Mitch Blair

Effectiveness of home based support for older people: systematic review and meta-analysis

Abstract Objective: To evaluate the effectiveness of home visiting programmes that offer health promotion and preventive care to older people. Design: Systematic review and meta-analysis of 15 studies of home visiting. Participants: Older people living at home, including frail older people at risk of adverse outcomes. Outcome measures: Mortality, admission to hospital, admission to institutional care, functional status, health status. Results: Home visiting was associated with a significant reduction in mortality. The pooled odds ratio for eight studies that assessed mortality in members of the general elderly population was 0.76 (95% confidence interval 0.64 to 0.89). Five studies of home visiting to frail older people who were at risk of adverse outcomes also showed a significant reduction in mortality (0.72; 0.54 to 0.97). Home visiting was associated with a significant reduction in admissions to long term care in members of the general elderly population (0.65; 0.46 to 0.91). For three studies of home visiting to frail, “at risk” older people, the pooled odds ratio was 0.55 (0.35 to 0.88). Meta-analysis of six studies of home visiting to members of the general elderly population showed no significant reduction in admissions to hospital (odds ratio 0.95; 0.80 to 1.09). Three studies showed no significant effect on health (standardised effect size 0.06; −0.07 to 0.18). Four studies showed no effect on activities of daily living (0.05; −0.07 to 0.17). Conclusion: Home visits to older people can reduce mortality and admission to long term institutional care. What is already known on this topic The benefits of regular, preventive home visits to older people are the subject of controversy A recent systematic review found no clear evidence that preventive home visits were effective What this study adds This meta-analysis of 15 trials shows that home visiting can reduce mortality and admission to institutional care among older people

Does home visiting improve parenting and the quality of the home environment? A systematic review and meta analysis

AIMS To evaluate the effectiveness of home visiting programmes on parenting and quality of the home environment. DESIGN Systematic review of the literature of randomised controlled trials and quasi-experimental studies evaluating home visiting programmes involving at least one postnatal visit. SUBJECTS Thirty four studies reported relevant outcomes; 26 used participants considered to be at risk of adverse maternal or child health outcomes; two used preterm or low birth weight infants; and two used infants with failure to thrive. Only eight used participants not considered to be at risk of adverse child health outcomes. RESULTS Seventeen studies reported Home Observation for Measurement of the Environment (HOME) scores, 27 reported other measures of parenting, and 10 reported both types of outcome. Twelve studies were entered into the meta analysis. This showed a significant effect of home visiting on HOME score. Similar results were found after restricting the analyses to randomised controlled trials and to higher quality studies. Twenty one of the 27 studies reporting other measures of parenting found significant treatment effects favouring the home visited group on a range of measures. CONCLUSIONS Home visiting programmes were associated with an improvement in the quality of the home environment. Few studies used UK health visitors, so caution must be exercised in extrapolating the results to current UK health visiting practice. Further work is needed to evaluate whether UK health visitors can achieve similar results. Comparisons with similar programmes delivered by paraprofessionals or community mothers are also needed.

Health services for children in western Europe

Western European health systems are not keeping pace with changes in child health needs. Non-communicable diseases are increasingly common causes of childhood illness and death. Countries are responding to changing needs by adapting child health services in different ways and useful insights can be gained through comparison, especially because some have better outcomes, or have made more progress, than others. Although overall child health has improved throughout Europe, wide inequities remain. Health services and social and cultural determinants contribute to differences in health outcomes. Improvement of child health and reduction of suffering are achievable goals. Development of systems more responsive to evolving child health needs is likely to necessitate reconfiguring of health services as part of a whole-systems approach to improvement of health. Chronic care services and first-contact care systems are important aspects. The Swedish and Dutch experiences of development of integrated systems emphasise the importance of supportive policies backed by adequate funding. France, the UK, Italy, and Germany offer further insights into chronic care services in different health systems. First-contact care models and the outcomes they deliver are highly variable. Comparisons between systems are challenging. Important issues emerging include the organisation of first-contact models, professional training, arrangements for provision of out-of-hours services, and task-sharing between doctors and nurses. Flexible first-contact models in which child health professionals work closely together could offer a way to balance the need to provide expertise with ready access. Strategies to improve child health and health services in Europe necessitate a whole-systems approach in three interdependent systems-practice (chronic care models, first-contact care, competency standards for child health professionals), plans (child health indicator sets, reliable systems for capture and analysis of data, scale-up of child health research, anticipation of future child health needs), and policy (translation of high-level goals into actionable policies, open and transparent accountability structures, political commitment to delivery of improvements in child health and equity throughout Europe).

