Educating the educated: The impact of educational interventions on knowledge, attitudes and confidence of healthcare professionals in caring for patients with intellectual disability: A systematic review

ABSTRACT

Background:

The attitudes, perceptions and inherent biases of healthcare professionals (HCPs) have the potential to influence and inform health outcomes of people with intellectual disability. This review aimed to identify what educational interventions have been conducted to improve the attitude, knowledge, and confidence of HCPs in caring for people with intellectual disability.

Method:

A systematic literature review was conducted using Medline, ERIC and PsycINFO. Inclusion criteria included: articles published after 1980 in English, quantitative and mixed methods studies.

Results:

Of 1444 articles yielded, 10 met the inclusion criteria. Studies predominantly included doctors and nurses. Almost half (40%) of the studies reported interventions that were effective in changing perceived confidence and attitudes, while 60% achieved improvement in knowledge or skills based on Kirkpatrick classification.

Conclusions:

Training is valuable in improving knowledge, broadening perspectives, and increasing confidence in managing people with intellectual disability but there are limited studies in this area.

KEYWORDS:

• Intellectual
• disability
• education
• intervention
• attitudes
• confidence
• healthcare

There are over half a million Australians living with intellectual disability (Australian Institute of Health and Welfare, 2020), yet this group appears to be the recipients of sub-optimal services and outcomes when it comes to healthcare (Heslop et al., 2014; Mimmo et al., 2018; Weise et al., 2021). Despite representing a sizable portion of the population, people with intellectual disability are consistently over-represented as a group that experience a high burden of morbidity, poor health outcomes and mortality when compared to the rest of the general population (Tracy & McDonald, 2015).

Global treaties and national legislation such as the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) and the Australian Disability Discrimination Act of 1992 enshrine the “full and effective participation and inclusion” of people with disabilities in society (United Nations, 2006). These protections work to uphold equal access to high quality standards of healthcare in the absence of discrimination. Despite these well-intentioned safeguards, the recent Australian Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (from here after referred to as the “Royal Commission”) raised many issues which point to a gap between reality and the standards outlined in the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), with systemic failings of the healthcare system continue to pervade and undermine the provision of equal, high quality healthcare services to Australian people living with intellectual disability (Royal Commission into Violence, 2020) Public hearing 10 in particular highlighted the lack of education and training of health professionals (Disability Royal Commission, 2020). This, in combination with the fact that people living with intellectual disability often have complex needs and an inflated risk of increased contact with the health system (Boulet et al., 2009) creates an undesirable predisposition for deeply ingrained, lifelong inequality in health outcomes. Specifically, hearing four of the recent Royal Commission illuminated the fact that people with intellectual disability have a significantly higher mortality rate compared to the general population, significantly lower life expectancy and are grossly overrepresented in avoidable hospitalisations. This has been partially attributed to poor rates of preventative care, higher rates of missed diagnoses, and lack of evidence-based disease management, in patients with intellectual disability when compared to the general population (Glover et al., 2017; Krahn et al., 2006; Lennox et al., 2007; Webb & Rogers, 1999).

In recognising that people with intellectual disability often have difficulties with communication and complex comorbidities that may contribute to these health disparities, stigmatising attitudes and limited knowledge have been shown to be held by many mainstream healthcare professionals (HCPs) and are likely to compound these sub-optimal outcomes (Desroches, 2019; Pelleboer-Gunnink et al., 2017; Wilson et al., 2022). For example, studies have shown clinicians tend to dismiss mental health problems as “part of the disability,” known more formally as “diagnostic overshadowing,” which can lead to misdiagnosis and inappropriate treatment (Kenten et al., 2019; Mason & Scior, 2004; Werner et al., 2013). Furthermore, people with intellectual disability and their carers have described negative comments and overt discrimination as a significant experience when accessing services in general hospitals (Gibbs et al., 2008). This was further supported in findings from the Royal Commission – which revealed that some mainstream healthcare professionals were ill-equipped to provide quality care to those with intellectual disability, partly due to attitudes, lack of confidence and limited knowledge about the unique needs of people with intellectual disability (Royal Commission into Violence, 2020).

