The reported views and experiences of cancer service users from minority ethnic groups: a critical review of the literature

There is growing evidence of inequalities in access to high-quality cancer services between minority and majority ethnic groups. However, little research has been carried out from the perspective of users from minority ethnic groups themselves. This paper reports a review of the British literature exploring the views and experiences of cancer service users from minority ethnic groups. We reviewed 25 qualitative studies that reported the experiences of people from minority ethnic groups. The studies highlighted significant issues and challenges, including comprehension and communication barriers, a lack of awareness of the existence of services and a perceived failure by providers to accommodate religious and cultural diversity. This paper critically discusses some of the explanations commonly invoked for ethnic inequalities in access to high-quality care, such as the belief that the lack of use of services reflects a lack of need. Despite positive initiatives to respond better to the needs of minority groups, we suggest the impact of these remains highly variable. Institutional racism within services is still much in evidence.

An evaluation of the introduction of Clinical Trial Officer roles into the cancer clinical trial setting in the UK

The National Cancer Research Network (NCRN) was created in 2001 to improve the infrastructure for cancer research within the National Health Service (NHS) in the UK and ensure that research is better integrated with cancer care. The NCRN consists of 34 regional networks which map onto the 34 cancer networks that were established following the publication of the NHS Cancer Plan with its aim of improving the coordination and delivery of cancer care and treatment nationally. An objective of the NCRN is to increase recruitment into cancer trials through improved support. One cancer research network responded by introducing Clinical Trial Officers (CTOs) into the cancer clinical trial setting in order to combine the range of tasks required to support clinical trials into a single role with the ultimate aim of increasing recruitment into cancer clinical trials. Evaluation during the first 14 months of their introduction assessed the impact of the new CTO role on cancer trial recruitment, its acceptability to those involved in trials and its effectiveness in achieving increased recruitment. Evaluation identified appropriate induction and training programmes required to support these new roles and the identification of a model for the introduction of CTO posts in other networks across the country. The findings presented in this paper identify that CTO roles can effectively be introduced into a cancer network and have an impact on recruitment to clinical trials within that network. The data collected provided an in-depth insight into how these roles were perceived, have developed and what supporting structures need to be in place to enable them to flourish. Recruitment in the network has increased and there has been a raising of awareness of clinical trials and cancer research across the whole of the cancer network where the CTOs were based. We conclude that CTO roles can offer a creative alternative to staffing cancer clinical trial units and that such a model could be introduced across other networks. Similar models could also be introduced into other disease settings where clinical research is taking place.

A randomised controlled trial of nurse-managed trial conclusion following early phase cancer trial participation

The effect of a nurse-managed intervention, for early phase cancer trial participants at trial conclusion, on psychosocial outcomes was evaluated at two cancer centres in the Midlands, England using a randomised controlled trial. It involved 117 patients who were participating in an early phase cancer clinical trial. It was a nurse-managed trial exit, which included a trial exit interview, trial feedback information leaflet and telephone follow-up compared with standard care at trial conclusion. Psychological distress at 1 week and 4-6 weeks post-trial conclusion, patient's knowledge and understanding and patient's satisfaction were assessed. The results showed there was no significant difference between the two groups regarding scores for anxiety and depression at time one and time two. There is some suggestion that the intervention reduced anxiety from trial conclusion to follow-up (P=0.27). Patients in both groups felt they had contributed to cancer research through trial participation. However, intervention patients were more likely to feel that they knew how the trial was going (P<0.001), knew how other people in the trial were doing (P=0.001), had all the feedback they needed about the trial they took part in (P<0.01) and knew how they would be followed up (P=0.02). Patient satisfaction with the intervention was high (median score=4.5 where 5 is greatest satisfaction). In conclusion, nurse-managed trial conclusion led to positive outcomes for patients who had recently completed a clinical trial.

Effectiveness of home based support for older people: systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of home visiting programmes that offer health promotion and preventive care to older people.

DESIGN

Systematic review and meta-analysis of 15 studies of home visiting.

PARTICIPANTS

older people living at home, including frail older people at risk of adverse outcomes.

OUTCOME MEASURES

Mortality, admission to hospital, admission to institutional care, functional status, health status.

RESULTS

Home visiting was associated with a significant reduction in mortality. The pooled odds ratio for eight studies that assessed mortality in members of the general elderly population was 0.76 (95% confidence interval 0.64 to 0.89). Five studies of home visiting to frail older people who were at risk of adverse outcomes also showed a significant reduction in mortality (0.72; 0.54 to 0.97). Home visiting was associated with a significant reduction in admissions to long term institutional care in members of the general elderly population (0.65; 0.46 to 0.91). For three studies of home visiting to frail, "at risk" older people, the pooled odds ratio was 0.55 (0.35 to 0.88). Meta-analysis of six studies of home visiting to members of the general elderly population showed no significant reduction in admissions to hospital (odds ratio 0.95; 0.80 to 1.09). Three studies showed no significant effect on health (standardised effect size 0.06; -0.07 to 0.18). Four studies showed no effect on activities of daily living (0.05; -0.07 to 0.17).

