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Seizingopportunities:thehealthvisitor

DrKarenWhittakerReaderinChildandFamilyHealth,SchoolofNursing,

CollegeofHealthandWellbeingUniversityofCentralLancashire

Presentedat:#HVweek28th Sept2016

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Overview

• Lookattheroleofthehealthvisitor• Drawingonhistoryandresearchexamples• Considerwhyfocusonchildren• Sharealittleofmyowncareerstory• Considerthechancetoseizeopportunity

– Forhealthofchildren– Forfamiliesandcommunities– Fornurses

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19th CenturyOrigins- 150yearsinthemaking

• 1862:ManchesterandSalford SanitaryAssociation• Employedhomevisitorstoimprovehealth–

hygiene,motherandbabycare• Healthdeterminantsandprotectingchildren– targeted

• 1929:LocalGovernmentAct;requiredhomevisitsbyahealthvisitortoallnewmothers,withinamonthofbirth.

• Policyenablinguniversalapproach

• 1974:HealthVisitorstransferredfromlocalauthorityemploymentintotheNHS

• Standardised employmentanduniversalrighttoservice

• 2011- 2015:ImplementationplanexpansionofHealthVisiting workforceandreshapingofbothhealthvisitingandschoolnursing.

• 2012- 150yearsanniversary• Endorseneedforknowledgeable,skilledpractitioners,clear

onfocustoworkwith familiesandcommunities

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WhyFocusonChildren?Historically• theneedtoinvestin&protectchildren-

addresscruelty,poorconditionsandnutrition(Dingwall 1982)

• Improvethesurvivalandfitnessoffuturecitizensintheinterestsof‘nationalefficiency’– mothers were ignorant of the correct

methods of childrearing and needed to be educated (viewnotedbyBryder 2002)

• Assistingchildrenrequiressupportformothers- mothers’ friend (Davies,1988)

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Forme….

Student nurse and health visitor at the University

of Manchester -placements in City of

Salford, where I went on to practice during the

1990’s

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Freshfocusonchildrenandfamilies,proposalsincluded:• Anenhancedandexpanded

roleforhealthvisitors– Workbeyond‘health’– Shiftfromdealingwithto

preventingproblems

• Acheson(1998)Publichealthinquiry– Childpovertyandhealth

divide

EvolvingPoliticsGeneralElection1997NewPolitics&NewLabour

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Seizingopportunities..

• Newjob– UCLan1997• Lecturingandpracticeinhealthvisiting

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ParentingasPublicHealthConcern

• Theory– Parentingself-efficacy– Resources- wellbeing

• Salutogenesis(Cowley&Billings1999)

• Programmes– Visitinge.g.NurseFamilyPartnership&Groupbased

• Evidencebase– Cochranereviews(Barlow&Coren2000)

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Complexity

Parentingprogrammesaresocialandcomplex

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BeingBold…

StartingaPhD…

Seizingopportunities• Askthequestion..

Takeonthechallenge• Fundingapplication• Distancelearning• Ventureintotheunknown

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TheStudy• Question?

– Howdoparentingserviceswork– andforwhominwhatcircumstances?

– SpecificinterestinthePositiveParentingProgramme• Realisticevaluation

– Contexts,MechanismsandOutcomes– Theorydriven– self-efficacy– Socialprogrammeshavelayers

• Mixedmethodstocollectdata– Survey– Detailedanalysisofselectedcases

– (Whittaker,2008)

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Personal world with informal

systems

Home visiting

Parent-child group

Positive parenting course

Course for parents

Community events/activities

FindoutGetthere

BethereStaythere

Moveonormoveout

Parenting Service

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MainMessagesforApplication

• Differentfacilitiescanworkinacomplementaryfashion

• Interpersonalrelationshipswerekeyfeaturesofparentsjourneys

• Informalnetworksaredistinctsourcesofinfluenceandsupport

• Practitionershaveakeyroleinshapingenvironmentsthroughuseofinterpersonalskills– Improveexposureto+ve sourcesofself-efficacy(Whittaker,2008)

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Publichealthevidence

• Lifecourseresearch(Graham&Power2004;Kuh&Ben-Schlomo2004)

• EarlychilddevelopmentinequalitiesUNICEFsurvey(Irwinetal.2007)

• MentalPublicHealth(RCPsych2010)• Family&domesticviolence(Abramskyetal2011;NICE2014)

• Inequalitiesinhealth(Marmot2010)

• Impactonindividualsandsociety

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EvolvingPolitics

• Coalitiongovernment2010

• Promisedradicalprogrammeof4,200extrahealthvisitorsandservicetransformation.

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Opportunity….