An unfortunate paradox characterises the model of care delivered to people with intellectual disability in Australia, whereby healthcare is provided by a workforce of doctors and nurses who receive very little education in disability, and day-to-day support is primarily provided by unlicenced disability support staff who received very little education in health (Tracy & McDonald, 2015). This creates un-unified foundations in the disability workforce that can contribute to the well documented sub-optimal health outcomes for people living with intellectual disability. Until recently, post-graduate specialist medical training programs did not include competencies or learning objectives relating to the care of people with intellectual disability and medical school curricula in intellectual disability remains in varying amounts and of inconsistent quality (Tracy & McDonald, 2015). Furthermore, many doctors, nurses and allied health professionals in current practice have had little or no training at all in dealing with patients with intellectual disability (Cashin et al., 2022; Tracy & McDonald, 2015), owing to the urgent need for quality continued professional development (CPD) and training opportunities in this field. A further paradox arises whereby people with intellectual disability are over-represented in the healthcare system, yet their care is comparatively poorer and suffer more adverse events and negative experiences (Moloney et al., 2021; Ong et al., 2022), a likely contributing factor being these aforementioned gaps in training of the healthcare workforce.

It is difficult to ignore the sheer number of government enquiries, research and reviews that highlight the shortcomings in healthcare experienced by this population. Although we have the knowledge that change is needed, it is critical to move away from descriptive research and towards prescriptive research to better understand how we can effectively change this systemic pattern. Changing this pattern can potentially be achieved through interventions and programs designed to upskill healthcare providers and equalise the terrain of the Australian health system to make it be more accessible to those with intellectual disability.

Current research

Without addressing underlying biases, knowledge gaps and detrimental attitudes held, often unknowingly, by HCPs, it is unrealistic to expect meaningful change in the way that healthcare is delivered to people with intellectual disability. Some existing reviews have already started to target interventions that can be used to improve attitudes and stigma towards disability. For example, Shakespeare and Kleine (2013), reviewed the literature to evaluate interventions used to educate HCPs about all types of disability. Seewooruttun and Scior (2014), undertook a review to examine interventions aimed at increasing knowledge and improving attitudes towards intellectual disability in lay people – which included studies with police, HCPs, college students and the general population, which is helpful in a broader context but does not target the healthcare environment. Ioerger et al. (2019), investigated interventions targeting medical students attitudes and knowledge towards disability, yet similarly to Shakespeare and Kleine (2013), looked at all disability types. Adirim et al. (2021), conducted a systematic review investigating curricula in post-graduate medical training that targets knowledge, confidence and attitudes towards people with intellectual and developmental disability, including studies targeting autism spectrum disorder. Each of these reviews revealed that educational interventions show promise in improving attitudes and stigma towards disability, but often had high risk of bias, incomplete reporting and limitations of evaluation prohibited evidence-based conclusions (Ioerger et al., 2019). Furthermore, given the enormous breadth of disability impairment and specific needs in healthcare, it is important to investigate ways to target outcomes for specific groups such as people with intellectual disability.

The Australian National Disability Strategy (NDS) has highlighted that education of health providers is at the epicentre of an equality driven, person centred health system that can cater for the diverse needs of people with a disability (Commonwealth of Australia, 2020). By continuing to evaluate pre-existing interventions to further educate and improve healthcare providers’ service provision to people with intellectual disability, we can direct the development of efficacious and evidence-based programs to make for a more inclusive Australian healthcare system that caters for the diverse needs of all members of society. No previous reviews have directly looked at practicing HCPs from multiple disciplines, specifically regarding interventions that target attitudes, knowledge, and confidence in managing patients with intellectual disability. Hence, the aim of this study was to identify what interventions have been used to improve the attitudes, knowledge, and confidence of HCPs in caring for patients with intellectual disability.

Method

This systematic literature review of peer-reviewed articles was conducted in accordance with the Preferred Reporting items for Systematic review (Page et al., 2021). The team developed a list of key terms derived from a preliminary scope of the literature and other relevant systematic reviews (Adirim et al., 2021; Pelleboer-Gunnink et al., 2017) (see Table 1). The search was refined in consultation with a librarian who has expertise in health-related databases. Besides using key words with proximity operators the search strategy used Medical Subject Headings (MeSH). Subject headings/ index terms were tailored to each individual database. The search was conducted in a manner that included and combined the following concepts: “Health professionals” AND “educational intervention” AND “Intellectual disability” AND “change”/ “outcome.” Three databases MEDLINE, ERIC and PsycINFO were searched since inception until December 2021. The detailed search strategy is described in Appendix 1 supplementary material for search strategy.

Table 1. Keys concepts and terms used in the search.