Child public health

Introduction - Why child public health? 1. Child Health in the UK and Europe 2. Child Health in developing countries/the majority world 3. Determinants of Child Health 4. Child public health: lessons from the past 5. Key concepts and definitions 6. Child health and adult health 7. Techniques and resources for child public health practice 8. Child Public Health in practice: case scenarios

How parents choose to use CAM: A systematic review of theoretical models

BackgroundComplementary and Alternative Medicine (CAM) is widely used throughout the UK and the Western world. CAM is commonly used for children and the decision-making process to use CAM is affected by numerous factors. Most research on CAM use lacks a theoretical framework and is largely based on bivariate statistics. The aim of this review was to identify a conceptual model which could be used to explain the decision-making process in parental choice of CAM.MethodsA systematic search of the literature was carried out. A two-stage selection process with predetermined inclusion/exclusion criteria identified studies using a theoretical framework depicting the interaction of psychological factors involved in the CAM decision process. Papers were critically appraised and findings summarised.ResultsTwenty two studies using a theoretical model to predict CAM use were included in the final review; only one examined child use. Seven different models were identified. The most commonly used and successful model was Andersens Sociobehavioural Model (SBM). Two papers proposed modifications to the SBM for CAM use. Six qualitative studies developed their own model.ConclusionThe SBM modified for CAM use, which incorporates both psychological and pragmatic determinants, was identified as the best conceptual model of CAM use. This model provides a valuable framework for future research, and could be used to explain child CAM use. An understanding of the decision making process is crucial in promoting shared decision making between healthcare practitioners and parents and could inform service delivery, guidance and policy.

From health surveillance to health promotion: the changing focus in preventive children’s services

The shift from surveillance to promotion requires paediatricians to play several roles in a larger multidisciplinary and multi-agency team Child health surveillance programmes aim to prevent disease, detect physical and developmental abnormalities, and promote optimum health and development. There is growing evidence over the past decade that early intervention can change the life course for disadvantaged children. The emphasis has shifted from detecting developmental problems to preventing them and, in recognition of this change, the term “child health surveillance programme” has given way to “child health promotion programme”. Putting this programme into practice calls for awareness of the evidence as to what works. The evidence supports the need for a universal preschool service for all families and targeted intensive home visiting for high risk children. Preschool intervention and education benefit all children but particularly those at risk of educational failure. Children’s Centres may offer the opportunity to provide a more effective integrated service. The shift from surveillance to promotion requires paediatricians to play several roles in a larger multidisciplinary and multi-agency team, contributing to health promotion as well as facilitating early identification and providing expert diagnostic and management services. The current interest and investment in the promotion of optimum health and development for children is the result of emerging evidence that outcomes and life chances can be improved by preschool intervention programmes, coupled with growing concerns about health inequalities, educational under-achievement, juvenile crime, and social exclusion.1 Such concerns are not new; efforts to address their root causes date from the 19th century when there was a major public investment in sanitary reform and other environmental improvements. In the first half of the twentieth century, the major health concerns were nutritional deficiencies and infectious diseases. As these scourges came under control, more attention could be devoted to child rearing issues, …

Children's health and development: approaches to early identification and intervention

Many children arrive at school with problems of development and behaviour which affect their educational achievement and social interaction and can have lifelong consequences. There is a strong association between developmental vulnerability at school entry and a well-documented series of parent and family risk factors, often linked to social disadvantage. Strategies which are likely to make a difference to these children and improve outcomes include family support, high-quality early education and care programmes in the preschool years, and early detection of emerging problems and risk factors. The evidence suggests that these services and programmes are best delivered within a framework of progressive universalism—a universal basket of services for all children and families, with additional support commensurate with additional needs. This provides the best opportunity for early identification and appropriate intervention for emerging developmental problems and family issues that impact on childrens development. While there are a number of challenges that need to be addressed and overcome, such an approach is an important investment that will yield measurable educational, social and economic benefits over the long term.

