User-Centered Development of STOP (Successful Treatment for Paranoia): Material Development and Usability Testing for a Digital Therapeutic for Paranoia

BACKGROUND

Paranoia is a highly debilitating mental health condition. One novel intervention for paranoia is cognitive bias modification for paranoia (CBM-pa). CBM-pa comes from a class of interventions that focus on manipulating interpretation bias. Here, we aimed to develop and evaluate new therapy content for CBM-pa for later use in a self-administered digital therapeutic for paranoia called STOP ("Successful Treatment of Paranoia").

OBJECTIVE

This study aimed to (1) take a user-centered approach with input from living experts, clinicians, and academics to create and evaluate paranoia-relevant item content to be used in STOP and (2) engage with living experts and the design team from a digital health care solutions company to cocreate and pilot-test the STOP mobile app prototype.

METHODS

We invited 18 people with living or lived experiences of paranoia to create text exemplars of personal, everyday emotionally ambiguous scenarios that could provoke paranoid thoughts. Researchers then adapted 240 suitable exemplars into corresponding intervention items in the format commonly used for CBM training and created 240 control items for the purpose of testing STOP. Each item included newly developed, visually enriching graphics content to increase the engagement and realism of the basic text scenarios. All items were then evaluated for their paranoia severity and readability by living experts (n=8) and clinicians (n=7) and for their item length by the research team. Items were evenly distributed into six 40-item sessions based on these evaluations. Finalized items were presented in the STOP mobile app, which was co-designed with a digital health care solutions company, living or lived experts, and the academic team; user acceptance was evaluated across 2 pilot tests involving living or lived experts.

RESULTS

All materials reached predefined acceptable thresholds on all rating criteria: paranoia severity (intervention items: ≥1; control items: ≤1, readability: ≥3, and length of the scenarios), and there was no systematic difference between the intervention and control group materials overall or between individual sessions within each group. For item graphics, we also found no systematic differences in users' ratings of complexity (P=.68), attractiveness (P=.15), and interest (P=.14) between intervention and control group materials. User acceptance testing of the mobile app found that it is easy to use and navigate, interactive, and helpful.

CONCLUSIONS

Material development for any new digital therapeutic requires an iterative and rigorous process of testing involving multiple contributing groups. Appropriate user-centered development can create user-friendly mobile health apps, which may improve face validity and have a greater chance of being engaging and acceptable to the target end users.

The relationship between striatal dopamine and anterior cingulate glutamate in first episode psychosis changes with antipsychotic treatment

The neuromodulator dopamine and excitatory neurotransmitter glutamate have both been implicated in the pathogenesis of psychosis, and dopamine antagonists remain the predominant treatment for psychotic disorders. To date no study has measured the effect of antipsychotics on both of these indices together, in the same population of people with psychosis. Striatal dopamine synthesis capacity (Kicer) and anterior cingulate glutamate were measured using 18F-DOPA positron emission tomography and proton magnetic resonance spectroscopy respectively, before and after at least 5 weeks' naturalistic antipsychotic treatment in people with first episode psychosis (n = 18) and matched healthy controls (n = 20). The relationship between both measures at baseline and follow-up, and the change in this relationship was analyzed using a mixed linear model. Neither anterior cingulate glutamate concentrations (p = 0.75) nor striatal Kicer (p = 0.79) showed significant change following antipsychotic treatment. The change in relationship between whole striatal Kicer and anterior cingulate glutamate, however, was statistically significant (p = 0.017). This was reflected in a significant difference in relationship between both measures for patients and controls at baseline (t = 2.1, p = 0.04), that was not present at follow-up (t = 0.06, p = 0.96). Although we did not find any effect of antipsychotic treatment on absolute measures of dopamine synthesis capacity and anterior cingulate glutamate, the relationship between anterior cingluate glutamate and striatal dopamine synthesis capacity did change, suggesting that antipsychotic treatment affects the relationship between glutamate and dopamine.

Postnatal maternal depressive symptoms and behavioural outcomes in term-born and preterm-born toddlers: a longitudinal UK community cohort study

OBJECTIVES

To examine the association between maternal depressive symptoms in the immediate postnatal period and offspring's behavioural outcomes in a large cohort of term-born and preterm-born toddlers.

DESIGN AND PARTICIPANTS

Data were drawn from the Developing Human Connectome Project. Maternal postnatal depressive symptoms were assessed at term-equivalent age, and children's outcomes were evaluated at a median corrected age of 18.4 months (range 17.3-24.3).

