The Effectiveness of Public Health Nursing: A The Effectiveness of Public Health Nursing: A Review of Systematic ReviewsReview of Systematic Reviews

Lawrie ElliottLawrie Elliott11

Iain CrombieIain Crombie22

Linda IrvineLinda Irvine22

Jane CantrellJane Cantrell11

Julie TaylorJulie Taylor22

1 1 SchoolSchool of Nursing and Midwifery University of Dundee of Nursing and Midwifery University of Dundee 22 Department of Epidemiology and Public Health Department of Epidemiology and Public Health

University of DundeeUniversity of Dundee

AimAim

Conduct a review of the Conduct a review of the international scientific literature international scientific literature that gives the greatest coverage of that gives the greatest coverage of the role of nurses in improving the role of nurses in improving the public’s health.the public’s health.

Scientific literature included Scientific literature included primary papers and reviewsprimary papers and reviews

Public health nurse and public health Public health nurse and public health nursing nursing (inclusion criteria)(inclusion criteria)

any nurse including health visitors any nurse including health visitors and midwivesand midwives

mobilising resources to ensure mobilising resources to ensure healthhealth

preventing disease, prolonging life preventing disease, prolonging life and promoting healthand promoting health

interventions targeted at interventions targeted at individuals and specific groups in individuals and specific groups in societysociety

includes multi-disciplinary includes multi-disciplinary interventionsinterventions

Health topicsHealth topicsHealth PrioritiesHealth Priorities Client Groups Client Groups

Coronary Heart DiseaseCoronary Heart Disease Children & Adolescents Children & Adolescents

Cancers Cancers Maternal Maternal

Accident Prevention Accident Prevention Elderly Elderly

Mental Health Mental Health

Inequalities in Health Inequalities in Health

LifestylesLifestyles

SmokingSmoking

Abuse of Alcohol Abuse of Alcohol

Illicit Drug UseIllicit Drug Use

DietDiet

Physical ActivityPhysical Activity

Sexual HealthSexual Health

Sources of literatureSources of literature

Electronic databases (1989-1999)Electronic databases (1989-1999)

MedlineMedline EmbaseEmbase CinahlCinahl PsychLitPsychLit

Sources of literatureSources of literature

Authoritative BodiesAuthoritative Bodies Cochrane CollaborationCochrane Collaboration Centre for Evidence Based Nursing (UK)Centre for Evidence Based Nursing (UK) Health Technology Assessment (UK)Health Technology Assessment (UK) Health Education Authority (UK)Health Education Authority (UK) Health Education Board for ScotlandHealth Education Board for Scotland Centre for Reviews and Dissemination (UK)Centre for Reviews and Dissemination (UK) Public Health Research, Education Public Health Research, Education

& Development Program (Canada)& Development Program (Canada) United States Preventive Services TaskforceUnited States Preventive Services Taskforce

Sources of literatureSources of literature

ExpertsExperts

Public Health Review Reference Group and Public Health Review Reference Group and Literature Review Sub-CommitteeLiterature Review Sub-Committee

Cochrane Review GroupsCochrane Review Groups Key authors from authoritative groupsKey authors from authoritative groups Researchers publishing on selected topicsResearchers publishing on selected topics

Appraising the reviewsAppraising the reviews

AbstractsAbstracts

Relevant to Public HealthRelevant to Public Health Relevant to Nursing Relevant to Nursing

Synthesis of data from primary studiesSynthesis of data from primary studies

Number of reviews retrieved Number of reviews retrieved (n=301)(n=301)Coronary Heart DiseaseCoronary Heart Disease 3434CancersCancers 2424Mental HealthMental Health 1717Accident PreventionAccident Prevention 1010Child & Adolescent HealthChild & Adolescent Health 7070Maternal Health Maternal Health 3030Care of the ElderlyCare of the Elderly 3131SmokingSmoking 2525Abuse of AlcoholAbuse of Alcohol 8 8Illicit Drug UseIllicit Drug Use 1919DietDiet 1616Physical ActivityPhysical Activity 9 9Sexual HealthSexual Health 1313Inequalities in healthInequalities in health 2 2GeneralGeneral 3333

Detailed appraisalDetailed appraisal

Full PaperFull Paper Relevance (inclusion criteria)

Quality of literature search (data-bases, grey literature, experts)

Quality assessment of primary papers (clear aims, randomisation, objective outcomes)

Quality of analysis (heterogeneity, bias)

Reviews included (n= 168) and rejected (n= 133)Reviews included (n= 168) and rejected (n= 133)

Included RejectedIncluded RejectedCoronary heart diseaseCoronary heart disease 20 20 1414Cancers Cancers 8 8 16 16Mental healthMental health 9 9 8 8Accident preventionAccident prevention 8 8 2 2

