Interpretation of ambiguous pronouns in adults with intellectual disabilities.

BACKGROUND: Pronouns are referentially ambiguous (e.g. she could refer to any female), yet they are common in everyday conversations. Individuals with typical development (TD) employ several strategies to avoid pronoun interpretation errors, including the subject bias - an assumption that a pronoun typically refers to the subject (or, with the closely related order-of-mention bias, the first-mentioned character) of the previous sentence. However, it is unknown if adults with intellectual disability (ID) share this strategy or the extent to which the subject bias is associated with non-verbal abilities or receptive vocabulary. METHODS: We tested 22 adults with mixed-aetiology ID on their interpretation of ambiguous pronouns using the visual world eye-tracking paradigm and by asking a follow-up pronoun interpretation question. A group of TD adults was also tested to establish the strength of the subject bias with our materials and task. RESULTS: Adults with ID did demonstrate the subject bias, but it was significantly less robust than that seen in TD. For participants with ID, the subject bias was influenced by non-verbal IQ and receptive vocabulary at different stages of processing. CONCLUSIONS: Given the frequency of pronouns in conversation, strengthening the subject bias may help alleviate discourse and reading comprehension challenges for individuals with ID, particularly those with lower non-verbal and/or vocabulary skills.

Culturally appropriate health education for Type 2 diabetes in ethnic minority groups: an updated Cochrane Review of randomized controlled trials.

AIMS: To give an updated perspective of interventions from additional data collected since our first review, conducted in 2008. BACKGROUND: This updated Cochrane Review incorporates new information from recent randomized controlled trials on culturally appropriate diabetes health education interventions. METHODS: An electronic literature search of six databases was repeated, with databases of ongoing trials checked and three journals hand-searched. Meta-analysis was carried out for sufficiently homogeneous outcomes, and common themes among trials were highlighted. RESULTS: A total of 22 new trials were added to the original 11. Meta-analysis of 28 trials containing suitable data showed significant improvements in glycaemic control (HbA1c ) and diabetes knowledge over a period of 24 months, after the delivery of culturally appropriate education to participants, compared with those receiving 'conventional' care. There were no consistent benefits over the control group in other selected outcome measures, and lack of data continued to make analysis of several outcome measures difficult. CONCLUSIONS: Research activity in this field has increased considerably over the past 6 years, with culturally appropriate diabetes education showing consistent benefits over conventional care in terms of glycaemic control and diabetes knowledge, sustained in the short- to mid-term. Further research is needed to determine the clinical significance of these improvements and their cost-effectiveness.

Realist review to understand the efficacy of culturally appropriate diabetes education programmes.

AIMS: Minority populations often face linguistic, cultural and financial barriers to diabetes education and care. The aim was to understand why culturally appropriate diabetes education interventions work, when they work best and for whom they are most effective. METHODS: This review used a critical realist approach to examine culturally appropriate diabetes interventions. Beginning with the behavioural model and access to medical care, it reanalysed 11 randomized controlled trials from a Cochrane systematic review and related programme and training documents on culturally appropriate diabetes interventions. The analysis examined context and mechanism to understand their relationship to participant retention and statistically improved outcomes. RESULTS: Minority patients with language barriers and limited access to diabetes programmes responded to interventions using health workers from the same ethnic group and interventions promoting culturally acceptable and financially affordable food choices using local ingredients. Programme incentives improved retention in the programmes and this was associated with improved HbA(1c) levels at least in the short term. Adopting a positive learning environment, a flexible and less intensive approach, one-to-one teaching in informal settings compared with a group approach in clinics led to improved retention rates. CONCLUSIONS: Minority and uninsured migrants with unmet health needs showed the highest participation and HbA(1c) responses from culturally appropriate programmes.

Development and evaluation by a cluster randomised trial of a psychosocial intervention in children and teenagers experiencing diabetes: the DEPICTED study.

