Natalie Forster

Care planning for long-term conditions – a concept mapping

This article focuses on approaches within clinical practice that seek to actively involve patients with long‐term conditions (LTCs) and how professionals may understand and implement them. Personalized care planning is one such approach, but its current lack of conceptual clarity might have impeded its widespread implementation to date. A variety of overlapping concepts coexist in the literature, which have the potential to impair both clinical and research agendas. The aim of this article is therefore to explore the meaning of the concept of care planning in relation to other overlapping concepts and how this translates into clinical practice implementation.

Cost-effectiveness of health-related lifestyle advice delivered by peer or lay advisors: synthesis of evidence from a systematic review

BackgroundDevelopment of new peer or lay health-related lifestyle advisor (HRLA) roles is one response to the need to enhance public engagement in, and improve cost-effectiveness of, health improvement interventions. This article synthesises evidence on the cost-effectiveness of HRLA interventions aimed at adults in developed countries, derived from the first systematic review of the effectiveness, cost-effectiveness, equity and acceptability of different types of HRLA role.MethodsThe best available evidence on the cost-effectiveness of HRLA interventions was obtained using systematic searches of 20 electronic databases and key journals, as well as searches of the grey literature and the internet. Interventions were classified according to the primary health behaviour targeted and intervention costs were estimated where necessary. Lifetime health gains were estimated (in quality-adjusted life years, where possible), based on evidence of effectiveness of HRLAs in combination with published estimates of the lifetime health gains resulting from lifestyle changes, and assumptions over relapse. Incremental cost-effectiveness ratios are reported.ResultsEvidence of the cost-effectiveness of HRLAs was identified from 24 trials included in the systematic review. The interventions were grouped into eight areas. We found little evidence of effectiveness of HRLAs for promotion of exercise/improved diets. Where HRLAs were effective cost-effectiveness varied considerably: Incremental Cost effectiveness Ratios were estimated at £6,000 for smoking cessation; £14,000 for a telephone based type 2 diabetes management; and £250,000 or greater for promotion of mammography attendance and for HIV prevention amongst drug users. We lacked sufficient evidence to estimate ICERs for breastfeeding promotion and mental health promotion, or to assess the impact of HRLAs on health inequalities.ConclusionsOverall, there is limited evidence suggesting that HRLAs are cost-effective in terms of changing health-related knowledge, behaviours or health outcomes. The evidence that does exist indicates that HRLAs are only cost-effective when they target behaviours likely to have a large impact on overall health-related quality of life. Further development of HRLA interventions needs to target specific population health needs where potential exists for significant improvement, and include rigorous evaluation to ensure that HRLAs provide sufficient value for money.

A realist synthesis of the evidence on outreach programmes for health improvement of Traveller Communities

Background Improving the health of Traveller Communities is an international public health concern but there is little evidence on effective interventions. This study aimed to explain how, for whom and in what circumstances outreach works in Traveller Communities. Methods A realist synthesis was undertaken. Systematic literature searches were conducted between August and November 2011. Grey literature was sought and key stakeholders were involved throughout the review process. Iterative steps of data extraction, analysis and synthesis, followed by additional searches were undertaken. Results An explanatory framework details how, why and in what circumstances participation, behaviour change or social capital development happened. The trust status of outreach workers is an important context of outreach interventions, in conjunction with their ability to negotiate the intervention focus. The higher the outreach workers trust status, the lower the imperative that they negotiate the intervention focus. A ‘menu’ of reasoning mechanisms is presented, leading to key engagement outcomes. Conclusions Adopting a realist analysis, this study offers a framework with explanatory purchase as to the potential of outreach to improve health in marginalized groups.

Looking after yourself: Clinical understandings of chronic-care self-management strategies in rural and urban contexts of the United Kingdom and Australia

Objectives: This article reports on the outcomes of two similar projects undertaken during 2011–2012 in Australia (Rural Northern New South Wales) and the United Kingdom (Urban Northern United Kingdom) that sought to identify the strategies that health professionals employ to actively involve patients with chronic conditions in the planning and delivery of their care. In particular, this study explored understandings and contexts of care that impacted on the participants’ practices. This study was informed by the global shift to partnership approaches in health policy and the growing imperative to deliver patient or client-centred care. Methods: An ethnomethodological design was used, as ethnomethodology does not dictate a set of research methods or procedures, but rather is congruent with any method that seeks to explore what people do in their routine everyday lives. Focus groups and interviews were employed to explore the strategies used by a range of primary health-care providers, such as general practitioners, nurses, social workers, diabetes educators, dieticians and occupational therapists, to support clients to effectively manage their own chronic conditions. Results: Data from both studies were synthesised and analysed thematically, with the themes reflecting the context, similarities and differences of the two studies that the participants felt had either facilitated or blocked their efforts to support their clients to adopt self-care strategies. Conclusion: Supporting patients/clients to engage in actively self-managing their health-care needs requires changes to clients’ and clinicians’ traditional perspectives on their roles. The barriers and enablers to supporting clients to manage their own health needs were similar across both locations and included tensions in role identity and functions, the discourse of health-care professionals as ‘experts’ who deliver care and their level of confidence in being facilitators who ‘educate’ clients to effectively manage their health-care needs, rather than only the ‘providers’ of care.

Lay health advisers: scoping the role and intervention landscape

The use of lay health advisers has become an established approach within public health, in particular for impact on health inequalities and engaging socially excluded groups. Evidence on how differences in terms of the multiple role dimensions impact the outcomes of programs is limited. This creates ambiguity for decision makers on which roles should be implemented in different contexts for different needs. This paper applies realist logic to an inquiry to explore the mechanisms that may operate in lay-led intervention models and understand how, why, and in what respect these lead to particular outcomes. It draws on a project focusing on health-related lifestyle advisers and further insights gained from a subsequent related project about outreach with traveler communities. Analysis highlights multiple and potentially interacting aspects of lay health-adviser roles that may influence their success, including characteristics of lay health advisers, characteristics of target populations, purpose or intent of interventions, and how advice is given. A model is proposed from which to examine the contexts and mechanisms of lay health advisers that may impact outcomes, and is subsequently applied to two examples of reported lay health-adviser interventions. The combination of skills and characteristics of lay health advisers must be considered when planning which interventions might be appropriate when targeting specific needs or target populations. Focus only on the peer/layperson distinction may overlook other potentially important skills and mechanisms of action integral to lay health-adviser roles.

Realist synthesis: learning from a complex intervention targeted at a complex group and reported through a heterogeneous literature base

Traveller Communities constitute a complex population. A lack of reliable demographic data combined with nomadic lifestyles leads to unmet needs. Outreach has been utilized as a strategy to engage Traveller Communities in health improvement interventions. Using realist synthesis, a theory-driven approach which explores what it is about an intervention that works, for whom, in what circumstances, and why, we synthesized the available evidence on outreach interventions for Traveller Communities. We undertook comprehensive searches of electronic databases and gray literature to identify publications relevant to Traveller Communities and health. We then conducted expert hearings involving Traveller Community members and outreach workers to refine and validate our emerging findings. We found that outreach works best when community members feel they can trust the worker.