Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: a narrative review of the literature

First-Time Parents' Support Needs and Perceived Support From a Child Health Service With the Integrated New Families Home Visiting Programme

The transition to parenthood is complex and influenced by interacting factors related to society, the parents and the child. Professional support is considered to be one of the societal factors affecting this transition by facilitating parents' sense of confidence and their competence as parents. In this study, we aimed to explore first-time parents' support needs and experiences of support from a child health service with the integrated New Families home visiting programme, in the context of their transition to parenthood in the first year postnatally. Interpretive description guided this qualitative study. Six couples and one mother, all well-educated and employed, were interviewed individually (N = 13). The parents were recruited from the research project 'New Families - Innovation and Development of the Child Health Service in Oslo'. We found that being a first-time parent is perceived as overwhelming and that defining support needs may be challenging, particularly in the first period postnatally. In addition, the support needs are constantly changing due to the complexity of interacting factors and the ongoing development of confidence in the parental role. Retrospectively, the parents were satisfied overall with the support from the child health service. The home visit during pregnancy facilitated management and relational and informational continuity. However, we identified a need for even more proactive information provision and communication to optimise the service's availability and efficiency postnatally. In addition, the importance of peers and of approaching both mothers and fathers must be acknowledged in facilitating parental confidence.

Mixed methods feasibility and usability testing of a childhood obesity risk estimation tool

BACKGROUND

A Childhood Obesity Risk Estimation tool (SLOPE CORE) has been developed based on prediction models using routinely available maternity and early childhood data to estimate risk of childhood obesity at 4-5 years. This study aims to test the feasibility, acceptability and usability of SLOPE CORE within an enhanced health visiting (EHV) service in the UK, as one context in which this tool could be utilised.

METHODS

A mixed methods approach was used to assess feasibility of implementing SLOPE CORE. Health Visitors (HVs) were trained to use the tool, and in the processes for recruiting parents into the study. HVs were recruited using purposive sampling and parents by convenience sampling. HVs and parents were invited to take part in interviews or focus groups to explore their experiences of the tool. HVs were asked to complete a system usability scale (SUS) questionnaire.

RESULTS

Five HVs and seven parents took part in the study. HVs found SLOPE CORE easy to use with a mean SUS of 84.4, (n = 4, range 70-97.5) indicating excellent usability. Five HVs and three parents took part in qualitative work. The tool was acceptable and useful for both parents and HVs. Parents expressed a desire to know their child's risk of future obesity, provided this was accompanied by additional information, or support to modify risk. HVs appreciated the health promotion opportunity that the tool presented and felt that it facilitated difficult conversations around weight, by providing 'clinical evidence' for risk, and placing the focus of the conversation onto the tool result, rather than their professional judgement. The main potential barriers to use of the tool included the need for internet access, and concerns around time needed to have a sensitive discussion around a conceptually difficult topic (risk).

CONCLUSIONS

SLOPE CORE could potentially be useful in clinical practice. It may support targeting limited resources towards families most at risk of childhood obesity. Further research is needed to explore how the tool might be efficiently incorporated into practice, and to evaluate the impact of the tool, and any subsequent interventions, on preventing childhood obesity.

Improving connections to early childhood systems of care via a universal home visiting program in Massachusetts

Welcome Family is a universal, short-term nurse home visiting program designed to promote optimal maternal and infant physical and mental well-being and provide an entry point into the early childhood system of care to all families with newborns up to 8 weeks old living in defined communities in Massachusetts. The present study examines whether: 1) Welcome Family meets its goal of successfully connecting families to two early childhood programs-evidence-based home visiting (EBHV) and early intervention (EI)-relative to families with similar background experiences who do not participate in Welcome Family, and 2) whether these impacts are conditional on families' race and ethnicity and their primary language-two characteristics that are related to structural racism and health inequities. The study used coarsened exact matching (CEM) based on birth certificate data to match Welcome Family participants who enrolled during 2013-2017 to mothers and their infants living in the home visiting catchment areas who did not receive home visiting during the study period. Primary study outcomes included enrollment in any EBHV program supported by the Massachusetts Maternal, Infant, and Early Childhood Home Visiting (MA MIECHV) program up to age 1 year, measured using MA MIECHV home visiting program data, and EI service receipt for children aged up to age 3 years, measured using EI program data. Impacts were assessed by fitting weighted regression models adjusted for preterm birth, maternal depression, and substance use. Mothers' race, ethnicity, and language were included in the model as moderators of Welcome Family impacts on enrollment in EBHV and EI. Welcome Family participants (n = 3,866) had more than double the odds of EBHV enrollments up to age 1 and had 1.39 greater odds of receiving EI individualized family service plans (IFSPs) up to age 3 relative to the comparison group (n = 46,561). Mothers' primary language moderated Welcome Family impacts on EBHV enrollments. Universal, short-term programs such as Welcome Family may be an effective method of ensuring families who could benefit from more intensive early childhood services are identified, engaged, and enrolled.

