Why Health Visiting? What are the benefits for public ... · What are the benefits for public health from a universal service? ... Khaw KT and Marmot M (2008) 2nd edition Rose‟s

Why Health Visiting?

What are the benefits for public

health from a universal service?

Sarah Cowley

9th April 2015

Two key themes

• Why a proportionate

universal service?

Focus on Foundation

Years

• Education

infrastructure

• Getting

• NHS Operating

Framework

• Why Health

Visiting – or

Maternal, Child &

Family Health

Nursing?

Inequalities in early childhood:

proportionate universalism

• “Giving every child the best start in life is crucial to

reducing health inequalities across the life course. .

. .

• “(We need) to increase the proportion of overall

expenditure allocated (to early years, and it) should

be focused proportionately across the social

gradient to ensure effective support to parents,

starting in pregnancy and continuing through the

transition of the child into primary school. . . . .”

Marmot (2010 p 23) Fair Society, Healthy Lives

Focus on the Foundation Years

• Strong, expanding evidence

showing the period from

pregnancy to two years old

sets the scene for later mental

and physical health, social

and economic well-being

• Direct links to cognitive

functioning, obesity, heart

disease, mental health, health

inequalities and more

• Social gradient demonstrates

need for universal service,

delivered proportionately

• Foundations of health1:

– Stable, responsive

relationships

– Safe, supportive

environments

– Appropriate nutrition

1www.developingchild.harvard.edu

Both. . and. . not . either. . or. .

• Universal and targeting

• Need for targeted services delivered from within

universal provision delivered to all

• Population assessment (service commissioner)

and family/individual assessment (practitioner)

• Different intensities and types of provision according

to individual need

• Generalist health visiting (Child and Family Health

Nursing) and embedded specific, evidence based

interventions

• Take into account social gradient and prevention

paradox

Social gradient

• Differences in health and well-being are graded

throughout society.

• Health inequalities are particularly significant

between the top (best-off) and the bottom (worst-

off) of the gradient,

• . . . but they run through the whole population, so

each socioeconomic step, up or down and from the

highest to the lowest, affects the child‟s life

chances.

Australian Early

Development Indicators

• “a national measure of how well we are supporting

our children‟s development.”

• Data from 97.5% of all Australian children in their

first year at school

• Five domains measured

1. Physical health and well-being

2. Social competence

3. Emotional maturity

4. Language and cognitive skills

(schools based)

5. Communication skills, general knowledge

www.aedi.org.au

Physical health and well-being

• Physical readiness for

school day

• Physical dependence

• Gross and fine motor

skills

Scores range 0-10

<10th centile = developmentally

vulnerable

10-25th centile = developmental

at risk

>25th centile = developmentally

on track

• Mapped by quintile:

Australian Bureau of

Statistics (ABS) Indexes for

Relative Socio-Economic

Disadvantage (IRSD)

Physical health and wellbeing

Base=247,232 5year-old children

Social competence

• Overall social competence

• Responsibility and respect

• Approaches to learning

• Readiness to explore new

things

Scores range 0-10


vulnerable


at risk


on track





Disadvantage (IRSD)

Social competence


Emotional maturity

• Pro-social and helping

behaviour

• Anxious and fearful

behaviour

• Aggressive behaviour

• Hyperactivity and

inattention

Scores range 0-10


vulnerable


at risk


on track





Disadvantage (IRSD)

Emotional maturity


Language and cognitive skills

(school based)

• Basic literacy

• Interest in

literacy/numeracy and

memory

• Advanced literacy

• Basic numeracy

Scores range 0-10


vulnerable


at risk


on track





Disadvantage (IRSD)

Language and cognitive skills

(school based)


Communication skills and

general knowledge

• Single score based on

teachers observations of

broad developmental

competencies and skills

measured in the school

context

• Children from language

backgrounds other than

English may be proficient

in their home language

Scores range 0-10


vulnerable


at risk


on track





Disadvantage (IRSD)

Communication skills, general

knowledge


Overall results: vulnerable on one

or more AEDI domains: % children

Base=246,421 children (one domain) 246,873 (two domains)

Where Australian children live - 97.5%

of all 5 year olds included in census

Base = 246,421 5year old children

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

quintile 1(disadvantaged)

quintile 2 quintile 3 quintile 4 quintile 5(advantaged)

Total Children

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

quintile 1(disadvantaged)

quintile 2 quintile 3 quintile 4 quintile 5(advantaged)

Number of Children with Indicators

one domain two or more domainsNumber of Domains

Number of children whose development is

at risk (one domain) or vulnerable (two

domains) in each quintile

71% of Children – 40,102

29% of

Children –

16,668

Data pooled across 246,421 children (one domain) 246,873 (two domains)

Number of children affected by family

disadvantage indicators in each centile

65% of Children - 864,465

35% of

Children

-

475,164

„Prevention paradox‟

• “A large number of people at small risk may give

rise to more cases of disease than a small number

of people at high risk”

