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English Pages [370] Year 2020
Table of contents :
Front Cover
Community Public Health in Policy and Practice
Copyright Page
Contents
Foreword
References
Preface to second edition
References
List of Contributors
Acknowledgements
Preface to third edition
References
1 Getting the systems right: human ecology
1 Basics of community public health practice: theory and application
Introduction
Public health
Environmental change
Personal preventive measures
Therapeutic measures
Health inequalities
Proportionate universalism
Ecological outlook
A note about health
Salutogenesis
Strengths-based practice
Social capital
Person centredness and human valuing
Conclusion
Discussion Questions
References
Resources
2 Public health practice within communities
Introduction
Working with communities: history and background
Community-centred approaches: origins and influences
Why work with communities in public health?
The current UK public health context
Legislation, health and social care reform and public health commissioning
Models for modern public health nursing delivery in communities
Local levers and mechanisms for public health delivery in communities
Opportunities for integrated public health work in communities
Defining a ‘community’ in public health
Concepts, theories and critiques
Innovation and wider thinking about ‘community’ for public health practitioners
Healthy settings as opportunities for community action to address wider determinants of health
Models and approaches for community-centred public health practice
Key concepts for community-centred public health
Participation
Community assets for health
Equity
Empowerment
Community-centred approaches and practical application in child and family public health
Strengthening communities
Volunteer and peer roles
Collaboration and partnerships
Access to community resources
Evaluation of community-centred approaches
Discussion Questions
References
Further reading and resources
3 Complex place-based interventions for health
Introduction
‘Wicked issues’ in contemporary UK society
Complexity
Place-based interventions in practice
Theories of change and logic models for place-based interventions
Finding my place within place-based approaches
Critique and summary
Discussion Questions
References
Further reading and resources
4 Planning public health strategies
Introduction
What are public health strategies?
The policy context of public health planning
Public health planning case studies
Case Study 4.1: Public health planning for asylum seekers
Case Study 4.2: Public health planning for Gypsies, Roma and Travellers
Applying public health planning to your own practice
Conclusion
Discussion Questions
References
Resources
5 Leadership development for public health practice
Introduction
Underpinning leadership theories in nursing and health
Transformational leadership
Collective leadership
Leadership in public health nursing policy
Leadership development model
Overview of the leadership development model component parts
Identity
Illustrating how the leadership development model can be used in practice
Conclusions
Discussion Questions
Acknowledgement
References
Further reading
Resources
2 Working to create health: salutogenesis
6 Health needs assessment
Health needs
Health and social care
Need for what?
Need and needs assessment
The nature of need
Needs assessments
Ideals
Timing
Types
Assessing community health needs
Defined populations
Wider context
Clarify purpose of assessment
Which data to collect?
Readily available
Collected specifically for the assessment
Need for prevention
Focus on children and families
Universal or targeted services
Universal prevention: assessment for health promotion
Assessment for targeted services
Assessment for indicated prevention
Assessment for selective prevention
Conclusion
Discussion Questions
References
Recommended reading and resources
7 Relationships and partnership working for public health
Introduction
Partnership working
Partnership with individuals and families
Unpacking the Family Partnership Model
Anticipated outcomes of the helping process
Qualities for partnership working
Skills for partnership working
Parent–Health Visitor Relationships
Therapeutic relationships
Identifying measurable factors
Measuring parent–health visitor relationships
Conclusions
Discussion Questions
Acknowledgements
References
Resources and further reading
8 Public health and the life course: supporting parents and families
Introduction
Early life and public health
Life-course evidence
Poverty and families
Policy initiatives promoting family and parenting support
The meaning of family support
The availability of parenting and family support
Service delivery
Home visiting
Volunteer and lay visiting programmes
Parenting groups
Educational/parenting programmes
Referred parenting groups for children with disruptive behaviour
Traditional antenatal and postnatal classes/groups
Support for fathers
Perinatal mental health support
Relationship support
One-to-one approaches to supporting parent–child interactions
Conclusions and implications for practice
Discussion Questions
References
Further Reading
9 Public health practice in a digital world
Introduction to the use of apps and social media within the context of public health
Apps, social media and ‘digital technology’
Advising and signposting clients to information and advice: issues to consider
Safeguarding: an issue when using apps and social media
Case studies
Conclusions
Discussion Questions
References
Suggested reading and resources
10 Health programme decision making and implementation science
Introduction
Health programme decision-making strategies
Frameworks and tools to assist in selection of evidence-based programs
Hexagon tool
RE-AIM model
Practical, Robust Implementation and Sustainability Model
Business research methods
Summary
Translating programmes for implementation
How to translate
Issues in translation
Adaptation processes
Change management
Summary
Implementation strategies
Continuous quality improvement processes
Measuring quality
Sustainability
Summary
Conclusion
Discussion Questions
References
Further reading and resources
11 The economics of prevention in the early years
Introduction
Inequalities emerge early
How economists think about child development
Impacts of early interventions
Costs and benefits of early interventions
Conclusion
Discussion Questions
References
Further Reading
3 Working with individuals and families: human valuing
12 Breastfeeding for a healthy start
Introduction
The First 1000 Critical Days
The incidence and prevalence of breastfeeding in the UK
The public health benefits of breastfeeding
The cost-effectiveness of breastfeeding
Cost benefits to babies and children
Cost benefits for mothers
Calculating the cost-effectiveness of breastfeeding
Offering mothers financial incentives to breastfeed
The Becoming Breastfeeding Friendly Project
Why don’t more women breastfeed in the UK?
The Mother’s Perspective
Influence of family members
Infectious disease
The ‘Competition’
What can health visitors do to support, promote and protect breastfeeding?
Discussion Questions
References
Resources and further reading
13 Safeguarding children: a public health imperative
Introduction
Safeguarding Children and Public Health
The world view
Outcomes for children
The impact of neglect on brain development
Adverse Childhood Experiences
Importance of early intervention and resilience work
Intervening early
Safeguarding children: policy
Key definitions
Safeguarding children
Defining child abuse and neglect
Contextual safeguarding
Children in need
Policy focus: understanding the definitions
Impact on public health: statistics
Gathering the data
Section 47 enquiries, initial child protection conferences and child protection plans
Looked-after children
Learning from case reviews
Safeguarding and promoting the welfare of children
Child health promotion programmes
Safeguarding children: the continuum of need
Early/low intervention
Moving along the continuum of need
High professional intervention: targeted support and integrated working
Working in partnership for population safeguarding
Multi-agency safeguarding arrangements
Individual and organisational responsibilities
Training needs of practitioners
Conclusion
Discussion Questions
References
Resources
14 Immunisation: ethics, effectiveness, organisation
Introduction
UK childhood immunisation programme
Organisation of the programme and immunisation services
Consent to immunisation
Who can give informed consent?
Unique nature of immunisation
Wider benefits and ethical issues
Determinants of vaccine uptake
Perceptions of vaccines and diseases
Vaccine hesitancy
The decision to immunise
Sources of information used by parents
Health care professionals
Internet and social media
Vaccine controversies
Other aspects of the right to choose
Ethical conflicts for health care professionals
Should immunisation be mandatory?
Conclusion
Discussion Questions
References
Further Reading
15 Leadership through alongsideness
Introduction
Ruth’s story: practice development
Discoveries
Beginning to reach the socially excluded: sustainability
Containment, reciprocity, reassurance and encouragement
Understanding my values
Strategic work linked to research and the project
Robyn’s story: from public health action to practical alongsideness
A new method of enquiry
Human emotional needs
Developing values of alongsideness
Respect for people
Self-determination, containment and encouragement
Power of connection and humour
Process of becoming: offers a kind of evaluation
Taking responsibility
Accepting differences
Alongsideness as reflective practice
Integrating our insights: leadership by alongsideness
Conclusion
Discussion questions
References
Further Reading
Index
Postscript: The Covid-19 Pandemic unfolding as this book went to press
Covid-19
Impact of health protection measures
References
COMMUNITY PUBLIC HEALTH IN POLICY AND PRACTICE A SOURCEBOOK
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THIRD EDITION
COMMUNITY PUBLIC HEALTH IN POLICY AND PRACTICE A SOURCEBOOK E DITED BY
DAME SARAH COWLEY
DBE BA PHD PGDE RGN RHV HVT
Emeritus Professor, Florence Nightingale Faculty of Nursing and Midwifery King’s College London, London, UK
KAREN WHITTAKER
BN(HONS) MSC PHD PGCERT RGN RHV
Reader in Child and Family Health School of Nursing University of Central Lancashire Preston, UK FOREWORD BY
CHERYLL ADAMS CBE BSC(HONS) MSC DNURSING SRN HV Executive Director Institute of Health Visiting London, UK
Copyright r 2021, Elsevier Limited. All rights reserved. First edition 2002 Second edition 2008 Third edition 2021 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the publisher (other than as may be noted herein). Notices Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or the value of such product or the claims made of it by its manufacturer. ISBN: 978-0-7020-7944-3
Content Strategists: Serena Castelnovo/Poppy Garraway Smith Senior Content Development Specialist: Helen Leng Content Coordinator: Kirsty Guest Senior Project Manager: Karthikeyan Murthy Design: Renee Duenow Illustration Manager: Deanna Sorenson Marketing Manager: Bergen Farthing Printed in Poland Last digit is the print number: 9 8 7 6 5 4 3 2 1
Contents Foreword vi Preface to second edition viii List of Contributors x Acknowledgements xi Preface to third edition xii
8. Public health and the life course: supporting parents and families 159 Karen Whittaker 9. Public health practice in a digital world 183 Toity Deave 10. Health programme decision making and implementation science 199 Lynn Kemp 11. The economics of prevention in the early years 219 Gabriella Conti
1 Getting the systems right: human ecology 1. Basics of community public health practice: theory and application 3 Karen Whittaker and Sarah Cowley 2. Public health practice within communities 33 Clare Jackson 3. Complex place-based interventions for health 55 Robert Nettleton 4. Planning public health strategies 71 Louise Condon and Amanda Jane Thomas 5. Leadership development for public health practice 85 Karen Stansfield
3 Working with individuals and families: human valuing 12. Breastfeeding for a healthy start 241 Sally Kendall and Rowena Merritt 13. Safeguarding children: a public health imperative 263 Jane V. Appleton, Jayne Harrison and Kathy Mumby-Croft 14. Immunisation: ethics, effectiveness, organisation 293 Helen Bedford 15. Leadership through alongsideness 317 Robyn Pound and Ruth Grant
2 Working to create health: salutogenesis
Index 339
6. Health needs assessment 103 Sarah Cowley 7. Relationships and partnership working for public health 131 Sarah Cowley and Christine Bidmead
Postscript: The Covid-19 Pandemic unfolding as this book went to press Sarah Cowley and Karen Whittaker
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Foreword years matter: get it right then for children, and there is so much benefit to later health as well as social outcomes. My hope is that, long before a fourth edition of this text becomes necessary, the current fall in immunisation rates in childhood, which have caused the UK to lose its measles-free status, with epidemics of measles and mumps being seen again, will have been turned around. This is where community health and the public health workforce can be very effective. On a recent visit to a community clinic in a deprived part of Nairobi, I learnt of their 100% uptake of the measles, mumps and rubella vaccine. We have the network of public health workers, largely health visitors and school nurses, who can achieve this here too. Before the next edition is published, I would also like to see the UK improve its position in the international league tables for childhood poverty and child health—there is much to play for. In the words of Nelson Mandela, ‘ The true character of society is revealed in how it treats its children’. The UK, and England in particular, needs to do better. At these crossroads, it is important for leaders in public health policy and practice to have access to the latest evidence and thinking to be able to lead and influence new directions for health improvement. In particular, they need to make a difference where the evidence is clearest. Indeed, as recorded in so many chapters in this book, the past 30 years have provided an explosion of new evidence for both the importance of early intervention and how to
I am delighted to be invited again to write a foreword for this book, now in its third edition. Its publication coincides with an important moment for community public health. Marmot et al.’s Fair Society Healthy Lives (2010) has reached its 10th birthday and published a new report on how things have changed over the past decade (Marmot et al., 2020). Parts of the United Kingdom (UK) face new challenges and complications for its public’s health after many years of austerity, including a reduction in life expectancy and a rising rate of infant mortality. But there are many other new public health challenges—for example, global warming and the inevitable migrations of people which will come with it, and new and terrifying diseases which can spread very quickly through international travel if outbreaks are not quickly contained, as with the pandemic novel coronavirus COVID-19. In addition, the growth of chronic diseases (e.g. obesity and the resultant type 2 diabetes, and mental illness) has reached epidemic proportions, with uncontained rates in childhood. However, these latter epidemics are largely preventable by the application of science through policy and health promotion. The others can, to a significant extent, be contained through positive intercountry dialogue at the level of the United Nations and World Health Organization, and with the application of good planning, investment and public health principles in-country. Essential, though, is an understanding of the now conclusive science that the very earliest
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work most effectively with individuals and families. The power of co-production is increasingly widely accepted and is something we use to good effect in the Institute of Health Visiting. So, also, is the framework used in this book: human ecology, salutogenesis and human valuing (Cowley et al., 2015) represent an orientation for practice for health visitors and potentially other community public health workers. In conclusion, whilst embracing the future, we should not forget lessons from the past. For example, the Principles of Health Visiting: Opening the Door to Public Health (Cowley and Frost, 2006) remain part of a powerful framework for effective public health practice. With new organisational and government constraints curtailing the wider roles of health visitors, many of their opportunities for facilitating health have been lost, to the detriment of the public’s health. I hope that with the publication of this book at least two of these principles will rise again: facilitating health-enhancing activities at a community level and influencing policies affecting health. There is no one who better understands the needs of any community and how it may be best helped than the community public health practitioners working within it. However, they also need autonomy to act in that
population’s best interests. The Institute of Health Visiting will continue to work for a strengthened health visiting and public health workforce. We hope that new national Nursing and Midwifery Council (NMC) standards for practice, due to be published in 2020, will provide one mechanism for achieving this. Dr Cheryll Adams, CBE Executive Director Institute of Health Visiting
References Cowley, S., Frost, M., 2006. The principles of health visiting: opening the door to public health practice in the 21st century. Community Practitioners’ and Health Visitors’ Association and United Kingdom Standing Conference on Specialist Community Public Health Nursing Education, London. Cowley, S., Whittaker, K., Malone, M., Donetto, S., Grigulis, A., Maben, J., 2015. Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: a narrative review of the literature. International Journal of Nursing Studies 52 (1), 465480. Marmot, M., Allen, J., Boyce, T., Goldblatt, P., Morrison, J., 2020. Health equity in England: The Marmot Review 10 years on. Institute of Health Equity, London. Marmot, M., Goldblatt, P., Allen, J., Boyce, T., McNeish, D., Grady, M., et al., 2010. Fair society healthy lives. Institute of Health Equity, London.
