Elucidating managerial, staff and client perspectives on the Speech and Language Therapy service in Malta.

BACKGROUND: Speech and language therapy (SLT) services are fundamental for communication, academic and social development. Evidence shows that demand for services is increasing, and this can adversely affect the quality of care. There are limited published studies in relation to the demand and quality of speech and language services in Malta. AIMS: To elucidate the perspectives of speech-language pathologists (SLPs), service managers and parents of clients about the impact of factors pertaining to human resource development (HRD), human resource management (HRM) and the environment on the quality of the children's SLT service in western Malta. Also, to outline the beneficial strategies or recommendations to improve the quality of the service provided. METHODS & PROCEDURES: A mixed-method study was used. Quantitative data provided by the Speech and Language Center (SLC) were analysed to determine demand over time using descriptive statistics. Qualitative data from one-to-one interviews using a bespoke questionnaire with managers, SLPs and parents were transcribed and analysed. Common and distinct themes in relation to the quality of services were then formulated and evaluated. OUTCOME & RESULTS: Quantitative results highlighted that clients were not receiving the required number of the therapeutic sessions. In total, nine themes in relation to the quality of the SLT service were identified by parents, SLPs and managers. The factors affecting the service quality were outlined and subdivided under three branches: HRD, HRM and the environment. All factors within these subgroups are expected to enhance the quality of the service provided if they are enhanced and improved upon. Additionally, the results showed that a discrepancy between the perceived and offered SLT services was felt from the managers' and SLPs' perspectives; however, this was not felt by parents. For parents, the main concern was the availability and frequency of the therapeutic sessions provided. CONCLUSION & IMPLICATIONS: Insights from SLPs, managers and parents of clients highlighted the barriers and enablers of quality of service in SLT services for children. These findings can be used to improve services in Malta and other countries with similar contexts, mainly by altering time management, reducing demands and improving availability. WHAT THIS PAPER ADDS: What is already known on the subject SLT is proven to enhance a child's communication skills. Increasing demands for therapy can affect the quality of the service provided, ultimately affecting the child's progress. There is a gap in the evidence base regarding the quality of speech and language services for children in Malta and the factors which affect the quality of the service. What this study adds to the existing knowledge This is the first study of its kind in Malta. It seeks to identify the quality of SLT services for children from three different perspectives: service managers, SLPs and parents. In addition, this study investigated what affects the quality of SLT services positively or negatively. Through this study, the impeding factors were divided into three domains; HRD factors, HRM factors and environmental factors. These domains were mentioned by all three groups of participants because they affected the service negatively or positively. The main negative aspects included bad time management, high demands, and reduced availabilities and accessibilities, whilst positive aspects included improved support, relationships and the environment. What are the practical and clinical implications of this work? This study suggests reducing the managerial and administrational demands on SLPs and improving session frequency would enhance the quality of service. In relation to the three domains, the HRD factors that would enhance the quality of service are: SLPs' and parental competencies, enhancing SLPs' positive characteristics, positive attitudes and cooperation from all personas; for HRM resources the factors important for quality are strategic and risk management, workforce and recruitment; and for the environmental factors the physical environment and resources are important as they affect the service depending on their condition, that is, improved resources result in improved service. Such alterations would reduce the SLPs' demotivation and burnout due to reduced responsibilities, whilst improving accessibility and availability, ultimately enhancing the quality of the service provided.

Trajectories of Child Cognitive and Socioemotional Development and Associations with Adolescent Health in the UK Millennium Cohort Study.

OBJECTIVE: To identify and describe distinct trajectories of cognitive and socioemotional development during childhood and to examine their relationships with adolescent health. STUDY DESIGN: We used group-based multitrajectory modeling applied to longitudinal data on 11 564 children up to age 14 years from the UK Millennium Cohort study to identify trajectories of cognitive and socioemotional development measured using validated instruments. We assessed associations between the derived trajectories and baseline socioeconomic, parental, and school factors using multinomial regression. Logistic regression was used to assess associations between trajectory groups and adolescent health at age 14 and 17 years. RESULTS: Four child development trajectories were identified: "no problems" (76.5%); "late socio-emotional problems" (10.1%); "early cognitive and socioemotional problems" (8.6%); and "persistent cognitive and socioemotional problems" (4.8%). Those in the problem trajectories were more socioeconomically disadvantaged. Compared with the "no problem" trajectory, the "late socioemotional problems" trajectory had increased odds of overweight and mental ill-health at age 14 years of 1.50 (95% CI 1.24-1.81) and 2.51 (2.03-3.10), respectively. For the "persistent problems" group, the OR for overweight was 1.41 (1.04-1.91), and for mental ill-health, 3.01 (2.10-3.30). For both groups, the associations persisted to age 17 years. CONCLUSIONS: In a representative UK cohort, groups of distinct trajectories of cognitive and socioemotional development were identified. Adverse development, if unresolved, can have a negative impact on weight and mental health in adolescence. Socioemotional development was the main driver of the impact on adolescent health and this requires emphasis in child health policy.

