Working together with people with intellectual disability to make a difference: a protocol for a mixed-method co-production study to address inequities in cervical screening participation

Introduction

Cervical cancer is one of the most preventable cancers yet remains a disease of inequity for people with intellectual disability, in part due to low screening rates. The ScreenEQUAL project will use an integrated knowledge translation (iKT) model to co-produce and evaluate accessible cervical screening resources with and for this group.

Methods

Stage 1 will qualitatively explore facilitators and barriers to screening participation for people with intellectual disability, families and support people, healthcare providers and disability sector stakeholders (n ≈ 20 in each group). An accessible multimodal screening resource, accompanying supporting materials for families and support people, and trauma-informed healthcare provider training materials will then be co-produced through a series of workshops. Stage 2 will recruit people with intellectual disability aged 25 to 74 who are due or overdue for screening into a single-arm trial (n = 48). Trained support people will provide them with the co-produced resource in accessible workshops (intervention) and support them in completing pre-post questions to assess informed decision-making. A subset will participate in qualitative post-intervention interviews including optional body-mapping (n ≈ 20). Screening uptake in the 9-months following the intervention will be measured through data linkage. Family members and support people (n = 48) and healthcare providers (n = 433) will be recruited into single-arm sub-studies. Over a 4-month period they will, respectively, receive the accompanying supporting materials, and the trauma-informed training materials. Both groups will complete pre-post online surveys. A subset of each group (n ≈ 20) will be invited to participate in post-intervention semi-structured interviews.

Outcomes and analysis

Our primary outcome is a change in informed decision-making by people with intellectual disability across the domains of knowledge, attitudes, and screening intention. Secondary outcomes include: (i) uptake of screening in the 9-months following the intervention workshops, (ii) changes in health literacy, attitudes and self-efficacy of family members and support people, and (iii) changes in knowledge, attitudes, self-efficacy and preparedness of screening providers. Each participant group will evaluate acceptability, feasibility and usability of the resources.

Discussion

If found to be effective and acceptable, the co-produced cervical screening resources and training materials will be made freely available through the ScreenEQUAL website to support national, and potentially international, scale-up.

Reasons for Encounters and Comorbidities in Adolescents with Intellectual Disability in General Practice: A Retrospective Analysis of Data from the Ask Study

Adolescents with intellectual disability have substantial health needs. This retrospective analysis of data from the Ask Study describes reasons for primary care encounters and the prevalence and incidence of chronic physical and mental conditions among a cohort of community-dwelling adolescents with intellectual disability. Participants attended secondary schools in southern Queensland, Australia. Primary care data were extracted from primary care records. Demographic and health information was collected using carer-completed questionnaires. Reasons for primary care encounters, disease prevalence at age 16 years, and disease incidence through adolescence were reported. Data were obtained for 432 adolescents with intellectual disability (median follow-up: 4.1 years). Skin problems (29.4 per 100 encounters) were the most common reason patients presented for primary care, followed by psychological and behavioural problems (14.4 per 100 encounters) and musculoskeletal problems (13.8 per 100 encounters). Conditions with the highest prevalence were autism spectrum disorder (18.6%) and asthma (18.1%). The prevalence of epilepsy, visual impairment, and cerebral palsy were 14.7, 11.1, and 8.0%, respectively. Gastroesophageal reflux had the highest incidence (9.4 cases per 1000 person-years). Adolescents with intellectual disability have significant healthcare needs, which general practitioners need to be aware of and address. Study findings should inform the development of training programs for general practitioners.

Views about primary care health checks for autistic adults: UK survey findings

BACKGROUND

Compared with the general population, autistic adults experience higher rates of physical and mental health conditions, premature morbidity and mortality, and barriers to health care. A health check for autistic people may improve their health outcomes.

AIM

To establish the views of autistic people towards a primary care health check for autistic people.

DESIGN & SETTING

Cross-sectional questionnaire study in England and Wales.

METHOD

A questionnaire was sent to autistic adults with physical health conditions in England and Wales. A total of 458 people (441 autistic adults and 17 proxy responders) completed the questionnaire.

RESULTS

Most responders (73.4%, n = 336) thought a health check is needed for all autistic people. Around half of the participants thought a health check should be offered from childhood and the health check appointment should last between 15 and 30 minutes. Autistic people were positive about providing primary care staff with contextual information regarding their health and the reasonable adjustments they would like before their health check appointment. Training about autism and the health check was considered important, alongside adequate time for discussions in the health check appointment (all by over 70% of responders). The clinician's autism knowledge, seeing a familiar clinician, environmental adaptations, appropriate information, and accessible appointments were considered particularly important in making a health check accessible.

CONCLUSION

Autistic people and relatives were supportive of a primary care health check for autistic people. Information gathered was used to support the design of a primary care health check for autistic adults.

Access to general practice for people with intellectual disability in Australia: a systematic scoping review

BACKGROUND

People with intellectual disability experience inadequate access to general practice and poorer health outcomes than the general population. While some access barriers have been identified for this population, these studies have often used narrow definitions of access, which may not encompass the multiple dimensions that influence access to general practice. To address this gap, we conducted a scoping review to identify factors impacting access to general practice for people with intellectual disability in Australia, using a holistic framework of access conceptualised by Levesque and colleagues.

METHODS

This scoping review followed Joanna Briggs Institute methodology and was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Medline (Ovid), Scopus, CINAHL, Informit and PsycINFO databases were searched. Screening, full-text review and data extraction were completed by two independent reviewers, with consensus reached at each stage of the study. Data were extracted, coded and synthesised through deductive qualitative analysis - using the five corresponding conceptual dimensions within Levesque and colleagues' theoretical framework of access, which incorporate both supply-side features of health systems and services, and demand-side characteristics of consumers and populations.

RESULTS

The search identified 1364 publications. After duplicate removal, title and abstract screening and full-text review, 44 publications were included. Supply-side factors were more commonly reported than demand-side factors, with the following issues frequently identified as impacting access to general practice: limited general practitioner education about, and/or experience of, people with intellectual disability; communication difficulties; and inadequate continuity of care. Less frequently included were factors such as the health literacy levels, promotion of general practice services and availability of complete medical records.

CONCLUSIONS

This is the first scoping review to assess access barriers for people with intellectual disability using a comprehensive conceptualisation of access. The findings highlight the need for increased efforts to address demand-side dimensions of access to general practice and offer a basis for a balanced portfolio of strategies that can support recent policy initiatives to enhance access to care for people with intellectual disability.

Co-design of an NHS primary care health check for autistic adults

Autistic people experience more health conditions and earlier mortality. This study investigated views about a primary care health check for autistic adults to inform its design. Fifty-one people participated in consultation groups and interviews, comprising autistic adults (some with co-occurring intellectual disabilities), adults with intellectual disabilities, supporters and health professionals. Participants wanted the health check to cover physical and mental health and social functioning. They emphasised the importance of sharing information about individual needs and associated adjustments before the health check. They highlighted the need to change the way healthcare services communicate with autistic people, such as reducing phone contact and booking appointments online. They wanted individual choice in how the health check was completed, with video call or email offered alongside face-to-face. Participants raised the need for further training of primary care staff on autism, to highlight the diversity of experiences of autistic people and ways in which difficulties, such as pain, may present differently. Clinicians raised questions about the capacity of mental health and social care services to meet the additional needs potentially identified through the health check. This study represents a key step in the development and co-design of a UK primary care health check for autistic people.

