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An Evaluation of the Implementation of Hand Held Health Records with Adults with Learning Disabilities: A Cluster Randomized Controlled Trial

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Title: An Evaluation of the Implementation of Hand Held Health Records with Adults with Learning Disabilities: A Cluster Randomized Controlled Trial
Language: English
Authors: Turk, Vicky, Burchell, Sarah, Burrha, Sukhjinder
Source: Journal of Applied Research in Intellectual Disabilities. Mar 2010 23(2):100-111.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
Peer Reviewed: Y
Physical Description: PDF
Page Count: 12
Publication Date: 2010
Document Type: Journal Articles
Reports - Evaluative
Descriptors: Control Groups, Intervention, Learning Disabilities, Evaluation, Handheld Devices, Records (Forms), Adults, Interviews, Cluster Grouping
DOI: 10.1111/j.1468-3148.2009.00518.x
ISSN: 1360-2322
Abstract: Background: Personal health records were implemented with adults with learning disabilities (AWLD) to try to improve their health-care. Materials and Method: Forty GP practices were randomized to the Personal Health Profile (PHP) implementation or control group. Two hundred and one AWLD were interviewed at baseline and 163 followed up after 12 months intervention (PHP group). AWLD and carers of AWLD were employed as research interviewers. AWLD were full research participants. Results: Annual consultation rates in the intervention and control groups at baseline were low (2.3 and 2.6 visits respectively). A slightly greater increase occurred over the year in the intervention group 0.6 (-0.4 to 1.6) visits/year compared with controls. AWLD in PHP group reported more health problems at follow-up 0.9 (0.0 to 1.8). AWLD liked their PHP (92%) but only 63% AWLD and 55% carers reported PHP usage. Carers had high turnover (34%). Conclusions: No significant outcomes were achieved by the intervention.
Abstractor: As Provided
Entry Date: 2010
Accession Number: EJ874347
Database: ERIC
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  Value: <anid>AN0048225072;e0301mar.10;2019Jun04.08:08;v2.2.500</anid> <title id="AN0048225072-1">An Evaluation of the Implementation of Hand Held Health Records with Adults with Learning Disabilities: A Cluster Randomized Controlled Trial. </title> <p>Background  Personal health records were implemented with adults with learning disabilities (AWLD) to try to improve their health‐care. Materials and Method  Forty GP practices were randomized to the Personal Health Profile (PHP) implementation or control group. Two hundred and one AWLD were interviewed at baseline and 163 followed up after 12 months intervention (PHP group). AWLD and carers of AWLD were employed as research interviewers. AWLD were full research participants. Results  Annual consultation rates in the intervention and control groups at baseline were low (2.3 and 2.6 visits respectively). A slightly greater increase occurred over the year in the intervention group 0.6 (−0.4 to 1.6) visits/year compared with controls. AWLD in PHP group reported more health problems at follow‐up 0.9 (0.0 to 1.8). AWLD liked their PHP (92%) but only 63% AWLD and 55% carers reported PHP usage. Carers had high turnover (34%). Conclusions  No significant outcomes were achieved by the intervention.</p> <p>Keywords: patient centred care; primary health care; randomized controlled trial; hand held record</p> <p>Adults with leaning disabilities (AWLD) have high health needs ([<reflink idref="bib35" id="ref1">35</reflink>], [<reflink idref="bib29" id="ref2">29</reflink>],[<reflink idref="bib31" id="ref3">31</reflink>]), reduced longevity ([<reflink idref="bib12" id="ref4">12</reflink>]; [<reflink idref="bib2" id="ref5">2</reflink>]) and clear evidence of health inequalities ([<reflink idref="bib17" id="ref6">17</reflink>]; [<reflink idref="bib6" id="ref7">6</reflink>]; [<reflink idref="bib30" id="ref8">30</reflink>]). They also have little involvement in their health care or in health promotion activities ([<reflink idref="bib28" id="ref9">28</reflink>]). Despite these findings few large research trials of interventions designed to improve health have been published. Most have involved evaluating health screening interventions (e.g. [<reflink idref="bib15" id="ref10">15</reflink>]; [<reflink idref="bib16" id="ref11">16</reflink>]; [<reflink idref="bib5" id="ref12">5</reflink>]) with only a few using rigorous RCT or CRT designs ([<reflink idref="bib20" id="ref13">20</reflink>], [<reflink idref="bib21" id="ref14">21</reflink>]).</p> <p>The current research assessed the impact of implementing a hand held health record, called the Personal Health Profile (PHP), on GP consultations and on the health knowledge of AWLD and/or their carers. AWLD, as well as carers, were full research participants, and the inclusive aspect of the methodology was an integral aspect of the research design. The rationale for hand held records is briefly overviewed followed by the rationale for inclusive methodology.</p> <hd id="AN0048225072-2">The intervention – the personal health profile</hd> <p>Hand held health records were first developed in child health and maternity services, but have since been implemented in a variety of other client groups e.g. diabetes ([<reflink idref="bib7" id="ref15">7</reflink>]) and cancer ([<reflink idref="bib9" id="ref16">9</reflink>]). They are designed to empower individuals to have a better knowledge of their health needs and services required/received. In most cases both service user and professionals input information into a shared record, enabling the record holder to be more proactive in seeking out help and following up interventions. Existing research has explored aspects such as retention and usage levels ([<reflink idref="bib14" id="ref17">14</reflink>]), or levels of satisfaction with keeping a client record ([<reflink idref="bib14" id="ref18">14</reflink>]). On these measures, hand held records are found to show positive outcomes e.g. 93% satisfaction level and 89% retention ([<reflink idref="bib14" id="ref19">14</reflink>]; [<reflink idref="bib32" id="ref20">32</reflink>]).</p> <p>There is only one published evaluation of a hand held record implemented with individuals (adolescents) with learning disabilities ([<reflink idref="bib21" id="ref21">21</reflink>]), with the diary described in an earlier paper ([<reflink idref="bib18" id="ref22">18</reflink>], [<reflink idref="bib19" id="ref23">19</reflink>]). The evaluation reported the diary to be well received but did not show any measurable effects on communication or health.