A REVIEW OF THE CONTRIBUTION OF NURSES, MIDWIVES AND HEALTH VISITORS TO IMPROVING THE PUBLIC’S HEALTH
Working together for a healthy, caring Scotland
The Effectiveness Of Public Health Nursing: A Review Of Systematic Reviews
Lawrence Elliott1 Director of Health Services Research Iain K Crombie2 Professor Linda Irvine2 Research Fellow Jane Cantrell1 Lecturer/Researcher Julie Taylor1 Lecturer/Researcher
1
School of Nursing and Midwifery Department of Epidemiology and Public Health University of Dundee Ninewells Hospital & Medical School Dundee DD1 9SY
2
Correspondence to:
Dr L Elliott
[email protected]
or
Dr L Irvine
[email protected]
Table of Contents PRELIMINARIES Acknowledgements Abbreviations used Executive Summary
INTRODUCTION . Public Health Public Health Nursing Background to the Literature Review Scale of the Literature Review Rationale for using systematic reviews Aims of the review
METHODS
i ii iii
1 2 3 3 4 4 4
5
Selection of health topics for review
5
The search for literature Authoritative groups Experts in the field
6 6 6
Electronic searches The databases Search strategies Reviews and primary papers
7 7 7 7
The search for reviews Initial search Developing the search
8 8 8
Appraising the reviews
8
Assessment of review papers The quality of the literature search Assessment of primary papers included in reviews Synthesis of the findings
9 9 9 10
Presentation of the findings in this report
10
The search for primary papers
10
Retrieval of primary papers
11
Bibliographic software
11
RESULTS Presentation of the data from systematic reviews The Primary papers
Section 1 Coronary Heart Disease Table 1.1 Cholesterol Reducing Diets Table 1.2 Modification of Dietary Fat Intake Table 1.3 Dietary Supplementation to Reduce Cholesterol and Blood Pressure Table 1.4 Weight Loss Diets Table 1.5 Dietary Sodium Restriction Table 1.6 Alcohol Restriction Table 1.7 Exercise Table 1.8 Psycho-Educational and Cognitive Behavioural Interventions Table 1.9 Multiple Risk Factor Interventions Table 1.10 Screening for High Blood Pressure and Management of Hypertension Table 1.11 Publications not included in this review
Section 2 Cancer Table 2.1 Screening Compliance Table 2.3 Counselling on Measures to Reduce the Risks of Cancer Table 2.4 Publications not included in this review
Section 3 Mental Health Table 3.1 The Effectiveness of Community Mental Health Nursing Table 3.2 Prevention of Suicide Table 3.3 Prevention of Repeated Suicide Attempts and Deliberate Self Harm Table 3.4 Brief Psychological Interventions for Trauma Related Symptoms Table 3.5 Prevention of Stress among Carers of Highly Dependent Relatives Table 3.6 Bereavement Counselling Table 3.7 Screening for Depression Table 3.8 Publications not included in this review
Section 4 Accident Prevention Table 4.1 Prevention of Household Accidents Table 4.2 Prevention of Back Pain Table 4.3 Prevention of Falls in the Elderly Table 4.4 Publications not included in this review
12 12 12
13 17 19 20 21 22 23 24 25 26 28 29
34 37 39 40
44 49 50 51 52 53 54 55 56
60 63 64 65 66
Section 5 Child And Adolescent Health
69
Sexual Health Diet and Exercise Drug Use Preventive Service Use and Immunisation Mental Health Accidents Child Protection
71 71 72 72 72 73 73
Table 5.1 Sexual health: Prevention of teenage pregnancy Table 5.2 Risk Behaviour Table 5.3 Knowledge, Attitudes and Skills Table 5.4 Diet and Exercise; Eating Behaviour and Physical Development Table 5.5 Diet and Exercise; Knowledge Table 5.6 Drug Use: Behaviour Table 5.7 Drug Use; Knowledge and Attitudes Table 5.8 Preventive Service Use and Immunisation Table 5.9 Screening Table 5.10 Mental health Table 5.11 Accidents Table 5.12 Child Protection Table 5.13 Publications not included in this review
Section 6 Maternal Health Table 6.1 Antenatal Care Table 6.2 Antenatal Care; Smoking Table 6.3 Antenatal Diet Table 6.4 Perinatal Care Table 6.5 Postnatal - Mental Health Table 6.6 Publications not included in this review
Section 7 Care Of The Elderly Table 7.1 Preventive Home Visits Table 7.2 Prevention of Falls Table 7.3 Diet Table 7.4 Care of Elderly Persons Discharged from Hospital Table 7.5 Outreach Programmes for Depressed Elderly Persons Table 7.6 Screening Table 7.7 Publications not included in this review
Section 8 Smoking Table 8.1 Nursing Interventions and Smoking Cessation Table 8.2 Summary of the UK Smoking Cessation Guidelines Table 8.3 Brief Interventions for Smoking Cessation Table 8.4 Behavioural Counselling by a Trained Counsellor Table 8.5 Group Therapy for Smoking Cessation Table 8.6 Interventions in Pregnancy Table 8.7 Training Health Professionals to Counsel Smokers Table 8.8 Publications not included in this review
Section 9 Alcohol Abuse Table 9.1 Brief Interventions Table 9.2 Publications not included in this review
76 77 79 80 82 83 85 86 87 88 90 91 92
102 105 107 108 109 110 111
118 121 122 123 124 125 126 127
132 136 137 138 140 141 142 143 144
149 152 153
Section 10 Illicit Drug Use Table 10.1 Illicit Drugs Use Table 10.2 Publications not Included in this review
Section 11 Diet Table 11.1 Ethnic Minority Groups Table 11.2 Elderly People Table 11.3 Obesity Table 11.4 Professional Interventions Table 11.5 School and University Settings Table 11.6 Workplace Table 11.7 Primary Care Settings Table 11.8 Community Settings Table 11.9 Publications not included in this review
Section 12 Physical Activity Table 12.1 Adults Table 12.2 Whole Population Table 12.3 Publications not included in this review
Section 13 Sexual Health Table 13.1 HIV Counselling and Testing Table 13.2 Primary Prevention of HIV Transmission Table 13.3 Sexual Risk Reduction Table 13.4 Use of Educational Videos in Sexually Transmitted Disease Clinics Table 13.5 Prevention of Unintentional Pregnancy Table 13.6 Publications not included in this review
Section 14 Inequalities in Health Table 14.1 Publications not included in this review
Section 15 General Table 15.1 General Public Health Interventions Table 15.2 Publications not included in this review
DISCUSSION
156 159 160
163 166 167 168 169 170 171 172 173 174
177 180 181 182
184 188 189 190 191 192 193
196 200
204 207 209
212
Limitations of this review Completeness of coverage Quality of the reviews Relevance of the review findings
213 213 214 214
Types of Public Health Interventions
215
The effectiveness of Public Health interventions Effective interventions Ineffective interventions Interventions with insufficient evidence to measure effectiveness
215 215 216 217
Barriers to improving Public Health
218
Issues for future research The nature of the intervention Length of follow-up The cost of Public Health interventions Qualitative research
218 219 219 219 219
RECOMMENDATIONS Service Research
APPENDICES Appendix 1 Literature Review Sub-Committee Appendix 2 Experts in the Field of Public Health Appendix 3 Authoritative Groups Appendix 4 Embase Search Strategies Appendix 5 Table i Selection of Reviews for Appraisal Table ii Reviews Included and Rejected Table iii Primary Papers Identified Table iv Primary Papers Retrieved Appendix 6 Abstract Appraisal Form Appendix 7 Full Paper Appraisal Form
221 221 222
223 223 224 229 232 241 241 242 243 244 245 246
i
Acknowledgements This review of literature reviews was commissioned by Chief Scientist Office on behalf of the Chief Nursing Officer, Scotland. We are grateful for the advice and guidance given by the Literature Review Sub-Committee, Scottish Executive (Appendix 1) We take this opportunity to acknowledge the contribution of the many experts in the field of Public Health who have provided references and information on studies relevant to the review (Appendix 2). We would like to thank the staff of the Nursing and Midwifery Library (Tayside and Fife), the Medical Library, Ninewells Hospital and Medical School and the Main Library, University of Dundee. Finally we would like to thank Arlene Stewart for secretarial and administrative support throughout the project.
ii
Abbreviations used AHCPR
US Agency for Health Care Policy and Research
AIDS
Acquired Immune Deficiency Syndrome
CMO
Chief Medical Officer
CNO
Chief Nursing Officer
CRD
NHS Centre for Reviews and Dissemination
HEA
Health Education Authority
HEBS
Health Education Board for Scotland
HIV
Human Immunodeficiency Virus
HTA
Health Technology Assessment
MeSH
Medical Subject Heading
NHSiS
National Health Service in Scotland
NRT
Nicotine Replacement Therapy
PHRED
Public Health Research, Education and Development Program, Canada
RCT
Randomised Controlled Trial
STD
Sexually transmitted disease
UNS
Universal Neonatal Screening
USPST
US Preventive Services Task Force
iii
Executive Summary Background The Chief Nursing Officer is conducting a review of the Nursing contribution to Public Health. Early in that review the importance of reviewing the literature on the effectiveness of Public Health Nursing was recognised. A multi-disciplinary team at Dundee University was commissioned to conduct the literature search and to produce the final report within a six month period. Aims To review the literature on the effectiveness of interventions relevant to Public Health Nursing; critically appraise the evidence; and synthesise the findings in a report. Method The literature review focused on 14 health topics which are major health priorities for the NHSiS, involved client groups where nurses have a major input, and addressed lifestyle choices important to Public Health. Seventy two electronic searches were conducted in four major databases: Cinahl, Embase, Medline, and PsychLit. The search was restricted to English language publications published between 1989 and 1999. The reports produced by seven authoritative organisations were obtained by searching relevant web sites and by personal communication. These searches were augmented by requests to experts in the field. Findings The searches uncovered approximately 700 primary studies and almost 300 review papers. Given this wealth of evidence, attention was focused on systematic reviews because these would enable coverage of the widest range of topics in the greatest depth. Many effective interventions were identified across all major health topics, but often these were only weakly beneficial. Successful interventions • Educational interventions often increase health knowledge, and interactive approaches are more successful than didactic methods. However the effect of increased knowledge on behaviour is at best uncertain.
•
Behavioural change is more likely to occur when education or counselling is combined with environmental modification. This includes legislative change and the provision of the means to modify behaviour eg. improving building design, providing safety equipment, providing health technologies or changing service provision.
