"It's not easy to change the mentality": Challenges to sex education delivery for persons with intellectual disability.

BACKGROUND: Sex education for people with intellectual disability is in its infancy in countries where their sexual expression is still considered a taboo. This study aimed at exploring the experiences of professionals involved in providing sex education to people with intellectual disability across a number of services in a Maltese context. METHOD: Qualitative research was conducted using interviews to explore professionals' experiences of sex education provision. RESULTS: Amid a persistent culture of sexual suppression, desexualisation, infantalization and control remain barriers to sex education delivery. Findings underline the need for services to have clear policies that aid professionals in delivering sex education, while mitigating conflicts encountered. Recommendations highlight sex positive environments and services, with a pro-active approach to sex education. CONCLUSION: In spite of internationally binding legislation and local policies, further changes need to be made on the ground to provide persons with intellectual disability with effective access to sex education.

Perceived impact and feasibility of strategies to improve access to healthy foods in Washington State, USA.

OBJECTIVE: The present study measured the perceived impact and political and implementation feasibility of state-level policy strategies related to increasing access to healthy foods and limiting unhealthy foods. DESIGN: Potential state-level policy strategies to improve access to healthy foods were identified through a review of evidence-based literature and policy recommendations. Respondents rated the perceived impact and political and implementation feasibility of each policy on a five-point scale using online surveys. SETTING: Washington State policy process. SUBJECTS: Forty-nine content experts (national researchers and subject experts), forty policy experts (state elected officials or their staff, gubernatorial or legislative policy analysts) and forty-five other stakeholders (state-level advocates, programme administrators, food producers). RESULTS: In aggregate, respondents rated policy impact and implementation feasibility higher than political feasibility. Policy experts rated policy strategies as less politically feasible compared with content experts (P < 0·02) or other stakeholders (P < 0·001). Eight policy strategies were rated above the median for impact and political and implementation feasibility. These included policies related to nutrition standards in schools and child-care facilities, food distribution systems, urban planning projects, water availability, joint use agreements and breast-feeding supports. CONCLUSIONS: Although they may be perceived as potentially impactful, some policies will be more difficult to enact than others. Information about the potential feasibility of policies to improve access to healthy foods can be used to focus limited policy process resources on strategies with the highest potential for enactment, implementation and impact.

Continuity of care in the transition from child to adult diabetes services: a realistic evaluation study.

OBJECTIVES: To identify the continuity mechanisms central to a smooth transition from child to adult diabetes care, the service components through which these can be achieved and their inter-relations in different contexts. METHODS: A realistic evaluation study of five models of transition in England comprising: organizational analysis (semi-structured interviews with 38 health care professionals and selected observations); case studies of 46 young people under-going transition and 39 carers (three qualitative interviews over a 12-18 month period, medical record review and clinical interviews); surveys of 82 (32% response rate at least once and 11% response rate at two time points) young people in the population approaching, undergoing or less than 12 months post-transition, and their carers (questionnaires included psychosocial outcome measures); and a costs and consequences analysis. RESULTS: Seven continuities contribute to smooth transition: relational, longitudinal, management, informational, flexible, developmental and cultural. Relational, longitudinal, flexible and cultural continuity are the most important. Models with high levels of relational, longitudinal, flexible and cultural continuity achieve smooth transition with relatively informal, low-cost informational and management continuity mechanisms. Models with low levels of relational and longitudinal continuity need to invest in more formal interventions to facilitate management, flexible and informational continuity so that smooth transition is not compromised. CONCLUSIONS: Focusing on continuity mechanisms, their inter-relations and the effectiveness of different constellations of service components in achieving smooth transition has furnished evidence to inform the development of innovative models which build on the logic of these findings but are sensitive to local context. Further studies are needed to confirm the quantitative findings from a broader range of services and patients.

Construction and crystal structure of recombinant STNV capsids.

A codon-optimised gene has been expressed in Escherichia coli to produce the coat protein (CP) of the Satellite Tobacco Necrosis Virus. This protein assembles in vivo into capsids closely resembling those of the T=1 wild-type virus. These virus-like particles (VLPs) package the recombinant mRNA transcript and can be disassembled and reassembled using different buffer conditions. The X-ray crystal structure of the VLP has been solved and refined at 1.4 Å resolution and shown to be very similar to that of wild-type Satellite Tobacco Necrosis Virus, except that icosahedral symmetry constraints could be removed to reveal differences between subunits, presumably owing to crystal packing. An additional low-resolution X-ray crystal structure determination revealed well-ordered RNA fragments lodged near the inside surface of the capsid, close to basic clusters formed by the N-terminal helices that project into the interior of the particle. The RNA consists of multiple copies of a 3-bp helical stem, with a single unpaired base at the 3' end, and probably consists of a number of short stem-loops where the loop region is disordered. The arrangement of the RNA is different from that observed in other satellite viruses.