</p> <p>The current PHP was developed for AWLD and their carers in the London Boroughs of Greenwich and Bexley. It has sections on all aspects of health, enabling AWLD to see how the concept of health and disability can be broken down into different components/aspects e.g. teeth, skin and diet. It has been audited and positive outcomes reported in areas such as: AWLD/carer empowerment, ease of use and improved communication between AWLD/carer and GP ([<reflink idref="bib33" id="ref24">33</reflink>]). More details of the PHP are given in the method section.</p> <p>The research design involved AWLD and their carers in most areas of the research process, e.g. membership of the steering committee, staff recruitment and piloting research measures. They were also included as full research participants. AWLD and carers of AWLD were employed as the research interviewers (the AWLD supported by seconded staff). This design was chosen for two main reasons:</p> <p></p> <p>• 1</p> <p></p> <ulist> <item> To follow current good research and ethical practice in developing user involvement in the development and evaluation of health services in general ([<reflink idref="bib4" id="ref25">4</reflink>]) and learning disabilities services in particular ([<reflink idref="bib8" id="ref26">8</reflink>][<reflink idref="bib23" id="ref27">23</reflink>]).</item> <p></p> </ulist> <p>• 2</p> <p></p> <ulist> <item> There is a developing literature highlighting reasons for, and benefits of, involving AWLD in research e.g. [<reflink idref="bib37" id="ref28">37</reflink>]; [<reflink idref="bib34" id="ref29">34</reflink>]; [<reflink idref="bib38" id="ref30">38</reflink>]. In particular it ensures barriers are broken down between interviewer and interviewee ([<reflink idref="bib27" id="ref31">27</reflink>]), that topics, measures and findings are made more accessible to AWLD, and that the process and results produce a more grounded and honest account of the researched topic.</item> </ulist> <p>The hypothesis was that AWLD and/or their carers would not only find holding a PHP useful, but it would result in demonstrable gains including:</p> <p></p> <p>• 1</p> <p></p> <ulist> <item> Increased attendance at GPs (the primary outcome measure) and other health care services.</item> <p></p> </ulist> <p>• 2</p> <p></p> <ulist> <item> Increased general knowledge of health.</item> <p></p> </ulist> <p>• 3</p> <p></p> <ulist> <item> Increased knowledge of personal health problems.</item> <p></p> </ulist> <p>• 4</p> <p></p> <ulist> <item> Increased satisfaction and improved communication with GPs.</item> </ulist> <hd id="AN0048225072-3">Materials and Method</hd> <p></p> <hd id="AN0048225072-4">Participants – GP practices and AWLD</hd> <p></p> <hd id="AN0048225072-5">GP practices</hd> <p>Practices were eligible if at least one identified AWLD was registered with the practice and the practice had not been involved in an earlier PHP pilot implementation project. There were 63 eligible practices in the two boroughs of Greenwich and Bexley with 604 AWLD on their registers who were all approached and invited to participate. Forty three practices (68%) consented to inclusion into the study (452 on their registers). Figure 1 shows the flow of practices and participants through the study from these 43 practices.</p> <p>Graph: 1 Flowchart of recruitment and participation of GP practices and AWLD to the study.</p> <hd id="AN0048225072-6">AWLD</hd> <p>All participants were identified from the joint health/social services learning disability registers held in each borough. The registers included all known adults (18 years and above) with moderate‐to‐profound learning disabilities (IQ ≤ 50) and some adults with mild learning disabilities (IQ = 51–70) who had additional complex needs. No attempt was made to verify degree of learning disabilities of the AWLD but information on degree of disabilities was obtained for those who had a carer interview using the Disability Assessment Schedule ([<reflink idref="bib13" id="ref32">13</reflink>]).</p> <hd id="AN0048225072-7">Randomization details</hd> <p>Following recruitment of all the known patients from each practice, GP practices were randomized, to intervention or control group, in batches of practices, using computer generated sequences, by the independent statistician using stratified randomization. The four dichotomous stratification factors were (i) single handed or not (ii) Bexley or Greenwich practice (iii) more than or <10 AWLD on register and (iv) none or at least one residential service with AWLD.</p> <hd id="AN0048225072-8">The personal health profile</hd> <p>The PHP comprises an A5 ring binder containing 50 double‐sided pages separated into three sections. The first section is an introduction to the PHP. The second section is divided into eight chapters: general health, tablets and medicines, disability, epilepsy, mental health and behaviour, women's/men's health, lifestyle/healthy living and death and dying. In this section space is provided for AWLD and their carers to write in health issues, and details of any healthcare appointments, and outcomes. The third section contains information for carers, professionals and others. Individualized topic sheets are available for people with specific syndromes or healthcare needs [[<reflink idref="bib26" id="ref33">26</reflink>]; http://www.oxleas.nhs.uk/patientinfo/php.html].</p> <p>The PHP is not a stand‐alone product but depends on the participation of healthcare professionals to ensure it is updated and maintained. Implementation is therefore achieved by training GPs and primary health care (PCT) staff in the philosophy, content and usage of the PHP before AWLD and/or carers are approached and offered a PHP. A similar training is then offered to the AWLD and they are helped to fill in the PHP and start using it.</p> <hd id="AN0048225072-9">Inclusive methodology</hd> <p>The chair of a local AWLD advocacy group and representatives from Mencap were involved in submitting the grant application and throughout all subsequent stages of the research. Four AWLD were employed and trained as researchers and completed the interviews of all research participants with AWLD. Four health or Learning Disability Team professionals were seconded to support the AWLD researchers including recording the interview responses of the AWLD research participants and helping code the responses. Four carers of AWLD were employed and trained as researchers and interviewed the carers of AWLD.</p> <hd id="AN0048225072-10">Ethics</hd> <p>Ethical committee approval was given by the Bexley and Greenwich NHS Research Ethics Committee. GP practices were approached for their consent to participate. Selected patients were then approached to gain the consent of the AWLD and/or assent of the carer as appropriate.</p> <hd id="AN0048225072-11">Measures</hd> <p>The primary outcome measure of GP consultations was obtained from the GP records. The instruments/measures were as follows:</p> <p></p> <p>• (a)</p> <p></p> <ulist> <item> Basic demographic information e.g. name, friends and family, activities and any sight or hearing problems that might affect the interview.