Lay abstract

Autistic people are on average more likely to experience poor health than people who are not autistic. Health checks have been shown to improve access to effective healthcare. This study investigated people’s views about a primary care health check for autistic adults. We held discussion groups and interviewed autistic adults, adults with intellectual disabilities, supporters and health professionals. People wanted the health check to look at a person’s physical and mental health, and how they were doing socially. They thought people should be able to share information about their needs and the reasonable adjustments they would like before the health check. They wanted healthcare services to change the way they communicate with autistic people, such as being able to book appointments online rather than by telephone. They wanted a choice in how the health check was completed, with video call or email offered as well as face-to-face appointments. People thought further training of primary care staff on autism was needed, to increase awareness of the diversity of experiences of autistic people and ways in which difficulties, such as pain, may present differently to non-autistic people. Clinicians raised questions about whether mental health and social care services could meet the additional needs that might be identified through the health check. We used this information to design an NHS primary care health check for autistic people in collaboration with autistic people, supporters and health professionals.

Roadmap for Creating Effective Communication Tools to Improve Health Equity for Persons With Intellectual and Developmental Disabilities

Persons with intellectual and developmental disabilities (IDD) live 20 fewer years than the average person and almost 40% of their deaths are from preventable causes. They suffer from well-documented disparities in health and healthcare, and much of this inequity is rooted in information transfer failures between patients, their caregivers, and their healthcare providers. Tools to improve communication between these stakeholders, such as health checks and hand-held health records, or health passports, have been implemented in Europe, Australia and Canada with mixed results, and there are no standard information tools currently in widespread use in the U.S. We review the evidence of the effectiveness of these tools, as well as their barriers to adoption, to inform proposed development of next-generation information transfer tools most useful to patients with IDD and their healthcare providers. The repair of health information transfer failures will be a major step toward achieving health equity for this population.

Prevalence and incidence of physical health conditions in people with intellectual disability - a systematic review

OBJECTIVE

To synthesize evidence on the prevalence and incidence of physical health conditions in people with intellectual disability (ID).

METHODS

We searched Medline, PsycInfo, and Embase for eligible studies and extracted the prevalence, incidence, and risk of physical health conditions in people with ID.

RESULTS

Of 131 eligible studies, we synthesized results from 77 moderate- to high-quality studies, which was mainly limited to high-income countries. The highest prevalence estimates were observed for epilepsy, ear and eye disorders, cerebral palsy, obesity, osteoporosis, congenital heart defects, and thyroid disorders. Some conditions were more common in people with a genetic syndrome. Compared with the general population, many health conditions occur more frequently among people with ID, including asthma and diabetes, while some conditions such as non-congenital circulatory diseases and solid cancers occur at the same or lower rate. The latter associations may reflect under-detection.

CONCLUSIONS

People with ID have a health profile more complex than previously known. There is a pressing need for targeted, evidence-informed population health initiatives including preventative programs for this population.

Complete physical examinations in Manitoba adults with an intellectual or developmental disability: A retrospective cohort study

BACKGROUND

Complete physical examinations (CPE) can identify health disparities in persons with intellectual or developmental disabilities. The objective of this study was to determine and compare rates of CPE among Manitoba adults with and without intellectual or developmental disabilities over time and to identify factors that were associated with receiving a CPE.

METHOD

A retrospective cohort study using linked administrative health and non-health data from 1995 to 2015 was conducted. Poisson and logistic regression were used to calculate CPE rates and examine factors associated with CPE.

RESULTS

The rates of CPE are decreasing over time and are higher among Manitobans with an intellectual or developmental disability. Characteristics such as being male, living rurally, low socioeconomic status, and high continuity of care led to lower odds of receiving a CPE.

CONCLUSIONS

The current state of CPE provision to adults with intellectual or developmental disabilities in Manitoba is encouraging but needs improvement.

Alternative and Augmentative Communication Technologies for Supporting Adults With Mild Intellectual Disabilities During Clinical Consultations: Scoping Review

Background

People with intellectual disabilities (IDs) face significant communication barriers when accessing health care services; they find it difficult to identify and describe conditions clearly enough to support practitioners in making an accurate diagnosis. In addition, medical professionals generally have little knowledge and understanding of the needs of people with ID, which may result in the use of consultation techniques that do not cater to their patients’ skills.

Objective

This review aims to identify and synthesize the literature on alternative and augmentative communication technologies that are used to support adults with mild ID during the exchange of information with medical practitioners.

Methods

We performed a scoping review of studies published in English that describe the technologies that are used to promote communication with patients with mild ID during medical consultations. The databases searched were PubMed, ACM Digital Library, and Google Scholar. A qualitative framework-based approach was used to synthesize the data and discern key recurring themes across the identified literature.

Results

Of the 1557 articles screened, 15 (0.96%) met our inclusion criteria. The bulk of the communication aids used focused on low-tech solutions, including patient passports, note-based prompts, Talking Mats, health diaries, and easy-read information sheets. Their influence on current practice ranged from advancing medical professionals’ knowledge of the health and communication needs of people with ID to increasing interagency collaboration, patient advocacy skills, and health promotion activities. The major barriers to the implementation of low-tech aids were a lack of portability and increased maintenance efforts. Only 3 studies explored the use of mobile apps to promote communication. Their findings indicated that high-tech solutions offer greater customization with regard to the accessibility and health care needs of people with ID.

Conclusions

Alternative and augmentative communication technologies have the potential to increase the quality of care provided to patients with mild ID; however, little work has been carried out in this area. Greater emphasis must be placed on (high-tech) two-way communication aids that empower patients to become involved in decisions regarding their care. Quantitative evaluation methods should be used to discern the true benefits of such aids, and researchers should describe their study protocols in depth to promote replication and generalizability.

"Constructing a health assessment questionnaire for people with intellectual disabilities: A cognitive interview study"

INTRODUCTION

Health assessment instruments can help to raise awareness among general practitioners of specific health problems in people with intellectual disabilities (PID). The present authors developed a health assessment questionnaire using the cognitive interview technique (CI) to improve the comprehensibility. The utility of this approach to questionnaire development involving PID is assessed.

METHOD

A qualitative approach using the CI was employed. The study included PID and their caregivers. The present authors interviewed 14 participants in 5 subsequent rounds. After each round, the questionnaire was adjusted until saturation was reached.

RESULTS

Three hundred and sixty three identified problems led to 316 changes to the questionnaire. Most problems (102) concerned the comprehension of the question, followed by problems in the "missing answer categories" and "inaccurate instruction" section.

CONCLUSION

The comprehensible health assessment questionnaire can help PID to take an active role in communication with their GP. The use of CI helped to improve the questionnaire. CI is a usable and valuable procedure for PID.

Intellectual disability content within pre-registration nursing curriculum: How is it taught?

BACKGROUND

Despite experiencing higher rates of physical and mental health conditions compared with the general population, people with intellectual disability face inequitable access to healthcare services. Improving education of healthcare professionals is one way to reduce these inequalities.

OBJECTIVE

To determine how intellectual disability content is taught within Australian nursing schools.

DESIGN

A two-phase audit of Australian nursing curricula content was conducted using an interview and online survey.

SETTING

Nursing schools Australia-wide providing pre-registration courses.

PARTICIPANTS

For Phase 1, course coordinators from 31 nursing schools completed an interview on course structure. Teaching staff from 15 schools in which intellectual disability content was identified completed an online survey for Phase 2.

METHODS

Methods used to teach intellectual disability content and who taught the content were audited using an online survey.

RESULTS

Across the 15 schools offering intellectual disability content, lectures were the most common teaching method (82% of units), followed by tutorials (59%), workshops (26%), then other methods (e.g. e-learning; 12%). Approximately three-quarters of intellectual disability teaching used some problem-and/or enquiry-based learning. Only one nursing school involved a person with intellectual disability in delivering teaching content. Six (19%) participating schools identified staff who specialise in intellectual disability, and seven (23%) identified staff with a declared interest in the area.

