1. No category

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
•
Population assessment (service commissioner)
and family/individual assessment (practitioner)
•
•
•
Need for targeted services delivered from within
universal provision delivered to all
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 (worstoff) 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
5.
(schools based)
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
<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)
Social competence
Base=247,189 5year-old children
Emotional maturity
•
•
•
•
Pro-social and helping
behaviour
Anxious and fearful
behaviour
Aggressive behaviour
Hyperactivity and
inattention
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)
Emotional maturity
Base=246,197 5year-old children
Language and cognitive skills
(school based)
• Basic literacy
Scores range 0-10
• Interest in
<10th centile = developmentally
•
•
literacy/numeracy and
memory
Advanced literacy
Basic numeracy
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)
Language and cognitive skills
(school based)
Base=246,810 5year-old children
Communication skills and
general knowledge
• Single score based on
Scores range 0-10
•
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
<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)
Communication skills, general
knowledge
Base=247,212 5year-old children
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
Total Children
70,000
60,000
50,000
40,000
30,000
20,000
10,000
quintile 1
(disadvantaged)
quintile 2
Base = 246,421 5year old children
quintile 3
quintile 4
quintile 5
(advantaged)
Number of children whose development is
at risk (one domain) or vulnerable (two
domains) in each quintile
Number of Children with Indicators
Number of Domains
one domain
two or more domains
18,000
16,000
14,000
12,000
10,000
8,000
29% of
Children –
16,668
71% of Children – 40,102
6,000
4,000
2,000
quintile 1
(disadvantaged)
quintile 2
quintile 3
quintile 4
quintile 5
(advantaged)
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
12,000
Unconfirmed Feb 2015
= 11982 wte
11,500
11,000 10,680
10,050
10,070
9,500
10,190
10,046
9,999
9,912
10,137
9,809
9,000
8,500
8385
7941
20
12
20
06
20
04
20
02
20
00
19
88
7,500
8017
Target = 12,292 WTE
(May 2015)
19
98
8,000
9550
9,376
9,056
8764
8519
20
14
10,020
20
10
10,000
10800
20
08
10,500
*
WTE health visitors
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
Shifting focus
of attention to
need
Situation,
resources to
meet need
Simultaneous
assessment,
prevention,
intervention
Bronfenbrenner‟s (1986) concept of nested systems
Health visiting practice
• Focus on situation and resources
needed for prevention and promotion
• Community and caregiver capacity1
• Foundations of health1
Wider community
Neighbourhood
Family
Stable, responsive relationships
Safe, supportive
environments
Appropriate
nutrition
1www.developingchild.harvard.edu
Parent
Child
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
Literature review
Narrative synthesis of
health visiting practice
Empirical study
Recruitment and
retention for health
visiting
AIMS
Empirical study
Voice of service
users
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.
‘Why Health Visiting?’
review of the literature
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
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
Salutogenic
(health creation)
Person-centred
Person-incontext
Bidmead C (2013) http://www.kcl.ac.uk/nursing/research/nnru/publications/Reports/Appendices-12-02-13.pdf
For families universality should mean:
•
Universal „offer‟ of:
•
„Service journey‟
– Five mandated contacts: everyone gets this
– Healthy Child Programme (HCP)
– Service on their own terms
– 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 multifaceted/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 centrebased) 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
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
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