Reassurance or judgement? Parents' views on the delivery of child health surveillance programmes

"I haven't even taken them to the doctors, because I have that fear of what to expect": a qualitative description study exploring perceptions and experiences of early childhood healthcare among ethnically diverse caregivers in Aotearoa New Zealand

Background

Equity underpins Aotearoa New Zealand's publicly funded healthcare system; however, ethnic inequality persists. This qualitative study explored the perceptions and experiences of ethnically diverse parents accessing health services for their children.

Methods

A qualitative description methodology informed interviews and focus groups that were conducted with caregivers of preschool aged children who identified as being of Māori, Pacific, Asian and/or European ethnicity (n = 145). Data were analysed following a reflexive thematic analytic approach.

Findings

Five themes were constructed. Hierarchies of knowledge and trust Caregivers relied on multiple sources of health information and particularly trusted providers or other caregivers who had children. Relational versustransactional health encounters Caregivers were often disappointed that health providers did not build trusting relationships to support positive experiences. Bad mother vibe Mothers often felt judged by providers when accessing care and felt pressure to conform. The 'slow burn' of waiting Caregivers were often frustrated by how slow and fragmented the health system was, which was particularly distressing if their child was unwell or required referral. Navigating complexity Caregivers had to be proactive and assertive to ensure their child received care amidst the numerous barriers they faced, including discrimination and bias. While many commonalities were shared by ethnicity, unique to Indigenous Māori caregivers were the ongoing colonial traumas that impacted their ability to trust the healthcare system.

Interpretation

A non-judgemental, competent, and culturally sensitive approach by healthcare professionals and services may help foster trusting relationships and positive health encounters. Strategies to improve trust, ease of access and navigation are needed to mitigate existing complexity, fragmentation, and counter-intuitive nature of the NZ healthcare system. Caregivers require more autonomy over decisions about their child's care and availability of services that reflect their cultural values. Policies are required to alleviate the indirect costs of accessing healthcare, prioritising of whānau/family-centred care, and addressing pervasive racism and bias within the system.

Funding

Health Research Council of New Zealand (19/263) .

Feeling the clunk: Managing and attributing uncertainty in screening for developmental dysplasia of the hip in infancy

The management of uncertainty in clinical practice has been an enduring topic of sociological scholarship. However, little of this addresses how uncertainty and non-knowledge are attributed to the self and other actors. We take the example of checking for developmental dysplasia of the hip (DDH), part of infant screening in UK primary care, to examine the 'double contingency' of attributions of uncertainty and ignorance. Our data come from interviews with parents and General Practitioners (GPs), and observations of the six-week check conducted as part of a study to develop a checklist to aid GPs' diagnostic and referral decisions. Parents' pervasive uncertainties about managing with a new-born infant place them in a trusting relation to biomedicine, in which knowledge about infant hips is delegated to the clinical team: most described themselves as not-knowing about DDH. GPs focus on the uncertainties of applying sensory and experiential knowledge of infant bodies, in a consultation with more diffuse aims than screening for DDH. A prototype checklist, developed by orthopaedic specialists, was an explicit attempt to reduce uncertainty around thresholds for referral. However, using the checklist surfaced multiple logics of uncertainty. It also surfaced attributions of uncertainty and non-knowledge to other actors: orthopaedic specialists' assumptions about GPs' uncertain technical knowledge; GPs' assumptions about orthopaedic specialists' ignorance of the primary care setting; and clinicians' assumptions about the role of parental ignorance. This 'double contingency' of attributions of other actors' non-knowledge is a salient additional dimension to the uncertainty that infuses biomedical practice.

Parents' expectations and experiences of the 6-week baby check: a qualitative study in primary care

Background

The Newborn and Infant Physical Examination (NIPE) programme requires all babies to have a comprehensive health check at 6–8 weeks of age. These are typically completed by GPs. Although person-centred care has achieved prominence in maternity care policy in recent years, there is limited empirical evidence on what parents and/or carers expect from the check, and how far experiences meet their needs.

Aim

 To explore the expectations and experiences of parents attending their GP for a baby check.

Design & setting

A qualitative study was undertaken in primary care in London.