CONCLUSION

While some nursing schools are using diverse methods to teach intellectual disability content, many are not; as a result, nursing students may miss out on acquiring the attributes which enable them to address the significant health inequalities faced by this group. A specific deficit was identified relating to inclusive teaching and clinical contact with people with intellectual disability.

Are we making a difference in primary care for adults with intellectual and developmental disabilities?

OBJECTIVES

To examine the impact of the dissemination of guidelines to physicians and of a population-level health communication intervention on the percentage of adults with intellectual and developmental disabilities (IDD) receiving preventive care through primary care.

METHODS

Noninstitutionalized adults with IDD in the province of Ontario, Canada, aged 40 to 64 years were matched to Ontarians without such disabilities each fiscal year (FY) from 2003 to 2016. Health administrative data were used to create a composite measure of receipt of recommended preventive primary care. Age-adjusted rates were used to assess trends, and average two-year rate ratios (RRs) and confidence intervals (CIs) were used to evaluate the effectiveness of the interventions.

RESULTS

The number of adults with IDD identified ranged from 20 030 in FY 2003 to 28 080 in FY 2016. The percentage of adults with IDD receiving recommended preventive primary care ranged from 43.4% in 2003 to 55.7% in 2015. Men with IDD had a 53.7% increase across the 13 years, while women with IDD only had a 30.9% increase. When evaluating the impact of the interventions, men with IDD were 4% more likely (RR: 1.04; 95% CI: 1.02-1.05) to receive recommended primary care in FY 2015 and FY 2016 as compared to FY 2009 and FY 2010; in contrast, women with IDD were 5% less likely (RR: 0.95; 95% CI: 0.93-0.98). A comparable drop was observed among women without IDD.

CONCLUSIONS

Nearly 45% of adults with IDD in Ontario still do not receive recommended preventive care through primary care. Long-term impacts of the interventions introduced in the province may still occur over time, so ongoing monitoring is warranted. Special attention should be given to the preventive care needs of women with IDD.

Development of a health assessment instrument for people with intellectual disabilities: a Delphi study

BACKGROUND

People with intellectual disabilities (IDs) experience health inequalities. Applying health assessments is one way of diminishing these inequalities. A health assessment instrument can support general practitioners (GPs) in providing better medical care to people with ID.

OBJECTIVES

The aim of this study was to determine which items should be part of a health assessment instrument for people with ID to be used in primary care.

METHODS

This Delphi consensus study was conducted among 24 GP experts and 21 ID physicians. We performed three anonymous sequential online questionnaire rounds. We started with 82 'general' items and 14 items concerning physical and additional examinations derived from the international literature and a focus group study among Dutch GPs. We definitely included items if more than 75% of the GP experts agreed on their inclusion.

RESULTS

The participation rate in all rounds was above 88%. The expert groups proposed 10 new items. Consensus was reached on 64 'general' items related to highly prevalent diseases, public health and health promotion. Consensus was also reached on 18 physical and additional examination items.

CONCLUSIONS

For the first time, experts in a Delphi study were able to arrive at a selection of items for a health assessment instrument for people with ID. The overall agreement among the GPs and ID physicians was good. Because the experts prefer that patients complete the health assessment questionnaire at home, questions that cover these items must be formulated clearly.

Intellectual disability content within tertiary medical curriculum: how is it taught and by whom?

BACKGROUND

Individuals with intellectual disability experience higher rates of physical and mental health conditions compared with the general population, yet have inequitable access to health care services. Improving the workplace capacity of medical professionals to meet the needs of this population is one way to reduce barriers to care and improve health outcomes. Using diverse pedagogy appropriate to learning outcomes to teach medical students about intellectual disability is a necessary step in improving future workplace capacity. However, there is a lack of research into how, and by whom, medical students are taught about intellectual disability. The aim of this study was to investigate this through an audit of Australian medical school curricula.

METHODS

The Deans of Australian universities that provide accredited medical degrees (n = 20) were invited by email to participate in a two-phase audit of intellectual disability content in the curricula. Phase 1 (n = 14 schools) involved the Dean's delegate completing a telephone interview or questionnaire regarding medical course structure. If intellectual disability content was identified, a unit coordinator was invited to complete a survey regarding how this content was taught and by whom (Phase 2; n = 12 schools).

RESULTS

There was considerable variability across Australian medical schools regarding methods used to teach content about intellectual disability. Didactic teaching methods were most frequently used (62% of units included some form of lecture), but workshops and tutorials were reasonably well represented (34% of units contained one or both). Thirty-six percent of units included two or more teaching methods. Almost all schools (83%) used some problem- and/or enquiry-based learning. Educator backgrounds included medicine, nursing, and allied health. A majority of schools (n = 9, 75%) involved people with intellectual disability designing and teaching content, but the extent to which this occurred was inconsistent.

CONCLUSIONS

Renewing curricula around intellectual disability across all medical schools by introducing varied teaching methods and the inclusion of people with intellectual disability would assist students to develop knowledge, skills, attitudes, and confidence in intellectual disability health. Such renewal offers the potential to reduce barriers to service this population regularly face, thereby improving their health outcomes.

Long-term condition management in adults with intellectual disability in primary care: a systematic review

Background

Adults with intellectual disabilities have higher morbidity and earlier mortality than the general population. Access to primary health care is lower, despite a higher prevalence of many long-term conditions.

Aim

To synthesise the evidence for the management of long-term conditions in adults with intellectual disabilities and identify barriers and facilitators to management in primary care.

Design & setting

Mixed-methods systematic review.

Method

Seven electronic databases were searched to identify both quantitative and qualitative studies concerning identification and management of long-term conditions in adults with intellectual disability in primary care. Both the screening of titles, abstracts, and full texts, and the quality assessment were carried out in duplicate. Findings were combined in a narrative synthesis.

Results

Fifty-two studies were identified. Adults with intellectual disabilities are less likely than the general population to receive screening and health promotion interventions. Annual health checks may improve screening, identification of health needs, and management of long-term conditions. Health checks have been implemented in various primary care contexts, but the long-term impact on outcomes has not been investigated. Qualitative findings highlighted barriers and facilitators to primary care access, communication, and disease management. Accounts of experiences of adults with intellectual disabilities reveal a dilemma between promoting self-care and ensuring access to services, while avoiding paternalistic care.

Conclusion

Adults with intellectual disabilities face numerous barriers to managing long-term conditions. Reasonable adjustments, based on the experience of adults with intellectual disability, in addition to intervention such as health checks, may improve access and management, but longer-term evaluation of their effectiveness is required.

Embedding routine health checks for adults with intellectual disabilities in primary care: practice nurse perceptions

BACKGROUND

Adults with intellectual disabilities (IDs) have consistently poorer health outcomes than the general population. There is evidence that routine health checks in primary care may improve outcomes. We conducted a randomised controlled trial of practice nurse led health checks. Here, we report findings from the nested qualitative study.

AIM

To explore practice nurse perceptions and experience of delivering an anticipatory health check for adults with IDs.

DESIGN AND SETTING

Qualitative study in General Practices located in NHS Greater Glasgow and Clyde, Scotland, UK.

METHOD

Eleven practice nurses from 11 intervention practices participated in a semi-structured interview. Analysis was guided by a framework approach.