</item> <p></p> </ulist> <p>• (b)</p> <p></p> <ulist> <item> Degree and type of disability – Disability Assessment Schedule ([<reflink idref="bib13" id="ref34">13</reflink>]).</item> <p></p> </ulist> <p>• (c)</p> <p></p> <ulist> <item> The OK Health Checklist ([<reflink idref="bib22" id="ref35">22</reflink>]) was selected as the main informant based health assessment as it was considered the most comprehensive and relevant tool available. With the authors permission, an adapted version was devised for AWLD, using simple language, large typeface, symbols/pictures, and many questions with a simple 'yes', 'no' and 'don't know' response structure (details available: V. Turk, S. Burchell, S. Burrha, R. Corney, S. Elliott, S. Kerry, C. Molloy, K. Painter & P. Pritchard, unpubl. data).</item> <p></p> </ulist> <p>• (d)</p> <p></p> <ulist> <item> A newly devised terminology checklist called the Knowledge of Health Problems and Terminology Checklist (KHPT) to measure the number and type of health needs known by the AWLD and/or their carer to be present or recently treated, comprising 12 sections/categories and 36 category items (details available: V. Turk, S. Burchell, S. Burrha, R. Corney, S. Elliot, S. Kerry, C. Molloy, K. Painter & P. Pritchard, unpubl. data).</item> <p></p> </ulist> <p>• (e)</p> <p></p> <ulist> <item> The Client Services Receipt Inventory (CSRI) ([<reflink idref="bib10" id="ref36">10</reflink>]) – This is a carer measure of GP visits and use of (i) hospital and (ii) community services. The hospital based services include accident and emergency as well as all general medical, surgical and psychiatric inpatient, outpatient and day hospital attendances. The community based services include a wide range of healthcare professionals such as dentists, community learning disability team multidisciplinary professionals and specialist therapists such as art and music therapists.</item> <p></p> </ulist> <p>• (f)</p> <p></p> <ulist> <item> Questions relating to satisfaction with primary care consultations and communication with the GP. For the latter, six questions were asked of carers, and two of AWLD. Carers were asked three questions relating to their last consultation and the same three questions about consultations in general. These three questions comprised whether GPs usually spoke directly to AWLD, whether they gave the AWLD enough information about their health and whether they gave AWLD clear instructions about following a course of medication. The two AWLD questions were about their last appointment and were whether the GP gave them enough information and whether they were told about their medicine.</item> <p></p> </ulist> <p>• (g)</p> <p></p> <ulist> <item> At follow‐up, the intervention group participants were asked additional questions about the perceived problems/benefits of having a PHP and their use of the PHP.</item> </ulist> <hd id="AN0048225072-12">Procedure</hd> <p>The off site statistician informed the local researchers which patients on each practice register to approach for inclusion. These patients were then contacted by the researchers to (i) ensure they were still with the identified practice and (ii) gain the consent of the AWLD and/or assent of the carer as appropriate. When individual patients within practices were ineligible or failed to consent to inclusion the statistician provided a replacement name where possible. The maximum number of participants per practice was adjusted up from 10 to 11 at this point to aid sufficient recruitment of AWLD. GP recruitment took place between September 2002 and June 2003. After initial interviews had been completed, practices were randomized to PHP or control group. The clinical implementation team was independent of the research team and comprised two staff members, one of whom was an employed AWLD. They gave GPs and practice staff in the PHP implementation group individual or practice based training (minimum of 1 h). AWLD in these practices were then contacted by the implementation team, and those consenting to inclusion were given information on the PHP and helped to fill it in. The date of the first implementation was on 24th June 2003 and the last implementation was carried out on 14th April 2004. No contact was made with GPs or AWLD in the control group.</p> <hd id="AN0048225072-13">Initial interviews</hd> <p> <bold>AWLD. </bold> The AWLD chose whether they wanted to be interviewed at their home or in their day care provision. Consent was rechecked at the beginning of the interview. After this the order of the interview was as follows:</p> <p></p> <p>• 1</p> <p></p> <ulist> <item> Basic background information.</item> <p></p> </ulist> <p>• 2</p> <p></p> <ulist> <item> Knowledge of Health Problems and Terminology Checklist (KHPT).</item> <p></p> </ulist> <p>• 3</p> <p></p> <ulist> <item> Adapted 'OK' Health Checklist plus supplementary questions.</item> <p></p> </ulist> <p>• 4</p> <p></p> <ulist> <item> Information on GP visits in past year.</item> </ulist> <p>The research interview was carried out by a researcher with LD with a supporting professional keeping the records. The interview usually took between 60–90 min to administer over one or two meetings.</p> <p> <bold>Carers. </bold> Nearly all carers were interviewed in their home/work place, the remainder choosing to be interviewed at the day care venue of the AWLD they cared for. Consent to participate in the research was followed by the interview order as follows:</p> <p></p> <p>• 1</p> <p></p> <ulist> <item> Basic background information.</item> <p></p> </ulist> <p>• 2</p> <p></p> <p>• KHPT.</p> <p></p> <p>• 3</p> <p></p> <ulist> <item> 'OK' Health Checklist plus supplementary questions.</item> <p></p> </ulist> <p>• 4</p> <p></p> <ulist> <item> Disability Assessment Schedule (DAS).</item> <p></p> </ulist> <p>• 5</p> <p></p> <ulist> <item> Information on GP visits in past year.</item> <p></p> </ulist> <p>• 6</p> <p></p> <p>• CSRI.</p> <p>The interview, carried out by a trained carer researcher usually took between 90 and 120 min to administer over one or two meetings. The interviews took place between January and August 2003.</p> <hd id="AN0048225072-14">Follow up interviews</hd> <p>These were arranged approximately 1 year after implementation of the PHP for the PHP group. For the control group, this was calculated by ascertaining the median implementation date for each GP practice in the PHP group and using these dates as notional implementation times for a similar GP practice in the control group. By adding a year to these notional dates, the re‐interview schedule for the control group was computed. The lag in time to train GPs and implement the PHPs meant the average total time between initial and follow‐up interview was 19.1 months (PHP group) and 19.2 months (control group). The follow‐up interviews took place between July 2004 and April 2005.