Benefit or burden: introducing paraprofessional support staff to health visiting teams: the case of Starting Well

With increased public-sector funding to expand and improve frontline services, pre-existing skill shortages within key professional workforces have become more acute. One response to this has been to encourage the development of skill-mix approaches which allow tasks previously undertaken by professional staff groupings to be assumed by new paraprofessional employees. Within the UK National Health Service, one group of professionals who are being challenged to change their way of working in this way are health visitors. Starting Well, one of Scotland's four health demonstration projects, which was established in 2000 to bring about a step-change in child health within deprived communities in Glasgow, operated as a pilot for such a skill-mix model of health visiting. The project was evaluated using a multimethod approach that encompassed the study of both processes and outcomes. The present paper reports on a process evaluation of the project's implementation that addressed the rationale underlying the development of Starting Well's skill-mix approach and the challenges which this model faced in practice. The perceptions of both managerial staff (n=18) and those working in practice (n=33) were gathered using semistructured interviews which sought to elicit and test Starting Well's theory of change in relation to the use of paraprofessional staff. Two sets of interviews were conducted with each group of staff between 2001 and 2003. Two main types of challenge were identified: deploying potentially vulnerable members of staff; and co-management of paraprofessionals by the health service and a voluntary-sector organisation. A potential challenge identified from the literature, i.e. that of implementing a new role within an existing team, proved to be less problematic within Starting Well. These issues are discussed in relation to current policy and practice debates.     

The potential of ecological theory for building an integrated framework to develop the public health contribution of health visiting

In line with recent UK and Scottish policy imperatives, there is increasing pressure for the health visiting service to assume an enhanced role in improving public health. Although health visiting has so far maintained its unique position as a primarily preventive service within the UK health service, its distinctive contribution now appears under threat. The continuing absence of a comprehensive and integrated conceptual basis for practice has a negative impact on the profession’s ability to respond to current challenges. Establishing an integrative framework to conceptualise health visiting practice would enable more sensitive, focused and appropriate research, education and evaluation in relation to practice. Work in this area could thus usefully contribute to the future development of the service at a difficult time. Our paper aims to make such a contribution. In support of our conceptual aims, we draw on a study of health visiting practice undertaken within a large conurbation in central Scotland. The study used a mixed method, collaborative approach involving 12 audio‐recorded and observed health visitor–client interactions, semi‐structured interviews with the 12 HVs and 12 clients, examination of related documentation and workshops with the HV participants. We critically consider prevalent models of health visiting practice and describe the more integrative conceptual approach provided by Bronfenbrenner’s ecological, ‘person‐in‐context’ framework. The paper subsequently explores relationships between this framework and understandings of need demonstrated by health visitors who participated in our study. Current policy emphasises the need to focus on public health and social inclusion in order to improve health. However, if this policy is to be translated into practice, we must develop a more adequate understanding of how practitioners work effectively with families and individuals in a sensitive and context‐specific manner. Bronfenbrenner’s framework appears to offer a promising means of building on the current strengths of the health visiting service to further develop a ‘person‐in‐context’ approach to health improvement that is mindful of and responsive to multiple, inter‐related influences on health. We therefore recommend further research to directly test the utility of this framework.     

Focusing upon children and men in situations of domestic violence: an analysis of the gendered nature of British health visiting

Despite considerable feminist critiques of British health visiting work which have pointed to its gendered nature, this issue has received very little attention within the professional literature. The emphasis has been upon the 'health' focus, often highlighting the needs of marginalized groups. The recent professional interest in women experiencing domestic violence draws upon a long-standing feminist concern which has established the extent and nature of domestic violence, and the difficulties facing women in seeking help about their situation. The present paper reports some findings from a study of British health visiting practice in relation to women experiencing domestic violence. Drawing upon interview data from 24 health visitors, this paper focuses specifically upon health visitors' accounts of their practice in relation to both children and men when they were aware women were experiencing domestic violence. Their concerns, which include child welfare and personal safety illustrate some of the complexities facing practitioners when faced with domestic violence situations. The analysis also highlights the gendered practices inherent within health visiting work.     

