How Toddlers Use Core and Fringe Vocabulary: What's in an Utterance?

PURPOSE: Selecting vocabulary for preliterate individuals who use augmentative and alternative communication presents multiple challenges, as the number of symbols provided must be balanced with cognitive, motoric, and other needs. Prioritizing certain types of vocabulary thus becomes a necessity. For example, prioritizing core vocabulary-that is, words that are commonly used across a group of people and contexts-is a common practice that attempts to address some of these issues. However, most core vocabulary research to date has narrowly focused on individual word counts, ignoring other critical aspects of language development such as how vocabulary aligns with typical development and how children use core and fringe vocabulary within their utterances. METHOD: Descriptive and inferential statistics were used to analyze 112 transcripts to describe how typically developing toddlers (aged 2.5 years) use core and fringe vocabulary within their utterances, in reference to a range of commonly used core vocabulary lists. RESULTS: Results indicated that the proportion of the toddlers' utterances that consisted of only core, only fringe, or core + fringe vocabulary varied dramatically depending on the size of the core vocabulary list used, with smaller core lists yielding few "core-only" utterances. Furthermore, utterances containing both core and fringe vocabulary were both grammatically and semantically superior to utterances containing only core or only fringe vocabulary, as evidenced by measures such as mean length of utterance and total number of words. CONCLUSION: Thus, relying on word frequency counts is an insufficient basis for selecting vocabulary for aided preliterate communicators.

Applying a Developmental Model to Preliterate Aided Language Learning.

PURPOSE: Childhood spoken language interventions and augmentative and alternative communication (AAC) interventions share a common purpose: maximizing communication and language outcomes. To ensure that interventions for children who require AAC also address expressive language acquisition, this clinical focus article focuses on how to apply a developmental model of language acquisition to guide AAC decision making for preliterate aided communicators, with a particular focus on vocabulary selection. METHOD: A brief review of early expressive language development is presented, along with arguments for why relying on a developmental model to guide AAC decision making is so critical. A series of detailed examples of how to apply a developmental model to various AAC vocabulary selection approaches are provided, including analyses of how well each approach aligns with pragmatic, semantic, grammatical, and narrative development. CONCLUSIONS: No single AAC approach for preliterate AAC language learners adequately addresses both immediate and longer-term expressive language needs; every approach has both strengths and weaknesses. Clinical decision making requires an analysis of each approach to ensure that AAC service delivery teams clearly understand the inevitable linguistic gaps, with plans put into place to fill in those gaps with different approaches. Future efforts to improve preliterate AAC service provision should use a developmental model of language as a starting point, in combination with input from families, educators, and clinicians to ensure the feasibility of the chosen approaches.

Understanding the audience in framing research: empirical evidence from three studies examining HIV framing in China.

Guided by framing theory, this three-phase mixed-methods study explored (a) how Chinese government-sponsored newspapers frame HIV and (b) framing effects on people's HIV beliefs. A content analysis of two government-sponsored newspapers and a survey of 210 readers showed discrepancies in frame and frame valence. In-depth follow-up interviews with 15 media and public health experts revealed that the discrepancies were related to people's attitudes toward the media and beliefs about HIV, which could further be explained by the political environment, media ecology, historical framing, and cultural identities in China. We discuss theoretical implications for framing theory and practical implications for HIV media coverage.

Oncologists' Perceptions of Strategies for Discussing the Cost of Care with Cancer Patients and the Meaning of Those Conversations.

To better understand what makes cost-of-care communication between oncologists and cancer patients more or less successful, we conducted in-depth interviews with 32 oncologists (22 male, 10 female) who were board-certified in medical, surgical, or radiation oncology. Through qualitative descriptive analysis by four coders, we found that oncologists used six broad strategies to discuss cost with patients: open discussion, avoidance, reassurance, warning, outsourcing, and educating. We also found that oncologists invoked certain meanings of cost conversations: cost conversations as holistic care, coercion, a matter of timing, risking patient suspicions, advocacy, unwanted distraction, transparency, bad news delivery, problem-solving, pointless, informed decision making, or irrelevant. These meanings appeared to be linked to oncologists enacting certain strategies (e.g., oncologists who invoked cost conversations as holistic care tended to enact open discussion, those who saw cost conversations as risky tended to use avoidance). Theoretically, our results suggest that the invoked meaning of a difficult conversation may be a key explanatory mechanism for differentiating high-quality from low-quality communication in cost conversations. Practically, our findings suggest that oncologists should consider how well the invoked meaning of the cost conversation is serving their own and their patients' goals.

Patients' attitudes toward deprescribing and their experiences communicating with clinicians and pharmacists.

