policies and laws. For instance, from the late 1990s, some universities in China launched sexuality education courses . HoweverFor further discussion about interrelationships of sexuality education, school types, and aspiration, I thus want to stress the hierarchy of China’s education system. After compulsory education, middle school graduates choose and are chosen by their high school entrance examination (HSEE) results to continue their study in the academic pathway or vocational pathway . Due to For Brine , social Mental Health [As highlighted earlier in this paper, Jinru and Kangni, my schoolteacher participants who were both Mental Health teachers at the vocational school, told me that they were teaching sexuality-related topics. These topics included gender inequality, intimacy, romantic relationships, unintended pregnancy, masturbation, sexual desire, and some other issues in the Mental Health module. Their teaching activities were based on the teaching and learning materials named l Health , which aThis revision aims to implement the spirit of the 19th National Congress of the Communist Party of China, based on the Xin Jinping Though in the Chinese Characteristic Socialism for a New Era. It serves the vocational school students’ mental health education, and helps students understand and deal with the mental health and behavioural problems they will face during their growth, studying, living, job-seeking, and working .Mental Health textbook that are designed explicitly for vocational school students:Vocational school students, in this case, have been uniquely highlighted for the potential problems they may encounter in the future. On pages 50 and 51, there are some examples from the Activity 1: DiscussionWeiwei had her surgical abortion due to the unintended pregnancy. How would she be harmed physically and psychologically? Activity 2: Water ExchangeTeachers should have prepared several glasses of coloured water in advance. You can choose one colour and exchange water with others—give a small amount of water to others, and get a small amount of water from others in different colours. Please observe the changes in water in your glass.You can have a look at the colour of water in your glass. How do you feel?Have you gained any inspirations?How would you deal with your sexual ideas and sexual desire in the future? Activity 1 concerning abortion reflects a debate regarding its advantages in recent decades worldwide. For example, researchers ,55,56 arFurthermore, Activity 2 tells students that sexual contact will make them “dirty” while using water as a metaphor for chastity, as the result of the activity is relatively straightforward because the water’s colour gets darker when water from the different glasses is mixed. On page 49, Activity 2 intends to foreground the importance of students’ chastity as is indicated earlier: “If you do value the affection, first of all, cherish your own body”, and “Cherish yourselves like the way you cherish pure water. Do not lose yourselves, and make your youth beautiful forever!” Mental Health textbook is an outcome of the institutional discrimination against vocational school students along with the stratification within China’s education system since its reformation about half a century ago. From a more institutional perspective, the school’s category becomes a field for shaping the youth sexuality education experiences.Echoing Skeggs’s  words saconstructed them to be. As explained by nearly all my schoolteacher participants, in both academic and vocational schools, vocational school students start their socialisation much earlier than their peers in the academic pathway. As such, they assumed that vocational school students would have many more opportunities to have sex, or “troubles”, than others. To some extent it is positive that the government has begun to encourage high schools to educate their students about sexuality. However, it is still highly conventional and oppressive. The widespread stereotype of seeing vocational school students as potential “trouble makers” can leave schools and students divided into different levels and deepen social stratification in education. With such discrimination and inequality, it is hardly surprising to see the arduousness of implementing sexuality education systematically in the education system.When I asked about the youth’s aspirations during interviews, vocational school students described how they belittled themselves according to what society made to be vocational school students by society. As a result, institutionally, youth sexuality education experiences can be severely influenced by their class-determined school types and differentiated aspirations.Schoolteachers and students themselves highlight the importance of academic competence, even if at the vocational school which is constructed as a field where academic performance is less crucial. Echoing the education policy in China, around half of the middle school graduates have to go to vocational schools. To some extent, vocational school students are At the beginning of this paper, I unpacked sexuality education in China’s context. Through the analysis above, it is not difficult to see that sexuality education exists in China. Most importantly, sexuality is not just something young people learn about in school. Rather, it is more like air—it exists everywhere and is a part of everyone’s life. The cultures, politics, practices, and norms that exist inside and outside young people’s classrooms have heavily influenced young people’s sexuality education experiences.In my Ph.D. research, I raise the concept of “sexuality education with Chinese characteristics” to explain the institutional barriers to implementing evidence-based sexuality education and draw upon the youth sexuality education experience from personal and institutional perspectives. This is one of the possible ways to understand why vocational school students have to experience the class-determined projection in this “class sorter” . The praHowever, the above consideration of comprehensive sexuality education and evidence-based education are far lagging in China . There iThis study is limited, in that this research was done in only two high schools in Tianjin. For future research, some more discussion about the diversity of school types could be considered. To be specific, there can be some other research projects focusing on schools in remote areas and elite international schools in China. Therefore, young people’s experiences with sexuality education could be explored in a more multi-dimensional way. Moreover, I would like to appeal to academics to pay more attention to the marginal groups such as vocational school students and teachers and their unheard voices, so that they can be seen and heard.