Developing accessible speech technology with users with dysarthric speech.

The Voiceitt app is designed for people with dysarthric speech, to support vocal communication and access to voice-driven technologies. Sixty-six participants were recruited to test the Voiceitt app and share feedback with developers. Most had physical, sensory, or cognitive impairments in addition to atypical speech. The project team liaised with individuals, their families and local support teams to provide access to the app and associated equipment. Testing was user-led, with participants asked to identify and test use cases most relevant to their daily lives over three months or more. Ongoing technical support and training were provided remotely and in-person throughout their testing. Semi-structured interviews were used to collect feedback on users' experiences, with delivery adapted to individuals' needs and preferences. Informal feedback was collected through ongoing contact between participants, their families and support teams and the project team. User feedback has led to improvements to the user interface and functionality, including faster voice training, simplified navigation, the introduction of game-style features and of switch access as an alternative to touchscreen access. This work offers a case-study in meaningful engagement with diverse disabled users of assistive technology in commercial software development.

'Finishing the race' - a cohort study of weight and blood glucose change among the first 36,000 patients in a large-scale diabetes prevention programme.

BACKGROUND: The NHS Diabetes Prevention Programme for England, "Healthier You", encourages behaviour change regarding healthy eating and physical exercise among people identified to be at high risk of developing type 2 diabetes. The aim of this research was to examine change, and factors associated with change, in measures of HbA1c and weight in participants and completers of the programme between 2016 and 2019. METHODS: Participant-level data collected by programme service providers on referrals prior to March 2018 was analysed. Changes from baseline to both 6 months and completion in HbA1c and weight were examined using mixed effects linear regression, adjusting for patient characteristics, service provider and site. RESULTS: Completers had average improvements in HbA1c of 2.1 mmol/mol [95% CI: - 2.2, - 2.0] (0.19% [95% CI: - 0.20, - 0.18]) and reductions of 3.6 kg [95% CI: - 3.6, - 3.5] in weight, in absolute terms. Variation across the four providers was observed at both time points: two providers had significantly smaller average reductions in HbA1c and one provider had a significantly smaller average reduction in weight compared to the other providers. At both time points, ex- or current smokers had smaller reductions in HbA1c than non-smokers and those from minority ethnic groups lost less weight than White participants. For both outcomes, associations with other factors were small or null and variation across sites remained after adjustment for provider and case mix. CONCLUSIONS: Participants who completed the programme, on average, experienced improvements in weight and HbA1c. There was substantial variation in HbA1c change and smaller variation in weight loss between providers and across different sites. Aside from an association between HbA1c change and smoking, and between weight loss and ethnicity, results were broadly similar regardless of patient characteristics.

How effective are social norms interventions in changing the clinical behaviours of healthcare workers? A systematic review and meta-analysis.

BACKGROUND: Healthcare workers perform clinical behaviours which impact on patient diagnoses, care, treatment and recovery. Some methods of supporting healthcare workers in changing their behaviour make use of social norms by exposing healthcare workers to the beliefs, values, attitudes or behaviours of a reference group or person. This review aimed to evaluate evidence on (i) the effect of social norms interventions on healthcare worker clinical behaviour change and (ii) the contexts, modes of delivery and behaviour change techniques (BCTs) associated with effectiveness. METHODS: Systematic review and meta-analysis of randomised controlled trials. Searches were undertaken in seven databases. The primary outcome was compliance with a desired healthcare worker clinical behaviour and the secondary outcome was patient health outcomes. Outcomes were converted into standardised mean differences (SMDs). We performed meta-analyses and presented forest plots, stratified by five social norms BCTs (social comparison, credible source, social reward, social incentive and information about others' approval). Sources of variation in social norms BCTs, context and mode of delivery were explored using forest plots, meta-regression and network meta-analysis. RESULTS: Combined data from 116 trials suggested that social norms interventions were associated with an improvement in healthcare worker clinical behaviour outcomes of 0.08 SMDs (95%CI 0.07 to 0.10) (n = 100 comparisons), and an improvement in patient health outcomes of 0.17 SMDs (95%CI 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I2 of 85.4% (healthcare worker clinical behaviour) and 91.5% (patient health outcomes). Credible source was more effective on average, compared to control conditions (SMD 0.30, 95%CI 0.13 to 0.47, n = 7). Social comparison also appeared effective, both on its own (SMD 0.05, 95%CI 0.03 to 0.08, n = 33) and with other BCTs, and seemed particularly effective when combined with prompts/cues (0.33, 95%CI 0.22 to 0.44, n = 5). CONCLUSIONS: Social norms interventions appeared to be an effective method of changing the clinical behaviour of healthcare workers and have a positive effect on patient health outcomes in a variety of health service contexts. Although the overall result is modest and variable, there is the potential for social norms interventions to be applied at large scale. TRIAL REGISTRATION: PROSPERO CRD42016045718 .

