A structured health needs assessment tool: acceptability and effectiveness for health visiting

A Medical Translation Assistant for Non-English-Speaking Caregivers of Children With Special Health Care Needs: Proposal for a Scalable and Interoperable Mobile App

BACKGROUND

Communication and comprehension of medical information are known barriers in health communication and equity, especially for non-English-speaking caregivers of children with special health care needs.

OBJECTIVE

The objective of this proposal was to develop an interoperable and scalable medical translation app for non-English-speaking caregivers to facilitate the conversation between provider and caregiver/patient.

METHODS

We employed user-centered and participatory design methods to understand the problems and develop a solution by engaging the stakeholder team (including caregivers, physicians, researchers, clinical informaticists, nurses, developers, nutritionists, pharmacists, and interpreters) and non-English-speaking caregiver participants.

RESULTS

Considering the lack of interpreter service accessibility and advancement in translation technology, our team will develop and test an integrated, multimodal (voice-interactive and text-based) patient portal communication and translation app to enable non-English-speaking caregivers to communicate with providers using their preferred languages. For this initial prototype, we will focus on the Spanish language and Spanish-speaking families to test technical feasibility and evaluate usability.

CONCLUSIONS

Our proposal brings a unique perspective to medical translation and communication between caregiver and provider by (1) enabling voice entry and transcription in health care communications, (2) integrating with patient portals to facilitate caregiver and provider communications, and (3) adopting a translation verification model to improve accuracy of artificial intelligence-facilitated translations. Expected outcomes include improved health communications, literacy, and health equity. In addition, data points will be collected to improve autotranslation services in medical communications. We believe our proposed solution is affordable, interoperable, and scalable for health systems.

Language Translation Apps in Health Care Settings: Expert Opinion

BACKGROUND

Currently, over 300 languages are spoken in Australian homes. People without proficient English from non-English speaking countries may not receive equitable care if their health care workers do not speak their primary language. Use of professional interpreters is considered the gold standard; however, for a variety of reasons, it is often limited to key aspects of care such as diagnosis and consent. With the emergence of mobile technologies, health care workers are increasingly using digital translation tools to fill this gap. However, many of these technologies have not been developed for health care settings and their use has not been evaluated.

OBJECTIVE

This study aimed to evaluate iPad-compatible language translation apps to determine their suitability for enabling everyday conversations in health care settings.

METHODS

Translation apps were identified by searching the Apple iTunes Store and published and grey literature. Criteria for inclusion were that the apps were available at no cost, able to translate at least one of the top 10 languages spoken in Australia, and available for use on iPad. Apps that met inclusion criteria were reviewed in 2 stages. Stage 1 was the feature analysis conducted by 2 independent researchers, where apps were evaluated for offline use, input and output methods, and number of languages. Stage 2 was the analysis of suitability for everyday communication in the health care setting, conducted by 2 independent professionals with expertise in translation and cross-cultural communication. Apps that enabled key aspects of care normally within the realm of professional interpreters, such as assessment, treatment and discharge planning, and seeking consent for medical treatments, were considered unsuitable.

RESULTS

In total, 15 apps were evaluated. Of these, 8 apps contained voice-to-voice and voice-to-text translation options. In addition, 6 apps were restricted to using preset health phrases, whereas 1 app used a combination of free input and preset phrases. However, 5 apps were excluded before stage 2. In addition, 6 of the 10 remaining apps reviewed in stage 2 were specifically designed for health care translation purposes. Of these, 2 apps were rated as suitable for everyday communication in the health care setting-culturally and linguistically diverse Assist and Talk To Me. Both apps contained simple and appropriate preset health phrases and did not contain conversations that are normally within the realm of professional interpreters.

CONCLUSIONS

All iPad-compatible translation apps require a degree of caution and consideration when used in health care settings, and none should replace professional interpreters. However, some apps may be suitable for everyday conversations, such as those that enable preset phrases to be translated on subject matters that do not require a professional interpreter. Further research into the use of translation technology for these types of conversations is needed.

Street-level bureaucracy and policy implementation in community public health nursing: a qualitative study of the experiences of student and novice health visitors

Aim To explore the experiences of student and novice health visitors in implementing health visiting policy reform pre- and post-qualification.

BACKGROUND

In England, public health nursing has been subject to major policy reform. The Health Visitor Implementation Plan (2011) set out a plan to recruit increasing numbers of nurses and midwives to the profession to deliver an expanded and refocussed health visiting service. Exploring this policy change from the viewpoint of those new to health visiting offers a unique perspective into how a specific policy vision is translated into nursing practice.