Key concept	Key terms
(i) Health Professionals	Health personnel OR healthcare professional OR healthcare provider OR healthcare worker OR health professional OR nurse OR doctor OR physician OR residency OR registrar OR intern OR paediatr* OR psychiatr* OR clinician OR allied health professional
(ii) Educational Intervention	Graduate education OR postgraduate education OR teaching OR training OR program OR workshop OR nursing education OR medical education OR intervention OR training program OR internship OR residency OR curriculum OR education
(iii) Intellectual Disability	Intellectual disability OR mental deficiency OR developmental disorder OR developmental disability OR mental retard or mentally retard* OR intellectually disabled person OR intellectually disabled people OR handicap*
(iv) Change/ Outcome	attitud* OR perception OR knowledge OR confidence OR competence

References were downloaded into EndNote™ 20 were duplicates were removed. The remaining articles were uploaded to “JBI-SUMARI” software (v 5·0; JBI, Adelaide, SA, Australia). Titles were then screened for relevance and then by abstract for study population (healthcare professionals), intervention focus(knowledge, attitudes or confidence levels) and specificity for intellectual disability. The remaining articles then underwent full text screening by two authors GH and GG with application of the inclusion criteria (Table 2). Additional articles were included through a process of reference tracing. A data extraction sheet was used to summarise the information and results from the included articles.

Table 2. Inclusion and exclusion criteria.

	Inclusion	Exclusion
Publication date	Any time after 1980
Article availability	Full text available
Article language	English
Publication type	Journal article	Book chapters, commentary, opinions, viewpoints, letters, editorials,
Study type	Quantitative or mix methods primary research	Qualitative studies
Intervention participants	Any registered healthcare professional actively providing healthcare to patients	Students, residential support workers, community support workers.
Disability type	Intellectual disability	Other type of disability
Study relevance/ focus	Focuses on evaluating interventions that have been implemented to change knowledge, attitudes and confidence of HCPs in managing patients with intellectual disability.	Not reporting an education intervention.

Intervention evaluation was summarised for each paper with the additional application of a Kirkpatrick classification score. Scores were calculated independently by GH and GG. Kirkpatrick classification is a tool used widely used in medical education to evaluate training programs. Using this model, researchers can assess the effectiveness of a training intervention at various levels. For consistency with other relevant systematic reviews, this paper used a modified Kirkpatrick classification system from Adirim et al. (2021). A score of zero was applied to papers with no change in learning or learner perception, a score of (1) representing alteration in learner perspective or comfort, a score of (2) applied to papers with measurable improvement in learning, skills or knowledge, a score of (3) representing change in behaviour or practice as a result of the intervention and a score of (4) being the goal, representing a traceable difference in outcomes due to the behavioural change. Each paper was also subject to a quality appraisal using a tool developed by Hawker et al. (2002). This assessment tool was chosen as it is designed to evaluate studies compromising a variety of research paradigms. The quality appraisal was conducted independently by GH and GG. Disagreements in Kirkpatrick and quality scores were discussed to reach a consensus.

Results

A total of 1444 articles were yielded from the initial search, with ten meeting the inclusion criteria after title, abstract and full text screening (Figure 1).

Figure 1. Search strategy.

Study characteristics

Table 3 summarises the study characteristics for the ten included publications. One-third of the articles were published in the 1980s (Berg et al., 1983; Procci et al., 1981; Wysocki et al., 1987), four in the 2000s (Adler et al., 2005; Lowe et al., 2007; Melville et al., 2006; Ruedrich et al., 2007) and the outstanding in the 2010s (Balogh et al., 2015; Bartkowski et al., 2018; Dagnan et al., 2018). The majority of the studies were conducted in North America, with half in the United States (USA) (Bartkowski et al., 2018; Berg et al., 1983; Procci et al., 1981; Ruedrich et al., 2007; Wysocki et al., 1987), and one in Canada (Balogh et al., 2015). The remainder of the studies, (n = 4), were conducted in the United Kingdom (UK) (Adler et al., 2005; Dagnan et al., 2018; Lowe et al., 2007; Melville et al., 2006).

Table 3. Study characteristics.