Health visiting in the UK in light of the COVID-19 pandemic experience (RReHOPE): a realist review protocol

INTRODUCTION

Health visiting services, providing support to under 5s and their families, are organised and delivered in very different ways in different parts of the UK. While there has been attention to the key components of health visiting practice and what works well and how, there is little research on how health visiting services are organised and delivered and how that affects their ability to meet their objectives. The COVID-19 pandemic rapidly disrupted service delivery from March 2020. This realist review aims to synthesise the evidence on changes during the pandemic to identify the potential for improving health visiting services and their delivery.

METHODS AND ANALYSIS

This review will follow the RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) quality standards and Pawson's five iterative stages to locate existing theories, search for evidence, select literature, extract data, synthesise evidence and draw conclusions. It will be guided by stakeholder engagement with practitioners, commissioners, policymakers, policy advocates and people with lived experience. This approach will consider the emerging strategies and evolving contexts in which the services are delivered, and the varied outcomes for different groups. A realist logic of analysis will be used to make sense of what was happening to health visiting services during and following the pandemic response through the identification and testing of programme theories. Our refined programme theory will then be used to develop recommendations for improving the organisation, delivery and ongoing postpandemic recovery of health visiting services.

ETHICS AND DISSEMINATION

General University Ethics Panel approval has been obtained from University of Stirling (reference 7662). Dissemination will build on links to policymakers, commissioners, providers, policy advocates and the public. A range of audiences will be targeted using outputs tailored to each. A final stakeholder event focused on knowledge mobilisation will aid development of recommendations.

PROSPERO REGISTRATION NUMBER

CRD42022343117.

Identification of families in need of support: Correlates of adverse childhood experiences in the right@home sustained nurse home visiting program

Background

Little is known about the efficacy of pregnancy screening tools using non-sensitive sociodemographic questions to identify the possible presence of as yet undiagnosed disease in individuals and later adverse childhood events disclosure.

Objectives

The study aims were to: 1) record the prevalence of risk disclosed by families during receipt of a sustained nurse home visiting program; and 2) explore patterns of relationships between the disclosed risks for their child having adverse experiences and the antenatal screening tool, which used non-sensitive demographic questions.

Design

Retrospective, observational study.

Participants and methods

Data about the participants in the intervention arm of the Australian right@home trial, which is scaffolded on the Maternal Early Childhood Sustained Home-visiting model, collected between 2013 and 2017 were used. Screening data from the 10-item antenatal survey of non-sensitive demographic risk factors and disclosed risks recorded by the nurse in audited case files during the subsequent 2 year intervention were examined (n = 348). Prevalence of disclosed risks for their child having adverse experiences were analysed in 2019 using multiple response frequencies. Phi correlations were conducted to test associations between screening factors and disclosed risks.

Results

Among the 348 intervention participants whose files were audited, 300 were noted by nurses to have disclosed risks during the intervention, with an average of four disclosures. The most prevalent maternal disclosures were depression or anxiety (57.8%). Mental health issues were the most prevalent partner and family disclosures. Screening tool questions on maternal smoking in pregnancy, not living with another adult, poverty and self-reporting anxious mood were significantly associated with a number of disclosed risks for their child having adverse experiences.

Conclusions

These findings suggest that a non-sensitive sociodemographic screening tool may help to identify families at higher risk for adverse childhood experiences for whom support from a sustained nurse home visiting program may be beneficial.

Study protocol: a mixed-methods study to evaluate which health visiting models in England are most promising for mitigating the harms of adverse childhood experiences

INTRODUCTION

Exposure to adverse childhood experiences (ACEs) is associated with poorer health outcomes throughout life. In England, health visiting is a long-standing, nationally implemented service that aims to prevent and mitigate the impact of adversity in early childhood, including for children exposed to ACEs. A range of health visiting service delivery practices exist across England (from the minimum five recommended contacts to tailored intensive interventions), but there is a lack of evidence on who receives what services, how this varies across local authorities (LAs) and the associated outcomes.

METHODS AND ANALYSIS

This study will integrate findings from analysis of individual-level, deidentified administrative data related to hospital admissions (Hospital Episode Statistics (HES)) and health visiting contacts (Community Services Data Set (CSDS)), aggregate LA-level data, in-depth case studies in up to six LAs (including interviews with mothers), a national survey of health visiting services, and workshops with stakeholders and experts by experience. We will use an empirical-to-conceptual approach to develop a typology of health visiting service delivery in England, starting with a data-driven classification generated from latent class analysis of CSDS-HES data, which will be refined based on all other available qualitative and quantitative data. We will then evaluate which models of health visiting are most promising for mitigating the impact of ACEs on child and maternal outcomes using CSDS-HES data for a cohort of children born on 1 April 2015 to 31 March 2019.

ETHICS AND DISSEMINATION

The University College London Institute of Education Research Ethics Committee approved this study. Results will be submitted for publication in a peer-reviewed journal and summaries will be provided to key stakeholders including the funders, policy-makers, local commissioners and families.

Being orientated towards social justice: Learning for health visitor practice

Not applicable.

