An integrated understanding of the impact of hospital at home: a mixed-methods study to articulate and test a programme theory.

BACKGROUND: Hospital at Home (HaH) provides intensive, hospital-level care in patients' homes for acute conditions that would normally require hospitalisation, using multidisciplinary teams. As a programme of complex medical-social interventions, a HaH programme theory has not been fully articulated although implicit in the structures, functions, and activities of the existing HaH services. We aimed to unearth the tacit theory from international evidence and test the soundness of it by studying UK HaH services. METHODS: We conducted a literature review (29 articles) adopting a 'realist review' approach (theory articulation) and examined 11 UK-based services by interviewing up to 3 staff members from each service (theory testing). The review and interview data were analysed using Framework Analysis and Purposive Text Analysis. RESULTS: The programme theory has three components- the organisational, utilisation and impact theories. The impact theory consists of key assumptions about the change processes brought about by HaH's activities and functions, as detailed in the organisational and utilisation theories. HaH teams should encompass multiple disciplines to deliver comprehensive assessments and have skill sets for physically delivering hospital-level processes of care in the home. They should aim to treat a broad range of conditions in patients who are clinically complex and felt to be vulnerable to hospital acquired harms. Services should cover 7 days a week, have plans for 24/7 response and deliver relational continuity of care through consistent staffing. As a result, patients' and carers' knowledge, skills, and confidence in disease management and self-care should be strengthened with a sense of safety during HaH treatment, and carers better supported to fulfil their role with minimal added care burden. CONCLUSIONS: There are organisational factors for HaH services and healthcare processes that contribute to better experience of care and outcomes for patients. HaH services should deliver care using hospital level processes through teams that have a focus on holistic and individually tailored care with continuity of therapeutic relationships between professionals and patients and carers resulting in less complexity and fragmentation of care. This analysis informs how HaH services can organise resources and design processes of care to optimise patient satisfaction and outcomes.

Context, Process, and Participant Response in the Implementation of Family Support Programmes in Spain / El contexto, el proceso y la respuesta de los participantes en la implementación de programas de apoyo familiar en España

Implementation research addresses how well a programme is conducted when applied in real-world conditions. However, research based on quality standards is still scarce as it requires monitoring context, process, and participant response. This study applies implementation quality standards to 57 Spanish parenting and family support programmes identified in the COST European Family Support Network project, using an ten-component evaluation sheet sheet. Descriptive analyses showed a good implementation level. The latent profile analysis identified four patterns defined by programme setting: profile 1, Social Services/NGO setting (21.1%), profile 2, Health setting (31.6%), profile 3, Multi-setting (14%), and profile 4, Educational setting (33.3%), differing in professional discipline, training, participant response, and professional perception of implementation. Profile memberships were related to programme outcomes, scaling up, and sustainability. Findings illustrate conceptual and practical challenges that researchers and professionals usually encounter during implementation, and the efforts required to deliver programmes effectively in real-world settings in Spain.(AU)

La investigación sobre implementación se ocupa de la calidad con la que se aplica un programa en condiciones del mundo real. Sin embargo, la investigación basada en patrones de calidad es aún escasa, ya que requiere supervisar el contexto, el proceso y la respuesta de los participantes. El presente estudio aplica los patrones de calidad a 57 programas españoles de apoyo parental y familiar identificados en el proyecto COST-European Family Support Network, enlos que se utilizó una hoja de evaluación de diez componentes. Los análisis descriptivos mostraron un buen nivel de implementación. El análisis de clases latentes detectó cuatro perfiles definidos por el entorno donde se aplica el programa: el perfil 1, contexto de los servicios sociales/ONG (21.1%), el perfil 2, contexto sanitario (31.6%), el perfil 3, diversos contextos (14%), y el perfil 4, entorno educativo (33.3%), que difieren en la disciplina del profesional, la formación, las respuestas de los participantes y la percepción que tiene el profesional sobre la implementación. La pertenencia a los diversos perfiles se relacionaba con los resultados del programa, su ampliación a gran escala y la sostenibilidad. Los resultados ponen de manifiesto los desafíos conceptuales y prácticos que tanto investigadores como profesionales suelen encontrar durante la implementación, así como los esfuerzos necesarios para aplicar los programas de forma efectiva en contextos reales en España.(AU)

Uptake and impact of vaccinating primary school-age children against influenza: experiences of a live attenuated influenza vaccine programme, England, 2015/16.