Degenerate RNA packaging signals in the genome of Satellite Tobacco Necrosis Virus: implications for the assembly of a T=1 capsid.

Using a recombinant, T=1 Satellite Tobacco Necrosis Virus (STNV)-like particle expressed in Escherichia coli, we have established conditions for in vitro disassembly and reassembly of the viral capsid. In vivo assembly is dependent on the presence of the coat protein (CP) N-terminal region, and in vitro assembly requires RNA. Using immobilised CP monomers under reassembly conditions with "free" CP subunits, we have prepared a range of partially assembled CP species for RNA aptamer selection. SELEX directed against the RNA-binding face of the STNV CP resulted in the isolation of several clones, one of which (B3) matches the STNV-1 genome in 16 out of 25 nucleotide positions, including across a statistically significant 10/10 stretch. This 10-base region folds into a stem-loop displaying the motif ACAA and has been shown to bind to STNV CP. Analysis of the other aptamer sequences reveals that the majority can be folded into stem-loops displaying versions of this motif. Using a sequence and secondary structure search motif to analyse the genomic sequence of STNV-1, we identified 30 stem-loops displaying the sequence motif AxxA. The implication is that there are many stem-loops in the genome carrying essential recognition features for binding STNV CP. Secondary structure predictions of the genomic RNA using Mfold showed that only 8 out of 30 of these stem-loops would be formed in the lowest-energy structure. These results are consistent with an assembly mechanism based on kinetically driven folding of the RNA.

Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change counselling (PRE-EMPT): protocol for a general practice-based cluster randomised trial.

BACKGROUND: Smoking, excessive alcohol consumption, lack of exercise and an unhealthy diet are the key modifiable factors contributing to premature morbidity and mortality in the developed world. Brief interventions in health care consultations can be effective in changing single health behaviours. General Practice holds considerable potential for primary prevention through modifying patients' multiple risk behaviours, but feasible, acceptable and effective interventions are poorly developed, and uptake by practitioners is low. Through a process of theoretical development, modeling and exploratory trials, we have developed an intervention called Behaviour Change Counselling (BCC) derived from Motivational Interviewing (MI). This paper describes the protocol for an evaluation of a training intervention (the Talking Lifestyles Programme) which will enable practitioners to routinely use BCC during consultations for the above four risk behaviours. METHODS/DESIGN: This cluster randomised controlled efficacy trial (RCT) will evaluate the outcomes and costs of this training intervention for General Practitioners (GPs) and nurses. Training methods will include: a practice-based seminar, online self-directed learning, and reflecting on video recorded and simulated consultations. The intervention will be evaluated in 29 practices in Wales, UK; two clinicians will take part (one GP and one nurse) from each practice. In intervention practices both clinicians will receive training. The aim is to recruit 2000 patients into the study with an expected 30% drop out. The primary outcome will be the proportion of patients making changes in one or more of the four behaviours at three months. Results will be compared for patients seeing clinicians trained in BCC with patients seeing non-BCC trained clinicians. Economic and process evaluations will also be conducted. DISCUSSION: Opportunistic engagement by health professionals potentially represents a cost effective medical intervention. This study integrates an existing, innovative intervention method with an innovative training model to enable clinicians to routinely use BCC, providing them with new tools to encourage and support people to make healthier choices. This trial will evaluate effectiveness in primary care and determine costs of the intervention.

Training in motivational interviewing: a systematic review.

Motivational interviewing (MI), an evidence-based counseling approach, has received much recognition from a wide variety of health care professionals. Because of the rising interest in MI, there is increasing demand for training in this counseling approach. The MI training community has answered this call and as a result placed much emphasis on studying the MI training process. The purpose of this article is to provide a systematic review of the published research on MI training. Our goal is to provide a consolidated account of MI trainings outlining the populations receiving training, methods used, and training outcomes. We also identify which aspects of the (W. R. Miller & T. B. Moyers, 2006) eight stages of learning MI each study addressed. Recommendations for advancing the MI training research are highlighted.

Teaching motivational interviewing: using role play is as effective as using simulated patients.

CONTEXT: Although several studies of motivational interviewing (MI) as an intervention have been conducted, there has been little research into how best to teach MI. Practice and rehearsal is often beneficial in helping practitioners to acquire communication skills, but there have been few studies into what types of practice and rehearsal are most effective. METHODS: Health care professionals (who attended a 2-day workshop in MI) were randomly assigned to conduct skills practice sessions with either a simulated patient (SP) or a fellow trainee. Their competence was assessed before and after training using the Behaviour Change Counselling Index, a validated rating scale. Participants also scored each practice session in terms of their affect and its perceived applicability to everyday clinical work. RESULTS: There was no significant difference in skill levels between groups following training and no significant difference between groups in their scoring of the affect and applicability of each practice session. There was little indication of an association between how participants felt about their practice sessions and their skill levels. CONCLUSIONS: Trainees reached the same level of competence in MI following a 2-day workshop, regardless of whether they practised with an SP or a fellow trainee during training.