Towards health equity: core components of an extended home visiting intervention in disadvantaged areas of Sweden

BACKGROUND

Understanding the mechanisms of implementation of public health interventions in community settings is a key aspect of programme assessments. To determine core components and establish a programme theory are important tools to improve functioning and support dissemination of programme models to new locations. An extended early childhood home visiting intervention has been developed on-site in a socioeconomically disadvantaged area of Sweden since 2013 with the aim of reducing persisting health inequities in the population. This study aimed at investigating the core programme components and how the intervention was perceived to contribute towards health equity from early childhood.

METHODS

Qualitative framework method was applied in a document analysis and subsequent semi-structured interviews with 15 key actors involved in the programme.

RESULTS

The intervention was found to be constituted of five core components centred around the situation-based, parental strengthening work method delivered by a qualified team of child health care nurse and social worker. The programme theory foresaw positive effects on child and parental health, responsive parenting practices, families' use of welfare services according to need and increased integration and participation in society. The principles of Proportionate Universalism were recognised in the programme theory and the intervention was perceived as an important contribution to creating conditions for improved health equity for the families. Still, barriers to health equity were identified on the structural level which limit the potential impact of the programme.

CONCLUSIONS

The core components of the Extended home visiting programme in Rinkeby correspond well to those of similar evidence-based home visiting interventions. Combining focus on early childhood development and responsive parenting with promoting access to the universal welfare services and integration into society are considered important steppingstones towards health equity. However, a favourable macro-political environment is required in the endeavour to balance the structural determinants' influence on health inequities. Improved availability and accessibility to welfare services that respond to the needs of the families regarding housing, education and employment are priorities.

TRIAL REGISTRATION

The study was retrospectively registered on 11/08/2016 in the ISRCTN registry ( ISRCTN11832097 ).

Interprofessional Teamwork to Promote Health: First-Time Parents' Experiences of a Combined Home Visit by Midwife and Child Health Care Nurse

BACKGROUND

To achieve the requisites for a child's healthy development and to reduce health inequalities, it is important to promote health initiatives at an early stage in a child's life and to include the parents. Home visits by healthcare professionals have been found to have positive health effects for both the baby and the parents. From an extended home visit programme in Sweden, our aim was to illuminate first-time parents' experience of a home visit conducted by a midwife and a child health care nurse 1-2 weeks postnatal.

METHODS

Data was collected by interviews (n = 13) with first-time parents. The transcribed texts were analyzed using inductive content analysis.

RESULTS

The participants' experiences could be understood from the two themes, A trust in the professionals and Feeling safe as a new parent. The participants experienced that the midwives and the child health care nurses complemented each other and appreciated to get knowledge and information from both professions. In their own home, they felt secured and relaxed, and the professionals could help them provide a safe home environment for the child.

CONCLUSION

By meeting both professionals at the same time and in their own home, the participants experienced that the needs of the baby and their needs and concerns as new parents were included and supported.

Sustained nurse home-visiting with culturally and linguistically diverse families: Australian nurses' perspectives

BACKGROUND

In Australia, sustained nurse home-visiting (SNHV) programs are designed and implemented to promote positive outcomes for mothers with young children experiencing complex life challenges. Despite the crucial role of trained public health nurses, there is a dearth of research about their experiences delivering these programs to culturally and linguistically diverse (CALD) families with limited English proficiency (LEP).

AIM

This study aimed to explore the experiences of public health nurses in providing services to CALD families with LEP.

METHOD

Two focus groups were conducted with 13 public health nurses in two major local health districts in Sydney. The focus groups were audio recorded for transcription purposes, and thematically analyzed. A socioecological framework was applied during the analysis process.

RESULT

Five major themes were identified: (1) program issues; (2) service system issues in understanding and responding to diverse women; (3) issues working with interpreters; (4) trusting relationships; and (5) mother-related facilitators.

DISCUSSION

To achieve better access and engagement for CALD families, it is crucial that public health nurses increase their knowledge and awareness about potential challenges, such as female interpreter availability, and facilitators, such as engaging the broader family, in order to effectively deliver healthcare services to diverse populations.

Norwegian fathers' experiences with a home visiting program

OBJECTIVE

To explore fathers' experiences with a Norwegian home visiting program during the prenatal period and the first-year postpartum.

DESIGN

Qualitative design with interpretive description (ID) as the methodological approach.

SAMPLE

Individual interviews with fathers (n = 13) who received home visits by a public health nurse (PHN) within the New Families home visiting program.

MEASURES

Interviews were guided by a semi-structured interview-guide, which contained open-ended questions encouraging informants to reflect on their experiences with home visits. The analysis of the data was informed by content analysis.

RESULTS

Two main themes that reflect the fathers' experiences emerged: (1) The importance of being on their home ground captures the fathers' experience of receiving home visits and building a trusting relationship with the PHN. (2) Including fathers in the home visit represents their thoughts about the content and focus of the home visits.

CONCLUSIONS

Fathers experienced the universal New Families home visiting program as an important contribution towards a more available and tailored service, with the home environment as a suitable arena for developing a trusting relationship with the PHN. However, the fathers often felt insufficiently included in the home visits, with only scant attention towards them as independent caregivers, their emotional reactions, roles, and family relationships. Pre-birth home visits might contribute to strengthening preparations for fatherhood and increase fathers' engagement in the Child Health Service.