• NationalNursingResearchUnit

• King’sCollegeLondon• PolicyResearchProgrammeonHealthVisitingtosupportthe‘CalltoAction’

• Threeresearchstudies

NNRUTeamatthe2012CPHVAConference

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Projectbackground

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Empiricalstudy

Exploringserviceusers’views

AIMS

LiteraturereviewNarrativesynthesisofhealthvisiting

practice

EmpiricalstudyRecruitmentand

retentionforhealthvisiting

StartandStay

•Whatpeoplewantfromtheirjob•Aspirations•Promotionofjobsatisfaction•Whatattracts&keepspeople

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

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Whatwasvalued

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Whatwasvalued

Whittaker et al 2015

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Theprogrammeofhealthvisitorresearch

Researchdetailinghealthvisitingpracticethatmakesadifferencetochildrenandfamilies

Existingliteratureshowsapurposeful

orientationtopractice,realisedthrough

relationships,homevisitingandneeds

assessment

Parents valueenablingrespectful

relationshipsfrompractitionersabletolistenandmatchservicetoneed

Healthvisitorsvaluerespectfulline

managementenablingprofessionalautonomy

forflexibleclientfocusedservice

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

Therelationshipwithparentremainsatthecentre ofthehealthvisitorwork

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Developmentalscience

• Infantbraindevelopmentandcaregiverrelationships(Shonkoff&Philips2000)

• Nurturingstrongparent-childrelationshipsforviolenceprevention(WHO2009)

• Lancetseriesonearlychildhood(2007,2011)• Toxicstress(Shonkoffetal.2012a;2012b)

• Callsforpoliciesandinvestmentthatsupportuniversalearlychildhooddevelopmentinterventions– includinghomevisiting(UNICEF2012;Garner2013)

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WHO2013MeetingonHumanCapital

‘Considerableprogresshasbeenmadeinimprovingchildsurvival.However,inordertohelpchildrenreachtheirfulldevelopmentpotential,toavoidlaterchronicdiseaseandtomovetowardssustainabledevelopmentandsocialequity,thechildsurvivalandchilddevelopmentagendasneedtobeintertwined.’(WHO2013,page13)

See YouTube clip by Prof Heckmann http://www.youtube.com/watch?v=g9E2slx9tgo

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Actionson…

Survival• SavetheChildrentraining

midwives,nursesanddoctorsinmotherkangaroocare– tokeepthebabywarmthroughskin-to-skincontact– toimprovethesurvivalchancesoflowbirth-weightbabies

Earlychilddevelopment(ECD)Chan(2013)ofWHOnoted…• Healthserviceshaveaunique

responsibility– duetopotentialreachwithallfamilies

UNICEFandWHOhavebeendevelopingresourcesandNetworksPromotionofuniversalECDsupportviaHomeVisiting

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ActionthroughHomeVisitingInternationally• Healthvisitor- UK,Denmark&Norway• Childhealthnurse- Sweden• Publichealthnurse- America,Canada,Ireland• Child&familyhealthnurse– Australia• Plunketnurse- NewZealand• Socialnurses- Belgium• Ladyhealthvisitors&LadyHealthWorkers– Pakistan• Patronagenurse– Serbia,Kosovo

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Theessenceofpractice• ResearchevidenceshowsthatUKhealthvisitingisconcernedwith:

• Health-creation(Salutogenic),• Demonstratingapositiveregardforothers(humanvaluing),• Recognising theperson-in-situation(humanecology)

• Thisorientationunderpinneddeliveryoftheservicethroughthreecorepractices:

• healthvisitor-parentrelationships,• healthvisitorhomevisitingand• healthvisitorneedsassessment

See:Cowley etal.(2013)WhyHealthVisiting?At:http://www.kcl.ac.uk/nursing/research/nnru/publications/index.aspx

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Workingincontextofpublichealth• Afocusonearlylife

• Awareofsocialdeterminantsofhealth

• Keeping inmindthe:– child– parent– family– neighbourhood– andlargercommunity

– DrawingontheideasofBronfenbrenner(1986)humanecology

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UNICEFinEasternEuropeWorkingwitharangeofcountriesto:• Developregionalframework• Standardsforpractice• Designofserviceofeducational

modules• Facilitatenetworks• Influencepolicy

– Creatingaroadmap• UniversalMaternalchildhealth&ECD• Nurseeducationandprofessional

regulation• Comprehensivesystem

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England- goodpracticemodel

• Dedicatedworkforce,specificallyeducatedandskilledinfamilyhomevisiting&communitypractice

• Evidenceinformedguidanceforservices– HealthyChildProgramme(DH2009;Axford etal2015)

• Clearplanforserviceinvestmentanddevelopment– Detailinglevelsofservicebasedonprinciplesofproportionateuniversalism

• Community BuildingCapital• Universal Universal• Universalplus Enhanced• Universalpartnershipplus Intense

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UNICEFHomeVisitingStandards

DevelopedforCentralEasternEuropeanCountries• Emphasisonuniversalism• SupportingECD• Engagingparentsasan

imperative• Workingwith andnoton• Purposefulhomevisiting• Skilled,knowledgeablehome

visitingnurses- continuity• Comprehensive

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AprivilegedworthwhileroleAsexplainedbyastudentandanexperiencedhealthvisitorintheStartandStayStudy(Whittakeretal2015)

• Ithighlightspeoples’strengthsinthefaceofadversity.

• Notwofamiliesarethesameandeachandeverybirthnotificationand“movementsin”presentsexcitingchallenge.Thefirsttimeyouknockonthedooryouarestartinganewandexcitingjourney.