The 2015/16 influenza season was the third season of the introduction of an intra-nasally administered live attenuated influenza vaccine (LAIV) for children in England. All children aged 2‒6 years were offered LAIV, and in addition, a series of geographically discrete areas piloted vaccinating school-age children 7‒11 years old. Influenza A(H1N1)pdm09 was the dominant circulating strain during 2015/16 followed by influenza B. We measured influenza vaccine uptake and the overall and indirect effect of vaccinating children of primary school -age, by comparing cumulative disease incidence in targeted and non-targeted age groups in vaccine pilot and non-pilot areas in England. Uptake of 57.9% (range: 43.6-72.0) was achieved in the five pilot areas for children aged 5‒11 years. In pilot areas, cumulative emergency department respiratory attendances, influenza-confirmed hospitalisations and intensive care unit admissions were consistently lower, albeit mostly non-significantly, in targeted and non-targeted age groups compared with non-pilot areas. Effect sizes were less for adults and more severe endpoints. Vaccination of healthy primary school-age children with LAIV at moderately high levels continues to be associated with population-level reductions in influenza-related respiratory illness. Further work to evaluate the population-level impact of the programme is required.

Implementation, utilization and influence of a community-based participatory nutrition promotion programme in rural Ethiopia: programme impact pathway analysis.

OBJECTIVE: A community-based participatory nutrition promotion (CPNP) programme, involving a 2-week group nutrition session, attempted to improve child feeding and hygiene. The implementation, utilization and influence of the CPNP programme were examined by programme impact pathway (PIP) analysis. DESIGN: Five CPNP programme components were evaluated: (i) degree of implementation; (ii) participants' perception of the nutrition sessions; (iii) participants' message recall; (iv) utilization of feeding and hygiene practices at early programme stage; and (v) participants' engagement in other programmes. SETTING: Habro and Melka Bello districts, Ethiopia. SUBJECTS: Records of 372 nutrition sessions, as part of a cluster-randomized trial, among mothers (n 876 in intervention area, n 914 in control area) from a household survey and CPNP participants (n 197) from a recall survey. RESULTS: Overall, most activities related to nutrition sessions were successfully operated with high fidelity (>90 %), but a few elements of the protocol were only moderately achieved. The recall survey among participants showed a positive perception of the sessions (~90 %) and a moderate level of message recall (~65 %). The household survey found that the CPNP participants had higher minimum dietary diversity at the early stage (34·0 v. 19·9 %, P=0·01) and a higher involvement in the Essential Nutrition Action (ENA) programme over a year of follow-up (28·2 v. 18·3 %; P<0·0001) compared with non-participants within the intervention area. CONCLUSIONS: Our PIP analysis suggests that CPNP was feasibly implemented, promoted a sustained utilization of proper feeding behaviours, and enhanced participation in the existing ENA programme. These findings provide a possible explanation to understanding CPNP's effectiveness.

Perceived impact of Ghana's conditional cash transfer on child health.

A plethora of studies from sub-Saharan Africa indicate that orphaned and vulnerable children are exposed to adverse health, education and other social outcomes. Across diverse settings, conditional cash transfer (CCT) programmes have been successful in improving health outcomes amongst vulnerable children. This study explored the pathways of CCTs' impact on the health of orphans and vulnerable children in rural Ghana. Due to the multi-dimensional nature of CCTs, the programme impact theory was used to conceptualize CCTs' pathways of impact on child health. A qualitative descriptive exploratory approach was used for this study. This study drew on the perspectives of 18 caregivers, 4 community leaders and 3 programme implementers from two rural districts in Ghana. Semi-structured individual interviews were conducted with the participants. Thematic content analysis was conducted on the interview transcripts to pull together core themes running through the entire data set. Five organizing themes emerged from the interview transcripts: improved child nutrition, health service utilization, poverty reduction and social transformation, improved education and improved emotional health and well-being demonstrating the pathways through which CCTs work to improve child health. The results indicated that CCTs offer a valuable social protection instrument for improving the health of orphans and vulnerable children by addressing the social determinants of child health such as nutrition, access to health care, child poverty and education.