Child & Adolescent healthChild & Adolescent health 49 49 21 21Maternal health Maternal health 27 27 3 3Care of the elderlyCare of the elderly 11 11 10 10SmokingSmoking 18 18 7 7Abuse of alcoholAbuse of alcohol 3 3 5 5Illicit drug useIllicit drug use 7 7 12 12DietDiet 9 9 7 7Physical activityPhysical activity 8 8 1 1Sexual healthSexual health 8 8 5 5GeneralGeneral 13 20 13 20

Overview of study outcomesOverview of study outcomes(n= 362)(n= 362)

Strong effect (11%) Strong effect (11%)

Weak effect (42%)Weak effect (42%)

Ineffective (20%)Ineffective (20%)

Harmful (3%)Harmful (3%)

Insufficient evidence (24%)Insufficient evidence (24%)

ChallengeChallenge of successof success

Knowledge Knowledge

BehaviourBehaviour

Health gainHealth gain

Increasing knowledgeIncreasing knowledge

Interactive teaching and BP monitoringInteractive teaching and BP monitoring (hypertension(hypertension knowledge in adults)knowledge in adults)

Interactive teachingInteractive teaching

(healthy eating knowledge in school children)(healthy eating knowledge in school children)

Videos in STD clinicsVideos in STD clinics (knowledge of STD's and condom use)(knowledge of STD's and condom use)

Behaviour changeBehaviour change

HIV testing and counsellingHIV testing and counselling (increases condom use in sero-discordant (increases condom use in sero-discordant

couples)couples)

Psychological interventions Psychological interventions (strengthen (strengthen coping skills in children) coping skills in children)

Smoking cessation interventions Smoking cessation interventions (smoking cessation in pregnant women)(smoking cessation in pregnant women)

Health gainHealth gain

Strict low fat diets Strict low fat diets (reduces blood cholesterol in clinic populations)(reduces blood cholesterol in clinic populations)

Education with environmental and Education with environmental and legislative changelegislative change

(reduces injury in children) (reduces injury in children)

Behavioural interventions aimed at Behavioural interventions aimed at reducing environmental hazardsreducing environmental hazards

(reduces falls in the elderly)(reduces falls in the elderly)

Features of SuccessFeatures of Success Interactive teachingInteractive teaching

Environmental modification Environmental modification

Theory basedTheory based

Multi-agencyMulti-agency

High risk groupsHigh risk groups

Long-term/multi-sessionLong-term/multi-session

UnsuccessfulUnsuccessful InterventionsInterventions

Passive information giving

Poorly structured

Lack achievable aims

Non-theory based

Prohibition rather than safe practice

LimitationsLimitations

Limited coverage Limited coverage a) missed recently published primary papers b)interventions not a) missed recently published primary papers b)interventions not

yet subject to reviewyet subject to review

c) qualitative researchc) qualitative research

Restricted definition of nurse’s role in public Restricted definition of nurse’s role in public health (social problems?) health (social problems?)

Applicability to UKApplicability to UK

StrengthsStrengths

Broad overview of public health nursingBroad overview of public health nursing

Review aggregated from large number of Review aggregated from large number of

studies (weight of evidence)studies (weight of evidence)

Comprehensive searchComprehensive search

Consistency across health topicsConsistency across health topics

Rapid ReviewingRapid Reviewing

ChallengesChallenges

Assessing the quality of reviewsAssessing the quality of reviews

Establishing intervention outcomes at the outsetEstablishing intervention outcomes at the outset

Designing research/evaluation to assess these Designing research/evaluation to assess these

outcomesoutcomes

Training nurses in public healthTraining nurses in public health

Elliott L, Crombie IK, Irvine L, Cantrell J, Taylor J.Elliott L, Crombie IK, Irvine L, Cantrell J, Taylor J.(2001) (2001) The effectiveness of public health nursing: A The effectiveness of public health nursing: A review of systematic reviews.review of systematic reviews. The Stationary Office, The Stationary Office, Edinburgh.Edinburgh.

l.elliott@dundee.ac.ukl.elliott@dundee.ac.uk

Available from:Available from:

The Stationary Office BookshopThe Stationary Office Bookshop

71 Lothian Road71 Lothian Road

Edinburgh, UKEdinburgh, UK

EH3 9AZEH3 9AZ

Tel:(+) 0870-606-5566 ISBN 1 84268 472 8Tel:(+) 0870-606-5566 ISBN 1 84268 472 8

Methods paperMethods paper

Elliott L, Crombie I.K., Irvine L., Cantrell J., Elliott L, Crombie I.K., Irvine L., Cantrell J., Taylor J. The effectiveness of public health Taylor J. The effectiveness of public health nursing: The problems and solutions in carrying nursing: The problems and solutions in carrying out a review of systematic reviews. Journal of out a review of systematic reviews. Journal of Advanced Nursing (in press)Advanced Nursing (in press)