•
Effective behaviour change strategies which are based on theoretical models from the disciplines of psychology and sociology are more likely to be effective. Skills training is a desirable component of behaviour modification interventions.
•
Multi-agency strategies are more likely to succeed in modifying behaviour. This may involve collaboration with other health professionals and those from non-health sectors eg. social workers, housing officials, teachers, peers and family members.
•
Interventions targeted at high-risk groups are often more successful than interventions delivered to the general population. High risk individuals may perceive interventions to be more relevant and may be more motivated to change.
•
Many behaviour changes require long term interventions to achieve and sustain health gains.
iv
Ineffective Interventions • The passive transfer of information seldom achieves behaviour change.
•
Interventions intended to provide general support, or which lack clearly stated achievable aims, are often unsuccessful
•
Brief unfocused interventions, that are unsupported by theory, are unsuccessful in most settings.
•
Interventions that involve complete prohibition rather than encouraging safe practices or skills development.
We would urge some caution when interpreting these findings. Given the limited time available it was only possible to review systematic reviews, thus the coverage is not as comprehensive as would be desired. Further we have relied on the conclusions drawn by the authors of these reviews, as we were unable to examine the cited primary papers or replicate the synthesis of data from these papers. Finally, many of the studies cited in the reviews come from outwith the UK so their findings may not apply to this country. Despite these limitations we are confident that the general conclusions are valid. We have taken advantage of the advice given by experts and much of our work is based on reviews undertaken by authoritative bodies. There is also an impressive consistency in the characteristics of successful interventions across health topics. Conclusions Nurses have a central role to play in the delivery of effective Public Health interventions. To be able to deliver interventions effectively nurses need to be trained in the skills of behavioural change. Nurses also need to have greater involvement in the design and conduct of research studies. This would ensure that research of relevance to nursing was undertaken and the findings effectively disseminated. There is an urgent need for primary research and systematic reviews in Public Health Nursing.
Introduction
2
Introduction Public Health Public Health is the process of mobilising resources to ensure the condition in which people can be healthy1. It is concerned with the prevention of disease and the promotion of health of communities. In this sense communities may refer to regions of a country, to client groups (eg. children, the elderly, or socially disadvantaged people, or to people with particular health problems eg. heart disease or mental health)2. Inequalities in health, the reasons for these and solution to these are prominent issues for Public Health. Nurses*, who have extensive and close contact with many sections of the community, could thus have a pivotal role in improving the health of the public. The origins of Public Health can be traced back many centuries3, but the discipline really came of age in the 19th century. In particular the cholera epidemics in England in the 1830s focused attention on the need to act at the community level to control the burden of disease. The challenges facing us in the 21st Century are quite different: the infectious diseases have largely been brought under control and it is the chronic diseases of cancer, cardiovascular disease and respiratory disease which are the major causes of death. But the response of Public Health remains the same: to try to prevent or control morbidity and mortality at the community level. An important distinction in Public Health is between the high risk group and the whole community approaches. The high risk approach is limited to the usually small number of individuals thought to be most likely to suffer some adverse health outcome (eg. a heart attack). The rationale for this approach is that a given change among high risk individuals will have greater effect than in low risk individuals. The high risk strategy is likely to be more cost effective. The limitation of this approach is that it ignores the large proportion of individuals who are at low risk. Because of their numbers many adverse health outcomes will occur, even though individually they are at low risk. Thus, focusing exclusively on high risk could leave a substantial Public Health problem unaddressed. The choice between high and low risk strategies depends on the likelihood of effecting change, the level of disease risk in high and low risk groups and the cost effectiveness of the intervention. A further distinction is between primary, secondary and tertiary prevention. Primary prevention is concerned with preventing a disease from occurring at all, as in the promotion of safe sex to prevent HIV transmission. Secondary prevention seeks to detect a disease in its early stages so that it may be more easily treated. The classic example of this is screening for cervical cancer. Finally, tertiary prevention tries to minimise the long term consequences of disease, for example screening for diabetic retinopathy to prevent sight loss. The Public Health approach recognises the multifactorial nature of health. The physical environment, the social environment and individual health behaviour all influence the diseases we develop. Indeed lifestyle factors such as smoking, excessive alcohol consumption, poor diet and lack of exercise, are major determinants of ill health1. Tackling these problems and the causes of inequalities in health are key priorities in the government’s white paper Towards a Healthier Scotland4. From the public health perspective encouraging good nutrition or the practice of safe sex are as legitimate activities as the provision of immunisation or ante-natal care. Thus in addition to the utilisation of health care services, Public Health Nursing will focus on the role of the nurse in disease prevention and health promotion. * For brevity, and unless otherwise stated, the term nurse includes nurses, midwives and health visitors.
3
Public Health Nursing There are several reasons why nurses can make an important contribution to Public Health. Nurses are perceived by the public as working in partnership with their patients and are therefore well placed to deliver interventions aimed at improving health. Apart from patient management in the hospital or primary care setting, some nurses have access to the public in the workplace, schools and in the home. Nurses can have contact with many client groups, and importantly with groups who usually have little contact with health professionals eg. adolescents and healthy adults, particularly men. Home visiting has also been an important part of nursing care for many years5. These visits give nurses a unique opportunity to intervene, particularly with vulnerable groups eg. babies and children, women during pregnancy and the postnatal period and the elderly. The behavioural interventions typically associated with Public Health may be more readily accepted by nurses whose tradition and training emphasise the importance of the psychological and social aspects of care. Public Health Nursing, while of vast potential, faces a number of challenges. As with all activities within the field of Public Health, it must try to ensure the greatest health improvement for the greatest number of people6. The challenge at the national level is to set priorities for Public Health Nursing interventions. These need to focus on the outstanding health problems for which interventions of proven effectiveness are available. The challenge for the nurse practitioner is to incorporate the principles of Public Health into routine practice. This review of the literature was undertaken to identify the evidence available to support the nursing contribution to Public Health. What nurses need to know is whether the service they provide meets their clients needs and has a beneficial effect on health outcomes.
Background to the Literature Review The white paper, Towards a Healthier Scotland4, intimated that the Chief Nursing Officer would initiate a review of the nurses’ contribution to improving the public’s health. The importance of the nursing contribution was also emphasised in the Review of the Public Health Function in Scotland 6, which was led by the Chief Medical Officer. Two of the key messages in that report are the need for a multidisciplinary approach to Public Health and the “considerable scope for further involvement of nurses in the drive to improve Public Health”. The review of Public Health Nursing, led by of the Chief Nursing Officer, began in September 1999. The importance of reviewing the literature on the effectiveness of Public Health Nursing was recognised. A literature review would identify effective interventions, inform and comment on nursing input and make recommendations for further evaluation of the nurses’ role. In February 2000 a multi-disciplinary team from the University of Dundee was commissioned to undertake the literature review, the findings of which are presented in this report. The definition of Public Health as “preventing disease, prolonging life and promoting health through the organised efforts of society”, has been adopted by the Public Health Nursing review. This definition was first proposed by Winslow, Professor of Public Health at Yale University in 19207. It was adopted in the Acheson Report (1988)8, and was subsequently used in the CMO’s Review of Public Health Function in Scotland6.
4
Scale of the literature review The remit of the literature review was to conduct a literature search, synthesise the findings and produce a report within a six month period. This severely limited the scale of work which could be undertaken. To evaluate fully the effectiveness of services or interventions, it would be necessary to carry out rigorous systematic reviews in every area of nursing practice pertinent to Public Health. Clearly in the limited time available, it was impossible to do this. Therefore the study design incorporated methods which would allow pooling of the evidence from published systematic reviews.
Rationale for using systematic reviews The practice of reviewing reviews has been used previously by the NHS Research and Development Health Technology Assessment Programme; namely a review of reviews of health promotion in schools and health promoting schools9 and more recently on the pharmacological management of multiple sclerosis10. Collating the results, conclusions and recommendations from existing systematic reviews also allowed us to comment on a wide range of health topics and resulted in the following benefits: •
a wide range of topic areas could be evaluated in a limited period of time
•
the evidence of effectiveness of interventions is aggregated from a large number of primary studies and a very large population base
•
the search for published and unpublished literature was comprehensive, thus reducing the possibility of publication bias affecting the overall conclusions
Aims of the review To construct a comprehensive list of published and unpublished primary studies and review articles using a pre-defined search strategy. To appraise and critically assess the evidence for effectiveness of interventions relevant to Public Health Nursing. To synthesise the resulting evidence and submit a report which fully meets Chief Scientist Office requirements. References 1. Detels R, Breslow L. Current scope and concerns in Public Health. In: The Oxford Textbook of Public Health. Oxford: Oxford University Press, 1997:3-17. 2. NHS Executive. Resource Pack. NHS Eastern Region 1999. 3. Rosen G. A History of Public Health. 2 ed. Baltimore: The Johns Hopkins University Press, 1993. 4. The Scottish Office Department of Health. Towards a Healthier Scotland. A White Paper on Health. The Stationery Office. Edinburgh, 1999. 5. Hanks CA, Smith J. Implementing nurse home visitation programs. Public Health Nursing 1999;16(4):235-245. 6. The Scottish Executive. Review of the Public Health Function in Scotland. The Stationery Office. Edinburgh, 1999. 7.
Winslow C. The untilled fields of Public Health. Science 1920;51:23-33.
8. Department of Health. Public Health in England, Report of the Committee of Inquiry into the Future Development of Public Health Function (The Acheson Report). The Stationery Office. London, 1988. 9. Lister-Sharp D. Health promoting schools and health promotion in schools: two systematic reviews. Health Technology Assessment Programme 1999. 10. Clegg A, Bryant J, Milne R. Disease-modifying drugs for multiple sclerosis: a rapid and systematic review. Health Technology Assessment Programme 2000.
5
Methods This report is based on a literature review of publications on health interventions relevant to Public Health Nursing. This includes interventions solely relating to nursing as well as those thought to be applicable to nursing eg. behavioural change interventions carried out by multi-disciplinary teams. The technique of the systematic review is the recognised method by which large amounts of data from primary studies can be evaluated and summarised. It “involves the application of scientific strategies, in ways that limit bias to the assembly, critical appraisal, and synthesis of all relevant studies that address a specific clinical problem”1. The systematic review has supplanted the so-called narrative review which had been found to produce unreliable findings2. This present review developed from the methodology for conducting a systematic review outlined by the NHS Centre for Reviews and Dissemination3. The time constraints for the completion for this report meant that all the processes of the systematic review could not be achieved. Specifically, we were unable to examine the primary papers cited in the reviews or replicate the synthesis of data from these papers. Instead we had to rely on the conclusions drawn by the authors of these reviews.