</p> <p>Follow‐up interviews were identical to the initial interviews with some additional questions asked, at the end of the interview, to those in the PHP group on their views and usage of the PHP.</p> <hd id="AN0048225072-15">Medical records</hd> <p>After the follow‐up interviews a nurse researcher accessed the GP medical records of health appointments, health screening visits and medications for all the participating AWLD. The information was collected from a year before the initial research interviews up to the time of the follow up interview.</p> <hd id="AN0048225072-16">Statistical analysis</hd> <p>Change from baseline in number of visits per year in the PHP group was compared with the change in the control group using an independent sample <emph>t</emph>‐test, the means for each practice being weighted by the number of participants from each practice ([<reflink idref="bib3" id="ref37">3</reflink>]). Secondary outcomes were analysed in the same way using mean values for each practice. Some composite measures were created:</p> <p></p> <p>• 1</p> <p></p> <ulist> <item> Average of responses to six (carer) or two (AWLD) questions on GP communication each scored as one for a 'yes' response (good communication) and zero for a 'no' response (no/inadequate communication) – resultant score range from 0 to 1.</item> <p></p> </ulist> <p>• 2</p> <p></p> <ulist> <item> Total numbers of health problems reported in the 12 sections of the KHPT.</item> </ulist> <hd id="AN0048225072-17">Sample size/power</hd> <p>The power calculation was based on an expected increase in GP visits from 3.2 visits per annum (SD 4.2) reported in research available at that time ([<reflink idref="bib36" id="ref38">36</reflink>]), to that of other members of the general population i.e. five visits per annum ([<reflink idref="bib24" id="ref39">24</reflink>]). In order to identify a rise in average visiting rates from 3.2 to 5 with a standard deviation of 4.2, power set at 0.8 and significance level set at 0.05, 88 individuals per group would be required if patients were individually randomized. To allow for clustering the intra‐cluster correlation was estimated to be 0.01 giving a design effect of 1.04 if an average of five patients were to be recruited per practice. This required an increased sample of 92 per group.</p> <hd id="AN0048225072-18">Reliability analyses</hd> <p>Inter‐rater and test–retest reliability analyses were conducted:</p> <p></p> <p>• (a)</p> <p></p> <ulist> <item> Twelve inter‐rater reliability checks of coding for interviews of AWLD and 12 inter‐rater coding checks for carer interviews were obtained. The overall inter‐rater coding reliability was 96.3% for the AWLD interviews and 93.9% for the carer interviews.</item> <p></p> </ulist> <p>• (b)</p> <p></p> <ulist> <item> Separate samples of 19 carers and 15 AWLD were recruited and completed test–retest reliability interviews 2 weeks apart. The results were analysed using Spearman's correlation coefficient (for ordinal, scaled and interval data), and chance corrected proportional agreement – weighted kappa (for nominal data). Interpretation of the resulting kappa values was taken from [<reflink idref="bib1" id="ref40">1</reflink>], with values below 0.20 considered weak, and higher values as fair (0.21–0.40), moderate (0.41–0.60), good (0.61–0.80) or very good (0.81–1.00). Where variables were found to be unreliable or to have weak reliability, the variable was dropped from analysis.</item> </ulist> <hd id="AN0048225072-19">Results</hd> <p>The results are reported as follows: (i) the passage of participants through the CRT, (ii) a description of the sample characteristics at initial interview, (iii) knowledge of intervention group, use of PHP and carer turnover and (iv) results on the main outcome measures.</p> <hd id="AN0048225072-20">The passage of individual AWLD and the GP practice clusters through the trial</hd> <p>Sixty‐three GP practices were approached to take part in the study of which 43 agreed (452 potential AWLD). The accepting and declining practices were not different on key demographic factors. AWLD and/or their carers from consenting practices were randomly selected and invited to participate. The flow of people through the CRT is shown in Figure 1, also showing the GPs and/or AWLD that were lost to the study through the successive stages of the CRT. This included seven deaths, over a period <2 years (average age at death = 39; range 19–80). Five deaths were in the PHP implementation group. In total, 163 AWLD and/or their carers from 39 different GP practices completed the follow‐up interviews.</p> <p>The design of the study meant that each of the research participants could have data in the study resulting from either or both of the two sources (AWLD and carer). It also meant there were more interviews than participants (where AWLDs and their carers were interviewed). This had the advantage that at follow‐up AWLDs were not lost from the trial if they had a carer and AWLD interview, and only one of the two sources of information dropped out. It also means, however, that some participants in the study had data from two sources at initial interview and only one at follow‐up.</p> <p>Table 1 shows the numbers of AWLD and/or their carers interviewed initially and at follow‐up. Hence, at the initial interviews there were 201 overall participants whose data comprised 168 carer interviews (93 carer only interviews) and 108 AWLD interviews (33 interviews without a carer interview and 75 with a carer being separately interviewed). Therefore over half the sample of AWLD at initial interview (108 of 201 – response rate of 54%) completed the research interview. This suggests the adaptations of the measures for AWLD had enabled their participation in the research. However, at follow‐up a differential drop‐out rate was found for AWLD (35/108, 32.4%) compared with carers (24/168, 18.3%). This was because of more AWLD than carers refusing a follow‐up interview and/or becoming ineligible through moving house/job/GP.</p> <p>1  The number of AWLD and/or their carers interviewed</p> <p> <ephtml> <table><thead valign="bottom"><tr><th valign="bottom">Interview type</th><th>1st stage interviews</th><th>2nd stage interviews</th></tr><tr><th>PHP
<italic>n (%)</italic></th><th>Control
<italic>n (%)</italic></th><th>Total
<italic>n (%)</italic></th><th>PHP
<italic>n (%)</italic></th><th>Control
<italic>n (%)</italic></th><th>Total
