Child / Family Health Program Planning in Public Health: What's the Evidence?

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Child/Family Health Program Planning:

Discussing Review-Level Evidence

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What’s the evidence? Winzenberg, T.M., Shaw, K., Fryer, J., & Jones, G. (2006).

Calcium supplementation for improving bone mineral density in children. Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD005119.

Newton, M. S. & Ciliska, D. (2006). Internet-based innovations for the prevention of eating disorders: A systematic review. Eating Disorders, 14(5), 365-384.

Stinson, J., Wilson, R., Gill, N., Yamada, J., & Holt, J. (2009). A systematic review of internet-based self-management interventions for youth with health conditions. Journal of Pediatric Psychology, 34, 495-510.

Shepperd, S., Doll, H., Gowers, S., James, A., Fazel, M., Fitzpatrick R., & Pollock, J. (2009). Alternatives to inpatient mental health care for children and young people. Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD006410.

http://www.health-evidence.ca/articles/show/21957

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Welcome! This webinar has been made possible with support from the

Canadian Institutes of Health Research

Child/Family Health Program Planning:

Discussing Review-Level Evidence

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Maureen Dobbins Scientific Director Tel: 905 525-9140 ext 22481 E-mail: [email protected]

Kara DeCorby Administrative Director Tel: (905) 525-9140 ext. 20461 E-mail: [email protected]

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Daiva Tirilis Research Coordinator Tel: (905) 525-9140 ext. 20460 E-mail: [email protected]

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Robyn Traynor Research Coordinator

The Health Evidence Team

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CIHR-Funded Reviews Winzenberg, T.M., Shaw, K., Fryer, J., & Jones, G. (2006).

Calcium supplementation for improving bone mineral density in children. Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD005119.

Newton, M. S. & Ciliska, D. (2006). Internet-based innovations for the prevention of eating disorders: A systematic review. Eating Disorders, 14(5), 365-384.

Stinson, J., Wilson, R., Gill, N., Yamada, J., & Holt, J. (2009). A systematic review of internet-based self-management interventions for youth with health conditions. Journal of Pediatric Psychology, 34, 495-510.

Shepperd, S., Doll, H., Gowers, S., James, A., Fazel, M., Fitzpatrick R., & Pollock, J. (2009). Alternatives to inpatient mental health care for children and young people. Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD006410.

http://www.health-evidence.ca/articles/show/21957

Evaluation

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Questions?

Summary Statement: Winzenberg(2006)

Overall Considerations

Considerations for Public Health Practice Conclusions from Health Evidence General Implications

Calcium supplementation had: • a small, positive effect on bone mineral

density for upper limb (short term but not long term)

• no impact on bone mineral content for total body, femoral neck, or lumbar spine

Baseline calcium intake, gender, physical activity, duration of supplementation and type (e.g. milk extract) did not impact findings. The association between the increase in upper limb bone mineral density and fracture risk was not directly assessed in the studies. NOTE: The results were taken from the sensitivity analyses, representing a more conservative estimate of effect.

This review suggests there are no gains to be made from promoting calcium supplementation among healthy children. Public health decision makers should note that fracture rates were not assessed. However, it is unlikely that the small increase in bone mineral density of the upper limb will lead to a clinically significant decrease in fracture risk later in life. Evidence remains insufficient to make conclusions specific to peripubertal or non-Caucasian populations, or those with a baseline calcium intake <500 mg/day.











































Interpreting the Evidence

Calcium supplementation (19 RCTs, 2859 children)

What’s the evidence? Implications for practice & policy

• Calcium supplementation led to an increase in upper limb bone mineral density compared to placebo (SMD 0.14 mg/cm2, 95% CI 0.04, 0.24) (13 studies); an effect equal to a ~1.7% greater increase in supplemented groups, which at best would reduce absolute fracture risk in children by 0.1-0.2% per annum based on average peak fracture incidence. However, results were not maintained after stopping supplementation.

• No impact observed on femoral neck or lumbar spine bone mineral density, or on total body bone mineral content.

• Calcium supplementation among healthy children by public health is not supported at this time.

• There is insufficient evidence to support calcium supplementation of any dose/duration among healthy children to increase long-term lumbar bone mineral content, femoral neck bone mineral density, total body bone mineral content, or upper limb bone mineral density.

Calcium Supplementation Calcium supplementation led to an increase in upper limb bone mineral density

compared to placebo (SMD +0.14 mg/cm2, 95%CI 0.04, 0.24)




• Calcium supplementation led to an increase in upper limb bone mineral density compared to placebo (SMD 0.14 mg/cm2, 95%CI 0.04, 0.24) (13 studies); an effect equal to a ~1.7% greater increase in supplemented groups, which at best would reduce absolute fracture risk in children by 0.1-0.2% per annum based on average peak fracture incidence. However, results were not maintained after supplementation was stopped.























Baseline calcium intake, gender, physical activity, duration of supplementation and type (e.g. milk extract) did not impact findings. The association between upper limb bone mineral density and fracture risk is unknown.


Questions?