Effect of training on primary care residents' performance in brief alcohol intervention: a randomized controlled trial.

BACKGROUND: Brief alcohol interventions (BAI) reduce alcohol use and related problems in primary care patients with hazardous drinking behavior. The effectiveness of teaching BAI on the performance of primary care residents has not been fully evaluated. METHODS: A cluster randomized controlled trial was conducted with 26 primary care residents who were randomized to either an 8-hour, interactive BAI training workshop (intervention) or a lipid management workshop (control). During the 6-month period after training (i.e., from October 1, 2003 to March 30, 2004), 506 hazardous drinkers were identified in primary care, 260 of whom were included in the study. Patients were interviewed immediately and then 3 months after meeting with each resident to evaluate their perceptions of the BAI experience and to document drinking patterns. RESULTS: Patients reported that BAI trained residents: conducted more components of BAI than did controls (2.4 vs 1.5, p = .001); were more likely to explain safe drinking limits (27% vs 10%, p = .001) and provide feedback on patients' alcohol use (33% vs 21%, p = .03); and more often sought patient opinions on drinking limits (19% vs 6%, p = .02). No between-group differences were observed in patient drinking patterns or in use of 9 of the 12 BAI components. CONCLUSIONS: The BAI-trained residents did not put a majority of BAI components into practice, thus it is difficult to evaluate the influence of BAI on the reduction of alcohol use among hazardous drinkers.

The use of simulated patients and role-play in communication skills training: a review of the literature to August 2005.

OBJECTIVE: To assess whether the practice and rehearsal of communication skills is likely to lead to better outcomes following training, and whether the use of simulated patients in training is likely to be superior to role-play in terms of communication skill acquisition. METHODS: The databases Medline, Amed, Cinahl, BNI, Embase, Psychinfo and HMIC were searched for articles which compared the use of simulated patients and/or role-play in training healthcare practitioners in acquiring communication skills. RESULTS: Most studies appear to indicate that outcomes are better in communication skills training programs where skills practice has taken place. However, a number of methodological weaknesses make concrete conclusions difficult to draw. There was just one study that directly compared the use of role-play with simulated patients. This found no significant difference in outcomes between the two methods. CONCLUSION: There is a need for more well-designed studies that assess skill acquisition following the use of simulated patients and/or role-play in a number of different settings. PRACTICE IMPLICATIONS: Simulated patients and role-play are frequently used in teaching communication skills worldwide. Given the expense of using simulated patients, educators should be made aware of cheaper alternatives that may be equally effective in facilitating the acquisition of communication skills.

When smokers are resistant to change: experimental analysis of the effect of patient resistance on practitioner behaviour.

AIMS: In the field of motivational interviewing, practitioner confrontational behaviour has been associated with lower levels of patient behaviour change. We set out to explore whether resistance to change among smokers affects practitioner confrontational and other behaviours. DESIGN: Experimental manipulation of levels of patient resistance in a role play. SETTING: The study was conducted at the start of a 2-day health behaviour change workshop. PARTICIPANTS: Thirty-two practitioners who had registered for the workshop. INTERVENTION: The practitioners were assigned randomly to interview a standardized patient (actor) who portrayed a smoker who had been briefed to display either high or low levels of resistance to change. MEASUREMENTS: Interviews were audiotaped and transcribed. Practitioners and standardized patients completed interview ratings at the end of each interview. After listening to each taped interview practitioners were assigned a global score for confrontation, empathy and expert instructional style. Interviews were then submitted to a qualitative analysis. FINDINGS: Higher levels of practitioner confrontational behaviour were observed in the high resistance group. This was evident both from the global scores (median 2 versus 0, P = 0.001) and the qualitative analysis. Global scores for empathy and expert instruction were not significantly different. Qualitative analysis also suggests a pervasive negative impact on other practitioner behaviours. CONCLUSIONS: Higher patient resistance probably leads to an increase in confrontational and other negative behaviours in health professionals attempting to promote behaviour change. This challenges important assumptions about the influence of practitioner behaviour on patient behaviour and subsequent health-related outcomes.

Measuring adaptations of motivational interviewing: the development and validation of the behavior change counseling index (BECCI).

One of the most common challenges faced by health professionals is encouraging patients to change their behavior to improve their health. This paper reports the development of a checklist, the behavior change counseling index (BECCI). This aims to measure practitioner competence in behavior change counseling (BCC), an adaptation of motivational interviewing suitable for brief consultations in healthcare settings. The checklist has demonstrated acceptable levels of validity, reliability and responsiveness, and aims to assist trainers and researchers in assessing change in practitioner behavior before, during and after training in BCC. BECCI will also provide valuable information about the standard of BCC that practitioners were trained to deliver in studies of BCC as an intervention.