Method

Content analysis was undertaken of transcripts of semi-structured interviews. Interviews were conducted with a total of 16 participants (14 mothers and two fathers) who had recently attended for a 6-week check for their baby.

Results

Despite the availability of plentiful sources of general advice on infants’ health and development, a thorough check by a trusted GP was an important milestone for most parents. They had few specific expectations of the check in terms of what examinations were undertaken, but even experienced parents anticipated reassurance about their baby’s normal development. Many also hoped for reassurance about their own parenting. Parents appreciated GPs who explained what they were doing during the examination; space to raise any concerns; and combined mother and baby checks. Referrals to secondary care were generally experienced as reassuring rather than a source of anxiety.

Conclusion

The baby check meets needs beyond those of the NIPE screening programme. Protecting the time for a thorough consultation is important for parents at what can be a vulnerable time.

"Reassurance that you're doing okay, or guidance if you're not": A qualitative descriptive study of pregnant first time mothers' expectations and information needs about postnatal care in England

Objective

To explore what first time mothers in England expect from postnatal care while they are pregnant, what they would ideally like, where they get their information on postnatal care, and their views on the sufficiency of this information.

Design

A qualitative descriptive interview-based study.

Setting

England

Participants

A maximum variation sample of 40 women who were currently in the third trimester of pregnancy; aged 16 or over; planning to give birth in England and had not given birth previously.

Methods

Semi structured interviews were carried out between October 2017 and March 2018, by telephone (n = 32) and face to face (n = 8). Interviews were analysed using thematic analysis.

Results

There were six themes and twelve subthemes. The themes were: (1) ‘Piecing together snippets of information’ containing subthemes ‘Incomplete official sources’ and ‘Other mothers’ stories’; (2) ‘Planning ahead or going with the flow’ containing subthemes ‘Wanting more information’ and ‘Postnatal care not a priority’; (3) ‘Judgement or reassurance’ containing subthemes ‘Real: Being judged’, ‘Ideal: Reassurance and non-judgmental advice’; (4) ‘Focus of care’ containing subthemes ‘Real: A focus on checks and feeding’, ‘Ideal: More focus on mother's wellbeing’; (5) ‘A system under pressure’ containing subthemes ‘Real: Busy midwives, reactive care’, ‘Ideal: Reliable, proactive information’; (6) ‘Deciding about discharge’, containing subthemes ‘Real: Confusion about decision-making’, ‘Ideal: More control over length of hospital stay’.

Key conclusions

First time mothers’ experience of the transition to parenthood could be improved by antenatal access to comprehensive information about the timing, location, content and purpose of postnatal care. Information should take a woman-centred perspective and cover all settings (hospitals, birth centres, home, community), including the roles and responsibilities of all the professionals who may be involved.

Implications for practice

Clear and comprehensive information about postnatal care should be provided to all women in ways that are accessible at any stage of pregnancy or the postnatal period. As women pregnant for the first time worry about being judged if they seek professional advice and reassurance postnatally, information about postnatal care should aim to address this.

Creating opportunities for occupational development using the concerns report method

BACKGROUND

Little research has focused on working with communities to promote and support children's occupational development.

AIM/OBJECTIVE

We used the Concerns Report Method (CRM) to identify community supports for parents with young children that could enhance children's occupational development.

MATERIAL AND METHOD

We conducted interviews/focus groups with parents (n = 29) and service providers (n = 11). We used content analysis to identify four themes: availability, barriers and facilitators, parent/child transitions, and making connections. The themes were used to create a concerns report survey for parents and service providers. A random sample of parents (n = 319) and convenience sample of service providers (n = 47) in one community area of a Canadian urban center completed the on-line survey. We held a community forum to review the results and identify solutions for action.

RESULTS

Parents' highest priorities included childcare, supports in community schools, preschool programs, and supports in one location. Service providers highest priorities included: identification of developmental concerns; parenting education; programs for fathers, programs that offer child care, a doctor, and child care.

CONCLUSIONS

Service providers need to engage parents and consider parents' perspectives when planning services to ensure community supports will meet parent identified needs.

SIGNIFICANCE

Using community-based participatory research approaches, occupational therapists can contribute to children's occupational development.