Selection of health topics for review To present the material in a coherent form, the literature review was organised by health topics which are particularly relevant to Public Health in Scotland. Topics are divided into three categories: •
the major health priorities Coronary heart disease Cancers Accident prevention Mental Health Inequalities in health
•
client groups where nurses have a major input Child and adolescent health Maternal health Care of the elderly
•
lifestyles important to Public Health Smoking Alcohol abuse Illicit drug use Diet Physical activity Sexual health
Coronary heart disease and cancers together with prevention of accidents and promotion of mental health are currently the main Scottish health priorities. Targets for reducing mortality from coronary heart disease and cancer have been set for the period up to 20104, therefore it is important to identify strategies which nurses can use to assist in achieving these targets. Tackling inequalities in health is also of major importance and is described as an “overarching aim” in improving the Public Health4. Studies which test interventions to address ways of reducing inequalities were therefore sought.
6
Areas in which client groups could benefit from nursing interventions to improve health are in child health, maternal health and care of the elderly. These groups have regular contact with nurses in a variety of settings which provide opportunities for nurses to intervene. Life styles particularly relevant to Public Health include: smoking; abuse of alcohol; illicit drug use; physical activity; diet and sexual health. Current targets to reduce health risks from lifestyle behaviours include reducing smoking in adolescents and pregnant women, reducing the incidence of men and women whose weekly alcohol consumption is in excess of the safe limits and reducing teenage pregnancy rates4.
The search for literature Three main sources were used to identify relevant publications: authoritative review groups; acknowledged experts on topics within the field of Public Health and Public Health Nursing and electronic databases of published papers. Most papers were identified from the electronic databases. Authoritative groups Several internationally recognised groups have ongoing reviews of the literature and produce and update reviews regularly. Many of the topics reviewed are relevant to Public Health. Reviews were sought from: Cochrane Collaboration Centre for Evidence Based Nursing, UK Health Technology Assessment, UK Health Education Authority, UK Health Education Board for Scotland Centre for Reviews and Dissemination, University of York, UK Public Health Research, Education and Development Program, Canada United States Preventive Services Taskforce The majority of these groups have Internet sites which were interrogated for relevant reviews. Information and Website addresses for the groups can be found in Appendix 3. Some of the reviews were downloaded from the Internet whilst others were obtained from the review groups. Experts in the field In an attempt to maximise the amount of information captured by the literature search, known experts in the field of Public Health and Public Health Nursing were contacted. Names of experts were obtained from a variety of sources: Cochrane Collaboration Review Groups; key authors from all of the authoritative bodies listed above; researchers who have published widely in the selected topic areas; and experts identified by the Literature Review Sub-Committee (Scottish Executive). The list of experts responding to our request for information is given in Appendix 2.
7
Electronic searches The main sources of publications were extensive searches of electronic databases. The search strategies involved several requirements and were conducted in a series of steps described below. The databases Four databases were searched for relevant papers. The databases most likely to give the highest yield of relevant publications and the most comprehensive coverage of the medical, nursing and social sciences literature are: MEDLINE EMBASE Cinahl PsychLit All of the databases were searched for the years 1989 to 1999. The searches were limited to English language publications. Search strategies To identify literature suitable for review, five categories of searches were developed. Publications had to be relevant to: •
Public Health function
•
nurse group
•
selected health topic area
•
a study design which allowed assessment of effectiveness of the intervention (search for primary papers)
•
literature review (search for review papers)
A total of 72 search strategies were carried out, 18 on each of the four databases. The search strategies developed for EMBASE are given in Appendix 4. A complete list of all searches used in the four databases is available from the authors. Search strategies were developed using a combination of Medical Subject Headings (MeSH terms) and text words to maximise the retrieval of publications. Where possible pre-defined searches were used or adapted to suit the databases included in this review. The search for Public Health Function was based on a systematic review on health promotion in schools5 and the searches for literature reviews and study design were based on the NHS Centre for Reviews and Dissemination searches3. The searches were developed to be as consistent as possible across the databases. However, as the MeSH terms differed in every database, the searches were not identical. The short time available limited the opportunity to refine the searches. Reviews and primary papers An early decision was taken to focus on systematic reviews. However it was acknowledged that some readers might wish to pursue individual topics in more depth. Thus separate searches were conducted for primary research studies. As different search strategies were needed for the primary papers, these are described separately. A comprehensive list of primary papers retrieved for each health topic appears at the end of each section in the results.
8
The search for reviews Initial search The initial search was planned to be all inclusive and ensure that comprehensive coverage of the topics could be obtained. To achieve this the initial search for review papers was not restricted to systematic reviews or meta-analyses, but included all types of reviews. Systematic reviews were then identified by inspection of the complete set of reviews obtained. Review papers were identified by combining the four of the searches described above ie. public health function and nurse group and health topic and review Developing the search From the initial screening of the abstracts it became evident that relevant publications were missed. Some reviews of interventions suitable for delivery by nurses were not identified by searches which included a term relating to a nurse group. The search for reviews was therefore broadened to include any article that was relevant to Public Health irrespective of the health professional who delivered the intervention. Interventions relevant to nursing were identified by inspection of the review papers identified. The health topic strategies were also omitted from the search, again to maximise the yield of relevant publications. Thus the search for reviews of the literature on interventions which could improve Public Health was made as wide as possible using the combined searches: public health function and review
Appraising the reviews Abstracts of review papers identified by the electronic searches were read carefully to assess whether the full paper should be retrieved. A data abstraction form was used to guide the appraisal exercise (Appendix 6). Inclusion criteria included: •
relevance to Public Health interventions
•
relevance to nursing
•
synthesis of data from primary studies
Exclusion criteria included: •
disease management
•
interventions not relevant to nursing eg. pharmacological, surgical or medical interventions
•
position papers
•
commentaries
•
expert opinion
•
policy papers
9
Abstracts were read by one reviewer and a randomly chosen subset (10%) were read by two reviewers. Of the subset, there was 92% agreement on the abstracts selected for retrieval and 100% agreement was reached by discussion. All other abstracts for which a reviewer was unsure about the relevance of the topic, were read by a second reviewer. A decision about inclusion was reached by discussion.
Assessment of review papers Papers thought suitable for appraisal were retrieved either from the University of Dundee Library or by inter-library loan (Table i, Appendix 5). These were subjected to a two stage assessment. The initial assessment confirmed whether a paper was relevant to the review. The second stage of assessment involved a detailed appraisal of three broad areas of enquiry6. The form designed for this review (Appendix 7) assessed: •
the quality of the literature search
•
the quality of the papers included in the review
•
the methods used to synthesise the findings
The quality of the literature search An assessment was made on whether a comprehensive search for primary papers was carried out. An exhaustive search for relevant literature involves searching several electronic databases, searching for grey literature, conference abstracts and hand searching of the journals most likely to contain papers relevant to the topic. The electronic databases do not contain references of all of the published literature7,8. Some studies may be unpublished. Contacting experts in the field for references or information on unpublished data should be undertaken. This comprehensive searching reduces the possibility of publication bias. Studies with positive outcomes are more likely to be published in quality journals or are more likely to be submitted for publication than interventions showing no effect or a negative effect. To be sure that the search has been comprehensive some formal test for publication bias should ideally be carried out. This is conventionally done using a funnel plot in which the estimated effect size is plotted against a measure of the precision of the estimate9,10. Three main criteria were used to assess the literature search: the quality of the electronic search; whether the reviewers made an attempt to obtain grey literature and whether the possibility of publication bias was addressed. Assessment of primary papers included in reviews Each systematic review was then assessed on the quality of primary papers included. It is recommended that assessment of primary papers should be blinded and carried out by at least two independent reviewers, although in practice blinded review seldom occurs. High quality papers were those which assessed the primary papers on the quality of methodology. This included a clearly defined intervention, the use of well defined study groups, a description of randomisation methods, the use of objective outcomes, blinded assessment of the outcomes, whether the authors stated sample sizes and effect sizes and whether attrition was addressed.
10
Synthesis of the findings Finally, the quality of data synthesis was assessed. Synthesis of data from the primary studies involves providing a summary of the effectiveness of the intervention investigated. This may be done by a narrative assessment of the combined results, usually with a graphical presentation. Or a meta-analysis may be carried out in which a summary estimate is calculated. Formal meta-analysis cannot be used when studies are few or heterogeneous. The systematic reviews were also assessed on whether heterogeneity was addressed or whether sensitivity analysis had been performed. On the basis of these criteria, each systematic review was graded as good, acceptable or, if the review failed to perform these three steps adequately, it was rejected. Any difficulties in grading were resolved through discussion with three of the review team. The review papers included and rejected are presented in the tables in each section of the results chapter and summarised in Table ii of Appendix 5.
Presentation of the findings in this report The findings of the systematic reviews included in this review of the literature are collated and summarised by health topic. The strength of the effectiveness of the interventions are presented on a scale of 1-5. In some cases joint scores eg. 2/3 are given to indicate that the evidence is of intermediate strength. 1 indicates a strong beneficial effect of an intervention 2 indicates a weak beneficial effect 3 indicates that the intervention has been shown to be ineffective 4 indicates that an intervention may be harmful 5 indicates that there is insufficient evidence available to show that an intervention has any effect in the client group in which it was tested
The search for primary papers The search for primary papers involved combining the individual searches as in the search for reviews ie. public health function and nurse group and health topic and study design The number of publications identified by these searches were far in excess of what was anticipated (Table iii, Appendix 5). From the papers identified we found that relevant Public Health interventions were numerous and diverse. Diversity occurred in many ways: the setting in which studies were carried out, eg. primary care, hospital, workplace or schools; the population or client group studied eg. by age, gender, social group; the different health professions delivering the interventions; the extent of training of health professionals to deliver the interventions; the duration and intensity of interventions; the outcomes measured in individual studies eg. morbidity or mortality, changes in behaviour, knowledge or attitudes.