Community public health in policy and practice
Preface to second edition The first edition of this book was published at a time of considerable change across public health, health visiting and community nursing, so it began with an analysis of the differences and similarities among the three occupations (Cowley, 2002). This showed that the key concepts of decisional control, professional and client autonomy, empowerment and consumer choice were prioritised differently by each occupation, according to their diverse public health purposes. Now, as then, all these are reflected in whether • The priority focus is on individuals or whole populations • The service is mainly about the determinants of health or caring for people with established health problems • The social or biomedical model of health is prioritised • Matters are considered the legitimate interest of publicly funded services or should remain private. That chapter (Cowley, 2002), like the whole first edition, emphasised both the important contributions made by all three occupations and the essentially multidisciplinary nature of public health and primary care. It suggested that the nursing profession, too, should begin to view itself as multidisciplinary in nature. Instead of describing the roles of individual occupational groups, a focus on the three levels of public health functioning identified by the (then) chief medical officer (CMO) seemed more useful. He explained: 1. Most professionals, including managers in the National Health Service, local
authorities and elsewhere (e.g. teachers), would benefit from a better basic understanding of public health. Knowledge of how to gain access to more specialist input would be useful to strengthen their role in furthering health improvement goals in their daily work, a role they may not recognise as contributing to public health. 2. A smaller group of ‘hands-on’ public health practitioners spend a substantial part of their working practice furthering health by working with communities and groups. They need more specialised knowledge and skills in their respective fields. This group includes public health nurses, health promotion specialists, health visitors, community development workers and environmental health officers. 3. A still smaller group are public health specialists, who come from a variety of professional backgrounds and experience, and need a core of knowledge, skills and experience. This core is in urgent need of definition so that generic public health specialists can be fully acknowledged for their contribution. This group includes professionals from backgrounds such as the social sciences, statistics, environmental health, medicine, nursing, health promotion and dental public health. (Department of Health, 1998, p. 15)
Since that report, the skills and knowledge needed to operate as a public health specialist have been defined and refined into performance standards required for entry onto a professional register. However, far less attention
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has been paid to the skills and knowledge needed by the middle-sized group of ‘grassroots’ public health practitioners, who were the focus of the first edition of this book, and who remain central in this updated edition. Although their collective, substantial contribution to the public health was highlighted by the CMO’s development project in 1998, this group of grass-roots practitioners occupies a contested and widely neglected professional space. There are ongoing discussions about how best to represent the specific knowledge and skills of environmental health officers, health promotion specialists and other defined specialist groups within the new, multidisciplinary public health register. Whilst public health is striving to promote and regularise notions of multidisciplinarity, a more centralising, unidisciplinary approach has gained ground within the nursing profession. Despite longstanding ambivalence between the distinct professions of health visiting and nursing, the Nursing and Midwifery Order 2001 formalised a decision to combine them by removing all reference to health visitors from the laws in which it had previously been mentioned, and to close their register in 2004. The new register held by the Nursing and Midwifery Council (NMC) includes a part for ‘Specialist Community Public Health Nurses’, with health visitors being incorporated under that title (NMC, 2004). These widespread and highly contested changes in regulation, education and naming of professions have led to much confusion. However, there has been a parallel, more positive and useful emphasis on developing and describing all services in relation to their purpose and client/user group, rather than by the name of the professionals providing them. The title of this second edition was chosen to reflect this newer formulation, emphasising multidisciplinarity and service focus rather than individual professions, whilst retaining the essential emphasis on policy and practice. At the same time, familiar occupational titles, such as health visitor, community development worker, midwife
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or nurse, are still used within the chapters, recognising the continued division of labour and major contributions to public health made by specific grassroots occupations. The second edition was completely reorganised, expanded and updated, with 14 chapters in 4 sections. To keep pace with the rapid progress and many changes across the field of community public health, seven new chapters are included and four chapters, despite having similar titles, have been completely rewritten for this second edition. The three remaining chapters have been substantially updated. Each chapter provides extensive research, conceptual critique and a breadth of information about sources and resources for further information. Decisions about which aspects to retain or delete from this second edition were as difficult as with the first; even though it is larger, it could easily have been twice the length! It is clearly impossible to encompass all possible aspects of public health concern within a single volume, and that is not the intention. Instead, details about underlying skills, knowledge, ways of working and methods for organising services to improve health are set out. As before, this is a sourcebook for students or established practitioners alike, especially those involved in either revamping existing services or developing a focus on a new area of interest or topic of public health concern. I hope it proves useful. Sarah Cowley London, 2007
References Cowley, S., 2002. Public health practice in nursing and health visiting. In: Cowley, S. (Ed.), Public Health Policy and Practice: A Sourcebook for Health Visitors and Community Nurses. Baillie`re Tindall, London, pp. 524. Department of Health (DH), 1998. Chief Medical Officer’s Project to Strengthen the Public Health Function in England: A Report of the Emerging Findings. DH, London. Nursing and Midwifery Council (NMC), 2004. Standards of Proficiency for Specialist Community Public Health Nurses. NMC, London.
List of Contributors The editor(s) would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new edition would not have been possible. Clare Jackson, BSc(Hons), PG Dip, MSc, MPH, RNA, SCPHN, Public Health Speciality Registrar, Health Education North West, Blackpool, UK Lynn Kemp, PhD, MBus, BHSc(Nursing), RN, Distinguished Professor, School of Nursing and Midwifery, Western Sydney University, Penrith, Australia Sally Kendall, BSc(Hons), PhD, Professor of Community Nursing and Public Health, Centre for Health Services Studies, University of Kent, Canterbury, UK, Adjunct Professor, Ngangk Yira Research Centre for Aboriginal Health, Murdoch University, Perth, Australia Rowena Merritt, BSc (Hons), D.Phil, Research Fellow, Centre for Health Services Studies, University of Kent, Canterbury UK Kathy Mumby-Croft, BA(Hons) MA, PhD, RGN, RSCN, RHV, Lecturer, Department of Nursing, Oxford Brookes University, Oxford, UK Robert Nettleton, DEd, MSc(Nurs), PGDipEd, BNurs, Education Lead, Institute of Health Visiting, London, UK Robyn Pound, BA, PhD, RGN, RHV, FAETC, Practitioner Researcher, Make a Move Charity, Bath, UK Karen Stansfield, DBA, MMedSci, BSc (Hons), Associate Dean, Enterprise and Engagement, School of Health and Society, University of Salford, Salford, UK Amanda Jane Thomas, RGN, HV dip, MA in Child Welfare and Applied Childhood Studies, PGtHE, Lecturer, Department of Nursing, Swansea University, Swansea, UK Karen Whittaker, BN(HONS), MSc, PhD, PGCert, RGN, RHV, Reader in Child and Family Health, School of Nursing, University of Central Lancashire, Preston, UK
Jane V. Appleton, PhD, RGN, RHV, BA (Hons), MSc, PGCEA, Professor of Primary and Community Care, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK Helen Bedford, PhD, MSc, BSc, Professor, Great Ormond Street Institute of Child Health, University College London, London, UK Christine Bidmead [Deceased], MSc, PhD, RGN, RHV, Former Training Facilitator, Centre for Parent and Child Support, South London and Maudsley NHS Foundation Trust, London, UK Louise Condon, BA(Hons), MSc, PhD, Professor, Department of Nursing, Swansea University, Swansea, UK Gabriella Conti, BSc, MSc, PhD, Associate Professor in Economics, Centre for Longitudinal Studies, Department of Economics and Department of Social Science, University College London, London, UK Sarah Cowley, DBE, BA, PhD, PGDE, RGN, RHV, HVT, Emeritus Professor, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, UK Toity Deave, PhD, MSc(Epid), PGDip HV, MMedSci, SRN, Associate Professor, Centre for Academic Child Health, Nursing & Midwifery, University of the West of England, Bristol, UK Ruth Grant, MSc, RHV, RGN, Retired Health Visitor, formerly Bath and North East Somerset Community Care and Health Services Jayne Harrison, BN (Hons), RGN, RHV, Trust Lead Nurse for Safeguarding Children, Oxford Health NHS Foundation Trust, Oxford , UK
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Acknowledgements for all the activities behind the scenes and for patiently and efficiently dealing with any queries along the way. The support and expertise of the many contributors who cheerfully updated, completely rewrote or developed new chapters to meet new demands of an ever-changing world cannot be overstated— very many thanks to you all.
The third edition of this book owes its existence to the foresight of Serena Castelnovo from Elsevier, who identified the need for it and smoothed the path to its production for editors and contributors alike. Huge thanks are also due to Helen Leng, Kirsty Guest, Poppy Garraway Smith, Karthikeyan Murthy and the rest of the wonderful team at Elsevier,
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Preface to third edition awareness of the importance of the first 1000 days of life (House of Commons, 2019) and indeed the whole of childhood and early adulthood, as the ‘first 8000 days’ start to enter our lexicon of critical periods (Bundy et al., 2018). We have far more knowledge now about how to help ensure that children and young people get the best start in life, with potential opportunities to start making inroads into corrosive inequalities, should political conditions start to recognise the need for change. Such recognition is now being advocated at a global level, with the Sustainable Development Goals (United Nations, 2015) shining a light, particularly, on developing countries, but also on continued needs stemming from deprivation in wealthier places, like the UK. The World Health Organization (WHO) continues to provide clear guidance, as their Nurturing Care Framework (WHO, 2018) builds on evidence from eminent reports such as those from the Center on the Developing Child at Harvard University (2010, 2016) and the Lancet child development series (Black et al., 2017; Britto et al., 2017). In health visiting, too, there have been advances in evidence, albeit on a smaller scale. Also, the Nursing and Midwifery Council (NMC) has begun a review of the Specialist Community Public Health Nursing (SCPHN) part of the register, including standards for health visitor training. Both of these changes have influenced how we chose to organise this third edition of the text. The second edition followed the principles of health
More than a decade has passed since the second edition of this book was published—just before the 2008 global financial crash reminded us of many public health lessons that we thought we had learnt long ago. Measles has gone and come again in the United Kingdom (UK) as vaccine levels fell. Life expectancy, which had been creeping ever higher, has stalled in its progress. Infant mortality rates, always a marker of current and future population health, are faltering as well. Governments have changed, and the fateful 2016 referendum on UK membership in the European Union divided the country as never before. We have seen that world progress requires sound health systems to deal with terrifying epidemics such as those caused by the Ebola virus. As we go to press, the novel coronavirus and resulting COVID-19 pandemic has focused attention on the basics of infectious disease control. It looks set to change the world in lasting and sometimes unexpected ways, reminding us that such health emergencies, including the threat of antibiotic resistance, amongst other concerns, require international solutions. Throughout all of this period, civil unrest across the world has created global migration at a level not seen since the Second World War, and the planet has grown inexorably warmer, with associated extreme weather events affecting Britain as elsewhere. Yet despite the challenges, there has been progress and much to celebrate in the field of community public health, particularly as the evidence base has expanded exponentially. There is ever-increasing
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visiting (Council for the Education and Training of Health Visiting 1977; Cowley and Frost, 2006), drawing on the way the NMC used these to frame SCPHN standards for practice. The four principles are: 1. The search for health needs 2. The stimulation of an awareness of health needs 3. The influence on policies affecting health 4. The facilitation of health-enhancing activities. Those principles have stood the test of time as a means to explain health visiting practice and—as the NMC discovered— provided a useful organising framework for other community public health nurses. As we finalise the manuscript, we do not know the outcome of the NMC review or if the principles will still be used to inform any new standards that may be forthcoming, but we have new evidence of health visitors’ ‘orientation to practice’, identified from a narrative review of literature stretching back over 25 to 30 years of research (Cowley et al., 2015). Like the principles of health visiting, this has proved its worth as a framework for describing the educational needs of school nurses and health visitors in a new Recommended National Curriculum put forward by the Institute of Health Visiting (iHV, 2018). The orientation to practice describes how health visitors (and potentially, other community public health workers) integrate an understanding of three key issues into their practice: 1. Human ecology, including both the social context in which individuals and families live, and how the systems in which practitioners work can help support what they do
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2. Salutogenesis, which is concerned with understanding how health is created, including and extending notions of disease prevention and health promotion 3. Human valuing, encompassing personcentred care and appreciation of diversity across individuals, families and social groups. Each of these aspects, and the associated underpinning theories, are explained in a new first chapter, which serves as something of an introduction to the rest of the book. It also incorporates more information about public health, particularly elements that are of direct relevance for anyone working in community public health. Professionals working in community public health, it explains, focus particularly on understanding how the social, economic and political context affects health and health inequalities, including but extending beyond the circumscribed boundaries set by a focus on specific disorders and behaviours. This work is often directed at influencing and changing the sociocultural context as much as the healthrelated activities of individuals. That first chapter is one of eight completely new ones in this edition. Only one chapter (15) from the 2008 edition has been retained with minimal updating, as the practice focus seemed still directly relevant. Six other chapters have been radically updated and rewritten, with some including new authors or slight changes in the title. As in the previous editions, we have aimed to provide a sourcebook for students and experienced practitioners alike. It is primarily directed at health visitors and school nurses, so the main focus is on families and children, particularly in the early years, but we hope it will also be of interest to practitioners from the many other community public health fields. The text explains how public health practice
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addresses topics, such as infant nutrition, child safeguarding or protection from disease (see Chapters 12, 13 and 14), are operationalised through realistic needs assessment (see Chapter 6), relationship building (see Chapter 7), home visiting (see Chapter 8) and outreach within community settings (see Chapters 3 and 4). Advances in knowledge about health, service infrastructure and communication technology (see Chapters 2 and 9) mean that practitioners also need, first, to keep abreast of new ways of working with diverse communities and teams, to provide leadership (see Chapters 5 and 15), second, to recognise cost-efficient and affordable ways of working (see Chapter 11) and third, to implement evidence (Chapter 10) that can achieve sustainable change and improvements for equitable health. No single book can encompass all the information needed for practice, and we are very aware of some omissions, but we hope we have managed to explain how policies influence what is expected and possible in practice, along with most of the pertinent information needed to succeed in the important field of community public health.