<italic>n (%)</italic></th></tr></thead><tbody valign="top"><tr><td>Carer only</td><td>49 (48)</td><td>44 (44)</td><td>93 (46)</td><td>44 (56)</td><td>46 (55)</td><td>90 (55)</td></tr><tr><td>AWLD only</td><td>16 (16)</td><td>17 (17)</td><td>33 (16)</td><td>9 (11)</td><td>10 (12)</td><td>19 (12)</td></tr><tr><td>Carer and AWLD</td><td>37 (36)</td><td>38 (38)</td><td>75 (37)</td><td>26 (33)</td><td>28 (33)</td><td>54 (33)</td></tr><tr><td>Totals</td><td>102</td><td>99</td><td>201</td><td>79</td><td>84</td><td>163</td></tr></tbody></table> </ephtml> </p> <p>1 AWLD, adults with learning disabilities.</p> <hd id="AN0048225072-21">Baseline characteristics of GP practices and AWLD</hd> <p></p> <hd id="AN0048225072-22">GP characteristics</hd> <p>Seventeen GP practices were in Bexley and 23 in Greenwich. Only seven practices (17.5%) were single handed GPs. The average patient numbers in the 40 GP practices comprising the baseline sample was 5638 (SD = 3240, range = 1211–15 271), and average Indices of Multiple Deprivation ([<reflink idref="bib25" id="ref41">25</reflink>]) 27.5 (SD = 15.5, range = 5.6–56.9). 18 GP practices (45%) had 11 or more AWLD on their register and 22 (55%) had at least one residential service for AWLD within their practice. On all these factors the practices were well balanced between the PHP and control groups.</p> <hd id="AN0048225072-23">AWLD and their carers at initial interview</hd> <p>Baseline interviews were completed for 102 AWLD participants in the PHP intervention group and 99 in the control group. The carers of the 168 participants with carer interviews were asked if they knew the cause of the LD of the AWLD. A cause or problem type was identified by 89 (53%) carers. The most common 'causes' reported were: Down syndrome – 27 (16%), autistic spectrum disorder – 21 (12.5%), cerebral palsy – 16 (9.5%), another syndrome – 12 (7.1%), and other congenital factors, peri‐natal birth problems or epilepsy – 11 (6.7%).</p> <p>Table 2 gives detailed demographic information of the AWLD and/or their carers at initial interview broken down by intervention group. Overall there was a slight preponderance of men (61%). Only 17 AWLD (8.6%) were from an ethnic minority. The table also gives details of self help skills and the nature and degree of sensory, communication and behavioural disabilities in the sample as measured by the DAS.</p> <p>2  Demographic characteristics of initial sample</p> <p> <ephtml> <table><thead valign="bottom"><tr><th valign="bottom">Characteristic</th><th>PHP group (<italic>n </italic>=<italic> 102)</italic></th><th>Control group (<italic>n </italic>=<italic> 99)</italic></th></tr><tr><th><italic>n</italic></th><th>Mean (SD) 
or %</th><th><italic>n</italic></th><th>Mean (SD)
or %</th></tr></thead><tbody valign="top"><tr><td>Age</td><td>102</td><td>40.4 (13.4)</td><td>99</td><td>39.0 (13)</td></tr><tr><td>Gender: female</td><td>41</td><td>40%</td><td>37</td><td>37%</td></tr><tr><td>Residential status</td></tr><tr><td> Flat/house</td><td>38</td><td>45%</td><td>45</td><td>55%</td></tr><tr><td> Staffed home</td><td>40</td><td>47%</td><td>33</td><td>40%</td></tr><tr><td> Other/missing</td><td>8</td><td>8%</td><td>4</td><td>5%</td></tr><tr><td>Ethnicity: non‐white</td><td>7</td><td>7%</td><td>10</td><td>10%</td></tr><tr><td>In paid work</td><td>9</td><td>12%</td><td>6</td><td>8%</td></tr><tr><td>Carer type: relative</td><td>39</td><td>45%</td><td>45</td><td>55%</td></tr><tr><td>No. medications (GP records)</td><td>79</td><td>2.6 (2.6)</td><td>90</td><td>1.7 (2.4)</td></tr><tr><td>No. of GP visits in past year (GP records)</td><td>92</td><td>2.5 (3.4)</td><td>95</td><td>2.6 (2.7)</td></tr><tr><td>Disability (from DAS):</td></tr><tr><td> Mobility: walks unaided</td><td>53</td><td>62%</td><td>43</td><td>53%</td></tr><tr><td> Ability to feed self: without help</td><td>63</td><td>73%</td><td>52</td><td>63%</td></tr><tr><td> Ability to dress self: without help</td><td>46</td><td>54%</td><td>38</td><td>46%</td></tr><tr><td> Ability to wash self: without help</td><td>37</td><td>43%</td><td>30</td><td>37%</td></tr><tr><td> Vision: normal</td><td>63</td><td>75%</td><td>60</td><td>73%</td></tr><tr><td> Hearing: normal</td><td>76</td><td>89%</td><td>74</td><td>93%</td></tr><tr><td> Expressive communication: more than a few words/signs</td><td>62</td><td>72%</td><td>55</td><td>67%</td></tr><tr><td> Receptive communication: more than a few simple commands</td><td>81</td><td>94%</td><td>71</td><td>87%</td></tr><tr><td> Social interaction: sociable</td><td>51</td><td>61%</td><td>45</td><td>55%</td></tr><tr><td> Physical aggression: does not occur</td><td>53</td><td>62%</td><td>65</td><td>79%</td></tr><tr><td> Verbal aggression/outbursts: does not occur</td><td>47</td><td>55%</td><td>50</td><td>62%</td></tr><tr><td> Self injurious behaviour: does not occur</td><td>60</td><td>70%</td><td>64</td><td>78%</td></tr><tr><td> Overactive: does not occur</td><td>68</td><td>80%</td><td>59</td><td>72%</td></tr></tbody></table> </ephtml> </p> <p>GP records showed that the average number of visits in the past year (pa) was 2.6 (SD = 3.1, range = 0–22). This low rate is consistent with earlier published consultation rates (e.g. 3.2 pa; [<reflink idref="bib36" id="ref42">36</reflink>]), but not with more recently reported research e.g. 5.4 pa ([<reflink idref="bib16" id="ref43">16</reflink>]); 4.6–4.8 pa ([<reflink idref="bib20" id="ref44">20</reflink>]); 5.4 pa ([<reflink idref="bib31" id="ref45">31</reflink>]). The average number of medications prescribed was 2.2 (SD = 2.6, range = 0–11).</p> <hd id="AN0048225072-24">Knowledge of intervention group and use of PHP</hd> <p>Before each follow‐up interview, the research interviewers were asked to guess whether the participant was in the intervention or control group. They guessed correctly in 52% of cases (AWLD) and 63% of cases (carers) suggesting they had remained blind to the randomization process (a few carers inadvertently informed them when the follow‐up interviews were arranged).</p> <p>At follow‐up AWLD and/or their carers were asked if they had been given a PHP. They were not always correct. Overall, 117/144 (81%) of the carers and 58/73 (79%) of the AWLD at follow‐up correctly identified their group. Of the 56 carers who correctly reported being in the PHP group, only 10 (18%) said the AWLD had used it and only 22 (39%) said they had used it on behalf of the AWLD (55% combined). AWLD were more likely to have indicated having used it. Of the 27 AWLD who correctly said they had a PHP, 17 said they had used it (63%). Only 16 of the 56 carers (29%) and 12 of the 27 AWLD (44%) said they had taken the PHP to their GP.</p> <p>Continuity of carer was examined as one factor that may have contributed to why the knowledge of the intervention group and use of the PHP was low. There was a consistent carer at initial and follow‐up interview in only 97 of the 147 follow‐up carer interviews (66%). This was mainly attributable to moves and turnover of paid carers. Only 44% (36/81) follow‐up interviews with paid carers were with the same carer as baseline, compared with 94% (61/66) follow‐up interviews with unpaid carers.