11
Retrieval of primary papers Abstracts identified by electronic searches were carefully read and papers were selected for retrieval using a data abstraction check list. •
the publication was relevant to the health topic
•
the study described an intervention which was delivered by nurses or could be delivered by nurses
•
the study design incorporated a control group
The appraisal of the abstracts gave a large number of potentially relevant primary papers which were retrieved (Table iv, Appendix 5). Many relevant papers were identified for each of the topics. The largest number of papers identified were in the areas of child health, maternal health and in care of the elderly. Many primary papers were also identified in coronary heart disease, cancer and smoking. Synthesis of the findings from all of the relevant primary papers, although urgently required, was far beyond the scope of this review. In order to synthesise the findings from the papers identified, many systematic reviews would be required across the health topics. The papers identified by these searches provide an overview of areas relevant to Public Health Nursing. Many of these areas have been subject to multiple studies and would benefit from systematic review.
Bibliographic software The reference management software package Endnote was used for this review. The package allowed direct transfer of references from the electronic databases. References were coded according to: source of the reference; whether the paper was a review or primary study; and health topic. This system of coding ensured that lists of publications could be easily retrieved according to topic area or publication type.
References 1. Cook DG, Mulrow CD, Haynes RB. Systematic Reviews: synthesis of best evidence for clinical decisions. Ann Intern Med 1997;126:376-380 2. Mulrow CD. Rationale for systematic reviews. BMJ 1994;309:597-599. 3. NHS Centre for Reviews and Dissemination. Undertaking systematic reviews of research on effectiveness. University of York 1996(CRD Report 4). 4. The Scottish Office Department of Health. Towards a Healthier Scotland. A White Paper on Health. The Stationery Office. Edinburgh, 1999. 5. Lister-Sharp D. Health promoting schools and health promotion in schools: two systematic reviews. Health Technology Assessment Programme 1999. 6. Crombie IK. The Pocket Guide to Critical Appraisal. London: BMJ Publishing Group, 1996. 7.
Dickersin K, Scherer E, Lefebvre C. Identifying relevant studies for systematic reviews. BMJ 1994;309:1286-1291.
8. Knipschild P. Only fanatics can do better. BMJ 1994;309:719-721. 9. Egger M, Davey Smith G. Bias in location and selection of studies. BMJ 1998;316:61-6. 10. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315:629-634.
12
Results Presentation of the data from systematic reviews This chapter is divided into sections by health topic. Each section begins with a brief outline of the Public Health issues relevant to the health topic. It also lists the risk factors for the topic and the interventions which have been subject to systematic review. The findings from these systematic reviews are summarised in the text and full details are given in the tables which follow. Recommendations for practice, where applicable, appear at the end of each summary. The tables briefly describe the intervention and its aims. They also state the year, source of the publication, quality score and, where possible, the number of primary studies included in each review. The effectiveness of each of the interventions is described and an assessment of the strength of evidence is made. Finally an overall summary of the principal findings is given. Often two or more reviews have assessed one intervention. When similar conclusions are reached these are stated once, but when findings are discrepant each is given separately. Further if one review raises issues not covered by others it is cited in the text or tables. Not surprisingly there is considerable overlap of the primary papers included in such reviews. This makes it impossible to give a count of the total number of primary papers for these interventions. The findings reported here are based on the conclusions reported in the systematic reviews. References to the systematic reviews are listed after the tables. Due to time constraints we were unable to examine the primary papers or replicate the synthesis of data from these papers.
The Primary papers Separate searches were conducted to identify primary papers relevant to Public Health Nursing. These papers were identified from searches which included a reference to nurses or nursing in the title, abstract or MeSH term. The references for these papers are listed at the end of each section alphabetically by author. Appraisal of these papers was not possible in the time available. However they are included so that those with a special interest in a particular topic could have access to this wider list of papers.
13
Section 1 Coronary Heart Disease
14
Section 1 Coronary Heart Disease Coronary heart disease is one of the major causes of morbidity and mortality in Scotland, accounting for almost one fifth of all deaths1. The incidence of coronary heart disease is high for both men and women compared with other European countries. Although the death rate from coronary heart disease is falling, morbidity and mortality remain unacceptably high. The current health target is to reduce premature mortality from coronary heart disease by 50% during the period 1995-20102. Identified risk factors The principal risk factors for developing coronary heart disease are smoking, high blood pressure, high total blood cholesterol and physical inactivity. Risk factors for hypertension include obesity, sedentary lifestyle, high salt consumption, stress and high alcohol consumption3. Hypertension and hypercholesterolaemia can be successfully treated by pharmacological treatments, the details of which are beyond the scope of this review. Nurses need to know whether nonpharmacological interventions are also effective, alone or in conjunction with medication, in reducing the risks factors, morbidity and mortality associated with coronary heart disease. Interventions assessed Dietary interventions Cognitive behavioural interventions Psycho-educational interventions Exercise programmes Multiple risk factor interventions Summary of effectiveness of interventions Pharmacological therapies are highly effective. Anti-hypertensive medications reduce coronary heart disease and stroke mortality. Drug treatment for high cholesterol reduces mortality in those at high risk of developing coronary heart disease. Nurses should encourage patients to comply with these therapies. Smoking cessation is the most important non-pharmacological intervention in the prevention of coronary heart disease (details of effective interventions are given in Section 8). Smoking cessation in conjunction with exercise particularly targeted at high risk groups has been shown to be effective in reducing mortality4. Many dietary interventions aimed at reducing cardiovascular disease have been tested. The majority of dietary interventions attempt to reduce blood cholesterol levels or hypertension thereby reducing the risk of coronary heart disease. Cholesterol reducing diets Low fat diets can lead to a reduction in cholesterol levels especially when patients strictly adhere to these (Table 1.1). Studies undertaken in institutions have shown substantial reductions in cholesterol levels but dietary interventions in community subjects have a much more modest beneficial effect. Increasing the intensity of dietary interventions causes a greater reduction in cholesterol levels in high risk groups5. Dietary advice given in the primary care settings have at best a very weak beneficial effect in reducing cholesterol levels and there is insufficient evidence that work place interventions are effective in reducing cholesterol6. Compliance with low fat diets is a major problem for community-based studies.
15
Cholesterol reduction by dietary modification is greatest in subjects at high risk of developing coronary heart disease and in those who have existing disease (Table 1.1 and Table 1.2). Interventions are more effective when focused on diet alone rather than on multiple life style interventions. Changes in dietary intake need to be long term to have a sustained effect on cholesterol reduction. Interventions are more effective when they incorporate behavioural theories (Table 1.2)7. Although they successfully lower cholesterol levels, low fat diets have not been shown to reduce coronary heart disease mortality, and there is insufficient evidence to show that cholesterol reducing diets will reduce coronary heart disease events (Table 1.1). Dietary advice in community subjects can be expected to reduce cholesterol levels by only 3-6%, therefore it may be worthwhile directing interventions at high risk groups8. Blood pressure Non-pharmacological interventions can reduce blood pressure, but the effect on morbidity is unknown. Weight reduction is the most effective intervention3, with significant decreases in diastolic and systolic blood pressure in middle aged and elderly individuals3,4 (Table 1.4). One review suggests that the need for anti-hypertensive medication may be reduced if overweight hypertensive individuals lose weight9. Salt restriction may have a weak beneficial effect on older hypertensive patients, but not in the normotensive population (Table 1.5). Fish oil supplementation, reducing alcohol consumption and stress management have very weak effects in reducing blood pressure (Table 1.3). Exercise has been shown to have a beneficial effect in reducing blood pressure, but it is unclear whether the reduction is due to the associated weight loss (Table 1.7). Cognitive behavioural interventions eg. meditation, relaxation, progressive relaxation techniques and stress management have not been fully evaluated in coronary heart disease. Some reviewers report methodological weakness in studies in these areas (Table 1.8). Tested interventions have been shown to be better than no treatment but not superior to sham techniques eg. “pseudo-meditation” or selfmonitoring10. Interventions appear to be more effective when they are customised to individual patient needs and are multi-component eg. medication combined with cognitive behavioural interventions. There is evidence that interventions need to be delivered over a long period of time in order to be effective. For example, multi-component cognitive interventions could be considered for hypertensive patients who perceive stress to be a problem, or in subjects facing major life-events11. Multiple risk interventions in the general population (advice on exercise, weight loss, diet, smoking, drug treatment of hypertension) have a very weak, non-significant effect on disease (Table 1.9). These interventions are ineffective in reducing total mortality or morbidity from cardiovascular disease when used in the general population or in the work force of middle aged adults12. However, multiple risk interventions are more effective at reducing risk factors in high risk groups, (especially smoking cessation and exercise) and are effective in reducing total coronary heart disease and stroke mortality in patients post myocardial infarction. Those most likely to benefit are patients with hypertension who are given medication and counselling. There is insufficient evidence to show whether screening for hypertension increases coverage of the population or increases detection of hypertension compared to usual care13(Table 1.10). Programmes conducted in shopping centres, for example, are not effective in increasing screening in vulnerable groups, eg. socially disadvantaged or ethnic groups. Case finding, by incorporating protocols into practice or placing reminders to record blood pressure in case records may be effective, but interventions shown to be effective may not be feasible in general practice.
16
Recommendations Interventions are most effective when targeted at patients at high risk of cardiovascular disease or those with diagnosed disease. Therefore health promoting interventions (particularly smoking advice and exercise) should be targeted at those at high risk. Interventions aimed at promoting dietary change should be focused specifically on diet rather than on multiple lifestyle changes. Programmes should incorporate behavioural theories and patients should be actively involved. High adherence to dietary change must be sustained in order to have a beneficial effect. The effectiveness of hypertension clinics, in particular nurse led clinics have not been evaluated. It has been suggested that randomised controlled trial of nurse-led management and physician-led management should be undertaken13. Current interventions, aimed at individuals, have only small beneficial effects on mortality from coronary heart disease. Alternative interventions would include promotion of local health alliances and national policy changes in both fiscal policy and legislation. These could help to reduce smoking, dietary fat consumption, hidden salt and calories and to promote exercise may be more effective in reducing coronary heart disease3. Different approaches to behaviour change are needed. “For example the availability of healthy foods and better access to sporting facilities may have a greater impact on dietary and exercise patterns respectively, than health professional advice”14.