EXPOSURE AND OUTCOMES

Preterm birth was defined as <37 weeks completed gestation. Maternal depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale (EPDS). Toddlers' outcome measures were parent-rated Child Behaviour Checklist 1^1/2-5 Total (CBCL) and Quantitative Checklist for Autism in Toddlers (Q-CHAT) scores. Toddlers' cognition was assessed with the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III).

RESULTS

Higher maternal EPDS scores were associated with toddlers' higher CBCL (B=0.93, 95% CI 0.43 to 1.44, p<0.001, f²=0.05) and Q-CHAT scores (B=0.27, 95% CI 0.03 to 0.52, p=0.031, f²=0.01). Maternal EPDS, toddlers' CBCL and Q-CHAT scores did not differ between preterm (n=97; 19.1% of the total sample) and term participants. Maternal EPDS score did not disproportionately affect preterm children with respect to CBCL or Q-CHAT scores.

CONCLUSIONS

Our findings indicate that children whose mothers reported increased depressive symptoms in the early postnatal period, including subclinical symptoms, exhibit more parent-reported behavioural problems in toddlerhood. These associations were independent of gestational age. Further research is needed to confirm the clinical significance of these findings.

Education and social care predictors of offending trajectories: A UK administrative data linkage study

ObjectivesTotal annual costs of crime in England and Wales is estimated at £50bn.The age-crime curve indicates that criminal behavioural peaks in adolescence and decreases in adulthood.  Life-course persistent offenders begin to behave antisocially early in childhood and continue this behaviour into adulthood. By contrast, adolescent-limited offenders exhibit most of their antisocial behaviour during adolescence, with a minority continuing to offend into adulthood. However, evidence suggests that this curve conceals distinct developmental trajectories. Prospective cohort study data has highlighted distinct risk factors for these offending trajectories, but this research is limited because of small sample sizes for disadvantaged groups, selection bias and infrequency of data collection. ApproachThe current study began in February 2022 and is one of the first to use UK linked national crime and education records. The aim is to: (1) establish the offending trajectories of individuals between the ages of 10 and 32 years following their first recorded conviction or caution using national crime records; and (2) develop prediction models of these offending trajectories using administrative education and social care data. ResultsIn my talk, I will share findings on the offending trajectories identified and present some early results on the key education and social care drivers of the offending trajectories. ConclusionsFindings from the project have the potential to identify previously unknown, or confirm lesser known, offending trajectories using real world data based on the UK population. It may also lead to the detection of previously unknown risk or protective factors for offending, which has implications for early intervention and could help inform criminal justice system responses to early antisocial behaviour.

Two-stage sampling in the estimation of growth parameters and percentile norms: sample weights versus auxiliary variable estimation

BACKGROUND

The use of auxiliary variables with maximum likelihood parameter estimation for surveys that miss data by design is not a widespread approach, despite its documented improved efficiency over traditional approaches that deploy sampling weights. Although efficiency gains from the use of Normally distributed auxiliary variables in a model have been recorded in the literature, little is known about the effects of non-Normal auxiliary variables in the parameter estimation.

METHODS

We simulate growth data to mimic SCALES, a two-stage survey of language development with a screening phase (stage one) for which data are observed for the whole sample and an intensive assessments phase (stage two), for which data are observed for a sub-sample, selected using stratified random sampling. In the simulation, we allow a fully observed Poisson distributed stratification criterion to be correlated with the partially observed model responses and develop five generalised structural equation growth models that host the auxiliary information from this criterion. We compare these models with each other and with a weighted growth model in terms of bias, efficiency, and coverage. We finally apply our best performing model to SCALES data and show how to obtain growth parameters and population norms.

RESULTS

Parameter estimation from a model that incorporates a non-Normal auxiliary variable is unbiased and more efficient than its weighted counterpart. The auxiliary variable method is capable of producing efficient population percentile norms and velocities.

CONCLUSIONS

The deployment of a fully observed variable that dominates the selection of the sample and correlates strongly with the incomplete variable of interest appears beneficial for the estimation process.