References Black, M.M., Walker, S.P., Fernald, L.C.H., et al., 2017. Early childhood development coming of age: science through the life course. Lancet 389 (10064), 7790. Britto, P.R., Lye, S.J., Proulx, K., Yousafzai, A.K., Matthews, S.G., Vaivada, T., et al., 2017. Nurturing care: promoting early childhood development. Lancet 389 (10064), 91102. Bundy, D.A.P., de Silva, N., Horton, S., Patton, G.C., Schultz, L., Jamison, D.T., et al., 2018. Investment in child and adolescent health and development: key messages from disease control priorities, 3rd edition. Lancet 391 (10121), 687699. Center on the Developing Child at Harvard University, 2010. The Foundations of Lifelong Health are Built in
Early Childhood. ,https://developingchild.harvard .edu/resources/the-foundations-of-lifelong-health-arebuilt-in-early-childhood/. (accessed 26/03/2020) Center on the Developing Child at Harvard University, 2016. Building Core Capabilities for Life: the Science Behind the Skills Adults Need to Succeed in Parenting and in the Workplace. ,http:// developingchild.harvard.edu/wp-content/uploads/ 2016/03/Building-Core-Capabilities-for-Life.pdf. (accessed 26/03/2020) Council for the Education and Training of Health Visiting (CETHV), 1977. An Investigation into the Principles of Health Visiting. CETHV, London. Cowley, S., Frost, M., 2006. The Principles of Health Visiting: Opening the Door to Public Health Practice in the 21st Century. Community Practitioners’ and Health Visitors’ Association and UK Standing Conference on Specialist Community Public Health Nursing Education, London. Cowley, S., Whittaker, K., Malone, M., Donetto, S., Grigulis, A., Maben, J., 2015. Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: a narrative review of the literature. Int. J. Nurs. Stud. 52 (1), 465480. House of Commons Health and Social Care Committee 2019 First 1000 days of life. Thirteenth Report of Session 2017/19. HC 1496. ,https:// publications.parliament.uk/pa/cm201719/cmselect/ cmhealth/1496/1496.pdf. (accessed 25/02/2020) Institute of Health Visiting, 2018. Recommended National Curriculum Specialist Community Public Health Nursing—Health Visiting/School Nursing (0-19 child public health services). Institute of Health Visiting, London. https://ihv.org.uk/wpcontent/uploads/2019/03/Recommended-NationalCurriculum-FINAL-19.3.19.pdf (accessed 06/05/ 2020). United Nations, 2015. Transforming our World: the 2030 Agenda for Sustainable Development. United Nations, New York. World Health Organization, United Nations Children’s Fund, World Bank Group, 2018. Nurturing Care for Early Childhood Development: A Framework for Helping Children Survive and Thrive to Transform Health and Human Potential. World Health Organization, Geneva.
Sarah Cowley Karen Whittaker May 2020
S E C T I O N
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Getting the systems right: human ecology Introduction to Section 1 Public health provision involves a complex web of factors that, when functioning collectively as part of a comprehensive service system, offer something more than the sum of the parts. This first section considers different factors pertinent to the system supporting public health practice and service provision. Ecological theory provides the underpinning perspective on the operation of the multilayered service system and thereby the relevance of political, cultural, material and social factors. Chapter 1 opens the discussion about theory and application to public health, including specific details of human ecology and the insight this perspective brings to understanding the contexts within which health is experienced or acted on through service provision. Throughout this section, we address the issue of ‘community’ (notably in Chapter 2), including how it is defined and can be engaged to support equitable participation in good health. Chapter 3 affords specific attention to the complex nature of communities and offers ‘place-based’ initiatives as a positive approach to managing complexity and addressed community needs. Alternative strategies needed when meeting the needs of marginalised groups and those at risk of falling outside mainstream service structures are explored in Chapter 4. The section rounds off with the first of two chapters (Chapters 5 and 15) that direct attention to the contribution of leadership, which powerfully sets the tone for teamwork and shapes the culture of the service system. Chapter 5 therefore explains the factors within public health that help determine the direction of travel across a team or broader system. 1. Basics of community public health practice: theory and application. Karen Whittaker & Sarah Cowley 2. Public health practice within communities. Clare Jackson 3. Complex place-based interventions for health. Robert Nettleton 4. Planning public health strategies. Louise Condon & Amanda Jane Thomas 5. Leadership development for public health practice. Karen Stansfield
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C H A P T E R
1 Basics of community public health practice: theory and application Karen Whittaker and Sarah Cowley KEY ISSUES • Public health
• Using an ecological outlook to enlarge public health potential and action
• Health inequalities and proportionate universalism
• Salutogenesis—creating good health • Person-centred care—human valuing
Introduction The World Health Organization (WHO, 1998) describes public health as a social and political concept aimed at improving health, prolonging life and improving the quality of life among whole populations through health promotion, disease prevention and other forms of health intervention. Professionals working in community public health focus particularly on understanding how the social, economic and political context affects health and health inequalities, including but extending beyond the circumscribed boundaries set by a focus on specific disorders and behaviours. Community public health work is often directed at influencing and changing the sociocultural context as much as the healthrelated activities of individuals. This chapter begins with an explanation of some of the background and key issues regarding public health and health inequalities, including the importance of delivering services through a system of proportionate universalism, with a priority focus on the early years. Continuing with the service delivery theme, the second half of the chapter focuses on some of the key theories and understandings required by practitioners working in community public health as they explore and influence the situations from which health and health inequalities arise. To guide the decision about which of the many potentially useful theories to include, we focused on three areas identified as central to
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health visitors’ ‘orientation to practice’, through a large scoping study by Cowley et al. (2013, 2015). These areas are human ecology, salutogenesis and human valuing.
Public health The most widely accepted definition of public health is the one coined by Sir Donald Acheson, as ‘the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society’ (Acheson, 1988). Ashton and Seymour (1998) described four phases of public health, starting with a focus on environmental change early in the 19th century, then moving to personal preventive measures by the end of that century. As the 20th century progressed, therapeutic interventions seemed to hold much promise, before their limitations were realised and the ‘new public health’ emerged, with a focus on a more holistic, humanistic philosophy and a broad, socially based belief in the value of health. Eventually, the need for all four approaches became clear. More recently, increasing knowledge about the social determinants of health and the impact of early child development on health inequalities (Maggi et al., 2010) has focused public health minds on the need for a life-course approach, prioritising pregnancy and the start of life (Marmot et al., 2010, 2020; see Chapter 8).
Environmental change The need to prevent disease and keep epidemics in check has existed as long as human beings have lived together in large groups, but public health as an entity was largely formalised in the 19th century in the United Kingdom (UK). The Industrial Revolution created conditions that brought together a great need with a culture of inquiry that aided the search for scientific solutions (Morley, 2007). Mass migration from the countryside to towns led to uncontrolled growth in slums, squalor, dire conditions at home and work for large swathes of the population, along with devastating levels of poverty that the (thencurrent) Poor Laws were ill-equipped to deal with. Edwin Chadwick’s (1842) seminal inquiry about the Sanitary Conditions of the Labouring Population of Great Britain helped to formalise laws designed to protect the health of the population, paving the way for new legal regulations of buildings and working conditions, along with safe water supply, sewage and food. These technical and engineering solutions to the huge public health problems of the day foreshadowed current ‘health protection’ measures, in which regulatory solutions ensure compliance to avoid foreseeable risks. Matters such as speed limits, building regulations, health and safety at work, food hygiene and air quality all have a major contribution in ensuring the health of our population, along with recently rediscovered controls on movements to prevent the spread of infectious diseases like COVID-19. Victorian conditions have not returned to Britain yet, but the present situation remains grim for many families. As an example, in 2015, the National Society for the Prevention of Cruelty for Children reported on the conditions for homeless babies up to the age of 2 years (see Box 1.1). Although not actually living on the streets, many were in ‘non-decent’ or overcrowded housing, which may fall outside the legal requirements for home safety in the UK, with likely risks from unsafe electrical sockets, unguarded fires, dampness and ingrained
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BOX 1.1
Homelessness in Britain
Homeless Babies in England, 2015 At the end of 2018 Approximately 15,700 babies younger than 2 year of age were classed as statutorily homeless in England Of these, approximately 710 live in bed-andbreakfast (B & B) accommodation, many without access to a kitchen and with shared bathrooms Of these, up to 170 had been in B & B accommodation for longer than 6 weeks Highly mobile families or those living in poor conditions featured in 45% of Serious Case Reviews
There were 62,000 statutorily homeless families There were 124,000 children among these families, 80% more than in 2010 In 2017: 92,000 children were thought to be in ‘sofa surfing’ families And an estimated 120,000 children were in ‘temporary accommodation’ Approximately 51,000 (40%) of these children had been in temporary accommodation for more than 6 months, and some 6000 (5%) for more than a year A further 375,000 children lived in families who were at financial risk of becoming homeless
Source: Hogg et al., 2015
Source: Children’s Commissioner, 2019
dirt, poor heating and ventilation (Hogg et al., 2015). The Children’s Commissioner for England (2019) has also noted that figures for families recognised by authorities as homeless may be only the ‘tip of the iceberg’. Many more families are living in overcrowded, temporary and inadequate housing conditions, perhaps staying with friends or relatives (known as ‘sofa surfing’) where there is inadequate space, with no national data to reflect the extent of the difficulties. Vulnerable families are particularly at risk of exploitation from unscrupulous landlords, and the spectre of slum housing (such as the so-called sheds with beds, which lack basic requirements such as a safe power supply, clean running water and ventilation) is rising in England again. Even official temporary housing might consist of converted office blocks or shipping containers, without basic safety needs. Such poor living conditions are highly risky for children’s health, development or even survival, especially for infants. Slum housing remains prevalent across the developing world, including in mediumresource countries that may be expanding rapidly. Living and working conditions in shanty towns, favelas and sweatshops can be every bit as harsh those faced by our Victorian forebears. The Sustainable Development Goals (SDGs) set by the United Nations (UN) (2015) provide an overarching framework for improvement internationally, (as discussed later; see Chapter 8 for more details).
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However, as Chadwick (1842) found nearly two centuries ago, measures designed to improve health are both highly political and emotionally charged. As a social reformer, Chadwick made the case that improved working and living conditions would be economically advantageous, and legal frameworks began to emerge requiring local government to take responsibility for the health of their local population (Morley, 2007). Likewise, campaigns for social and health funding today almost always include economic analyses (see Chapter 11).
Personal preventive measures Moral judgements suggesting that individual behaviour is the main cause of difficulties, whether illness or social conditions, remain common. They were powerful motivators in the mid- to late 19th-century shift toward personal preventive measures and education, as public health officials aimed to change individuals’ health-related behaviour. Several new professions, such as health visiting and school nursing, emerged during this period. Current practice in health education, patient teaching and health promotion stem from this strand of public health, which continues to be much needed. England’s recent Green Paper on prevention (Cabinet Office and Department of Health and Social Care, 2019), for example, places much store on the use of data to ensure messages are personalised to reach segments of the population who most need them—citing the example that 90% of social media messages about smoking are seen by those who smoke. However, delivering health messages alone is rarely effective. Instead, modern approaches to health promotion have developed, particularly since publication of the WHO’s Ottawa Charter for Health Promotion (1986). These approaches involve strengthening personal and community skills in ways that enable and empower people to be confident, informed and engaged in decisions that influence the determinants of health (more of which are discussed later) and supporting the development of health literacy (Nutbeam et al., 2018). The concept of health literacy has emerged as a way of describing how services, organisations and systems make health information and resources available and accessible (International Union for Health Promotion and Education Global Working Group on Health Literacy, 2018). Definitions of health promotion and health literacy are shown in Box 1.2. A number of the most successful health improvement programmes incorporate both these concepts—for example, various home visiting programmes that were designed to take account of social context and enable parents to focus on things they can control within their situation (see Chapter 8 and Goldfeld et al., 2018). Home visiting offers a means of delivering personal prevention messages and reaching people in their own situation. Going to where people live their lives provides a great opportunity to align health messages to family needs and the situation and circumstances that impact on them (Hanson et al., 2019). Acting on health inequities across the Europe and Central Asia region, the UN Children’s Fund (UNICEF) has been actively supporting country partners to reform home visiting services, previously developed as medical interventions, to incorporate focused support with parenting and early child development (Schwethelm et al., 2019). In collaboration with International Step by Step Association (ISSA), UNICEF has developed a series
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BOX 1.2
Health Promotion and Health Literacy
Health promotion
Health literacy
Health is a resource for everyday life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities.
Health literacy is the combination of personal competencies and situational resources needed for people to access, understand, appraise and use information and services to make decisions about health.
Health promotion is the process of enabling people to increase control over, and to improve their health. Source: WHO Ottawa Charter for Health Promotion, 1986
It includes the capacity to communicate, assert and act on these decisions. Source: International Union for Health Promotion and Education (IUHPE) Position Statement, 2018
of learning resources (UNICEF and ISSA, 2017) for home visitors, with key messages and practices for meeting individual family needs, whilst accommodating a range of social complexities. This work is reported to be making an important difference, increasing the number of babies being exclusively breastfed; improving numbers of children receiving developmental assessments and where necessary additional help; and a 10% improvement in vaccination coverage (Schwethelm et al., 2019).