[Theoretical and practical challenges of proportionate universalism: a reviewAnálise dos desafios teóricos e práticos de universalismo proporcional]

OBJECTIVE

In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it. The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues.

METHODS

We searched for all articles published until 6th of February 2020, mentioning "Proportionate Universalism" or its synonyms "Targeted universalism" OR "Progressive Universalism" as a topic in all Web of Science databases.

RESULTS

This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs.

CONCLUSION

This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.

Contributions of Preventive Social Services in Early Childhood Home Visiting in a Disadvantaged Area of Sweden: The Practice of the Parental Advisor

Early childhood home visiting to improve health and development is commonly delivered by child health care (CHC) whereas home visitors from the social services are rare. We applied a constructivist grounded theory approach to explore the practice and contributions of parental advisors from the preventive social services in a home visiting collaboration with CHC in a socioeconomically disadvantaged area of Sweden. The analysis rendered a conceptual model of a situation-based practice, built on interactive encounters between parents and professionals. It includes strengthening of positive parenting, connecting parents to additional services, early detection of needs and provision of psychosocial support in accordance with each family's specific situation. Rooted in the training and experience in social work, the practice can be seen as contributory to the delivery of complex support to families through home visiting and could provide input to efforts of improving training of home visitors in different contexts.

Primary Care Research - Influencing and Implementing Into Policy

This editorial describes how research in primary health care can be used to influence policy. It draws on previous literature to give an example from the UK of how research in one part of primary care, the health-visiting service, has endeavoured to use evidence to influence policy and practice. The editorial considers frameworks for policy implementation such as Bardach's eight phase approach and concepts that can inform policy implementation such as Lipsky's Street-Level Bureaucrat approach.

Methylome Patterns of Cattle Adaptation to Heat Stress

Heat stress has a detrimental impact on cattle health, welfare and productivity by affecting gene expression, metabolism and immune response, but little is known on the epigenetic mechanisms mediating the effect of temperature at the cellular and organism level. In this study, we investigated genome-wide DNA methylation in blood samples collected from 5 bulls of the heat stress resilient Nellore breed and 5 bulls of the Angus that are more heat stress susceptible, exposed to the sun and high temperature-high humidity during the summer season of the Brazilian South-East region. The methylomes were analyzed during and after the exposure by Reduced Representation Bisulfite Sequencing, which provided genome-wide single-base resolution methylation profiles. Significant methylation changes between stressful and recovery periods were observed in 819 genes. Among these, 351 were only seen in Angus, 366 were specific to Nellore, and 102 showed significant changes in methylation patterns in both breeds. KEGG and Gene Ontology (GO) enrichment analyses showed that responses were breed-specific. Interestingly, in Nellore significant genes and pathways were mainly involved in stress responses and cellular defense and were under methylated during heat stress, whereas in Angus the response was less focused. These preliminary results suggest that heat challenge induces changes in methylation patterns in specific loci, which should be further scrutinized to assess their role in heat tolerance.

Knowledge of and Attitudes Toward Perinatal Home Visiting in Women with High-Risk Pregnancies

INTRODUCTION

Published research indicates that some perinatal home visiting programs are highly effective. However, there is a dearth of information regarding how these services apply to women experiencing a high-risk pregnancy. The aim of this study was to determine the potential acceptability of home visiting services within this vulnerable population and identify what services women want.

METHODS

Four focus groups (N = 32) were conducted with a population of low-income, pregnant individuals in medically underserved central Georgia (United States). Participants were evaluated based on their current exposure to home visiting, receptiveness to home visiting, and reasons for apprehension regarding home visiting.

RESULTS

The results of this study were mixed, with women expressing both interest in and reluctance about home visiting programs. Themes of distrust and fear of judgment or persecution existed. Women also varied with regard to what home visiting services they would like offered. Those discussed included assistance with maternal or infant medical needs, maternal function tasks, household tasks, and child care.

DISCUSSION

Home visiting programs can be effective for improving maternal and child health outcomes. However, not all home visiting programs effectively reach their target population. More research is needed to determine what women who have high-risk conditions during pregnancy want help with and how to increase receptiveness. The results of this study could be informative to health care providers who treat persons with high-risk conditions in identifying adjunctive services for those in need of additional support.

The Care Ethics of Child Health Nurses in Danish Asylum Centers: An Ethnographic Study

Child health nurses play an important role in promoting the health and well-being of children and families seeking asylum. However, little is known about how they establish caring partnerships with families in asylum centers. In this article, we examine the ethical care practices that child health nurses within Danish asylum centers adopt to overcome barriers, related to culture, language and migration history, in delivering care. We conducted ethnographic fieldwork in four Danish Red Cross asylum centers, involving participant observation and individual interviews with 20 families and six child health nurses. A thematic analysis of the material reveals five ethical care practices; compassionate care, humanitarian care, flexible care, collaborative care, and supportive care. We show how the confluence of these types of care enables child health nurses to promote health and well-being of children seeking asylum, and discuss the enabling role of the humanitarian culture that prevails within the asylum centers.

