Study demographics
Sixteen papers met the inclusion criteria and were included in the review. Country of origin included the UK (n = 7) (13, 14, 15, 16, 17, 18, 19), the USA (n = 5) (20, 21, 22, 23, 24), Canada (n = 2) (25, 26), and Australia (n = 2) (27, 28). Five studies were conducted in the 1990s (14, 19, 21, 24, 28), one in the 2000s (27), nine in the 2010s (15–18, 20, 22, 23, 25, 26) and one in the 2020s (13). Most papers were conducted solely with medical students, however one included physical therapy students (20), one included physical therapy, occupational therapy, and nursing students (26), and one also included those already in the workforce; nursing assistants, nurses, and resident physicians (21).
Seven studies measured outcomes using mixed-methods (13, 19, 23 − 5, 27, 28) eight quantitatively (14–18, 20, 21, 26) and one qualitatively (22). Only one study (25) had a control group and utilised a randomised control trial design.
Eleven of the interventions involved direct lived experience in the delivery of teaching (13–16, 19, 20, 22, 24, 25, 27, 28). Two involved videos of people with intellectual disability (17, 26), one involved parents of a person with a disability (23), and two studies did not report lived experience inclusion (18, 21). Ten of the interventions were elective (15, 16, 19–21, 23, 25–28), with five compulsory (13, 17, 18, 22, 24), and one unclear (14). Table 2 provides an overview of the 16 studies included in this review, giving key characteristics.
Table 2
Summary of study characteristics
Author | Year of Study | Design | Origin | Study population | Sample size | Disability focus | Intervention Category | Lived experience (Y/N) | Compulsory (Y/N) |
Abdi & Metcalf | 2020 | Mixed methods | Wales | Year 4 | 66 | Intellectual | Communication skills workshop | Y | Y |
Coret et al | 2018 | Mixed methods - control | Canada | Year 1 | 27 | Intellectual and Developmental | Simulation with SP's | Y | N |
Garavatti et al | 2018 | Quantitative | America | Year 2 | 20* | Developmental (including intellectual) | Simulation with SP's | Y | N |
Hall & Hollins | 1996 | Quantitative | England | Unknown | 28 | Down syndrome | Drama workshop | Y | Unknown |
Harper & Wandsworth | 1992 | Quantitative | America | Year 2 | 12* | ‘Mental retardation' | Classroom based | Unclear | N |
Harwood & Hassiotis | 2014 | Quantitative | England | Year 4 | 69 | Intellectual | Classroom based | N** | Y |
Jones et al | 2015 | Quantitative | Canada | Year 2 | 94* | Intellectual | Classroom based | N** | N |
Jones & Donald | 2007 | Mixed methods | Australia | Year 4 | 26 | Intellectual | Placement | Y | N |
Karl et al | 2013 | Qualitative | America | Year 3 | 144 | Developmental | Placement | Y | Y |
May | 1991 | Mixed methods | Scotland | Year 2 | 24 | ‘Mental retardation' | Placement | Y | N |
Sheppard et al | 2017 | Mixed methods | America | Year 2 | 112 | Mixed- Autism/Down Syndrome/Intellectual Disability | Panel discussion | N** | N |
Sinai et al | 2013 | Quantitative | England | Year 4 | 136 | Intellectual | Classroom based | N | Y |
Thomas et al | 2014 | Quantitative | England | Year 4 | 47 | Intellectual | Simulation with SP's | Y | N |
Tracy & Graves | 1996 | Mixed methods | Australia | Year 1 | 25 | Developmental | Placement | Y | N |
Watkins & Colgate | 2016 | Quantitative | Wales | Year 3 | 23 | Intellectual | Simulation with SP's | Y | N |
Widrick et al | 1991 | Mixed methods | America | Year 3 | 39 | ‘Mental retardation' | At home visits | Y | Y |
*Footnote: |
*Garavatti et al also included 20 physical therapy students in their study. Harper and Wandsworth also included 12 nursing assistants, 9 nurses and 11 resident physicians. |
Jones et al 2015 also included psychology, occupational therapists, psychical therapists and nursing students. |
**Harwood and Hassiotis and Jones et al 2015 had lived experience in videos but not in person delivery. Sheppard et al involved parents of those with a disability. |
Insert Table 2: Summary of study characteristics
Intervention categories