Therapeutic measures As the 20th century progressed, therapeutic interventions and medical progress seemed to hold much promise, with scientific and pharmacological advances beyond anything imaginable in previous years. Whilst medical services contribute greatly to improved health and longevity across the world, their supremacy in terms of improving population health were questioned in the 1970s by Thomas McKeown, a physician and social historian. In brief, he noted the rapid rise in population between the late 18th and mid-20th centuries but attributed it more to a decline in mortality than a rise in fertility (McKeown, 1976). He emphasized the importance of economic growth, rising living standards and improved nutrition as the main reasons for increased life expectancy, rather than improvements in modern medicine. This radical interpretation was influential in emphasising the importance to health of living and working conditions, even though his dismissal of the importance of medical treatments has been widely refuted, particularly for the past century. Catillon et al. (2018), for example, show there is a stronger case that personal medicine affected health in the second half of the 20th century than in the preceding 150 years. ‘Big medicine’, they say, brought big benefits, especially to the older population—but at big cost. Rising medical costs have refocused attention on prevention and social contexts,
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with health care now generally recognised as just one important determinant among many of health and lifespan. Szreter (2002) pointed out that McKeown may have downplayed the impact of therapeutic advances, but he succeeded in focusing attention back onto the social determinants of health. He also largely disregarded the important campaigning and social activism embedded within the medical public health movement, which was galvanised in the late 20th century partly as a result of McKeown’s critique. Such activism contributed to the interest of the UN (2015) in improving worldwide wellbeing, culminating most recently in the SDGs, which are summarised in Box 1.3. One (SDG3) is to ‘Ensure healthy lives and promote well-being for all, at all ages,’ which has one specific target, numbered 3.8, to achieve universal health coverage, including financial risk protection, access to quality essential health care services and to safe, effective, quality and affordable essential medicines and vaccines for all (United Nations, 2015). Community public health workers can use the SDGs to explain how their activities to address local health needs at an individual and community level also have a broader relevance to global concerns. Examples of actions relevant to health visitors, school nurses and others working in community public health are set against each of the SDGs, summarised in Box 1.3.
Health inequalities Providing health care and public health protection for all helps to raise the wellbeing of the whole population, but different approaches are needed to avoid inequalities in health outcomes. Historically, the fact that people with low or unreliable incomes tended to die at a younger age than their richer counterparts, or to experience more disease and disability, was readily explained by hunger or by hazardous living and working conditions. However, as public health improvements, control of many infectious diseases and higher standards of living occurred across the developed world, it became clear that there were still wide disparities between health and life expectancy, depending on where people lived and their status on the social scale. Infant mortality (deaths before 1 year of age, per 1000 live births) provides an example. In England, the 2017 infant mortality rate was highest in the most deprived areas of England at 5.2 deaths per 1000 live births and lowest in the least deprived areas at 2.7 deaths per 1000 live births (Office for National Statistics, 2019). Two things are notable about these data as shown in Figure 1.1. First, all pregnant women have the right to receive free maternity care and maternity leave in England, regardless of their status on the social scale. Second, infant mortality rates follow a social gradient—that is, there is not only a difference between the rate for the best off, living in the least deprived areas and the worst off people living in the most deprived areas, but also a stepwise difference between each centile, showing a clear social gradient. The different centiles come from the English Index of Multiple Deprivation (IMD), which is based on 39 separate indicators organised across 7 distinct domains of deprivation (Income, Employment, Education, Health, Crime, Barriers to Housing and Services, Living Environment) (Ministry of Housing, Communities and Local Government, 2019).
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Health inequalities
BOX 1.3
Sustainable Development Goals and Local Public Health Action
Sustainable development goals (United Nations, 2015)
Key areas of community public health concern and action
Goal 1. End poverty in all its forms everywhere.
Understanding experiences of family poverty and provision of person-centred service; identifying opportunities to address family poverty, including advice on welfare benefits; exposing the impact of family and child homelessness. Recognising and understanding family food behaviour; facilitating access to helping services; liaising with food banks; breakfast clubs; action on obesogenic environments in schools, workplaces, neighbourhoods. Primary health care and community public health provision; provision of child health development and family health reviews; education on immunisation; interventions of tobacco use; nonaccidental injury. Child school attendance; access to preschool provision; school nursing service.
Goal 2. End hunger, achieve food security, improved nutrition and promote sustainable agriculture.
Goal 3. Ensure healthy lives and promote wellbeing for all, at all ages
Goal 4. Ensure inclusive and equitable quality education; promote lifelong learning opportunities. Goal 5. Achieve gender equality; empower all women and girls.
Equitable child and family health service for all; fathers and coparents.
Goal 6. Ensure availability and sustainable management of water and sanitation for all.
Family access to water utilities; toilet facilities in local communities and schools; recognising each person’s housing situation and impact. Identifying needs associated with family poverty; identifying eligibility for benefits such as winter fuel allowance and fuel poverty. Adult health and occupational health provision; childcare access and costs; maternity and paternity rights; adult education and training opportunities for parents.
Goal 7. Ensure access to affordable, reliable, sustainable and modern energy for all.
Goal 8. Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all.
Continued
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BOX 1.3
Sustainable development goals (United Nations, 2015)
Key areas of community public health concern and action
Goal 9. Build resilient infrastructure, promote inclusive and sustainable industrialisation and foster innovation.
Impact of employment/unemployment; gig economy/zero-hour contracts and impact on family life; industry and impact local community social, economic and physical environment; campaigning action on affordable housing. Awareness of social determinants of health and social gradient; provision of child and family health services on basis of proportionate universalism. Supporting community engagement in local issues and events to enable community cohesion across generations; action on affordable housing. Supporting child and family action on recycling, reusing (e.g. via baby clothes and school uniform community swap shops) Campaigning for safe (low-carbon) transport infrastructure for children and families to access school (e.g. ‘walking buses’), employment and community services Water awareness: refillable drinking water facilities in schools and community buildings to reduce plastic use. Managing personal and household hygiene influencing use and disposal of detergents and chemicals. Campaigning for urban parks and green spaces etc; supporting families to make use of existing green spaces. Domestic violence education and support; safeguarding action; role model nurturing care practices; needs assessment and action for vulnerable groups and individuals; collaborate to reduce violent crime. Action and coproduction through areabased programmes (e.g. A Better Start); strategic alliance formation with local partners and community members.
Goal 10. Reduce inequality within and among countries
Goal 11. Make cities and human settlements inclusive, safe, resilient and sustainable.
Goal 12. Ensure sustainable consumption and production patterns. Goal 13. Take urgent action to combat climate change and its impacts.
Goal 14. Conserve and sustainably use the oceans, seas and marine resources for sustainable development.
Goal 15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests etc. Goal 16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all.
Goal 17. Strengthen the means of implementation and revitalize global partnership for sustainable development.
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Health inequalities
7.5
Rates per 1,000 live births
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2
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FIGURE 1.1 Decrease in the infant mortality rates for the most and least deprived areas in England since 2008. Source: Office for National Statistics.
The index measures relative levels of deprivation in 32,844 small areas or neighbourhoods, called Lower-layer Super Output Areas, showing that deprivation is dispersed across the country, with clusters of deprivation persisting in some large towns and cities. Most advanced countries have similar local measures. A summary of the Scottish Index of Multiple Deprivation makes the useful point that not everyone in a deprived area has a low income: that condition applies only to one in three people living in such a place (Scottish Government, 2016). Also, two of three people with a low income do not live in deprived areas. So, despite their usefulness, neither income nor neighbourhood alone account for the full spectrum of need. Similar gradients apply across the UK, which has many neighbourhoods with a mixture of different people and housing types. The English Index of Multiple Deprivation centiles are used again for Figure 1.2, which shows the social gradient for childhood obesity in England in 2018. It is, perhaps, easy to understand that the poorest families access the cheapest, calorie-laden food, whereas those with sufficient funds can readily afford more expensive food, such as fresh fish or fruit. Indeed, some deprived neighbourhoods are ‘fresh food deserts,’ with neither greengrocers nor supermarkets, but with plentiful fat- and sugar-laden fast-food outlets. Again, however, the charts show a clear stepwise difference between each centile, right across the board, not only a distinction between those living in very deprived areas and those in the most expensive places. A similar gradient, running right across society, is seen for almost all conditions and causes of death, both within and between countries, whether physical or mental health. The social gradient began to be noticed in the closing decades of the past century, as a result of longitudinal studies like the two Whitehall Studies, which have tracked thousands of civil servants since 1967. These studies revealed that those who were lowest on the work ladder were likely to have heart attacks before those in charge, which ran counter to the received wisdom of the time, with high-powered work viewed as the most stressful and so most likely to lead to heart disease (Marmot, 2004, 2015). Once noted,
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C
A Deprivation - Reception
Deprivation - Year 6
There is a strong relationship between deprivation and obesity.
Obesity prevalence was over twice as high for children living in the most deprived areas (26.9%) than for children living the least deprived areas (11.4%).
Obesity prevalence was over twice as high for children living in the most deprived areas (13.3%) than for children living in the least deprived areas (5.9%).
% Obese 30
% Obese 15
26.9 13.3
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0
0 Most deprived
Most deprived
Least deprived
B
Least deprived
D Severe obesity prevalence was almost four times as high for children living in the most deprived areas (3.9%) than for children living in the least deprived areas (1.0%).
Severe obesity prevalence was over four times as high for children living in the most deprived areas (7.1% and 1.5% respectively).
% Severely obese 4
% Severely obese
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2
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2.2 1.5
0
0 Most deprived
Least deprived
In general underweight prevalence decreases as deprivation decreases (not shown on chart).
Most deprived
Least deprived
Combined overweight and obesity prevalence ranged from 41.5% for children living in the most deprived areas to 24.1% for children living in the least deprived areas (not shown on chart).
FIGURE 1.2 Childhood obesity. Source: National Child Measurement Programme, NHS Digital, 2019. https:// digital.nhs.uk/data-and-information/publications/statistical/national-child-measurement-programme/2018-19-school-year/ deprivation (acessed 16 March 2020)
however, the social gradient was seen to be ubiquitous, with the UK consistently amongst the most unequal countries in the developed world (Organisation for Economic Cooperation and Development (OECD), 2019). Country-wide inequalities are measured by using the Gini coefficient, which measures income inequality on a continuum, with complete equality set at 0 and complete inequality at 1. In 2017, the Gini measure for the UK was 0.357 (see https://data.oecd.org/inequality/income-inequality.htm#indicator-chart). Health inequalities follow income level quite closely, but (as shown by the deprivation indicators) measures of wealth or poverty alone do not fully explain the differences, so public health practitioners need to be able to understand individual family experiences of poverty and how they differ—of which more discussion follows. Furthermore, explaining the social gradient poses a challenge, particularly in understanding the differences in the middle of the curve. As Wilkinson (2006) noted, the material privations of having a house with a smaller lawn to mow or one less car hardly seemed plausible explanations for the fact that those in executive grades have substantially poorer health than their senior managers, who were working in the same offices. Early in his career, Wilkinson (1996) proposed that the psychosocial liberalisation that accompanies economic development may, indeed, be a major determinant of health, but
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Proportionate universalism
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the accompanying social stresses from living in hierarchical societies turn out to be a major contributing factor to health inequalities. Further, health inequalities themselves appear to drive a series of major public health and policy concerns, such as drug use, obesity, violent crime, life expectancy and social or community relations (Wilkinson and Pickett, 2010), for which there is strong epidemiological evidence (Pickett and Wilkinson, 2015). Health inequalities, therefore, affect the whole of society, not just those at the ‘sharp end’ of poverty and deprivation, and their solutions are intensely political in nature. The WHO established a Commission on Social Determinants of Health (CSDH) to consider what could be done to improve health equity through an international focus on the social determinants of health. The CSDH report (2008) emphasised the fact that avoidable health inequalities are social in nature, linked to questions of justice. The term ‘inequity’ is used to show the fundamental lack of fairness and political choice involved in the way opportunities and resources are distributed in society. The directness in the CSDH report drew surprised comments from some who preferred to downplay the social and political basis of health inequalities, perhaps by describing them only as ‘disparities’ or ‘variations’. However, Sir Michael Marmot (who chaired the CSDH) went on to chair a strategic review of health inequalities in England, where he responded to a critic who had labelled the CSDH ‘ideology with evidence,’ writing ‘We do have an ideological position: health inequalities that could be avoided by reasonable means are unfair. Putting them right is a matter of social justice. But the evidence matters. Good intentions are not enough’ (Marmot et al., 2010, p. 3). Since the initial CSDH report, the WHO has continued to champion policies to promote health equity, tracking the extent of expenditure and progress in each country against a range of key indicators (WHO, 2019), and research into the social determinants of health has continued apace. However, in the UK, the proposed additional expenditure has not been forthcoming. A Public Health White Paper was published in the UK, with health inequalities at its heart, but it was dropped after a change of government and inequalities have continued to increase, with a simultaneous slowing of improvements in life expectancy (Marmot et al., 2020). The UK’s life expectancy is below that of many comparator countries now, especially for women, for whom there has been no improvement since the slowdown started in 2011. Inequalities are widening, and the UK’s health care expenditure and resources are below those of comparator countries, although the effect of widening inequalities on the mortality slowdown is not clear-cut (Raleigh, 2018).
Proportionate universalism The Marmot Review (Marmot et al., 2010) made a number of policy recommendations, summarized in Box 1.4. Early childhood development was singled out as the highest priority, and the Review team called for a ‘second revolution in the early years’ (the first revolution being the large and growing amount of recent evidence, which has shown the importance of this period of life, see Chapter 8), to increase the proportion of overall expenditure allocated there. This additional expenditure, they said, should be focused proportionately across the social gradient to ensure effective support to parents (starting in pregnancy and continuing through the transition of the child into primary school)
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BOX 1.4
Policy recommendations from Marmot Review (2010)
Six domains for action
Early child development (ECD)
Proportionate universalism
Early child development
ECD is the highest priority
Education and lifelong learning
Giving every child the best start in life is crucial to reducing health inequalities across the life course.
Actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage
Employment and working conditions Minimum income needed for health living Healthy and sustainable environments in which to live and work A social determinants approach to prevention— addressing the causes of the causes.
