The introduction of a novel scheme in Weston-super-Mare described by Abel et al.,[1] which utilises a health care mentor to assist palliative care patients identify supportive networks within their communities and seeks to foster the development of compassionate community networks is to be congratulated. While the scheme is undoubtedly innovative in a palliative care setting a comparable model was initiated in a generalist commun...
The introduction of a novel scheme in Weston-super-Mare described by Abel et al.,[1] which utilises a health care mentor to assist palliative care patients identify supportive networks within their communities and seeks to foster the development of compassionate community networks is to be congratulated. While the scheme is undoubtedly innovative in a palliative care setting a comparable model was initiated in a generalist community health care setting in Scotland almost a decade ago. The WHO Europe Family Health Nursing Pilot in Scotland[2] was supported by the delivery of an educational programme by the University of Stirling from 2001-2005. The pilot was part of a wider European initiative developed from the recommendations of HEALTH 21.[3] Assessment and documentation used by nursing staff in the pilot was based on the Calgary Family Assessment Model [4] and included the use of genograms and ecomaps. There have been several published evaluations of the Family Health Nursing Pilot and a conceptual model of Family Centred Health Care developed.[2,5,6,7] Congruent with compassionate communities the emphasis of this model is to shift the focus from an individual to a community perspective. Whilst it is clear that the authors view the use of health care mentors as only the first step in developing autonomous community networks, they may perhaps draw parallels from the Family Health Nurse Pilot to facilitate development of their current scheme in Weston-super-Mare.
1.Abel J, Bowra J, Walter T, Howarth G. Compassionate community networks: supporting home dying. BMJ Support Palliat Care 2011; 1:129-133.
2. Scottish Executive. The WHO Europe Family Health Nursing Pilot in Scotland Final Report. Edinburgh: Scottish Executive 2006.
3. World Health Organisation (WHO). Europe HEALTH21: Health for all in the 21st Century. Copenhagen: WHO Europe 1998.
4. Wright L, Leahey M. Nurses and Families: a guide to family assessment and Intervention. Third edition. Philadelphia: FA Davis Company 2000.
5. MacDuff C, West BJM. An evaluation of the first year of family health nursing practice in Scotland. International Journal of Nursing Studies 2005; 42:47-59
6. Murray I. Family Health Nurse Project--An Education Program of the World Health Organization : The University of Stirling Experience Journal of Family Nursing 2008;14(4):469-485
7. Parfitt B A, Cornish F, Whyte L, Van Hooren M. Family Centred Health Care: The Contribution of Family Health Nurses. An Evaluation of the Family Health Nurse Role, Phase 2: School of Nursing, Midwifery and Community Health, Glasgow Caledonian University 2006.
Conflict of Interest:
I am employed by the University of Stirling but I was not a member of the institution during the Family Health Nurse Pilot.
We are grateful for the opportunity to respond to Chu and Percy's
interesting comments on our paper. We accept that older and younger age
may be associated with more medical problems in mothers and this could
explain some of the higher mortality in bereaved parents versus non-
bereaved parents, however the increased mortality findings were
demonstrated for fathers as well as mothers. Although the age of the
mother may ex...
We are grateful for the opportunity to respond to Chu and Percy's
interesting comments on our paper. We accept that older and younger age
may be associated with more medical problems in mothers and this could
explain some of the higher mortality in bereaved parents versus non-
bereaved parents, however the increased mortality findings were
demonstrated for fathers as well as mothers. Although the age of the
mother may explain some of the variation, there must be additional factors
which explain some of the excess mortality. Regarding the consolidation of
stillbirth and infant death records, we found that there was no difference
in mortality rates between those who experienced stillbirth and those who
experienced infant death. We therefore felt it was appropriate to combine
the data from these groups. In addition, the association between age of
child at time of death and impact on the parent is far from certain, as
reported by in previous studies such as Anderson (2005), Engelkemeyer
& Marwit (2008) and Hazzard, Weston and Gutterres (1992). We have
additional manuscripts under review which will further support the view
that grief following the loss of a child is unrelated to the age of the
child at the time of their death. Finally, Chu and Percy suggest that an
alternative sampling method would yield more data. The limitation of the
Scottish sample is due to the protocols followed by the Scottish
Longitudinal Study and as such, the authors were restricted to the data
made available by this service. Sampling higher than 5.3% of the Scottish
population is not currently possible, unfortunately.
We thank Chu and Percy for their comments on this research and for their
insight into possible alternative explanations for the excess mortality in
bereaved parents.
References
Anderson, M., Marwit, S. J., Vandenberg, B., & Chibnall, J. (2005).
Psychological and religious coping strategies of mothers bereaved by the
sudden death of a child. Death Studies, 29(9), 811-826.