OBJECTIVE: To develop and evaluate a health-care communication training programme to help diabetes health-care professionals (HCPs) counsel their patients more skilfully, particularly in relation to behaviour change. DESIGN: The HCP training was assessed using a pragmatic, cluster randomised controlled trial. The primary and secondary analyses were intention-to-treat comparisons of outcomes using multilevel modelling to allow for cluster (service) and individual effects, and involved two-level linear models. SETTING: Twenty-six UK paediatric diabetes services. PARTICIPANTS: The training was delivered to HCPs (doctors, nurses, dietitians and psychologists) working in paediatric diabetes services and the effectiveness of this training was measured in 693 children aged 4-15 years and families after 1 year (95.3% follow-up). INTERVENTIONS: A blended learning programme was informed by a systematic review of the literature, telephone and questionnaire surveys of professional practice, focus groups with children and parents, experimental consultations and three developmental workshops involving a stakeholder group. The programme focused on agenda-setting, flexible styles of communication (particularly guiding) and a menu of strategies using web-based training and practical workshops. MAIN OUTCOME MEASURES: The primary trial outcome was a change in glycosylated haemoglobin (HbA1c) levels between the start and finish of a 12-month study period. Secondary trial outcomes included change in quality of life, other clinical [including body mass index (BMI)] and psychosocial measures (assessed at participant level as listed above) and cost (assessed at service level). In addition, patient details (HbA1c levels, height, weight, BMI, insulin regimen), health service contacts and patient-borne costs were recorded at each clinic visit, along with details of who patients consulted with, for how long, and whether or not patients consulted on their own at each visit. Patients and carers were also asked to complete an interim questionnaire assessing patient enablement (or feelings towards clinic visit for younger patients aged 7-10 years) at their first clinic visit following the start of the trial. The cost of the intervention included the cost of training intervention teams. RESULTS: Trained staff showed better skills than control subjects in agenda-setting and consultation strategies, which waned from 4 to 12 months. There was no effect on HbA1c levels (p = 0.5). Patients in intervention clinics experienced a loss of confidence in their ability to manage diabetes, whereas controls showed surprisingly reduced barriers (p = 0.03) and improved adherence (p = 0.05). Patients in intervention clinics reported short-term increased ability (p = 0.04) to cope with diabetes. Parents in the intervention arm experienced greater excitement (p = 0.03) about clinic visits and improved continuity of care (p = 0.01) without the adverse effects seen in their offspring. The mean cost of training was £13,145 per site or £2163 per trainee. There was no significant difference in total NHS costs (including training) between groups (p = 0.1). CONCLUSIONS: Diabetes HCPs can be trained to improve consultation skills, but these skills need reinforcing. Over 1 year, no benefits were seen in children, unlike parents, who may be better placed to support their offspring. Further modification of this training is required to improve outcomes that may need to be measured over a longer time to see effects. TRIAL REGISTRATION: Current Controlled Trials ISRCTN61568050. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 15, No. 29. See the HTA programme website for further project information.

The experiences of children and their parents in paediatric diabetes services should inform the development of communication skills for healthcare staff (the DEPICTED Study).

AIMS: The aims of this study were to describe users' experience of paediatric diabetes services to inform development of an intervention to improve communication between staff and patients in secondary care within a wider study (the DEPICTED Study). METHODS: Methods adapted for paediatric settings were used to set up six audio-recorded focus discussion groups with a total of 32 participants. Transcriptions and notes were coded thematically (supported by NVivo software) and analytic themes developed with discussion between researchers. RESULTS: Three main themes developed: the lack of two-way conversation about glycaemic control in clinic settings; the restricting experience of living with diabetes; and the difficult interactions around diabetes the children had with their schools. Doctors in particular were seen as struggling to link these themes of everyday life in their consultations with children and their parents. Children felt marginalized in clinics, despite active involvement in their own blood glucose management at home. CONCLUSIONS: Health professionals need to balance a requirement for good glycaemic control with realism and appreciation of their patients' efforts. There is a need for a systematic approach to consulting, in particular using agenda setting to ensure that the issues of both the patient and the professional are addressed. A framework for a conceptual approach is discussed. How a patient is involved is as important as what is communicated during a consultation.