Increase the proportion of overall expenditure allocated to ECD Focus expenditure across the social gradient to ensure effective support to parents, starting in pregnancy and continuing through transition of the child into primary school
Greater intensity of action is needed for those with greater social and economic disadvantage Focusing solely on the most disadvantaged will not reduce the health gradient, and will only tackle a small part of the problem
(Marmot et al., 2010, p. 22). Interest in ensuring good services for the ‘first 1000 days of life’—that is, from pregnancy to the age of 2—has become increasingly prominent since publication of Marmot’s work, along with a massive and growing evidence base showing the importance of this period for a child’s development, later health and health inequalities (e.g. Maggi et al., 2010; Black et al., 2017; Health and Social Care Committee, 2019). Indeed, Marmot et al. (2020) reiterate their earlier recommendations, stressing that national priorities should focus on wellbeing as a central goal of policy, across the whole government. The term ‘proportionate universalism’ was introduced with the recommendation that ‘to reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage’ (Marmot et al., 2010, p. 16). This emphasis reopened long-standing debates about whether policy funding is best spent on providing universal services or targeting only the most disadvantaged. Drawing on Rose’s epidemiology, the Marmot team stress that focusing solely on the most disadvantaged will not reduce the health gradient and will only tackle a small part of the problem. This is because a large number of people at small risk or in low-risk areas (e.g., the two of three people living on low incomes in nondeprived areas, as mentioned earlier) may give rise to more cases of disease than a small number of people at high risk. High-risk groups make up a relatively small proportion of the population (Rose
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Ecological outlook
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et al., 2008). Universal provision is needed to shift the curve of the gradient and distribution of need across the whole population to reduce overall prevalence of any particular health need. In general, providing a combination of universal services and targeted programmes, which change in nature and intensity according to need, has become a favoured recommendation for inequality reduction across the entire social gradient (Pearce et al., 2019). Much of the academic debate about how to operationalise this form of provision has focused on new services, in areas where country-wide inequalities are rife and universal services limited. Carey et al. (2015) developed a policy framework to guide health equity actions, which is helpful to discussions in British community public health, where funding is often under threat despite being part of a universal free-at-the-point-of-delivery health service. They make the point that different levels or types of help or support for families may be appropriate, depending on their particular circumstances, whether health, cultural or social (Carey et al., 2015). This encapsulates the idea of providing a basic level of service to everyone, then increasing or varying it in proportion to particular, identified needs, to flatten the curve of the social gradient—that is, according to particularist principles (Carey and Crammond, 2017). This ‘universalism with particularist principles’ is operationalised in British health visiting, by offering all eligible families (that is, expectant parents and those with children younger than 5 years) at least a minimum, mandated service, regardless of their situation or needs—a single contact is not enough. Then after individual assessment of need, the level of service is decided with additional or different provision directed at particular, identified needs. The service description varies across the four countries of the UK, but in all cases includes a universal level, a level of short-term specific input for indicated prevention (sometimes known as ‘universal plus’) and selective prevention for children and families with more complex, long-term needs or living with predicted high risk (see Cowley et al., 2018 and Chapter 6 for more details). Proportionate universal services to reduce health inequalities and promote health and wellbeing need to be based on a strong evidence base (Center on the Developing Child at Harvard University, 2010; Black et al., 2017; National Scientific Council on the Developing Child, 2018) and understanding about how societies and families operate. Three key concepts that underpin health visiting practice were identified through a large scoping review of the literature (Cowley et al., 2013, 2015) and, as they appear to be useful across community public health, they are detailed in the second half of this chapter. The three key theoretical concepts are human ecology, salutogenesis and human valuing, which each share ideas and values in common. As well as providing explanations and useful frameworks for underpinning research, these three theories appear useful for guiding and grounding practical activities such as home visiting and relationship building, as shown in Figure 1.3.
Ecological outlook Ecological theory has been explained as pertinent to a range of health and social challenges (Richard et al., 2011), including promotion of physical activity (Richard et al., 2011); early child development (Kemp et al., 2012; Schwethelm et al., 2019); public mental health
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1. Basics of community public health practice: theory and application
Supporting health actions in different settings, recognising external influences Human Ecology
Salutogenesis Practice operationalised through: Home visiting Relationship building
Recognise each Needs assessment person’s ability Positive regard Community reach and desire to for the other know their own person, respecting needs, to act to their situation in the protect or improve family, community their health, or that of or workplace their family
Human Valuing
FIGURE 1.3 Orientation to practice. After Cowley et al., 2015.
(Ericksson et al., 2018); child safeguarding (Firmin, 2019); smoking cessation (Pratt et al., 2019); and teenage pregnancy (Garney et al., 2019). Further, the substantial review of evidence explaining health visiting practice identified human ecology, along with human valuing and a focus on health creation, as an important theoretical principle underpinning the orientation of health vising practice (Cowley et al., 2013, 2015). Early introductions to human ecology (Park, 1936, 1952) explain it as the interrelations between people within a multilayered social world, and a parallel is drawn with explanations of the interrelations between animals and plants within the natural world. Park (1936) makes reference to the ‘web of life’ as illustrated by the popular children’s rhyme ‘The House That Jack Built,’ which recounts a linked chain of events (involving a cow, dog, cat, rat and pile of malt), where each event is dependent on the former and their sequence. Importantly, with human ecology there was the appreciation that the relations between people occur within spaces shaped not just by natural environmental features but additionally by economic, political and moral constraining factors.
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Ecological outlook
Since Park’s early publications, social and developmental psychologists have advanced the theoretical principles generating ecological models and approaches for addressing health concerns and health promotion within public health (Richard et al., 2011). Of note is the model advanced by developmental psychologist Urie Bronfenbrenner (1977), which provided a perspective on understanding social contexts and the behaviours of people within those contexts. This influenced a growth in ecological models and approaches for health and social care (Richard et al., 2011; Trickett, 2019), which are built from Bronfenbrenner’s original premise that the real world exists as a series of nested interactive ecological levels. People exist within this multilayered system that, like Russian dolls, nest within each other (Figure 1.4) (Bronfenbrenner, 2005). The community or the family are located within the levels and connect to one another as social structures. At a community level, public policy is enacted and services important to ordinary daily living are organised and delivered. These features shape the social circumstances within which families operate, and in turn set the context for parenting within families. Effects from policies pass like ripples from the wider community, through parents, directly toward children. Human ecology therefore enables public health practitioners to account for the part context plays and the bidirectional sets of influences that are felt through long- and shortrange relationships with the community and family. Pathways of influence that stem from the relationships children learn to have with others after interacting with their parents reach out to the wider community and vice versa. For example, the stress that parents experience when feeling overwhelmed by children’s behaviour can continue to exert its effects when the parent subsequently interacts with others in the family or even the workplace. At its worst, family stress affects individual performance in wider community environments, placing greater demands on settings—namely, workplaces and schools used by other families. These interactions create macrosystem effects and provide a perspective on how children, parents, family and community fit together interactively. Bronfenbrenner later
Community Family Parent Child
FIGURE 1.4 Ecological systems of influences on adults and children.
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1. Basics of community public health practice: theory and application
describes this theoretical perspective as a bioecological model involving people as ‘active agents’ who operate within ‘responsive environments’ (Bronfenbrenner, 2005, p. 143). Pearce et al. (2019) make particular use of Bronfenbrenner’s ecological framework for human development when expanding arguments about the social determinants of health affecting child inequities and inequalities. They note the complementary features of the bioecological representation of people, families and communities as a nested system (see Figure 1.4), and Dahlgren and Whitehead’s rainbow model (Dahlgren and Whitehead 1991) representing connections between individuals, environments and health (see Figure 1.5). Both models have been used to underpin arguments for action at different levels (represented as layers) of the social system. For the sake of addressing pathways to inequity experienced by children, Pearce et al. (2019) advance arguments for use of both models by combining the key elements of each within a single visual display (Figure 1.5) that highlights pathways of action across social, cultural, political and economic societal structures that connect with the behaviours and experiences of people as individuals and in groups. The combined model gives attention to how the social determinants of health (SDH) are interrelated, vertically and horizontally and when considered through a life course perspective, opportunities for policy action can be pinpointed against time (stages of vulnerability) and junctures where social determinants of health converge. Evidence from a review of health visiting research shows how practice can be oriented in such a way that due account is given to the immediate and long-range contexts of children’s lives. Indeed, when the practitioners are able to attend to the person in their situation (the home or community context), they have a better chance of succeeding in their service offer (Cowley et al., 2013, 2015). Examples of health visitors acting and taking due account of the parental circumstance and the situation for care delivery to address stages
Socio-economic, cultural, commercial, political & physical climate
rt
Living & working conditions
po
ns Tra
We lfa
re
alt h
Emp loy & in ment com e M en ta l he & ph alt ys h ica
care Child
Walk ab
ls
ices
erv al s
s tion
CHILD
Loc
ility
l
He
ing
lifica Qua
h alt urs He vio ha
lace
us
Household resources Fa o & mily ty lc re ali a u i lat stru c q o ion ct g S n Parents & carers i sh ure s u ips Ho Parenting & child health behaviours be
Wor kp
ct
e nn
Ho
Cri me
o ho Sc
&
So
cia lc ar e
Community s ion
FIGURE 1.5 Combined models to illustrate pathways for action on child health. After Pearce et al. (2019).
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Salutogenesis
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of vulnerability commonly experienced by parents include providing assessment and intervention in the home situation when parents are anxious about child development (Wiggins et al., 2004) or when mothers are experiencing early symptoms of postnatal depression (Turner et al., 2010) and attuning to parental doubts, previous experiences and existing resources when supporting first-time and ongoing parental engagement with community services (Kirkpatrick et al., 2007).
A note about health Working in public health requires a wide range of understandings of the meaning of the term ‘health’. It is a key construct, which is often taken for granted but which needs some consideration before moving on to the theory of salutogenesis, which concerns health creation. Anderson (1984) undertook a literature review to clarify the different perspectives, in preparation for the Ottawa Charter for Health Promotion (World Health Organization, 1986). The Ottawa Charter was a seminal document that helped to push back against the perceived supremacy of therapeutic interventions as the only way to improve public health in the third quarter of the 20th century. Anderson (1984) identified that health could be viewed as a product, as potential or as a process (see Box 1.5). Seedhouse (1986) wrote at length about the idea of health as potential, and Cowley (1995) found that health visitors tended to treat health as an ongoing process. These two ideas are explored further later, in examining the two other elements identified as central to the health visiting ‘orientation to practice’: first salutogenesis, then human valuing.
Salutogenesis The term ‘salutogenesis’ literally means ‘health creating’ and it stands in opposition to the more familiar notion of ‘disease-creating’, implied by ‘pathogenesis’. Medical sociologist Aaron Antonovsky grew up in the postwar years surrounded by survivors of the Holocaust. He became fascinated by the need to understand how, despite having experienced such unimaginable horrors, some survivors seemed able to move forward and live positive, healthy lives. This curiosity led him to develop a theory that explained health as a sense of coherence, which is described as the extent to which one has a pervasive, enduring and dynamic feeling of confidence that things will work out as well as can reasonably be expected. The theory is located very closely in the person’s own context, expectations and culture (so draws on ecological thinking), but it incorporates practical and physiological aspects as well. The sense of coherence stems from three global concepts of manageability, meaningfulness and comprehensibility, which are generalised resistance resources that develop from life events and experiences. These enable individuals to cope with whatever stresses they face, and the sense of coherence is indistinguishable from health and wellbeing overall (Antonovsky, 1979, 1987). The sense of coherence is measurable using the SOC Scale, which comes in two forms: one with 13 items and a more detailed one with 29 items. They have been validated cross-culturally and internationally and have been used in more than 20 different countries (Antonovsky, 1993). The idea of manageability refers to the extent to which people feel they have the resources to meet demands that arise in their daily lives. This includes resources that are
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BOX 1.5
Constructions of health
Ways of viewing health (after Anderson, 1984) As an outcome or product—a state or endpoint: • The archetypal (traditional) medical
formulation, in which health is viewed as a ‘product’, bound up with notions of disease and measurable deviations from a biological norm As a potential or capacity—a starting point: • Links health with an ability to cope with,
or adapt to, environmental challenges as well as an ability to realize personal goals and aspirations; health regarded as the ‘foundation for achievement’ (Seedhouse, 1986) As a process: an ongoing, continuous part of life
Definitions of health Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity (World Health Organization, 1946). Health is a resource for everyday life, not the object of living. Health is a positive concept emphasizing social and personal resources as well as physical capabilities (World Health Organization, 1986). Health is the ability to adapt and selfmanage. It consists of three domains of physical, mental and social health; and (for purposes of research and practice) a set of dynamic features and dimensions that can be measured (Huber et al., 2011).
• Relating to optimum physical growth and
body development; it may be cumulative in relation to learning and development, or cyclical in phases of creation and destruction.
under direct individual control or those accessible from family, friends or the community. This may involve having the confidence that they can learn how to manage a new baby, for example, or a young person may feel able to deal with the transition from school to college as they grow into adulthood. Health care professionals may serve as ‘resources’ if they are able to help in practical ways or teach ways of coping. The idea of manageability depends quite closely on people experiencing a practical and physical sense of selfempowerment in coping with their own biology and threats to health. Comprehensibility refers to the extent to which sense and order can be drawn from the situation, and the world seems understandable, ordered, consistent and clear. In translating an exceptional experience into the ‘normal’ context of their everyday lives, people make sense of what is happening to them and can gain strength to deal with the situation. Transitions along the life course may be normal in the sense of occurring to everyone, but they can seem exceptional when met for the first time—so pregnancy, childbirth and
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Salutogenesis
getting used to a new baby in the family can be stressful experiences ameliorated by understanding what to expect and how to deal with the situation. Excellent opportunities for health education arise in such cases; others include developmental challenges such as puberty or menopause, and events such as leaving school, moving house or taking up a new job. The sense of meaningfulness individuals can gain from a situation refers to their ability to participate fully in the processes shaping their future. To be fully engaged in the healthcreating processes of their own lives, people need to ‘make sense’ of events and issues in an emotional as well as a cognitive sense. Sense making may include faith-based understandings as well as coping mechanisms developed in the context of their own family, friends, personal contacts and reasons for living. At the time that Antonovsky was developing his seminal theory about salutogenesis, it was still common for health promotion to rely on an archetypal, pathogenic view of how best to improve health (Antonovsky, 1996), but his theory helped to bring about a paradigm shift. Box 1.6 summarises the key differences between a mindset based on pathogenesis or on salutogenesis.