References 1. The Scottish Office Department of Health. Working together for a Healthier Scotland. A Consultation Document. The Stationery Office. Edinburgh, 1998. 2. The Scottish Office Department of Health. Towards a Healthier Scotland. A White Paper on Health. The Stationery Office. Edinburgh, 1999. 3. Ebrahim S, Smith GD. Lowering blood pressure: a systematic review of sustained effects of non-pharmacological interventions. Journal of Public Health Medicine 1998;20(4):441-8. 4. Ebrahim S, Davey Smith G. Health promotion in older people for cardiovascular disease prevention - a systematic review and meta-analysis. Health Education Authority 1996. 5. Brunner E, White I, Thorogood M, Bristow A, Curle D, Marmot M. Can dietary interventions change diet and cardiovascular risk factors? A meta-analysis of randomized controlled trials. American Journal of Public Health 1997;87(9):1415-1422. 6. Wilson MG, Holman PB, Hammck A. A comprehensive review of the effects of worksite health promotion on health-related outcomes. American Journal of Health Promotion 1996;10:429-435. 7.
Hooper L, Summerbell CD, Higgins JPT, Thompson RL, Clements G, Capps N, et al. Reduced or modified dietary fat for prevention of cardiovascular disease. (Cochrane Review) In: The Cochrane Library, Issue 3, 2000. Oxford: Update Software.
8. Tang JL, Armitage JM, Lancaster T, Silagy CA, Fowler GH, Neil HAW. Systematic review of diatary intervention trials to lower blood total cholesterol in free-living subjects. BMJ 1998;316(7139):1213-20. 9. Mulrow CD, Chiquette E, Angel L, Cornell J, Summerbell C, Anagnostelis L, et al. Dieting to reduce body weight for controlling hypertension in adults. (Cochrane Review) In: The Cochrane Library, Issue 3, 2000. Oxford: Update Software. 10. Eisenberg DM, Delblanco TL, Berkey CS, Kaptchuk TJ, Kupelnick B, Kuhl J, et al. Cognitive behavioural techniques for hypertension: are they effective? Annals of Internal Medicine 1993;118(12):964-971. 11. Spence JD, Barnett PA, Linden W, Ramsden V, Taenzer P. Recommendations on stress management. Canadian Medical Association Journal 1999;160(9):S46-S50. 12. Ebrahim S, Smith GD. Systematic review of randomised controlled trials of multiple risk factor interventions for preventing coronary heart disease. BMJ 1997;314(7095):1666-74. 13. Ebrahim S. Detection, adherence and control of hypertension for the prevention of stroke: a systematic review. Health Technology Assessment Programme 1998. 14. Ebrahim S, Davey Smith G. Multiple risk factor interventions for primary prevention of coronary heart disease. (Cochrane Review) In: The Cochrane Library, Issue 3, 2000. Oxford: Update Software.
1998 1998 1998 1998 1997 1997 1996 1996
Tang1 Ebrahim2a Yu-Poth3 Ebrahim4b Howell5 Brunner6 Wilson7 Ebrahim8
BMJ Journal of Public Health Medicine American Journal of Clinical Nutrition Effective Health Care American Journal of Clinical Nutrition Am J Public Health Am J Health Promotion Health Education Authority
Source
1 1 2 2 2 1 2 1
Quality score 1 good, 2 acceptable
19 28 37 undetermined 224 17 52 12
Number of primary studies
Low fat diets can lead to a substantial reduction in cholesterol levels in metabolic ward studies, when a strict dietary regimen is used (Tang) Very low fat diets can lead to a substantial reduction in cholesterol in post myocardial infarction elderly males (Ebrahim, 1996) Low fat diets have a small beneficial effect in reducing cholesterol levels in elderly subjects and in the general population (Ebrahim, 1996, Ebrahim, 1998a, Howell, Brunner) 2 Low fat diets lead to small improvement in the lipid profile of subjects (Yu-Poth) 2/3 Individualised dietary advice in free living subjects on low fat diets have a very weak effect in reducing cholesterol levels. Step 2 diets are more effective than Step 1 diets. Compliance is a problem in general population (Tang). 2/3 Very weak evidence that cholesterol levels will be reduced by garlic, oats or soy protein enriched diets 2/3 Dietary counselling given in the primary care setting has a very weak effect in reducing cholesterol levels 3 Low fat diets are ineffective at reducing coronary heart disease morbidity (Ebrahim, 1996) 3 There is no evidence that coronary heart disease mortality will be reduced by low fat diet (Ebrahim, 1998b)
1 1 2
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Year
First Author
MAIN AIMS To reduce blood cholesterol
INTERVENTION(S) STUDIED Advice to reduce fat and cholesterol intake by use of low fat or modified fat diets. American Heart Association Step 1 (24mths), partly because of short follow-up periods. There is also limited evidence about the impact of interventions on sexually transmitted diseases (STDs) (Table 5.2). Diet and Exercise There is strong evidence that interventions, particularly school based programmes, improve food knowledge3 (Table 5.5). These programmes share common characteristics with others that achieve dietary behavioural change eg. theory based, long-term, involve parents and food choice. Again, knowledge can be improved whereas behavioural change is difficult to achieve. There is weak evidence that Public Health interventions improve children’s dietary intake and increase physical activity (Table 5.4). Environmental or policy changes linked to education seem to have greater impact eg. demand breast feeding for babies, changing school meals, encouraging exercise as part of school curricula, cooking classes. These interventions are generally skill based. Long-term interventions seem to work better than short-term interventions eg. combining pre and postnatal interventions with the health visitor will sustain breast feeding up to 3 months. Long-term school interventions and the involvement of parents helps, as does collaboration with other professionals eg. dietitian or health visitor. Theoretically based, focused interventions are more effective than non-theoretically based, unfocused programmes. Targeting specific groups is also more effective than community wide interventions. There are identified harms (Table 5.4). Scheduled (up to 4 hourly) breast feeding may increase breast problems and lead to discontinuation of breast feeding by 4-6 weeks after delivery. Reviewers recommend that scheduled breast feeding should be stopped in favour of demand feeding5. The distribution of commercial hospital discharge packs containing baby feed formula or advice may reduce the number of women who continue to breast feed for the first 16 weeks and should therefore be stopped6. There is generally insufficient evidence on interventions to improve post weaning diets, pre-school diets, nursery and day care meals, children’s food choice. There is also a lack of long-term follow-up studies of dietary interventions and few community based studies or comparative studies. In addition most of the evidence comes from the USA which can limit its relevance in this country.
72
Drug Use School health interventions improve knowledge of the harmful effects of drugs, including smoking and alcohol3 (Table 5.7). These effects may last up to one year. Increases in knowledge are more easily achieved than are changes in behaviour, skills or attitudes. Interventions most likely to change behaviour involve skills training, target specific groups, and include multi-professional working eg. teachers, nurses and parents. There is weak and sometimes conflicting evidence that Public Health interventions prevent or reduce drug use and drug related harm (Table 5.6). Some studies show reductions in alcohol use among school children that may last for 2 years. However other studies found that a school-based intervention increased alcohol use among boys3,7 (Table 5.6). There is some disagreement between reviewers in comparing the short-term impact of didactic versus interactive teaching. Thomas et al suggest interactive teaching is more effective, whilst White et al suggest that didactic teaching is equally effective4,8 (Table 5.6). Involving parents and peers in delivering the interventions may be beneficial. Interventions targeting specific groups may have a greater impact eg. smokers, drug and alcohol users, single sex groups. In the face of this evidence, many reviewers argue that Public Health interventions have little impact on children’s smoking, alcohol and drug use. There is insufficient data in the field of drugs prevention and more rigorously designed studies are required. Aggregating the results from studies is difficult due to the diversity of the programmes and the outcome measures used. Further 70% of studies are from the USA and may not translate to the UK. This is important given the UK emphasis on harm reduction rather than abstinence. Preventive Service Use and Immunisation There is weak evidence that health visiting increases the uptake of immunisation and preventive services, especially among socially deprived families (Table 5.8). However, many studies lack a strong theoretical framework and have small sample sizes. Screening There is weak evidence that health visitors and other nurses can increase the uptake of child screening (Table 5.9). The health visitor hearing distraction test is effective in detecting hearing difficulties only if used in conjunction with other more sophisticated tests. The test has poor sensitivity and specificity and results in a low yield compared with other tests carried out by audiologists. Health visitors may be able to identify other conditions such as glue ear. Child growth monitoring may improve a mother’s nutritional knowledge. However, there is no evidence that growth monitoring improves a child’s nutritional status. Health visitors are relatively ineffective at testing for common vision defects compared with orthoptists (Table 5.9). Screening for common eye defects may lead to potentially harmful interventions and should be stopped9. There is also insufficient evidence to support screening for speech problems as the effects on morbidity are unknown. Parents are as effective in detecting speech problems as health visitors. However, health visitors should be trained in assessing children identified by parents as having speech problems. Mental Health There is strong evidence that school based programmes improve the coping techniques and reduce psychological problems among school children10 (Table 5.10). Programmes targeted at children with psychological problems can be more focused and are more effective than general prevention
73
programmes. Most schools programmes are led by mental health specialists. The evidence for school programmes in reducing or preventing suicide or suicidal thoughts is weaker and interventions may even lead to an increase in suicidal thoughts among school boys11 (Table 5.10). There is some disagreement on this question as Lister-Sharp suggests that schools programmes may prevent suicide3. There is weak evidence that school programmes improve self-esteem, anger, and anxiety problems (Table 5.10). There is also weak evidence that health visiting can improve parenting skills and the home environment, although there is insufficient evidence that it improves the mothers’ social support networks. Psycho-social support can increase mother-child bonding. Health visiting can also improve the intellectual development of failure to thrive children and children of low income families12. Hayward suggests that health visitors can successfully target and affect the mental health of low income families13 but Ciliska et al disagrees14. Health visiting can improve behaviour in babies, particularly temper, sleep and feeding problems. Breast feeding also helps sleep problems. Effective interventions target specific groups eg. low income families, are theory based and involve multi-agency working. There is insufficient evidence for the following interventions: promotion of breast feeding to improve mother child interactions; school based programmes to control violence among children. Evaluation of interventions is problematic due to programme diversity, and lack of long-term follow up. Further as most studies are from the USA their findings may not be applicable to the UK. There are many other nursing programmes which have not been evaluated. Accidents There is strong evidence that community based education programmes will reduce injury if accompanied by environmental measures eg. legislation, traffic calming, safety devices15 (Table 5.11). The evidence that home visits prevent accidents is equivocal12,16 (Table 5.11). Schools programmes may help to improve knowledge and attitudes, particularly if this involves skills training eg. road crossing. Endorsement by an outside expert is beneficial. Involving parents will also help reduce the likelihood of burns, poisoning, falls and drowning. Towner et al advocate a multifaceted approach in reducing accidents eg. nurses working with teachers, parents, together with environmental and legislative measures. There is insufficient evidence that home visiting reduces accidents and insufficient evidence that community education methods work without environmental measures. Serious accidents are relatively rare, and studies are often too small to detect any effect. Child protection There is strong evidence that education programmes increase knowledge and self protection skills in children17 (Table 5.12). School and home based programmes have a weak effect in increasing children’s knowledge and skills in dealing with sexual abuse (Table 5.12). It has been claimed that home visiting may reduce other forms of abuse and child neglect18. However this is disputed by recent reviews which argue that there is insufficient evidence that home visiting or school based programmes (including those directed at low income families) prevent or reduce child physical abuse or neglect3,12. MacMillan et al argue that there is insufficient evidence that community programs reduce sexual abuse19. Well focused programmes seem to have a greater impact but few interventions are theory based. Older school children seem to respond better to programmes than young children. Very few programmes involve parents. Reported sample sizes are often inadequate as large samples are required to detect the effect of interventions on relatively rare events eg. serious injury.
