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The effectiveness of home visiting as a delivery strategy for public health nursing interventions: a systematic overview |
Ciliska D, Hayward S, Thomas H, Mitchell A, Dobbins M, Underwood J, Rafael A, Martin E |
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Authors' objectives To examine the effectiveness of public health nursing (PHN) interventions offered through the strategy of home visiting.
Searching MEDLINE and CINAHL were searched from 1979 to 1993 using the keywords 'PHN' or 'CHN' and 'effectiveness', 'comparative', 'control' or 'evaluative' 'study'; the term 'home visiting' was applied for more specific searching back to 1989. Relevant authors were searched on-line from 1986 to 1993, and the following journals were handsearched from 1990 to 1993: Canadian Journal of Public Health, Canadian Journal of Nursing Research, American Journal of Public Health, Nursing Research, Image, School Health, Journal of Advanced Nursing, Journal of Community Health Nursing, Public Health Nursing, and American Journal of Health Promotion.
Additional material was obtained by examining published bibliographies, abstracts of workshops and conference papers, directories of nurse researchers, library holdings, content lists of 107 public health-related journals (September 1992 to October 1993) and relevant references (back to 1980), and by contacting key informants.
Study selection Study designs of evaluations included in the reviewQuasi-randomised and randomised controlled trials (RCTs), and 2 cohort studies. Studies had to have fulfilled the following criteria: (1) evaluated an intervention or a programme; (2)described an intervention within the scope of PHN practice in Canada; (3) provided information on client-focused outcomes and cost; (4) described a prospective study; and (5) had a control or comparison group.
Specific interventions included in the reviewAny evaluative study of an intervention within the scope of PHN carried out in the home. Specific interventions found in the identified studies included: prenatal interventions (social support with health and nutrition information); postnatal interventions (parent-training, counselling in postnatal depression, health and development information, family support, helping parents to manage self-identified problems, and child development interventions); pre-school interventions; and interventions with the elderly.
Participants included in the reviewClients of any age group who received an intervention in the home by a public health nurse were included.
Outcomes assessed in the reviewPhysical health and development, mental health and development, social health, health habits, knowledge and service utilisation, were assessed.
How were decisions on the relevance of primary studies made?A secondary reviewer assessed a subset (18%) of the studies and the level of agreement was checked.
Assessment of study quality There were 6 criteria against which all studies where tested, and rated as either 'pass', 'moderate' or 'fail': (1) method of allocation to the study groups; (2) level of agreement to participate in the study; (3) control for confounders; (4) method of data collection; (5) quantitative measure of effect; and (6) cost analysis and percentage of participant follow-up. Articles judged to be strong needed to have been allocated a 'pass' for at least 4 criteria and have had no 'fail'; to be classed 'moderate', at least 3 criteria allocated 'moderate' were required with no 'fail'; and a study was 'weak' if it contained at least 1 criterion designated 'fail'. A secondary reviewer assessed a subset (26%) of the included studies and the level of agreement was checked.
Data extraction A data extraction tool was developed and pretested. The data extracted were: years data collected; theoretical basis for intervention; sample size; number and size of control and experimental groups; intervention target (individual, family, group); population characteristics (rural, urban, socio-economic status, education, level of risk, ethnicity, marital status); intervention strategy (teaching, emotional support, counselling, case-management, social enhancement, physical care, other); intervention intensity, timing, duration of contact; level of compliance with intervention; follow-up period; types of analysis; outcomes; measurement units; and statistical significance.
Methods of synthesis How were the studies combined?A narrative synthesis of each of the strong and moderately strong studies was given.
How were differences between studies investigated?The authors do not state how differences between the studies were investigated.
Results of the review Seventy-seven articles were quality assessed, and of these, 14 articles (11 studies, 4,434 patients) of strong or moderate quality were included in the review. There were 3 RCTs (2,685 patients), 6 controlled clinical trials (1,597 patients) and 2 cohort studies (152 patients).
A summary of the narrative synthesis suggests the following: there were no negative effects of home visiting; there was positive effect of home visiting on physical health, mental health and development, social health, health habits, knowledge and service utilisation. Some articles suggest no effect or selective effects. No 2 studies have similar interventions and outcomes. Hence the difficulty in presenting coherent results.
Authors' conclusions There are no negative effects of home visiting, i.e. home visits have not been shown to do any harm. The studies demonstrate a positive impact of home visiting on physical health, mental health and development, social health, health habits, knowledge and service utilisation. The effects seem to be mediated by the intensity of the intervention and the pre-existing level of health and social status of the client.
CRD commentary It is unclear whether foreign language articles were included or not, or whether there was any attempt to locate unpublished studies.
It is unclear why the authors have linked cost analysis and percentage of participant follow-up as one of the 6 quality criteria, or whether this is a mistake and there were 7 quality criteria.
The narrative of the review is not well structured, but this probably reflects the broad topics included in the primary studies.
It is difficult to separate out the effects of home visiting in the primary studies because of the multi-pronged approach of most of the studies. In summarising the results, the authors reference studies to validate specific summary points. However, on three occasions these references refer the reader to papers that have not been analysed in the review.
Bibliographic details Ciliska D, Hayward S, Thomas H, Mitchell A, Dobbins M, Underwood J, Rafael A, Martin E. The effectiveness of home visiting as a delivery strategy for public health nursing interventions: a systematic overview. Hamilton, ON, Canada: McMaster University; Toronto, ON, Canada:. Working paper series; 94-7. 1994 Other publications of related interest Ciliska D, Hayward S, Thomas H, Mitchell A, Dobbins M, Underwood J. A systematic overview of the effectiveness of home visiting as a delivery strategy for public health nursing interventions. Can J Public Health 1996;87:193-8.
Indexing Status Subject indexing assigned by CRD MeSH Community Health Nursing; Health Care Facilities, Manpower, and Services; Home Nursing; Nursing Care; Public Health Nursing AccessionNumber 11995002485 Date bibliographic record published 31/07/1996 Date abstract record published 31/07/1996 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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