Structuring health needs assessments: the medicalisation of health visiting

This paper draws on Foucault to understand the changing discourse and impact of structured 'health needs assessments' on health visiting practice. Literature about this activity makes little mention of the long-standing social purposes of health visiting, which include surveillance of vulnerable and invisible populations, providing them, where needed, with help and support to access protective and supportive services. Instead, the discourse has been concerned primarily with an epidemiological focus and public health, which is associated with risk factors and assessments. The use of pre-defined needs assessment schedules suggests that health visiting activity can be sanctioned and clients' needs serviced only if they reach the threshold of pre-determined, epidemiologically-defined risk. Their effect on practice is examined through a conversation analysis of ten health visitor/client interactions using two different structured needs assessment tools. The study indicates that the health visitors, like their clients, were controlled by institutional expectations of their role; analysis of their conversations shows how they achieved the requirements of the organisational agenda. Structuring client needs and health visiting practice through the use of formal needs assessment tools emphasises the epidemiological focus of the health service above the need to arrange support for vulnerable individuals. In this respect, it serves as a marker in the continued medicalisation of health visiting.     

Health demonstration projects: Evaluating a community-based health intervention programme to improve young people's sexual health

There has been criticism of systematic reviews and meta-analyses that have shown little evidence of effect of interventions to improve teenage sexual health. Moreover, there is considerable controversy surrounding the validity of outcomes and rigour of design in evaluation methods for community-based programmes. In this climate, Scotland launched Healthy Respect, one of four community-based national Demonstration Projects, to address teenage sexual health. Healthy Respect is a complex and multi-stranded intervention in Lothian Region that includes education and health-promotion activities and alternative ways to provide sexual health services for young people. A multidisciplinary research team at the University of Aberdeen was appointed to undertake an independent evaluation of this demonstration project. Challenging some aspects of theory-based evaluation, it is argued that adopting both quantitative and qualitative methods will provide an understanding of both the context and process of this Health Demonstration Project, as well as tracking outcomes, including behavioural change, in the target population. The authors’ evaluation includes: examining the process of implementation; comparative regional mapping of the service context including inter-agency partnership working; and assessing effectiveness using a quasi-experimental design and adjusted, population-based, behavioural and sexual health outcomes. Evaluation from these key perspectives contributes to a balanced appraisal of a complex, community-based health promotion and service delivery intervention.     

An investigation of the influence of research-based indicators of breast feeding duration on health visitors' visiting decisions

Health visitors from two health authorities in the North East of England were asked to indicate when they would first propose to visit and how often they would expect to visit in the next 6 months a (fictitious) new client who was breast feeding a 14-day-old baby. The study provided no evidence that the health visitors modified their visiting behaviour in response to a mother's age or age at leaving school, factors that Wright & Walker (1983) had identified as predictors of early termination of breast feeding. However, significant differences were found in proposed visiting behaviour to a number of other new clients who were included in the study to provide an appropriate context and to help disguise the nature of the manipulations. These differences were attributed to the variation in the ages of the babies and to the existence of specific problems. Significant differences were also found between the responses of the health visitors from the two health authorities. These were explained in terms of different caseloads in a mainly rural versus a mainly urban area. The implications of these results for the assumption that the implementation of research findings can be left to individual health professionals are discussed.     

The Ashodaya PrEP project: Lessons and implications for scaling up PrEP from a community-led demonstration project among female sex workers in Mysore,India

ABSTRACT

To inform PrEP roll out, Ashodaya Samithi, a sex workers’ collective, conducted a community-led prospective demonstration project among female sex workers in Mysore and Mandya, India. Following a community preparedness phase and pre-screening, participants were recruited for clinical screening and enrolment, provided PrEP as part of combination HIV prevention, and followed for 16 months. Adherence was measured by self-reported pill intake and by tenofovir blood level testing among a subset of participants. Of the 647 participants enrolled, 640 completed follow-up. Condom use remained stable and no HIV seroconversions occurred. Self-reported daily PrEP intake over the last month was 97.97% at the end of the study. Tenofovir blood levels >40?ng/mL (consistent with steady state dosing) were detected among 80% (n?=?68/85) and 90.48% (n?=?76/84) of participants at month 3 and 6, respectively. Our study holds important insights for rolling out PrEP in community settings as part of targeted HIV prevention interventions.     