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Whathealthvisitorsneedtokeepdoing..• Connectingandworkingcloselywithfamilies

• Buildonknowledgeandbreadthofeducationandbereadytolearnsomemore…

• Collectevidenceofpractice• Networkandsharetoinformfuturepracticeandservicecommissioning

• Seizetheopportunities!

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Thankyou

Contact:Kwhittaker1@uclan.ac.uk

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References1• AbramskyT.,WattsC.,Garcia-MorenoC.,etal.(2011)Whatfactorsareassociated

withrecentintimatepartnerviolence?BMCPublicHealth 11, 109.• Axford,Netal2015.RapidReviewtoUpdateEvidencefortheHealthyChild

Programme0–5.PublicHealthEngland.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/429740/150520RapidReviewHealthyChildProg_UPDATE_poisons_final.pdf

• Bronfebrenner,U.(1986)Ecologyofthefamilyasacontextforhumandevelopment:Researchperspectives.DevelopmentalPsychology 22(6):723-42

• BryderL.(2002)ThePlunketnurseasaNewZealandicon.Accessed:27-2-2014.http://www.nursing.manchester.ac.uk/ukchnm/publications/seminarpapers/ .

• ChanM.(2013)Linkingchildsurvivalandchilddevelopmentforhealth,equity,andsustainabledevelopmentTheLancet381:1514-5

• Cowley,S.,Whittaker,K.,Malone,M.,Donetto,S.,Grigulis,A.,Maben,J.,Whyhealthvisiting?Examiningthepotentialpublichealthbenefitsfromhealthvisitingpracticewithinauniversalservice:anarrativereviewoftheliterature.,InternationalJournalofNursingStudies(2014),http://dx.doi.org/10.1016/j.ijnurstu.2014.07.013

• Davies,C.(1988)TheHealthVisitorasMother'sFriend:Awoman'splaceinpublichealth.TheSocietyfortheSocialHistoryofMedicine,1(1),39-59.

• Dingwall,R.(1982)Communitynursingandcivilliberty,JournalofAdvancedNursing,7,337–46.

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• Garner,AS(2013)HomeVisitingandtheBiologyofToxicStress:OpportunitiestoAddressEarlyChildhoodAdversity.Pediatrics 132(Supplement2):S65-S73

• GrahamH,PowerC(2004)Childhooddisadvantageandhealthinequalities:aframeworkforpolicybasedonlifecourse research.Child:Care,Health&Development30(6):671-678.

• Irwin,L.,Siddiqi,A.,andHertzman,C.(2007)Earlychilddevelopment:Apowerfulequalizer- FinalreportfortheWorldHealthOrganization’sCommissionontheSocialDeterminantsofHealth.UniversityofBritishColumbia:Availableat:http://factsforlife.org/pdf/a91213.pdf.

• Kuh,D.,Ben-Shlomo,Y.(Eds)(2004)ALifeCourseApproachtoChronicDiseaseEpidemiology.(2nd Edition) Oxford,OxfordUniversityPress

• TheLancet(2007)andChildDevelopmentinDevelopingCountries2http://www.who.int/maternal_child_adolescent/documents/lancet_child_development/en/ TheLancet(2011)www.thelancet.com/series/child-development-in-developing-countries-2

• MarmotM(2010)FairSociety,HealthyLives.TheMarmotReview.www.ucl.ac.uk/marmotreview Marmot(2013)UniversalhealthcoverageandsocialdeterminantsofhealthTheLancet 382,1227-8www.thelancet.com/pdfs/journals/lancet/PIIS0140673613617912.pdf

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• NationalInstituteforHealthandCareExcellence(NICE)(2014).Domesticviolenceandabuse:howhealthservices,socialcareandtheorganisationstheyworkwithcanrespondeffectively.NICEpublichealthguidance50.http://guidance.nice.org.uk/PHG/44 .

• ShonkoffJP,GarnerAS,SiegelBS,etal.(2012a)TheLifelongEffectsofEarlyChildhoodAdversityandToxicStress.Pediatrics,129(1),232-246.

• ShonkoffJP,AkilH,ChangHI,etal.(2000and2012b)Fromneuronstoneighborhoods:anupdate. NationalResearchCouncilandIoM.NationalAcademyPress,WashingtonDC.

• ShonkoffJP(2014)ChangingtheNarrativeforEarlyChildhoodInvestmentJAMAPediatr.2014;168(2):105-106.doi:10.1001/jamapediatrics.2013.4212.

• WHO(2013)Nurturinghumancapitalalongthelifecourse:Investinginearlychilddevelopmentwww.who.int/maternal_child_adolescent/documents/investing_ecd/en/

• Whittaker,K.(2008)Arealisticevaluationofhowparentsexperiencetheprocessofformalparentingsupport.PhDThesis.Kings’sCollege,London.

• Whittaker,K.A.,Malone,M.,Cowley,S.,Grigulis,A.,Nicholson,C.,Maben,J.(2015)Makingadifferenceforchildrenandfamilies.Anappreciativeinquiryofhealthvisitorvaluesandwhytheystartandstayinpost.HealthandSocialCareintheCommunity.doi:10.1111/hsc.12307