'Going the distance': an independent cohort study of engagement and dropout among the first 100 000 referrals into a large-scale diabetes prevention program.

INTRODUCTION: Diabetes prevention programs (DPPs) are effective, in a pre-diabetic population, in reducing weight, lowering glycated hemoglobin and slowing the progression to diabetes. Little is known about the relationship between participation in DPPsand participant characteristics or service delivery. We investigated uptake and retention in England's NHS DPP, reporting on variability among patient subgroups, providers, and sites. RESEARCH DESIGN AND METHODS: This prospective cohort study included 99 473 adults with non-diabetic hyperglycemia referred to the English DPP between 2016 and 2017. The program seeks to change health behaviors by offering at least 16 hours of group education and exercise. Multilevel logistic regression models were used to analyze variation in uptake, retention, and completion. RESULTS: Uptake among 99 473 adults referred to the program was 56% (55 275). Among 55 275 who started the program, 34% (18 562) achieved the required dose and 22% (12 127) completed the full course. After adjustment for variation in case mix, substantial heterogeneity in uptake and retention was seen across four service providers (uptake OR 1.77 (1.33, 2.34), 4.30 (3.01, 6.15), and 1.45 (1.07, 1.97) compared with the reference provider) and between sites (uptake for typical individuals ranged from 0.32 to 0.78 across the middle 95% of sites, intraclass correlation coefficient (ICC) 0.07). Higher levels of retention and completion were seen where some out-of-hours provision was offered (retention OR 1.32 (1.25, 1.39)). CONCLUSIONS: This study provides the first independent assessment of participation in the English DPP and the first study internationally to examine the impact of DPP service delivery on participation. When implementing a large-scale DPP, heterogeneity in service provision between different providers and sites can result in variable participation beyond that attributable to case mix, with potential consequences for effectiveness and health inequalities. Extending out-of-hours provision may improve participation in prevention programs.

Epidemiology and determinants of non-diabetic hyperglycaemia and its conversion to type 2 diabetes mellitus, 2000-2015: cohort population study using UK electronic health records.

OBJECTIVES: To study the characteristics of UK individuals identified with non-diabetic hyperglycaemia (NDH) and their conversion rates to type 2 diabetes mellitus (T2DM) from 2000 to 2015, using the Clinical Practice Research Datalink. DESIGN: Cohort study. SETTINGS: UK primary Care Practices. PARTICIPANTS: Electronic health records identified 14 272 participants with NDH, from 2000 to 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Baseline characteristics and conversion trends from NDH to T2DM were explored. Cox proportional hazards models evaluated predictors of conversion. RESULTS: Crude conversion was 4% within 6 months of NDH diagnosis, 7% annually, 13% within 2 years, 17% within 3 years and 23% within 5 years. However, 1-year conversion fell from 8% in 2000 to 4% in 2014. Individuals aged 45-54 were at the highest risk of developing T2DM (HR 1.20, 95% CI 1.15 to 1.25- compared with those aged 18-44), and the risk reduced with older age. A body mass index (BMI) above 30 kg/m2 was strongly associated with conversion (HR 2.02, 95% CI 1.92 to 2.13-compared with those with a normal BMI). Depression (HR 1.10, 95% CI 1.07 to 1.13), smoking (HR 1.07, 95% CI 1.03 to 1.11-compared with non-smokers) or residing in the most deprived areas (HR 1.17, 95% CI 1.11 to 1.24-compared with residents of the most affluent areas) was modestly associated with conversion. CONCLUSION: Although the rate of conversion from NDH to T2DM fell between 2010 and 2015, this is likely due to changes over time in the cut-off points for defining NDH, and more people of lower diabetes risk being diagnosed with NDH over time. People aged 45-54, smokers, depressed, with high BMI and more deprived are at increased risk of conversion to T2DM.

The impact of changing provider remuneration on clinical activity and quality of care: Evaluation of a pilot NHS contract in Northern Ireland.