An evaluation of the impact of a national health demonstration project on testing and management for Chlamydia trachomatis infections in two regions of Scotland

OBJECTIVES: To compare clinical practice relating to testing for, and management of, genital Chlamydia trachomatis infection in the Lothian and Grampian regions of Scotland as part of an evaluation of a Government-funded health demonstration project in Lothian, Healthy Respect. STUDY DESIGN: Clinical audit against standards developed from a national clinical guideline. METHODS: Clinical practice relating to testing for, and management of, genital C. trachomatis infection was assessed against standards for good quality care developed from a national clinical guideline (Scottish Intercollegiate Guidelines Network Guideline 42). Audit methods comprised: postal survey of primary care clinicians; review of referral letters from primary to secondary care; and review of primary and secondary care patient case records. Findings from Lothian and Grampian were compared. RESULTS: Questionnaires were returned by 167 primary care clinicians in Lothian and 96 in Grampian. Clinicians in Lothian and Grampian gave similar responses relating to: testing of symptomatic patients (87 vs 88%); offer of testing for asymptomatic young patients (55 vs 55%); choice of antichlamydial agent (47 vs 42% azithromycin as first line); and follow-up strategies (50 vs 51% offer follow-up in primary care). Clinicians in Lothian were significantly more likely to participate in partner notification work (57 vs 44%; P=0.04) and to agree with statements reflecting 'perceived self-efficacy' in chlamydia-related care (57 vs 48%; P=0.006). Referral letters from primary to secondary care were reviewed for 31 women with genital symptoms in Lothian and 28 in Grampian. More women in Lothian were tested for chlamydia prior to referral (65 vs 39%; difference not significant). Review of primary care records for consultations in young people (145 in Lothian; 203 in Grampian) showed a higher level of chlamydia testing in Grampian (Lothian, 14%; Grampian, 34%; P<0.0001). However, review of secondary care records (n=39) showed a much higher level of testing in Lothian (Lothian, 75%; Grampian, 9%; P<0.0001). Review of secondary care records relating to proven chlamydia-positive women (n=159) suggested better care in Lothian in relation to ensuring antibiotic treatment (Lothian, 91%; Grampian, 74%; P=0.004), and use of the preferred antibiotic, azithromycin (Lothian, 78%; Grampian, 37%; P<0.0001). However, documented referral to a health adviser appeared to be better in Grampian (Lothian, 32%; Grampian, 48%; P=0.048). CONCLUSIONS: During the period of activity of the Healthy Respect demonstration project, few differences were detected between clinicians in Lothian and Grampian with regard to chlamydia-related practice. In both regions, clinicians appeared to be very aware of the need to test for chlamydia in patients with relevant symptoms, but were less likely to offer opportunistic testing to young patients without specific symptoms. These findings suggest that Healthy Respect in Lothian has had little impact on clinicians. However, these findings must be considered within the context of a broader evaluation, and it is noteworthy that the few significant differences that were detected tended to suggest better practice in Lothian.     

Moving health professionals as an alternative to moving patients: The contribution of overseas visiting medical specialists to the health system in Malta

Cross-border healthcare has become a major policy issue in the past years across the European Union. Professional mobility, as a means of providing specialised health services has not been given sufficient attention in both the research and policy agendas. This paper presents a case study of the contribution made by visiting overseas medical specialists to the health system in Malta. Twenty-five semi-structured interviews were conducted. A grounded theory approach was utilised in view of the limited amount of literature available on the subject. Qualitative content analysis revealed one superordinate theme, being the value of the service, and three further subthemes, which include the quality of the service provided, its longevity and durability, as well as the critical contributions of expatriates. The service is an integral component of the local health service. This study makes an important contribution to the literature on cross-border healthcare. Lessons learnt may be transferable to other small island states and territories. The European Reference Networks being developed at EU level may need to focus more on the benefits that can accrue through short term professional mobility than has been the case to date. The findings also serve to propose several important features that need to be in place to increase the chances of longevity, sustainability, quality and cost effectiveness in cross border health care services.     

