Does Supplementary Prenatal Nursing and Home Visitation Support Improve Resource Use in a Universal Health Care System? A Randomized Controlled Trial in Canada

ABSTRACT: Background: The addition of supplementary prenatal support may improve the health and well‐being of high‐risk women and families. The objective of this randomized controlled trial was to examine the impact of supplementary prenatal care on resource use among a community‐based population of pregnant women. Methods: Pregnant women from three urban maternity clinics were randomized (a) to current standard of physician care, (b) to current standard of care plus consultation with a nurse, or (c) to (b) plus consultation with a home visitor. Participants were 1,352 women who received 3 telephone interviews. The primary outcome was resource use (e.g., attended prenatal classes, used nutritional counseling). Results: Overall, those in the nurse intervention group were more likely to attend an “Early Bird” prenatal class and parenting classes, and to use nutrition counseling and agencies that assist with child care. Women provided with extra nursing and home visitation supports were more likely to use a written resource guide, nutrition counseling, and agencies that assist with child care. Among women at higher risk (e.g., language barriers, young maternal age, low income), the nurse intervention significantly increased use of early prenatal classes, whereas the nurse and home visitor intervention significantly increased use of the written resource guide and nutrition counseling. The intervention substantially increased the amount of information received on numerous pregnancy‐related topics but had little impact on resource use for mental health and poverty‐related needs. Among those with added support, resource use among low‐risk women was generally greater than among high‐risk women. Conclusions: Additional support provided by nurses, or nurses and home visitors, can successfully address informational needs and increase the likelihood that women will use existing community‐based resources. This finding was true even for high‐risk women, although this intervention did not reduce the difference in resource use between high‐ and low‐risk women. (BIRTH 33:3 September 2006)     

To market! To market! A new dawn for community care?

The public sector in Britain has been subjected to over a decade of major reform aimed at breaking up public service monopolies, at containing costs while at the same time opening services up to greater consumer choice. Health and social services have not been exempt from this revolution in the organization and management of public sector services. The long-standing policy of care in the community is being subjected to market principles and the introduction of a ‘contract culture’ very similar to the NHS reforms introduced in 1991. This paper reviews the origins of these developments in the doctrines of ‘new public management’, a movement which has proved attractive to policy-makers in many countries. Local authority social services departments have been identified as the lead agency for the development of a mixed economy of care following a review of community care policy by the government's health adviser, Sir Roy Griffiths, and a subsequent white paper. This paper examines the limited empirical evidence available on how managers and providers are meeting the challenge bestowed upon them, and concludes that most authorities are moving ahead cautiously if at all. Only a handful of authorities studied have embraced the reforms with any degree of enthusiasm. The paper concludes with an assessment of the reforms from two perspectives: a pessimistic one and an optimistic one. There are many worrying features of the reforms, not least among these being a lack of clarity over their intended purpose. Tensions and contradictions are plentiful, which places in jeopardy the certainty of the reforms in becoming user led rather than provider driven. A more optimistic scenario is that the changes are leading to a loosening up of services and practices which have often suffered from sclerotic tendencies, paternalism and sometimes complacency. If the reform process is skilfully handled and not rushed and if the ends are clearly established and communicated then users and carers could prove to be the principal beneficiaries.     

Determinants of decision-making in the screening procedure of a community psychiatric service

This study is a predictor analysis of the screening procedure followed by a psychiatric service for a period of 1 year preceding and a period of 1 year following the introduction of community psychiatry. Throughout this period, the psychiatric service consisted of a local service within the catchment area and a central service at a psychiatric hospital outside the area. At the time of the reorganization, the responsibility for the psychiatric service was transferred from the public health authorities to the social services. Before the reorganization, screenings were conducted on the basis of referral papers or simply as a result of telephone communication. After the reorganization, the screening procedure was intensified by means of a pre-examination. One aim of the reorganization was to ensure that the severely mentally ill take priority over patients characterized predominantly by social strain. Patients with manic-depressive psychosis and other psychoses showed a significantly increased probability of being accepted for treatment, whereas those with schizophrenia showed no significant increase, irrespective of the service reorganization. Similarly, manic-depressive psychosis and other psychoses (not schizophrenia) were significant predictors of hospitalization at the mental hospital outside the catchment area as well as hospitalization in the local facilities, irrespective of the service reorganization. Indicators of social strain were not given higher priority following the service reorganization.     

Methods of Measuring Community Characteristics

There is increasing interest in the influence of community characteristics on child development and family functioning. In order to address questions on community influence, it is important to be aware of the measures available and their strengths and limitations. Useful strategies have been developed within a number of disciplines, including sociology, social and community psychology, and criminology. Methods include summarising information from existing administrative databases and census data, conducting observations, and using survey instruments with residents. The most commonly used methods are reviewed and their psychometric properties described .     

Education in family and community health: the challenge faced by a new medical school

This paper describes the efforts of the Department of Family and Community Health at Sultan Qaboos University in providing opportunities for the development of 'hands-on' problem-solving skills appropriate for Oman. The curriculum of the Department is discussed, highlighting the unusual emphasis of this discipline in both the preclinical and clinical curriculum of the College of Medicine. The importance of continuous assessment and supervision of students is discussed. Course-work in the preclinical curriculum of the Department is kept to a minimum. Field-work forms an important part of preclinical training, where application and problem-based learning are emphasized. During the clinical years the students are exposed to an integrated series of lectures and practicals covering core knowledge in clinical medicine. Practical clinical training, over a total period of 15 weeks, takes place at a variety of sites where common problems in primary health care in Oman are handled by students under supervision.     

The implications of Project 2000 and the formation of links with higher education for the professional and academic needs of nurse teachers in the United Kingdom

A national study was conducted between 1991 and 1994 to explore and describe the changing role of the nurse teacher following the introduction of Project 2000 pre-registration nursing courses. Multiple methods were used to collect data from a wide variety of respondents (nurse teachers, midwife teachers, clinical nurses, health service managers and higher education lecturers). This paper presents the findings relating to the impact of Project 2000 and the move into higher education on the continuing educational needs of nurse teachers. Views on college strategies for staff development, the changing nature of teachers'academic and professional development needs and the problems of the conflicting demands experienced are reported. The research highlights the need for clinical credibility to be clearly defined in relation to nurse teachers and for educational institutions to place more emphasis on teachers'clinical development if the rhetoric of policy is to become a reality.     

The early recognition of dementia in the elderly: A preliminary communication about a longitudinal study using the gms–agecat package (community version)

A random community sample of 1070 subjects aged over 65 was interviewed by trained non-medical interviewers using the Geriatric Mental State, community version (GMSA). A sub-sample of 126 subjects was selected so as to contain possible early cases of dementia, pseudo-dementia, and normal subjects; and re-interviewed, a mean 1 year and 23 weeks later, by a group of psychiatrists in training. The computer diagnosis AGECAT, based on GMSA applied by non-medical raters, had predicted at initial interview, nine out of twelve cases of dementia at follow-up and five out of nine borderline cases. An Organic/Depression Index may prove useful in predicting which of those cases with early organic levels will eventually develop dementia, depression or recover.     

Who speaks for the children?

• ? It would probably be a truism to say that most professional nurses consider patient/client advocacy to be an essential component of their role—indeed, there is a UKCC Advisory paper (Exercising Accountability, 1989), which categorically states that this is so. ‘The introductory paragraphs of the Code of Professional Conduct, together with several of its clauses, include clearly the expectation that the practitioner will accept a role as an advocate on behalf of his or her patients/clients.’
• ? Some professional nurses, however, consider advocacy to be too altruistic an activity and prefer to leave it to others.