Home visiting services for children in low-income families?
In the UK, health visitors are responsible for promoting health in young families and this has traditionally incorporated home visiting as part of care. In a climate of financial challenges, it is important to establish the clinical and cost effectiveness of health care interventions and this can be particularly challenging for health promotion activities where outcomes may be difficult to measure or require very long follow up times. In the USA, the Nurse Family Partnership model of early-life home visiting has a robust evidence-base in relation to the benefits on parenting, infant health and child behaviour outcomes. However, it remains unclear whether the benefits of home visiting programmes extend beyond early childhood and whether interventions delivered by paraprofessionals (those without any formal professional accreditations) are as effective as those delivered by degree-educated nurses.
This USA randomised controlled trial recruited pregnant, low-income, first time mothers. The participants were randomly allocated to a control group, a nurse home visiting group or a paraprofessional home visiting group. Those in the nurse or paraprofessional groups received home visits until their child reached 24 months. The children were assessed at six and nine years of age. The study found that children who had received nurse home visits showed better cognitive and behavioural outcomes than children in the control group but children who had received paraprofessional visits showed few differences compared to children in the control group.
A commentary notes that this study adds to the growing body of evidence to support home visiting for low-income, first time mother during pregnancy and the first two years of infancy. However, it does raise questions about the efficacy of paraprofessionals. It is possible that pregnant women are more receptive to professional accredited health care providers or that nurses have more diverse skills in this field and greater access to community resources (such as childcare opportunities or healthcare provision) than paraprofessionals. Further research that could explore this in greater depth would be useful to unpack and understand this issue.
Olds DL, Holmberg JR, Donelan-McCall N, et al. Effects of home visits by paraprofessionals and by nurses on children: follow-up of a randomized trial at ages 6 and 9 years. JAMA Pediatrics 2014;168:114–21
Dodge K.A. Nurse home visits for infants and toddlers of low-income families improve behavioural, language and attention outcomes at age 6–9 years; paraprofessional visits improve visual attention and task switching Evidence Based Nursing 2015 April; 18, 2 p 50
Do compression stockings prevent post-thrombotic syndrome?
Post-thrombotic syndrome is a chronic condition that develops in one-in-three patients who experience deep vein thrombosis (DVT). Post-thrombotic syndrome (PTS) can range from minor limb swelling to leg ulceration. There is evidence to suggest that elastic compression stockings reduce venous hypertension and it has been proposed that they may also prevent the development of PTS.
A USA randomised controlled trial recruited patients diagnosed with their first episode of DVT. These patients were randomly allocated to receive high compression stockings (30-40mmHG) or very low compression placebo stockings (5mmHg). The participants were provided with stockings within two weeks of their DVT diagnosis and were asked to wear them for two years. Stockings were replaced six monthly, when damaged or when the patient’s leg changed size. The results found no difference in the incidence of PTS between the two groups.
A commentary argues that the strong methodology of this study provides definitive evidence that elastic compression stockings should not be routinely used following a first episode of DVT. These results are not consistent with previously published trials and meta-analyses, which did support the use of compression stockings for preventing PTS, but it should be noted that the methodology of these previous studies limited their generalisability. Although the results of this study do not support the routine use of compression stockings, other preventative measure such as addressing patient specific risk factors, optimising anti-coagulant therapy and surgical interventions for venous valves should be considered. It is also worth noting that it is possible that compression stockings may have a useful therapeutic role in treating the symptoms of established PTS.
Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet 2014;383:880–8.
Kanaan A Elastic compression stockings fail to prevent post-thrombotic syndrome after a first deep vein thrombosis? Evidence Based Nursing 2015 January; 18,
1 p 22
PhD DN RGN
Lecturer in Community Nursing
School of Healthcare, University of Leeds
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