Examining the social construction of surveillance: A critical issue for health visitors and public health nurses working with mothers and children

AIMS AND OBJECTIVES

To critically examine surveillance practices of health visitors (HV) in the UK and public health nurses (PHNs) in Canada.

BACKGROUND

The practice and meaning of surveillance shifts and changes depending on the context and intent of relationships between mothers and HVs or PHNs.

DESIGN

We present the context and practice of HVs in the UK and PHNs in Canada and provide a comprehensive literature review regarding surveillance of mothers within public health systems. We then present our critique of the meaning and practice of surveillance across different settings.

METHODS

Concepts from Foucault and discourse analysis are used to critically examine and discuss the meaning of surveillance.

RESULTS

Surveillance is a complex concept that shifts meaning and is socially and institutionally constructed through relations of power.

CONCLUSIONS

Healthcare providers need to understand the different meanings and practices associated with surveillance to effectively inform practice.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers should be aware of how their positions of expert and privilege within healthcare systems affect relationships with mothers. A more comprehensive understanding of personal, social and institutional aspects of surveillance will provide opportunities to reflect upon and change practices that are supportive of mothers and their families.

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.

Responding to families with complex needs: a national survey of child and family health nurses

AIMS

The aim of this study was to explore the extent to which Australian child and family health nurses work with families with complex needs and how their practice responds to the needs of these families.

BACKGROUND

Many families with young children face challenges to their parenting capacity, potentially placing their children at risk of poorer developmental outcomes. Nurses increasingly work with families with mental health problems, trauma histories and/or substance dependence. Universal child health services must respond effectively to these challenges, to address health inequalities and to promote the best outcomes for all children and families.

DESIGN

The descriptive study used cross-sectional data from the first national survey of child and family health nurses in Australia, conducted during 2011.

METHODS

Survey data reported how often, where and how child and family health nurses worked with families with complex needs and their confidence in nursing tasks.

FINDINGS

Many, but not all, of the 679 respondents saw families with complex needs in their regular weekly caseload. Child and family health nurses with diverse and complex caseloads reported using varied approaches to support their clients. They often undertook additional professional development and leadership roles compared with nurses who reported less complex caseloads. Most respondents reported high levels of professional confidence.

CONCLUSION

For health services providing universal support and early intervention for families at risk, the findings underscore the importance of appropriate education, training and support for child and family health professionals. The findings can inform the organization and delivery of services for families in Australia and internationally.

A qualitative study of parents' experiences using family support services: applying the concept of surface and depth

United Kingdom policy and practice endorses family support for child well-being. Achieving such support requires multi-agency approaches that consider all aspects of parents' and children's lives and which offer practical, social and emotional help. The potential for services to make a positive impact on parents and their families will depend in part on the level and nature of engagement. In this paper, a case is made for the application of the two-part surface and depth concept for understanding how practitioners engage with families and how they might improve the chances of supporting sustainable differences for parents and families. To illustrate, qualitative data from a review of family centre support provided by a north of England local authority are presented. The review was commissioned to explore why families often need to re-engage with intensive support services. Data were drawn from interviews with parents (n = 18, recruited following a survey of all those registered with the service during April-May 2009) and discussions with family centre support workers (n = 4), and following thematic analysis, three dominant themes emerged--resources available, staff approach and real life--which were appraised in the light of the surface and depth concept. Much of the work with parents effectively dealt with pressing needs. This felt gratifying for both parent and worker and supported immediate service engagement. However, each noted that the more complex issues in parents' lives went unchallenged and thus the sustainability of progress in terms of parenting practice was questionable. A strengths focused approach by staff that understood needs in the context of parents' real-life circumstances was important to parent engagement. Thus, longer term benefits from family support require practitioners to work with parents to problem solve immediate issues while also digging deeper to acknowledge and seek to resolve the more complex challenges parents face in their real lives.

Parents' views on how health professionals should work with them now to get the best for their child in the future

BACKGROUND

Pregnancy and the first years of life are important times for future child well-being. Early identification of families and children who might be likely to experience poorer outcomes could enable health professionals and parents to work together to promote each child's well-being. Little is known about the acceptability and feasibility of such an approach to parents.

OBJECTIVE

To investigate parents' views about how health professionals should identify and work with families who may benefit from additional input to maximize their children's future health and well-being.

