Skill-mix interventions in health promotion and prevention across the life cycle

Ten reviews analysed changes to the roles and skills of teams or individual professions to expand health promotion activities across the lifespan (Table 4.1). The settings and teams varied considerably, but most of the interventions took place in ambulatory health care settings. Some reviews also analysed skill-mix changes in non-health sectors, such as schools or the homes of at-risk groups. Selected reviews focused on health promotion activities and/or prevention for children, such as healthy eating and weight reduction programmes at schools run by nurses (Reference Schroeder, Travers and SmaldoneSchroeder, Travers & Smaldone, 2016). The skill-mix interventions outside the traditional boundaries of the primary care settings involved home visit programmes by nurses or other professionals to prevent child maltreatment (Reference Dalziel and SegalDalziel & Segal, 2012), and home visits for pregnant women at risk (Reference Abbott and ElliottAbbott & Elliott, 2017). In the other reviews, the interventions took place (mainly) in primary or ambulatory care settings.

The reviews evaluated the outcomes of skill-mix innovations with a large number of different interventions as well as outcome measures used.

• Two systematic reviews analysed the impact of interventions to reduce overweight and obesity among children or adults attending primary care providers, run by school nurses (Reference Schroeder, Travers and SmaldoneSchroeder, Travers & Smaldone, 2016) or various primary care professions (Reference Bhattarai, Prevost and WrightBhattarai et al., 2013). The interventions included a mix of education, changes to nutrition and physical activity programmes as well as counselling to school children and parents (Reference Bhattarai, Prevost and WrightBhattarai et al., 2013; Reference Schroeder, Travers and SmaldoneSchroeder et al., Travers & Smaldone, 2016). Meta-analysis revealed a significant reduction in children’s weight (Reference Schroeder, Travers and SmaldoneSchroeder, Travers & Smaldone, 2016) and a significant increase of the intake of fruits, vegetables and dietary fibre among individuals attending primary care providers, whereas fat intake decreased (Reference Bhattarai, Prevost and WrightBhattarai et al., 2013).

• Physical activity promotion for sedentary adults was delivered by various primary care providers who applied different strategies, such as counselling, advice and motivational interviewing. Self-reported physical activity significantly improved and positive effects were reported for cardiorespiratory fitness. However, one of six studies also reported adverse events, notably a significant increase of 11% in falls and 6% in injuries within 12 months follow up (Reference Orrow, Kinmonth and SandersonOrrow et al., 2012).

• Skill-mix interventions that focused on enhanced maternity and child health through improved education, counselling and collaboration among professions revealed an improvement on several outcome measures (Reference Kroll-Desrosiers, Crawford and Moore SimasKroll-Desrosiers et al., 2016; Reference Lewin, Munabi-Babigumira and GlentonLewin et al., 2010), including improved birth weight, particularly among ethnic minorities (Reference Kroll-Desrosiers, Crawford and Moore SimasKroll-Desrosiers et al., 2016) and significantly improved outcomes on breastfeeding and childhood immunization uptake (Reference Lewin, Munabi-Babigumira and GlentonLewin et al., 2010). Interventions that showed enhanced care coordination were also associated with cost savings (Reference Kroll-Desrosiers, Crawford and Moore SimasKroll-Desrosiers et al., 2016).

• Two home visit programmes on health promotion and prevention for disadvantaged (pregnant) women or mothers resulted in fewer inpatient hospital stays, improved health, self-efficacy and fewer depressive symptoms (Reference Abbott and ElliottAbbott & Elliott, 2017). Moreover, significant increases in prenatal care utilization and birth weight were also found (Reference Issel, Forrestal and SlaughterIssel et al., 2011). One home visit programme for children at risk of maltreatment resulted in cost savings (Reference Dalziel and SegalDalziel & Segal, 2012). The most cost-effective programmes reported by Reference Dalziel and SegalDalziel & Segal (2012) used professional home visitors (for example, nurses, midwives, social workers) in a multidisciplinary team, who targeted high-risk populations and included interventions beyond home visiting.

• Reference Saba, Diep and SainiSaba et al. (2014) analysed a smoking cessation programme through counselling by community pharmacists, targeted at patients with tobacco consumption and provided at an individual or group level. Overall, these smoking cessation sessions in community pharmacies were associated with improved abstinence rates.