Reference	Country	Participants	Setting	Pedagogical Methodology	Study Design	Timeline
Adler et al. (2005)	UK	Optometrists (n = 39), trainee optometrists (n = 49), ophthalmologists, (n = 1). Control group Optometrist (n = 83)	Special Olympics UK summer games	Theoretical (Didactic lectures), Experiential (Direct patient interaction at special Olympics pop up clinic).	Pre/Post intervention between groups design (control received ½ day non didactic lectures only, experimental group received lectures + clinical experience with intellectual disability patients)	1 d didactic training and at least 2 days of voluntary interaction with patients with intellectual disability.
Balogh et al. (2015)	Canada, Ontario	Nurses, nurse practitioners and physicians, n = 47 (of these n = 24 were in the control group)	Varied	Theoretical (3 x online modules centred around case scenarios, reference material for reading), Interactive (2x face-to-face workshops).	Pre/Post intervention between groups design (control received reference material, experimental group received reference material + 6 month continuing education course)	6 months
Bartkowski et al. (2018)	USA, Mississippi	Physicians and nurses, n = 544 pre-test 447 post-test	HCPs delivering care in community based residential settings. This was part of a State wide clinician improvement program.	Theoretical (clinician education seminar)	Pre/Post intervention within groups design	90 min single event
Berg et al. (1983)	USA, Phoenix	Paediatric residents, n = 11 Control (n = 13)	Variety of paediatric healthcare settings (e.g., psychiatric clinics, ambulatory clinics and counselling centres) as part of the Phoenix Hospitals Affiliated Paediatric Program (PHAPP)	Theoretical (didactic teaching), Experiential (direct patient interaction on rotation).	Pre/post intervention within groups design with 24 month follow up between groups comparison with control	2 months
Dagnan et al. (2018)	UK	Psychological therapy practitioners, n = 68. Primary Wellbeing Practitioners n = 32 & High Intensity Practitioners n = 36	Psychological Therapies (IAPT) services.	Theoretical (8 OR 4 × 75 min) sessions covering 8 point curriculum (8 or 4 sessions administered depending on level of therapist qualification).	Pre/post intervention within groups design	1–2 days
Lowe et al. (2007)	UK, South Wales	Registered nurses (n = 70) and nursing assistants (n = 52), n = 122	Classroom setting National Health Service (NHS)	Theoretical (lectures, video tapes, information handouts), Interactive (group discussions, practical exercises).	Pre/post intervention within groups design	80 h direct teaching across 10 days
Melville et al. (2006)	UK, Greater Glasgow Scotland	Nurses n = 123 Group 1 = 42 Group 2 = 21 Group 3 (control) = 60	Primary care	Theoretical (45 page written training pack, didactic presentations from interdisciplinary professionals and person with intellectual disability), Interactive (2 × 45 min workshops)	Three group pre/post intervention between groups design	3 h training event with 3 month access to training pack
Procci et al. (1981)	USA, Los Angeles	School nurses, n = 340	Elementary schools, junior high schools and senior high schools.	Theoretical (10–17 didactic lectures/ discussion forums)	Pre/post no control group	17 × 3 h sessions lecture/discussion format.
Ruedrich et al. (2007)	USA	Psychiatric residents (PGY 3 or 4), n = 23	Hospital based clinics, group homes, worksites for people with intellectual disability	Theoretical (didactic lectures and clinician lead teaching), Immersive (multidisciplinary site visits), Experiential (clinical experience).	Post intervention survey – no control group	12–16 h per week for 3–4 months.
Wysocki et al. (1987).	USA, Texas	Paediatric residents, n = 12	Varied	Theoretical (didactic and reading), Immersive (home visits, parental interaction), Interactive (interdisciplinary conference)	Pre/post intervention within groups design	4 × half day sessions at weekly intervals

A total of three articles evaluated interventions that targeted doctors alone (Berg et al., 1983; Ruedrich et al., 2007; Wysocki et al., 1987), three articles targeted nurses alone (Lowe et al., 2007; Melville et al., 2006; Procci et al., 1981), two articles targeted a combination of nurses and doctors (Balogh et al., 2015; Bartkowski et al., 2018)one targeted therapists (Dagnan et al., 2018) and one targeted optometrists (Adler et al., 2005).

Intervention characteristics and pedagogical methodology

The majority (40%) of studies were conducted as single session training programs (Adler et al., 2005; Bartkowski et al., 2018; Dagnan et al., 2018), with Melville et al (Melville et al., 2006), included in this category given the intervention was primarily a one-off training workshop, despite including 3-month access to written study materials. Two were considered “short term,” being less than 1 month in duration (Lowe et al., 2007; Wysocki et al., 1987) and three were greater than 2 months in duration (Balogh et al., 2015; Berg et al., 1983; Ruedrich et al., 2007). One study did not specify the timeline across which the intervention spanned but specified that there were seventeen 3-hour lecture sessions (Procci et al., 1981).