CONCLUSION

Home visits to older people can reduce mortality and admission to long term institutional care.

Universal vs. selective services: the case of British health visiting

AIMS

This paper discusses whether there should be universal or selective provision of health visiting services. The aim is to show the central relevance of the work of the late epidemiologist, Geoffery Rose, to arguments advocating the retention of a universal health visiting service.

BACKGROUND

In the United Kingdom (UK), health visiting moved, in the early years of the twentieth century, from being focused on the needs of poor families to becoming a universally provided service. Recent debates about the future of British health visiting have again raised the issue of whether health visiting remains a universal service, or should be targeted only on the most needy.

STRUCTURE

Following an exposition of Rose's work, two kinds of problems with which health visitors are concerned, depression and child abuse, are used to illustrate the ways in which Rose's approach can be applied to health visiting. CENTRAL THESIS: Rose argued that the bulk of problems in society arise in the many who are not at especially high risk, rather than in the few who are at high risk. This is because of a very large number of people who are not at especially high risk. Consequently, following Rose, this paper argues that in relation to such problems as depression or child abuse, to target health visiting services only on those at high risk would be to leave untouched a vast burden of health and social problems. In the context of identifying people who are at greatest risk, Rose argued that no screening instrument can ever be sufficiently precise to accurately identify those most likely to suffer problems. In corroboration of Rose's argument, this paper illustrates the pitfalls of health visitors' attempts to screen for families at greatest risk through the use of such instruments as checklists of risk factors.

CONCLUSIONS

It is concluded that it is neither possible to screen accurately for those at greatest risk, nor desirable to target services only on those at greatest risk. Therefore, it is advocated that health visiting should remain a universal service. However, it is recognized that within a universally provided service, some clients will require a greater intensity of input than others. In assessing the need for services, it is argued that the professional judgements of health visitors are crucial.

Does home visiting improve parenting and the quality of the home environment? A systematic review and meta analysis

AIMS

To evaluate the effectiveness of home visiting programmes on parenting and quality of the home environment.

DESIGN

Systematic review of the literature of randomised controlled trials and quasi-experimental studies evaluating home visiting programmes involving at least one postnatal visit.

SUBJECTS

Thirty four studies reported relevant outcomes; 26 used participants considered to be at risk of adverse maternal or child health outcomes; two used preterm or low birth weight infants; and two used infants with failure to thrive. Only eight used participants not considered to be at risk of adverse child health outcomes.

RESULTS

Seventeen studies reported Home Observation for Measurement of the Environment (HOME) scores, 27 reported other measures of parenting, and 10 reported both types of outcome. Twelve studies were entered into the meta analysis. This showed a significant effect of home visiting on HOME score. Similar results were found after restricting the analyses to randomised controlled trials and to higher quality studies. Twenty one of the 27 studies reporting other measures of parenting found significant treatment effects favouring the home visited group on a range of measures.

CONCLUSIONS

Home visiting programmes were associated with an improvement in the quality of the home environment. Few studies used UK health visitors, so caution must be exercised in extrapolating the results to current UK health visiting practice. Further work is needed to evaluate whether UK health visitors can achieve similar results. Comparisons with similar programmes delivered by paraprofessionals or community mothers are also needed.

Evidence-based practice and health visiting: the need for theoretical underpinnings for evaluation

In this paper we argue that evidence-based practice, which is being introduced throughout the British National Health Service to make decisions about the allocation of limited resources, provides a welcome opportunity for health visitors to demonstrate their efficacy, skills and professionalism. However, the paper argues that to view health visiting as evidence-based is not to reduce health visiting merely to a technology through which scientific solutions are applied to social problems. Rather, health visiting needs to be viewed as a political movement, based on a particular model of society, which shapes the goals which health visitors pursue and influences the strategies they adopt to achieve their goals. The paper describes various models of health visiting as a way of showing how the goals of health visiting are always framed within a particular set of assumptions and causal explanations. The paper then turns to look at the issue of evaluating health visiting services. It is argued that evaluation should properly take account of the models which shape health visitors' goals and intervention strategies, and in turn, health visitors need to be explicit about the theoretical frameworks underpinning their interventions. Finally, it is argued that health visitors' knowledge and understanding of a range of models of society enables them to move between the various models to choose the most appropriate and effective means of intervention. Hence it is concluded that the emphasis on evidence-based practice provides health visitors with a valuable opportunity to show that their unique, professional skills and understanding are the preconditions for effective intervention.