RESULTS

Practice nurses reported initially feeling 'swamped' and 'baffled' by the prospect of the intervention, but early misgivings were not realised. Health checks were incorporated into daily routines with relative ease, but this was largely contingent on existing patient engagement. The intervention was thought most successful with patients already well known to the practice. Chronic disease management models are commonly used by practice nurses and participants tailored health checks to existing practice. It emerged that few of the nurses utilised the breadth of the check instead modifying the check to respond to individual patients' needs. As such, already recognised 'problems' or issues dominated the health check process. Engaging with the health checks in this way appeared to increase the acceptability and feasibility of the check for nurses. There was universal support for the health check ethos, although some questioned whether all adults with IDs would access the health checks, and as a consequence, the long-term benefits of checks.

CONCLUSION

While the trial found the intervention to be dominant over standard health care, the adjustments nurses made may not have maximised potential benefits to patients. Increasing training could further improve the benefits that health checks provide for people with IDs.

A systematic review of the methodological and practical challenges of undertaking randomised-controlled trials with cognitive disability populations

Approximately 10% of the world's population have a cognitive disability. Cognitive disabilities can have a profound impact on a person's social, cognitive or mental functioning, requiring high levels of costly health and social support. Therefore, it is imperative that interventions and services received are based upon a sound evidence-base. For many interventions for this population, this evidence-base does not yet exist and there is a need for more Randomised Controlled Trials (RCTs). The process of conducting RCTs with disabled populations is fraught with methodological challenges. We need a better understanding of these methodological barriers if the evidence-bases are to be developed. The purpose of this study was to explore the methodological and practical barriers to conducting trials with adults with cognitive disabilities. As a case example, the literature regarding RCTs for people with intellectual disabilities (ID) was used to highlight these pertinent issues. A systematic literature review was conducted of RCTs with adults with ID, published from 2000 to 2017. A total of 53 papers met the inclusion criteria and were reviewed. Some of the barriers reported were specific to the RCT methodology and others specific to people with disabilities. Notable barriers included; difficulties recruiting; obtaining consent; resistance to the use of control groups; engaging with carers, staff and stakeholders; the need to adapt interventions and resources to be disability-accessible; and staff turnover. Conducting RCTs with people with cognitive disabilities can be challenging, however with reasonable adjustments, many of these barriers can be overcome. Researchers are not maximising the sharing of their experience-base. As a result, the development of evidence-bases remains slow and the health inequities of people with disabilities will continue to grow. The importance of the MRC guidelines on process evaluations, together with implications for the dissemination of 'evidence-base' and 'experience-base' are discussed.

Twenty-Five Year Survival of Children with Intellectual Disability in Western Australia

OBJECTIVES

To investigate survival up to early adulthood for children with intellectual disability and compare their risk of mortality with that of children without intellectual disability.

STUDY DESIGN

This was a retrospective cohort study of all live births in Western Australia between January 1, 1983 and December 31, 2010. Children with an intellectual disability (n = 10 593) were identified from the Western Australian Intellectual Disability Exploring Answers Database. Vital status was determined from linkage to the Western Australian Mortality database. Kaplan-Meier product limit estimates and 95% CIs were computed by level of intellectual disability. Hazard ratios (HRs) and 95% CIs were calculated from Cox proportional hazard regression models adjusting for potential confounders.

RESULTS

After adjusting for potential confounders, compared with those without intellectual disability, children with intellectual disability had a 6-fold increased risk of mortality at 1-5 years of age (adjusted HR [aHR] = 6.0, 95%CI: 4.8, 7.6), a 12-fold increased risk at 6-10 years of age (aHR = 12.6, 95% CI: 9.0, 17.7) and a 5-fold increased risk at 11-25 years of age (aHR = 4.9, 95% CI: 3.9, 6.1). Children with severe intellectual disability were at even greater risk. No difference in survival was observed for Aboriginal children with intellectual disability compared with non-Aboriginal children with intellectual disability.

CONCLUSIONS

Although children with intellectual disability experience higher mortality at all ages compared with those without intellectual disability, the greatest burden is for those with severe intellectual disability. However, even children with mild to moderate intellectual disability have increased risk of death compared with unaffected children.

General practice encounters for young patients with autism spectrum disorder in Australia

This study compared the patient demographics and reasons for encounter in general practice for patients <25 years with and without an autism spectrum disorder identified as a reason for encounter and/or problem managed. The Bettering the Evaluation and Care of Health programme collected information about clinical activities in Australian general practice. Each year, the programme recruited a random sample of 1000 general practitioners, each of whom collected data for 100 consecutive consultations (encounters). Encounters with patients <25 years, where at least one autism spectrum disorder was recorded as a reason for encounter and/or a problem managed (n = 579), were compared with all other encounters (n = 281,473) from April 2000 to March 2014 inclusive. Data were age–sex standardised. Patients at autism spectrum disorder encounters (compared to non-autism spectrum disorder encounters) were more likely to be younger and male. There was a dramatic rise in the number of general practitioner consultations at autism spectrum disorder encounters from 2000 to 2013. More reasons for encounter were recorded at autism spectrum disorder encounters than at non-autism spectrum disorder encounters (156.4 (95% confidence interval: 144.0–168.8) and 140.5 (95% confidence interval: 140.0–141.0), respectively). At autism spectrum disorder (vs non-autism spectrum disorder) encounters, there were more psychological, general and unspecified, and social reasons for encounter and fewer preventive and acute health reasons for encounter. People with an autism spectrum disorder have complex health care needs that require a skilled general practice workforce.

Prevalence, types and associations of medically unexplained symptoms and signs. A cross-sectional study of 1023 adults with intellectual disabilities

BACKGROUND

Medically unexplained symptoms and signs are common in the general population and can respond to appropriate managements. We aimed to quantify the types and prevalence of unexplained symptoms and signs experienced by adults with ID and to determine the associated factors.

METHOD

In a population-based study, 1023 adults with ID aged 16 and over had a detailed health assessment, which systematically considered symptoms and signs. Descriptive data were generated on their symptoms and signs. Backwards stepwise logistic modelling was undertaken to determine the factors independently associated with the unexplained symptoms.

RESULTS

Medically unexplained symptoms and signs were present in 664 (64.9%), 3.8 times higher than in the general population, and 470 (45.9%) had multiple unexplained symptoms or signs. Some were similar to those reported in the general population, such as dyspnoea, dyspepsia, headache, nausea and dizziness. However, others are not commonly reported in the general population, including dysphagia, ataxia, polyuria, oedema and skin rash. Having unexplained symptoms and signs was independently associated with older age, female gender, not having Down syndrome, extent of ID and more GP visits in the last 12 months. It was not associated with living in deprived areas, type of living/support arrangements, number of hospital visit in the last 12 months, smoking, autism, problem behaviours or mental disorders.

CONCLUSIONS

People with ID have substantial additional unexplained symptoms and signs, some of which are painful or disabling. These findings should inform the content of health checks undertaken for adults with intellectual disabilities, which should not just focus on management of their long-term conditions and health promotion.

Primary health care for people with an intellectual disability: an exploration of consultations, problems identified, and their management in Australia

BACKGROUND

People with an intellectual disability (ID) have more complex and different patterns of health care needs than the general population. They experience a greater burden of multi-morbidity, high levels of undetected and unmanaged health issues, and premature mortality than the general population. Primary care has a key role in the health care of people with an ID. Currently, very little is known about the consultation type and length, problems managed, and how general practitioners (GPs) manage these problems for people with an ID compared with the general population. This information would provide valuable insights into how GPs are achieving the health guidelines and facilitating people with an ID to achieve the highest attainable standard of health.

METHODS

A secondary analysis of data was collected from January 2003 to December 2012 from the Bettering the Evaluation and Care of Health (BEACH) programme. Consultation type, consultation length in minutes, problem(s) managed during the consultation, medications, treatments provided, and referrals made, pre and post age-sex standardisation, at all GP encounters with people identified in the encounter record as having an ID ('ID' encounters, n = 690) were compared with those at 'non-ID' encounters (n = 970 641). Statistical significance was tested with 95% confidence intervals.