Mental Health Risks Among Informal Waste Workers in Kathmandu Valley, Nepal.

Informal waste workers are a vulnerable population group who are often socio-economically marginalized and disadvantaged, with more likelihood of experiencing ill health than the general population. To explore the determinants of mental ill health in this group, we conducted a cross-sectional survey of 1278 informal waste-workers in Nepal in 2017, using a demographic health assessment questionnaire and a modified Patient Health Questionnaire (PHQ-9). We looked at the potential associations between various exposure factors and mental health outcomes and found that 27.4% of waste-workers had depressive symptoms, more likely to be reported by female (OR 2.290), older person (OR 7.757), divorced/separated (5.859), and those with ill health (OR 2.030), or disability (OR 3.562). Waste-workers with access to social protection (OR 0.538) and financial savings (OR 0.280) were less likely to have depressive symptoms. There are key risk factors that may enable identification of particularly vulnerable persons within this group and also protective factors that may help improve their mental health resilience.

Transitioning to Telemedicine During COVID-19: Impact on Perceptions and Use of Telemedicine Procedures for the Diagnosis of Autism in Toddlers.

The COVID-19 pandemic has increased the use of telemedicine as an avenue to address the need for diagnostic clarification in young children at risk for autism spectrum disorder (ASD). Although preliminary research has supported the use of telemedicine for identifying ASD in toddlers, little is known about the experiences of practitioners attempting direct-to-home tele-assessment. We surveyed diagnostic providers regarding changes in practice behavior in the initial months of the COVID-19 pandemic and their perceptions of ASD tele-assessment. We also examined the use of the TELE-ASD-PEDS, a novel tool for ASD tele-assessment, in response to COVID-19 at seven sites across the country. Results support the clinical acceptability and diagnostic utility of ASD tele-assessment while also highlighting critical avenues of future investigation.

Relationships between Child Development at School Entry and Adolescent Health-A Participatory Systematic Review.

The relationship between child development and adolescent health, and how this may be modified by socio-economic conditions, is poorly understood. This limits cross-sector interventions to address adolescent health inequality. This review summarises evidence on the associations between child development at school starting age and subsequent health in adolescence and identifies factors affecting associations. We undertook a participatory systematic review, searching electronic databases (MEDLINE, PsycINFO, ASSIA and ERIC) for articles published between November 1990 and November 2020. Observational, intervention and review studies reporting a measure of child development and subsequent health outcomes, specifically weight and mental health, were included. Studies were individually and collectively assessed for quality using a comparative rating system of stronger, weaker, inconsistent or limited evidence. Associations between child development and adolescent health outcomes were assessed and reported by four domains of child development (socio-emotional, cognitive, language and communication, and physical development). A conceptual diagram, produced with stakeholders at the outset of the study, acted as a framework for narrative synthesis of factors that modify or mediate associations. Thirty-four studies were included. Analysis indicated stronger evidence of associations between measures of socio-emotional development and subsequent mental health and weight outcomes; in particular, positive associations between early externalising behaviours and later internalising and externalising, and negative associations between emotional wellbeing and later internalising and unhealthy weight. For all other domains of child development, although associations with subsequent health were positive, the evidence was either weaker, inconsistent or limited. There was limited evidence on factors that altered associations. Positive socio-emotional development at school starting age appears particularly important for subsequent mental health and weight in adolescence. More collaborative research across health and education is needed on other domains of development and on the mechanisms that link development and later health, and on how any relationship is modified by socio-economic context.

National or population level interventions addressing the social determinants of mental health - an umbrella review.

BACKGROUND: Social circumstances in which people live and work impact the population's mental health. We aimed to synthesise evidence identifying effective interventions and policies that influence the social determinants of mental health at national or scaled population level. We searched five databases (Cochrane Library, Global Health, MEDLINE, EMBASE and PsycINFO) between Jan 1st 2000 and July 23rd 2019 to identify systematic reviews of population-level interventions or policies addressing a recognised social determinant of mental health and collected mental health outcomes. There were no restrictions on country, sub-population or age. A narrative overview of results is provided. Quality assessment was conducted using Assessment of Multiple Systematic Reviews (AMSTAR 2). This study was registered on PROSPERO (CRD42019140198). RESULTS: We identified 20 reviews for inclusion. Most reviews were of low or critically low quality. Primary studies were mostly observational and from higher income settings. Higher quality evidence indicates more generous welfare benefits may reduce socioeconomic inequalities in mental health outcomes. Lower quality evidence suggests unemployment insurance, warm housing interventions, neighbourhood renewal, paid parental leave, gender equality policies, community-based parenting programmes, and less restrictive migration policies are associated with improved mental health outcomes. Low quality evidence suggests restriction of access to lethal means and multi-component suicide prevention programmes are associated with reduced suicide risk. CONCLUSION: This umbrella review has identified a small and overall low-quality evidence base for population level interventions addressing the social determinants of mental health. There are significant gaps in the evidence base for key policy areas, which limit ability of national policymakers to understand how to effectively improve population mental health.

