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An ounce of prevention is worth a pound of cure: preventive home visits among healthy seniors
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.ORCID iD: 0000-0002-3975-4868
2009 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Ett hekto förebyggande insatser är värt ett kilo bot : förebyggande hembesök för seniorer (Swedish)
Abstract [en]

The aim of this thesis is to contribute to existing knowledge. If the knowledge is not useful in building society it has limited value. In order to be a tool for decision-makers, Preventive Home Visits (PHVs) are described and discussed according to a realist synthesis approach. The premise of this approach is that a single trial cannot tell the whole story and that understanding theoutcome pattern is much more important than seeking regularities in results across different trials. In order to understand the o utcome pattern, the PHV strategy in Nordmaling is examined against other trials and scientific work, and also in grey literature such as reports and workingpapers.

An increasing population of seniors means that resources for health and elderly care are being scrutinised in order to achieve the best possible health for the money invested. PHVs represent one strategy that attempts to promote health among independent seniors. This thesis is a multidisciplinary study aiming to gain knowledge about the effects of PHVs and to understand the mechanisms of importance when implementing this particular strategy. The point of departure is a study conducted in Nordmaling in the north of Sweden among healthy seniors aged 75 years and over.

The study, conducted as a controlled trial during 2000 and 2001, showed a decrease in mortality as well as the utilisation of care, and an improvement in indicators of perceived health. Cost analyses showed significant savings for the municipality following a reduction in the use of home help. These and other savings combined with costs of the intervention were related to saved life years and used to conduct health economic analyses. Medical and social records from the primary health centre and the municipality, along with official registers provided information for modelling health economic analyses from a lifetime perspective. Results showed that the costs of PHVs were less than 10 000 Euros per gained life year, against an acceptable level of cost effectiveness of 50 000 Euros. Using a shorter time perspective, the result was even more favourable for PHVs. It was evident that the time window used in the analyses, the normative choice of including future healthcare costs or not, and how to handle the value of the seniors’ production were important factors in determining the results.

Two years after the trial, in-depth interviews were conducted with 5 seniors who had experienced PHVs, in order to gain understanding of the outcome of the PHV trial in Nordmaling.

Participants were selected with respect to their health and how they responded to advice given during the PHV trial. Grounded Theory was used to analyse the interviews. Seniors who used autonomous coping strategies in everyday life gained less from PHVs than other seniors. All participants could benefit from PHVs, but in order for these to be successful it was important for the home visitor to be professional and to understand how the different coping strategies of seniors worked.

Taken together, the different aspects of this study raised normative questions that are discussed in this thesis. One, whether the production of seniors has any monetary value in health economic analyses conducted from a societal perspective, was addressed in a smaller diary study where 23 seniors were asked to keep a diary in order to identify everything they did over a oneweek period. It was evident that most of the respondents “produced” a lot, however the production of seniors is rarely taken into account in health economic analyses. The concept of “senior production” includes both the market value of what seniors do, as well as the value of what society can avoid doing if the seniors are independent and healthy.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2009. , 65 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1278
Keyword [en]
preventive home visits, mortality, care utilisation, senior production, cost effectiveness, realist synthesis
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
hälso- och sjukvårdsforskning
Identifiers
URN: urn:nbn:se:umu:diva-25653ISBN: 978-91-7264-825-8 (print)OAI: oai:DiVA.org:umu-25653DiVA: diva2:232947
Distributor:
Epidemiologi och folkhälsovetenskap, 901 87, Umeå
Public defence
2009-09-18, Rum 135, Allmänmedicin, Byggnad 9A, Norrlands Universitetsjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2009-08-28 Created: 2009-08-26 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Preventive home visits postpone mortality: a controlled trial with time-limited results
Open this publication in new window or tab >>Preventive home visits postpone mortality: a controlled trial with time-limited results
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2006 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 6, no 220Article in journal (Refereed) Published
Abstract [en]

Background: There is a debate on whether preventive home visits to older people have any impact. This study was undertaken to investigate whether preventive home visits by professional health workers to older persons can postpone mortality in a Swedish context.

Method: A controlled trial in a small community in the north of Sweden. Participants are healthy pensioners aged 75 years and over. 196 pensioners were selected as the intervention group and 346 as the control group. The intervention, two visits per year, lasted two years.

Results: During the intervention, mortality was 27 per 1000 in the intervention group and 48 per 1000 in the control group. The incidence rate ratio for the control group IR2000–2001 was 1,79 (95%CI = 0,94–3,40). Analysing the data with an "on treatment approach" gave a significant result, 2,31 (95%CI = 1,07–5,02) After the trial the difference between the groups disappeared.

Conclusion: Preventive home visits in a healthy older population can postpone mortality in a Swedish context if they are carried out by professional health-workers in a structured way. When the home visit programme ended the effect on mortality disappeared. These findings are dependent on contextual factors that make it difficult to form general policy recommendations.