RESULTS

This study identified significant differences in consultation types, consultation length, problem(s) managed during the consultation, medications, treatments provided, and referrals made at 'ID' encounters compared with 'non-ID' encounters. 'ID' encounters had more indirect encounters, longer consultations, more problems managed, but an under management of common health conditions in people with an ID. Administrative rather than medically related actions dominated clinical treatments for people at 'ID' encounters, and they received fewer procedural treatments, referrals to specialists, and medications compared with those at 'non-ID' encounters.

CONCLUSION

The significant differences in consultations, problems identified and managed suggest that GPs may require additional support to (1) identify and manage common medical conditions experienced by people with an ID; (2) manage the increased time required for consultations; and (3) directly consult with people with an ID. Further research is required to determine why GPs managed problems in a significantly different way for people with an ID.

Health assessment instruments for people with intellectual disabilities-A systematic review

BACKGROUND

People with intellectual disabilities (ID) experience health disparities and are less likely to undergo recommended age- and gender-specific screening and health promotion. New diagnoses are frequently missed. Assessments with the aid of health assessment instruments are a way to address these problems.

AIM

The aim of this review is to find the available health assessment instruments for people with ID used in primary care and evaluate their quality.

METHODS

We conducted an electronic literature search of papers published between January 2000 and May 2016. After a two-phase selection process (kappa: 0.81 and 0.77) we collected data from the 29 included peer-reviewed articles on the following four domains; development, clinimetric properties (i.e. validity, reliability, feasibility, acceptability), content (i.e. ID-related health problems, prevention and health promotion topics) and effectiveness of the instruments.

RESULTS/CONCLUSIONS

We distinguished 20 different health assessment instruments. Limited information was found on the development of the instruments as well as on their clinimetric properties. The content of the instruments was rather diverse. The included papers agreed that health assessment instruments are effective. However, only three instruments evaluated effectiveness in a randomised controlled trial. Patients with ID, carers and general practitioners (GPs) generally appreciated the health assessment instruments.

IMPLICATION

Two instruments, "Stay well and healthy -Health risk appraisal (SWH-HRA)"and the "Comprehensive Health Assessment Programme (CHAP)", appeared to have the highest quality. These instruments can be used to construct a health assessment instrument for people with ID that meets scientific standards.

GPs' opinions of health assessment instruments for people with intellectual disabilities: a qualitative study

BACKGROUND

GPs provide health care to people with intellectual disabilities (ID). People with ID find it difficult to express themselves concerning health-related matters. Applying health assessments is an effective method to reveal health needs, and can play a role in prevention and health promotion.

AIM

The aim of this qualitative study was to explore GPs' considerations about applying a health assessment for people with ID.

DESIGN AND SETTING

This focus group study was conducted among a selection of Dutch GPs.

METHOD

An interview guide was developed. All discussions were audiorecorded and transcribed. Analysis was performed using the framework analysis approach. Two researchers independently applied open coding and identified a thematic framework. This framework and the summaries of views per theme were discussed in the research team.

RESULTS

After four focus groups, with 23 GPs, saturation was reached. Three main themes evolved: health assessments in relation to GPs' responsibility; the usefulness and necessity of health assessments; and barriers to using health assessments on people with ID. A health assessment instrument for people with ID can help GPs to focus on certain issues that are not so common in the general population. GPs are motivated to use such a tool if it is scientifically tested, and results in significant health gains. However, GPs identify barriers at the level of GP, patient, and organisation.

CONCLUSION

Most GPs in the focus groups consider providing medical care to people with ID their responsibility and indicate that a health assessment instrument could be a valuable tool. In order to deliver good care, they need education and support. Many barriers need to be overcome before a health assessment instrument can be implemented.

A health advocacy intervention for adolescents with intellectual disability: a cluster randomized controlled trial

AIM

Adolescents with intellectual disability experience poorer heath than their peers in the general population, partially due to communication barriers and knowledge gaps in their health history. This study aimed to test a health intervention package against usual care for a range of health promotion and disease detection outcomes.

METHOD

A parallel-group cluster randomized controlled trial was conducted with Australian adolescents with intellectual disability living in the community. Randomization occurred at school level. The intervention package consisted of classroom-based health education, a hand-held personalized health record, and a health check. Evidence of health promotion, disease prevention, and case-finding activities were extracted from general practitioners' records for 12 months post-intervention.

RESULTS

Clinical data was available for 435 of 592 (73.5%) participants from 85 schools. Adolescents allocated to receive the health intervention were more likely to have their vision (odds ratio [OR] 3.3; 95% confidence interval [CI] 1.8-6.1) and hearing (OR 2.7; 95% CI 1.0-7.3) tested, their blood pressure checked (OR 2.4; 95% CI 1.6-3.7), and weight recorded (OR 4.8; 95% CI 3.1-7.6). There was no difference between health intervention and usual care for identification of new diseases.

INTERPRETATION

The school-based intervention package increased healthcare activity in adolescents with intellectual disability living in the community.

Primary health care for people with an intellectual disability: an exploration of demographic characteristics and reasons for encounters from the BEACH programme

BACKGROUND

People with an intellectual disability (ID) have complex and different patterns of healthcare needs. Poor participation in primary health care contributes to the high levels of undetected and unmanaged health issues and premature deaths of people with an ID. Limited research is available on the characteristics of people with an ID, their reasons for consulting general practitioners (GPs), and if these differ to people without an ID. Gaining such insights may provide an avenue to better understand patterns of primary care use and potential gaps in usage by people with an ID given their complex health profile compared with people without an ID.

METHOD

A secondary analysis of data collected January 2003 to December 2012 from The Bettering the Evaluation and Care of Health programme was used. Participant characteristics and their reasons for encounter, pre- and post-age-sex standardisation, at all GP encounters with people identified in the encounter record as having an ID ('ID' encounters, n = 690) were compared with those at 'non-ID' encounters (n = 970 641). Statistical significance was tested with chi-squared statistics or 95% confidence intervals as appropriate.

RESULTS

This study identified significant differences in participant characteristics and their reasons for consulting GPs at ID encounters compared with non-ID encounters. Participants at ID encounters had a skewed demography, an over-representation of presentations for psychological, social and 'general and unspecified' reasons, and an under-representation of presentations for core physical health and preventive health measures. Administrative rather than medically related reasons dominated presentations to general practice at ID encounters.

CONCLUSION

There are significant differences in the characteristics of participants and their reasons for presentation to general practice in Australia for participants at ID encounters compared with non-ID encounters. This work suggests that there is a difference in service use patterns between these two groups. These findings may suggest that people with an ID experience barriers to participating in essential primary healthcare services.

Intellectual disability health content within nursing curriculum: An audit of what our future nurses are taught

BACKGROUND

Individuals with intellectual disability experience chronic and complex health issues, but face considerable barriers to healthcare. One such barrier is inadequate education of healthcare professionals.

OBJECTIVE

To establish the quantity and nature of intellectual disability content offered within Australian nursing degree curricula.

DESIGN

A two-phase national audit of nursing curriculum content was conducted using an interview and online survey.

SETTING

Australian nursing schools offering pre-registration courses.

PARTICIPANTS

Pre-registration course coordinators from 31 universities completed the Phase 1 interview on course structure. Unit coordinators and teaching staff from 15 universities in which intellectual disability content was identified completed the Phase 2 online survey.

METHODS

Quantity of compulsory and elective intellectual disability content offered (units and teaching time) and the nature of the content (broad categories, specific topics, and inclusive teaching) were audited using an online survey.