In regards to pedagogical/teaching methodology, all of the studies incorporated a theoretical component, meaning inclusion of reading materials, seminars or didactic lectures. In addition to the theoretical component, 30% included an experiential pedagogical framework (Adler et al., 2005; Berg et al., 1983; Ruedrich et al., 2007), characterised by direct clinical experience with patients with intellectual disability. Four incorporated interactive components to the training such as group discussions (Lowe et al., 2007; Wysocki et al., 1987), workshop style activities (Balogh et al., 2015; Melville et al., 2006) or practical exercises (Lowe et al., 2007). Limited studies (n = 2) included an immersive component to the training, involving multidisciplinary site visits (Ruedrich et al., 2007) or home visits with direct interaction with the parents of children with intellectual disability (Wysocki et al., 1987). All of the interventions evaluated in the articles had some focus on knowledge or clinical knowledge surrounding management of patients with intellectual disability. Furthermore, all articles prioritised content that was geared towards improving confidence or comfort in treating patients with intellectual disability. Only two of studies had a focus on attitudinal change (Dagnan et al., 2018; Lowe et al., 2007).

Educational outcomes

A summary of intervention outcomes and findings for each of the 10 articles is displayed in Table 4. Half of the articles measured changes in intellectual disability knowledge pre-and post-intervention (Balogh et al., 2015; Bartkowski et al., 2018; Berg et al., 1983; Lowe et al., 2007; Melville et al., 2006). One study evaluated skill level based on nursing supervisor observation post intervention, however with limited statistical analysis and information regarding method (Procci et al., 1981). Two studies made assessments of knowledge based on learner self-assessment of perceived understanding relating to care of patients with intellectual disability (Adler et al., 2005; Wysocki et al., 1987). All of the studies employed self-assessment of perceived confidence or comfort in managing patients with intellectual disability post intervention, with various scales specific to each intervention.

Table 4. Study results.

