The protocol for the Families First Edmonton trial (FFE): a randomized community-based trial to compare four service integration approaches for families with low-income

Self-reported and parent-reported mental health in children from low-income families in Agder, Norway: results from baseline measurements of New Patterns project participants

BACKGROUND

Poverty may pose risks to child and adolescent mental health, but few studies have reported on this association among children and adolescents in low-income families in Norway.

METHODS

Based on a sample participating in an intervention for low-income families in Norway, we report data from the survey administered at the start of the intervention. Mental health problems were measured using the Strengths and Difficulties Questionnaire (SDQ; self-report (SR) n = 148; parent/proxy-report (PR) n = 153, mean age = 10.8). Demographic and family characteristics were obtained from parent reported data. Results are presented by gender and migration background. Regression analysis was used to investigate the relative contribution of background factors to mental health symptoms. The distribution of scores is compared to UK norms.

RESULTS

Participants reported relatively high scores on the Strengths and Difficulties Questionnaire (SDQ) Total Difficulties Scale (parent/proxy-report, PR mean=10.7; self-report, SR mean=10.1). Participants with non-immigrant backgrounds scored considerably higher on the Total Difficulties Scale (PR mean difference=2.9; SR 5.3) and on most other domains measured with the SDQ compared with their peers with immigration backgrounds. Participants generally scored higher than or equal to UK norms.

CONCLUSION

Participants in the current study had many symptoms of mental health problems, with large differences between those with and without a migrant background. Interventions for low-income families should be based on detailed knowledge about differences in family risks, resources and needs.

Anxiety and healthcare satisfaction of mothers with children hospitalized in the pediatric emergency service

OBJECTIVES

This cross-sectional study was conducted to determine the anxiety and healthcare satisfaction levels of mothers with children hospitalized in the pediatric emergency service and the relationship between them.

METHODS

The study sample comprised mothers (n = 316) with children hospitalized in the pediatric emergency service of a tertiary hospital in Turkey. Intsitutional and ethics committee approval was obtained, and data were collected using the Questionnare Form, State Anxiety Inventory (SAI), and PedsQL Healthcare Satisfaction Scale (PHSS).

RESULTS

The SAI mean scores of mothers were moderate (45.30 ± 9.29) and their PHSS total mean scores were high (70.74 ± 23.80). In the study, there was a low-level negative correlation between the SAI mean scores of the mothers and the PHSS subscales and total scale mean scores (p < 0.05). We found a relationship between the PHSS mean scores of mothers and the SAI mean scores, maternal age, education level, and waiting time for the examination, explaining 13.5% of the scores on the PHSS scale (p < 0.05).

CONCLUSION

In this study, the mothers had moderate anxiety and high healthcare satisfaction levels. Anxiety, educational level, and the waiting for an examination affected the healthcare satisfaction of mothers. The anxiety of mothers whose children are hospitalized in the pediatric emergency service should be reduced by conducting interventional studies.

Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation

BACKGROUND

Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis.

OBJECTIVES

To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events.

MAIN RESULTS

We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies.

AUTHORS' CONCLUSIONS

The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.

Mobilising social support to improve mental health for children and adolescents: A systematic review using principles of realist synthesis

Social support is a well-recognised protective factor for children's mental health. Whilst many interventions exist that seek to mobilise social support to improve children's mental health, not much is known about how to best do this. We sought to generate knowledge about the ways in which social support can be mobilised to improve children's mental health. We conducted a systematic review, which followed the principles of a realist synthesis. The following databases were searched: PubMed, CINAHL, Ovid MEDLINE, PsychINFO, EMBASE, Child and Adolescent Studies, EconLit and SocINDEX. Studies were included if the age of participants was between 0 and 18 years and they evaluated or described programme theories of interventions that sought to improve children's mental health by mobilising social support. Relevance and quality of studies were assessed, and data were extracted and analysed narratively. Thirty-three articles were included. Studies varied substantially with regard to the detail in which they described the processes of mobilising social support and expected mechanisms to improve children's mental health. Those that provided this detail showed the following: Intervention components included explaining the benefits of social support and relationships to families and modelling friendly relationships to improve social skills. Pathways to improved outcomes reflected bi-directional and dynamic relationships between social support and mental health, and complex and long-term processes of establishing relationship qualities such as trust and reciprocity. Parents' ability to mobilise social support for themselves and on behalf of children was assumed to impact on their children's mental health, and (future) ability to mobilise social support. Although interventions were considered affordable, some required substantial human and financial resources from existing systems. Mobilising social support for vulnerable children can be a complex process that requires careful planning, and theory-informed evaluations can have an important role in increasing knowledge about how to best address social support and loneliness in children.