Promoting children’s health when a parent has a mental health problem: a mixed methods study of the experiences and views of health visitors and their co-workers

Background

Unrecognised and untreated parental mental illness is a major adverse childhood experience with potentially life-long consequences for health and wellbeing. In the United Kingdom (UK) health visitors provide a universal health promotion service to children aged 0–5 years, which includes safeguarding. This preventive work is highly relevant to policy aims of improving outcomes for children living with adverse childhood experiences, but is currently under researched. The aim of this study was to explore how health visitors promote young children’s wellbeing when a parent has a mental health problem, and to co-produce strategies to improve child health outcomes.

Methods

A mixed methods study was conducted, consisting of a cross-sectional survey and consensus workshops in Wales, UK. In phase 1 health visitors (n = 174) responded to an online questionnaire designed to explore the nature and scope of their preventive work with families experiencing mental ill health. For phase 2 providers of health and other support services (n = 38) took part in Nominal Group Technique workshops to co-produce strategies for better joint working to protect the wellbeing of children living with parental ill health.

Results

We identified that health visitors routinely provide support to families where parents have a range of mental health problems, including severe mental illness. Most practice is focused on mothers with depression, and fewer respondents were confident about working with fathers. Unmet training needs were identified in relation to adult mental illness, particularly the impact upon children. Solutions to working more effectively with professional and voluntary agencies included raising awareness of professional roles and responsibilities, timely two-way communication, taking a strengths-based approach and maintaining a focus on the child.

Conclusions

This study provided evidence on the range of parental mental ill health encountered by health visitors and the strategies they use to protect children’s wellbeing. Increasing the effectiveness of joint working is key to improving outcomes for babies and young children, including greater use of voluntary sector services. This study has implications for those who commission and provide health and welfare services for children, and adult mental health services.

Theoretical and practical challenges of proportionate universalism: a review

OBJECTIVE

In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it.The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues.

METHODS

We searched for all articles published until 6th of February 2020, mentioning "Proportionate Universalism" or its synonyms "Targeted universalism" OR "Progressive Universalism" as a topic in all Web of Science databases.

RESULTS

This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs.

CONCLUSION

This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.

Using the TIDieR checklist to describe health visitor support for mothers with mental health problems: Analysis of a cross-sectional survey

At least half of the 20% of mothers who experience mental health problems (MHPs) during pregnancy or after birth are not receiving the help they need that will lead to recovery. In order to identify where improvements need to be made, it is necessary to describe exactly what is being done and the barriers and facilitators that compromise or enhance optimal care. The majority of mothers experience mild to moderate anxiety or depression. The expectation is that primary care professionals, such as health visitors (HVs), can provide the support they need that will lead to recovery. The aim of this study was to explore the views of HVs regarding the content and purpose of an intervention to support mothers with MHPs, described as 'listening visits' (LVs). A link to an online survey was offered to the members and champions of the Institute of Health Visiting (n = 9,474) March-May 2016. The survey was completed by 1,599 (17%) of the target population, of whom 85% were offering LVs. The Template for Intervention Description and Replication (TIDieR) checklist was used to provide a framework to describe commonalities and variations in practice. There appeared to be a shared understanding of the rationale for LVs but a lack of agreement about what the intervention should be called, the techniques that should be used and the duration, frequency and expected outcomes of the intervention. Contextual factors such as staff shortages; conflicting priorities; the needs and circumstances of mothers; the capability and motivation of HVs; inadequate training and supervision; and the absence of clear guidance contributed to variations in perceptions and practice. There are many ways in which the HV contribution to the assessment and management of mothers with MHPs could be improved. The intervention delivered by HVs needs to be more clearly articulated. The contextual factors influencing competent and consistent practice also need to be addressed.

Home level bureaucracy: moving beyond the 'street' to uncover the ways that place shapes the ways that community public health nurses implement domestic abuse policy

Street-level bureaucracy is an increasingly useful way to understand how strategic policy is implemented in day-to-day practice. This approach has uncovered the ways that individual health and social care practitioners work within institutional constraints to influence policy implementation at the micro-level. Nonetheless, despite the diversity of settings where these street-level bureaucrats (SLBs) work, little attention has been focused on the impact of place on policy delivery. This paper draws on empirical research to examine the ways that delivering government domestic abuse policy in the intimate space of the family home shapes the delivery of strategic policy in the everyday. Drawing on qualitative research with Health Visitors (HVs) in the UK in 2016, the study findings illuminate the ways that the material, socio-spatial and idealised boundaries of the family home shape the implementation of policy. Key themes in the HV's narratives emerged as they described themselves as both a danger and in danger in the family home. In challenging the ontological security of the home (Giddens 1990) - privacy, security and control are key concepts here - HVs described how they shape their actions to achieve policy outcomes while simultaneously managing threats to the home, to professional identity and to self.

Is socioeconomic inequality in postnatal depression an early-life root of disadvantage for children?

