BackgroundCommunity engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.ObjectivesTo undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.Data sourcesDatabases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.Review methodsStudy eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.ResultsThe theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.LimitationsDifferences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.ConclusionsCommunity engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.FundingThe National Institute for Health Research Public Health Research programme.

Background: Advance care planning (ACP), a process of discussion and review con-

One of the key objectives of the community care reforms of 1990 in the United Kingdom was the development of a flourishing independent sector alongside good quality public services. The aims of the reforms were to increase the available range of options, widen consumer choice and promote independence. The purpose of the study reported here was to examine -from the perspective of older service users, their carers and care managers -experiences at the operational level of arranging, delivering and receiving care services. The findings are based on data gathered in seven local authorities including reviews of case files, policy documents and faceto-face, in-depth interviews with 55 users, 37 carers and 28 care managers. There is evidence of a pronounced emphasis on procedure-based systems of care management. Potentially this has two significant consequences. First, the fostering of personal relationships may be subordinated to the organisation of short-term tasks and thereby may threaten patterns of trust and accountability. Second, the associated fragmentation of the assessment and care management process which in turn can lead to discontinuities of care for users and their carers. The paper concludes that there is still some way to go before care managers as micro-commissioners have sufficient and reliable information or available service capacity to match providers' capabilities with users' and carers' needs.

What is known about this topic Understanding the economic consequences of deinstitutionalisation is fundamentally important. What this paper adds dThe evidence base on the economics of deinstitutionalisation is modest and uneven across countries. There are strong economic arguments for closing psychiatric hospitals in favour of community-based arrangements, but rebalancing care will not generate great savings. There are also many challenges. Decision-makers should plan a dynamic community-based system to match the needs of people moving from institutions, and must take the long view. AbstractMany European mental health systems are undergoing change as community-centred care replaces large-scale institutions. We review empirical evidence from three countries (UK, Germany, Italy) that have made good progress with this rebalancing of care. We focus particularly on the economic consequences of deinstitutionalisation. A systematic literature review was conducted using a broad search strategy in accordance with established guidelines. We searched the International Bibliography of the Social Sciences, Health Management Information Consortium, British Nursing Index and PUBMED ⁄ Medline to 2008. The on-line search was supplemented by advice and assistance from contacts with government departments, European Commission, professional networks and known local experts. Community-based models of care are not inherently more costly than institutions, once account is taken of individuals' needs and the quality of care. New community-based care arrangements could be more expensive than long-stay hospital care but may still be seen as more cost-effective because, when properly set up and managed, they deliver better outcomes. Understanding the economic consequences of deinstitutionalisation is fundamental to success. Local stakeholders and budget controllers need to be aware of the underlying policy and operational plan. Joint planning and commissioning or devolving certain powers and responsibilities to care managers may aid development of effective and cost-effective care. People's needs, preferences and circumstances vary, and so their service requirements and support costs also vary, opening up the possibility for purposive targeting of services on needs to improve the ability of a care system to improve well-being from constrained resources. As the institutional ⁄ community balance shifts, strategic planning should also ensure that the new care arrangements address the specific contexts of different patient groups. Decision-makers have to plan a dynamic communitybased system to match the needs of people moving from institutions, and must take the long view.

This systematic review explored the effectiveness of technology-based interventions in promoting the mental health and wellbeing of people aged 65 and over. Data were collected as part of a wider review commissioned by the National Institute for Health and Care Excellence (NICE) in England on the effectiveness of different actions to promote the mental wellbeing and independence of older people. All studies identified through this review were subject to a detailed critical appraisal of quality, looking at internal and external validity. Twenty-one papers covering evaluations of technological interventions were identified. They examined the psychosocial effects of technologies for education, exposure to, and/or training to use, computers and the internet, telephone/internet communication and computer gaming. Few studies took the form of randomized controlled trials, with little comparability in outcome measures, resulting in an inconsistent evidence base with moderate strength and quality. However, three out of six studies with high or moderate quality ratings (all focused on computer/internet training) reported statistically significant positive effects on psychosocial outcomes, including increased life satisfaction and experienced social support, as well as reduced depression levels among intervention recipients. The review results highlight the need for more methodologically rigorous studies evaluating the effects of technology-based interventions on mental wellbeing. Well-performed technology-based interventions to promote various aspects of mental wellbeing, as identified in this review, can serve as best practice examples in this emerging field.