标准示范与情景演示法改善医护人员手卫生

目的通过采取标准示范与情景演示法对医护人员进行手卫生教育培训,提高神经外科医护人员手卫生依从率与正确率。方法选取某院神经外科全体医护人员为研究对象,依据美国Dreyfus健康基金会项目的方法,首先分析2015年1月—2016年11月的手卫生监测结果并确立问题,制定预期目标。2016年12月—2017年9月,采取标准示范与情景演示法分阶段对医护人员进行手卫生教育培训,采用明查法和盲查法调查医护人员培训前后手卫生情况并进行比较。结果培训前神经外科医护人员手卫生依从率为31.51%,培训后手卫生依从率盲查为45.21%,明查为80.79%;三组手卫生依从率比较,差异有统计学意义(χ~2=363.46,P0.001)。培训前神经外科医护人员手卫生正确率为69.26%,培训后手卫生正确率盲查为79.20%,明查为84.41%;三组手卫生正确率比较,差异有统计学意义(χ~2=24.62,P0.001)。神经外科医护人员洗手皂液与速干手消毒剂日平均消耗量培训前为5.06 mL/床日,培训后为10.06 mL/床日。结论通过采取标准示范与情景演示法对医护人员进行手卫生教育培训,可提升医护人员手卫生依从性与正确性。采用明查与盲查相结合的调查方法,可有效摒除人为趋从因素的存在。     

Establishing the validity and reliability of clinical practice guidelines used to identify families requiring increased health visitor support

One of health visitors' main roles is that of case finding and actively searching for health needs. This paper describes part of the findings of a study evaluating the clinical practice guidelines issued to health visitors to assist them in identifying families requiring increased health visitor support. A postal questionnaire was distributed to all Community Trust Chief Nurses in England (179), employing health visiting staff. The aim of the questionnaire was to assess the extent to which clinical guidelines are used throughout the country to identify families requiring extra health visiting support and to examine their validity and reliability. The survey results confirm the widespread existence of clinical guidelines in England to assist health visitors in identifying vulnerable families requiring extra support. The study provides evidence that the guidelines are largely subjective and invalid in nature. Questions are raised about the relationship between clinical guidelines and professional judgements.     

甘肃省静宁县实施母子系统保健项目效果分析

目的评价甘肃省静宁县母子系统保健项目工作实施效果。方法收集该县24个乡镇2005—2011年的妇幼年度报表进行统计、分析。结论通过母子系统保健项目的实施,有效提高了该县孕产妇和儿童健康水平,同时卫生服务提供和服务利用水平也有一定提高,为今后妇幼卫生工作的开展打下了坚实的基础。     

高危儿的营养支持与健康管理

高危儿发生率和存活率越来越高,但出院后的高危儿面临一系列生长和发育问题,需要长期、系统、全面、细致的健康管理.高危儿的健康管理建议从营养支持入手,结合能力促进、疾病管理和预防(包括疫苗接种),实行三级网络管理模式,提高随访率和依从性,全方位促进高危儿全面发展,促进高危儿发育达到正常或尽可能接近正常儿童,减轻家庭焦虑,提...     

The contribution of health discussion groups with students to campus health promotion

Based on the idea of implementing health promotion in the university setting, this project is aimed at identifying determinants of health and well-being in the working and living environment of students and at developing targeted health interventions. The approach of health discussion groups is a well-established tool in workplace health promotion to enable participation and empowerment. This concept was innovatively applied and evaluated with the student body. There were seven sessions held at the University of Bielefeld with students from five different areas, a representative of the university management and a representative from the compulsory accident assurance. Process evaluation was done through standardized questionnaires and guided interviews with the participants while its impact was assessed in a follow-up period of 3 years by the amount of effects. Data included 11 distinct topics from the areas of study conditions, learning and their living environment with a total of 46 ideas for health-promoting actions. The process evaluation showed highly positive results, both in quantitative as well as qualitative approaches. Critical points were the resistances of students to participate in health discussion groups and the low confidence of students in the implementation of the proposed measures. The follow-up after 3 years showed that 11% of proposed actions could not be implemented, while 43% have resulted in recommendations for policy guidelines, 20% were fully implemented and 26% is still in progress. In conclusion, the health discussion group proved to be a useful instrument for student participation in university-based health promotion. Special emphasis should be given towards decreasing barriers for participation. The implementation of the proposed actions is highly depending on well-established structures of health promotion, such as a steering committee, and the commitment of the university management.     

