Children´s priorities to improve the acceptability of MDR-TB treatment: qualitative data from South Africa.

BACKGROUND: Multidrug-resistant TB (MDR-TB) treatment for children frequently includes unpalatable drugs with low overall acceptability. This can negatively impact children and their caregivers´ treatment experiences and is an important contributor to poor adherence, and potentially, poor treatment outcomes. Children and their caregivers´ preferences for MDR-TB treatment are not well documented. We describe children and caregivers´ priorities to inform future MDR-TB treatment regimens.METHODS: We conducted a cross-sectional qualitative study at a TB hospital in South Africa using semi-structured interviews and participatory research activities with caregivers and children routinely diagnosed and treated for MDR-TB between June and August 2018.RESULTS: We conducted 15 interviews with children and their caregivers. Children ranged from 2 to 17 years of age (median age: 8.3 years). Children and caregivers had an overall negative experience of MDR-TB treatment. Children and caregivers described how future MDR-TB drugs and regimens should prioritise sweeter flavours, fewer pills, brighter colours, and formulations that are easy to prepare and administer and dispensed in colourful, small and discrete packaging.CONCLUSIONS: MDR-TB treatment acceptability remains low, and negatively impacts children and their caregivers´ treatment experiences. Improving the overall acceptability of MDR-TB treatment requires engaging with children and their caregivers to better understand their priorities for new treatment regimens and child-friendly formulations.

Reasons for poor uptake of TB preventive therapy in South Africa.

BACKGROUND: South Africa has one the highest TB and HIV burdens globally. TB preventive therapy (TPT) reduces the risk of TB disease and TB-related mortality in adults and children living with HIV and is indicated for use in TB-exposed HIV-negative individuals and children. TPT implementation in South Africa remains suboptimal. METHODS: We conducted a pragmatic review of TPT implementation using multiple data sources, including informant interviews (n = 134), semi-structured observations (n = 93) and TB patient folder reviews in 31 health facilities purposively selected across three high TB burden provinces. We used case descriptive analysis and thematic coding to identify barriers and facilitators to TPT implementation. RESULTS: TPT programme implementation was suboptimal, with inadequate monitoring even in health districts with well-functioning TB services. Health workers reported scepticism about TPT effectiveness, deprioritised TPT in practice and expressed divergent opinions about the cadres of staff responsible for implementation. Service- and facility-level barriers included ineffective contact tracing, resource shortages, lack of standardised reporting mechanisms and insufficient patient education on TPT. Patient-level barriers included socio-economic factors. CONCLUSIONS: Improving TPT implementation will require radically simplified and more feasible systems and training for all cadres of health workers. Partnership with communities to stimulate demand driven service uptake can potentially facilitate implementation.

CONTEXTE: L'Afrique du Sud a l'une des charges de TB et de VIH les plus élevées au monde. La thérapie préventive contre la TB (TPT) réduit le risque de TB maladie et de mortalité liée à la TB chez les adultes et les enfants vivant avec le VIH et est indiquée chez les personnes et les enfants séronégatifs exposés à la TB. La mise en œuvre du TPT en Afrique du Sud reste sous-optimale. MÉTHODES: Nous avons procédé à un examen pragmatique de la mise en œuvre du TPT à l'aide de plusieurs sources de données, notamment des entretiens avec des informateurs (n = 134), des observations semi-structurées (n = 93) et des examens de dossiers de patients atteints de TB dans 31 établissements de santé sélectionnés à dessein dans trois provinces fortement touchées par la TB. Nous avons utilisé une analyse descriptive des cas et un codage thématique pour identifier les obstacles et les facilitateurs de la mise en œuvre du programme TPT. RÉSULTATS: La mise en œuvre du programme TPT était sousoptimale, avec un suivi inadéquat, y compris dans les districts sanitaires où les services de lutte contre la TB fonctionnaient correctement. Les agents de santé ont fait part de leur scepticisme quant à l'efficacité de la TPT, n'ont pas accordé la priorité à la TPT dans la pratique et ont exprimé des opinions divergentes sur les cadres du personnel responsables de la mise en œuvre. Les obstacles au niveau des services et des établissements comprennent l'inefficacité de la recherche des contacts, la pénurie de ressources, l'absence de mécanismes de déclaration standardisés et l'insuffisance de l'éducation des patients sur la TPT. Les obstacles au niveau des patients comprenaient des facteurs socio-économiques. CONCLUSIONS: L'amélioration de la mise en œuvre des TPT nécessitera des systèmes radicalement simplifiés et plus réalisables ainsi qu'une formation pour tous les cadres du personnel de santé. Un partenariat avec les communautés pour stimuler l'adoption de services axés sur la demande peut potentiellement faciliter la mise en œuvre.

Relationship between theory of mind and language ability in children and adolescents with intellectual disability.