BOX 1.6
Alternative perspectives on health
Pathogenesis
Salutogenesis
Main focus: • Disorder (i.e. treatment of disease), problems, difficulties, dysfunction
• Order (i.e. sense of coherence, of well-
Concerned with:
• Professional knowledge; medical science
and objective understanding: empirical measurements Prevention involves:
• Identifying risk factors (e.g. of disease,
disability, delayed development); identifying and removing barriers to health
Essentially reactive:
• Looks to the future if it can be scientifically
predicted
Main focus:
being and personal experience) Concerned with:
• Lay knowledge; personal experience
and subjective understanding: human values Prevention involves:
• Creating resources for health (e.g.
caring, trust, autonomy, growth, development); promoting healthy activities such as participation, involvement Essentially proactive:
• Looks at the potential for improving the
future
Individual emphasis:
• Separateness and single focus (e.g. germ
theory of disease, medical prescription, single patient)
Social focus:
• Sociocultural context and integration—
meaningfulness, comprehensibility and manageability
Source: Cowley, 2006
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1. Basics of community public health practice: theory and application
Cowley et al. (2015) found evidence of health visitors’ salutogenic approaches, including being proactive by, for example, making the most of opportunities to share health information (McIntosh and Shute, 2007) or acting on concerns (Barlow et al., 2007); being solution-focused by developing a strategy based on parental needs and goals (Bidmead, 2013) or by investing effort to work with others to provide new community resources (Whittaker and Cowley, 2012) (see also Chapter 15); and promoting resources for health, both personal and situational (in the person’s context or environment) by working closely with individuals and helping connections between community members (Hanafin and Cowley, 2006; Whittaker, 2008). Collectively these types of actions help with raising awareness of opportunities to reduce risks of harm and to promote resilience or resources that can help minimise the impact of stressors. As suggested in Box 1.6, this often means a focus on social context and the process of developing resources (Cowley and Billings, 1999), rather than homing in on a single issue or problem. Of course, focusing on a specific issue may be exactly what is needed in some instance, such as in acute illness, for example. The salutogenic focus on community and individual experiences was illustrated in a study by Cowley and Billings (1999). They interviewed the main carer (mostly mothers) in 50 families with resident children about how they maintained their health, and what helped or hindered. Their analysis illustrated clear examples of the way the parents developed their own resources for health maintenance (things such as learning from experience, being self-aware and using local facilities, such as parks, community centres and so on) and how health professionals could help or hinder. The parents articulated very clearly the importance of accessible, friendly and knowledgeable services, whereas a perceived failure to listen, lack of needed support or unhelpful advice could make what seems like a bad situation worse. Such salutogenic thinking underpins strengths-based approaches to practice.
Strengths-based practice Strengths-based practice is described as a collaborative process between the person supported by services and those supporting them, allowing them to work together to determine an outcome that draws on the person’s strengths and assets. As such, it concerns itself principally with the quality of the relationship that develops between those providing and those being supported, as well as the elements that the person seeking support brings to the process. Working in a collaborative way promotes the opportunity for individuals to be coproducers of services and support rather than solely consumers of those services (Social Care Institute for Excellence, 2015; also see Chapter 4). The Care Act 2014 places a duty on local government to promote individual wellbeing for those in need of care and support, which the Department of Health and Social Care (2019) suggests creates a fundamental link to strengths-based practice. They identify nine areas of wellbeing, which help to demonstrate the breadth of the concept and once more illustrates the social basis of salutogenesis: • • • •
Social and economic wellbeing Personal dignity Physical, mental and emotional health Protection from abuse and neglect
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• • • • •
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Domestic, family and personal relationships Personal control Individual contribution to society Suitability of living arrangements Work, education, training and recreation
The significance of personal and community-based resources can be explained by theories of social capital.
Social capital Social capital is a complex concept, with several different theoretical roots, summarised in Box 1.7, which each emphasize different aspects, such as relationships, trust, social networks and community participation. The emphasis on producing resources makes a close link between social capital and Antonovsky’s salutogenic theory, described earlier, which
BOX 1.7
Social capital
Theorist
Key features
James Coleman (1988) Interested in drawing together sociological and economic perspectives to explain social actions.
Social capital is seen as one part of human capital. It is defined by its productive function. It generates resources through relationships.
Pierre Bourdieu (1997) Social capital is part of a wider theory, encompassing a range of different forms of capital, including economic, symbolic, social and cultural capital.
Social capital encompasses a range of actual and potential resources A person might accumulate and use it in social relationships. It may be derived from being the member of a group or network. Communitarian outlook; locality, neighbourhood and community feature more highly than relationships and networks. Norms of reciprocity and networks of civic engagement become embedded and enacted through ‘moral resources’ such as trust and cooperation. These are generated across the whole social system, not only by individuals.
Robert Putnam (1993, 2000) Political scientist who sought an explanation for perceived decline in neighbourly activities and civic engagement.
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1. Basics of community public health practice: theory and application
similarly emphasises the general ‘resources’ of manageability, meaningfulness and comprehensibility. The ownership of capital is considered an advantage, and social capital may be viewed as the advantage gained by an individual or a group of individuals (such as a community) as a result of being part of a social network (Hean et al., 2003). As well as networks, resources such as trust and support, norms of cooperation, reciprocity, participation and solidarity with community members are also considered central to the idea of social capital (Putnam 1993). Putnam (2000) used the term ‘bonding social capital’ to describe the close bonds that form among friends, family or members of the same church or social group, meaning it functions as a form of ‘social glue’. The looser, cross-cutting ties between work colleagues or acquaintances in the neighbourhood act as ‘bridging social capital’, which is likened to the ‘social oil’ that lubricates social relationships amongst newcomers or anyone with a different outlook to those in the close-knit, bonded group. The presence of both forms of social capital is necessary; a closely bonded group is essential for social support and to provide a solid base for society, but it could lead to introspection and suspicion of new ideas or people, which is avoided by the existence of bridging social capital. A third aspect, called ‘linking social capital’ was proposed by Szreter and Woolcock (2004, p. 655), as ‘norms of respect and networks of trusting relationships between people who are interacting across explicit, formal or institutionalized power or authority gradients in society’. This encompasses the role of professionals in potentially promoting and supporting the development of social capital. Given the different power structures, it is also possible that the authorities might (inadvertently or not) cut across or undermine neighbourhood support systems, sometimes damaging existing social networks and resources. Szreter and Woolcock (2004) propose that theories of social capital may emphasise different aspects, such a focus on the primacy of support networks or an emphasis on economic and social inequality, or to argue that access to resources explains health outcomes. Uphoff et al. (2013) clarified the psychosocial pathway through which social capital and socioeconomic inequalities affect health and health inequalities. They suggest that the concept of social capital captures both a buffer function of the social environment on health and the potentially negative effects arising from social inequality and exclusion. Social capital can create a more positive society or—by promoting social exclusion—can be a negative force. Social capital should thus be built not only from the bottom up (though both bridging and bonding capital) but also facilitated from the top down, which particularly requires linking capital. Community public health workers can help with this facilitation process through groups and advocacy support.
Person centredness and human valuing Building capital in the form of resources for health that are both personal and situational as illustrated by Cowley and Billings (1999) requires service offers and responses that communicate human valuing—that is, a positive regard for others based on the value of all human life. Human valuing is the third aspect of the orientation to practice for health visitors detailed in the comprehensive Why Health Visiting review (Cowley et al., 2013). Evidence for this comes from research showing how optimal service provision
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Person centredness and human valuing
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involves health visitors keeping the needs of the person or family ‘in mind’ (Cowley et al., 2015). Demonstrating value and a positive regard was felt by those using the service when the health visitor shifts their focus to align with parents’ needs (Appleton & Cowley, 2008; Turner et al., 2010); paces practice (waiting for the right time to ask a question) to accommodate an unmet need, that would otherwise be missed (Wilson et al., 2008); or seeks to build on a person’s strengths by inviting them to share their existing knowledge, enabling it to be properly acknowledged and used as a basis for moving forward (Kirkpatrick et al., 2007; Puura et al., 2005). The human valuing elements just outlined (tailoring practice by shifting its focus and pace and seeking strengths to enable a person to fulfil their potential) are consistent with a Rogerian person-centred approach (explained further later), applicable to all care situations where the goal is development or growth of a person (Rogers, 1980). Specific application of the person-centred approach has been made as part of a cluster randomised controlled trial testing health visiting provision for women experiencing postnatal depression (Morrell et al., 2009). The trial was the largest test of a health visitor intervention ever completed, where participating health visitors had received additional training in cognitive behavioural and person-centred approaches (Morrell et al., 2011). Positive effects were found, with women in the intervention group achieving greater reductions in postnatal depression scores than those in the control group (Morrell et al., 2009). The results, including a further economic analysis of the impacts of practice (Henderson et al., 2018) lend support for investing in training health visitors in additional psychological interventions, either during initial role preparation before qualification or after qualification (Morrell et al., 2011). Person-centredness has its roots in psychotherapy and the earlier work of psychologist Carl Rogers (19021987), who in the 1950s wrote about how a therapist might engage with a client in a non-directive, client-focused (as opposed to therapist-focused) way that acknowledged the potential of the person to self-direct and reach their own sense of fulfilment. Reflecting on a lifetime of work, Rogers (1980) expresses his thinking as an approach which is firmly based on the assumption that people have within themselves resources for self-understanding, for shifting their self-concept and for self-directing their behaviour. However, realising these resources, or tapping into them, requires circumstances that offer facilitative psychological attitudes that foster growth. Practitioners working in helping relationships can seek to foster a positive climate and to tap into the potential of the person being helped by using a ‘person-centred approach’ (Rogers, 1980). This has three essential elements expressed as attitudes of genuineness, acceptance and empathy; these are outlined in brief in later text and are also discussed as qualities of partnership working in Chapter 7. • Communicating genuineness, realness or congruence requires the practitioner to behave as true to herself or himself as possible, avoiding a professional front. The practitioner’s transparency means that the client can see what the practitioner is in the relationship. This ‘realness’ communicates honesty and opens opportunity for growth in the client and for the practitioner that there is congruence between what they experience, are aware of and what if appropriate, can be expressed. • Demonstrating acceptance, caring or prizing is identified by Rogers as important to facilitate change in another and is also described as providing a positive regard for the
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other person. To indicate ‘caring’, the practitioner accepts the other person, their experience and the feelings invoked in the moment. By verbally acknowledging what the person has expressed, the practitioner can ‘prize’ the other person’s contribution and thus give value to the experience of others. • Demonstrating an empathetic understanding complements the aforementioned attitudes. The practitioner is engaged in active, attentive listening to accurately sense the feelings of the other person and attune to their experience. In communicating an accurate understanding of the present experience, the practitioner provides the other person with space to recognise or connect with their own experience and grow in their awareness of its impact on feelings. When combined with ‘being real’ and accepting of the other person, empathy allows the practitioner to confirm the value of the person and all that they are. This, Rogers explains, is a potent source of growth, enabling the person to prize themself, their contribution and recognise their own value (Rogers, 1980). As noted earlier, the person-centred approach has relevance to various human encounters operating as part of a helping relationship. The approach is not restricted to psychotherapeutic counselling, and evidence for the wider application of the core tenets of person-centred thinking can be found in adult education (Heim, 2012; Bryan et al., 2015) and health care (Christie et al., 2012) as well as in general discussion about management of workplace relations (Shefer et al., 2018). An enduring feature of Rogers’ original theory is communicating positive regard (value and respect) for others and is now a critical feature of current health care guides for care processes and the human interactions between staff and patients (The Health Foundation 2014; Health Education England, Skills for Health and Skills for Care, 2017). In nursing, developments include the person-centred practice framework (McCormack and McCance, 2010), which has been considered within different hospital nursing care contexts (Laird et al., 2015; McConnell et al., 2016; Slater et al., 2017). More broadly the notion of personcentred care is espoused (The Health Foundation, 2014), though also critiqued, by others (McCormack et al., 2015), noting a limited focus on the practice of care to the detriment of attention on culture and thereby the context of care supported by the organisation. Arguably ecological principles (as expressed earlier in this chapter) would dictate that behaviours learned and experienced at one level of the service system (employing organisation) will have an impact at other levels of the service system (community setting or family home) as people move and interact. Thus fostering a care orientation of personcentredness requires practitioners to have the opportunity to experience personcentredness for themselves. Of note, for health visitors and other public health practitioners, working in the ‘first 1000 days’ period is the compatibility of arguments for investment in a person-centred culture with those made by the WHO (2018) for staff to be recipients of nurturing care which enables people to survive, thrive and transform (see Chapter 8). That is, by shaping the organisational context where practitioners are exposed to conditions to engage in prosocial interactions (survive) opportunities for learning (thrive) and enabled to build on existing strengths to affect positive change (transform), ecological principles would dictate that they will be better placed to facilitate a similar climate whilst helping families.
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Discussion Questions
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Conclusion The two parts of this chapter provide a critical review of some core theories and concepts that are ‘part and parcel’ of either the landscape of public health practice or the delivery of public health practitioner roles. The first section considers the breadth of the field of practice, showing how human health is inextricably connected to a wide number of issues at a global scale. The UN sustainable development goals set out the key areas of interest for sustaining a healthy planet and hence, for sustaining human life. This includes the environment and concern for factors impacting on conditions for living, such as poverty and access to sufficient food, as well as politics and its influence on systems of education and health services. Addressing poverty and those aspects of life that aggravate the experience of poverty, such as the presence of illness or disease, environmental disaster or unequal distribution of community resources, is critical for combatting inequalities in health and shifting the social gradient. The orientation to practice outlined in the second half of the chapter is values-based and theory-driven. It was identified through a scoping study of health visiting research literature (Cowley et al., 2013), which provides a defining form of practice for that profession, but the underpinning theories are not discipline-specific. These theories provide a basis for practice premised on the assumption that people possess the potential to grow, discover and implement solutions to the challenges that arise in life and thereby act to create good health. This outlook accepts that there exist layers of society and that circumstances within which people find themselves can activate human potential. Equally, human behaviour can shape their circumstances. Ecological principles explain how behaviours and political events at different levels of society affect the lives of individuals, families and communities. Community public health practitioners work to assess needs and human potential whilst taking into account the person’s existing circumstances, made possible by interacting with people either in the home or community. They have the capacity to work across these layers, investing in relationships that communicate value for the person, their life and contribution to their own health and that of others, thus providing a specific and valuable route to improving the public’s health.