Care Coordination for Vulnerable Families in the Sydney Local Health District: What Works for Whom, under What Circumstances, and Why?

Introduction:

Healthy Homes and Neighbourhoods (HHAN), an integrated care programme in the Sydney Local Health District (SLHD), seeks to address the needs of disadvantaged families through care coordination, as one of its components. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, service-providers and partner organisations.

Methods:

Critical realist methodology was utilised to undertake a qualitative evaluation of the impact of care coordination. Purposive sampling was used to select a total of 37 participants for interview, including consumers, service-providers and key stakeholders. Thematic analysis was undertaken to derive the major modes of intervention of HHAN, and data representing these elements was coded and summarised under contexts, mechanisms and outcomes.

Results:

Analysis indicates that care coordination has a positive impact on clients’ sense of independence, self-awareness and outlook on life. Trust and favourable interpersonal relations were identified as major underlying mechanisms for a successful client-provider working relationship. The identified modes of intervention facilitating positive consumer outcomes included accessibility, flexibility and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery.

Conclusions:

This study suggests that a care coordination model may be effective in engaging disadvantaged families in healthcare, assist them in navigating the health system and can lead to beneficial health and social outcomes. Successful implementation of care coordination requires flexible programme design and experienced and skilful clinicians to fulfil the care coordinator role. There is a need to appreciate the negative impact that the complex and siloed health system can have on disadvantaged families.

Service-integration approaches for families with low income: a Families First Edmonton, community-based, randomized, controlled trial

Background

Increasing access to health and social services through service-integration approaches may provide a direct and sustainable way to improve health and social outcomes in low-income families.

Methods

We did a community-based randomized trial evaluating the effects of two service-integration practices (healthy family lifestyle and recreational activities for children) among low-income families in Alberta, Canada. These two practices in combination formed four groups: Self-Directed (no intervention), Family Healthy Lifestyle, Family Recreation, and Comprehensive (Family Healthy Lifestyle plus Family Recreation programs). The primary outcome was the total number of service linkages.

Results

We randomized 1168 families, 50 % of which were retained through the last follow-up visit. The number of service linkages for all three intervention groups was not significantly different from the number of linkages in the Self-Directed group (Comprehensive 1.15 (95 % CI 0.98–1.35), Family Healthy Lifestyle 1.17 (0.99–1.38), and Family Recreation 1.12 (0.95–1.32) rate ratios). However, when we explored the number of linkages by the categories of linkages, we found significantly more healthcare service linkages in the Comprehensive group compared to the Self-Directed group (1.27 (1.06–1.51)) and significantly more linkages with child-development services in the Family Healthy Lifestyle group compared to the Self-Directed group (3.27 (1.59-6.74)). The monthly hours of direct intervention was much lower than the assigned number of hours (ranging from 5 to 32 % of the assigned hours).

Conclusions

Our findings are relevant to two challenges faced by policymakers and funders. First, if funds are to be expended on service-integration approaches, then, given the lack of intervention fidelity found in this study, policymakers need to insist, and therefore fund a) a well-described practice, b) auditing of that practice, c) retention of family participants, and d) examination of family use and outcomes. Second, if child-development services are widely required and are difficult for low-income families to access, then current policy needs to be examined.

Trial registration

ClinicalTrials.gov, NCT00705328. Registered on 24 June 2008.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1444-8) contains supplementary material, which is available to authorized users.