Purpose: Developing effective deprescribing interventions relies on understanding attitudes, beliefs, and communication challenges of those involved in the deprescribing decision-making process, including the patient, the primary care clinician, and the pharmacist. The objective of this study was to assess patients' beliefs and attitudes and identify facilitators of and barriers to deprescribing. Methods: As part of a larger study, we recruited patients ⩾18 years of age taking ⩾3 chronic medications. Participants were recruited from retail pharmacies associated with the University of Kentucky HealthCare system. They completed an electronic survey that included demographic information, questions about communication with their primary care clinician and pharmacists, and the revised Patients' Attitudes Toward Deprescribing (rPATD) questionnaire. Results: Our analyses included 103 participants (n = 65 identified as female and n = 74 as White/Caucasian) with a mean age of 50.4 years [standard deviation (SD) = 15.5]. Participants reported taking an average of 8.4 daily medications (SD = 6.1). Most participants reported effective communication with clinicians and pharmacists (66.9%) and expressed willingness to stop one of their medications if their clinician said it was possible (83.5%). Predictors of willingness to accept deprescribing were older age [odds ratio (OR) = 2.99, 95% confidence interval (CI) = 1.45-6.2], college/graduate degree (OR = 55.25, 95% CI = 5.74-531.4), perceiving medications as less appropriate (OR = 8.99, 95% CI = 1.1-73.62), and perceived effectiveness of communication with the clinician or pharmacist (OR = 4.56, 95% CI = 0.85-24.35). Conclusion: Adults taking ⩾3 chronic medications expressed high willingness to accept deprescribing of medications when their doctor said it was possible. Targeted strategies to facilitate communication within the patient-primary care clinician-pharmacist triad that consider patient characteristics such as age and education level may be necessary ingredients for developing successful deprescribing interventions. Plain Language Summary: Are patients willing to accept stopping medications? Sometimes, medicines that a patient takes regularly become inappropriate. In other words, the risks of adverse effects might be greater than a medicine's potential benefits. The decision to stop such medicines should involve the patient and consider their preferences. We surveyed a group of patients taking multiple medicines to see how they felt about having those medicines stopped. We also asked patients whether and how much they talk to their primary care clinician and pharmacists about their medicines. To qualify for this study, patients had to be at least 18 years old and to take three or more medicines daily; they also needed to speak English. Participants provided demographic information and answered questions about their medicines, their communication with primary care clinicians and pharmacists, and their feelings about having one or more of their medicines stopped. We recruited 107 people and were able to use responses from 103 of them. Their average age was 50 years; 65 of them identified as female, and 75 identified as White/Caucasian. Most of our participants mentioned having conversations with primary care clinicians and pharmacists and said they would be willing to stop a medication if their clinician said it was possible. Older participants, those with more years of education, those who thought their medications might lead to side effects, and those who communicated with their clinician or pharmacists were more willing to have one of their medicines stopped.Our results indicate that patient characteristics and communication with clinicians and pharmacists are factors to consider when designing interventions to reduce the use of inappropriate medicines.

Aided Language Measures: Establishing Observer Agreement for Communicators in Early Language Phases.

PURPOSE: Although many valid, reliable, and developmentally sensitive measures exist to monitor the language gains of children who rely on spoken language to communicate, the same is not true for graphic symbol communicators. This study is a first step in developing such measures by examining the interobserver agreement (IOA) and within-observer agreement of 13 measures designed to monitor the language progress of children who use aided augmentative and alternative communication (AAC). These measures are based on the Graphic Symbol Utterance and Sentence Development Framework (Binger et al., 2020) and are hypothesized to capture various phases of graphic symbol communication. METHOD: Four graduate student observers coded 13 measures across 57 different play-based sessions of children with Down syndrome ages 3;0-5;11 (years;months). For IOA, sessions were coded by two different observers. For within-observer agreement, all sessions were recoded by the same coders. Corpus-level analyses were completed to characterize the nature of the samples (e.g., average mean length of utterance for the samples). IOA and within-observer agreement were examined for each utterance. RESULTS: Across all observers and measures, acceptable levels of IOA and within-observer agreement were achieved, with most measures yielding relatively high levels of agreement. Some differences were noted across measures, with the less experienced coders demonstrating less agreement on select measures. CONCLUSIONS: Results provide initial evidence that many measures based on the Graphic Symbol Utterance and Sentence Development Framework can be reliably coded. These findings are a first step in developing psychometrically sound measures to monitor the expressive language progress of children who use AAC. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19601551.

Examining gain- and loss-framed messages in a novel breast cancer screening/cardiovascular context: Does framing matter?