• One review assessed the contribution of various primary care providers to enhance health literacy among various population groups, including healthy adults and people at risk for developing chronic conditions (Reference Dennis, Williams and TaggartDennis et al., 2012). The skill-mix interventions varied considerably, ranging from expanded roles to include health literacy counselling, to intense, bundled packages of counselling, goal setting, group empowerment sessions to develop health literacy skills and lifestyle changes. Interventions delivered by physicians were generally brief, but those provided by nurses and other health professions tended to be more comprehensive and resulted in a higher number of studies with improved health literacy outcomes.

Skill-mix interventions in prevention targeting at-risk groups

A second group of reviews concerned interventions that were directed at specific risk groups. The groups again varied considerably: some interventions were targeted at groups that were at risk of cardiovascular diseases (Table 4.2), that were overweight or obese (Table 4.3), or that had multiple risk factors (Table 4.4). Several systematic reviews also included patients who had already been diagnosed with a disease, whereby the focus was to delay the progression of the disease and prevent the onset of multimorbidity, hence the inclusion of these reviews in this chapter. Interventions took place in the primary or community care setting in various countries around the world. The majority of interventions introduced new roles for different professionals or shifted tasks from physicians to other professions.

The outcomes of these skill-mix innovations covered a range of different interventions as well as patient- and health-system-related outcome measures:

• Out of the seven reviews identified, five addressed the prevention and management of cardiovascular risk factors by various professions, including pharmacists and/or nurses, alone or in collaboration with other professions such as GPs. Nurse- and pharmacist-led interventions comprised educational programmes, medication management and reminder systems. Patient-related outcomes improved for both nurse and pharmacist-led interventions. Overall, total cholesterol (Reference Deichmann, Morledge and UlepDeichmann et al., 2016; Reference Santschi, Chiolero and BurnandSantschi et al., 2011, Reference Santschi, Chiolero and Paradis2012), risk of smoking (Reference Santschi, Chiolero and BurnandSantschi et al., 2011), body mass index (Reference Santschi, Chiolero and ParadisSantschi et al., 2012) and blood pressure (Reference Santschi, Chiolero and BurnandSantschi et al., 2011, Reference Santschi, Chiolero and Paradis2012, Reference Santschi, Chiolero and Colosimo2014) were reduced significantly in the intervention groups and quality of life improved (Reference Rice, Say and BetihavasRice, Say & Betihavas, 2018). Reference Deichmann, Morledge and UlepDeichmann et al. (2016) reported significantly improved medication adherence on lipid lowering intake. Cost-effectiveness was reported for nurse-led interventions. Moreover, nurse-led education to at-risk groups led to reduced readmission and hospitalization rates (Reference Rice, Say and BetihavasRice et al., 2018).

• Interventions provided by community pharmacists covered patient education and follow up as well as identification of drug-related problems and providing therapeutic recommendations to physicians. Most studies reported positive effects on patient-related outcomes. Interventions for patients with diabetes and hypertension showed clinically reduced blood pressure and glycated haemoglobin (Reference Ifeanyi Chiazor, Evans and van WoerdenIfeanyi Chiazor et al., 2015).

• Clinic-based interventions by physiotherapists aimed at increasing physical activity generally involved face-to-face contact on a one-to-one basis, and often included additional telephone contact. The interventions showed significant positive effects on the total physical activity and significantly helped patients to achieve the minimum recommended level of physical activity (Reference Kunstler, Cook and FreeneKunstler et al., 2018).

Six systematic reviews reported on interventions directed at populations with a high body mass index, including adults and children with overweight or obesity and patients with special nutritional needs (Table 4.3).

• The effects of nurse-led weight management and lifestyle counselling were evaluated in three systematic reviews. The programmes encompassed consultation, motivational interviewing and education. Body mass index and overweight were significantly reduced in the intervention groups (Reference Petit Francis, Spaulding and Turkson-OcranPetit Francis et al., 2017; Reference Sargent, Forrest and ParkerSargent, Forrest & Parker, 2012; Reference van Dillen and Hiddinkvan Dillen & Hiddink, 2014). Significant improvements were also reported for weight control, blood pressure, cholesterol and physical activity (Reference Sargent, Forrest and ParkerSargent et al., 2012). Successful programmes involved nurses engaged in health promotion activities, operating within multidisciplinary teams and/or providing consultations, physical activity education and coaching over the phone (Reference van Dillen and Hiddinkvan Dillen & Hiddink, 2014).

• Individualized nutrition care for patients with special dietary needs delivered by health care professionals including dieticians and nurses working alone or in teams ranged from assessment and diagnosis to intervention and monitoring. These interventions led to a signi?cant increase of the daily intake of vegetables, fruits, fish and high-fibre bread (Reference Ball, Leveritt and CassBall et al., 2015), and significantly improved glycemic control, dietary change, anthropometry, cholesterol, triglycerides (Reference Mitchell, Ball and RossMitchell et al., 2017).