• High risk groups make up a relatively small

proportion of the population

• Need to shift the curve of the gradient and

distribution of need across the whole population to

reduce overall prevalence

• A universal service, delivered proportionately

according to need, can achieve this

Khaw KT and Marmot M (2008) 2nd edition Rose‟s Strategy of Preventive Medicine

Whole time equivalent (WTE) health visitors

employed in England Sept (1988) 1998-2014

10,680

10,020

10,070

10,050

10,046

10,190

9,912

9,999 10,137

9,809

9,376

9,056

8764 8519

8017 7941

8385

9550

10800

7,500

8,000

8,500

9,000

9,500

10,000

10,500

11,000

11,500

12,000

1988

1998

2000

2002

2004

2006

2008

2010

2012

2014

WTE health visitors

UnconfirmedFeb2015=11982wte

Target=12,292WTE(May2015)

Source: Information Centre for Health and Social Care Unconfirmed data – management figures

*

Updated Health Visitor

Implementation Plan

Growing the workforce

Professional mobilisation

Service transformation

Wider community

Neighbourhood

Family

Parent

Child

Bronfenbrenner‟s (1986) concept of nested systems

Shifting focus

of attention to

need

Situation,

resources to

meet need

Simultaneous

assessment,

prevention,

intervention

Wider community

Neighbourhood

Family

Parent

Child

Health visiting practice

• Focus on situation and resources

needed for prevention and promotion

• Community and caregiver capacity1

• Foundations of health1

Stable, responsive relationships

Safe, supportive

environments

Appropriate

nutrition

1www.developingchild.harvard.edu

Plan to Transform Health Visiting Services 2011

Service vision for health visiting services in England: Nov 10

4-5-6 model to explain transformed

health visiting service

Acknowledgements

Empirical study Voice of service

users

AIMS

Literature review Narrative synthesis of health visiting practice

Empirical study

Recruitment and retention for health

visiting

This work was commissioned and supported by the Department of Health in England as

part of the work of the Policy Research Programme. The views expressed are those of

the authors and not necessarily those of the Department of Health.

Overarching question

• What are the key components of health visitor

interventions and relationships between the current

health visiting service, its processes and outcomes for

children and families?

Method

• A scoping study and narrative review of the research

about health visiting practice to distil information from

diverse forms of evidence: 348 papers reviewed in full,

after screening title & abstracts of 3000+ papers

‘Why Health Visiting?’ review of the literature

Orientation to practice to enable

positive „service journey‟

Older and more recent research papers

were consistent in the way practice was

described as:

• Salutogenic (health-creating),

• Demonstrating a positive person-centred

approach (human valuing),

• Recognising the person-in-situation (human

ecology)

Service delivered through a single,

purposeful process

This orientation underpinned delivery of

the service through three core practices:

• health visitor-parent relationships,

• health visitor home visiting and

• health visitor needs assessment.

• Empirical study showed that

parents also value health

visiting outside the home (Donetto and Maben 2014)

Relational process; focused practice

Bidmead C (2013) http://www.kcl.ac.uk/nursing/research/nnru/publications/Reports/Appendices-12-02-13.pdf

Salutogenic

(health creation)

Person-centred

Person-in-

context

For families -

universality should mean:

• Universal „offer‟ of:

– Five mandated contacts: everyone gets this

– Healthy Child Programme (HCP)

– Service on their own terms

• „Service journey‟

– Meet/get to know health visitor: trust relationship,

partnership working – „relational autonomy‟

– Services delivered to all – i.e., home visits (HCP)

– Health visiting outside home – well baby clinics, groups

etc, in conjunction with others (e.g. Children‟s Centres)

• „Open secret‟ of safeguarding/child protection

Cowley et al (2014) http://dx.doi.org/10.1016/j.ijnurstu.2014.07.013

„Universal Plus:‟ simultaneous

prevention and treatment

• Across six high priority areas

and more, e.g.

– Specially trained health

visitors can simultaneously

prevent Brugha et al 2010,

detect and treat post-natal

depression through „listening

visits‟ Morrell et al 2009

– Identify who needs

parenting support; refer to

and deliver successful

parenting programmes Whittaker and Cornthwaite 2000,

Stewart-Brown et al 2004

Mental health

• Post-natal depression (PND)

• Early identification and treatment with listening visits Morrell et al 2009

• Prevention of PND Brugha et al 2010

• More relaxed mothering Wiggins et al 2005, Barlow et al 2007,

Christie et al 2011

• Improved mother/infant interaction Davis et al 2005, Barlow

et al 2007

• Special needs: Reduced children‟s ADHD

symptoms and improved maternal well-being, by

HV working in specialist team Sonuga-Barke et al 2001

Universal Partnership Plus: Maternal Early

Childhood Sustained Home Visiting (MECSH)

• Designed to capitalise on what is known about

successful programmes

• Sufficient intensity and duration: home visits + groups

• Strengths based practice using „family partnership

model‟ - FPM (Davis et al 2002)

• Two generational (parent and child) and multi-

faceted/community based

• Highly skilled professionals

• And to add in:

• Support and develop existing, generic service

• „Shift the curve‟ by targeting „worst-off‟ 20% or more

Kemp et al ( 2011) Archives of Disease in Childhood 96:533-540.