Impact of child development at primary school entry on adolescent health-protocol for a participatory systematic review.

BACKGROUND: Reducing child health inequalities is a global health priority and evidence suggests that optimal development of knowledge, skills and attributes in early childhood could reduce health risks across the life course. Despite a strong policy rhetoric on giving children the 'best start in life', socioeconomic inequalities in children's development when they start school persist. So too do inequalities in child and adolescent health. These in turn influence health inequalities in adulthood. Understanding how developmental processes affect health in the context of socioeconomic factors as children age could inform a holistic policy approach to health and development from childhood through to adolescence. However, the relationship between child development and early adolescent health consequences is poorly understood. Therefore the aim of this review is to summarise evidence on the associations between child development at primary school starting age (3-7 years) and subsequent health in adolescence (8-15 years) and the factors that mediate or moderate this relationship. METHOD: A participatory systematic review method will be used. The search strategy will include; searches of electronic databases (MEDLINE, PsycINFO, ASSIA and ERIC) from November 1990 onwards, grey literature, reference searches and discussions with stakeholders. Articles will be screened using inclusion and exclusion criteria at title and abstract level, and at full article level. Observational, intervention and review studies reporting a measure of child development at the age of starting school and health outcomes in early adolescence, from a member country of the Organisation for Economic Co-operation and Development, will be included. The primary outcome will be health and wellbeing outcomes (such as weight, mental health, socio-emotional behaviour, dietary habits). Secondary outcomes will include educational outcomes. Studies will be assessed for quality using appropriate tools. A conceptual model, produced with stakeholders at the outset of the study, will act as a framework for extracting and analysing evidence. The model will be refined through analysis of the included literature. Narrative synthesis will be used to generate findings and produce a diagram of the relationship between child development and adolescent health. DISCUSSION: The review will elucidate how children's development at the age of starting school is related to subsequent health outcomes in contexts of socioeconomic inequality. This will inform ways to intervene to improve health and reduce health inequality in adolescents. The findings will generate knowledge of cross-sector relevance for health and education and promote inter-sectoral coherence in addressing health inequalities throughout childhood. PROTOCOL REGISTRATION: This systematic review protocol has been registered with PROSPERO CRD42020210011 .

Learning across the UK: a review of public health systems and policy approaches to early child development since political devolution.

BACKGROUND: Giving children the best start in life is critical for their future health and wellbeing. Political devolution in the UK provides a natural experiment to explore how public health systems contribute to children's early developmental outcomes across four countries. METHOD: A systematic literature review and input from a stakeholder group was used to develop a public health systems framework. This framework then informed analysis of public health policy approaches to early child development. RESULTS: A total of 118 studies met the inclusion criteria. All national policies championed a 'prevention approach' to early child development. Political factors shaped divergence, with variation in national conceptualizations of child development ('preparing for life' versus 'preparing for school') and pre-school provision ('universal entitlement' or 'earned benefit'). Poverty and resourcing were identified as key system factors that influenced outcomes. Scotland and Wales have enacted distinctive legislation focusing on wider determinants. However, this is limited by the extent of devolved powers. CONCLUSION: The systems framework clarifies policy complexity relating to early child development. The divergence of child development policies in the four countries and, particularly, the explicit recognition in Scottish and Welsh policy of wider determinants, creates scope for this topic to be a tracer area to compare UK public health systems longer term.

Increasing Access to Autism Spectrum Disorder Diagnostic Consultation in Rural and Underserved Communities: Streamlined Evaluation Within Primary Care.