• One Cochrane review analysed two types of interventions on weight reduction. Interventions by health professionals covered different strategies including educational programmes, whereas interventions addressing the care organization involved multidisciplinary teams and shared care models. Significantly reduced weight and body mass index scores were reported for the dietician-led and shared care (dietician–physician) interventions. Interventions directed at professionals, such as education, tailoring and clinical decision tools, showed only a small positive effect on weight loss. Weight loss was achieved at modest costs in the interventions provided by physicians only or in collaboration with dieticians (Reference Flodgren, Gonçalves-Bradley and SummerbellFlodgren et al., 2017).

Six systematic reviews were concerned with multiple risk groups (Table 4.4). The interventions focused on task shifting and the uptake of new roles by nurses, pharmacists or lay health workers. The results in terms of patient and health system outcomes were mixed.

• One review evaluated task shifting with regard to secondary prevention from physicians to nurses. Nurse practitioners and other specialized nurses with additional training took over tasks from physicians in the secondary prevention and performed them independently or under supervision of a physician. Prevention measures were delivered during the course of disease to patients with various diagnoses. Most studies included in this review did not show a difference in patient-related outcomes between nurse-led and physician-led care. Some studies showed better outcomes for nurse-led secondary prevention of heart diseases, for managing dyspepsia and for lowering cardiovascular risk in individuals with diabetes and for significantly lowering differences in mean fall from baseline for stroke risk (Reference Martínez-González, Tandjung and DjalaliMartínez-González et al., 2015).

• Several reviews evaluated health-related lifestyle advice performed by either trained lay health workers (Reference Pennington, Visram and DonaldsonPennington et al., 2013) or by various health care professionals (Reference Frerichs, Kaltenbacher and van de LeurFrerichs et al., 2012; Reference Tapsell and NealeTapsell & Neale, 2016). The interventions were directed at adults with different health conditions and encompassed education, counselling and support delivered in person, via telephone or electronically. Improved cardiovascular risk factors (Reference Frerichs, Kaltenbacher and van de LeurFrerichs et al., 2012) and physical activity and significantly improved blood pressure, blood glucose control, weight (Reference Tapsell and NealeTapsell & Neale, 2016) and blood lipids (Reference Pennington, Visram and DonaldsonPennington et al., 2013) were reported. However, little evidence of effectiveness, measured via resource use, was reported for interventions promoting exercise or healthy diets. Where interventions were effective, their cost-effectiveness varied greatly. Incremental cost-effectiveness ratios were estimated at £6000 for smoking cessation, £14 000 for a telephone-based type 2 diabetes management and £250 000 or greater for promotion of mammography attendance and for HIV prevention among drug users (Reference Pennington, Visram and DonaldsonPennington et al., 2013).

• One review focused on pharmacist interventions to prevent diabetes or cardiovascular diseases in patients at risk or to improve self-management in already diagnosed patients. The interventions combined patient education, follow up, identifying drug-related problems and providing recommendations for the prevention and management of the diseases. Patient education, patient follow up, identification of drug-related problems and subsequent physician recommendations were effective in the majority of studies (Reference Evans, Watson and EurichEvans et al., 2011).

• One review focused on nurse-led prevention of falling in older patients with multiple risk factors at risk of admission to hospital, residential or nursing care. The review showed a significantly reduced risk of death associated with the intervention, but could not show a significant effect on the number of falls and admissions to hospital and residential care. The identified economic evaluations tended to show cost savings, but faced several methodological shortcomings (Reference Tappenden, Campbell and RawdinTappenden et al., 2012).

Skill-mix interventions targeting screenings

Seven reviews focused on interventions by health professionals or lay health workers to facilitate the access to screenings. There were also non-health professionals involved, such as firefighters.

• The role of a patient navigator was introduced in three reviews for patients completing screenings, mostly targeting vulnerable individuals. Patient navigators, including health professionals, trained lay persons and community health workers and provided assistance in person, via mail or phone to increase screening and diagnostic rates. As a result, patients were significantly more likely to attend recommended care events and attend screenings (Reference Ali-Faisal, Colella and Medina-JaudesAli-Faisal et al., 2017). Reference Roland, Milliken and RohanRoland et al. (2017)) also reported increased screening and mammography uptake and improved completion of diagnostics, referral and follow up. Reference Genoff, Zaballa and GanyGenoff et al. (2016) showed significantly improved screening rates for breast, cervical and colorectal cancer.