DESIGN

A qualitative study using focus groups.

SETTING AND PARTICIPANTS

Eleven focus groups were conducted with a total of 54 parents; 42 mothers and 12 fathers living in the north of England.

RESULTS

Parents welcomed the idea of preventive services. They strongly believed that everyone should have access to services to enhance child well-being whilst recognizing that some families need additional support. Making judgements about who should receive additional services based on specific criteria evoked powerful emotions because of the implication of failure. Parents projected a belief in themselves as 'good parents' even in adverse circumstances.

CONCLUSIONS

Targeted additional preventive services can be acceptable and welcome if health professionals introduce them sensitively, in the context of an existing relationship, providing parents are active participants.

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

INTRODUCTION

There is increasing international interest in universal, health promoting services for pregnancy and the first three years of life and the concept of proportionate universalism. Drawing on a narrative review of literature, this paper explores mechanisms by which such services might contribute to health improvement and reducing health inequalities.

OBJECTIVES

Through a narrative review of empirical literature, to identify: (1) What are the key components of health visiting practice? (2) How are they reflected in implementing the universal service/provision envisaged in the English Health Visitor Implementation Plan (HVIP)?

DESIGN

The paper draws upon a scoping study and narrative review.

REVIEW METHODS

We used three complementary approaches to search the widely dispersed literature: (1) broad, general search, (2) structured search, using topic-specific search terms, (3) seminal paper search. Our key inclusion criterion was information about health visiting practice. We included empirical papers from United Kingdom (UK) from 2004 to February 2012 and older seminal papers identified in search (3), identifying a total of 348 papers for inclusion. A thematic content analysis compared the older (up to 2003) with more recent research (2004 onwards).

RESULTS

The analysis revealed health visiting practice as potentially characterized by a particular 'orientation to practice.' This embodied the values, skills and attitudes needed to deliver universal health visiting services through salutogenesis (health creation), person-centredness (human valuing) and viewing the person in situation (human ecology). Research about health visiting actions focuses on home visiting, needs assessment and parent-health visitor relationships. The detailed description of health visitors' skills, attitudes, values, and their application in practice, provides an explanation of how universal provision can potentially help to promote health and shift the social gradient of health inequalities.

CONCLUSIONS

Identification of needs across an undifferentiated, universal caseload, combined with an outreach style that enhances uptake of needed services and appropriate health or parenting information, creates opportunities for parents who may otherwise have remained unaware of, or unwilling to engage with such provision. There is a lack of evaluative research about health visiting practice, service organization or universal health visiting as potential mechanisms for promoting health and reducing health inequalities. This paper offers a potential foundation for such research in future.

Patterns of primary care service use by families with young children

BACKGROUND

In the UK, early years policy emphasizes that all families should have access to support tailored to their individual needs. Knowledge of the determinants of health service use should help to inform rational and equitable planning and delivery of services to parents.

OBJECTIVES

We seek to investigate the determinants of primary care service use in families with preschool children.

METHODS

Determinants of service use in two population cohorts (families with children aged 0-1 and 2-3 years) from the Growing Up in Scotland study are presented. Services related to use of the family doctor or health visitor for information on the child's health or behaviour in the last year.

RESULTS

A range of socio-demographic determinants were significant predictors of service use on multivariate analysis. Determinants of service use differed between the health visitor and family doctor.

CONCLUSIONS

The analysis provides an insight into the determinants and patterns of health service use by families with young children at two stages of development. While some of our findings are expected or supported by previous research, others highlight areas that require further investigation.

'Can they really identify mental health problems at the age of three?' Parent and practitioner views about screening young children's social and emotional development

OBJECTIVE

To report the views of parents, general practitioners and practice nurses on the proposed changes to incorporate social and emotional health checks of three-year-olds into the Healthy Kids Check, a one-off pre-school health assessment delivered through general practice.

METHOD

Participants were recruited from three socio-culturally diverse urban areas of Melbourne for a qualitative study involving 28 parent interviews and six focus groups with a total of 40 practitioners. Participants discussed child social and emotional development, health-seeking and preventive health care for young children. Transcripts were thematically analysed.