This paper investigates the role that socioeconomic inequality in postnatal depression might play in intergenerational transmission of inequality. Infants' development is thought to be particularly sensitive to mothers' mental health at this time, suggesting that greater early-life exposure to maternal depression among disadvantaged groups might be a root of later socioeconomic inequalities. Heightened contact with health services during this period presents opportunities for intervention, but higher unmet need for treatment of postnatal depression among the disadvantaged might be widening inequalities. The aim of this study is to quantify the potential contribution of postnatal depression to socioeconomic inequalities in adverse childhood health and development outcomes. Regression-based decomposition of the concentration index is used to explore the association between income inequality in postnatal depressive symptoms and income inequality in children's outcomes. Four problems of early adolescence are explored: emotional and conduct problems, special educational needs, and low self-assessed health. Data are taken from the UK Millennium Cohort Study, with a sample of 4359 mothers and children with complete data on outcomes and covariates, and a second sample of 5441 when missing covariates are filled using multiple imputation. The key finding is that socioeconomic inequality in maternal postnatal depression is a significant contributor to inequalities in special educational needs, emotional problems, and low self-assessed health for children at age 11 years, even after accounting for a range of other factors that might explain such associations. These findings highlight the importance of understanding the impact of postnatal depression interventions on inequalities, and the downstream influence on children's outcomes. Addressing inequalities in mothers' postnatal depression might be an avenue for reducing early-life disadvantage for children.

Knowledge, attitude and practice among Health Visitors in the United Kingdom toward children's oral health

OBJECTIVES

The purpose of this study was to determine knowledge, attitude, and practical behavior of health visitors regarding children's oral health in the United Kingdom (UK).

METHODS

A web-based self-administered survey with 18 closed and 2 open ended questions was distributed to a convenience sample of approximately 9,000 health visitors who were currently employed in the United Kingdom and a member of the Institute of Health Visiting.

RESULTS

A total of 1,088 health visitors completed the survey, resulting in a response rate of 12%. One-third of the health visitors reported that they had not received oral health training previously. Almost all agreed that oral health advice/promotion should be included in their routine health visiting contacts. Previous oral health training/education was associated with an increase in oral health knowledge; confidence in entering a discussion with parents/caregivers and willingness to be involved in dental referral process.

CONCLUSIONS

The results of our study support the need for health visitors to receive oral health training in oral health promotion including oral health risk assessment, guidance on evidence based up-to-date prevention measures, increasing the dental attendance prevalence at early stages and awareness of including specific oral health guidelines/fact sheets into their regular practice.

Family-Focused Practice for Families Affected by Maternal Mental Illness and Substance Misuse in Home Visiting: A Qualitative Systematic Review

Maternal mental illness is a major public health issue and can adversely affect the whole family. Increasingly, research and policy are recognizing the benefits of a family-focused approach to practice, an approach that emphasizes the family as the unit of care. This review was conducted with the aim of systematically analyzing the qualitative literature surrounding health visitors' family-focused practice with mothers who have mental illness and/or substance misuse. Through the synthesis, we developed three main findings: (a) parents' needs regarding health visitors' family-focused practice, (b) the ambiguity of mental illness in health visiting, and (c) the challenges of family-focused practice in health visiting. Above all, health visitors, families, and mothers with mental illness experience many challenges in family-focused practice, even though it is both desirable and beneficial. This calls for a deeper understanding of how family-focused practice can be effectively practiced in health visiting.

A better start for health equity? Qualitative content analysis of implementation of extended postnatal home visiting in a disadvantaged area in Sweden

Background

Health inequities among children in Sweden persist despite the country’s well-developed welfare system and near universal access to the national child health care programme. A multisectoral extended home visiting intervention, based on the principles of proportionate universalism, has been carried out in a disadvantaged area since 2013. The present study investigates the content of the meetings between families and professionals during the home visits to gain a deeper understanding of how it relates to a health equity perspective on early childhood development.

Methods

Three child health care nurses documented 501 visits to the families of 98 children between 2013 and 2016. A qualitative data-driven conventional content analysis was performed on all data from the cycle of six visits per child, and a general content model was developed. Additional content analysis was carried out on the data from visits to families who experienced adverse situations or greater needs.

Results

The analysis revealed that the home visits covered three main categories of content related to the health, care and development of the child; the strengthening of roles and relations within the new family unit; and the influence and support located in the broader external context around the family. The model of categories and sub-categories proved stable over all six visits. Families with extra needs received continuous attention to their additional issues during the visits, as well as the standard content described in the content model.

Conclusions

This study on home visiting implementation indicates that the participating families received programme content which covered all the domains of nurturing care as recommended by the WHO Commission on Social Determinants of Health and recent research. The content of the home visits can be understood to create enabling conditions for health equity effects. The intervention can be seen to represent a practical example of proportionate universalism.

Ethical considerations for the design and implementation of child injury prevention interventions: the example of delivering and installing safety equipment into the home

INTRODUCTION

Public health ethics is a growing field of academic interest but ethical discussion of injury prevention seems to have received limited attention. Interventions that promise to be effective are not necessarily-without explicit justification-'good' and 'right' interventions in every sense. This paper explores public health ethics in the context of child injury prevention with the objective to initiate interdisciplinary dialogue on the ethics of child safety interventions.