OBJECTIVE: Preliminary feasibility and clinical utility research has demonstrated that implementation of a streamlined diagnostic model embedded within primary care (PC) clinics promotes early identification of young children with autism spectrum disorder (ASD). Use of this model results in dramatically reduced waits for diagnostic consultation, high levels of family/provider satisfaction, and reductions in referrals to overtaxed tertiary diagnostic centers. The current study extends this work by providing data before/after implementation of a streamlined model across a diverse range of PC clinics that provide health care to rural and underserved communities. METHODS: The streamlined assessment involved record/history review, diagnostic interview, standard rating scales, and an interactive screening tool. Eighty children between the ages of 19 and 47 months were seen across 5 different clinics. Data were collected through chart review. RESULTS: Implementation of streamlined model resulted in a significant decrease in latency to diagnostic conclusion from a mean of 144.7 to 49.9 days. Children were likely to experience a greater reduction in wait times if they were a PC patient versus a non-PC patient. CONCLUSION: Results show significant reduction in wait times for ASD diagnostic decisions across both PC and non-PC patients. By reducing waits and identifying concerns more efficiently, we may increase the ability of families to access early intervention and support services.

Going upstream - an umbrella review of the macroeconomic determinants of health and health inequalities.

BACKGROUND: The social determinants of health have been widely recognised yet there remains a lack of clarity regarding what constitute the macro-economic determinants of health and what can be done to address them. An umbrella review of systematic reviews was conducted to identify the evidence for the health and health inequalities impact of population level macroeconomic factors, strategies, policies and interventions. METHODS: Nine databases were searched for systematic reviews meeting the Database of Abstracts of Reviews of Effects (DARE) criteria using a novel conceptual framework. Studies were assessed for quality using a standardised instrument and a narrative overview of the findings is presented. RESULTS: The review found a large (n = 62) but low quality systematic review-level evidence base. The results indicated that action to promote employment and improve working conditions can help improve health and reduce gender-based health inequalities. Evidence suggests that market regulation of tobacco, alcohol and food is likely to be effective at improving health and reducing inequalities in health including strong taxation, or restriction of advertising and availability. Privatisation of utilities and alcohol sectors, income inequality, and economic crises are likely to increase health inequalities. Left of centre governments and welfare state generosity may have a positive health impact, but evidence on specific welfare interventions is mixed. Trade and trade policies were found to have a mixed effect. There were no systematic reviews of the health impact of monetary policy or of large economic institutions such as central banks and regulatory organisations. CONCLUSIONS: The results of this study provide a simple yet comprehensive framework to support policy-makers and practitioners in addressing the macroeconomic determinants of health. Further research is needed in low and middle income countries and further reviews are needed to summarise evidence in key gaps identified by this review. TRIAL REGISTRATION: Protocol for umbrella review prospectively registered with PROSPERO CRD42017068357.

Validation of an LC-MS/MS method for simultaneous quantification of venlafaxine and its five metabolites in rat plasma and its application in a pharmacokinetic study.

A sensitive, selective, and reliable LC-MS/MS method was developed and validated for simultaneous quantification of venlafaxine (VEN) and its 5 metabolites (ODV, NDV, NNDDV, OHV and NODDV) in rat plasma. The calibration ranges are 15.0 to 6000 ng/mL for VEN, 1.00 to 400 ng/mL for ODV, 5.00 to 2000 ng/mL for NDV, 1.00 to 400 ng/mL for NNDDV, 10.0 to 4000 ng/mL for OHV, and 0.200 to 20.0 ng/mL for NODDV. Briefly, 50 µL of rat plasma was extracted using liquid-liquid extraction (LLE) with methyl tert-butyl ether (MTBE). The analytes were separated on an Agilent SB-Phenyl (50 mm × 4.6 mm, 3.5 µm) column using a binary gradient of 0.1% formic acid in water versus 0.1% formic acid in acetonitrile at a flow rate of 0.8 mL/min. The method was validated following FDA guidance for bioanalytical method validation. Validated method was successfully applied to a pharmacokinetic study of VEN orally administered to rats.

Cumulative Instructional Time and Relative Effectiveness Conclusions: Extending Research on Response Intervals, Learning, and Measurement Scale.

Adapted alternating treatments designs were used to evaluate three computer-based flashcard reading interventions (1-s, 3-s, or 5-s response intervals) across two students with disabilities. When learning was plotted with cumulative instructional sessions on the horizontal axis, the session-series graphs suggest that the interventions were similarly effective. When the same data were plotted as a function of cumulative instructional seconds, time-series graphs suggest that the 1-s intervention caused the most rapid learning for one student. Discussion focuses on applied implications of comparative effectiveness studies and why measures of cumulative instructional time are needed to identify the most effective intervention(s).Comparative effectiveness studies may not identify the intervention which causes the most rapid learning.Session-series repeated measures are not the same as time-series repeated measures.Measuring the time students spend in each intervention (i.e., cumulative instructional seconds) allows practitioners to identify interventions that enhance learning most rapidly.Student time spent working under interventions is critical for drawing applied conclusions.