Update on Transplacental Transfer of IgG Subclasses: Impact of Maternal and Fetal Factors

Transplacental antibody transfer from mother to fetus provides protection from infection in the first weeks of life, and the four different subclasses of IgG (IgG1, IgG2, IgG3, and IgG4) have diverse roles in protection against infection. In this study, we evaluated concentrations and transplacental transfer ratios of the IgG subclasses in a healthy UK-based cohort of mother-cord pairs, and investigated associations with maternal, obstetric, and fetal factors. In agreement with previous studies, we found a strong association between maternal and cord IgG for all subclasses. We report a transfer efficiency hierarchy of IgG1>IgG3>IgG4=IgG2 in our study population, and our review of the literature demonstrates that there is no consensus in the hierarchy of subclass transfer, despite the commonly made statement that the order is IgG1>IgG4>IgG3>IgG2. We report additional data regarding negative associations between elevated maternal IgG concentrations and maternal/cord transfer ratios, finding an effect on IgG1, IgG2, and IgG3 subclasses. Levels of IgG subclasses were the same between venous and arterial blood samples from the umbilical cord, but there was a significantly higher level of total IgG in arterial blood. We found no correlation between placental FcRn protein levels and IgG transfer in our cohort, suggesting that IgG is the main determinant of observed differences in transplacental transfer ratios at term. Neonatal IgG1 and IgG4 levels were increased with later gestation at delivery, independent of any increase in transplacental transfer, indicating that the benefit of later gestation is through accumulation of these subclasses in the fetus. Neonatal IgG2 levels and transfer ratios were reduced in rhesus-negative pregnancies, suggesting that administered anti-D antibodies may compete for transplacental transfer of this subclass. Maternal influenza vaccination resulted in elevated maternal and neonatal levels of IgG4, whereas maternal Tdap vaccination had no impact on neonatal levels of the subclasses, nor transfer. However, within Tdap vaccinated pregnancies, later gestation at Tdap vaccination was associated with higher transplacental transfer. Our study provides information regarding levels and transfer of IgG subclasses in healthy term pregnancies and demonstrates the importance of recording detailed clinical information in studies of antibody transfer, including parity, ethnicity, and timing of maternal vaccine delivery.

Does Inattention and Hyperactivity Moderate the Relation Between Speed of Processing and Language Skills?

The causal role of speed of processing (SOP) in developmental language disorder (DLD) is unclear given that SOP has been implicated in other neurodevelopmental disorders such as attention-deficit/hyperactivity disorder. This study investigated associations between SOP, language, and inattention/hyperactivity in a U.K. epidemiological cohort (N = 528). Monolingual children from a range of socioeconomic backgrounds were assessed longitudinally; at ages 5-6 (2012/2013) and 7-8 years (2014/2015). Persistent weaknesses in SOP characterized children with DLD but did not predict language longitudinally. Ratings of inattention/hyperactivity moderated the association between SOP and language, indicating that SOP deficits are particularly detrimental for language when coupled with poor attention/hyperactivity. SOP may be a shared risk factor for DLD and inattention/hyperactivity or a general marker of neurodevelopmental disorder.

Antibody responses to Bordetella pertussis and other childhood vaccines in infants born to mothers who received pertussis vaccine in pregnancy - a prospective, observational cohort study from the United Kingdom

The maternal Tdap (tetanus, diphtheria and acellular pertussis) vaccination programme in the United Kingdom has successfully reduced cases of pertussis in young infants. In addition to prevention of pertussis cases, it is also important to investigate the persistence of maternal antibodies during infancy and the possible interference of maternal antibodies with infant responses to vaccines. We recruited mother–infant pairs from vaccinated and unvaccinated pregnancies and measured concentrations of immunoglobulin (Ig)G against pertussis toxin (PTx), filamentous haemagglutinin (FHA), pertactin (Prn), diphtheria toxin (DTx), tetanus toxoid (TTx) Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae in mothers and infants at birth, and in infants at 7 weeks and at 5 months. Thirty‐one mother–infant pairs were tested. Tdap‐vaccinated women had significantly higher antibody against Tdap antigens, compared to unvaccinated women (DTx, P = 0·01; PTx, FHA, Prn and TTx, P < 0·001). All antibodies were actively transferred to the infants (transfer ratio  > 1) with higher transfer of DTx (P = 0·04) and TTx (P = 0·02) antibody in Tdap‐vaccinated pregnancies compared to unvaccinated pregnancies. Infants from Tdap‐vaccinated pregnancies had significantly elevated antibodies to all antigens at birth (P < 0.001) and at 7 weeks (FHA, Prn, TTx, P < 0·001; DTx, P = 0.01; PTx, P = 0·004) compared to infants from unvaccinated pregnancies. Infants from Tdap‐vaccinated and ‐unvaccinated pregnancies had comparable antibody concentrations following primary pertussis immunization (PTx, P = 0·77; FHA, P = 0·58; Prn, P = 0·60; DTx, P = 0·09; TTx, P = 0·88). These results support maternal immunization as a method of protecting vulnerable infants during their first weeks of life.