METHOD

A framework of seven public health ethics principles (non-maleficence, health maximisation, beneficence, respect for autonomy, justice, efficiency and proportionality) were applied to an intervention to promote child safety in the home.

RESULTS

Preventing child injury in the home is ethically challenging due to the requirement for the state to intervene in the private sphere. Non-maleficence and beneficence are difficult to judge within this intervention as these are likely to be highly dependent on the nature of intervention delivery, in particular, the quality of communication. Respect for autonomy is challenged by an intervention occurring in the home. The socioeconomic gradient in child injury risk is an important factor but a nuanced approach could help to avoid exacerbating inequalities or stigmatisation. Equally, a nuanced approach may be necessary to accommodate the principles of proportionality and efficiency within the local context.

CONCLUSION

We conclude that this intervention is justifiable from an ethical perspective but that this type of reflection loop is helpful to identify the impact of interventions beyond effectiveness.

Realist evaluation of an enhanced health visiting programme

Background

The health visitors’ role in many countries is changing. In Scotland, the role has undergone substantial changes through the introduction of an enhanced health visiting programme, which includes increased, structured home visits. This evaluation was conducted within NHS Ayrshire and Arran, one of the 14 Scottish Health Boards. Our aim was to understand and explain how, and why, the programme could contribute to improving health and wellbeing outcomes for children and families.

Methods

We used a realist evaluation approach, conducted in three phases. In phase one, eight managerial staff involved in developing and implementing the programme provided data, which were used to develop initial programme theories. In phase two, the programme theories were tested using qualitative data from 25 health visitors and 22 parents. The programme theories were refined through analyses and interpretation of data in phase three.

Results

The home visiting context provided by the programme interacted with the mechanisms of the programme and produced outcomes such as early identification of health and wellbeing issues amongst families who needed more support, leading to referral and engagement with sources of additional help. The home visits facilitated development of parent-health visitor relationships, and parents considered health visitors as their first point of contact on children’s wellbeing and developmental-related issues. Moreover, the programme provided more clarity to health visitors’ role, which in turn enhanced partnership working. However, there were aspects of the programme that may require further development. For instance, both parents and health visitors were concerned about the wide gaps between some home visits.

Conclusions

The enhanced health visiting programme increased opportunities for monitoring and early identification of health and wellbeing concerns. It created structures for a more efficient partnership working and ensured that the needs of children and families were supported. These benefits need to be evaluated further in an effectiveness study.

A qualitative study exploring parental perspectives and involvement in health visiting services during the Health Visitor Implementation Plan in the South West of England

Internationally, there is a strong interest in engaging the public more widely in both the development and governance of public services. This study aimed to explore family perspectives on the introduction of a new policy initiative called the 'Health Visitor Implementation Plan' (Department of Health [2011] Health Visitor Implementation Plan 2011-15: A Call to Action) and their experiences of the new health visitor service provision. The policy aimed to increase the health visitor workforce by 4200 additional practitioners between 2011 and 2015, in parallel with introducing a new service model to provide comprehensive and accessible support for parents with children 0-5 years. Using a qualitative approach, data were collected via semi-structured interviews and focus groups with 22 parents between March 2013 and March 2014. Questions focused around the extent to which the new service met parental expectation and need. Participants were recruited through Children's Centres and interviewed during established group sessions. Analysis was conducted using thematic analysis and constant comparative methods. The participants were asked to share their experiences of the health visiting service and their views on this national policy initiative. Although asked to comment on the policy at nation and local level, their responses were predominantly around personal experience. Parents welcomed the increase in workforce capacity and positive experiences centred on health visitors who were caring, knowledgeable, skilled and facilitated positive outcomes. Many of the negative experiences were seen to be due to poor relationships between the parent and the health visitor. Parents were influenced by the communication skills and personal attributes of the individual health visitors, including time to listen. The strength of parental opinion indicated that parents are willing to contribute to service development, consequently policy makers and health visitors themselves need to have clarity around the purpose and mechanism of parental involvement if meaningful partnership is to become a reality.

Making a difference for children and families: an appreciative inquiry of health visitor values and why they start and stay in post

The study aimed to develop an understanding of health visitor recruitment and retention by examining what existing staff and new recruits wanted from their job, their professional aspirations and what would encourage them to start and stay in employment. Following a period of steady decline in numbers, the health visitor workforce in England has recently been invested in and expanded to deliver universal child public health. To capitalise on this large investment, managers need an understanding of factors influencing workforce retention and continuing recruitment of health visitors. The study was designed using an interpretive approach and involved students (n = 17) and qualified health visitors (n = 22) from the north and south of England. Appreciative inquiry (AI) exercises were used as methods of data collection during 2012. During AI exercises students and health visitors wrote about 'a practice experience you have felt excited and motivated by and briefly describe the factors that contributed to this'. Participants were invited to discuss their written accounts of practice with a peer during an audio-recorded sharing session. Participants gave consent for written accounts and transcribed recordings to be used as study data, which was examined using framework analysis. In exploring personal meanings of health visiting, participants spoke about the common aspiration to make a difference to children and families. To achieve this, they expected their job to allow them to: connect with families; work with others; use their knowledge, skills and experience; use professional autonomy. The study offers new insights into health visitors' aspirations, showing consistency with conceptual explanations of optimal professional practice. Psychological contract theory illustrates connections between professional aspirations and work commitment. Managers can use these findings as part of workforce recruitment and retention strategies and for building on the health visitor commitment to making a difference to children and families.