Reference	Focus of content	Evaluation Methodology	Relevant Findings	Kirkpatrick Score	Quality Appraisal
Adler et al. (2005)	Communication with people with intellectual disability, knowledge about intellectual disability and common ocular defects in people with intellectual disability, confidence working with intellectual disability.	10-item scale to assess self-reported knowledge, attitudes and confidence in working with people with intellectual disability. Results were compared with a group of control subjects who received similar lectures without the clinical experience.	Statistically significantly increased self-reported knowledge and confidence post intervention for optometrists who received the full intervention vs the control group (Wilcoxon SRT z = −4.434, p < 0.001.) Statistically significantly increased self-perceived confidence in working with patients with intellectual disability in both groups with significantly higher improvements in self perceived confidence in the group that received didactic teaching AND experiential interaction (z = −3.673, p < 0.001)	1	Fair (B)
Balogh et al. (2015)	Knowledge of primary care relating to people with developmental delay/ intellectual disability, Comfort/ confidence level in providing care to patients with developmental delay/ intellectual disability.	33-item survey with multiple choice knowledge assessment and self-assessed comfort in caring for patients with developmental delay/ intellectual disability.	Comfort levels with providing primary care to adults with developmental delay increased for both groups over time, but there was a statistically significantly greater increase for the participants in the intervention group (p = 0.01). The intervention group participants showed statistically significantly increased knowledge scores of primary care related to adults with developmental delay (p = 0.01) compared to the control group.	2	Good (A)
Bartkowski et al. (2018)	Clinician knowledge relating to people with intellectual and developmental disability. E.g., regarding history of treatment in socio-cultural context, common medical problems and diagnostic skills, competence with intellectual disability	6-item knowledge quiz pre and post intervention, subjective assessment of treatment competence pre and post intervention on “competence barometer” from 0–100.	Participants were statistically significantly more likely to select correct knowledge answer when compared with pre-test answer (p < 0.001). Subjective self-appraisal of treatment competence increased after seminars (p < 0.001)	2	Good (A)
Berg et al. (1983)	Knowledge regarding medical assessment/ treatment of patients with biosocial challenges; shift attitudes and improve competence	10-question assessment of perceived competence, 15-part assessment of attitudes towards dealing with patient group, 33-part MCQ assessment of factual knowledge in biosocial paediatrics.	Statistically significantly higher scores on: Post-test assessment of factual knowledge (p < 0.005). Improvement in feelings of competence in diagnosis, treatment and knowledge of community resources (p < 0.01) More confident in treating the patient group (p < 0.008) Improvement in overall attitude towards “mental retardation” (p < 0.003), Down’s syndrome (p < 0.008), “physical handicaps” (p < 0.003) and learning disabilities (p < 0.085). Those who participated in the program scored significantly higher on scores of knowledge and confidence 12–24 months later than those who did not participate.	2	Poor (C)
Dagnan et al. (2018)	Knowledge about intellectual disability (epidemiology, nature, causes, assessment, therapeutic techniques), attitudes (common stigma) and confidence in working with intellectual disability	Therapy Confidence Scale–Intellectual Disabilities (TCS-ID) a 14-item scale describing confidence of therapists working with intellectual disability, 5-item General Therapeutic Self Efficacy scale, 5-item adapted scale assessing attitudes towards treatment of people with intellectual disability	Statistically significant increase in therapist: Confidence post intervention (p < 0.001) and at 3-month follow up (p < 0.001) Self-efficacy post intervention (p < 0.001) and at 3-month follow up (p < 0.001). Attitudes towards intellectual disability post intervention (p < 0.001) and at 3-month follow up (p < 0.001).	2	Fair (B)
Lowe et al. (2007)	Attitudes and knowledge about patients with challenging behaviour, operational expertise and support, confidence	15-item scale perceived confidence, emotional response and attributions. 15 questions of knowledge and the confidence in coping with aggression self-efficacy scale.	Statistically significantly increased knowledge levels immediately after training, (p < 0.001). Enduring change in perceived confidence immediately after training (p < 0.001) and at 1-year follow up (p = 0.001).	2	Fair (B)
Melville et al. (2006)	Knowledge about health needs of people with intellectual disability, self-efficacy (perceived skills competence in working with people with intellectual disability).	24-item assessment of intellectual disability related health knowledge, 3-item assessment of self-efficacy on 5-point Likert scale.	Statistically significant increase in knowledge of participants who participated in the intervention compared to those who did not (p = 0.005) Self-efficacy of participants that received both components of the training was statistically significantly greater than those who did not do the training (p = 0.004). Participation in the two components of the training was associated with statistically significantly greater change in knowledge and self-efficacy than those receiving training pack alone. 66.6% of participants reported that they made changes to clinical practice post intervention.	2	Good (A)
Procci et al. (1981)	Knowledge about “handicapping conditions,” clinical competence and clinical skills.	Criterion referenced test after each session, self evaluation of competence, nursing supervisor evaluation of skill level	Self-reported increased clinical competence and observed increase in nursing skill levels and performance levels as assessed by supervisors. No statistical analysis provided.	1	Poor (C)
Ruedrich et al. (2007)	Basic knowledge about intellectual disability (epidemiology, historical and modern context, patterns of care, approaches, laws pertaining to treatment and biomedical aspects of care) and understanding of intellectual disability in community setting, competence in intellectual disability.	16-item survey assessing confidence, interest and post residency clinical activity with people with intellectual disability.	Participants strongly endorsed rotation as influential in building capacity, confidence and satisfaction in working with patients with intellectual disability.	1	Fair (B)
Wysocki et al. (1987)	Clinical and practical knowledge about managing children with developmental disabilities, confidence in intellectual disability.	13-item self-evaluation assessing perceptions of abilities and knowledge before and after training	Statistically significantly increased perceived knowledge and competence post intervention (p < 0.001), particularly in ability to communicate effectively with other professionals about needs of patients, understanding of available community resources and sensitivity to needs to children with a development delay.	1	Poor (C)

A variety of outcomes were found upon application of the Kirkpatrick model for assessing outcomes of educational interventions. Forty per cent of interventions achieved Kirkpatrick level 1 score, representing a subjective alteration in learner perspective or comfort relating to managing patients with intellectual disability (Adler et al., 2005; Procci et al., 1981; Wysocki et al., 1987). Six studies achieved Kirkpatrick level 2, demonstrating alteration in objective measures of knowledge or skills (Balogh et al., 2015; Bartkowski et al., 2018; Berg et al., 1983; Dagnan et al., 2018; Lowe et al., 2007; Melville et al., 2006)_.