Standardizing test scores for a target population: The LMS method illustrated using language measures from the SCALES project

BACKGROUND

Centile curves and standard scores are common in epidemiological research. However, standardised norms and centile growth curves for language disorder that reflect the entire UK local school population do not exist.

METHODS

Scores on six language indices assessing receptive and expressive functioning of children were obtained from the SCALES population survey. Monolingual English speaking participants were aged between five and nine years. Children who attended special schools at study intake, or who were learning English as an additional language were excluded. We constructed language norms using the LMS method of standardisation which allows for skewed measurements. We made use of probability weights that were produced from a two-step logistic model. Distributions of estimated standard scores from an intensively assessed sub-population and from the full population were contrasted to demonstrate the role of weights.

RESULTS

Non-overlapping centile curves and standardised scores at each age were obtained for the six language indices. The use of weights was essential at retrieving the target distribution of the scores. An online calculator that estimates standardised scores for the measures was constructed and made freely available.

CONCLUSIONS

The findings highlight the usefulness and flexibility of the LMS method at dealing with the standardisation of linguistic and educational measures that are sufficiently continuous. The paper adds to the existing literature by providing population norms for a number of language tests that were calculated from the same group of individuals.

Language growth in children with heterogeneous language disorders: a population study

BACKGROUND

Language development has been characterised by significant individual stability from school entry. However, the extent to which trajectories of language growth vary in children with language disorder as a function of co-occurring developmental challenges is a question of theoretical import, with implications for service provision.

METHODS

SCALES employed a population-based survey design with sample weighting procedures to estimate growth in core language skills over the first three years of school. A stratified sample (n = 529) received comprehensive assessment of language, nonverbal IQ, and social, emotional and behavioural difficulties at 5-6 years of age and 95% of the sample (n = 499) were assessed again at ages 7-8. Language growth was measured using both raw and standard scores in children with typical development, children with language disorder of unknown origin, and children with language disorders associated with a known clinical condition and/or intellectual disability.

RESULTS

Overall, language was stable at the individual level (estimated ICC = 0.95) over the first three years of school. Linear mixed effects models highlighted steady growth in language raw scores across all three groups, including those with multiple developmental challenges. There was little evidence, however, that children with language disorders were narrowing the gap with peers (z-scores). Adjusted models indicated that while nonverbal ability, socioeconomic status and social, emotional and behavioural deficits predicted initial language score (intercept), none predicted language growth (slope).

CONCLUSIONS

These findings corroborate previous studies suggesting stable language trajectories after ages 5-6 years, but add considerably to previous work by demonstrating similar developmental patterns in children with additional nonverbal cognitive deficits, social, emotional, and behavioural challenges, social disadvantage or clinical diagnoses.

Intravascular versus surface cooling for targeted temperature management after out-of-hospital cardiac arrest - an analysis of the TTM trial data

Background

Targeted temperature management is recommended after out-of-hospital cardiac arrest and may be achieved using a variety of cooling devices. This study was conducted to explore the performance and outcomes for intravascular versus surface devices for targeted temperature management after out-of-hospital cardiac arrest.

Method

A retrospective analysis of data from the Targeted Temperature Management trial. N = 934. A total of 240 patients (26%) managed with intravascular versus 694 (74%) with surface devices. Devices were assessed for speed and precision during the induction, maintenance and rewarming phases in addition to adverse events. All-cause mortality, as well as a composite of poor neurological function or death, as evaluated by the Cerebral Performance Category and modified Rankin scale were analysed.