Perinatal Nurse Home Visiting Referral Patterns Among Women With Diabetes and Hypertension in Philadelphia

OBJECTIVE

To examine access to perinatal nurse home visiting services for high-risk pregnant women who have diabetes or hypertension.

DESIGN

Secondary data analysis.

SETTING

Philadelphia, PA.

PARTICIPANTS

Pregnant women who had a live birth during 2012 and those referred to a community-based agency for perinatal nurse home visiting because of their diagnosis of diabetes or hypertension.

METHODS

Access to services was measured by examining referral information (dosage, diagnosis, gestational age at time of referral, and insurance type) retrieved from administrative logs of the community-based organization that provides perinatal home visiting to high-risk pregnant women. The population-based prevalence rates of hypertension and diabetes were calculated from birth record data provided by the Philadelphia Department of Public Health.

RESULTS

During 2012, 595 pregnant women were referred for perinatal nurse home visiting services. The mean gestational age when referred for services was 24.9 weeks (standard deviation = 8.5) with a mean number of 8.8 authorized visits (standard deviation = 8). Associated with more authorized visits was having Medicaid as the insurance type and medical diagnoses that included hypertension (p < .01). Philadelphia prevalence rates for diabetes and hypertension varied by race and ethnicity (p < .001); Asian mothers had the greatest rates for diabetes and Black mothers the greatest rates for hypertension.

CONCLUSION

Various models of home visiting programs exist to improve maternal and child health outcomes. Because maternal morbidity and mortality rates are rising in the United States, further research about perinatal nurse home visiting programs for pregnant women with diabetes and hypertension is warranted.

Health visitor education for today's Britain: Messages from a narrative review of the health visitor literature

OBJECTIVES

This paper draws on a narrative review of the literature, commissioned to support the Health Visitor Implementation Plan, and aimed at identifying messages about the knowledge, skills, and abilities needed by health visitors to work within the current system of health care provision.

DESIGN

The scoping study and narrative review used three complementary approaches: a broad search, a structured search, and a seminal paper search to identify empirical papers from the health visitor literature for review. The key inclusion criteria were messages of relevance for practice.

DATA SOURCES

378 papers were reviewed. These included empirical papers from the United Kingdom (UK) from 2004 to February 2012, older research identified in the seminal paper search and international literature from 2000 to January 2016.

REVIEW METHODS

The review papers were read by members of the multidisciplinary research team which included health visitor academics, social scientists, and a clinical psychologist managed the international literature. Thematic content analysis was used to identify main messages. These were tabulated and shared between researchers in order to compare emergent findings and to confirm dominant themes.

RESULTS

The analysis identified an 'orientation to practice' based on salutogenesis (health creation), human valuing (person-centred care), and viewing the person in situation (human ecology) as the aspirational core of health visitors' work. This was realised through home visiting, needs assessment, and relationship formation at different levels of service provision. A wide range of knowledge, skills, and abilities were required, including knowledge of health as a process and skills in engagement, building trust, and making professional judgments. These are currently difficult to impart within a 45week health visitor programme and are facilitated through ad hoc post-registration education and training. The international literature reported both similarities and differences between the working practices of health visitors in the UK and public health nurses worldwide. Challenges related to the education of each were identified.

CONCLUSIONS

The breadth and scope of knowledge, skills, and abilities required by health visitors make a review of current educational provision desirable. Three potential models for health visitor education are described.

A Review of the Effects of Anxiety During Pregnancy on Children's Health

Background:

Although pregnancy is often portrayed as a time of great joy, that’s not the reality for all women. The adverse, long-term, stable, and sometimes, irreparable effects of anxiety during pregnancy can change pregnancy into an agonizing and unpleasant event of women’s life span.

Aim:

The aim of this study was to explore the adverse effects of anxiety in pregnancy on children’s health in order to promote child health.

Methods:

In this narrative review the researchers searched in public databases like Google Scholar general search engine, and then more specific: Science Direct, Scientific Information Database, Magiran, Irandoc, Pubmed, Scopus, Cochrane library, and Psych info using Medical Subject Headings (MeSH) keywords: anxiety, maternal anxiety, pregnancy, pregnancy outcome, control and prevention restricted to English / Persian language, during the 20 years ago. Then those articles written by renowned experts were selected. At first, a list of 60 papers generated from the initial search. Then reviewers studied titles and abstracts and finally, quality assessment of full text studies was performed by two independent reviewers. Researchers reviewed summary of all articles sought, ultimately used data from 25 full articles to compile this review paper.

Results:

The findings were classified into four groups Biological, Mental, Behavioral, and Medical effects of anxiety during pregnancy.

Conclusions:

The effects of anxiety during pregnancy on offspring’s health are serious and thought-provoking to which the need for identifying and screening of anxiety disorders in prenatal care is necessary.