Culturally appropriate health education for Type 2 diabetes in ethnic minority groups: a systematic and narrative review of randomized controlled trials.

To determine if culturally appropriate health education is more effective than 'usual' health education for people with diabetes from ethnic minority groups living in high- and upper-middle-income countries. A systematic review with meta-analysis, following the methodology of the Cochrane Collaboration. Electronic literature searches of nine databases were made, with hand searching of three journals and 16 author contacts. The criteria for inclusion into the analysis were randomized controlled trials of a specified diabetes health education intervention, and a named ethnic minority group with Type 2 diabetes. Data were collected on HbA(1c), blood pressure, and quality-of-life measures. A narrative review was also performed. Few studies fitted the selection criteria, and were heterogeneous in methodologies and outcome measures, making meta-analysis difficult. HbA(1c) showed an improvement at 3 months [weighted mean difference (WMD) -0.32%, 95% confidence interval (CI) -0.63, -0.01] and 6 months post intervention (WMD -0.60%, 95% CI -0.85, -0.35). Knowledge scores also improved in the intervention groups at 6 months (standardized mean difference 0.46, 95% CI 0.27, 0.65). There was only one longer-term follow-up study, and one formal cost-effectiveness analysis. Culturally appropriate health education was more effective than 'usual' health education in improving HbA(1c) and knowledge in the short to medium term. Due to poor standardization between studies, the data did not allow determination of the key elements of interventions across countries, ethnic groups and health systems, or a broad view of their cost-effectiveness. The narrative review identifies learning points to direct future research.

"Sharing the impact of the disease": a workshop on suffering for medical students.

OBJECTIVES: : To investigate the attitudes of early clinical students to the concept of suffering and the work of Eric Cassell. DESIGN: : Qualitative case study using group interviews and questionnaires. SETTING: : A United Kingdom medical school. PARTICIPANTS: : Two whole-year cohorts of third-year medical students (n = 557). INTERVENTIONS: : Group interviews involving 57 randomly selected students, with exploration of emergent themes using free text and Lickert scale questionnaires. RESULTS: : Students engaged readily with the concept of suffering and were able to identify a patient they had encountered who was suffering. Barriers to student involvement with suffering were identified. Students saw engaging with patient suffering as a clinical skill. Many students saw the ideas of Eric Cassell as plausible, although few were convinced that relief of suffering should be the central goal of medicine. CONCLUSIONS: : The work of Eric Cassell formed the basis of a teaching intervention with medical students who identified engaging with suffering as a clinical skill.

Current issues in nutritional management of very low birth weight infants.

Infants less than 1,500 g birth weight (very low birth weight, VLBW) are at risk for significant nutritional deficiencies. Enhancing nutritional care of these infants during their first months of life may have important short and long-term benefits. In this article we will consider several areas of recent research in the nutritional management of VLBW infants. In particular we will focus on issues related to the introduction and use of enteral nutrition. These issues include avoiding mineral deficiencies, early (minimal) enteral nutrition, human milk fortification, and postdischarge nutrition. Transitioning VLBW infants successfully to enteral nutrition is a key to their achieving adequate growth and development without the long-term risks related to parenteral nutrition. Human milk is a key component of any strategy for enteral nutrition of all infants. Its introduction in the first days of life leads to improved growth and better health outcomes for infants. However, although some nutrients are initially increased in the milk of mothers delivering prematurely, there are inadequate amounts of calcium, phosphorus, zinc and other nutrients to meet the needs of the VLBW infant during growth. Therefore, safe and effective means of fortifying human milk are essential to the care of VLBW infants. The optimal approaches for this fortification and the potential risks related to human milk fortification remain controversial. Limited data are available for the optimal content, initiation and methods for mixing fortifier with human milk.

Effect of culturally appropriate health education on glycaemic control and knowledge of diabetes in British Pakistani women with type 2 diabetes mellitus.