METHODS

A descriptive qualitative study in which participants were enrolled on a one-year post-graduate health visiting course at a University in South West of England. Qualitative data were collected pre- and post-qualification. A total of 16 interviews and a focus group were conducted with nine participants between September 2012 and March 2013. Findings Descriptive data were interpreted using Lipsky's theoretical framework of street-level bureaucracy. Three themes emerged which relate to this 'bottom-up' perspective on policy implementation; readiness to operationalise policy, challenges in delivering the service vision; and using discretion in delivering the vision. Community public health nurses operate as street-level bureaucrats in negotiating the demands of policy and practice, and by this means, attempt to reconcile professional values with institutional constraints. Barriers to policy implementation at a local level mediate the effects of policy reform, ultimately impacting upon outcomes for children and families.

Parents' views on how health professionals should work with them now to get the best for their child in the future

BACKGROUND

Pregnancy and the first years of life are important times for future child well-being. Early identification of families and children who might be likely to experience poorer outcomes could enable health professionals and parents to work together to promote each child's well-being. Little is known about the acceptability and feasibility of such an approach to parents.

OBJECTIVE

To investigate parents' views about how health professionals should identify and work with families who may benefit from additional input to maximize their children's future health and well-being.

DESIGN

A qualitative study using focus groups.

SETTING AND PARTICIPANTS

Eleven focus groups were conducted with a total of 54 parents; 42 mothers and 12 fathers living in the north of England.

RESULTS

Parents welcomed the idea of preventive services. They strongly believed that everyone should have access to services to enhance child well-being whilst recognizing that some families need additional support. Making judgements about who should receive additional services based on specific criteria evoked powerful emotions because of the implication of failure. Parents projected a belief in themselves as 'good parents' even in adverse circumstances.

CONCLUSIONS

Targeted additional preventive services can be acceptable and welcome if health professionals introduce them sensitively, in the context of an existing relationship, providing parents are active participants.

Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: a narrative review of the literature

INTRODUCTION

There is increasing international interest in universal, health promoting services for pregnancy and the first three years of life and the concept of proportionate universalism. Drawing on a narrative review of literature, this paper explores mechanisms by which such services might contribute to health improvement and reducing health inequalities.

OBJECTIVES

Through a narrative review of empirical literature, to identify: (1) What are the key components of health visiting practice? (2) How are they reflected in implementing the universal service/provision envisaged in the English Health Visitor Implementation Plan (HVIP)?

DESIGN

The paper draws upon a scoping study and narrative review.

REVIEW METHODS

We used three complementary approaches to search the widely dispersed literature: (1) broad, general search, (2) structured search, using topic-specific search terms, (3) seminal paper search. Our key inclusion criterion was information about health visiting practice. We included empirical papers from United Kingdom (UK) from 2004 to February 2012 and older seminal papers identified in search (3), identifying a total of 348 papers for inclusion. A thematic content analysis compared the older (up to 2003) with more recent research (2004 onwards).

RESULTS

The analysis revealed health visiting practice as potentially characterized by a particular 'orientation to practice.' This embodied the values, skills and attitudes needed to deliver universal health visiting services through salutogenesis (health creation), person-centredness (human valuing) and viewing the person in situation (human ecology). Research about health visiting actions focuses on home visiting, needs assessment and parent-health visitor relationships. The detailed description of health visitors' skills, attitudes, values, and their application in practice, provides an explanation of how universal provision can potentially help to promote health and shift the social gradient of health inequalities.

CONCLUSIONS

Identification of needs across an undifferentiated, universal caseload, combined with an outreach style that enhances uptake of needed services and appropriate health or parenting information, creates opportunities for parents who may otherwise have remained unaware of, or unwilling to engage with such provision. There is a lack of evaluative research about health visiting practice, service organization or universal health visiting as potential mechanisms for promoting health and reducing health inequalities. This paper offers a potential foundation for such research in future.

Moving from a universal to targeted child health programme: which children receive enhanced care? A population-based study using routinely available data

BACKGROUND

There is a current emphasis on 'progressive universal' delivery of the UK child health programme, with a core universal service complemented by enhanced support provided according to need. In Scotland, a three-category indicator of need, the 'Health Plan Indicator' (HPI) is used to identify children requiring enhanced support from the child health programme to facilitate this.