Studies were categorized based on their main intervention type, according to the most commonly used terms within the paper. Four studies (15, 16, 20, 25) were categorized as a simulation with a standardized patient. This included a workshop style structure where students would visit ‘stations’ and perform a clinical encounter role play with someone with an intellectual or developmental disability, followed by a debrief or reflective session. A further four studies (17, 18, 21, 26) were classified as classroom based, which included didactic lectures, e-learning, seminars, self-study instructional text, and videos. Another four studies (19, 22, 27, 28) were placement-based, which included spending a varied amount of time (one day to eight weeks) in a variety of environments such as a school for those with an intellectual disability, primary care or hospital services for people with intellectual disabilities. One study (14) was a drama workshop with a theatre company of adults with Down’s Syndrome, and one study (13) was a communication workshop with a session by the speech and language therapy team, involving in person case studies with a simulated patient. Another category was a Question and Answer panel discussion (23), with parents of children with a disability. The final category was home visits (24) where students would visit a child with a disability and their parents in their own home as a one-off meeting, in between a preparatory and reflective lecture. Students would not be advised of the specific disability of the child before visiting them, in order to avoid pre-assumptions.
Outcomes measured
A variety of outcomes were measured; both quantitatively and quantitatively, across all studies. These included satisfaction, knowledge, attitudes, comfort, communication, skill/practice, understanding, professional identity, and awareness. Table 3 describes the outcomes measured and the key findings from each study, which are summarized in the following section.
Table 3
Outcome measures and key findings of each study
Author, Year | Target outcome | Research tool | Key Findings/discussion |
Abdi & Metcalf, 2020 | Attitudes | ADTP-B and semi structured interviews | Paired sample t tests showed scores were significantly higher in the ATDP-B questionnaire after the teaching session (M = 122, SD = 17.2 to M = 115, SD = 14.5) t (65) = 6.20, p < 0.001. The average difference in ATDP-B scores before and after the teaching session was 6.92. Qualitative results helped to expand upon the quantitative, showing that students felt the teaching session allowed them to develop professional identity, and overcome communication barriers. |
Coret et al, 2018 | Communication and comfort | Focus groups, own survey | Both control and narrative groups improved in comfort, confidence and competence but mean rating scores were higher for students in the narrative group. However, these trends are descriptive only. Qualitative findings highlighted the need for adaptable communication styles and the universality of person-centred communication. |
Garavatti et al, 2018 | Attitude and comfort | RSA, ADTP, IDP | The ATDP results showed improvement pre and post (84 vs 81.6) p < 0.05, as well as the IDP (70.9 vs 65,6) p = 0.01, however these were not significant. Medical students improved their comfort levels, with the RSI improving from 83.45 to 73 (p < 0.001). |
Hall & Hollins, 1996 | Attitude | Own survey | For all statements, there was more agreement with positive statements and less agreement with negative statements after the workshop than before it. Seven of the changes achieved statistical significance. For example 1. People with DS are poor communicators median 23 v 14 pre post (P < 0.001). 7. People with DS tend to be frightening median 8 v 6 pre post (p = 0.05). |
Harper & Wandsworth, 1992 | Knowledge and skill | Own survey | Change in medical students' knowledge did not show significance. Medical students did significantly improve on elements of communication skill after taking part in the intervention and at 6 week follow up eg medical students increased their use of open-ended questions (from 32.3 to 50.1 mean seconds, (t-test, P < .05), whilst decreasing the amount of time they spent using declarative sentences 143.4 to 105.4 mean seconds (t-test, P < .05). |
Harwood & Hassiotis, 2014 | Satisfaction and knowledge | Own survey | This study focused on satisfaction and knowledge, but did not measure significance. The study indicated that students showed a positive outlook towards those with an intellectual disability and appreciated the need for training (91%). |
Jones et al, 2015 | Knowledge, attitudes, skill | Own survey | Attitudes towards those with an intellectual disability did not show statistically significant change and stayed neutral. Skill change was observed (pre post 68% vs 73%) but this also showed no statistical significance. Medical students’ knowledge scores did show a significant difference between pre course (M = 0.50, SD = 0.23) and post course (M = 0.69, SD = 0.23); t(93) = − 7.407,p ≤ .01. |