RESULTS

Over half (52%) of the schools offered no intellectual disability content. For units of study that contained some auditable intellectual disability content, the area was taught on average for 3.6h per unit of study. Units were evenly distributed across the three years of study. Just three participating schools offered 50% of all units audited. Clinical assessment skills, and ethics and legal issues were most frequently taught, while human rights issues and preventative health were poorly represented. Only one nursing school involved a person with intellectual disability in content development or delivery.

CONCLUSION

Despite significant unmet health needs of people with intellectual disability, there is considerable variability in the teaching of key intellectual disability content, with many gaps evident. Equipping nursing students with skills in this area is vital to building workforce capacity.

Characteristics influencing attendance at a primary care health check for people with intellectual disability: An individual participant data meta-analysis

BACKGROUND

Health checks benefit adolescents and adults with intellectual disability, however uptake is low despite government-funded incentives.

AIM

To assess the characteristics of people with intellectual disability who, when offered a health check with their primary care physician at no cost, completed the health check.

METHODS AND PROCEDURES

Data from three randomised controlled trials considering health checks in people with intellectual disability living in the community were included in an individual-patient data meta-analysis. The studies used the same health check and the participant characteristics investigated (age, sex, cause of disability, level of disability and socio-economic position) were defined identically, but participants were sourced from different settings: adults living in 24-h supported accommodation, adults living in private dwellings, and school-attending adolescents.

OUTCOMES AND RESULTS

In total 715 participants were offered health checks. Compared to participants with Down syndrome, participants with other known causes of disability were more likely not to attend their health check (odds ratio;95%CI)=(2.5;1.4-4.7), as were participants with no known cause of disability (2.3;1.2-4.3). These associations remained significant after adjusting for potentially confounding variables.

CONCLUSION AND IMPLICATION

Down syndrome was the only characteristic positively associated with health check attendance across all study settings. Future research should focus on strategies to increase health check uptake in this population.

Intellectual disability health content within medical curriculum: an audit of what our future doctors are taught

BACKGROUND

There is a high burden of unmet health needs for people with intellectual disability. Despite experiencing significantly higher rates of morbidity and mortality compared with the general population, this group faces greater barriers to accessing healthcare. While increasing workplace capacity is one way to reduce this inequitable access, previous research indicates a scarcity of undergraduate teaching in intellectual disability. The aim of the study was to determine the extent and nature of intellectual disability content currently offered within medical degree curricula.

METHODS

All Australian universities (n = 20) providing accredited medical training were invited to participate in a two-phase audit via an email invitation to the Dean of each medical school. The Dean's delegate from 14 medical schools completed Phase 1, which involved a questionnaire or telephone interview about the overall medical course structure. Unit coordinators and/or teaching staff from 12 medical schools completed Phase 2, which involved an online survey about intellectual disability content within the curriculum.

RESULTS

In Australia, medical school curricula contain a median of 2.55 h of compulsory intellectual disability content. The majority of universities only offer a small amount of compulsory content. Of compulsory units, intellectual disability teaching is minimal in sexual health and emergency medicine (only one unit offered in one school for each). Topics of key relevance in intellectual disability health such as human rights issues, interdisciplinary team work and preventative health are poorly represented in intellectual disability teaching. Elective content varies markedly across universities (1 to 122 h), but emergency medicine, women's health, men's health and many other specialist medicine areas are not represented. Inclusive practice is inconsistent in degree and nature, but a majority of universities (nine) involve people with intellectual disability in the development or delivery of content.

CONCLUSIONS

There is a mismatch between the considerable unmet health needs of people with intellectual disability and the inconsistent teaching within medical schools. Future doctors will be better equipped to support the health and wellbeing of people with intellectual disability if curricula are enhanced in this area.

Review of Interventions to Enhance the Health Communication of People With Intellectual Disabilities: A Communicative Health Literacy Perspective

BACKGROUND

Communicative health literacy is a term relating to the range of competencies and capabilities patients bring to the task of seeking information about their health and sharing it with others. This exchange can be problematic for people with intellectual disabilities. The aim of this review was to synthesize findings from interventions designed to improve health communication for people with intellectual disabilities.

MATERIALS AND METHOD

Available evidence was systematically reviewed, and findings from 14 articles were synthesized in a narrative review.

RESULTS AND CONCLUSIONS

Interventions addressed communicative aspects of health consultations, taking into account emotional factors and social context. Questions remain about how such interventions might impact on real-life health consultations and how issues of power might be resolved.

Systematic Review of Health Promotion Programs Focused on Behavioral Changes for People With Intellectual Disability

People with intellectual disability (ID) experience high rates of chronic health problems and poor overall health compared to people without disabilities. Recent attention to health risk behaviors such as poor diet, lack of physical activity, and underuse of health care has led to the development of several programs intended to reduce disparities in this population through health promotion programs. A review of the literature was conducted focusing on programs developed to target behavioral changes in the person with ID. Thirteen studies, evaluating 10 different health promotion programs, were found. Programs varied significantly in design, targeted health change, and demonstrated effectiveness. Components of each program are systematically reviewed and recommendations made for future programs based upon the current evidence.

Supporting primary healthcare professionals to care for people with intellectual disability: a research agenda

BACKGROUND

The vast health inequities experienced by people with intellectual disability remain indisputable. Persistent and contemporary challenges exist for primary healthcare providers and researchers working to contribute to improvements to the health and well-being of people with intellectual disability. Over two decades after the only review of supports for primary healthcare providers was published, this paper contributes to an evolving research agenda that aims to make meaningful gains in health-related outcomes for this group.

METHODS

The present authors updated the existing review by searching the international literature for developments and evaluations of multinational models of care.

RESULTS

Based on our review, we present three strategies to support primary healthcare providers: (i) effectively using what we know, (ii) considering other strategies that offer support to primary healthcare professionals and (iii) researching primary health care at the system level.

CONCLUSIONS

Strengthening primary care by supporting equitable provision of health-related care for people with intellectual disability is a much needed step towards improving health outcomes among people with intellectual disability. More descriptive quantitative and qualitative research, as well as intervention-based research underpinned by rigorous mixed-methods evaluating these strategies at the primary care level, which is sensitive to the needs of people with intellectual disability will assist primary care providers to provide better care and achieve better health outcomes.

ACCESSIBLE ABSTRACT

Many people with intellectual disability have poor health. The authors reviewed what has been written by other researchers about how to improve the health of people with intellectual disability. In the future, people who support adults with intellectual disability should continue doing what they do well, think of other ways to improve health, and do more research about health. At all times, the needs of people with intellectual disability should be the greatest concern for those trying to support them.

Health actions prompted by health assessments for people with intellectual disability exceed actions recorded in general practitioners' records

People with intellectual disability experience inadequate health care and have unmet health needs that can go unidentified or be poorly managed. Health assessments have been shown to significantly increase short-term clinical activity for people with intellectual disability. The aim of this study was to more accurately quantify the effect of health assessments for people with intellectual disability by comparing health actions recorded in health assessment booklets to actions recorded in general practitioners’ (GPs) records in the 12-month period following the health assessment. Participants were people with intellectual disability who had received a Comprehensive Health Assessment Program (CHAP), living in the community. The CHAP is a health assessment that is demonstrated to significantly increase health actions, compared with usual care, for people with intellectual disability. Data collected from three randomised controlled trials conducted in South-East Queensland, Australia, from 2000 to 2010 were pooled and analysed. The health assessment booklet contained significantly more information on health actions than GPs’ records. Notably, hearing tests (risk ratio (RR) = 5.9; 95% confidence interval (CI) = 4.7–7.4), breast checks (RR = 3.9; 95% CI = 2.7–5.7), and skin examinations (RR = 7.9; 95% CI = 5.9–10.7) were more likely to be recorded in the CHAP booklet. Health assessments increase health actions for people with intellectual disability to a significantly greater extent than previously demonstrated.

