**5.4 Worldwide tendencies: community health worker (CHW), misinformation, and telemedicine in home-based care for children**

The community health worker, named as such in the USA and defined as a frontline public health worker who is a trusted member of the community, is present under different names in several European countries [64]. This trusting relationship enables the worker to serve as an intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery [65]. Preventive maternal and child health (MCH) interventions delivered by CHWs through home visiting have improved important maternal and child outcomes. Efforts are targeted towards early prenatal care, breastfeeding, reduction of maternal morbidity and perinatal mortality and appropriate childhood immunizations. Home visiting interventions lead to a decreased incidence of preterm birth and low birthweight [66]. By having a common language, a similar socioeconomic status and understanding life experiences of their clients, CHWs are accepted by vulnerable and disenfranchised groups. Being integral contributors in collaborative health-based and community-based teams, CHWs improve comprehensive care and contribute to health improvements and cost savings [66].

Misinformation has reached an unprecedented level in the digital age. Forums, blogs and other alternative news sources facilitate fake news or inaccurate information penetration. Health information at every level, from ordinary people to researchers and policy-makers, is troubled by misinformation. It can contain false narratives and lead to poor decision-making and dangerous behaviours [67].

The Internet is a rapidly evolving territory. Intentionally or unintentionally misleading or provocative information may have serious consequences [68].

A research performed on 210 subjects showed, as expected, that people use search engines to learn about serious or highly stigmatic conditions, but surprisingly, an important amount of sensitive health information is sought and shared via social media [69]. The term telemedicine meaning "healing at a distance" was introduced in 1970 [70].

An international Group Consultation on WHO's Telemedicine Policy adopted the following definition for health telematics: "Health telematics is a composite term for health-related activities, services and systems, carried out over a distance by means of information and communication technologies, for the purpose of global health promotion, disease control and healthcare, as well as education, management and research for health" [71].

Telemedicine can be synchronous or asynchronous. Synchronous or "real-time" care consists in a bidirectional audio-visual videoconferencing between a patient and a more or less remote healthcare provider. Asynchronous or "store-and-forward" care comprises the transmission of medical information to a distant provider.

Telemedicine in children may be useful in improving paediatric concussion care in remote areas and communities [70]. Although international guidelines recommend urgent medical assessment after a concussion [72], a study on 126,654 children and youth showed that, at best, only one third of youth sought medical follow-up and obtained clearance to return to sport activities [73].

In many countries, including Romania, patients living in remote rural areas face numerous geographic, socioeconomic and cultural barriers in accessing primary and specialized healthcare services. Considering the fact that especially in these areas medical assessment and clearance for youth with concussion falls upon primary care providers, telemedicine would improve results and ease the pressure of malpractice.

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

obstetric fistula and maternal mortality.

Child marriage is considered a disguised form of sexual abuse, and it also represents a violation of children's rights. The boys are also concerned, but girls remain disproportionately affected. Poverty, lack of education, regional customs, tradition and religions can be a pressure that leads to child marriage. Child marriage is most common in developing countries, but it happens even in developed countries as many countries' laws allow children under 18 to marry upon parental consent or public authority. This practice denies children of their right for childhood, education or having their own opinion about sexuality and reproduction. Child marriage is linked to early pregnancy, health risks like sexually transmitted infections,

Emotional abuse is a behaviour model that affects a child's emotional development and his health outcome. It is more challenging than physical or sexual abuse, being often difficult to diagnose. Emotional abuse can lead to anxiety, depression,

Medical child abuse or factitious disorder imposed on another (previously called Munchausen syndrome by proxy) is an unnecessary and a potentially harmful treatment received by a child due to a caregiver seeking medical help for exaggerated or made-up symptoms of the child in his or her care [60]. It should be suspected if the child has frequent, unexplained health issues and multiple hospital admissions. The most common form when a mother induces an illness to her child consists in symptoms that usually occur only in her presence and may not be objectivized during the medical evaluation [61]. Neglect is very difficult to conceptualize, being an omission behaviour, and consists in failure of a parent or a caregiver to address the basic needs of a child. It can include physical necessities like food, hygiene, clothing, shelter or protection, educational (schooling and education) and medical neglect defined as a failure to provide necessary medical, dental or mental healthcare for

low self-esteem, post-traumatic stress disorder and suicidal tendency.