‘Is my child developing normally?’: a critical review of web-based resources for parents

Early detection of developmental problems improves outcomes for parents and children. Parents want to be involved in assessment and need high‐quality, accurate, and reliable data on child development to help monitor progress and inform decisions on referral. The aim of this paper is to review which websites are readily accessible to parents on child development and to assess their quality. An internet search (on Google and Yahoo) was conducted using the search terms ‘child development’, ‘parenting’, and ‘developmental milestones’. Criteria were agreed for evaluating web‐based resources, adapted from and based on previously reported methods. Data were collected on site content, diagrams and layout, readability (Flesch Reading Ease Scale), design, navigability, overall design, and interactive features. Forty‐four relevant websites were identified for further analysis: six government, three university, 15 health‐care professional, four American Academy of Pediatrics, 10 by journalists, and six undisclosed. The best websites are presented, with justification for their choice. Overall, information available for parents about child development is accurate but much of it is incomplete, unclear, or difficult to access. There is a need to develop an easily accessible, clear, and authoritative resource for parents with illustrations. Focus groups are being held to inform this research further.

Trends in the coverage of 'universal' child health reviews: observational study using routinely available data.

Objectives Universally offered child health reviews form the backbone of the UK child health programme. The reviews assess childrens health, development and well-being and facilitate access to additional support as required. The number of reviews offered per child has been reduced over recent years to allow more flexible provision of support to families in need: equitable coverage of the remaining reviews is therefore particularly important. This study assessed the coverage of universal child health reviews, with an emphasis on trends over time and inequalities in coverage by deprivation. Design Assessment of the coverage of child health reviews by area-based deprivation using routinely available data. Supplementary audit of the quality of the routine data source used. Setting Scotland. Participants Two cohorts of around 40 000 children each. The cohorts were born in 1998/1999 and 2007/2008 and eligible for the previous programme of five and the current programme of two preschool reviews, respectively. Outcome measures Coverage of the specified child health reviews for the whole cohorts and by deprivation. Results Coverage of the 10 day review is high (99%), but it progressively declines for reviews at older ages (86% for the 39–42 month review). Coverage is lower in children living in the most deprived areas for all reviews, and the discrepancy progressively increases for reviews at older ages (78% and 92% coverage for the 39–42 month review in most and least deprived groups). Coverage has been stable over time: it has not increased for the remaining reviews after reduction in the number of reviews provided. Conclusions The inverse care law continues to operate in relation to ‘universal’ child health reviews. Equitable uptake of reviews is important to ensure maximum likely impact on inequalities in childrens outcomes.

Getting evidence into practice—implementation science for paediatricians

It is estimated that on average it takes 17 years to get research findings used in day to day practice. Nearly two million scientific articles are published every year. There is a knowledge-practice gap which requires closing if we are to make optimum and timely use of the best evidence to inform and change our clinical practice. This article explores the theoretical background to knowledge translation and knowledge discovery and gives child health examples of how diffusion and dissemination of knowledge occurs in practice. It is suggested that there is a unique role for knowledge brokers in paediatrics to facilitate change and outlines how various barriers to change might be overcome. We know more than we think about what improves childrens health status. As readers of this and other journals will be only too aware, for virtually every research paper that is published, there is a sentence exhorting calls for more research. However, there is a substantial ‘know-do’ gap which exists between what we know already and how we implement it in practice to support our patients care. This gap has grown considerably with the exponential rise in new research findings being published every year. There were about 28 100 active scholarly peer-reviewed journals in August 2012, collectively publishing about 1.7–1.8 million articles a year.1 It is clear that it would be impossible for a practitioner to be able to read let alone use this new knowledge in day to day practice. One can appreciate why it might take some time for this to filter through to us. The following section gives two examples of how findings from basic science research took many years to be used in routine clinical practice. The first of these was the introduction of antenatal steroids in late pregnancy threatened by premature delivery to avoid …