Health visitor research programme

• Literature - evidence of benefits, if

sufficient staff, skills, knowledge

• Health Visitors‟ desire to make a

difference for children and families

• Parents‟ desire to be „known‟,

listened to and ease of access

• Shared desire for:

• Others to value their knowledge and

contribution

• Respectful, enabling relationships

• Flexible service (varied intensity +

type, e.g. home visits and centre-

based) to match need

What is needed?

Organisational support

• Conflicting demands (relationship vs. public health)

• Population needs (e.g., Key Performance

Indicators, targets) vs. individual/family needs

Sufficient time

• Staffing levels

• Equipment for job

Sufficient skills

• Education:

– Qualification/pre-registration programme – needs longer

– Continuous professional development

Health and Inequalities: universal

focus on the Foundation Years

• Known importance of

• Caregiver and Community

Capacities

• Foundations of Health

• Biology of Health

www.developingchild.harvard.edu

Emerging understandings:

• what is necessary (required) for child

development

• what is foundational: ie, other

elements will not work without it

• how to measure foundations and

requirements (assets/capacity)

• which outcomes are appropriate and

helpful to measure

• connections that exist between

problem-based (prevention) and

capacity-building (promotion)

approaches

• how to delineate attribution

http://www.developingchild.harvard.edu

Thank you!

[email protected]

‘Why Health Visiting’ References

Reports on NNRU website: http://www.kcl.ac.uk/nursing/research/nnru/publications/index.aspx

Bidmead C (2013) Health Visitor / Parent Relationships: a qualitative analysis. Appendix 1, in Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E & Maben J (2013b) Appendices for Why health visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. National Nursing Research Unit, King’s College London

Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E & Maben J (2013a) Why health visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. National Nursing Research Unit, King’s College London

Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E & Maben J (2013b) Appendices for Why health visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. National Nursing Research Unit, King’s College London

Donetto S, Malone M, Hughes, Morrow E, Cowley S, J Maben J (2013) Health visiting: the voice of service users. Learning from service users experiences to inform the development of UK health visiting practice and services. National Nursing Research Unit, King’s College London

Whittaker K, , Grigulis A, Hughes J, Cowley S, Morrow E, Nicholson C, Malone M & Maben J (2013) Start and Stay: the recruitment and retention of health visitors. National Nursing Research Unit, King’s College London

Policy+ 37: February 2013 - Can health visitors make the difference expected? http://www.kcl.ac.uk/nursing/research/nnru/Policy/policyplus.aspx

Published papers

Cowley S, Whittaker K, Malone M, Donetto S, Grigulis A & Maben J (2014) Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: a narrative review of the literature. International Journal of Nursing Studies. 52, 465-480

Donetto S & Maben J (2014) ‘These places are like a godsend’: a qualitative analysis of parents’ experiences of health visiting outside the home and of children’s centre services Health Expectations (online/earlyview) doi: 10.1111/hex.12226

http://www.kcl.ac.uk/nursing/research/nnru/publications/index.aspx

http://www.kcl.ac.uk/nursing/research/nnru/publications/index.aspx

http://www.kcl.ac.uk/nursing/research/nnru/Policy/policyplus.aspx

References Bronfenbrenner U. Ecology of the family as a context for human development: Research perspectives.

Developmental Psychology 1986. 22: 6, 723-742.

Barlow J., Davis H., McIntosh E., Jarrett P., Mockford C., & Stewart-Brown S. (2007) Role of home visiting in

improving parenting and health in families at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic

evaluation. Archives of Disease in Childhood 92, 229-233.

Brugha TS, Morrell CJ, Slade P & Walters SJ (2010). Universal prevention of depression in women postnatally: cluster randomized trial

evidence in primary care. Psychological Medicine, 41: 739-748

Centre for Community Child Health and Telethon Institute for Child Health Research (2009). A Snapshot of Early Childhood Development in

Australia – AEDI National Report 2009, Australian Government, Canberra. Reissued March 2011. www.aedi.org.au.

Christie J, Bunting B (2011) The effect of health visitors‟ postpartum home visit frequency on first-time mothers: Cluster randomised trial.

International Journal of Nursing Studies 48: 689–702

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Documents

Why Health Visiting? What are the benefits for public ... · What are the benefits for public health from a universal service? ... Khaw KT and Marmot M (2008) 2nd edition Rose‟s