Discussion Questions • Thinking about human ecology, consider how the setting in which children grow up affects their later chances in life (health inequalities and social gradient). • What different examples of health creating (salutogenic) activities can shape the public health experience of a community? • How can services communicate messages of human valuing to individuals, families and communities? What difference does it make to their health? • What activities can public health practitioners contribute to enhancing social capital? • How can health inequalities be addressed across a community when some people are seldom heard?
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Kirkpatrick, S., Barlow, J., Stewart-Brown, S., Davis, H., 2007. Working in partnership: user perceptions of intensive home visiting. Child. Abuse Rev. 16 (1), 3246. Laird, E.A., McCance, T., McCormack, B., Gribben, B., 2015. Patients’ experiences of in-hospital care when nursing staff were engaged in a practice development programme to promote person-centredness: a narrative analysis study. Int. J. Nurs. Stud. 52 (9), 14541462. Maggi, S., Irwin, L.J., Siddiqi, A., Hertzman, C., 2010. The social determinants of early child development: an overview. J. Paediatr. Child. Health 46, 627635. Marmot, M.G., 2004. The Status Syndrome. Bloomsbury, London. Marmot, M., 2015. The Health Gap: The Challenge of an Unequal World. Bloomsbury, London. Marmot, M. 2019. The Marmot Review 10 years on ,https://www.health.org.uk/news-and-comment/blogs/themarmot-review-10-years-on. (accessed12.10.19). Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., et al., 2010. Fair Society, Healthy Lives: The Marmot Review. Strategic Review of Health Inequalities in England Post-2010. Marmot Review, London. Available at: , http://www.instituteofhealthequity.org/about-us/the-institute-of-health-equity/our-current-work/ collaborating-with-the-health-foundation . . Marmot, M., Allen, J., Boyce, T., Goldblatt, P., Morrison, J., 2020. Health Equity in England: The Marmot Review 10 Years On. Institute of Health Equity, London. Available at: , http://www.instituteofhealthequity.org/ about-us/the-institute-of-health-equity/our-current-work/collaborating-with-the-health-foundation . . McConnell, D., McCance, T., Melby, V., 2016. Exploring person-centredness in emergency departments: a literature review. Int. Emerg. Nurs. 26, 3846. McCormack, B., Borg, M., Cardiff, S., Dewing, J., Jacobs, G., Janes, N., et al., 2015. Person-centredness—the ‘state’ of the art. FoNS 2015 Int. Pract. Dev. J. 5 (Supp l), 115. Available from: https://doi.org/10.19043/ ipdj.5SP.003 (accessed 16/03/2020). McCormack, B., McCance, T., 2010. Person-Centred Nursing: Theory and Practice. Wiley Blackwell, Oxford. McKeown, T., 1976. The Role of Modern Medicine: Dream, Mirage or Nemesis. The Nuffield Provincial Hospitals Trust, London, ,https://www.jstor.org/stable/3349533?seq51#page_scan_tab_contents. (accessed 22/03/2020). McIntosh, J., Shute, J., 2007. The process of health visiting and its contribution to parental support in the Starting Well demonstration project. Health Soc. Care Community 15 (1), 7785. Morrell, C.J., Slade, P., Warner, R., Paley, G., Dixon, S., Walters, S.J., et al., 2009. Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: pragmatic cluster randomised trial in primary care. Br. Med. J. 338. Morrell, C.J., Ricketts, T., Tudor, K., Williams, C., Curran, J., Barkham, M., 2011. Training health visitors in cognitive behavioural and person-centred approaches for depression in postnatal women as part of a cluster randomised trial and economic evaluation in primary care: the PoNDER trial. Prim. Health Care Res. Dev. 12 (1), 1120. Ministry of Housing, Communities and Local Government, 2019. The English Indices of Multiple Deprivation 2019—Statistical Release. Ministry of Housing, Communities and Local Government, London, ,https://www. gov.uk/government/statistics/english-indices-of-deprivation-2019. (accessed 08.10.19). Morley, I., 2007. City chaos, contagion, Chadwick, and social justice. Yale J. Biol. Med. 80 (2), 6172. National Scientific Council on the Developing Child, 2018. Understanding motivation: building the brain architecture that supports learning, health, and community participation. Working paper no. 14. ,www.developingchild.harvard.edu. (accessed 22/03/2020). NHS Digital, 2019. National Child Measurement Programme, School year 2018/2019. ,https://digital.nhs.uk/ data-and-information/publications/statistical/national-child-measurement-programme/2018-19-school-year. (accessed 22.10.19). Nutbeam, D., Levin-Zamir, D., Rowlands, G., 2018. Health literacy and health promotion in context. Glob. Health Promot. 25 (4), 35. Office for National Statistics, 2019. Child and infant mortality in England and Wales: 2017. ,https://www.ons. gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/2017#infant-mortality-rates-were-highest-in-the-most-deprived-areasin-england-in-2017. (accessed 07.10.20). OECD, 2019. Health for everyone? Social inequalities in health and health systems. OECD Health Policy Studies. OECD Publishing, Paris.
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Wiggins, M., Oakley, A., Roberts, I., Turner, H., Rajan, L., Austerberry, H., et al., 2004. The social support and family health study: a randomised controlled trial and economic evaluation of two alternative forms of postnatal support for mothers living in disadvantaged inner-city areas. Health Technol. Assess. 8 (32), iii, ixx, 1120. Wilkinson, 1996. Unhealthy Societies: Afflictions of Inequality. Routledge, London. Wilkinson, R., 2006. The impact of inequality; the empirical evidence. Renewal 14 (1), 2026. Wilkinson, R., Pickett, K., 2010. The Spirit Level: Why Equality is Better for Everyone. Penguin Books, London. Wilson, P., Barbour, R.S., Graham, C., Currie, M., et al., 2008. Health visitors’ assessments of parentchild relationships: a focus group study. Int. J. Nurs. Stud. 45 (8), 11371147. World Health Organization, 1946. Constitution. WHO, Geneva, ,https://www.who.int/governance/eb/who_ constitution_en.pdf. (accessed 25.10.19). World Health Organization, 1986. Ottawa Charter for Health Promotion. WHO, Ontario, Canada, ,https:// www.who.int/healthpromotion/conferences/previous/ottawa/en/. (accessed 25.10.19). World Health Organization, 1998. Health Promotion Glossary. WHO, Geneva. World Health Organization 2019 Healthy, prosperous lives for all: the European Health Equity Status Report. ,http://www.euro.who.int/en/publications/abstracts/health-equity-status-report-2019. (accessed 18.10.19). World Health Organization, United Nations Children’s Fund, World Bank, 2018. Nurturing Care for Early Childhood Development: A Framework for Helping Children Survive and Thrive to Transform Health and Human Potential. World Health Organization, Geneva, Licence: CC BY-NC-SA 3.0 IGO.
Resources A series of 8 evidence reviews and 14 short briefing papers, designed for local authorities and others with a responsibility for health and wellbeing. Available at: https://www.gov.uk/government/publications/local-action-on-healthinequalities-evidence-papers (accessed 02/05/2020). Institute of Health Equity, University College London, led by Professor Sir Michael Marmot, has a wealth of resources about health inequalities. Available at: http://www.instituteofhealthequity.org/home (accessed 02/05/2020). The Health Foundation, 2018. What Makes Us Healthy? An Introduction to the Social Determinants of Health. The Health Foundation, London. Available at: https://www.health.org.uk/publications/what-makes-us-healthy (accessed 02/05/2020). Department of Health and Social Care, 2019. Strengths-Based Practice. DHSC, London. A guide intended for social workers working with adults; it is equally applicable to other professionals and client age groups. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/778134/stengths-basedapproach-practice-framework-and-handbook.pdf (accessed 02/05/2020). This range of resources about strengths-based practice was stimulated by the Care Act 2014, but it is comprehensive and covers all ages and groups of service users. Available at: https://www.scie.org.uk/strengths-based-approaches (accessed 02/05/2020). Cowley, S., 2009. Social capital and health. In: Watkins, D., Cousins, J. (Eds.), Public Health and Community Health Nursing—Frameworks for Practice, 3rd edition Baillie`re Tindall/Elsevier, London, pp. 6779. Explains the links between social capital, health and health inequality, along with some of the complex criticisms and benefits of the theory. Includes examples to show how the concept is useful to explain work in health visiting and children’s centres.
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C H A P T E R
2 Public health practice within communities Clare Jackson KEY ISSUES • Working with communities: history and background • The current UK Public Health context
• Defining a ‘community’ in Public Health • Models and approaches for communitycentred public health practice
Introduction This chapter provides an introduction to community-centred public health practice. Community-centred approaches, a key tool to address health inequalities and the social determinants of health, have a long and varying history in a range of different disciplines. This chapter explores the current public health context and why public health with communities is more relevant than ever in addressing the challenges to population health. An insight into models for application to practice with a focus on child and family public health is also provided.
Working with communities: history and background Community-centred approaches: origins and influences Community-centred approaches have emerged as a family of community-level public health interventions in response to a dynamic and evolving public health system in the UK. The popularity of community development approaches in health during the 1980s
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and 1990s in the United Kingdom (UK) built on early social movements in the 1960s and 1970s, including civil rights, black power, the women’s movement and the self-help movement. Initially to address the wider determinants of health (Dahlgren and Whitehead, 1991) (although perhaps not recognised as such at the time), including housing and social policy, community development principles were first used specifically in health projects in the UK in the late 1970s. Founded on the principles of emergent social movements (justice, freedom, democracy and the end of discrimination, especially towards women, black people and the poor), community development for health was intended to level the power imbalance of ‘health care professionals’ over people through recognising individual experiences of health being of equal importance as scientific medical knowledge. Further, The Black Report (Townsend and Davidson, 1982) outlined that the most disadvantaged members of society experience the poorest health outcomes, but that social movements have the greatest potential impact on these groups. Community development offered a mechanism for professionals to work with these groups, who hold within them solutions to their own health, to reduce health inequalities and improve the health of the most vulnerable in society. Participation in health has been continuously advocated in policy since the Alma Ata Declaration of 1978, which states that ‘the people have a right and a duty to participate individually and collectively in the planning and implementation of their care’ (World Health Organization (WHO), 1978). More recently, Healthy Lives, Healthy People (Department of Health, 2010), the Localism Act 2011 (HM Government, 2011) and the Health and Social Care Act 2012 (Department of Health, 2012) have all legislated for or provided policy in the UK to support the requirement of participation of citizens in health decision making, including decisions about service provision and local health needs. Contemporary public health evidence in the UK has been pointing towards community development as one of a number of community-centred approaches for community health improvement and the narrowing of health inequalities. There are growing understanding and acceptance of the diversity of communities and structures within which they sit, which means that a range of approaches are now needed. Community development has a strong place within these approaches, but other solutions including assetbased methods, community-based participatory research and peer interventions are also recognised as offering a solution in some of the most deprived communities (Public Health England and National Health Service [NHS] England, 2015). There is acknowledgement that the needs of communities and the assets for health within them vary greatly, and that a suite of evidence-based tools for working with communities offers the greatest opportunities for positive change (Public Health England [PHE] and NHS England, 2015; PHE, 2018).
Why work with communities in public health? Public health is defined as ‘the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society’ (Acheson, 1988). Public health practice has long been rooted in values of equity, fairness and striving for achievement of optimal health and wellbeing for all, not merely the absence of disease (WHO,
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2006). Communities are integral parts of, and mechanisms for, the ‘organized efforts of society’, and there is a strong statutory and policy direction for doing things ‘with’ people rather than ‘to’ them (Department of Health, 2012; HM Government, 2011; Department of Health, 2010). This chapter later discusses the challenges and opportunities in 21st-century health and social care systems and the solutions that working with communities, as integral parts of this system, offer. There are a number of key benefits to community development and engagement work, which have both direct and indirect impacts on health and wellbeing (WHO, 2002), as follows: • Increasing democracy, recognising the fundamental human right and role in wellbeing • Combating social exclusion, especially in marginalised and disadvantaged populations • Empowering individuals and communities through the processes of participation to enhance sense of wellbeing and quality of life • Mobilising community resources and energy to develop and maximise community assets • Developing integrated and holistic approaches through real-life understanding of the local realities for health and wellbeing • Aiding decision making and designing more creative and, ultimately, effective services through local knowledge and experience • Ensuring community ownership and sustainability of programmes for the long term The potential resulting benefits to population health and wellbeing of successful community-centred practice include the narrowing of heath inequalities (Marmot et al., 2010, 2020; Garces-Ozanne et al., 2016), engaging with those most adversely affected by structural inequalities through hearing the voices of the most disadvantaged, thereby increasing access to a range of health promoting services. Further, in a time of great austerity and resource challenge (more about this later), community assets, both physical and skills-based, can be harnessed through community-centred practice to improve population health with the population themselves (Morgan and Ziglio, 2007) without exaggerating or promoting stigmas which exist in a health deficit model. Empowerment and social change models within communities have been demonstrated to have greater impact on public health than individual, lifestyle, education and behaviour change interventions (Lindacher et al., 2018).