Summary Statement: Newton(2006)



This high quality review is based on a small number of weak quality studies. Interventions consisting of psychoeducational readings and reflections, Internet-based body image journaling, and asynchronous Internet discussion groups resulted in: • perceptions of increased support • improved knowledge but had no impact on: • body satisfaction • eating disordered attitudes and behaviours Declining completion rates associated with: • discomfort with the intervention • lack of face-to-face contact • concerns with privacy/confidentiality

Eating disorder prevention programs should use/encourage internet-based programs and online discussion boards to improve healthy lifestyles, attitudes/ behaviours and knowledge. These programs are not as effective for improving disordered eating and symptomology. Public health should expect internet-based eating disorder programs to generate high satisfaction but should also be cautious given programs can create discomfort as personal information is disclosed and face-to-face contact is eliminated. Strategies to minimize anxiety and frustration should be considered. Given the low quality studies, available for this review, findings should be used cautiously.

























Body Satisfaction, Attitudes, and Behaviours (5 trials, 356 participants)


• No impact on restraint, eating concern, shape concern, weight concern, or eating disordered attitudes and behaviours, body satisfaction, or eating attitudes.

• Based on currently available evidence, internet-based public health programs are not supported.


Social Support (Internet-based discussion groups) (2 RCTs)


• Participants in the program reported a “moderate” amount of support, as well as self- and other-acceptance, from the on-line discussion boards.

• As a strategy to improve perceived social support among this population, public health may consider implementing intervention-based discussion groups.


Knowledge (1 RCT; 1 quasi-experiment)


• Statistically significant improvements in knowledge were observed when participants were exposed to a multi-session intervention focused on healthy lifestyle attitudes/ behaviours that also allowed time for participants to reflect on new learning and experiment with newly-acquired skills.

• Public health should consider Internet-based eating disorder prevention programs for improving knowledge related to healthy lifestyles and attitudes/behaviours.



Software Experience (qualitative findings based on 1 RCT and 1 quasi-experiment)


• Most (77.5%) reported high satisfaction with the program. Students reported feeling that: (1) they could talk about their concerns in the on-line discussion group and felt supported, (2) other group members understood their concerns, and (3) input they received from group members was trusted (1 RCT).

• Participants expressed high levels of anxiety/frustration related to participant posted Internet messages (1 RCT).

• Public health should provide internet-based prevention programs for eating disorders considering it was viewed as being “useful, helpful, and fun”.

• However, this type of program could negatively impact participants. Public health should consider the potential impact posted Internet messages could have on anxiety levels and frustration from posted messages.


























Questions?

Summary Statement: Stinson (2009)



Internet-based self-management interventions for youth with health conditions improved : • symptoms among participants • disease-specific knowledge (asthma) • cost effectiveness mixed effects on • health care utilization • quality of life The interventions appeared to be • most effective among children with asthma • more effective in certain sub-populations

(e.g. older children with lower SES and African Americans)

Public health should support Internet-based self-management interventions for older children with low SES, and African American youth to: • increase symptom-free days and medication

use , and decrease school days missed and activity restrictions

• increase asthma knowledge • decrease ER visits and physician consults • provide cost-effective educational programs

to improve health and asthma knowledge Internet-based self management interventions are not supported to: • improve quality of life • decrease health care utilization (other than

ER visits and physician consultation).






































Improving health outcomes in terms of symptom management or disease control (9 studies)


• Seven studies found improvements in symptom management or disease control (e.g., symptom free days, use of medications, days of school missed, and activity restrictions) among intervention groups compared to controls.

• Public health programs should consider using internet-based self-management education interventions to improve symptom free days, use of medications, days of school missed, and activity restrictions.


Disease-related Knowledge (4 studies)


• Two of three studies on asthma found an increase in knowledge among the intervention groups compared to controls, whereas another study found no improvements.

• No impact on improvements in an encopresis study

• Public health programs should use internet-based self-management education to increase asthma knowledge among children,

• At this time public health programs should not use internet-based education to improve knowledge on encopresis.


Quality of Life (6 studies)


• Only two of six studies found improvements in quality of life among intervention groups compared to controls.

• Four studies did not report outcome data.

• Public health programs should not rely on internet-based education programs for children with asthma to improve quality of life.


Health Care Resources (4 studies)


• Two studies on asthma participants found decreases in emergency room visits and physician consultations; one study observed a decrease in emergency room visits only, and a fourth study reported no effect.

• Public health programs should use internet-based programs for children with asthma to decrease emergency room visits and physician consultations, although no impact on hospitalizations and overall service use should be expected.


Cost-effectiveness (4 studies)


• All four studies found the intervention was more cost-effective than traditional education programs (e.g. labour costs, resource utilization, health insurance, and societal costs).

• Public health should incorporate internet-based education in program planning to achieve cost-effectiveness.










Questions?