Jones & Donald, 2007 | Satisfaction and understanding/importance | Open questionnaire, own survey | This study had a large focus around students experience of the intervention rather than its effect. Study did not measure significance but suggested improvement in understanding, with positive satisfaction. For example, all 21 participants strongly agreed that the placement gave them a better understanding of children with special needs. |
Karl et al, 2013 | Attitudes, comfort, communication | Reflective questionnaire | Qualitative analysis showed that students had overcome communication barriers, improved their attitudes and comfort level whilst working with people with disabilities and thought more about the organizational structure in the medical environment. |
May, 1991 | Satisfaction and attitudes | Questionnaire/word association | There was no significant change on attitude after the intervention. Word association showed that participants chose negative or positive words to represent someone with an intellectual disability in the same ratio as the beginning. Students' choice of ‘positive words’ were happy friendly loving and affectionate which can constitute to the negative stereotyping of those with a disability. The number of students wanting to work with someone with an intellectual disability decreased from 4 (17%) to 2 (12%). |
Sheppard et al, 2017 | Knowledge and understanding/importance | Discussion essays, own survey | The differences between the students pre and post assessment responses for the Level 1 questions (basics) showed significant increases in correct responses. For level 2 questions (application), the changes between the pre and post responses were statistically significant for correct responses, incorrect responses and do not know responses. Many students changed their answer choice from do not know to either the correct or incorrect answer after the program. Qualitative results helped to give more understanding of the physician, and helped students understand the importance of learning this topic. |
Sinai et al, 2013 | Knowledge and attitudes | CLAS-MR, own survey | There was no significant change in any of the attitude subscales between the beginning (T1) and the end (T2). Significant improvements were found when comparing answers to some of the knowledge based questionnaires from the beginning to the end. These included correctly identifying dyslexia is not a learning (intellectual) disability (T1 = 98 (73%) T2 = 54 (44%) P value = 0.001 and recognising the definition of learning (intellectual) disability (T1 = 105 (80%) Tw = 121 (95%) P value = 0.001. Analysis of paired data showed similar results apart from no significant difference being found in understanding the definition of learning disability. |
Thomas et al, 2014 | Comfort, communication, skill | Own survey based on 'healthcare provider questionnaire' | There was significant improvement in the scores in communicating with people with no disability (< 0.005), people with mild intellectual disability (p < 0.001) and people with severe intellectual disability (< 0.001). The mean scores were significantly higher for the severe disability scenario than the mild disability scenario, indicating the impact of the training was higher of terms of managing patients in this group. There were also significant improvements in students perceived skill when treating people in all three groups; no disability, mild disability or severe disability (1.43 (95% CI 0.50–2.35; t(46) = 3.14, P = 0.002), 6.47 (95% CI 5.27–7.67; t(46) = 10.82, P < 0.001) and 8.87 (95% CI 7.49–10.2; t(46) = 12.96, P < 0.001) respectively). There was a significant improvement in the type of clinical approach adopted by students in managing patients with none, mild or severe disability post-training. The corresponding mean differences were: 1.19 (95% CI 0.42–1.96, t(46) = 3.12, P < 0.005), 3.77 (95% CI 2.69–4.84, t(46) = 7.05, P < 0.001) and 5.48 (95% CI 4.12–6.84, t(46) = 8.13, P < 0.001) respectively. |
