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

1. The Effectiveness of Public Health Nursing: A Review of Systematic Reviews Lawrie Elliott1 Iain Crombie2 Linda Irvine2 Jane Cantrell1 Julie Taylor2 1 Schoolof Nursing and Midwifery University of Dundee 2 Department of Epidemiology and Public Health University of Dundee

2. Aim • Conduct a review of the international scientific literature that gives the greatest coverage of the role of nurses in improving the public’s health. • Scientific literature included primary papers and reviews

3. Public health nurse and public health nursing (inclusion criteria) • any nurse including health visitors and midwives • mobilising resources to ensure health • preventing disease, prolonging life and promoting health • interventions targeted at individuals and specific groups in society • includes multi-disciplinary interventions

4. Health topics Health Priorities Client Groups Coronary Heart Disease Children & Adolescents Cancers Maternal Accident Prevention Elderly Mental Health Inequalities in Health Lifestyles Smoking Abuse of Alcohol Illicit Drug Use Diet Physical Activity Sexual Health

5. Sources of literature Electronic databases (1989-1999) • Medline • Embase • Cinahl • PsychLit

6. Sources of literature Authoritative Bodies • Cochrane Collaboration • Centre for Evidence Based Nursing (UK) • Health Technology Assessment (UK) • Health Education Authority (UK) • Health Education Board for Scotland • Centre for Reviews and Dissemination (UK) • Public Health Research, Education & Development Program (Canada) • United States Preventive Services Taskforce

7. Sources of literature Experts • Public Health Review Reference Group and Literature Review Sub-Committee • Cochrane Review Groups • Key authors from authoritative groups • Researchers publishing on selected topics

8. Appraising the reviews Abstracts • Relevant to Public Health • Relevant to Nursing • Synthesis of data from primary studies

9. Number of reviews retrieved (n=301) Coronary Heart Disease 34 Cancers 24 Mental Health 17 Accident Prevention 10 Child & Adolescent Health 70 Maternal Health 30 Care of the Elderly 31 Smoking 25 Abuse of Alcohol 8 Illicit Drug Use 19 Diet 16 Physical Activity 9 Sexual Health 13 Inequalities in health 2 General 33

10. Detailed appraisal Full 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)

11. Reviews included (n= 168) and rejected (n= 133) Included Rejected Coronary heart disease 20 14 Cancers 8 16 Mental health 9 8 Accident prevention 8 2 Child & Adolescent health 49 21 Maternal health 27 3 Care of the elderly 11 10 Smoking 18 7 Abuse of alcohol 3 5 Illicit drug use 7 12 Diet 9 7 Physical activity 8 1 Sexual health 8 5 General 13 20

12. Overview of study outcomes(n= 362) • Strong effect (11%) • Weak effect (42%) • Ineffective (20%) • Harmful (3%) • Insufficient evidence (24%)

13. Challengeof success • Knowledge • Behaviour • Health gain

14. Increasing knowledge • Interactive teaching and BP monitoring (hypertensionknowledge in adults) • Interactive teaching (healthy eating knowledge in school children) • Videos in STD clinics (knowledge of STD's and condom use)

15. Behaviour change • HIV testing and counselling (increases condom use in sero-discordant couples) • Psychological interventions (strengthen coping skills in children) • Smoking cessation interventions (smoking cessation in pregnant women)

16. Health gain • Strict low fat diets (reduces blood cholesterol in clinic populations) • Education with environmental and legislative change (reduces injury in children) • Behavioural interventions aimed at reducing environmental hazards (reduces falls in the elderly)

17. Features of Success • Interactive teaching • Environmental modification • Theory based • Multi-agency • High risk groups • Long-term/multi-session

18. UnsuccessfulInterventions • Passive information giving • Poorly structured • Lack achievable aims • Non-theory based • Prohibition rather than safe practice

19. Limitations • Limited coverage a) missed recently published primary papers b)interventions not yet subject to review c) qualitative research • Restricted definition of nurse’s role in public health (social problems?) • Applicability to UK

20. Strengths • Broad overview of public health nursing • Review aggregated from large number of studies (weight of evidence) • Comprehensive search • Consistency across health topics • Rapid Reviewing

21. Challenges • Assessing the quality of reviews • Establishing intervention outcomes at the outset • Designing research/evaluation to assess these outcomes • Training nurses in public health

22. Elliott L, Crombie IK, Irvine L, Cantrell J, Taylor J.(2001) The effectiveness of public health nursing: A review of systematic reviews. The Stationary Office, Edinburgh. l.elliott@dundee.ac.uk Available from: The Stationary Office Bookshop 71 Lothian Road Edinburgh, UK EH3 9AZ Tel:(+) 0870-606-5566 ISBN 1 84268 472 8

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