Place, publisher, year, edition, pages
BIO Med Central Ldt, 2006
Keyword
Prevention, old age, mortality
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
hälso- och sjukvårdsforskning
Identifiers
urn:nbn:se:umu:diva-25641 (URN)10.1186/1471-2458-6-220 (DOI)
Available from: 2009-08-28 Created: 2009-08-26 Last updated: 2017-12-13Bibliographically approved
2. Preventive home visits to older people are cost-effective
Open this publication in new window or tab >>Preventive home visits to older people are cost-effective
2008 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 36, 265-271 p.Article in journal (Refereed) Published
Abstract [en]

Aims: There is ongoing debate over the effectiveness of preventive home visits (PHVs) for the elderly. A municipality in the north of Sweden carried out a controlled trial of such visits. Healthy seniors aged 75 years and over received two PHVs per year over 2 years. The aim of this study was to do a cost utility analysis of the intervention.

Methods: The intervention group (n=196) was compared with a control group (n=346), and a cost utility analysis was performed. The analysis was carried out with three different time perspectives. Data were sourced from official documents and medical and social records.

Results: From a societal perspective, using a time period of 4 years, the analysis of PHVs to healthy seniors showed net savings. When including estimated future costs for health and elderly care during gained life years, the result changed from a net saving to a cost of Euro 200,000. A lifetime perspective also resulted in net savings if the costs of future health and elderly care were not included in the analysis. In this case, the total costs rose to approximately Euro 900,000. The cost could also be expressed as Euro 14,200 per quality-adjusted life year gained if future costs for elderly care and healthcare were included.

Conclusions: PHVs represent a cost-effective intervention in this setting. The costs are justified by the outcomes.

Place, publisher, year, edition, pages
SAGE, 2008
Keyword
Community intervention, cost utility analysis, economic evaluation, older people, preventive home visits
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
hälso- och sjukvårdsforskning
Identifiers
urn:nbn:se:umu:diva-25642 (URN)10.1177/1403494807086983 (DOI)
Available from: 2009-08-28 Created: 2009-08-26 Last updated: 2017-12-13Bibliographically approved
3. Preventive home visits improve Swedish seniors´ coping strategies and health
Open this publication in new window or tab >>Preventive home visits improve Swedish seniors´ coping strategies and health
(English)In: Article in journal (Refereed) Submitted
Abstract [en]

Preventive home visits (PHVs) promote health in old age.  Research indicates that PHVs have a positive health effect on mortality, admissions to institutions, and falls.  To understand how seniors perceive PHVs and how they cope with everyday life when PHVs have ended, five individual research interviews were conducted with seniors aged 79 – 88 years. Seniors with a low degree of control over their daily life appeared to gain more from PHVs than other seniors. To help seniors to increase control seems essential if they are to lead an independent and healthy life. PHVs can contribute to positive health development by improving seniors’ sense of control over their everyday lives and processing the used coping strategies. It is important that home visitors understand how the different coping strategies used by seniors affect health.

Keyword
Preventive home visits, grounded theory, old people, ageing, Sweden, coping strategies
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Social Medicine
Identifiers
urn:nbn:se:umu:diva-25643 (URN)
Available from: 2009-08-28 Created: 2009-08-26 Last updated: 2015-04-29Bibliographically approved
4. Measuring the value of old people’s production: ideas based on diaries
Open this publication in new window or tab >>Measuring the value of old people’s production: ideas based on diaries
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(English)In: Article in journal (Refereed) Submitted
Abstract [en]

Objective:

Productive capacity is usually not valued for seniors who have retired. However, some seniors produce much more than we expect. In this diary-study senior activities are identified and value mechanisms are suggested. One question raised is if it is possible to scale up this diary study into a larger representative study.

Method:

Diaries kept for one week were collected among 23 seniors in the north of Sweden. They were analysed with a Grounded theory approach; an interplay between ideas and empirical data.

 Result:

Some productive senior activities must be valued as opportunity cost of time and others must be valued with replacement cost. In order to make the choice among these principally different methods the societal entitlement is important. When the societal entitlement does not exist the first method must be used and when it exists the latter must be used. 

Conclusion:

An explicit investigation of the content of the entitlement is needed to justify the choice of valuation method for each activity. Questions addressing senior production must be adjusted to the type of production. In order to understand senior production, degrees of free choice to conduct an activity, as well as describing health-related quality of life, are important.

Keyword
old, production, entitlement, intergenerational fairness
National Category
Economics and Business
Research subject
hälso- och sjukvårdsforskning
Identifiers
urn:nbn:se:umu:diva-25644 (URN)
Available from: 2009-08-28 Created: 2009-08-26 Last updated: 2015-04-29Bibliographically approved

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