74
Recommendations Multi-agency working is most effective in changing knowledge, attitudes and risk behaviour. Thus Public Health nurses should be prepared to work with other agencies in bringing about these changes. Examples include: schools; community centres; day care facilities; social work; other health experts; parents and child peers. Multi-agency working is also needed for the design, planning and implementation of interventions. Health education programmes should be linked with other environmental programmes to achieve maximum impact eg. changes in legislation, national safety programmes, mass media programmes, changing school meals, distributing condoms. Interactive skills based education programmes are more effective than didactic class room approaches eg. refusal skills, distinguishing normal from abnormal behaviour. Theory based and well focused programmes with clear aims and objectives are more effective than non-theory based general health programmes and are therefore recommended. Interventions focused on high risk groups are more effective than community-wide programmes. This includes interventions with parents and low income families. Children from deprived communities should be targeted by accident prevention programmes. Long-term interventions are recommended over short-term interventions. Long term interventions usually cost more but have greater beneficial effects. Risk reduction programmes should be advocated in addition to abstinence based programmes. Scheduled breast feeding for healthy babies should stop. Distributing hospital discharge packs containing baby feed should also be stopped. Population based screening for vision, hearing and speech defects should stop. There is the need for qualitative research in helping to design interventions and give a better understanding why certain programmes work while others fail. Very few studies appear to be carried out by nurses, or nursing departments. Many interventions appear to be appropriate for nursing, yet few specifically highlight a nursing role. Thus more nurse led and nurse practice research is required, including more detailed literature reviews.
75
References 1. The Scottish Office Department of Health. Working together for a Healthier Scotland. A Consultation Document. The Stationery Office, Edinburgh, 1998. 2. Dickson R, Fullerton D, Eastwood A, Sheldon T, Sharp F. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997;3(1):1-12. 3. Lister-Sharp D. Health promoting schools and health promotion in schools: two systematic reviews. Health Technology Assessment Programme 1999. 4. White D, Pitts M. Health promotion with young people for the prevention of substance misuse. Health Promotion Effectiveness Reviews 1997. 5. Renfrew MJ, Lang S, Maryin L, Woolridge MW. Feeding schedules in hospitals for newborn infants. (Cochrane Review) In: The Cochrane Library, Issue 3, 2000. Oxford: Update Software. 6. Donnelly A, Snowden HM, Renfrew MJ, Woolridge MW. Commercial hospital discharge packs for breastfeeding women. (Cochrane Review) In: The Cochrane Library, Issue 3, 2000. Oxford: Update Software. 7.
Foxcroft DR, Lister Sharp D, Lowe G. Alcohol misuse prevention for young people: A systematic review reveals methodological concerns and lack of reliable evidence of effectiveness. Addiction 1997;92(5):531-537.
8. Thomas H, Siracusa L, Ross G, Beath L, Hanna L, Michaud M, et al. Effectiveness of school-based interventions in reducing adolescent risk behaviour: a systematic review of reviews. Public Health Research, Education and Development Program 1999. 9. Snowdon SK, Stewart-Brown SL. Preschool vision screening. Health Technology Assessment Programme 1997;1(8):1-85. 10. Durlak JA, Wells AM. Primary prevention mental health programs for children and adolescents: A meta-analytic review. American Journal of Community Psychology 1997;25:115-152. 11. Ploeg J, Ciliska D, Brunton G, MacDonnell J, O'Brien M. The effectiveness of school-based curriculum suicide prevention programs for adolescents. Public Health Research, Education and Development Program 1999. 12. Elkan R, Kendrick D, Hewitt M, Robinson JJA, Tolley K, Blair M, et al. The effectiveness of domiciliary visiting: a systematic review of international studies and a selective review of the British Literature. Health Technology Assessment Programme 2000. 13. Hayward S, Ciliska D, Mitchell A, Thomas H, Underwood J, Dobbins M. Effectiveness of Public Health Nursing Interventions in Parent-Child Health: a systematic overview of literature reviews. Public Health Research, Education and Development Program 1996. 14. Ciliska D, Mastrilli P, Ploeg J, Hayward S, Brunton G, Underwood J. The effectiveness of home visiting as the delivery strategy for Public Health nursing interventions to clients in pre-natal and post-natal period: a systematic review. Public Health Research, Education and Development Program 1999. 15. Towner E, Dowswell T, Simpson G, Jarvis S. Health promotion in childhood and young adolescence for the prevention of unintentional injuries. Health Education Authority 1996. 16. Roberts I, Kramer MS, Suissa S. Does home visiting prevent childhood injury? A systematic review of randomised controlled trials. BMJ 1996;312(7022):29-33. 17. Rispens J, Aleman A, Goudena PP. Prevention of child sexual abuse victimisation: A meta-analysis of school programs. Child Abuse and Neglect 1997;21(10):975-987. 18. Guterman NB. Enrollment strategies in early home visitation to prevent physical child abuse and neglect and the 'Universal versus targeted' debate: A meta-analysis of population-based and screening-based programs. Child Abuse and Neglect 1999;23(9):863-890. 19. MacMillan HL, MacMillan JH, Offord DR, Griffith L, et al. Primary prevention of child sexual abuse: A critical review: II. Journal of Child Psychology and Psychiatry and Allied Disciplines 1994;35(5):857-876.
1999 1999 1997 1997 1996 1996
Lister-Sharp1 Di Censo2 Franklin3 Dickson4 Hayward5 Ciliska6
Health Technology Assessment Public Health Research, Education & Development Program J Marriage and the Family NHS Centre for Research and Development Public Health Research, Education & Development Program Canadian Journal of Public Health
Source
15 12 15 15 6 4
Number of primary studies
Weak effect in reducing pregnancy, especially with experimental control studies (Franklin). Those with family-planning clinics (Lister-Sharp) or using peers (Di Censo) may be more effective. Community based programmes and those emphasising contraceptive use rather than sexual abstinence may also be more effective (Franklin). There is also some evidence that school based interventions are effective, especially if delivered in conjunction with the distribution of contraceptives (Dickson). Multi-agency working is also effective (Hayward). Controlled trials have weaker effects compared with non-controlled (Franklin). Home visiting may reduce secondary pregnancy (Ciliska) Insufficient evidence on what theoretical aspects work best ie. theoretical basis not always stated (Lister-Sharp) Generally insufficient evidence relating to central question; pregnancy prevention programmes for young people. This is due to the lack of good studies or weak study design (Lister-Sharp, Di Censo, Dickson).
1 1 2 1 2 2
Quality score 1 good, 2 acceptable
SUMMARY There is generally weak evidence of the effectiveness of interventions in preventing pregnancy among young people. Those that do tend to have an educational and distribution of contraceptives. Community based interventions are effective in targeting hard to reach (and possibly) high risk groups. Multi-agency approaches seem worthwhile. In general, there is insufficient evidence relating to this question and studies may lack the power to detect statistically significant effects. There is no evidence of harmful effects.
5 5
2
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Year
First Author
MAIN AIMS Preventing pregnancy
INTERVENTION(S) STUDIED School and Community Based Interventions. Contraceptive and sex advice, issuing contraceptives, providing family planning clinics and skills based training (sometimes with nurses) (Lister-Sharp, 1999), sometimes with other professions including teachers or outside experts. Home visits (Ciliska). Abstinence programmes. Community based programmes often targeted at hard to reach groups.
Table 5.1 Child and Adolescent Health: Sexual health: Prevention of teenage pregnancy 76
1999 1999 1999 1997 1997 1997
Lister-Sharp1 Yamada2 Thomas7 Kim8 Franklin3 Dickson4
Health Technology Assessment Public Health Research Education & Development Program Public Health Research Education & Development Program J. of Adolescent Health J. of Marriage and the Family NHS Centre for Research and Development
Source
5
2 3
2 2 2
1 1 1 2 2 1
Quality score 1 good, 2 acceptable
49 (from 4 reviews) 24 151 (from 6 reviews) 40 16 15
Number of primary studies
Weak effect in delaying sexual activity, particularly in interventions that include information and life-skills training (Lister-Sharp). Weak effect in reducing the frequency of sex (Lister-Sharp), but negligible in the long-term (18 months) (Yamada, Thomas). Weak effect in increasing contraceptive use (Lister-Sharp) especially condom use (Yamada, Thomas. Kim). Community based interventions are particularly effective, perhaps due to lower distribution of contraceptives in school based programmes (Franklin). Controlled trials have weaker effects compared with non-controlled trials. Clinic-based or linked programmes are more effective, especially if access to family planning clinics is made easier, and may have an effect up to 24 months (Franklin, Dickson). Abstinence programmes are not very effective (Franklin). Mixed group interventions are better than single sex groups (Franklin). Targeting high risk groups or those yet to engage in risk behaviour may be more effective (Dickson). Weak effect in increasing sex refusal skills (Lister-Sharp). No effect on abstinence from sexual activity (Lister-Sharp, Thomas). Although a (2) weak effect in abstinence programmes was found by (Kim, Dickson). (5) insufficient evidence was also reported by Yamada. Insufficient evidence of the effect of interventions on STD infections (Yamada), and difficulty including enough high quality studies in a meta-analysis (Franklin). School-based interventions providing contraceptives have not been fully evaluated (Dickson).
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Year
First Author
MAIN AIMS Reduce sexual risk behaviour , including increasing contraceptive use or delaying sexual intercourse. Preventing HIV and other STD infections.