Refusing vaccination can also be considered "medical neglect".

aim for early recognition and intervention to protect children's wellbeing.

Child maltreatment provides a significant challenge for medical providers. Practitioners have an important role in prevention and recognition of neglect and abuse and assessment and treatment of children at risk. Once the condition is suspected, they are obligated to report it. Programmes of prevention and intervention

The primary approach is addressed to the general population by an anticipatory guidance for parents and care providers and by implementing media content and school programmes to educate the population about signs and behaviour of child

The secondary approach is addressed to families if risk factors such as poverty, low education, substance abuse, mental health issues, family conflict or violence, social isolation, neighbourhood disadvantage and violence are present. The purpose of intervention is to encourage positive interaction between parent and children and

Families with abused or neglected children may benefit from a tertiary approach. To assess these cases, the multidisciplinary team should consist of therapist, social workers, police, general practitioner, paediatrician and teachers. An individual plan best suited to the family needs (e.g. individual therapeutic interventions, home visiting, family behaviour therapy, social integration) has to be established. If the intervention fails, foster care system may be considered. In this case certain challenges need to be acknowledged: managing challenging behaviour, interacting with biological families and even guiding children

**132**

into adoption.

the child [62].

abuse and neglect.

to break down the coercive cycle [63].

Telemedicine and telehealth devices can improve and facilitate care in children with medical complexity. A single-centre nonblinded randomized clinical trial based on tracheostomy status demonstrated that the group utilizing a telehealth device obtained better results. Thus, at a device connectivity of 96% of the time and image and sound quality acceptable in 98% of visits, hospitalization rate was lower in the telehealth group [74].

Improvement of care in children with complex medical conditions has increased survival, contributing to a continuously rising percentage of paediatric population with chronic healthcare needs. The highest prevalence of children with special healthcare needs (19.8%) is estimated to be in the USA [75].

Introduced mainly to reduce the need for urgent care leading to recurrent emergency department visits and hospital admissions, synchronous digital health technologies are expected to improve parental caregiver outcomes such as quality of life, psychological health, satisfaction with care and social support. As expected, the majority of the papers on this topic originate from the USA and Australia. The explanations lie in the higher economic level but also in the necessity to cover by telemedicine remote areas with few inhabitants [76]. Feasibility-related outcomes were conducted on haematology/oncology/palliative care populations, autism spectrum disorder, asthma or mental health issues and included assessing acute clinical issues, providing psychosocial support, facilitating case conferences, providing routine care and follow-up, delivering therapy and monitoring progress and adherence acceptability [76].

The technical problems encountered were, as expected, both human related and technology related.

The programmes were aiming to provide patient care or replace in-person assessments. Telemedicine was delivered by a multidisciplinary team or nurses with various levels of expertise.

The positive results consisted of decreases in hospitalizations, quicker recovery and reductions in unplanned hospitalizations. No significant changes were recorded in emergency department visits or hospital admissions and in health-related quality of life. Family members reported overall high satisfaction scores with digital health interventions, and parents perceived availability of digital health to be "very important" in assisting them in managing their child's condition at home [77]. Some of the programmes actively involved families in the development, testing and refinement of the intervention. The results were encouraging, with the development of educational materials that were acceptable and useful to parents [76]. An important issue in telemedicine is the evaluation of the technologies available to families. A response bias may be linked to the gap existing between Caucasian and minority populations. Some interventions supplied equipment or internet services to families [78]. Technical issues, affecting digital health interventions, consisting mainly in disruption in connectivity did not alter overall satisfaction for clinicians, management and patients [79]. Even if most of the studies reported a favourable feedback, digital health was not always appropriate. Therapists had difficulty engaging with younger children with hearing loss during videoconferencing appointments, social workers preferred in-person appointments to facilitate a personal connection with patients, and some parents considered that face-to-face demonstrations of clinical skills were mandatory for optimal treatment fidelity [70]. Funding is an issue affecting digital health because of the restrictions related to reimbursement. Up to 36% of booked telehealth appointments are not billed by a faulty system [80].