BACKGROUND: The present study was designed to evaluate the validity of the false belief task as a measure of theory of mind development in individuals with intellectual disability (ID). In most if it variants, the false belief task is linguistically demanding. This raises the possibility that the finding that individuals with ID do poorly on it might reflect language difficulties rather than theory of mind difficulties. Complicating matters further, however, is the fact that there are theoretical reasons to suppose that there might be a relationship between some dimensions of language ability and theory of mind development in individuals with ID (as well as in other populations). METHOD: In the present study, children and adolescents with ID and typically developing (non-verbal) mental age matches completed a standard false belief task and several tasks designed to measure language ability. RESULTS: We reasoned that a pattern in which false belief performance was correlated with all measures of language ability would reflect an artefactual relationship, whereas a more highly circumscribed, theoretically sensible pattern of correlations that was similar across both groups would support the validity of the false belief task. CONCLUSIONS: The results indicated that for individuals with ID who have limited narrative language skills, those limitations contribute substantially to their failure on the false belief task. For individuals with ID who have more highly developed narrative language skills (about 40% of the sample tested), however, the false belief task may provide a valid measure of their progress towards acquiring an adequate theory of mind. This latter conclusion was suggested by the fact screening out individuals who failed to meet linguistic and cognitive prerequisites for dealing with the performance demands of the false belief task yielded non-significant correlations between false belief performance and the language measures for both the group with ID and the typically developing comparison group.

Parental scaffolding of the discourse of children and adolescents with intellectual disability: the case of, referential expressions.

Individuals with intellectual disability find the process of establishing referents to be an especially challenging component of discourse. The present study was designed to examine whether these problems partly result from a failure of parents to appropriately scaffold the discourse participation of individuals with intellectual disability. Children and adolescents with intellectual disability and their parents participated in two dyadic non-face-to-face referential tasks which afforded parents an opportunity to scaffold their children's behaviour as speaker and as listener. Comparisons were made with parents and their typically developing children who completed the same tasks. It was found that the parents of individuals with intellectual disability scaffolded their children's discourse participation to the same extent, as effectively and in the same manner as the parents of the typically developing children. The former were also found to adjust their scaffolding according to their children's level of behavioural competence. In summary, there is no evidence that parents contribute to the referential problems of individuals with intellectual disability.

Understanding referential expressions in context: use of common ground by children and adolescents with mental retardation.

Listeners interpret utterances against the common ground, or network of presuppositions shared with the speaker. The first purpose of the study was to determine whether individuals with mental retardation use the major sources of common ground (i.e., physical copresence, linguistic copresence, and community membership) to resolve referential ambiguity. The second purpose was to determine whether they seek confirmation of their referent choices in accordance with the certainty of interpretation afforded by the common ground. The third purpose was to determine whether they signal noncomprehension when faced with ambiguity and common ground that is not informative. The final purpose was to evaluate the relationship between within-group variability in common ground use and measures of nonverbal cognition, receptive and expressive language, and social cognition. Participants were school-age individuals with mental retardation and typically developing children matched to them on nonverbal MA. Common ground use was examined in a role-playing task in which the participant responded to ambiguous utterances. Common ground was manipulated within participants. We determined whether referent selections were appropriate for the common ground, whether they were accompanied by confirmation requests, and whether noncomprehension was signaled. Both groups used all sources of common ground to resolve referential ambiguity at better than chance levels but were less successful in using community membership. Both groups also requested confirmation of their referent choices most often when the common ground was based on community membership. Both groups signaled noncomprehension when the common ground was not informative. Different aspects of common ground use were related to different predictors for the group with mental retardation.

Preschoolers' communication during scripted interactions.

The communicative interactions of 15 dyads of four- to five-year-olds during pretend play involving routine, or scripted, events were investigated as a function of the children's knowledge of the scripts. Measures of the quantity and quality of interaction and the strategies that the children used to establish mutual knowledge (i.e. assess and adapt to their discourse partner's level of expertise), which is essential to good communication, were examined. Each dyad participated in a MATCHED condition (both members had extensive knowledge of the script) and a MISMATCHED condition (one member had extensive script knowledge and the other did not). Shared script knowledge facilitated communicative interactions, as indicated by more topic maintenance and fewer requests for clarification in the matched condition than in the mismatched condition. The children attempted to establish mutual knowledge more frequently in the mismatched condition than in the matched condition and, moreover, mutual knowledge establishment was related to the children's communicative effectiveness.

Signaling of noncomprehension by children and adolescents with mental retardation: effects of problem type and speaker identity.

Previous research has demonstrated considerable within-individual and within-group variability in the signaling of noncomprehension by persons with mental retardation. The first purpose of this study was to determine whether within-individual variability in such signaling was related to differences in the nature of the inadequate message and the identity of the speaker. The second purpose was to evaluate the relationship between within-group variability in noncomprehension signaling and measures of cognition, receptive and excessive language ability, speech intelligibility, and social cognition. Participants were school-age individuals with mild mental retardation and typically developing children matched to them on nonverbal MA. Noncomprehension signaling was examined in a direction-following task in which inadequate message type and speaker were manipulated. It was found that message type, but not speaker, influenced noncomprehension signaling, with no difference between the two groups. We also found that performance on a test of receptive language ability was the best predictor of noncomprehension signaling for persons with mental retardation.