云南不明原因猝死病区人群社会支持对心理健康的影响

目的 了解云南不明原因猝死病区人群的社会支持现况,分析社会支持对心理健康的影响.方法 采用社会支持评定量表、焦虑和抑郁自评量表进行横断面入户调查,用Epi Data 3.1软件建立数据库,用SPSS 11.0统计软件进行统计分析.结果 病区组和对照组相比,在社会支持方面,两组的总得分、主观支持和客观支持得分差异均有统计学意义(均有P＜0.05);在心理健康方面,两组在焦虑和抑郁得分差异均有统计学意义(均有P＜0.05),进一步进行了焦虑程度和抑郁程度比较,虽两组中无重度抑郁患者,但焦虑程度和抑郁程度上的差异均有统计学意义(均有P＜0.05).结论 病区人群因社会支持低于一般人群,导致心理健康状况较差,希望相关部门提供足够的社会支持,以改善病区人群心理健康状况.     

山西省公共卫生信息网络体系建设规划概略

从山西省实际出发 ,对山西省公共卫生网络体系建设的目标、实施原则、保障条件、建设内容及其功能作了概略性的论述。     

Integrating partner professionals. The Early Explorers project: Peers Early Education Partnership and the health visiting service

Background A range of voluntary sector organizations are involved in the delivery of services to children, particularly within the Early Year's sector and children's centres. Peers Early Education Partnership (PEEP) Early Explorers project is one example of the way in which explicit partnerships are being forged across statutory and voluntary sectors with the aim of improving outcomes for children and families. This paper reports an exploration of stakeholder views and experiences of two Early Explorer clinics located in areas of high deprivation. Methods Semi‐structured interviews were conducted with a purposive sample of stakeholders (n= 25) from children's centres, PEEP, the health visiting service and service users. Data were fully transcribed and analysed using a thematic approach. Results The data suggest that the two key groups of stakeholders providing Early Explorer clinics (i.e. health visitors and PEEP practitioners) had quite different objectives in terms of their early goals for the clinic, but that despite these differences good progress was achieved in terms of working together effectively. All stakeholders including service users referred to the presence of PEEP as having improved the quality of the clinic environment, and participating mothers identified a wide range of benefits from the enhanced service. However, somewhat restricted views about the role of practitioners within the clinics were identified by users, and the findings suggest that although the early goals for the clinic had been exceeded, these may have been limited in terms of true ‘partnership’ working. Conclusions Early Explorer clinics appeared to have enhanced the service provided within traditional child health clinics and to have provided practitioners with access to hard‐to‐reach families and parents with access to services that are consistent with the broader policy aims of improving parent–infant interaction. However, questions remain as to whether the benefit of ‘partnership’ working was fully realized.     

甘肃省卫生Ⅺ项目县基本公共卫生服务均等化现状分析——以甘谷县为例

目的:探讨在甘肃省卫XI项目县如何推行基本公共卫生服务的均等化,提高公共卫生的服务能力,为其他地区更好实施基本公共卫生服务均等化项目提供理论支持和实践经验。方法:采用统一设计的调查表进行调查,并结合知情者访谈。结果:样本地区基本公共卫生服务资源投入严重不足,主要的资源消耗在重点人群的公共卫生服务上;保证了较高的健康档案的建档率;采取多种方式进行健康教育;预防接种与传染病防治的工作体系健全;儿童与妇幼保健工作高效完成。结论:探索科学的基本公共卫生服务经费投入机制;合理配置公共卫生资源;加强绩效考核。