Type 2 diabetes is a growing problem in people of South Asian origin. It is associated with severe complications if it is not adequately controlled. This paper is a secondary assessment of 105 British Pakistani women within a larger randomized controlled trial of 200 Pakistani patients with diabetes. The trial used one-to-one structured diabetes health education, delivered by a linkworker with pictorial flashcards as a visual aid. Earlier published results from this study have shown that the women in the study knew less about diabetes and had poorer glycaemic control than men, which is why this assessment was performed to see what happened to them when they received appropriate health education. All patients were assessed before and 6 months after intervention by questionnaire and haemoglobin A1c blood tests to measure their overall blood sugar control. Nearly everyone improved their knowledge scores after 6 months in the intervention group, with women showing a catch-up improvement such that they equalled men. Multiple regression analysis found that glycaemic control improved in women receiving health education. Although this method of health education improved knowledge and glycaemic control in women in this sample, illiterate women did not do as well as their literate peers, continuing to score less on knowledge parameters. They also did not show an improvement in glycaemic control. Further work is needed to discover methods that will reach this sizeable subsection of the community.

Pakistani moslems with Type 2 diabetes mellitus: effect of sex, literacy skills, known diabetic complications and place of care on diabetic knowledge, reported self-monitoring management and glycaemic control.

AIMS: To study factors such as sex, educational status and place of care, which might influence knowledge and self-management of diabetes, and glycaemic control in a Pakistani moslem diabetic population attending primary care general practices (GP) and secondary care clinics at the Manchester Diabetes Centre (MDC). METHODS: Patients with Type 2 diabetes mellitus took part in a one-to-one semi-structured interview and gave blood for haemoglobin A1c levels. RESULTS: Two hundred and one patients entered the study. Knowledge about diabetic diets was good (average scores 72%), and patients claimed to perform regular glucose measurements (66%), but they were not good at applying their knowledge to problems in daily life. Only 24% knew how to manage persistent hyperglycaemia. Women were worse than men at this (19 vs. 31% (chi2 = 3.8, P = 0.05)), were less likely to understand why glucose levels should be monitored, and had poorer glycaemic control overall (HbA1c 8.8 vs. 8.1%, P = 0.04). Fifty-four patients were completely illiterate. They had similar knowledge scores to readers but were less able to handle problem scenarios. Forty-five of these patients were women, and multiple regression analysis showed they were more likely to have the poorest glycaemic control. No major differences were found between general practitioner and hospital attenders, or between patients with and without known complications, except that hospital attenders were more likely to have complications and poorer control. CONCLUSIONS: Women who cannot read in this population are likely to have poorer glycaemic control and may be finding it more difficult to learn how to apply their knowledge to daily life. This subgroup may need more intensive, culturally appropriate, health education and support.

One-to-one teaching with pictures--flashcard health education for British Asians with diabetes.

BACKGROUND: Type 2 diabetes is up to four times more common in British Asians, but they know little about its management and complications. AIM: To design and evaluate a structured pictorial teaching programme for Pakistani Moslem patients in Manchester with type 2 diabetes. METHOD: A randomized controlled trial of pictorial flashcard one-to-one education in 201 patients attending a hospital outpatient clinic or diabetic clinics in ten general practices in Manchester. Patients' knowledge, self-caring skills and attitudes to diabetes were measured on four topics before the structured teaching, and compared with results six months later. RESULTS: All parameters of knowledge were increased in the study group; for example, percentage scores for correctly identifying different food values increased from 57% to 71% (Analysis of Variance (ANOVA) adjusted difference +11.8%) and knowledge of one diabetic complication from 18% to 78%. Self-caring behaviour improved, with 92% of patients doing regular glucose tests at six months compared with 63% at the start. Attitudinal views were more resistant to change, with patients still finding it hard to choose suitable foods at social occasions. Haemoglobin A1c control improved by 0.34% over six months (ANOVA adjusted difference, 95% CI -0.8% to +0.1%). CONCLUSION: It is concluded that this health education programme can empower Asian diabetics to take control of their diets, learn to monitor and interpret glucose results, and understand the implications of poor glycaemic control for diabetic complications.