</p> <hd id="AN0048225072-25">Satisfaction with the PHP</hd> <p>Interview information from AWLD in the PHP group indicated that 23 of 25 (92%) of those who had a PHP expressed satisfaction with having it. They felt it had helped them in a number of ways e.g. knowing more about their health (20/23 (87%)), and helping them in their visits to the GP or hospital (13/18 (72%)). Comments given included:</p> <p>'Very good idea, really pleased to have it, all information is in there.''I couldn't do without it.''I think it helps a lot. It helps when I stay in (respite service). They keep it in the office.''I keep all my health records. It makes me feel happy. I keep it with me.''It tells me what to do.'</p> <p>Only 7/37 (19%) carers reported the PHP had helped them learn more about the health of the AWLD. These seven carers were amongst the 22 carers who had used the PHP. Comments from the carers about the PHP varied and included:</p> <p>'It's good. Everything relating to E is in there.''It allows J more control over his medical information.''I'm busy, and it's easy to forget.''I haven't wanted to bother the GP with it.'</p> <hd id="AN0048225072-26">Outcome measures</hd> <p></p> <hd id="AN0048225072-27">Increased attendance at GPs (the primary outcome measure) and other health care services</hd> <p>The GP visiting rate was found to be low for both groups at baseline, 2.3 visits and 2.6 visits per year in the intervention and control groups respectively. Although a greater increase in GP annual consultations was seen in the PHP group (increase of 1.4 visits per year) compared with the control group (increase of 0.8 visits per year), the difference was not statistically significant: effect size = 0.6 (−0.4 to 1.6) (Table 3).</p> <p>3  Main outcome measures</p> <p> <ephtml> <table><thead valign="bottom"><tr><th valign="bottom">Outcome measure</th><th>PHP practices</th><th>Control practices</th><th valign="bottom">Intervention effect</th></tr><tr><th>No. practices/ patients</th><th>Baseline
mean (SD)</th><th>12 months
mean (SD)</th><th> Difference
95% (SD)</th><th>No. practices/ patients</th><th>Baseline
mean (SD)</th><th>12 months
mean (SD)</th><th> Difference
95% (SD)</th></tr></thead><tbody valign="top"><tr><td>GP visits (medical notes)</td><td>20/79</td><td>2.3 (2.1)</td><td>3.7 (2.1)</td><td>1.4 (1.9)</td><td>19/84</td><td>2.6 (1.2)</td><td>3.4 (1.0)</td><td>0.8 (1.2)</td><td>0.6 (−0.4 to 1.6)</td></tr><tr><td>Carers only</td></tr><tr><td> No. hospital services received per annum</td><td>19/70</td><td>2.2 (0.6)</td><td>2.0 (0.8)</td><td>−0.2 (0.7)</td><td>19/74</td><td>2.2 (0.8)</td><td>2.2 (0.8)</td><td>−0.1 (0.9)</td><td>−0.1 (−0.6 to 0.4)</td></tr><tr><td> No. community based services received per annum</td><td>19/70</td><td>5.8 (5.0)</td><td>5.1 (2.4)</td><td>−0.7 (4.7)</td><td>19/74</td><td>4.9 (4.1)</td><td>4.1 (2.1)</td><td>−0.8 (4.3)</td><td>0.1 (−1.4 to 1.7)</td></tr><tr><td> No. valid responses to health problems (out of 12)</td><td>19/70</td><td>11.9 (0.2)</td><td>11.8 (0.3)</td><td>−0.1 (0.4)</td><td>19/74</td><td>11.9 (0.2)</td><td>11.8 (0.2)</td><td>−0.1 (0.3)</td><td>0.0 (−0.2 to 0.2)</td></tr><tr><td> No. category of health problems reported (out of 12)</td><td>17/50</td><td>3.6 (1.7)</td><td>3.2 (1.5)</td><td>−0.3 (1.7)</td><td>16/46</td><td>3.6 (2.1)</td><td>3.5 (2.3)</td><td>−0.1 (1.4)</td><td>−0.2 (−1.3 to 0.9)</td></tr><tr><td> Carer's opinion of GP's communication with AWLD (max = 1)</td><td>17/49</td><td>0.6 (0.2)</td><td>0.6 (0.1)</td><td>0.0 (0.2)</td><td>19/52</td><td>0.6 (0.2)</td><td>0.6 (0.1)</td><td>0.0 (0.2)</td><td>0.0 (−0.1 to 0.2)</td></tr><tr><td>AWLD only</td></tr><tr><td> No. valid responses to health problems (out of 12)</td><td>14/34</td><td>3.2 (2.3)</td><td>9.0 (2.2)</td><td>5.8 (2.9)</td><td>18/32</td><td>4.2 (2.8)</td><td>9.8 (2.7)</td><td>5.6 (3.7)</td><td>0.2 (−2.3 to 2.6)</td></tr><tr><td> No. category of health problems reported (out of 12)</td><td>19/34</td><td>0.3 (0.4)</td><td>2.0 (1.1)</td><td>1.6 (1.2)</td><td>18/32</td><td>0.7 (1.2)</td><td>1.4 (0.8)</td><td>0.7 (1.5)</td><td> 0.9* (0.0 to 1.8)</td></tr><tr><td> AWLD's opinion of GP's communication with them (max = 1)</td><td>12/16</td><td>0.9 (0.2)</td><td>0.9 (0.1)</td><td>0.0 (0.2)</td><td>14/20</td><td>0.9 (0.2)</td><td>0.8 (0.2)</td><td>−0.1 (0.3)</td><td>0.1 (−0.1 to 0.2)</td></tr></tbody></table> </ephtml> </p> <p>2 *Significant <emph>P</emph> < 0.05.</p> <p>Carers reported use of services (CSRI) showed a small decrease in the use of both hospital and community based services at follow‐up compared with baseline, rather than the expected increase. There was no evidence of any difference in the amount of contact with health services (CSRI) between the PHP and control groups at follow‐up (Table 3).</p> <hd id="AN0048225072-28">Increased general knowledge of health</hd> <p>This hypothesis had to be tested indirectly, as the research had not included an informant assessment of health knowledge. It was hypothesized that if the health knowledge of AWLD in the PHP group improved they would understand and be able to respond to more health terminology at follow‐up. The 12 categories of health problem in the KHPT were selected as the outcome measure, as this measure had shown better test–retest reliabilities for an aggregated variable across AWLD and carers than other equivalent measures. The 12 categories were where health problems were identified in a category or abstract form e.g. chest and breathing problems (rather than asthma or bronchitis which would then be given as an example of the category which followed). It was assumed that the presence of a valid response (a yes or a no response) on the 12 main categories in the checklist indicated the AWLD understood the health terminology, whereas a 'don't know' or missing response indicated they hadn't. The hypothesis was that at follow‐up interviews AWLD in the PHP group would give more valid responses than AWLD in the control group compared with baseline.</p> <p>For both the PHP and Control groups a large increase in number of valid responses of health problems was obtained at follow‐up (Table 3). Valid responses increased from low initial figures of between 3.2 and 4.2 valid responses to high figures between 9 and 9.8 (i.e. 75% of the 12 categories). However, there was no significant difference in the number of valid responses given by AWLD in the PHP and control group at follow‐up. The improvement in both groups could be due to the effect of completing the baseline research interview.</p> <hd id="AN0048225072-29">Increased knowledge of personal health problems</hd> <p>This hypothesis also had to be tested indirectly, as the research had not included a medical evaluation of actual health, and any increase in reporting of personal health problems at follow‐up could be attributable to increased knowledge or to an actual increase in problems. However, any actual increases obtained would be expected to be the same in both groups.