Longevity of effect

Only three of the ten studies explored persisting effects, with Berg et al (Berg et al., 1983), showing significantly higher scores on knowledge tests and confidence 12–24 months later than those who did not participate in the intervention, Lowe et al (Lowe et al., 2007), showing improvements in perceived confidence at 1-year follow up and Dagnan et al (Dagnan et al., 2018), showing improvements in therapist attitudes at 3 months' follow up.

Quality appraisal

Thirty per cent of studies achieved a rating of “Good” (Balogh et al., 2015; Bartkowski et al., 2018; Melville et al., 2006), 40% “Fair” (Adler et al., 2005; Dagnan et al., 2018; Lowe et al., 2007) and 30% “Poor” (Procci et al., 1981; Wysocki et al., 1987).

Discussion

This review identified and summarised what interventions have been conducted to target attitudes, knowledge, and confidence of HCPs in caring for patients with intellectual disability. Previous studies have reviewed interventions targeting students or lay people (Seewooruttun & Scior, 2014; Shakespeare & Kleine, 2013), overlooking a focus on the current healthcare workforce, or have focused on disability as a whole rather than specifically looking at intellectual disability (Ioerger et al., 2019; Shakespeare & Kleine, 2013). Given the findings from the Royal Commission (Royal Commission into Violence, 2020), highlighting poorer health outcomes and negative interactions with healthcare providers experienced by people with intellectual disability when they interface with the health system, this review is timely and important.

A key finding was the mere paucity of publications that fit the relatively broad inclusion criteria, with only ten studies yielded, and limited research occurring after 2010. From past reviews, most interventions appear to focus on pre-qualification training (Shakespeare & Kleine, 2013). Despite this, intellectual disability training in medical schools in Australia is still very limited and inadequately prepares prospective doctors and nurses for working with intellectual disability patients (Cashin et al., 2021; Cashin et al., 2022; Trollor et al., 2020). It is clear from this study and previous reviews that CPD prioritising intellectual disability in the healthcare sector is lacking. As a response to the growing literature outlining inequality in healthcare for people with intellectual disability and the introduction of the National Disability Insurance Scheme, some health agencies in Australia are, nevertheless, starting to respond. For example, specialist intellectual disability teams in New South Wales, in partnership with the Central and Eastern Sydney PHN (CESPHN) have launched “Project GROW,” providing specialist workshops to HCPs to increase awareness of how-to better care for people with intellectual disability in general and allied health practice (CESPHN, 2022). Although this shows positive gains in the field, these initiatives have not been evaluated yet. Hence, it is unclear how effective these interventions are and if they achieve the desired change.

The studies in this review summarised the impact that interventions had on attitudes, knowledge or confidence in managing patients with intellectual disability. To allow for comparison, a modified Kirkpatrick score was used to assess the effectiveness of the 10 identified interventions (Adirim et al., 2021).

It is clear that training in this field is valuable in its ability to shift perspectives and increase comfort/ confidence levels in managing patients with intellectual disability, as indicated by almost half of the studies achieving a Kirkpatrick level 1 score, however these findings rely on self-report data which are susceptible to bias. Additionally, knowledge is important in the provision of well-informed care. Although levels of knowledge were positively influenced by over half of the interventions, as represented by the allocation of Kirkpatrick 2 scores, none of the studies were able to demonstrate an effect on behaviour of HCPs or traceable change in outcome for patients with intellectual disability, as represented by a Kirkpatrick level 3 and 4 score respectively. While this may be reflective of limitations to the training interventions, it is more likely to be due to problems in the evaluation design. For example, Ruedrich et al. (2007), evaluated an intervention in the form of a 3-month rotation in intellectual disability, which included a theoretical component (didactic lectures), immersive component (site visits to group homes) and experiential component (direct patient management in a hospital setting for people with intellectual disability). In theory, this long-term, multi-modal intervention has the potential to incite true positive change for participating physicians and their patients, however, it was only engineered to achieve a Kirkpatrick level one score by virtue of utilising a self-report scale on perceived confidence. This was true across a number of the studies reviewed, which raises concern about the actual utility of the results being produced from these studies. Without more detailed consideration to evaluation methodology, it is difficult to determine what truly works in educational interventions designed to upskill HCPs in the field of intellectual disability. A study by Chatterton (1999), provides a good example of how studies can achieve higher Kirkpatrick scores. After the intervention was carried out, a knowledge test was administered and then video interaction between support staff and clients with intellectual disability was recorded in a residential facility, to establish whether staff’s learned knowledge was being applied to their practice. This multi-faceted evaluation strategy facilitates a more accurate understanding of whether training is influencing behaviour and inciting true change. The findings from our study do suggest that in general, training influences perceived, self-reported confidence and knowledge levels, however mixed-method evaluation measures to assess actual behavioural change are important for future researchers to consider.