Objective: Digital mammography can reveal not only breast cancer but also breast arterial calcification (BAC), which can indicate potential coronary artery disease. To explore ways to inform women of their BAC status in the context of a standard mammography results letter, we conducted a preliminary study comparing gain- and loss-framed messages to encourage follow-up cardiovascular care. Methods: U.S. women over age 40 with no heart disease history (N = 227) were randomly assigned to view a mammography letter including BAC information in one of seven ways (three gain-framed messages, three loss-framed messages, one comparison message). Results: Post-test measures indicated no significant differences on BAC knowledge, recall of test results and recommendations, perceived message effectiveness, or behavioral intentions for follow-up. Conclusion: Despite showing no significant differences between message conditions, results supported the messages' ability to clearly convey BAC information and encourage intention for follow-up cardiovascular care. Innovation: This experimental study represents the first published report examining the inclusion of BAC screening results within the mammography letter. It also explored the use of message framing in a dual detection-prevention context and suggests that future work should test the effects of including both framing tactics in messages designed to target dual-focus contexts.

Identifying Conversational Strategies for Psychiatrists in Discussing Substance Use with Adolescent Patients.

Child and adolescent psychiatrists are uniquely positioned to discuss substance use with high risk patients; however, there has been little research about these conversations and their characteristics. To identify communication strategies for navigating conversations about substance use with adolescent patients, we conducted 21 in-depth interviews with practicing child and adolescent psychiatrists. Findings from this study identify four strategies that child and adolescent psychiatrists reported as being successful: expressing empathy, avoiding resistance, honoring autonomy, and managing family involvement. In addition to describing these strategies, we briefly describe a theoretical framework that might help to explain the perceived success of these strategies, and we offer recommendations for how to apply our findings to improve psychiatric practice.

A Model of Determinants Influencing the Development of Child and Adolescent Psychiatrist Self-efficacy for Discussing Substance Use with Patients.

Child and adolescent psychiatrists are well situated to have meaningful conversations with a population at high risk of substance use: youth receiving psychiatric care. However, there has been a dearth of research about behavioral determinants that may influence psychiatrists' willingness to engage in these discussions. This study proposes a model of determinants to help identify influences on psychiatrists' levels of self-efficacy, which theoretically should predict their discussions about substance use. A national survey of child and adolescent psychiatrists was conducted to gather data to test this model, which predicted that training, past experiences with substance use discussions, and communication apprehension would influence self-efficacy. Results showed that the model was an excellent fit to the data, accounting for 49% of the variance in self-efficacy. We discuss how these findings could inform future training initiatives for child and adolescent psychiatrists.

Evaluation of a medication optimization intervention and predictors of medication adherence, patient satisfaction and medication adverse events in patients with rheumatoid arthritis.

BACKGROUND: Because effective treatment for rheumatoid arthritis (RA) is dependent on medication use, medication optimization is critically important. Medication adherence, patient satisfaction with care and medication adverse events are core concepts of medication optimization that are either a significant problem and/or understudied in patients with RA. OBJECTIVE: To (1) evaluate treatment effects from a medication optimization intervention; (2) assess treatment differences and changes over time in medication adherence, patient satisfaction, and medication adverse events; and (3) to determine whether age, gender, provider trust, and disease activity affect these outcomes. METHODS: We conducted a prospective, longitudinal intervention study (N = 143 RA patients) using repeated measures models. RESULTS: We did not identify significant intervention effects. For both the medication adherence and patient satisfaction models, the significant predictors in the model included age, gender and trust in provider. Older age, female gender (relative to male), and greater trust in the provider were associated with increased medication adherence scores and patient satisfaction. For the adverse events model, the only significant predictor in the model was gender. Compared with males, females were more likely to report experiencing adverse events. Time was significantly associated with decreased experiences of adverse events. CONCLUSION: This study has identified important predictors of medication adherence, patient satisfaction and medication adverse events in a sample of patients with RA which can facilitate targeted approaches to improve adherence in those high-risk groups.

Competencies for Health Communication Specialists: Survey of Health Communication Educators and Practitioners.

For more than two decades, health communication educators and practitioners have been working toward establishing a competency model to guide health communication education. This article reports the results of a survey to identify competencies for health communication specialists with master's degrees. To prepare the survey, a working group drafted a competency list through reviewing the literature and soliciting feedback from attendees at a professional society meeting, resulting in lists of items reflecting 18 knowledge domains, 11 skill sets, and 14 application bundles labeled "abilities." The survey asked participants to rate the 43 items in terms of their importance and provide their opinions about the preparation of health communication specialists. The survey was disseminated online through professional associations and completed by 142 participants (74 educators and 68 practitioners). Nearly all of the 43 items were rated "somewhat important" or higher. The lists were reduced to 10 knowledge domains, three skill sets, and five abilities through factor analyses. Replication of the findings and triangulation with studies employing different research methods will help advance this line of inquiry.