Results

For patients managed at 33 °C there was no difference between intravascular and surface groups in the median time taken to achieve target temperature (210 [interquartile range (IQR) 180] minutes vs. 240 [IQR 180] minutes, p = 0.58), maximum rate of cooling (1.0 [0.7] vs. 1.0 [0.9] °C/hr, p = 0.44), the number of patients who reached target temperature (within 4 hours (65% vs. 60%, p = 0.30); or ever (100% vs. 97%, p = 0.47), or episodes of overcooling (8% vs. 34%, p = 0.15). In the maintenance phase, cumulative temperature deviation (median 3.2 [IQR 5.0] °C hr vs. 9.3 [IQR 8.0] °C hr, p = <0.001), number of patients ever out of range (57.0% vs. 91.5%, p = 0.006) and median time out of range (1 [IQR 4.0] hours vs. 8.0 [IQR 9.0] hours, p = <0.001) were all significantly greater in the surface group although there was no difference in the occurrence of pyrexia. Adverse events were not different between intravascular and surface groups. There was no statistically significant difference in mortality (intravascular 46.3% vs. surface 50.0%; p = 0.32), Cerebral Performance Category scale 3–5 (49.0% vs. 54.3%; p = 0.18) or modified Rankin scale 4–6 (49.0% vs. 53.0%; p = 0.48).

Conclusions

Intravascular and surface cooling was equally effective during induction of mild hypothermia. However, surface cooling was associated with less precision during the maintenance phase. There was no difference in adverse events, mortality or poor neurological outcomes between patients treated with intravascular and surface cooling devices.

Trial registration

TTM trial ClinicalTrials.gov number https://clinicaltrials.gov/ct2/show/NCT01020916NCT01020916; 25 November 2009

Parent-mediated social communication therapy for young children with autism (PACT): long-term follow-up of a randomised controlled trial

BACKGROUND

It is not known whether early intervention can improve long-term autism symptom outcomes. We aimed to follow-up the Preschool Autism Communication Trial (PACT), to investigate whether the PACT intervention had a long-term effect on autism symptoms and continued effects on parent and child social interaction.

METHODS

PACT was a randomised controlled trial of a parent-mediated social communication intervention for children aged 2-4 years with core autism. Follow-up ascertainment was done at three specialised clinical services centres in the UK (London, Manchester, and Newcastle) at a median of 5·75 years (IQR 5·42-5·92) from the original trial endpoint. The main blinded outcomes were the comparative severity score (CSS) from the Autism Diagnostic Observation Schedule (ADOS), the Dyadic Communication Assessment Measure (DCMA) of the proportion of child initiatiations when interacting with the parent, and an expressive-receptive language composite. All analyses followed the intention-to-treat principle. PACT is registered with the ISRCTN registry, number ISRCTN58133827.

FINDINGS

121 (80%) of the 152 trial participants (59 [77%] of 77 assigned to PACT intervention vs 62 [83%] of 75 assigned to treatment as usual) were traced and consented to be assessed between July, 2013, and September, 2014. Mean age at follow-up was 10·5 years (SD 0·8). Group difference in favour of the PACT intervention based on ADOS CSS of log-odds effect size (ES) was 0·64 (95% CI 0·07 to 1·20) at treatment endpoint and ES 0·70 (95% CI -0·05 to 1·47) at follow-up, giving an overall reduction in symptom severity over the course of the whole trial and follow-up period (ES 0·55, 95% CI 0·14 to 0·91, p=0·004). Group difference in DCMA child initiations at follow-up showed a Cohen's d ES of 0·29 (95% CI -0.02 to 0.57) and was significant over the course of the study (ES 0·33, 95% CI 0·11 to 0·57, p=0·004). There were no group differences in the language composite at follow-up (ES 0·15, 95% CI -0·23 to 0·53).

INTERPRETATION

The results are the first to show long-term symptom reduction after a randomised controlled trial of early intervention in autism spectrum disorder. They support the clinical value of the PACT intervention and have implications for developmental theory.

FUNDING

Medical Research Council.

The impact of nonverbal ability on prevalence and clinical presentation of language disorder: evidence from a population study

BACKGROUND

Diagnosis of 'specific' language impairment traditionally required nonverbal IQ to be within normal limits, often resulting in restricted access to clinical services for children with lower NVIQ. Changes to DSM-5 criteria for language disorder removed this NVIQ requirement. This study sought to delineate the impact of varying NVIQ criteria on prevalence, clinical presentation and functional impact of language disorder in the first UK population study of language impairment at school entry.

METHODS

A population-based survey design with sample weighting procedures was used to estimate population prevalence. We surveyed state-maintained reception classrooms (n = 161 or 61% of eligible schools) in Surrey, England. From a total population of 12,398 children (ages 4-5 years), 7,267 (59%) were screened. A stratified subsample (n = 529) received comprehensive assessment of language, NVIQ, social, emotional and behavioural problems, and academic attainment.