Tracy & Graves, 1996 | Satisfaction and attitudes | Own survey, questionnaire/word association | Study did not measure significance but indicated students thought the intervention fulfilled their expectations (86% of 25) and changed feelings and beliefs (92% of 25). Students discussed the intervention contributing to their personal identity, as well as having more insight into the topic of learning disability. Word association identified a change from negative to positive outlooks ranging from 8–60% when using words to describe children with disabilities and 15–50% when using words to describe adults with disabilities. |
Watkins & Colgate, 2016 | Knowledge and understanding | Own survey | Students mean score within the knowledge domain significantly improved pre post (14.87 vs 10.65, p < 0.001). Students mean score within the affect and understanding domain also significantly improved (13.7 vs 10.52, p < 0.001). |
Widrick et al, 1991 | Attitude and awareness/insight | PMRS, student log book review | Students improved their attitudes pre to post test (35 vs 41, p < 0.001). Students also increased their expectations of capabilities of all three subgroups; those with a mild, moderate or severe intellectual disability. Qualitative results indicated students had improved their awareness and insight into intellectual disability. |
Insert Table 3: Outcome measures and key findings of each study
Satisfaction
Four studies (17, 19, 27, 28) measured how satisfied the students were with the intervention, all using non-standardized measures they had developed. None of these studies measured statistical significance of this outcome, and instead presented either percentages and agree/disagree statements (17, 27, 28), or mean scores across a five point scale (19).
Knowledge
Six studies (16–18, 21, 23, 26) measured whether the students had increased their knowledge after taking part in the intervention. All studies used non validated measures, and all developed their own measurement tool. Five of these studies assessed knowledge using pre-post measures (16, 18, 21, 23, 26), with one (17) measuring knowledge post intervention only.
Attitudes
Nine studies (13, 14, 18–20, 22, 24, 26, 28) measured attitude change, seven quantitatively (13, 14, 18–20, 24, 26), one qualitatively (22), and one using mixed methods (28). The following standardised measures were used:
1) Attitudes Towards Disabled People-B (ATDP-B) (29) (13, 20);
2) The ‘Interactions with Disabled People’ scale (IDP) (30) (20);
3) Prognostication about Mental Retardation scale (PMRS) (31) (24);
4) Community Living Attitudes Scale- Mental Retardation (CLAS-MR) (32) (18).
Four studies (14, 19, 26, 28) used non-standardised measures, including a word association method (19). The qualitative study measured attitude change through reflective questions (22).
Comfort
Change in students' comfort of being able to treat someone with an intellectual or developmental disability was measured in four studies: two quantitatively (20, 25), one qualitatively (22), and one through mixed methods (15). One study measured comfort using the Rehabilitations Situations Inventory (RSA) (33, (20). Two studies used their own non-validated survey (15, 25) and another measured comfort through reflective questions (22).
Communication
Improvement in communication skills was measured in four studies. Two used qualitative methods (13, 22), one mixed- methods (25), and one quantitative methods (15). Two used their own non-validated measure (15), with one using focus groups (25). One used reflective questionnaires (22), with the final using a combination of semi structured interviews and focus groups (13).
Skill/practice and understanding/importance
An improvement in skill (assessed through educator observations and self-reports) and understanding the importance of learning about intellectual disability were each measured separately in 3 studies. All three studies (15, 21, 26) used their own non-validated survey to measure an improvement of skills. Two of the studies (16, 27) also looked at student understanding of the importance of learning about intellectual disabilities measures through a non-validated survey, and one study analysed discussion essays qualitatively (23). Intervention effectiveness
All intervention types showed a positive trend when measuring satisfaction, however due to the use of non-validated measure, no studies reported statistical significance. Of the six studies measuring knowledge, four showed statistical significance (16, 28, 23, 26). These fell into the categories of classroom based (n = 2) panel discussion (n = 1), and simulation with simulated patients (n = 1).