Hand-held health records for individuals with intellectual disability: a systematic review

BACKGROUND

Hand-held health records (HHHRs) aim to empower individuals with intellectual disability (ID) and improve the communication between all those involved in their health care. HHHRs can be used to identify additional health needs and contribute to improved treatment for individuals with ID. This review summarises evidence concerning the use of HHHRs with individuals with ID.

METHODS

Systematic searching of electronic databases and email contact with established researchers in the field were used to identify relevant articles related to the use of HHHRs among individuals with ID.

RESULTS

Seven articles were identified and included for review. Studies involved the development, evaluation, acceptability and facilitators and barriers of implementation of HHHRs. HHHRs did not lead to improved short-term healthcare activity, but did lead to more discussion about health problems, increased health-related knowledge and awareness of personal health issues.

CONCLUSIONS

HHHRs are well accepted among users with ID. However, no short-term benefits were found and future research needs to examine the long-term effects of HHHRs.

Practice nurse health checks for adults with intellectual disabilities: a cluster-design, randomised controlled trial

BACKGROUND

Adults with intellectual disabilities have substantial health inequalities and poor access to health care. We assessed whether practice nurse-delivered health checks could improve the health of adults with intellectual disabilities compared with standard care.

METHODS

In this cluster-design, single-blind, randomised controlled trial, we included general practices in Scotland, UK. From June to December, 2011, we randomly assigned (1:1) these general practices to either health checks plus standard care (health-checks group), or standard care only (control group), and we recruited the patients from these practices. Randomisation was done with stratification by number of GPs per practice and number of registered patients with intellectual disabilities (<20 or ≥20). Two research assistants were masked to allocation, and undertook the review of 9 month medical records and interviews. Participants and carers were not masked. The intervention was one health check designed especially for people with intellectual disabilities delivered by a practice nurse. The objective was improvement in health and health care 9 months after randomisation, and the primary outcome was the incidence of newly detected health needs being met by this timepoint. Whether needs were met was established by the investigators being masked to group allocation. The analysis was by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN43324841.

FINDINGS

Between June 26 and Dec 20, 2011, we recruited 38 practices. 85 participants (from 16 practices) were randomly assigned to intervention and 67 (from 17 practices) to standard care; five of the identified practices did not supply any participants. 83 intervention and 66 standard care participants completed the trial. More newly detected health needs were met in the intervention group than in the control standard care group (median 1 [range 0-8], 76·4% met [SD 36·5] vs 2 [0-11], 72·6% met [35·4]; odds ratio [OR] 1·73 [95% CI 0·93-3·22], p=0·085), although this difference was not significant. Significantly more health monitoring needs were met in the intervention group than standard care (median 2 [0-20], 69·9% [SD 34·2] vs 2 [0-22], 56·8% [29·4], OR 2·38 [95% CI 1·31-4·32, p=0·0053]). The probability that health checks are cost effective was between 0·6 and 0·8, irrespective of the cost-effectiveness threshold level. Costs per patient were -£71·48 for health checks and -£20·56 for standard care. The difference (-£50·92) was not significant [95% CI -434 to 362]. No adverse events were attributable to the intervention.

INTERPRETATION

Health checks given by practice nurses to adults with intellectual disabilities produced health-care improvements that were more conducive to longer-term health than standard care given to this population. The intervention dominated standard care, being both cheaper and more effective. Health-check programmes might therefore be indicated for adults with intellectual disabilities.

FUNDING

Scottish Government Change Fund, NHS Greater Glasgow and Clyde Research and Development.

Assessment of an incentivised scheme to provide annual health checks in primary care for adults with intellectual disability: a longitudinal cohort study

BACKGROUND

People with intellectual disabilities (ID) have many comorbidities but experience inequities in access to health care. National Health Service England uses an opt-in incentive scheme to encourage annual health checks of patients with ID in primary care. We investigated whether the first 3 years of the programme had improved health care of people with ID.

METHODS

We did a longitudinal cohort study that used data from The Health Improvement Network primary care database. We did multivariate logistic regression to assess associations between various characteristics and whether or not practices had opted in to the incentivised scheme.

FINDINGS

We assessed data for 8692 patients from 222 incentivised practices and those for 918 patients in 48 non-incentivised practices. More blood tests (eg, total cholesterol, odds ratio [OR] 1·88, 95% CI 1·47-2·41, p<0·0001) general health measurements (eg, smoking status, 6·0, 4·10-8·79, p<0·0001), specific health assessments (eg, hearing, 24·0, 11·5-49·9, p<0·0001), and medication reviews (2·23, 1·68-2·97, p<0·0001) were done in incentivised than in non-incentivised practices, and more health action plans (6·15, 1·41-26·9, p=0·0156) and secondary care referrals (1·47, 1·05-2·05, p=0·0256) were made. Identification rates were higher in incentivised practices for thyroid disorder (OR 2·72, 95% CI 1·09-6·81, p=0·0323), gastrointestinal disorders (1·94, 1·03-3·65, p=0·0390), and obesity (2·49, 1·76-3·53, p<0·0001).

INTERPRETATION

Targeted annual health checks for people with ID in primary care could reduce health inequities.

FUNDING

National Institute for Health Research.

Out of sight, out of mind? The inclusion and identification of people with intellectual disability in public health research

AIMS

Adults with intellectual disability experience substantial health inequities. Public health research aiming to improve the lives of this population group is needed. We sought to investigate the extent to which a sample of international public health research includes and identifies people with intellectual disability.

METHODS

In this systematic review, we examined a select number of public health journals to determine (1) how often people with intellectual disability are explicitly included in randomised controlled trials (RCTs) and cohort studies and (2) how the presence of intellectual disability is identified and reported.

RESULTS

Among eligible articles in these selected public health journals, it was found that cohort studies passively exclude people with intellectual disability, while RCTs actively exclude this population. Most general population articles that explicitly identified people with intellectual disability did so through self-report or proxy report and databases.

CONCLUSIONS

A more extensive and adequate evidence base relating to the health of this overlooked population group is needed. A useful first step would be for researchers specialising in intellectual disability to identify how we can best assist mainstream researchers to include and identify people with intellectual disability in their population-level studies.

The impact of health checks for people with intellectual disabilities: an updated systematic review of evidence

Health checks for people with intellectual disabilities have been recommended as one component of international health policy responses to the poorer health of people with intellectual disabilities. This review updates a previously published review summarising evidence on the impact of health checks on the health and well-being of people with intellectual disabilities. Electronic literature searches and email contacts were used to identify literature relevant to the impact of health checks for people with intellectual disabilities published from 1989 to 2013. Forty-eight publications were identified, of which eight articles and two reports were newly identified and not included in the previous review. These involved checking the health of people with intellectual disabilities from a range of countries including a full range of people with intellectual disabilities. Health checks consistently led to detection of unmet health needs and targeted actions to address health needs. Health checks also had the potential to increase knowledge of the health needs of people with intellectual disabilities amongst health professionals and support staff, and to identify gaps in health services. Health checks are effective in identifying previously unrecognised health needs, including life threatening conditions. Future research should consider strategies for optimising the cost effectiveness or efficiency of health checks.

Interventions to promote health: crossing networks of intellectual and developmental disabilities and aging

BACKGROUND

People with intellectual and developmental disabilities experience lower levels of healthy behaviors as do older persons, making health promotion a key priority for these populations.