METHODS

Routine child health programme and hospital delivery records for a cohort of 36 871 Scottish children were used to explore the factors associated with being identified as requiring enhanced child health programme support using multilevel logistic regression modelling.

RESULTS

The following factors were all independently associated with an increased likelihood of being assessed as requiring enhanced support: (i) deprivation; (ii) young maternal age, maternal smoking and drug misuse; (iii) a previous stillbirth; (iv) prematurity; (v) being small for gestational age; (vi) no breastfeeding, admission to a special care baby unit; and (vii) medical, social or developmental concerns about the baby. There was a tendency for children living in areas with higher Health Visitor staffing levels to be more likely to be assessed as requiring enhanced support but this effect was not statistically significant. There was significant residual variation between areas in the likelihood of children being assessed as requiring enhanced support.

DISCUSSION

This study suggests Health Visitors take a complex range of factors into account when assessing which children require enhanced support from the child health programme. Health Visitors' workload may influence the likelihood of them identifying children as requiring enhanced support but this requires further clarification. There are clear differences between areas in allocation of the different HPI categories. Further work is required to explore the relationship between being identified as in need of enhanced support, the care actually provided to children, and their outcomes.

Digging over that old ground: an Australian perspective of women's experience of psychosocial assessment and depression screening in pregnancy and following birth

Background

There is increasing recognition of the need to identify risk factors for poor mental health in pregnancy and following birth. In New South Wales, Australia, health policy mandates psychosocial assessment and depression screening for all women at the antenatal booking visit and at six to eight weeks after birth. Few studies have explored in-depth women’s experience of assessment and how disclosures of sensitive information are managed by midwives and nurses. This paper describes women’s experience of psychosocial assessment and depression screening examining the meaning they attribute to assessment and how this influences their response.

Methods

This qualitative ethnographic study included 34 women who were observed antenatally in the clinic with 18 midwives and 20 of the same women who were observed during their interaction with 13 child and family health nurses after birth in the home or the clinic environment. An observational tool, 4D&4R, together with field notes was used to record observations and were analysed descriptively using frequencies. Women also participated in face to face interviews. Field note and interview data was analysed thematically and similarities and differences across different time points were identified.

Results

Most participants reported that it was acceptable to them to be asked the psychosocial questions however they felt unprepared for the sensitive nature of the questions asked. Women with a history of trauma or loss were distressed by retelling their experiences. Five key themes emerged. Three themes; ’Unexpected: a bit out of the blue’, ‘Intrusive: very personal questions’ and ‘Uncomfortable: digging over that old ground’, describe the impact that assessment had on women. Women also emphasised that the approach taken by the midwife or nurse during assessment influenced their experience and in some cases what they reported. This is reflected in the themes titled: Approach: ’sensitivity and care’ and ’being watched’.

Conclusions

The findings emphasise the need for health services to better prepare women for this assessment prior to and after birth. It is crucial that health professionals are educationally prepared for this work and receive ongoing training and support in order to always deliver care that is empathetic and sensitive to women who are disclosing personal information.

Negotiating policy in practice: child and family health nurses' approach to the process of postnatal psychosocial assessment

Background

There is growing recognition internationally of the need to identify women with risk factors for poor perinatal mental health in pregnancy and following birth. In the state of New South Wales, Australia the Supporting Families Early policy provides a framework of assessment and support for women and families and includes routine psychosocial assessment and depression screening. This study investigated the approach taken by Child and Family Health Nurses (CFHNs) following birth to assessment and screening as recommended by state policy. This was a qualitative ethnographic study that included 83 CFHN and 20 women. Observations occurred with thirteen nurses; with 20 women, in the home or the clinic environment. An additional 70 nurses participated in discussion groups. An observational tool (4D&4R) and field notes were used to record observations and analysed descriptively using frequencies. Field notes, interview data and discussion group transcripts were analysed thematically.

Methods

This was a qualitative ethnographic study that included 83 CFHN and 20 women. Observations occurred with thirteen nurses; with 20 women, in the home or the clinic environment. An additional 70 nurses participated in discussion groups. An observational tool (4D&4R) and field notes were used to record observations and analysed descriptively using frequencies. Field notes, interview data and discussion group transcripts were analysed thematically.

Results

CFHNs demonstrated a range of approaches to assessment and screening. Psychosocial assessment was conducted in 50% (10 out of the 20) of the interactions observed; however, all the women were screened using the Edinburgh Depression Scale. Four major themes that represent the approach taken to the assessment process were identified: ‘Engagement: getting that first bit right’, ‘Doing some paperwork’, ‘Creating comfort’ and ‘Psychosocial assessment: doing it another way’. Nurses utilised other skills such as observing the women interacting with their baby, taking note of non verbal communication and using intuition to develop a clinical decision.