OBJECTIVES: A pilot NHS dental contract was introduced in Northern Ireland between 2015 and 2016, which involved changing the method for paying general dental practitioners working in the NHS from fee-for-service (FFS) to capitation-based payments, providing an opportunity for a robust evaluation. We investigated the impact of a change in payment methods on clinical activity and the quality of care provided. DESIGN: A difference-in-difference (DiD) evaluation was applied to clinical activity data from pilot NHS dental practices in Northern Ireland compared to matched control NHS practices and applied to a questionnaire survey of patient-rated outcomes of health outcomes and care quality. We estimated the impact on access to care, treatment activity levels, practice finances and patient-rated outcomes of care of a change from FFS to a capitation-based system for 1 year, as well as the impact of a reversion back to FFS at the end of the pilot period. RESULTS: The monthly number of registered patients in the pilot practices increased more than the control practices during the capitation period, by 1.5 registrations per 1000 registered patients. The monthly reductions in the volumes of all treatments in the pilot practices during the capitation period were much larger than the control practices, with 175 fewer treatment items. All measures rapidly returned to baseline levels following reversion from capitation back to FFS. NHS income per month increased in pilot practices, by £5920 per month (calculated on FFS item cost basis) more than controls in the capitation period. The analysis of patient questionnaires suggest found that patients notice differences only in waiting times, skill-mix and number of radiographs, but not on other measures of healthcare process and quality. CONCLUSION: General dental practitioners working in the NHS respond rapidly and consistently to changes in provider payment methods. A move from FFS to a capitation-based system had little impact on access to care, but did produce large reductions in clinical activity and patient charge income. Patients noticed little change in the service they received. This shows that changes in remuneration contracts have the potential to meet policy goals, such as meeting the expectations of patients within a predictable cost envelope. However, it is unlikely that all policy goals can be met simply by changing payment methods. Therefore, work is also needed to identify and evaluate interventions that can complement changes in remuneration to achieve desirable outcomes.

The Feasibility and Effectiveness of PASS Plus, A Lay Health Worker Delivered Comprehensive Intervention for Autism Spectrum Disorders: Pilot RCT in a Rural Low and Middle Income Country Setting.

The treatment gap for autism globally is high. Our previous PASS intervention, delivered by community based lay health workers, showed effectiveness. This article reports the development and evaluation of a new "PASS 'Plus'" intervention in a rural population in India. Using formative research methods, we supplemented the PASS intervention with additional (Plus) modules to address autism comorbidities. This is the first time that a rigorous methodology has been used to evaluate autism symptom outcomes in a low and middle-income country setting. 40 parent-child dyads were recruited in a pilot randomized controlled trial against usual care (mean age 65 months (34 boys); n = 19 PASS Plus, n = 21 UC). 89% of intervention families partially or entirely completed the 12-session intervention. Intention to treat analysis showed a reduction in mean scores of autism symptom severity, though the confidence interval contains zero, (adjusted mean difference AMD -2.42 95% CI -7.75, 2.92; ES 0.22); large treatment effects on proximal outcomes of proportion of parent synchronous responses (AMD 0.35; 95% CI 0.18, 0.52; effect size ES 3.97) and proportion of child communication initiations with parent (AMD 0·17; 95% CI 0.03, 0.32; ES 1.02). Confidence intervals for effects on mutual shared attention (AMD 0.10; 95% CI -0.07, 0.27; ES 0.5) and co-morbid symptoms (AMD -9.0; 95% CI -24.26, 6.26; ES 0.32) contained zero. There were significant effects to improve parental mental health. PASS Plus shows good feasibility and adds to the evidence of the effectiveness of task sharing complex autism interventions to lay health workers in India. Autism Res 2019, 12: 328-339 © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This article describes the development of a comprehensive, community-delivered, intervention for young children with autism, which combines a previously developed parent-mediated communication intervention with support for co-morbid problems like challenging behaviors and sensory sensitivities. The unique aspect of this intervention is that it can be delivered by community health workers, addressing the lack of specialists in low resource settings. Our study reports the encouraging findings of a pilot trial evaluating its feasibility and effectiveness.

AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial.

BACKGROUND: A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition. METHODS: We did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20-29) or affective disorder (F30-39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS-AH). Analysis was by intention-to-treat with linear mixed models. The trial was prospectively registered with the ISRCTN registry, number 65314790. FINDINGS: Between Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy (n=75) or supportive counselling (n=75). 124 (83%) met the primary outcome. The reduction in PSYRATS-AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling (mean difference -3·82 [SE 1·47], 95% CI -6·70 to -0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy. INTERPRETATION: To our knowledge, this is the first powered, randomised controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations. FUNDING: Wellcome Trust.

Social anxiety across ethnicity: a confirmatory factor analysis of the FNE and SAD.

Previous research has established that social anxiety occurs at different rates in African American and European American populations (Grant et al., 2005), while psychometric investigations of widely used measures of psychopathology show differences in factor structure based on ethnic background (Carter, Miller, Sbrocco, Suchday, & Lewis, 1999; Chapman, Williams, Mast, & Woodruff-Borden, 2009). The current study examined response characteristics of 1276 African American and European American undergraduates completing the Fear of Negative Evaluation and Social Avoidance and Distress Scales (Watson & Friend, 1969). Confirmatory factor analyses failed to demonstrate factorial invariance in the two ethnic samples, and Wald tests suggested several items on both measures be dropped for African Americans. Results suggest the FNE and SAD operate differently across ethnic groups. Implications for the cross-cultural measurement of social anxiety and the importance of continued rigorous psychometric inquiry of commonly used measures are discussed.