Using the ImPAACT program with preschoolers with Down syndrome: a hybrid service-delivery model.

Three parents of preschool-aged children with Down syndrome using mobile augmentative and alternative communication (AAC) technologies to communicate participated indirect, systematic communication-partner instruction. Intervention featured an adaptation of the ImPAACT Program (Improving Partner Applications of Augmentative Communication Techniques; Kent-Walsh, Binger, & Malani, 2010) that included six face-to-face and three telepractice sessions. Parents learned to use the evidence-based Read-Ask-Answer (RAA) instructional strategy (Kent-Walsh, Binger, & Hasham, 2010) during shared storybook reading with their children. A single-case, multiple-probe across participants design was used to assess parents' accurate implementation of the instructional strategy and children's multimodal communicative turns. All three parents increased their use of the RAA strategy and maintained strategy use over time, and all three children increased their frequency of communicative turns taken and maintained higher turn-taking rates. Results support the use of the ImPAACT Program with parents of children with complex communication needs, including the integration of hybrid learning as part of the instructional approach.

Are Cost-of-Care Conversations Best Practice? A Qualitative Study of Oncologists' Attitudes and Practice.

PURPOSE: Patients' desire for cost conversations exceeds the incidence of such conversations, and many oncologists report avoiding cost conversations despite reporting willingness to have them. Our objective was to examine oncologists' attitudes toward cost conversations and how those attitudes affect practice. METHODS: An experienced investigator conducted individual interviews with oncologists practicing in Kentucky. Participants were asked about their attitude toward and experience with cost conversations and their advice for discussing cost with patients. Interview transcripts were analyzed by a four-member team using qualitative descriptive analysis to identify themes. RESULTS: Participants were 32 MDs (male = 68.8%) age 31-77 years who were board-certified in medical oncology (53.1%), surgical oncology (25.0%), or radiation oncology (21.9%). We categorized participants into two groups: (1) those who viewed cost conversations as best practice and reported pursuing such conversations (37.5%) and (2) those who viewed cost conversations as not best practice and reported avoiding them (62.5%). Our analysis revealed three parallel themes for each category: Cost conversation attitudes and practice were based on (1) making good treatment decisions, (2) being a good clinician, and (3) having a good relationship with patients. CONCLUSION: Not all oncologists view cost conversations as best practice. To improve cost conversation attitudes and practice, cost conversations can be framed as a strategic tool that-when used well-fosters optimal decision making, professionalism, and the therapeutic relationship.

Understanding Beliefs, Intention, and Behavior on Daily PrEP Uptake Among MSM in California and New York.

Pre-exposure prophylaxis (PrEP) is an effective daily prevention medicine to reduce the risks of HIV infections. Even though the number of PrEP users has been rapidly growing in the United States since 2012, only approximately 5% of the men who have sex with men (MSM) population is currently taking PrEP. This study examined PrEP uptake among MSM using the integrative model of behavioral prediction (IMBP) as the theoretical framework. The authors conducted formative elicitation interviews and a cross-sectional survey with MSM. Among the survey respondents, half of them were PrEP takers and half were not. The path modeling results showed that attitudes and norms predicted behavioral intention, and intention predicted PrEP uptake among MSM. The results also identified the strongest attitudinal predictors and normative referents of PrEP uptake. The study offers practical implications in helping professionals and scholars to understand PrEP uptake among MSM in a theoretically grounded way.

Primary Care Physicians' Strategic Pursuit of Multiple Goals in Cost-of-Care Conversations with Patients.

Despite the importance of cost-of-care conversations between physicians and patients, such discussions are not well understood. We used multiple goals theory to examine the specific goals that are salient in these discussions and how physicians pursue these goals. We used qualitative descriptive coding to analyze the verbatim transcripts from in-depth interviews with 36 primary care physicians. Our analysis identified a number of goals that are commonly salient in cost conversations, including task goals (reducing the cost of care, making treatment decisions, and promoting patient adherence), identity goals (reinforcing their professional identity as a "good doctor," acting as a steward of medical resources, being an advocate for patients, and preventing patient embarrassment), and relational goals (strengthening the physician-patient relationship and mitigating damage to the physician-patient relationship). In addition, participants articulated a number of ways in which these goals compete with each other, making cost conversations challenging. We found that physicians use a common repertoire of rhetorical strategies to manage these goals, including directly addressing cost, avoiding discussion of cost, and falsely reassuring patients about cost concerns. Our analysis revealed that the meaning of the cost conversation explains the connection between physicians' goals and strategies. Specifically, we found that physicians invoke polysemic meanings of cost conversations to achieve their multiple goals using seemingly contradictory strategies. The results of our analysis have implications for building theory and improving practice.