The use of digital health to care for children with medical complexity is a modern way to connect patients, some in remote areas, to expert care from health professionals while lowering the expenses and avoiding potential harms of the hospital-based care system.

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*The Family as Recipient and Provider of Home Care: A Primary Care Perspective*

**6. Family caregivers for home care recipients with advanced non-cancer** 

Conditions as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, liver failure and dementia represent the non-malignant lifethreatening illnesses which require a complex home care. The different trajectories of functional decline are useful for the home care providers, helping them to tailor strategies and make a better plan of care. Lunney identified four theoretical trajectories of chronic illnesses: sudden death, cancer death or terminal phase, death from organ failure and frailty and dementia [81]. In cancer, the clinical status of the patients is acceptable until the disease does not respond to the treatment and the rapid decline makes easier to predict the terminal stage. In non-oncological chronic diseases, the trajectory is different with several deteriorations and improvements of the clinical state and a slow decline line. In dementia or general frailty, the illness trajectory has a gradual and prolonged decline. The trajectory of renal failure disease may be that of a steady decline, with the rate of this decline varying according to the underlying renal pathology and other comorbidities [82]. Sometime the issues of caring for patients with non-oncological illnesses is more difficult than for patients with cancer because the prevalence of symptoms is higher and there is a prolonged trajectory of decline. Patients with non-oncological illnesses as opposed to patients with cancer are older and have many comorbidities and cognitive impairment. The barriers in home care assistance for the recipients with non-cancer illnesses include less predictable trajectory, the lack of knowledge regarding the care needs of end-stage period, the low use of and late referral to palliative care [83], the possible overwhelm of the palliative care services, the necessity of knowledge in different specialties and the necessity of training in the areas of symptom control [84], and prognostication in non-malignant disease tends to be less accurate than in cancer [85]. These recipients require a multidisciplinary home care team, because they have a multidimensional area of caring. The involvement of the family caregivers is valuable and implies management of digestive problems, balance of fluid and food intake, nutritional status and care of bedsores. Needs such as: fall risks, self-care capacity, instrumental activities of daily living, dementia, fecal and urinary incontinence are difficult to solve [86]. Compared with cancer patients, the non-malignant patient's needs are more complex: moderate and severe neurological issues, psychiatric problems, needs for assistance with defecation and bladder function and moderate and severe deterioration of vigilance (somnolent and comatose) [87]. A higher proportion of non-cancer patients was discharged and died at home, and the proportion of readmitted patients to the hospital

*DOI: http://dx.doi.org/10.5772/intechopen.91926*

was less than for oncological patients [87].

shown to be beneficial [89].

**7. Integration of basic palliative care in the Romanian general practice**

The majority of the incurable ill patients can be treated within primary care health professionals, and 10–15% will be in need of specialist palliative care (PC) [88]. Family physicians' role in primary palliative care and cooperation between specialist palliative care services should become stronger. Palliative care has

expanded since its relevance for non-oncological diseases has been widely acknowledged and integration of PC at an earlier stage in the disease process has been

The real palliative care extent in primary care is underestimated since the estimates of an average care by family doctor for three to four patients with PC needs per quarter do not appropriately reflect care for patients with non-oncological conditions [90]. There is a predominance of non-oncological chronic multi-morbid

**diseases**