RESULTS

The total population prevalence estimate of language disorder was 9.92% (95% CI 7.38, 13.20). The prevalence of language disorder of unknown origin was estimated to be 7.58% (95% CI 5.33, 10.66), while the prevalence of language impairment associated with intellectual disability and/or existing medical diagnosis was 2.34% (95% CI 1.40, 3.91). Children with language disorder displayed elevated symptoms of social, emotional and behavioural problems relative to peers, F(1, 466) = 7.88, p = .05, and 88% did not make expected academic progress. There were no differences between those with average and low-average NVIQ scores in severity of language deficit, social, emotional and behavioural problems, or educational attainment. In contrast, children with language impairments associated with known medical diagnosis and/or intellectual disability displayed more severe deficits on multiple measures.

CONCLUSIONS

At school entry, approximately two children in every class of 30 pupils will experience language disorder severe enough to hinder academic progress. Access to specialist clinical services should not depend on NVIQ.

Current practice, accuracy, effectiveness and cost-effectiveness of the school entry hearing screen

OBJECTIVES

To describe and analyse in detail current practice of school entry hearing screening (SES) in the UK.

DATA SOURCES

Main electronic databases were searched up to May 2005.

REVIEW METHODS

A national postal questionnaire survey was addressed to all leads for SES in the UK, considering current practice in terms of implementation, protocols, target population and performance data. Primary data from cohort studies in one area of London were examined. A systematic review of alternative SES tests, test performance and impact on outcomes was carried out. Finally, a review of published studies on costs, plus economic modelling of current and alternative programmes was prepared.

RESULTS

The survey suggested that SES is used in most of England, Wales and Scotland; just over 10% of respondents have abandoned the screen; others are awaiting national guidance. Coverage of SES is variable, but is often over 90% for children in state schools. Referral rates are variable, with a median of about 8%. The test used for the screen is the pure tone sweep test but with wide variation in implementation, with differing frequencies, pass criteria and retest protocols; written examples of protocols were often poor and ambiguous. There is no national approach to data collection, audit and quality assurance, and there are variable approaches at local level. The screen is performed in less than ideal test conditions and resources are often limited, which has an impact on the quality of the screen. The primary cohort studies show that the prevalence of permanent childhood hearing loss continues to increase through infancy. Of the 3.47 in 1000 children with a permanent hearing loss at school screen age, 1.89 in 1000 required identification after the newborn screen. Newborn hearing screening is likely to reduce significantly the yield of SES for permanent bilateral and unilateral hearing impairments; yield had fallen from about 1.11 in 1000 before newborn screening to about 0.34 in 1000 for cohorts that had had newborn screening, of which only 0.07 in 1000 were unilateral impairments. Just under 20% of permanent moderate or greater bilateral, mild bilateral and unilateral impairments, known to services as 6-year-olds or older, remained to be identified around the time of school entry. No good-quality published comparative trials of alternative screens or tests for SES were identified and studies concerned with the relative accuracy of alternative tests are difficult to compare and often flawed by differing referral criteria and case definitions; with full pure tone audiometry as the reference test, the pure tone sweep test appears to have high sensitivity and high specificity for minimal, mild and greater hearing impairments, better than alternative tests for which evidence was identified. There is insufficient evidence regarding possible harm of the screen. There were no published studies identified that examined the possible effects of SES on longer term outcomes. No good-quality published economic evaluations of SES were identified and a universal SES based on pure tone sweep tests was associated with higher costs and slightly higher quality-adjusted life-years (QALYs) compared with no screen and other screen alternatives; the incremental cost-effectiveness ratio for such a screen is around 2500 pounds per QALY gained; the range of expected costs, QALYs and net benefits was broad, indicating a considerable degree of uncertainty. Targeted screening could be more cost-effective than universal school entry screening; however, the lack of primary data and the wide limits for variables in the modelling mean that any conclusions must be considered indicative and exploratory only. A national screening programme for permanent hearing impairment at school entry meets all but three of the criteria for a screening programme, but at least six criteria are not met for screening for temporary hearing impairment.

CONCLUSIONS

The lack of good-quality evidence in this area remains a serious problem. Services should improve quality and audit screen performance for identification of previously unknown permanent hearing impairment, pending evidence-based policy decisions based on the research recommendations. Further research is needed into a number of important areas including the evaluation of an agreed national protocol for services delivering SES to make future studies and audits of screen performance more directly comparable.