</p> <p>The AWLD showed a significant increase in reporting of problems in the PHP group compared with the control group on the 12 categories of the KHPT (effect size 0.9, CI 0.0 to 1.8, <emph>P</emph> = 0.04) (Table 3). There was increased reporting in both AWLD groups, again suggesting an effect of the health interview. For the carers there was no significant increase in reporting in either group or between groups (effect size −0.2). The samples of AWLD and carers were different for these two analyses, with some in each group only having had a carer or an AWLD interview.</p> <hd id="AN0048225072-30">Increased satisfaction with primary care consultations and improved communication with GP</hd> <p>Over 90% of AWLD and carers in both the PHP and control group reported satisfaction with primary care consultations both at baseline and at follow‐up. The hypothesis of greater satisfaction in the PHP group was therefore not tested because of this high ceiling effect. Communication by the GP with the AWLD was examined using a composite measure (details in instruments and statistical analysis sections). There were no significant differences between the PHP and control group for either carers or AWLD and very little change between the initial and follow up assessments (Table 3).</p> <hd id="AN0048225072-31">Discussion</hd> <p>The number of visits to the GP by AWLD and their carers was lower than recently published studies. This is a cause for concern given the high number of health needs reported by participants and the number of medications prescribed. This low rate is consistent with earlier published consultation rates (e.g. 3.2 pa [<reflink idref="bib36" id="ref46">36</reflink>]), but not with more recently reported research e.g. 5.4 pa ([<reflink idref="bib16" id="ref47">16</reflink>]); 4.6–4.8 pa ([<reflink idref="bib20" id="ref48">20</reflink>]); 5.4 pa ([<reflink idref="bib31" id="ref49">31</reflink>]). It may be due to different sample characteristics such as recent studies using practices in university catchment areas, or in ongoing LD research programmes.</p> <p>In retrospect, it could be argued that the hypothesis that there would be increased health usage resulting from implementing a personal health record was unjustified and that greater emphasis should have been given to health literacy outcomes, where some positive evidence of PHP implementation was obtained. The PHP could include more health literacy advice on overcoming known barriers e.g. providing a good history, and taking a health advocate.</p> <p>More AWLD than carers dropped out by follow‐up. This appeared to be because of (i) some AWLD finding the research interview too long or feeling embarrassed at being asked intimate health questions (e.g. sexual, bowel/urinary) and (ii) the most able/independent AWLD being more socially mobile and more likely to have changed house/GP/jobs etc by follow‐up.</p> <p>An unexpectedly high turnover of carers had occurred by follow‐up. A similar finding was reported in the only other published CRT in this area ([<reflink idref="bib20" id="ref50">20</reflink>]). This shows the vulnerability of AWLD who are dependant on changing staff. It supports the need for accurate records of health histories and health needs/healthcare to be maintained.</p> <p>The low reported usage of the PHP, particularly by carers, may be related to high staff turnover coupled with other factors such as carers forgetting it, being too busy or being concerned about taking up the GPs time. The low number of GP visits recorded also made it harder for GPs, AWLD and carers to remember to use the PHP. As so few people used the PHP it was not surprising that not much difference was found on outcome measures.</p> <p>Despite the poor uptake of the PHP, many AWLDs and supporting carers and professionals remain ardent advocates of its use. Further analysis might be able to identify which people/subgroups use it effectively. It is clear, in retrospect, that interventions such as the PHP will only be beneficial if ongoing systems are in place to ensure staff, carers and AWLD are able to implement, and then continuously maintain and develop the intervention. In this research there was no ongoing resource to maintain the PHP after the implementation phase. On reflection this was unrealistic, particularly given the high carer turnover and low number of GP visits.</p> <p>The research design enabled the full participation of AWLD (i) as researchers and (ii) as research participants. It also created challenges that needed to be overcome e.g. the employment of local AWLDs and carers without previous research skills as researchers meant a lot of effort had to be put into researcher selection, recruitment and training. Ensuring AWLD could be full participants required a substantial investment of time to devise, adapt and pilot accessible measures. However, the differences that were found emerged from the AWLD interviews. It is likely they would not have been obtained in traditional research based only on interviewing employed professionals or carers. Many other challenges had to be overcome e.g. persuading reluctant GPs to participate, completing ambitious interview schedules, tracking down participants for follow‐up and providing accessible results for researchers and participants.</p> <hd id="AN0048225072-32">Conclusion</hd> <p>No significant increase in GP visits or usage of health services was found, attributable to the implementation of PHPs. This replicates another recent research study finding that health diaries did not show any measurable effects on communication or health ([<reflink idref="bib21" id="ref51">21</reflink>]), adding additional validity and generalizability to the current findings.</p> <p>Evidence was found of increased reporting of health problems by AWLD in the PHP group. Knowledge of health problems increased in both groups of AWLD, suggesting that this may be due to the research assessment interviews, which may have a health literacy component. As carers had such a high turnover rate, it also suggests that health literacy interventions targeted at AWLD may have more enduring effects than those targeted at carers.</p> <p>The PHP was liked by most of the AWLD and carers who used it. However, many AWLD and their carers did not use it. If PHPs are going to benefit a greater proportion of AWLD, more resources need to be allocated to their implementation and subsequent maintenance and development. Carers and AWLD should be helped to use the PHP for the first few consultations in primary care and then to maintain it via annual health checks and health action plans. As recently published research suggests health checks are effective in identifying new or poorly managed health conditions ([<reflink idref="bib5" id="ref52">5</reflink>]; [<reflink idref="bib20" id="ref53">20</reflink>]; [<reflink idref="bib11" id="ref54">11</reflink>]), this would seem an ideal process to incorporate personal health diaries/records.