Of the nine studies measuring attitude change, only three studies showed a statistically significant change pre-post intervention (13, 14, 24). The three intervention types were a communication workshop; drama workshop, and home visits. Two placement-based interventions reported attitude change through qualitative questionnaires or word association (22, 28). None of the classroom-based interventions demonstrated attitude change.
Three studies (15, 20, 22) showed that medical students comfort levels working with people with intellectual disabilities improved post-intervention, through either significant quantitative results or qualitative thematic analysis. These fell into the categories of simulations with a simulated patient (n = 2), and placement-based (n = 1). When looking at improved communication, statistical significance was found in one set of quantitative data (15) for a simulation. All the studies who measured this qualitatively (drama workshop, simulation, and placement-based) identified positive change (13, 22, 25). Only one of these studies also measured outcomes quantitatively however outcomes did not reach statistical significance (25). Two studies (15, 21), a simulation and classroom-based activity, showed statistical significance in changing and improving medical students' skill and their implementation in practice. This was assessed through educator observation and self-reports. One study (26), also classroom-based, was not statistically significant in improving skill.
When looking at understanding the importance of learning about intellectual disability, one study showed statistical significance in a simulation (16), whilst another showed a positive trend through a placement but did not measure statistical significance (27). Understanding was also shown as a qualitative theme in one study (23), which was a panel discussion with parents of people with a disability.
Qualitative outcomes
Two themes arose from qualitative studies; both found in two different studies; which were ‘professional identity’ and ‘awareness and insight’. Both Abdi (2020) and Tracy (1996) found that their intervention (communication skills workshop and a placement) had allowed students to develop a more professional identity as they were taught how to overcome communication barriers (13) and therefore identify more as a doctor, as well as perception of personal development and enhanced professional identity (28). One study (28) reported that placement-based interventions facilitated awareness of the family life of someone with an intellectual disability. Another study (24) similarly said that home visit-based interventions allowed students to grow their understanding of what living with an intellectual disability was like and see intellectual disability in ‘real life’.
Quality Assessment
The overall quality of studies meeting the inclusion criteria was low, with no papers scoring a 5 on either BEME score. 100% of papers scored a 3 or below on importance of findings, with 50% of studies scoring 3, 37.5% scoring 2 and 12.5% scoring 1. 56.25% of studies scored 3 or below on importance of overall paper, with 43.75% of studies scoring 4, 25% scoring 3, 18.75% scoring 2 and 12.5% scoring 1. 87.5% of all studies also scored a 2 or below on the Kirkpatrick score, with one study scoring a 1, and one study scoring 0. Quality scores are shown in Table 4.
Table 4
Quality Assessment Scores
Author | BEME score Findings | BEME score Overall importance | Kirkpatrick score |
Abdi & Metcalf, 2020 | 3 | 4 | 2 |
Coret et al, 2018 | 2 | 2 | 2 |
Garavatti et al, 2018 | 2 | 3 | 2 |
Hall & Hollins, 1996 | 3 | 2 | 2 |
Harper & Wandsworth, 1992 | 2 | 3 | 3 |
Harwood & Hassiotis, 2014 | 1 | 1 | 2 |
Jones et al, 2015 | 3 | 4 | 2 |
Jones & Donald, 2007 | 1 | 1 | 0 |
Karl et al, 2013 | 3 | 4 | 2 |
May, 1991 | 2 | 3 | 2 |
Sheppard et al, 2017 | 3 | 4 | 2 |
Sinai et al, 2013 | 3 | 4 | 2 |
Thomas et al, 2014 | 3 | 4 | 3 |
Tracy & Graves, 1996 | 2 | 2 | 1 |
Watkins & Colgate, 2016 | 3 | 4 | 2 |
Widrick et al, 1991 | 2 | 3 | 2 |