Conclusion

Overall, nurses’ took a sensitive and caring approach to assessment and screening, however, there were differences in interpretations of the policy recommendations across the two sites. Nurses adopt a flexible, relationship-based approach to the assessment process; however, they experience tension when required to incorporate structured psychosocial assessment processes. To undertake assessment and screening effectively, CFHNs require ongoing support, training and supervision to maintain this sensitive and emotionally challenging work.

Does nursing research impact on policy? A case study of health visiting research and UK health policy

The aim of this study was to critically examine the impact of nursing research on the development of health care policy using UK health visiting research as an example. We used established methods to evaluate research impact. This included a documentary review of over 30 policy documents, citation analyses on 19 papers and interviews with health visiting researchers. Although there were examples of policy documents being informed by health visiting research it was not always clear what role research had played in the development of recommendations. Information from researchers provided examples of local, national and international impact, although the extent to which papers may have impacted upon policy was less clear from the citation analyses. Many of the UK studies cited in policy documents were qualitative, observational or reflexive and a lack of evaluative research, in particular randomised controlled trials and other controlled evaluations, may limit the impact of health visiting research on health care policy in the UK. There is evidence that health visiting research has influenced health care policy but this has been limited and there is a need for more research to underpin and inform the role of the health visitor.

Community professionals' management of client care: a mixed-methods systematic review

OBJECTIVES

To review the literature on individual community professionals' caseload management (behaviours related to assessment, treatment and discharging of clients) to identify the main themes and concepts, and to synthesize the findings to inform practice, policy and research.

METHODS

Publications were systematically identified from electronic databases, hand searches of bibliographies, and contact with professional organizations. There were no restrictions on language, the nature of publications or publication year. Procedures were systematically applied for quality appraisal and data extraction. Qualitative and descriptive quantitative methods were used for data analysis and synthesis.

RESULTS

Search criteria yielded 2048 papers of which 42 papers met the inclusion criteria. Thirty-five percent of these were based on research, the rest on professionals' experiences. The papers covered 16 professional and 20 client populations, and their quality was generally poor. Analysis identified six broad themes: definitions of caseload management, caseload measurement and 'tools', models of caseload management practice, client-professional relationship, discharging and professional guidance. Six papers presented issues that related to but did not fit within these themes. Current caseload management tools and models of caseload management practice had a poor evidence base. Five papers described benefits of team-based approaches. Professional guidance for caseload management is limited in detail and relevance to daily practice.

CONCLUSIONS

Although there is a considerable literature on caseload management, it is not possible to make summative conclusions. Policy-makers and professional bodies should encourage and support development of research evidence about the ways to achieve effective, efficient and equitable caseload management. Health and social care services considering implementing caseload management tools or models of practice should critically appraise their basis, and consider their potential advantages as well as disadvantages.

Supporting nurse decision making in primary care: exploring use of and attitude to decision tools

Nurses are increasingly working more autonomously in extended roles, yet we know little about the nature of the decisions they make. Decisions vary in terms of complexity, ambiguity and presentation, and the nature of the decision task impacts on the process of decision making, such as the likelihood of using a decision tool. Thus, knowledge about the nature of nursing decisions is essential for development of effective decision tools. This article presents an analysis of 410 nurse-patient consultations and interviews with 76 primary care nurses, and explores the nature of the decisions that primary care nurses make and the impact of that on their use of and attitudes towards decision tools.

Health visiting assessment--unpacking critical attributes in health visitor needs assessment practice: a case study

BACKGROUND

Assessment of family health need is a central feature of health visiting practice in which a range of skills, knowledge and judgements are used. These assessments are pivotal in uncovering need, safeguarding children and in determining levels of health intervention to be offered to children and their families by the health visiting service in the UK.

OBJECTIVES

The central focus of this paper is to outline the critical attributes of the basic principles that underpin health visiting assessment practice that emerged as part of a case study enquiry.

DESIGN

A case study design informed by a constructivist methodology was used to examine health visitors' professional judgements and use of formal guidelines in identifying health needs and prioritising families requiring extra health visiting support.

SETTINGS

The main study was conducted in three community Trust case sites in England, UK, with pilot work being undertaken in a fourth site.