</p> <p>More research is needed on the effect that high turnover of paid carers has on the health and health knowledge of the AWLD they support. Interventions aimed at carers will have limited impact in settings with high carer turnover unless there are ongoing training and staff handover programmes. Longitudinal studies of AWLD that include carer reports must factor this high turnover rate into the study design, particularly in calculating sample size.</p> <p>The effects of employing AWLD and carers as research interviewers on the information obtained was not evaluated, and therefore the results obtained need to be interpreted in this context, especially when comparing results with other research using an alternative methodology and design. The research confirmed previous findings of high health needs, multiple disabilities, high mortality and low GP visiting rates. Out of an initial sample of 209 AWLD, seven deaths occurred over the research period (average age at death = 39 years, range 19–80).</p> <p>To our knowledge this is the first published CRT in the learning disability research field with AWLD employed as researcher interviewers. The design also facilitated the inclusion of AWLD as full participants in the CRT with over 50% of the initial sample of AWLD completing the baseline interview. The research has demonstrated it is possible to include AWLD in randomized controlled trials.</p> <hd id="AN0048225072-33">Acknowledgments</hd> <p>This work was undertaken by Oxleas NHS Foundation Trust who received funding from the NHS Executive London, Research & Development Programme. The views expressed in the publication are those of the authors and not necessarily those of the NHS Executive or the Department of Health. 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  Label: Title
  Group: Ti
  Data: An Evaluation of the Implementation of Hand Held Health Records with Adults with Learning Disabilities: A Cluster Randomized Controlled Trial
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  Data: <searchLink fieldCode="AR" term="%22Turk%2C+Vicky%22">Turk, Vicky</searchLink><br /><searchLink fieldCode="AR" term="%22Burchell%2C+Sarah%22">Burchell, Sarah</searchLink><br /><searchLink fieldCode="AR" term="%22Burrha%2C+Sukhjinder%22">Burrha, Sukhjinder</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Applied+Research+in+Intellectual+Disabilities%22"><i>Journal of Applied Research in Intellectual Disabilities</i></searchLink>. Mar 2010 23(2):100-111.
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  Data: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
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  Label: Physical Description
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  Data: PDF
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  Data: 12
– Name: DatePubCY
  Label: Publication Date
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  Data: 2010
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Evaluative
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  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Control+Groups%22">Control Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Learning+Disabilities%22">Learning Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Evaluation%22">Evaluation</searchLink><br /><searchLink fieldCode="DE" term="%22Handheld+Devices%22">Handheld Devices</searchLink><br /><searchLink fieldCode="DE" term="%22Records+%28Forms%29%22">Records (Forms)</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Interviews%22">Interviews</searchLink><br /><searchLink fieldCode="DE" term="%22Cluster+Grouping%22">Cluster Grouping</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/j.1468-3148.2009.00518.x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1360-2322
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: Personal health records were implemented with adults with learning disabilities (AWLD) to try to improve their health-care. Materials and Method: Forty GP practices were randomized to the Personal Health Profile (PHP) implementation or control group. Two hundred and one AWLD were interviewed at baseline and 163 followed up after 12 months intervention (PHP group). AWLD and carers of AWLD were employed as research interviewers. AWLD were full research participants. Results: Annual consultation rates in the intervention and control groups at baseline were low (2.3 and 2.6 visits respectively). A slightly greater increase occurred over the year in the intervention group 0.6 (-0.4 to 1.6) visits/year compared with controls. AWLD in PHP group reported more health problems at follow-up 0.9 (0.0 to 1.8). AWLD liked their PHP (92%) but only 63% AWLD and 55% carers reported PHP usage. Carers had high turnover (34%). Conclusions: No significant outcomes were achieved by the intervention.
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  Label: Entry Date
  Group: Date
  Data: 2010
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  Label: Accession Number
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  Data: EJ874347
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        Value: 10.1111/j.1468-3148.2009.00518.x
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      – Text: English
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      Pagination:
        PageCount: 12
        StartPage: 100
    Subjects:
      – SubjectFull: Control Groups
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Learning Disabilities
        Type: general
      – SubjectFull: Evaluation
        Type: general
      – SubjectFull: Handheld Devices
        Type: general
      – SubjectFull: Records (Forms)
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Interviews
        Type: general
      – SubjectFull: Cluster Grouping
        Type: general
    Titles:
      – TitleFull: An Evaluation of the Implementation of Hand Held Health Records with Adults with Learning Disabilities: A Cluster Randomized Controlled Trial
        Type: main
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            NameFull: Turk, Vicky
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            NameFull: Burchell, Sarah
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            NameFull: Burrha, Sukhjinder
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              Y: 2010
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            – TitleFull: Journal of Applied Research in Intellectual Disabilities
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