• Transdisciplinary secondary prevention interventions in the community targeting the social determinants of health were conducted through home visits in the review by Reference Abbott and ElliottAbbott and Elliott (2017). These were delivered by physicians, nurses, social workers, community health workers and firefighters. Disadvantaged population groups reported significantly improved mammography attendances, Papanicolaou cervical screenings and Hepatitis B screenings. However, no significant difference was found for prostate cancer screening rates among low-income African-American men.

• Interventions to improve screening of cervical cancer in women through patient navigation or education resulted in increased screening rates when interventions were delivered by lay health workers (Reference Glick, Clarke and BlanchardGlick et al., 2012).

• Nurse-delivered colorectal cancer screenings in asymptomatic adults aged 45 years or more showed that nurses detected significantly higher rates of adenomas compared with physicians, and polyps at comparable rates to endoscopists. Higher patient satisfaction and absence of complications were also among the positive outcomes. Regarding resource use, nurse-led screenings resulted in lower costs compared with physician-led services (Reference Joseph, Vaughan and StrandJoseph, Vaughan & Strand, 2015).

• One review focused on skin cancer screening, including the assessment and examination performed by nurse practitioners, other advanced practice nurses or specialized nurses. The interventions were compared to screenings conducted by physicians or general and expert dermatologists. Overall, nurses showed a high sensitivity to identify malignant lesions, although there were differences in their level of specialization and sensitivity (Reference Loescher, Harris and Curiel-LewandrowskiLoescher, Harris & Lewandrowski, 2011).

Education and training of the professionals involved in the skill-mix interventions

The training of the professionals was not systematically reported across the systematic reviews reported in the previous sections. However, some reviews provided information on the educational background of the professionals who had been included in the skill-mix interventions. For instance, Reference Loescher, Harris and Curiel-LewandrowskiLoescher, Harris & Lewandrowski (2011) noted that nurse practitioners and advanced practice nurses underwent additional training programmes for skin cancer screening ranging from 10 minutes to 4 months, demonstrating the variability in the length of training.

Limitations and strength of evidence

The systematic reviews presented above did not systematically report comparison groups and interventions. Due to the great heterogeneity of the interventions covered in the reviews, some of which report complex interventions that also alter the organization of care, the attribution of causality between skill-mix interventions and outcomes must be done with caution. Health-system-related outcomes were less frequently evaluated than patient/population-specific outcomes, whereas profession-specific outcomes are missing. The quality of the reviews also varied considerably: there were 13 meta-analyses, four cost-effectiveness analyses and two Cochrane reviews.

Conclusions: summary of the evidence

As documented in the majority of the reviews summarized above, skill-mix innovations for health promotion and prevention show evidence of positive outcomes for patients and for the health systems. Health promotion and primary prevention across the life cycle have become increasingly the remit of primary care professionals. Several skill-mix innovations have emerged that explicitly focus on health promotion or prevention, ranging from the allocation of tasks to nurses and pharmacists to shared care models. Overall, these have shown a positive impact on individuals or risk groups in terms of lifestyle choices and outcomes. Moreover, innovative programmes such as home visits to prevent child maltreatment can save costs. Outcomes associated with cardiovascular, body mass and various other risk factors have given proof of improved patient- and health-system-related effects. The introduction of patient navigators as well as transdisciplinary home visits can be an effective strategy to expand screening rates, particularly for vulnerable population groups or individuals who would otherwise not participate in screenings.