METHODS AND PARTICIPANTS

Fifteen health visitors participated in the main study and data were collected during 56 observed home visits to families receiving extra health visiting support. Separate in-depth interviews were conducted with the health visitors, pre- and post-home contacts, while 53 client interviews also took place.

RESULTS/CONCLUSIONS

The analysis suggests that there are certain fundamental elements associated with the majority of health visitor assessments and these have been termed assessment principles. These characteristics are integral to, and provide the basis upon which health visitors' assessments are conducted and professional judgement is formed. They reflect the basic principles of health visiting assessment practice, which exist despite the constraints and realities of the practice context and can be differentiated from the activity centred methods of assessment processes.

Reassurance or judgement? Parents' views on the delivery of child health surveillance programmes

BACKGROUND

The first year of a child's life is a crucial time for child development. Current guidance about child health surveillance and health promotion programmes emphasises a partnership approach between health professionals and parents when it comes to child health care. Parents' voices have been largely absent from discussions about local child health programmes. For partnership working to be effective and for local services to be able to evolve effectively parents' views are vital.

OBJECTIVES

This study aimed to explore parents' views on the child health surveillance and health promotion programmes offered during the first year of their child's life. The study aimed to be consumer-led through the involvement of lead parents in all stages of the research process.

METHODS

This study employed a qualitative methodology of focus groups and individual interviews. 35 participants were drawn from three general practices using a snowball sampling technique. Eligibility was determined as parents with a child under the age of one year or expecting a baby within the study timescale and registered at one of the 3 general practices. Focus groups were led by three 'parent-researchers' and individual interviews were conducted by a researcher. All focus groups and interviews were tape-recorded, transcribed and analysed using Atlas.Ti.

RESULTS

Several main themes were identified in this study. Firstly, when discussing scheduled health checks for children under one year of age parents expressed more positive feelings for the eight-week check which was seen to be comprehensive and informative rather than the eight-month check which was viewed as bureaucratic and less reassuring. Secondly, parents clearly articulated a need for reassurance and support from health professionals involved in child health surveillance and health promotion programmes. Thirdly, a crucial professional in the delivery of these programmes was the health visitor. Whilst parents expressed support for the concept of health visitors some health visitors were seen as bureaucratic and as making judgements of need based on socio-economic factors. Finally, some parents spoke of feeling excluded from accessing support as they were deemed not to be 'in need'.

CONCLUSIONS

Wider concepts of partnership working between health professionals and parents, and, needs assessment are important to this study. Crucial elements of the partnership appear to be missing and this coupled with needs assessments that leave parents feeling excluded mean that there are discrepancies between expectations and experiences of parents. These issues require consideration in order to improve services and experiences.

Health needs assessment tools: Progress and potential

Objectives:Health needs has attracted the interest of policy-makers, health economists, and health professionals as modern health services try to satisfy individual and population health needs to optimize resource utilization. Health needs can be assessed by administering various types of survey or interview-based instruments. If health needs are to be satisfied in changing health agendas in developed and developing countries, it is essential to employ valid and reliable tools. Despite the importance of needs assessment, no comprehensive review of tools is currently available. We carried out a literature search to define and categorize existing health needs assessment tools.

Methods:We reviewed medical and social search engines for items containing specific health needs–related words to identify needs tools across a range of specialties. Papers were reviewed in terms of design, subject matter, psychometric features, and method of administration method.

Results:Thirty-one employed in 52 studies including cancer, mental health, palliative care, multiple sclerosis, and cardiovascular disease tools were identified.

Conclusions:This report summarizes available health needs instruments in a range of diseases to assist researchers in accessing health needs resources more easily and to encourage further research in this field.

The guideline contradiction: health visitors' use of formal guidelines for identifying and assessing families in need

The aim of this paper is to examine health visitors' use of formal guidelines in identifying health needs and prioritizing families requiring extra health visiting support. With the increasing emphasis on targeted health visiting, a case study was used to explore the extent to which health visitors in three case sites use needs assessment guidelines in the assessment of family health need. The findings indicate how the presence of core visiting protocols hints at elements of control by managers, leading to conflicts in the relationship between professional judgements and official guidelines. Despite a management ethos of guideline formulation, several contradictions exist for which these guidelines are a focus. These include: little involvement of health visitors in guideline development, some staff not informed about the existence of formal guidelines, little evidence of guidelines contributing to improved client outcomes and their limited use by many health visitors in practice. Thus, even when guidelines exist, no accurate predictions can be made about health visitors' knowledge of or use of such guidelines in practice.

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.