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Background: Type 2 diabetes is a serious, pervasive metabolic condition that disproportionately affects ethnic minority patients. Telehealth interventions can facilitate type 2 diabetes monitoring and prevent secondary complications. However, trials designed to test the effectiveness of telehealth interventions may underrecruit or exclude ethnic minority patients, with language a potential barrier to recruitment. The underrepresentation of minorities in trials limits the external validity of the findings for this key patient demographic. Objective: This systematic review examines (1) the research reporting practices and prevalence of ethnic minority patients included in telehealth randomized controlled trials (RCTs) targeting type 2 diabetes and the trial characteristics associated with recruiting a high proportion of minority patients, and (2) the proportion of included RCTs that report using English language proficiency as a patient screening criterion and how and why they do so. Methods: Telehealth RCTs published in refereed journals targeting type 2 diabetes as a primary condition for adults in Western majority English-speaking countries were included. Ethnically targeted RCTs were excluded from the main review, but were included in a post hoc subgroup analysis. Abstract and full-text screening, risk of bias assessment, and data extraction were independently conducted by two reviewers. Results: Of 3358 records identified in the search, 79 articles comprising 58 RCTs were included. Nearly two-thirds of the RCTs (38/58) reported on the ethnic composition of participants, with a median proportion of 23.5% patients (range 0%-97.7%). Fourteen studies (24%) that included at least 30% minority patients were all US-based, predominantly recruited from urban areas, and described the target population as underserved, financially deprived, or uninsured. Eight of these 14 studies (57%) offered intervention materials in a language other than English or employed bilingual staff. Half of all identified RCTs (29/58) included language proficiency as a participant-screening criterion. Language proficiency was operationalized using nonstandardized measures (eg, having sufficient "verbal fluency"), with only three studies providing reasons for excluding patients on language grounds. Conclusions: There was considerable variability across studies in the inclusion of ethnic minority patients in RCTs, with higher participation rates in countries with legislation to mandate their inclusion (eg, United States) than in those without such legislation (eg, United Kingdom). Less than 25% of the RCTs recruited a sizeable proportion of ethnic minorities, which raises concerns about external validity. The lack of objective measures or common procedures for assessing language proficiency across trials implies that language-related eligibility decisions are often based on trial recruiters' impressionistic judgments, which could be subject to bias. The variability and inconsistent reporting on ethnicity and other socioeconomic factors in descriptions of research participants could be more specifically emphasized in trial reporting guidelines to promote best practice. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews: CRD42015024899

Background: PISA results appear to have a large impact upon government policy. The phenomenon is growing, with more countries taking part in PISA testing and politicians pointing to PISA results as reasons for their reforms. Purpose: The aims of this research were to depict the policy reactions to PISA across a number of jurisdictions, to see whether they exhibited similar patterns and whether the same reforms were evident. Sources of evidence: We investigated policy and media reactions to the 2009 and 2012 PISA results in six cases: Canada, China (Shanghai), England, France, Norway and Switzerland. Cases were selected to contrast high-performing jurisdictions (Canada, China) with average performers (England, France, Norway and Switzerland). Countries that had already been well reported on in the literature were excluded (Finland, Germany). Design and methods: Policy documents, media reports and academic articles in English, French, Mandarin and Norwegian relating to each of the cases were critically evaluated. Results: A policy reaction of 'scandalisation' was evident in four of the six cases; a technique used to motivate change. Five of the six cases showed 'standards-based reforms' and two had reforms in line with the 'ideal-governance' model. However, these are categorisations: the actual reforms had significant differences across countries. There are chronological problems with the notion that PISA results were causal with regard to policy in some instances. Countries with similar PISA results responded with different policies, reflecting their differing cultural and historical education system trajectories. Conclusions: The connection between PISA results and policy is not always obvious. The supranational spell of PISA in policy is in the way that PISA results are used as a magic wand in political rhetoric, as though they conjure particular policy choices. This serves as a distraction from the ideological basis for reforms. The same PISA results could motivate a range of different policy solutions.

Acknowledgements The Health Services Research Unit at the University of Aberdeen receives core funding from the Chief Scientist Office of the Scottish Government Health Directorates. Funding This work has received funding from the National Institute for Health Research (NIHR) INCLUDE initiative led from the Newcastle University CRN Cluster Office, NIHR Senior Investigator funding provided to PB and the UK Research Innovation-Medical Research Council COVID-19 Rapid Response funding (grant MR/V020544/1). MDW acknowledges support from the NIHR Newcastle Biomedical Research Centre. ; Peer reviewed ; Publisher PDF