Two significant variables of interest were pedagogical methodology and timeline of the intervention. Past research has suggested that direct experience with and teaching from people with intellectual disability holds the most promise in bringing about positive attitudinal and behavioural change (Seewooruttun & Scior, 2014; Shakespeare & Kleine, 2013). This is consistent with some of the findings from the present review as summarised in Table 4. For example, Adler et al. (2005) found that there was increased perceived self-confidence and knowledge in working with patients with intellectual disability reported by optometrists who engaged in experiential learning with intellectual disability patients when compared to those who just received didactic teaching. Similarly, Melville et al. (2006) showed significantly greater improvements to knowledge and self-efficacy in a group that received teaching from a multidisciplinary team including a member with intellectual disability, when compared to those who received a training pack alone.

Implications and future directions

The findings from the present review echo the importance for future researchers to prioritise incorporation of training run by people with lived experience, ultimately granting them the power to inform positive, and needs-driven change.

Another consideration in the development of future interventions is the longevity of effect. Three of the studies identified in this systematic review showed that changes were sustained after long-term follow up, with effects of training persisting at 3 months (Dagnan et al., 2018) and 1 year (Berg et al., 1983; Lowe et al., 2007) post intervention. This is important in determining how frequently CPD in this area needs to be carried out. Given many studies did not investigate long-term effects, more data is needed in this area to guide training programs in their timeline and frequency.

Furthermore, there is very limited literature that focuses solely on improving attitudes, knowledge, and confidence of HCPs in the current workforce, with a lot more of the literature focusing on students. This has implications for future research to target the practicing workforce in the form of CPD initiatives. The Australian Government is developing the Intellectual Disability Health Capability Framework. This Framework is expected to support and advocate the integration of capabilities and learning outcomes regarding the health of people with intellectual disability in the accreditation standards of health professionals (Australian Government Department of Health and Aged Care, 2022).

Finally, although the demeanour and skills of HCPs is highly important in achieving positive health experiences for people with intellectual disability, it must be acknowledged that health institutions need to prioritise creating more inclusive environments and the recruitment workforce should cater to the needs of people with disability entering the healthcare workforce. We have seen from the results of this study and previous studies that involving people with disability in training interventions has the greatest benefit. By the same token, welcoming and supporting people with disability into healthcare positions could be of significant benefit to achieving equality in healthcare. Future research should facilitate this possibility.

Limitations

From this review, it is clear that training does have a statistically significant effect on healthcare professionals’ attitudes, knowledge and confidence in managing patients with intellectual disability. Even if just a shift in subjective perspective, this is still a step in the right direction. Considering this however, it is important to consider the difference between “statistical significance” and “clinical significance” and interpret findings in light of limitations. The significant heterogeneity of evaluation methodologies made it difficult to ascertain the effectiveness of the interventions and their real-world effect on patients with intellectual disability. Some studies utilised self-report scales of confidence, knowledge, and attitudes, while others carried out knowledge assessments in the form of multiple-choice tests and written responses. None of the studies measured actual behavioural change of staff after the intervention. This heterogeneity, coupled with the small sample size, meant that it was not possible to stratify interventions based on features, for example, pedagogical framework or timeline, to see what particular aspects of an intervention are the most effective. Future research needs to consider this when designing evaluation, to consider ways of harnessing and measuring change that facilitate comparison and target “clinical significance,” not just “statistical significance.” It is also important to note that the studies were of fair or poor quality. Findings of this review are limited by only focusing on articles published in English. Due to the scope of our review i.e., excluding unpublished and grey literature, this review could have potentially omitted some studies. Nevertheless, this review highlights the need for more research but also of better research to improve disability education of HCPs.

Conclusion

It is undeniable that people with intellectual disability are challenged by healthcare systems that are not equipped to cater for their unique needs. The present review has identified trends and needs in this field moving forward. Education is at the epicentre of change, so finding successful, practical, and cost-effective ways of equipping HCPs to feel confident and knowledgeable when managing this growing patient group is critical if we want to grant people living with intellectual disability their enshrined right to equal, good quality and person-centred healthcare.

Disclosure statement

No potential conflict of interest was reported by the author(s).