OBJECTIVE

The aim of this paper is to review the two fields of developmental disability and aging health promotion research in order to understand strategies used by both and to identify emerging and innovative practices that disability researchers can learn from each other.

METHODS

We conducted scoping reviews of health promotion intervention peer reviewed articles in English from 1991 to 2011 for intellectual and developmental disabilities and from 2007 to 2011 for the more extensive gerontological literature. Two reviewers extracted data.

RESULTS

The disability review identified 34 studies and three main types of interventions: exercise, multi-component, and health screens. The aging review identified 176 articles which had a wider variety of intervention topics and techniques, with more articles including innovative approaches to bringing interventions to community settings across a wider variety of populations.

CONCLUSIONS

As people with intellectual and developmental disabilities are living longer, disability health promotion can look to the aging literature for ideas to incorporate in future interventions for people with intellectual and developmental disabilities, while the gerontological research can learn from the research in intellectual and developmental disabilities on ways to adapt health promotion interventions to people with cognitive and physical limitations. Use of universal design principles could enable greater inclusion of people with disabilities in health promotion interventions for the general aging population.

Health conditions and their impact among adolescents and young adults with Down syndrome

Objective

To examine the prevalence of medical conditions and use of health services among young adults with Down syndrome and describe the impact of these conditions upon their lives.

Methods

Using questionnaire data collected in 2011 from parents of young adults with Down syndrome we investigated the medical conditions experienced by their children in the previous 12 months. Univariate, linear and logistic regression analyses were performed.

Results

We found that in addition to the conditions commonly experienced by children with Down syndrome, including eye and vision problems (affecting 73%), ear and hearing problems (affecting 45%), cardiac (affecting 25%) and respiratory problems (affecting 36%), conditions also found to be prevalent within our young adult cohort included musculoskeletal conditions (affecting 61%), body weight (affecting 57%), skin (affecting 56%) and mental health (affecting 32%) conditions and among young women menstrual conditions (affecting 58%). Few parents reported that these conditions had no impact, with common impacts related to restrictions in opportunities to participate in employment and community leisure activities for the young people, as well as safety concerns.

Conclusion

There is the need to monitor, screen and provide appropriate strategies such as through the promotion of healthy lifestyles to prevent the development of comorbidities in young people with Down syndrome and, where present, to reduce their impact.

Carer-led health interventions to monitor, promote and improve the health of adults with intellectual disabilities in the community: a systematic review

Using carers to help assess, monitor, or promote health in people with intellectual disabilities (ID) may be one way of improving health outcomes in a population that experiences significant health inequalities. This paper provides a review of carer-led health interventions in various populations and healthcare settings, in order to investigate potential roles for carers in ID health care. We used rapid review methodology, using the Scopus database, citation tracking and input from ID healthcare professionals to identify relevant research. 24 studies were included in the final review. For people with ID, the only existing interventions found were carer-completed health diaries which, while being well received, failed to improve health outcomes. Studies in non-ID populations show that carers can successfully deliver screening procedures, health promotion interventions and interventions to improve coping skills, pain management and cognitive functioning. While such examples provide a useful starting point for the development of future carer-led health interventions for people with ID, the paucity of research in this area means that the most appropriate means of engaging carers in a way that will reliably impact on health outcomes in this population remains, as yet, unknown.

Improving access to electronic health records for people with intellectual disability: a qualitative study

People with intellectual disability represent ~2-3% of the Australian population and experience elevated rates of mortality and morbidity compared with the general population. People with intellectual disability, and their families and carers, must keep track of extensive medical information while also managing turnover of paid staff, general practitioners and other health professionals, making them beneficiaries of Australia's new eHealth record system. Although they are key users, there is a lack of knowledge about the accessibility of the system for individuals with intellectual disability, or those responsible for managing their health information. This is a missed opportunity to improve the lives of an already overlooked group. This study aimed to identify the facilitators and barriers to registering for an eHealth record network for people with intellectual disability and those supporting them to manage their health information. We interviewed potential users of eHealth records, including four people with intellectual disability, three family members and two residential support workers. Our findings suggest that decision-makers involved in the roll-out of the eHealth record networks should incorporate 'reasonable accommodations' to improve accessibility for people with intellectual disability and those who support them to manage their health information. This includes identifying and eliminating the barriers to accessibility of eHealth records and taking appropriate measures to promote access to individuals with intellectual disability. People with intellectual disability and the people who support them are a diverse group with a range of abilities. The translation of their views into practice will help to improve the eHealth system for this and other vulnerable population groups.

General practitioners' views on perceived and actual gains, benefits and barriers associated with the implementation of an Australian health assessment for people with intellectual disability

BACKGROUND

Health assessments for people with intellectual disability have been implemented in the UK, New Zealand and Australia, and have led to improved health outcomes. The Comprehensive Health Assessment Program (CHAP) has been shown to improve the health of people with intellectual disability. Similar to other health assessments, it is designed to address healthcare needs, many of which are often overlooked in this population, through better communication between the general practitioner (GP), support worker and the person with intellectual disability. This study investigates GP views of the perceived and actual benefits, gains and barriers associated with its uptake and use in practice.

METHOD

As part of a larger randomised controlled trial of the CHAP, 46 GPs in Queensland, Australia, completed two telephone interviews that included open-ended questions about their perceptions of the health assessment. The GPs were enrolled in the intervention arm of the trial. Interviews took place at commencement and conclusion of the trial to gain the views of GPs as they experienced using the CHAP. Thematic analysis was used to identify key themes and patterns from the GP responses.

RESULTS

Four themes were identified: better healthcare and uncertain benefits captured GP perceptions of the potential gains associated with use of the CHAP, while two further themes, organisational barriers in the general practice setting and engagement across the healthcare triad highlighted strengths and barriers related to implementation. Anticipated concerns about time raised by GPs at commencement of the trial were borne out in practice, but concerns about communication and cooperation of people with disabilities were not. Matters associated with support worker engagement emerged as an area of concern.

CONCLUSIONS

GPs perceive the CHAP as a structured and comprehensive approach to the detection of medical problems as well as an aid in overcoming communication barriers between the doctor and the person with disability. Our findings suggest that some GPs may find it difficult to predict the benefits of using health assessments such as the CHAP. Achieving optimal uptake is likely to require attention at policy and systems levels to address: GP time constraints in providing healthcare to this population; enhancement of support worker training and organisational structures to encourage comprehensive health assessment and follow-up activities; and GP awareness of the improved health outcomes shown to derive from the use of comprehensive health assessments.

Medication use among Australian adults with intellectual disability in primary healthcare settings: a cross-sectional study

BACKGROUND

There is concern about widespread medication use by people with intellectual disability (ID), especially psychotropic and anticonvulsant agents. However, there is sparse information on prescribing patterns in Australia.

METHOD

This cross-sectional study was conducted between 2000 and 2002 among adults with ID who live in the community in Brisbane, Australia. Medication data were extracted from a health screening tool. Demographic and medical data were collected from telephone interviews and medical records.

RESULTS

Of 117 participants, 35% were prescribed psychotropic medications, most commonly antipsychotics, and 26% anticonvulsants. Complementary medications (vitamins, minerals, amino acids, fish oil, and herbal products) were used by 29% of participants. After adjusting for potentially confounding variables, psychotropic medication use was significantly associated with having a psychiatric illness (adjusted odds ratio = 4.6, 95% CI [1.0, 20.6]) and challenging behaviours (4.4, [1.1, 17.3]).

CONCLUSIONS

People with ID use a broad range of medications. Psychotropic medications continue to be the most predominant agents prescribed for this population. Psychotropic medication use is positively associated with having a psychiatric illness and challenging behaviours.