INTERVENTION(S) STUDIED Similar to those preventing pregnancy. Schools based, using curricular or non-curricular initiatives (Lister -Sharp). Parents may be involved. School and community programmes. The majority of schools programmes used information with another component eg., skills training. Theoretical base was rarely reported (Lister-Sharp), however (Kim) included theoretically based HIV prevention interventions. Abstinence programmes and one-to-one counselling were also included (Dickson).
Table 5.2 Child and Adolescent Health: Sexual Health; Risk Behaviour
77
SUMMARY There is weak evidence of the effectiveness of programmes in reducing sexual risk behaviour. The most consistent effects appear in reducing risks rather than preventing risks eg. reducing the frequency of sex or increasing condom use rather than abstinence. Authors frequently cite the lack of good quality research in this area, particularly RCTs. Short-term, rather than long-term effects, are noted more frequently. Working with high risk groups seems to improve impact. Interactive, skills based programmes are better than didactic programmes. Timing is important ie. before engagement in risk behaviour. Theory based programmes are better than non-theory based. Focused programmes are better than unfocused programmes. Public Health practitioners could play a multifaceted role eg. facilitating groups, acting as consultants to teachers, helping to develop rigorous evaluation programmes. Often non-random studies show greater effects (Kim) and RCTs with long-term follow-ups eg. 5-10 years are required. No studies have tackled the underlying social causes of risk behaviour (Dickson).
Table 5.2 Child and Adolescent Health: Sexual Health: Risk Behaviour (continued). 78
1999 1997 1997
Lister-Sharp1 Kim8 Dickson4
Health Technology Assessment J. of Adolescent Health NHS Centre for Research and Development
Source
49 (from 4 reviews) 34 15
Number of primary studies
Weak effects on refusal skills (Lister-Sharp). Abstinence based programmes are no better than other programmes for improving refusal skills (Dickson). Programmes which combine the issuing of contraceptives with skills training are more effective in improving negotiation skills than abstinence based skills programmes alone (Dickson). Short-term effects on knowledge gains and attitude change in all studies reviewed (Lister-Sharp). Significant improvement on knowledge from 30/34 studies, however this was seen more in non-randomised studies. Interventions with a theoretical base had better outcomes (Kim)
1 2 1
Quality score 1 good, 2 acceptable
SUMMARY Programmes that combine the issuing of contraceptives with advice are effective in increasing knowledge on sexual risks and improving behaviour skills. Skills based programmes are better than didactic teaching and those based on psychological theories seem to produce better results. However, these gains may be short-term. This is partially due to the lack of long-term studies.
2
2
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Year
First Author
MAIN AIMS Increase knowledge of sexual risks, contraceptives and skills.
INTERVENTION(S) STUDIED Similar to those preventing pregnancy. School based, using curricular or non-curricular initiatives (Lister -Sharp). Parents may be involved. School and community programmes. The majority of Schools programmes used information with another component eg. skills training. Theoretical base was rarely reported (Lister-Sharp), however (Kim) included theoretically based HIV prevention interventions. Abstinence programmes and one-to-one counselling and didactic teaching were also included (Dickson).
Table 5.3 Child and Adolescent Health: Sexual Health: Knowledge, Attitudes and Skills
79
2000 2000 2000 2000 1999 1999 1998 1998 1998 1997 1997 1996 1994
Elkan9 Donnelly10 Sikorski11 Renfrew (a)12 Ciliska13 Lister-Sharp1 McArthur14 Tedstone (a)15 Tedstone16 Tedstone16 Reid17 Hayward5 Perez-Escamilla18
Health Technology Assessment Cochrane Cochrane Cochrane Public Health Research, Education & Development Program Health Technology Assessment Issues in Comprehensive Paediatric Nursing Health Technology Assessment Health Technology Assessment Health Technology Assessment Health Education Authority Public Health Research, Education & Development Program American Journal of Public Health
Source
2 2
2
2 1 1 1 1 1 2 1 1 2 2 2 2
Quality score 1 good, 2 acceptable
23 9 13 3 60 154 (from 8 reviews) 12 13 16 not stated undetermined not stated 18
Number of primary studies
Some evidence that hospital based interventions increase breast feeding up to 2 months (Perez-Escamilla, Sikorski). Antenatal class interventions may also increase the duration of breast feeding (Hayward). Long-term interventions (pre and postnatal together), with nurse or peer, and aimed at specific groups (ethnic/social) increase breast feeding (Tedstone). Health visiting may also encourage breast feeding up to 3 months (Elkan) On demand breast feeding is associated with fewer breast complications and continuation of breast feeding after 4-6 weeks (Renfrew a). Weak evidence of health visiting improving children’s diet and no studies examine long-term follow-up (Elkan). Increase in fruit, vegetable and fibre intake among pre-school children through home visit programmes and school based programmes (Ciliska, Lister-Sharp, McArthur). Reductions in salt and fat intake, especially after a change in school meal policy (Lister-Sharp). Multi-component long-term interventions were more successful eg. skills directed at behavioural change (Ciliska). The use of para-professionals, trained by nutritionists seems appropriate (Ciliska). Theoretically based programmes are more effective (Ciliska).
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Year
First Author
MAIN AIMS Promote healthy eating and physical development. Please note this includes breast feeding
INTERVENTION(S) STUDIED Hospital and community based (ante/postnatal) breast feeding interventions (Perez-Escamilla, Hayward, Tedstone (a)). Home visits by Health Visitors (Elkan). Community based interventions (4 yrs old +) including those involving parents, working in recipients’ homes or in schools. Some interventions included cooking lessons and peer educators (Ciliska). School based programmes, including those which aim to change school meals, school curriculum and involve parents (Lister-Sharp). Interventions aimed at weaning infants (Tedstone)
Table 5.4 Child and Adolescent Health: Diet and Exercise; Eating Behaviour and Physical Development 80
Scheduled breast feeding in hospital may increase breast problems and increase the likelihood of discontinuing breast feeding by 4-6 weeks (Renfrew (a)).
Commercial hospital discharge packs containing baby feeding formula or advice may marginally reduce the number of mothers who continue to breast feed for 16 weeks (Donnelly).
Insufficient evidence of the effects of post-weaning interventions on children’s diet (Tedstone a). Insufficient evidence of dietary changes resulting from pre-school programmes, mainly because dietary intake is not measured (Tedstone). Insufficient evidence of nutritional content of nursery and day care meals and effects of interventions on child food purchase preferences (Reid)
4
4
5
SUMMARY There is weak evidence of effectiveness of Public Health interventions to improve children’s dietary intake or physical activity. Changing school meals and encouraging exercise at school seem to have positive effects on diet. Involving parents also helps, especially where pre-school children are involved. Hospital and community based breast feeding programmes increase breast feeding and this is not affected by formula supplements (Perez-Escamill, Hayward). There is a lack of research on optimal weaning times and healthy eating patterns of weaned children (Tedstone a). Theoretical based approaches work better as do those targeting specific social groups (Tedstone a). Hospital breast feeding schedules may lead to increased breast problems and subsequently reduced breast feeding compared with demand breast feeding. Scheduled feeding may only be necessary for sick babies (Renfrew a). However other more relaxed hospital breast feeding support can increase the duration of breast feeding for up to 2 months (Sikorski). Health visitor support may increase the duration of breast feeding up to 3 months (Elkan). Commercial baby feeding formula packs should not be given upon discharge from hospital (Donnelly). There is generally insufficient evidence of the time effect, because there are few long-term studies. There is much more American research compared with UK, especially at pre-school level (Tedstone). There are no available data on the effects of Public Health programmes on the social determinants of food choice, including children’s food choice (Reid). There are also few good community based studies and comparative intervention studies (Hayward). Needs led assessments and interventions are also required for breast feeding (Tedstone a).
No significant reductions in BP, body fat, cholesterol and increases in exercise resulting from school based fitness programmes (Lister-Sharp). Hospital based formula supplement programmes have no effect on subsequent breast feeding (Perez-Escamilla) No effect of health visiting on children’s weight or height (Elkan) No effect of school programmes on sugar intake (Lister-Sharp).
3
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Table 5.4 Child and Adolescent Health: Diet and Exercise: Eating Behaviour and Physical Development (continued).
81
1999 1999 1998
Ciliska19 Lister-Sharp1 Tedstone16
Public Health Research Education & Development Program Health Technology Assessment Health Technology Assessment
Source
56 154 (from 8 reviews) 16
Number of primary studies
53/56 school studies reported gains in food knowledge (exercise studies included) (Lister-Sharp) Weak evidence of school based and pre-school programmes improving food knowledge, but maybe improved by introducing food education into curricula and involving parents (Ciliska, Tedstone).
1 1 1
Quality score 1 good, 2 acceptable
SUMMARY Interventions with a theoretical base, that are long-term, involve parents and provide choice are most effective (Ciliska, Lister-Sharp, Tedstone). There were stronger and more consistent effects on knowledge compared with eating behaviour, particularly in Lister-Sharp’s review. The major difference in knowledge gains is between pre-school and school children (better understanding among school children) and is thought to occur as a result of differences in understanding nutritional messages (Tedstone). This suggests that different approaches should be taken with different age groups. Few programmes were needs based. Qualitative research required to help design new programmes.