The effect of home visiting programmes on uptake of childhood immunization: a systematic review and meta-analysis

BACKGROUND

The aim of the study was to evaluate the effectiveness of home visiting programmes on the uptake of childhood immunization.

METHODS

A systematic review was carried out of the literature of controlled studies evaluating home visiting programmes involving at least one post-natal visit, which included tasks within the remit of British health visiting and reporting outcomes relevant to British health visiting. Eleven studies were considered, nine of which used socio-economically disadvantaged families. The outcome measure was uptake of a range of childhood immunizations.

RESULTS

Eleven studies reported uptake of immunization. Effect sizes from nine studies were included in the meta-analysis. Fixed effects models demonstrated a significant effect of home visiting for all studies and also for several subgroups of studies, but with significant heterogeneity of effect sizes. A random effects model failed to demonstrate an effect of home visiting.

CONCLUSIONS

Home visiting programmes have not been shown to be effective in increasing the uptake of immunization. Other methods of increasing uptake and reducing inequalities in uptake will need to be explored.

The effectiveness of health services: the case of health visiting

This article challenges the belief that health visiting is ineffective. Rebutting the arguments of some of health visiting's detractors, the authors point to a wealth of evidence that health visiting is effective. They acknowledge, however, that current methods of evaluating the effectiveness of many health services are far from perfect, and that some of the benefits of services like health visiting are more easily ascertained than others. The article discusses the dangers of defining such services as health visiting as technologies, arguing that ultimately, this is leading to a restriction in the kinds of activities which are seen as the proper domain of professionals such as health visitors. It is concluded that future debates concerning the effectiveness of health visiting must acknowledge the limitations of both current definitions of health visiting, and methods of evaluating health services. Finally, in looking to the future of health visiting, it is concluded health visitors have a far broader role to play than merely assuming responsibilities cast off by doctors.

The use of targets to improve the performance of health care providers: a discussion of government policy

The aim of this discussion paper is to examine the advantages and drawbacks of employing targets, or performance indicators, to improve the performance of those delivering health care services. The paper is based on an examination of two target-setting policies initiated by Government: the 1992 Health of the Nation strategy and the 1990 General Practitioners' Contract. It is argued that the introduction of both the General Practitioners' Contract and the Health of the Nation have indeed been accompanied by improvements in performance, however, there are a number of problems with targets. They tend to focus on those things that are most easily measured, and they may foster complacency on the part of providers who have already achieved upper target limits, and defensiveness on the part of those performing badly. National targets may skew local priorities; they may also be unrealistic and unattainable for particular, less privileged population groups. They may serve to widen inequalities in health, and can exacerbate the 'inverse care law' by encouraging providers to direct their efforts at the more advantaged sections of society, where such efforts are more likely to pay off in terms of overall improvements in the target level achieved. Finally, the achievement of some targets will not necessarily result in better health outcomes. The paper concludes that a target-setting approach to improving the quality of care must be based on the use of appropriate indicators, and must take account of differences between more and less advantaged sections of society.

Project 2000: a review of published research

The findings of research into the implementation of the Project 2000 reforms of nurse education in England and Wales are reviewed in this paper. The work of nine research teams who have published their findings between 1990 and 1994 is reviewed. Following a brief summary of the major Project 2000 recommendations, the findings of the various research teams are presented. Both successes and difficulties in implementing Project 2000 are highlighted. The findings are discussed in the light of the original Project 2000 proposals, and it is concluded that, notwithstanding 'teething' difficulties, the Project 2000 reforms are proving workable in practice.

Project 2000 and the replacement of the traditional student workforce

This paper reports on part of a 4-year study monitoring the implementation of Project 2000 in one health authority. Its focus is on the consequences for the nursing service of replacing traditional, pre-Project 2000 students with permanent staff. It is argued that the Department of Health, who have been responsible for funding the replacement programme, have underestimated the numbers of permanent staff required to replace the traditional student workforce, and that the Project 2000 replacement exercise has contributed to a deterioration in staffing levels and skill mix.

Project 2000: the gap between theory and practice

This article explores the theory-practice gap in the context of Project 2000. Drawing on the findings of empirical research into the implementation of Project 2000 in one district health authority, we conclude that tensions between education and service staff have far from disappeared with the advent of Project 2000. The article discusses firstly the difference in emphasis between education and service staff over the question of equipping students with practical skills during their Common Foundation Programme. Secondly, we discuss the fact that whilst educationalists are intent on fostering self-directed learning in students, service staff are more concerned with producing safe practitioners. The article concludes on an optimistic note, suggesting that although service and education staff may differ in the relative importance they attach to teaching students particular types of skill; and although they may be operating on different timescales, fundamental disagreements between the two groups are absent.