Intention to Behavior: Using the Integrative Model of Behavioral Prediction to Understand Actual Control of PrEP Uptake Among Gay Men.

PrEP is an effective daily prevention medicine used to reduce risks of HIV infections. Previous research has pointed out the intention-behavior gap on PrEP uptake among gay men. The current study built on research examining how the integrative model of behavioral prediction (IMBP) factors influences PrEP uptake among gay men to explore how actual control variables, namely skills and environmental constraints, moderated the intention-behavior relationship. We used results from formative interviews to construct a survey and collected data from 420 gay men. Results showed several factors that were associated with PrEP uptake among gay men. Specifically, the lack of access to an LGBTQ-friendly healthcare provider(s) and lack of English fluency had significant main effects on PrEP uptake behavior, while lack of access to a healthcare provider and lack of healthcare system knowledge were significant moderators of the intention-behavior relationship. This study advances our understanding of the IMBP and offers practical implications for PrEP promotion. Limitations and suggestions for future studies are discussed.

On Changing Beliefs in the Closed Human Mind.

About a hundred years ago, the world was faced with a pandemic that would ultimately infect 500 million people and kill 50 million. Today, we face a potentially similar situation. Although at times like these, the discipline of communication is essential to promoting public health and welfare through its knowledge of persuasive messaging and mass communication campaigns, to increase our effectiveness, we need to be more aware of and better account for the influence of political ideology on response to messaging. In this essay, I look to lessons from the foundation of our discipline and draw on a variety of ideas across psychology, cognitive science, and linguistics to suggest a way forward.

Working toward evidence-based guidelines for cost-of-care conversations between patients and physicians: A systematic review of the literature.

RATIONALE: As healthcare costs continue to rise, so does the importance of having cost-of-care conversations during medical office visits, especially for patients from vulnerable populations and patients with high-cost illnesses such as cancer. Such conversations remain relatively rare, however, even though physicians and patients say they want to have them. Furthermore, there is a lack of evidence-based guidelines for encouraging cost conversations and improving their quality. OBJECTIVE: The purpose of this project was to conduct a systematic review of the cost-of-care conversations literature, focusing on empirical studies to characterize the state of the literature and provide a foundation for developing evidence-based guidelines for these important conversations. METHOD: We searched seven electronic databases and identified an initial list of 1,986 records, 54 of which met inclusion criteria. We reviewed those articles to identify study purpose, use of theory, conceptual and operational definitions of cost conversations, sample characteristics, research methods, variables relevant to cost conversations, and relevant study findings. RESULTS: Results revealed that this literature (a) consists overwhelmingly of cross-sectional survey research set in the United States, (b) defines cost conversations chiefly as those focused on healthcare or medication costs (either in general or out-of-pocket), (c) is focused primarily on establishing incidence/frequency of cost conversations but also considers patient/provider desire for, attitudes/beliefs toward, and perceived barriers to cost conversations, and (d) lacks theoretical guidance. There were very few findings that could provide actionable evidence to guide quality conversations about reducing cost of care. We offer observations and recommendations for the next steps in cost conversations research so that patients and physicians can work together to promote quality care at affordable costs.

Tracking Early Sentence-Building Progress in Graphic Symbol Communication.

Purpose As is the case with children who rely on spoken language, speech-language pathologists must support and track the expressive language development of children with complex communication needs who use graphic symbols to communicate. This research note presents a framework of the progression of expressive English sentence development using graphic symbols and introduces possible approaches for measuring and analyzing graphic symbol use. Method Current issues in measuring graphic symbol utterances are explored, and a range of measures designed to analyze individual graphic symbol utterances as well as larger samples of utterances are presented. Results Both the Graphic Symbol Utterance and Sentence Development Framework and suggested measures are based on years of graphic symbol intervention research, including two large ongoing research studies of preschoolers with severe speech impairments. Our framework adapts the work of Hadley (2014) to depict expressive language progression from early symbol combinations to childlike and adultlike sentences and highlights developmental patterns unique to graphic symbol productions. Adaptations of existing measures (such as mean length of utterance) as well as measures unique to graphic symbol analyses are presented and discussed. Conclusion To accurately track changes in early graphic symbol utterance growth and complexity, a multidimensional approach, which includes analyses such as symbol relevance, word class diversity, and lexical diversity, is recommended.