1 2
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Year
First Author
MAIN AIMS Promote knowledge of healthy eating and exercise. Please note, this includes breast feeding
INTERVENTION(S) STUDIED Home visits by Health Visitors (Elkan). Community based interventions (4yrs old +) including those involving parents, working in recipients’ homes or in schools. Some interventions included cooking lessons and peer educators (Ciliska). School based programmes, including those that changed school meals, curriculum and involve parents (Lister-Sharp). Post-weaning infants (Tedstone)
Table 5.5 Child and Adolescent Health: Diet and Exercise; Knowledge 82
1999 1999 1999 1999 1997 1997 1997 1996 1993 1990
Lister-Sharp1 Sowden20 Stead21 Thomas7 White22 Foxcroft23 Tobler24 US Preventive Services Task Force25 Bruvold26 Bruvold27 Health Technology Assessment Cochrane Cochrane Public Health Research Education & Development Program Health Education Authority Addiction J of Primary Prevention US Preventive Services Task Force American Journal of Public Health J Drug Education
Source
5 4 5
3
2
1 1 1 1 1 2 2 2 2 2
Quality score 1 good, 2 acceptable
146 (out of 82 reviews) 13 5 18 62 33 90 undetermined 94 8
Number of primary studies
Short-term reductions in alcohol consumption resulting from schools programmes, particularly peer led and those using skills training (Thomas). It should be noted that White disagrees with the emphasis on skills training and argues that didactic teaching has just as much short-term impact on behaviour (White). Involving parents might also help (Lister-Sharp). Weak evidence of an impact of schools programmes in reducing alcohol use in the long-term ie. up to 2 years (Lister-Sharp). Same pattern emerges for smoking in the short-term, except in a small number of interventions where peer and parent involvement improved outcomes. Some community wide programmes report success up to 5 years, particularly intensive interventions (Thomas, White). Interactive programmes are more successful than non-interactive and those involving social skills (Tobler, Bruvold 1993). Like alcohol only a few drugs studies investigated long-term impact which, at best is 2 years. (2) Again partially effective in reducing cannabis use, but mainly in the short-term only. (2) or (3) for programmes dealing with drugs other than cannabis (Lister-Sharp). Most studies are conducted in the USA. Few programmes, apart from those concentrating on risk reduction, target specific groups ie. different ethic groups, boys or girls (White). A few studies provide weak evidence of community based programmes working better than school based programmes in reducing or preventing smoking. Many studies show no impact on smoking, alcohol or drug use. Aggregating the results of community studies is difficult due to programme and outcome measure diversity (White). Little evidence of reductions in smoking as a result of targeting retailers with information (Stead), however enforcement warnings have a small effect. No effect of many programmes on smoking and drugs behaviour in the short-term, ie. up to 1 year. There is insufficient evidence to show effectiveness of clinician counselling to prevent initiation of smoking (USPSTF) Some evidence of increasing alcohol consumption in the short-term (Foxcroft, Lister-Sharp) Generally insufficient data and more rigorously designed studies required (White, Foxcroft)
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Year
First Author
MAIN AIMS Prevent or reduce drug use, including smoking and alcohol use.
INTERVENTION(S) STUDIED School based interventions, including changing curriculum, some also had a community component. Schools programmes involve information giving, skills resistance and building self-esteem. Delivered by teachers, external experts or peers, rarely parents (Lister-Sharp). Information based schemes are common, some include skills training, theory based programmes are uncommon. The majority target tobacco, alcohol and cannabis (White). Community interventions include age restrictions on purchasing tobacco and targeting specific groups eg. using community centres (Sowden) giving advice to retailers (Stead).
Table 5.6 Child and Adolescent Health: Drug Use: Behaviour
83
SUMMARY Schools programmes are common and success is often linked to drug type eg. greater effect for smoking and cannabis use, less for other drugs and alcohol (Lister-Sharp). Many programmes improve knowledge, few change behaviour (especially in the long term). Parental involvement in school programmes is rare. A small, but significant number of programmes increased drug use, particularly alcohol use (Lister-Sharp). Programmes focusing on skills rather than didactic teaching are more effective in reducing risk behaviour (Lister-Sharp), although the evidence is not clear (White). Peer involvement is important. Theory-based programmes are more effective. More methodologically sound evaluations required and programmes should be targeted at hard to reach groups (White). A mixed approach combining knowledge and skills training is probably effective and targeting specific drugs is preferred to targeting whole populations (White). There is a lack of long-term studies.
Table 5.6 Child and Adolescent Health: Drug use; Behaviour (continued). 84
1999 1999 1997 1997 1997 1993 1990
Lister-Sharp1 Thomas7 White22 Foxcroft23 Tobler24 Bruvold26 Bruvold27
Health Technology Assessment Public Health Research Education & Development Program Health Education Authority Addiction J of Primary Prevention American Journal of Public Health J Drug Education
Source
There is insufficient evidence to assess the effectiveness of educational programmes for all drugs and more methodologically sound studies are required (White)
5
SUMMARY Greater effect sizes are seen in knowledge compared with attitudes or behaviour. A mixed approach involving knowledge and skills training is probably more effective. More intensive programmes are also more likely to be effective. Approximately 70% of studies are USA, thus more UK studies required. Longer follow-up is required ie. >3 years (Bruvold, Foxcroft, White). Targeting specific groups, especially community based research is required (White).
Drugs and alcohol interactive programmes have a greater impact in changing attitudes and refusal skills compared with didactic programmes, which have a better effect on knowledge. The change in attitude is not as great as the as change in knowledge (Bruvold, Lister-Sharp). Behaviour is also influenced more by skills based interventions (Bruvold, Tobler). Attitude change is related to behaviour change whilst knowledge change is not (Bruvold, Thomas)
2
146 (out of 82 reviews) 18 62 33 90 94 8
Number of primary studies
Schools based interventions have a clear and substantial effect on knowledge (Bruvold, Lister-Sharp). Changes may only last up to one year (White). Theoretically based programmes are more effective.
1 1 1 2 2 2 2
Quality score 1 good, 2 acceptable
1
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Year
First Author
MAIN AIMS Improve knowledge of harms associated with drug use and change attitudes
INTERVENTION(S) STUDIED School based interventions, including changing curriculum, some also had a community component. Schools programmes involve information giving, skills resistance and building self-esteem. Delivered by teachers, external experts or peers, rarely parents (Lister-Sharp). Information based programmes are common, some include skills training, theory based programmes are uncommon. The majority target tobacco, alcohol and cannabis (White). Community interventions include age restrictions on purchasing tobacco to targeting specific groups eg. using community centres (Sowden) giving advice to retailers (Stead).
Table 5.7 Child and Adolescent Health: Drug Use; Knowledge and Attitudes
85
2000 2000 1999 1996
Elkan9 Kendrick28 Mann29 Ciliska6
Health Technology Assessment Journal of Public Health Medicine Public Health Research Education & Development Program Canadian Journal of Public Health
Source
14 11 3 9
Number of primary studies
Weak evidence of health visiting increasing the uptake of child immunisation (Elkan, Kendrick, Mann) Insufficient evidence of health visiting increasing preventive health services (Elkan, Kendrick). However, Mann suggests that home visiting has a weak beneficial effect in increasing preventive health care attendance, especially among socially deprived groups.
2 1 1 2
Quality score 1 good, 2 acceptable
SUMMARY There is weak or insufficient evidence of health visiting interventions increasing the uptake of immunisation and preventive health services including visits to deprived families. New ways of tackling inequalities in uptake should be addressed (Elkan). Many studies lack a strong theoretical framework. Strong evidence is lacking due to large numbers required for such studies (Ciliska). The definition of preventive service varied and may only include a single ‘check up visit’.
2 5
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Year
First Author
MAIN AIMS Increase the uptake of immunisation and preventive services.
INTERVENTION(S) STUDIED Domiciliary visiting by nurses (Elkan, Ciliska), including deprived families. Nurse visits to child day care facilities (Mann)
Table 5.8 Child and Adolescent Health: Preventive Service Use and Immunisation 86
1999 1998 1997 1997
Panpanich30 Law31 Davis32 Snowdon33
Cochrane Health Technology Assessment Health Technology Assessment Health Technology Assessment
Source
2 38 undetermined 85
Number of primary studies
Some evidence that monitoring children’s growth improves mothers’ nutritional knowledge. No evidence that growth monitoring improves children’s nutritional status. Some evidence that the health visitor distraction test for hearing is effective only in cases first identified through the use of other screening tests. Enlisting the help of health visitors may increase the uptake of vision screening, however, vision screening may lead to harmful interventions (Snowdon). Vision screening for common eye defects may lead to interventions which do more harm than good. Present screening may therefore be unethical (Snowdon) Health visitors are relatively ineffective in testing for vision defects compared with orthoptists. The health visitor hearing distraction test has poor sensitivity and specificity and low yield compared with other forms of testing. Universal neonatal screening (UNS) also has a lower unit cost. (UNS includes electronic and reaction tests carried out by audiologists). Insufficient evidence to merit the introduction of universal speech screening and insufficient evidence of the effectiveness of health visitors versus any other professions in detecting speech problems (Law).
1 2 2 1
Quality score 1 good, 2 acceptable
SUMMARY There is surprisingly little evidence of effectiveness of health visiting in detecting developmental delay or speech defects by screening. Health visitors should rely on parents identification of speech problems but more training is required in assessing those children identified as having speech problems (Law). Good controlled trials are required and in some instances better screening instruments are required eg. speech (Law). Universal hearing screening is recommended, but only by audiologists, not health visitors. Health visitors could detect other conditions such as glue ear (Davis). Present pre-school vision screening should be discontinued (Snowdon).
5
2 3 2/3 2 4 4 4
FINDINGS Strength of evidence: 1 strong, 2 weak, 3 no effect, 4 harmful, 5 insufficient evidence
Year
First Author
MAIN AIMS To prevent death or morbidity by malnutrition To prevent morbidity by screening for speech, hearing, and vision defects and mental health problems. To increase the knowledge and uptake of screening services.
INTERVENTION(S) STUDIED Growth, speech, hearing, vision and mental health monitoring in children, mainly by health visitors or nurses.
Table 5.9 Child and Adolescent Health: Screening
87
2000 2000 2000 1999 1999 1999 1999 1998 1997 1997 1996 1996 1995
Renfrew (a)34 Renfrew (b)35 Elkan9 Ciliska(a)19 Lister-Sharp1 Thomas7 Ploeg36 Haney37 Tilford38 Durlak39 Hayward5 Ciliska(b)6 van Ijzendoorn40
Cochrane Cochrane Health Technology Assessment Public Health Research Education & Development Program Health Technology Assessment Public Health Research Education & Development Program Public Health Research Education & Development Program J of Clinical Child Psychology Health Education Authority American J. of Community Psychology Public Health Research Education & Development Program Canadian Journal of Public Health J Child Psychol, Psychiatry.
Source
3
1 2
1 1 2 2 1 1 1 2 2 2 2 2 2
Quality score 1 good, 2 acceptable
88 12 42 99 41 116 25 177 3 reviews 7 12
4
Number of primary studies
Schools based programmes strongly improve coping techniques and reduce psychological problems, even among normal subjects (Durlak) Health visiting can improve parenting skills and home environment (Ciliska (a), Elkan) but (5) insufficient evidence of health visiting improving social support to mothers (Elkan). Lower class parents seem less likely to respond (Hayward) although the opposite effect is found by (Ciliska (a)). Psycho-social support to mothers can increase bonding between mother and child (van Ijzendoorn). Health visiting can improve intellectual development, particularly in failure to thrive children or low income groups. Short-term impact only ie.