More informed decision-making

Shared decision-making, defined as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions” (Reference Elwyn, Frosch and ThomsonElwyn et al., 2012), as opposed to clinicians making decisions on behalf of patients, is gaining increasing prominence in health care. The trend is not restricted to decisions on medical treatment, but is also seen in preventive health and health promotion (for example, screening participation, vaccination, breastfeeding, diet advice). Policy-makers are often favourable towards the idea of shared decision-making, not only because they support the right of patients and citizens to be involved in decisions concerning their own health, but also because of its potential to reduce overuse of interventions that are not clearly associated with benefits for all, to reduce unwarranted health care practice variations, and to enhance the sustainability of the health care system (Reference Légaré, Adekpedjou and StaceyLégaré et al., 2018). The value of shared decision-making is supported by evidence from a growing number of studies showing knowledge gain by patients, more confidence in decisions, more active patient involvement, and generally a choice for more conservative treatment options (Reference Elwyn, Frosch and ThomsonElwyn et al., 2012). However, to allow for shared decisions, patients and citizens who decide on preventive measures must have the capacity to act independently and to make their own choices. Shared decision-making therefore depends on tasks that help confer agency on the patients by providing them with information about the likely benefits and risks of different options, and by supporting the decision-making process, taking into account their personal values and preferences. This process involves a continuing dialogue between health providers and decision-makers. Apart from a sufficient level of health literacy on the part of the patient, it requires adequate communication skills on the part of health workers. But more importantly, it also implies an important shift in the role of health workers, from that of an expert making decisions for the patient to that of an educator and coach in the decision-making process. To make this possible, new tasks must be added to their task description. The reviews summarized above make clear that new tasks and roles with a focus on health promotion or prevention are being introduced in primary care. Not only are tasks allocated to other actors such as nurses, nurse-practitioners, pharmacists, community health workers, patient navigators and lay persons, but more elaborate shared care models are also beginning to emerge. Overall, these skill-mix innovations have shown a positive impact on individuals or at-risk groups in terms of lifestyle choices and outcomes.

Internet as a health information source

With the availability of the internet and changes in media health coverage, the context in which patients consume medical and health information has changed dramatically. A Eurobarometer study on European citizens’ digital health literacy (Eurobarometer, 2014) revealed that six out of ten European respondents use the internet to search for health-related information, and over half of these do so at least once per month. Information about health topics is abundantly available, but not always accurate and often contradictory. As such, being well-informed about health is not so much a matter of finding information, but rather a question of finding out which information sources that are accessed give adequate and useful information, and whether they are reliable.

As these changes influence the ways in which individuals obtain, interpret and evaluate health information, they also have an impact on the role of health care providers. Whereas traditionally physicians were gatekeepers of health care information and services to their patients, most physicians are now experiencing the effects of patients coming to their offices armed with printouts from the internet and requesting certain procedures, tests or medications (Reference Hesse, Nelson and KrepsHesse et al., 2005). Although patients still rely on health care providers as their most trusted information source on health, the role of physicians may no longer be seen as solitary caretakers but as trusted partners in helping patients sort through information derived from an expanding network of personal and mediated information channels. Again, this new role requires a series of new skills and a reorganization of the task division within the health system, with tasks being allocated to a range of actors within the health sector to ensure that patients’ information needs and questions are being addressed.

A diverse and expanding primary care and public health workforce

Unlike the medical workforce, with its clearly established professions and curricula, the workforce for public health is very diverse. In addition to public health specialists (epidemiologists, health policy-makers, health educators, environmental health experts, health economists) and professionals in primary or ambulatory health care (physicians, nurses, dentists, pharmacists, midwives), there is also an important role for those who are not directly involved in health organizations, but whose activities can contribute to improving population health, such as social workers, teachers, police or urban planners (Reference Aluttis, Maier, Van den Broucke, Rechel and McKeeAluttis et al., 2014). In this regard, Reference DaviesDavies (2013) makes a distinction between specialist and mainstreamed public health and health promotion workers. The first are specialists at both academic and professional levels who have been trained in public health or health promotion as a scholarly discipline and who possess the knowledge, skills and practical experience to perform their tasks. The second are people inside and outside the health sector who work to promote health as defined by the Ottawa Charter, regardless of their professional designation. They represent the social movement aspect of public health and health promotion, more than the discipline.

Within the specialist public health and health promotion workforce, tasks are increasingly shared by or reallocated between professions. Prevention and health promotion tasks are taken up by specialists from a growing range of disciplines. For instance, public health nurses are added to primary care centres and general practice in a number of countries, including France, the Netherlands and Slovenia. In a similar vein, pharmacists increasingly take up a role as health promotion actors. This was seen in Belgium, for example, where a programme was introduced allowing pharmacists to be paid a fee to provide medico-pharmaceutical advice to clients using new medication (Box 4.2).

This trend also necessitates an enhanced collaboration between different disciplines involved in prevention and health promotion. When tasks shift, the collaboration between health workers from different disciplines needs to be re-calibrated. This is seen in a pilot project on setting up a system of regular and structured consultation between GPs and pharmacists in Brussels who sell diagnostic self-tests (Box 4.3).

Involvement of non-health professionals and citizens is also seen in mental health. Examples from Canada, the United Kingdom and France show the role of volunteers delivering “safe and well visits”, mobile crisis teams, or firefighters responding to people who have been confronted with traumatic experiences.