RESULTS

Common themes showed: (i) Although both parents and practitioners were receptive to the idea of social and emotional screening, parents had limited knowledge about mental health issues for young children and the need for early intervention. (ii) All groups questioned the current capabilities of practice staff to identify problems, and practitioners expressed a need for further training and tools. (iii) Parents and practitioners cautioned that screening may increase parental anxiety and lead to unnecessary referrals. Practitioners countered this with examples of cases not recognised by parents. (iv) Participants questioned the value of earlier identification of problems without effective and accessible therapeutic pathways.

CONCLUSIONS

For programmes to be effective, parents need to be reminded of the benefits of early intervention and encouraged to attend preventive health appointments. Practitioners require further training and tools specific to the primary care setting. Further investment in specialist and allied health services is considered essential to assure better outcomes for young children's mental health following screening and referral. Practitioners welcome a more collaborative relationship with other professionals (e.g. early educators) in assessing children's social and emotional development. General practice has the capability but requires a more structured approach to assessing the social and emotional health of young children.

Matching parenting support needs to service provision in a universal 13-month child health surveillance visit

BACKGROUND

The Glasgow Parenting Support Framework is an intervention to support families with preschool children. It provides structured support through universal and targeted interventions. Two routine family visits by health visitors have been piloted, one involving a home assessment when the child is 13 months old.

AIMS

To establish the need for parenting support in the population at 13 months and whether or not the home assessment improved the match of service provision to need.

METHODS

Health visitors were asked to collect data on existing problems and service provision to families, the mental state of the child's principal carer, an observation of the parent-child relationship and details of management plans. Data from the Child Health Surveillance System were also used.

RESULTS

Data were obtained for 549 families. Nine families were noted to have problems in the parent-child relationship. Carers in these families had poorer mental health. In all, 20% of families had a revisit scheduled: they were also more likely to have poor mental health. All families with possible problems in the relationship had a revisit scheduled. Depression scores measured during the pilot were a significant predictor of revisiting and referral, with an odds ratio of 1.37 for every one point increase in score on the Adult Wellbeing Scale depression subscale.

CONCLUSIONS

Current service provision matches need to some extent but routine visits focused on parenting difficulties at 13 months, particularly parental depression, may help to identify families needing support who would not otherwise have received it.

Trends in the coverage of 'universal' child health reviews: observational study using routinely available data

OBJECTIVES

Universally offered child health reviews form the backbone of the UK child health programme. The reviews assess children's health, development and well-being and facilitate access to additional support as required. The number of reviews offered per child has been reduced over recent years to allow more flexible provision of support to families in need: equitable coverage of the remaining reviews is therefore particularly important. This study assessed the coverage of universal child health reviews, with an emphasis on trends over time and inequalities in coverage by deprivation.

DESIGN

Assessment of the coverage of child health reviews by area-based deprivation using routinely available data. Supplementary audit of the quality of the routine data source used.

SETTING

Scotland.

PARTICIPANTS

Two cohorts of around 40 000 children each. The cohorts were born in 1998/1999 and 2007/2008 and eligible for the previous programme of five and the current programme of two preschool reviews, respectively.

OUTCOME MEASURES

Coverage of the specified child health reviews for the whole cohorts and by deprivation.

RESULTS

Coverage of the 10 day review is high (99%), but it progressively declines for reviews at older ages (86% for the 39-42 month review). Coverage is lower in children living in the most deprived areas for all reviews, and the discrepancy progressively increases for reviews at older ages (78% and 92% coverage for the 39-42 month review in most and least deprived groups). Coverage has been stable over time: it has not increased for the remaining reviews after reduction in the number of reviews provided.

CONCLUSIONS

The inverse care law continues to operate in relation to 'universal' child health reviews. Equitable uptake of reviews is important to ensure maximum likely impact on inequalities in children's outcomes.

Principles of British health visiting

In an international context, it is sometimes helpful to consider how concepts are understood in different countries, and to explore some different roles. Such knowledge rarely transfers directly from one country or place to another, but to hear about developments from elsewhere can spark ideas and thinking that may be helpful for local developments. This paper gives some brief background about how the health visiting profession developed in Great Britain, and then explains the values and principles that underpin its practice today. Some parallels are drawn with the health situation in modern Brazil.