Summary Statement: Shepperd (2009)



Children with non-specific emotional/ behavioural disorders Home-based multi-systemic therapy reduces: • symptoms such as aggression and hyperactivity

reported by teachers • days spent out-of-school • self-reported alcohol use Intensive home treatment or intensive home-based crisis intervention, does not improve: • symptom severity • number of symptoms • family cohesion

Youth with anorexia nervosa Specialist outpatient treatment does not improve: • # post-discharge nights at inpatient facility • outpatient appointments • day patient contacts

Based on this review, public health programs should include and/or support: • home-based multi-systemic

therapy for children with non-specific emotional/behavioural disorders

should not include/support: • intensive home treatment for

children with non-specific behavioural/emotional disorders

• specialist outpatient services for youth with anorexia nervosa

Public health decision makers should be aware that the interventions presented were based on limited evidence and small sample sizes.
























































Home-based multi-systemic therapy (MST) Definition Therapists provide therapy to the child and the family together in their home. Families are required to participate, and MST services - according to protocol - are available 24/7. MST therapists will continue to work with clients who are hospitalized. Multi-systemic therapy (MST) follows a standard protocol and is a family-centred, ecologically orientated therapy targeting individual, family, peer and environmental aspects of psychopathology in the community, and includes the development of aftercare plans. Family therapy, behavioural therapy and cognitive behavioural therapy are used. Comprehensive crisis plans are developed jointly by the therapist and the child psychiatrist and focus on mobilizing the problem-solving skills within the family and community.


Home-based Multi-systemic Therapy (MST) (2 trials)


• In treating psychosis, at four months, fewer teacher-reported symptoms (SMD -0.52 95% CI -0.90 to -0.14); fewer days spent out-of-school (SMD -0.47, 95% CI -0.85 to -0.09); and less self-reported alcohol use (SMD -0.49, 95% CI -0.87 to -0.11) were reported.

• A study of low quality reported reduced self-reported minor delinquency (SMD -2.72, 95%CI -3.71 to -1.72), Youth Risk Behaviour scores (SMD -0.90, 95% CI -1.64 to -0.16), and fewer days of hospitalization (0.53 days/month vs. 3.88 days/month)

• No impact on symptom severity, caregiver-reported symptoms, marijuana use, arrests, caregiver satisfaction, self-reported total drug use, family adaptability, and cohesion.

• Public health decision makers may consider supporting/encouraging MST as opposed to inpatient care for psychosis given positive impact on some outcomes may be realized. However, for many additional outcomes, for both the child and family, positive improvements should not be expected.




• In treating psychosis, at four months, fewer teacher-reported symptoms SMD -0.52 95% CI -0.90 to -0.14); fewer days spent out-of-school (SMD -0.47, 95% CI -0.85 to -0.09); and less self-reported alcohol use (SMD -0.49, 95% CI -0.87 to -0.11) were reported.


















Specialist Outpatient Services Definition Provided by a range of health care professionals in clinics. Included a motivational interview, cognitive behavioural therapy (CBT), parental counselling, dietary therapy and multi-modal feedback on weight management and monitoring.


Specialist Outpatient Services (1 trial)


• No impact on the number of post-discharge nights spent at an inpatient facility, outpatient appointments, or day patient contacts for youth with anorexia nervosa receiving cognitive behavioural therapy, motivational interviewing, and parent counselling compared to inpatient care.

• Public health decision makers should not promote specialist outpatient services over inpatient treatment for youth with anorexia nervosa, while acknowledging evidence is limited to a single study.

Intensive Home Treatment Definition Provides children with therapy in their home to solve problems with the way they interact with other people in the home and to improve their psychological symptoms. A problem-solving approach using a child and family centred approach is used, with importance placed on addressing difficulties with the psychosocial environment and alleviating individual psychiatric symptoms.


Intensive Home Treatment (2 trials)


• A greater proportion of children with emotional/behaviour disorders lived at home up to 3 years post-intervention (72% vs. 50%) compared to inpatient care.

• No impact on number of symptoms for children with behavioural/emotional disorders between groups at two-five years, or overall parent satisfaction compared to inpatient psychiatric admission.

• Public health decision makers should not promote intensive home treatment as an alternative to inpatient treatment.













Intensive Home-based Crisis Intervention Definition (Homebuilders model for crisis intervention) The focus is on the identification of family and individual psychosocial, cultural, community and welfare needs. Components include relationship building, reframing problems, anger management, communication, setting treatment goals and cognitive behavioural therapy. The aim is to prevent an out-of-home placement for children at high risk. Short-term out-of-home placement from three days is permitted for respite care purposes in some cases.


Intensive Home-based Crisis Intervention (1 trial)


• Intensive home-based crisis intervention for emotional/behavioural disorders found small improvements in social competency (SMD -0.34, 95%CI -0.67 to -0.01) compared to case management. Case management led to improved self-concept 6 months post-intervention.

• No impact at six months on child behaviour or family cohesion.

• Public health decision makers should promote intensive home-based crisis intervention to improve social competency in children with emotional/behavioural disorders.

• But should not promote intensive home-based crisis intervention over case management if the aim is to improve self concept, behaviour, and level of family cohesion.

































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Child / Family Health Program Planning in Public Health: What's the Evidence?