Engelkemeyer, S., & Marwit, S. J. (2008). Posttraumatic growth in
bereaved parents. Journal of Traumatic Stress, 21(3), 344-346.
Hazzard, A., Weston, J., & Gutterres, C. (1992). After A Childs Death
- Factors Related to Parental Bereavement. [6-50 months]. Journal of
Developmental and Behavioral Pediatrics, 13(1), 24-30.
We read with interest the article by Harper et al in the last edition
of this journal (2011;1:306-309). By establishing a correlation between
infant mortality and the increased mortality risk of the parents, the
article speaks, albeit indirectly, to the possible links between emotional
and physical states - a topic of important and growing interest. However,
two points present themselves about the authors' analysis - the f...
We read with interest the article by Harper et al in the last edition
of this journal (2011;1:306-309). By establishing a correlation between
infant mortality and the increased mortality risk of the parents, the
article speaks, albeit indirectly, to the possible links between emotional
and physical states - a topic of important and growing interest. However,
two points present themselves about the authors' analysis - the first is
statistical, the second conceptual.
Harper et al are direct about possible confounding factors for which
they were unable to control but which may nullify any causal link implied
by the statistical correlation they identify (p308). However, given their
use of census data, there is one possible confounding factor that they
might have controlled for - age of parent at the time of birth.
Harper et al imply that the small difference in mean age between the
comparison and control group means age should not raise concern. However,
if parent and infant mortality are more likely among both older and
younger parents, the difference in mean age might be minimal or invisible,
even though the casual implications of the chi-squared correlation would
be weakened. Previous research suggests that such a two-sided confounding
factor may exist for age. Young births, such as teenage pregnancies, have
been linked to worse outcomes for both mother and child (see, for example,
citations in Wellings and Kaye, 1999). Births to older parents are
similarly more likely to face complications and older parents would
naturally be closer to average life expectancies.
The results presented by the authors point towards this possibility.
The 'bereaved' group manifests a wider range of ages than the 'control'
group. The effect is most significant in the English data - the smallest
difference in standard deviations exists for the 1981-1991 cohort, which
is between 8.4 and 5.7. Since the English data manifest a higher relative
risk, it is worth exploring whether age may be such a confounding factor.
Year of birth might also be included in the analysis, to control for the
possibility that both infant and parent mortality risks may be shifting
over time.
The second concern is a conceptual one. If a ceteris paribus causal
link exists between the death of one's children and an increased mortality
risk for parents, it seems likely that this is linked to the trauma caused
by the loss of a loved one. But emotional bonds are not all equal - on
average, they might be expected to become stronger over time. From this
perspective, the average relative risk of parent mortality after a
miscarriage should be lower than death in childbirth, which would be lower
in turn than death in early infancy and the death of a young child.
The Dutch study (Li et al, 2003) referenced by Harper et al bears out
this principle - the relative risk of parent mortality in their study is
higher for a child dying aged between 1 and 11 months than a child dying
at less than one month. The analysis by Harper et al can be extended to
explore this hypothesis. Parents suffering stillbirths and infant
mortalities are currently combined into a single category - by splitting
the two groups, differences might be observed. The accidental inclusion of
parents whose child dies aged older than one in the 'non-bereaved' group
would bias effects downward, but differences may still be observable.
For the Scottish data, ethical non-identification reasons and small
sample sizes prevented such subgroup analysis (p307). However, the small
sample size resulted by design - the choice of 20 birthdays or 5.3% of the
population. Had the authors chosen a larger set of birthdays, it may have
been ethically possible to analyse the two subgroups in greater detail. No
such restriction applied to the English data.
The authors are to be congratulated on their research and we agree
with them that further statistical and case study work is required. We
hope that the suggestions are amenable to straightforward exploration on
similar datasets to those used by the authors.
Dr Wing Chu, ST1 Doctor in Palliative Care; Christian Percy,
Statistical Consultant
References
Wellings, K. and Kane, R. (1999), 'Trends in teenage pregnancy in England
and Wales: how can we explain them', J R Soc Med 1999;92:277-282
We are grateful for the opportunity to respond to Chu and Percy's interesting comments on our paper. We accept that older and younger age may be associated with more medical problems in mothers and this could explain some of the higher mortality in bereaved parents versus non- bereaved parents, however the increased mortality findings were demonstrated for fathers as well as mothers. Although the age of the mother may ex...
We read with interest the article by Harper et al in the last edition of this journal (2011;1:306-309). By establishing a correlation between infant mortality and the increased mortality risk of the parents, the article speaks, albeit indirectly, to the possible links between emotional and physical states - a topic of important and growing interest. However, two points present themselves about the authors' analysis - the f...
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