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Although parents with learning disabilities have attracted academic and professional attention because of concerns about their ability to care adequately for their children, there has been little systematic development of services for these families. This study seeks to understand the barriers to progress by investigating the issues faced by professionals who work with these parents. I investigate how professionals understand these parents, and clarify how these perceptions link to broader socially defined categories of competence, childhood, parenting and professional practice. I show how social constructions of disabled recipients of professional interventions, and of children, shape and constrain practice, with emphasis on the dilemmas and contradictions that practitioners face. I use a discourse analysis approach informed by discursive psychology and Foucault to examine transcribed interviews with twenty health and social care professionals who have had experience of working with learning disabled parents and their children. Dominant discourses emphasise, on the one hand the incompetence of learning disabled people as social actors and as parents, and on the other children's vulnerability and dependence. I investigate how practitioners attempt to reconcile what they perceive as their responsibility to promote 'normal' family life backed up by expert knowledge with an expectation that they acknowledge conceptions of human rights and client 'empowerment'. I challenge polarised views of professionals as either altruistic public servants or all powerful oppressors of disabled people. I argue that their options for action are limited by a professional climate preoccupied with risk and accountability. Nevertheless I identify examples of resistance to these dominant discourses, suggesting that further progress will be made when practitioners are encouraged to adopt a more critical approach to often taken-for-granted assumptions about disability, parenting and children.

Murine transfected fibroblast cell lines (TFCL) expressing HLA-DR1 (DR1) alone or co transfected with CD58 or CD54 were used as allostimulators to investigate the minimal triggering requirements for CD45R subset allogeneic proliferation. Whole PBMC and CD45R subsets gave weak alloresponses to DR1+TFCL. The proportion of responders was greater for PBMC than either of the CD45 subsets. Stronger alloresponses by PBMC and CD45R subsets against DR1+CD54 and DR1+CD58 TFCL were observed. Generally, CD45RA+ and CD45RO+ T cell subsets alone gave weaker alloresponses than whole PBMC. Recombining purified CD4+ CD45R subsets after separation, led to responses similar in magnitude to whole PBMC, implying that the reconstitution of CD45R subsets has a co-operative effect mediated through either physical contact or cytokines. Alloresponses by PBMC and CD4 CD45R populations to TFCL and LCL were all increased by the addition of IL-2. CD45RA+ T cell responses to TFCL and LCL were significantly enhanced by the presence of IL-4, whereas in comparison, CD45RO+T cells and not CD45RA+ alloresponses were augmented by the addition of IFN?. Whole PBMCs primed with DR1+TFCL that normally produce low levels of proliferation induced vigorous responses when rechallenged with either DR1+LCL or DR1+TFCL. This is a strong indication that HLA-DR expressed on the TFCL is recognised by the responder T cell despite reduced primary alloresponses. The addition of autologous monocytes or CD28 MAbs to alloresponses involving TFCL or LCL increased proliferative responses by both CD4+CD45RA+ and CD4+CD45RO+ T cells.

Background: Self-management education supports people to live with diabetes and is a key element of diabetes care as recommended in national and international guidelines. However, in many countries, fewer than a third of people with type 2 diabetes mellitus (T2DM) participate in self-management education, and many do not receive adequate ongoing support following programme attendance. This unsatisfactory provision of support may suggest that self-management education programmes are insufficiently integrated into the routine care of people with T2DM. Aims: This study explored integration in the context of self-management education programmes for people with T2DM in routine care to explain factors (components and mechanisms) that influence how people with T2DM and healthcare professionals (HCPs) experience and perceive the integration of such programmes at the patient, HCP and system levels. Methods: Using a qualitative case study design, data of three self-management education programmes from a quality improvement initiative in diabetes care were collected and analysed. In total, 20 people with T2DM and 36 HCPs participated in semi-structured in-depth interviews; 88 hours of direct programme observation were undertaken; and 14 programme documents were reviewed. The data from the different sources were triangulated within a thematic narrative approach and synthesised across cases guided by the perspectives of complex adaptive systems. Results: The study synthesis revealed components and mechanisms that describe the integration of self-management education into routine care. The identified components of integration were as follows: 1) person-centred care - the way HCPs support individual patients in engaging in self-management behaviour; 2) programme ethos - the approaches with which HCPs apply a theoretical programme framework in practice; 3) inter-professional work - the manner in which HCPs collaborate in delivering self- management education; 4) communal resources - the local structures and processes by which a programme's context encourages self-management education; and 5) programme regulations - the recommendations and guidelines that standardise self-management education within a system. The mechanisms of integration related to the extent to which patients: 1) identified with their condition and activity; 2) experienced social support; 3) engaged in co-creating their interactions with HCPs; and 4) received self-management support by HCPs who congruently deliver such a care paradigm. The components and mechanisms of integration were observed to interact at and between the levels of people with T2DM, HCPs and the care system. These findings thus made it possible to conceptualise person-centred integrated self-management education as a form of dynamic relationships within interacting systems. Conclusion: Understanding the context-specific nature of integration emphasises the need for a theory-driven approach. Dynamic relationships and interactions characterise the complexities associated with the integration of self-management education into routine care. Multiple strategies, which may collectively impact the behaviour of both people with T2DM and that of HCPs, are required to create the conditions for self-management behaviour to be developed and sustained in healthcare delivery. This knowledge may inform programme development and care delivery to better integrate self-management education into routine care. Follow-up research may investigate the potential benefits of programmes that incorporate person-centred care delivery with a whole-system approach of self-management support.

The purpose of this study was to address the gap in knowledge regarding the extent to which midwives in England are adapting information for pregnant women with learning disabilities, an area that has been previously unexplored. The research used an explanatory sequential mixed methods design from a social model of disability lens to develop multiple perspectives and a more complete understanding to address the research question. The study comprised two distinct phases - collection and analysis of quantitative data, followed by collection and analysis of qualitative data. The methods comprised a national e-mail survey questionnaire of all acute trusts with maternity units in England; three focus groups with midwives and one with policy makers and key stakeholders, and six semi-structured interviews with women with learning disabilities. Quantitative data were analysed using descriptive and inferential statistics and qualitative data were analysed using thematic analysis. The study found that antenatal information was generally not adapted by midwives for women with learning disabilities. Midwives perceived their lack of knowledge, education and time prevented adaptation of information. Mothers with learning disabilities who participated usually spoke positively about their antenatal care but most of them reported difficulty understanding the written information given during pregnancy. This research contributes to the small body of empirical evidence in the area of antenatal provision for women with learning disabilities. The findings have important implications for midwifery practice and ensuring services are accessible. The study describes the implications, makes recommendations and suggests areas for further research.