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Tappenden P, Campbell F, Rawdin A, et al. The Clinical Effectiveness and Cost-Effectiveness of Home-Based, Nurse-Led Health Promotion for Older People: A Systematic Review. Southampton (UK): NIHR Journals Library; 2012 Apr. (Health Technology Assessment, No. 16.20.)

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The Clinical Effectiveness and Cost-Effectiveness of Home-Based, Nurse-Led Health Promotion for Older People: A Systematic Review.

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1Background

Description of the health problem

In old age, reduction in physical function can lead to loss of independence, the need for hospital and long-term nursing home care, and premature death. The importance of physical, functional, psychological and social factors in realising a healthy old age is recognised by older people,1 health-care professionals,2 policy advisors3 and decision-makers.

As the number of older people increases, the needs of older people are expected to become an increasingly important health issue. It has been estimated that by the year 2025, around 20% of the population in industrial countries will be aged 65 years and over as a consequence of people living longer. Changing family structures and greater mobility in the working population mean that many more older people will be living alone, and social isolation and loneliness are likely to become increasingly widespread. It has been suggested that the number of older people with mental health problems will also grow; estimates suggest that, by the year 2021, more than 1 in every 15 people will be an older person experiencing a mental health problem.4

The objective of enabling older people to remain in their own homes has been a cornerstone of government policy for several decades. In recent years, considerable emphasis has been placed on health promotion and other preventative measures as a means of delaying the onset of illness and dependency that eventually lead older people to need long-term care.5

Home-based health promotion programmes for older people, carried out by nurses and other health-care professionals (such as occupational therapists and physiotherapists), have the potential to positively affect health and functional status, and may promote independent functioning of older people. Such programmes may also aim to reduce hospital and nursing/residential home admissions. A substantial number of studies have examined the effects of preventative home-visiting programmes on older people living in the community. Since 2000, 10 systematic reviews of the clinical effectiveness of home- or community-based programmes have been published.615 However, these reviews have reported inconsistent and conflicting results. Subgroup analyses of the largest published meta-analysis suggested that effective home-visiting programmes include multidimensional assessment and numerous follow-up visits and were targeted at individuals who were at lower risk of death.8 However, none of the existing reviews included an assessment of the cost-effectiveness of home-visiting programmes nor did they limit the analysis to the UK context. This assessment seeks to address these gaps and to explore what is known about the factors that may contribute to the effectiveness of this type of complex intervention.

Current service provision

Older people potentially have a great deal to gain from effective preventative programmes and from health promotion. Prevention services may lead to better health outcomes and a more efficient use of resources over the long term, with decreased demand on costly acute and social care services. However, there is evidence of an uneven uptake of health-promoting services such as immunisation and screening programmes in older people.16 Furthermore, general practitioners (GPs) may be less likely to discuss lifestyle changes such as weight reduction, smoking, alcohol and safe drinking with older people than with younger people.17

Nurses may play an important role in promoting health and preventing ill health in older people, who may experience a range of health and social care problems. The NHS Improvement Plan18 described a new clinical role for nurses. Known as community matrons, these experienced skilled nurses use case management techniques with patients who meet criteria denoting very high-intensity use of health care. With special intensive help, these patients are able to remain at home longer and to have more choice about their health care. Community nurses, including practice nurses, health visitors (public health nurses) and district nurses, are also well placed to promote health in older people. A recent survey of community nurses suggested that they recognise health promotion as part of their role but may be limited by a range of factors including organisational constraints, the absence of specific training, variable knowledge and the unplanned approach to this area of work, suggesting that nurses working in primary care may currently be ill equipped to enable older people to increase or maintain their levels of physical activity and function.19

Description of the intervention under assessment

The World Health Organization defines health promotion as ‘the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions’ (www.who.int/topics/health_promotion/en/). Health promotion can take a variety of forms including provision of advice and education for improving health and avoiding ill health, the implementation of service improvements and policy agenda-setting. Hubley and Copeman20 have put forward a framework for describing the range of activities that may be encompassed within health promotion programmes. This is comprised of three main types of activity: (1) health education, which involves communication directed at individuals, families and communities to influence; (2) service improvement, which involves quality and quantity of service; and (3) advocacy, which involves agenda-setting for healthy public policy.

Given the range of possible ways of implementing a home-based, nurse-led health promotion programme, the intervention under consideration within this assessment would be best described as a complex intervention, in that it that may comprise multiple, potentially interacting components. The focus within this assessment is principally on nurse-led health promotion activities undertaken within the subject's home. It should be noted, however, that within several of the studies included within this assessment, the home-based intervention did not consist solely of health promotion activities for the prevention of illness, but also extended to treatment and other care-related elements of nursing activity.

© 2012, Crown Copyright.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK98587

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