The current UK public health context Legislation, health and social care reform and public health commissioning The context within which public health in England now sits has shifted dramatically since the implementation of the Health and Social Care Act 2012 (Department of Health, 2012), separating commissioning of health services across a number of different bodies, including newly formed Clinical Commissioning Groups, NHS England Specialised
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Commissioning and, perhaps most importantly for public health, local government. The ring-fenced Public Health Grant to local authorities is the financial mechanism to support the statutory functions expected under the act (Department of Health, 2012), including a number of health services (National Child Measurement Programme, NHS Health Checks, sexual health services), public health advice to Clinical Commissioning Groups and some health protection responsibilities (Department of Health, 2012; Public Health England and the Association of Directors of Public Health, 2016). Of course, the ring-fenced grant is used much more widely than for the mandated, statutory services outlined earlier, as part of the local authority requirement to deliver wider public health functions (Public Health England and the Association of Directors of Public Health, 2016; Department of Health, 2012). As a result of reforms (Department of Health, 2012), school nursing commissioning was transferred to local authority public health teams on 1 April 2013, with health visitor commissioning transferring from NHS England to local authority at the later date of 1 October 2015, following the end of the health visitor implementation plan (Department of Health, 2011). There are a number of benefits and challenges to the placement of public health in local authorities, which are further discussed later in this chapter, including the opportunities for community-focussed public health practice. However, despite the NHS Five Year Forward View in 2014 (NHS, 2014) calling for a ‘radical upgrade in prevention and public health’, annual reductions in the local government public health grant (Department of Health, 2017, 2018) mean that it has never been more imperative for public health practitioners to use the evidence of ‘what works’ to improve public health in the most costeffective manner, working in partnership across the health and social care system. But it is important to retain our focus on the wider determinants of health (Dahlgren and Whitehead, 1991) and health inequalities, especially in a climate where individual responsibility for ‘lifestyle choices’ and secondary prevention (Naidoo and Wills, 2016) through the NHS are the focus of solutions to public health challenges, as set out in the NHS Long Term Plan (NHS, 2019). Community development offers such great opportunity for primary prevention (Naidoo and Wills, 2016) and is perhaps one of the most promising opportunities arising from the 2012 reforms and the move of public health back to local government.
Models for modern public health nursing delivery in communities The English 4-5-6 model of health visiting and school nursing (PHE, 2018b) established the public health service delivery model for child and family health in line with the progressive universalism approach developed by Marmot (Marmot et al., 2010) in his review of health inequalities, Fair Society, Healthy Lives. The Marmot Review 10 Years On (Marmot et al., 2020) re-emphasizes the importance of this approach. The ‘4’ of this model sets out the four levels of service delivery; ‘community’, ‘universal’, ‘universal plus’ and ‘universal partnership plus’. Despite the challenges of safeguarding and targeted caseloads for community practitioners (Children’s Commissioner for England, 2016), the public health evidence base clearly demonstrates that the greatest population health gains arise from universal and population-level strategies (Rose, 1985), with this approach also benefitting from reducing health inequalities substantially if delivered successfully and over long periods (Figure 2.1). Community development and community-focussed practice provide tools for whole population health improvement.
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Local levers and mechanisms for public health delivery in communities
The Bell Curve Shift in Populations Shifting the whole population into a lower risk category benefits more individuals than shifting high-risk individuals into a lower risk category
% of Population
Population approach: encourage everyone to change, shifting the entire distribution
Risk reduction approach: Move high-risk individuals into normal range
“Low”
“Normal” Level of risk
“High”
FIGURE 2.1 The bell curve shift in populations. Source: From https://bsahely.com/2018/05/08/sick-individuals-andsick-populations-by-geoffrey-rose/
Local levers and mechanisms for public health delivery in communities There are a number of local mechanisms created through the 2012 health reforms (Department of Health, 2012) through which practitioners and their organisations can lever influence and change, including the creation of Health and Wellbeing Boards in England (Department of Health, 2012) and Regional Partnership Boards in Wales (Welsh Government, 2018). Further, the planned update to the Children and Young People (Scotland) Act 2014 will offer opportunities for influence. Every local authority in England has a statutory duty to have a Health and Wellbeing Board, with the main aim of the board being the promotion of greater integration and partnership between the local authority, NHS and other local partners. The board has a statutory duty to produce a joint strategic needs assessment and a joint health and wellbeing strategy (Department of Health, 2012). Elected members are now, in general, well invested in their public health responsibilities (Local Government Association, 2017), and are influential figures in local communities who are held accountable for achievements and failures, including in public health. Building relationships with elected members for health and specific ward areas can provide practitioners invaluable links into those communities. This can help support the building of community level trust, lever financial and other resources from small ward-level funding streams and enhance integration with other community services, especially those which address the wider determinants of health (Figure 2.2). Further, acknowledgement and
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2. Public health practice within communities
Work environment
Water and sanitation
s
I
Education
Unemployment
d community net wo l an a i rk c s al lifestyle fa So u d cto i v i r d n
Dahlgen and Whitehead (1991), Social determinants of health.
s ion dit on
Ge ne ra l
FIGURE 2.2
ltural and env ic, cu iron om me n co nta e Living and working o i lc c conditions o s
Health care services Agriculture and food production
Age, sex and constitutional factors
Housing
celebration of community development successes for population health are likely to be heightened with elected member involvement.
Opportunities for integrated public health work in communities The role of the local authority public health team is to serve as both service commissioner and local area lead for public health strategy and policy. Undoubtedly, the role of commissioner has the potential to create unnecessary boundaries between the public health team and provider organisations and the practitioners within them, with the common misconception that the commissioner’s primary role is to critique and penalise provider services. Community engagement is at the heart of local government ethos, and practitioners should lean on the resource of the local public health team for public health knowledge and intelligence, support with partnerships across the local authority to address wider determinants of health and facilitation of relationships with elected members, amongst many other things that the team can offer. The new world of public health after 2012 reforms (Department of Health, 2012) offers, more than ever, the opportunity for integration, partnership and joined-up working for public health. This goes a step further when local communities are placed within the wider system of sustainability and transformation programmes and new models of accountable care organisations (The King’s Fund, 2018). For individual practitioners, school nurses and health visitors, these huge systems of change for health and social care have the potential to seem far too ‘macro’ to be relevant for community development and population heath interventions within locality areas. However, with these new models of integration follow great opportunities for innovative ways of locality working, extra resources for the facilitation of change, and committed leadership with transparent local plans for transformation. Engagement and consultation with local people is central to sustainability and transformation planning, and front-line practitioners undertaking community development need to be aware of the wider health and social care environment to avoid mixed messages to local people, ensure joined-up locality thinking Community public health in policy and practice
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Local levers and mechanisms for public health delivery in communities
and focus on the key agreed priorities to secure maximum local support. Public health practitioners undertaking community-centred public health approaches need to not only maximise opportunities and assets within the community of focus, but also reach out to the wider public health opportunities to achieve maximum success (Figure 2.3).
inants of health and w eterm ellb d l ein ia c o g c o E s l y es a s t b e o m l h G T l Environment Natura vironment Built En
Activities
•
ra
ce
vic
n tr
t
bs
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g
er
ity
• Age • Sex • Hereditary factors es
• Sh
elt e r e d h o u si n g
•
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op
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•S al oc ai •L r •T gi te
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en pm d o l and m e ar en dev clu b s dw t •B o • S por ts um o •P ns us urh ol o o a b tre r i h i s C s h pl a n s • N eig ne • en ss c • •P g ra Pe ing ay nts hy rket de s •D sic d • Tourism • Ma ar l s al a tria ie n m ctiv isio gf s nz ity pr prov yin on y a a l l o m P • • o p ti o n es All •C and otm • Pla lim arks y street P • ent ate V s • CCT s ch ture • Co ang ricul o n b s r e A r • vation officers es trate gies
•S
Li br ls a ia r c oc ie s So i un a • l g m • L c o e i e oh s ure c e ntre s ve om e si en ni rn •C on n m eg g e • A r e a c o m m itt e e s c d nt •R sc ho job an he s u g es m lth c s i a a v • in e r C e n s o m g m a i s sio nin g s e •H • Be es •B sm s nefi ac u ay sse t p i a s l p a w d s d s v u i c B i h e • n g n g i e c ontr •H els op o l d an n • ealth •A E h l a n a v t i n r o e n m rp i r q ries ola u e t a e li t rs y m o nitoring • Parks, cem s fo ant • Gr
en s er a dv s ic e C ar p a rk ing
conomy Local E Community Lifestyle
el ev d y
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tio es t n it sa n en • Yo mu fe m m ho o u p • t h gr o u p s • C ty Tra em lo sc e v d • ing en ed de •A sta n d nd m ic s t du o n e f a o t e c r d E s • x lt c •C •S ut om •E try ro pe n •W m on s e l u l u o nity le ed o r se yc arning • Scho as lim nt rva •C •C its te co s tio e t • c t dis a Street n na en lighting • Play sp po me rea sa pm lop s e o l v l e e • Bio d diversity • Sustainable •R dev ecy and cling g n ni • Home ins lation • Plan u H
ow nce loca fere f i l gov d ernment can make a
FIGURE 2.3 The social determinants of health and wellbeing. How local government can make a difference. Source: From Campbell (2010).
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Defining a ‘community’ in public health The English Oxford Dictionary provides several different definitions for a community (Oxford English Dictionary, 2019): • ‘A group of people living in the same place or having a particular characteristic in common’ • ‘The condition of sharing or having certain attitudes and interests in common’ • ‘A group of interdependent plants or animals growing or living together in natural conditions or occupying a specified habitat’
Concepts, theories and critiques On the surface, the concepts of community work, community development and community interventions feel familiar to public health practitioners, especially those whose work is grounded and based within ‘communities’. Yet, as a sociological construct, ‘community’ is much more debated and conceptualised (Barrett, 2015). On the one hand is the idea of geography: place (Marshall, 1998); community is socially constructed in a particular setting or location (Walmsley, 2006). This idea is countered with the suggestion that interactions and relationships are the founding elements of a community (Day and Murdoch, 1993), with some going as far as to suggest that commonality of location or place is irrelevant to the success of a community, as demonstrated by social networks online (Wellman, 2001).
Innovation and wider thinking about ‘community’ for public health practitioners In practice, community development in public health most commonly occurs in geographical or location-based populations. Published epidemiological data supporting health needs assessment, the practical and geographical organisation of community public health services and the current geographical health and social care system discussed earlier in this chapter mean that the community level (PHE, 2018b) of health visitor and school nursing practice is often an urban neighbourhood or rural village. This chapter does not suggest that these traditional, locality-based community development approaches are no longer relevant or beneficial to health. Rather, the intent is to encourage practitioners to be mindful of the other potential communities within which they can use community development approaches. Practitioners should embrace the opportunity to identify the health needs of relevant and diverse types of community, applying traditional community development approaches in a changing health and social care system.
Healthy settings as opportunities for community action to address wider determinants of health Public health at the community level should consider all levels of the determinants of health (Dahlgren and Whitehead, 1991). Whilst individual or community lifestyle and
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health-related behaviour change can sometimes seem the most natural focus of practice for public health practitioners, it is important to consider that there are also powerful opportunities available through community development work to address the environments and social worlds within which children and families live (Naidoo and Wills, 2016). Healthy settings approaches focus on the theory that ‘Health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love’ (WHO, 1986). The aim of a healthy setting is to create an environment where health can be maximised and healthy choices become default (Dooris, 2005). In a manner similar to the challenge of defining community as already discussed, ‘settings’ can be interpreted in a number of ways. The WHO suggests that a setting is a place where the environment is used and shaped by those in it, and three principles are generally satisfied: physical boundaries, people with defined roles and organisational structure (WHO, 2019). For health visitors and school nurses, the healthy settings approaches might be most useful in geographical communities, early years settings, schools and colleges, youth centres, NHS clinics and any other setting within which the community lives, works or plays. A ‘whole-setting’ approach to population health should include partnership working with the people who shape the setting (the population and professionals), recognising the public health leadership skills of public health practitioners (Yphantides et al., 2015; PHE, 2019) and using these to shape and develop the activities, policies and environment within the setting of opportunity, based on identified health needs.
Models and approaches for community-centred public health practice Key concepts for community-centred public health Participation It is important that in working with communities, participation by that community is maximised to the benefit of health. Participation and power are important concepts when working with marginalised communities; power can impact greatly on the ability of individuals and communities to achieve optimal health status. It has been suggested that there are three levels of power: the visible manifestations of power, the unseen but tangible manifestations of power and internalised powerlessness (Lukes, 1974). It is often the most marginalised or deprived groups who find themselves experiencing internalised powerlessness, leading to low levels of health motivation; attempts to engage these groups in community-centred approaches can increase the uptake of services, including those which impact on the wider determinants of health. To rebalance the power differences with communities, participants need to fully appreciate how power is shifted. The lower rungs of Arnstein’s (1969) ladder of participation (see Figure 2.4) demonstrate some types of participation which practitioners can fall into when time and resources are short. Unfortunately, participation on the lower rungs of the ladder can further marginalise and disempower communities, leaving them feeling more powerless than before what started as a wellintended participatory scheme. However, when applying this theory in practice, it is important to acknowledge that whilst power shifts to citizens higher up the ladder, there will undoubtedly be individuals
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FIGURE 2.4 8
Citizen Control
7
Delegated Power
6
Partnership
5
Placation
4
Consultation
3
Informing
2
Therapy
Ladder of participation. Source:
Arnstein (1969).
Citizen Power
Tokenism
Nonparticipation 1
Manipulation
or groups who break the general rules at any height of the ladder: activists within communities with whom professionals only consult or inform, and passive community members who fail to activate despite genuine opportunity for citizen control. Further, practitioners should be aware of the challenges within communities to participate at high levels, including poor health literacy, lack of motivated community leaders and distrust of professionals trying to support the development and implementation of participatory methods. Community assets for health Traditionally, public health practitioners have focussed on health needs assessment as a mechanism for understanding the health of a population and to inform planning of interventions or strategies for health improvement (see Chapter 6). However, this approach alone has been criticised for focussing on ‘what is wrong’ when there are many benefits to a community, both psychological and for empowerment, in focussing also on community assets—what is strong. Community assets can be mobilised by practitioners and the community themselves to support positive health and wellbeing. Examples of community assets include physical, environmental and economic resources; social networks, social capital and community cohesion; formal and informal groups, voluntary networks and mutual aid; and the skills, knowledge and commitment of the community as a whole and
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individuals within it (Foot and Hopkins, 2010; Morgan and Ziglio, 2007). Communitycentred approaches need to mobilise assets within communities, empowering individual and community control over health and promoting equity. Equity Equity and the concept of progressive universalism (Marmot et al., 2010) are fundamental to community-centred approaches. In times of scarce resources and widening health inequalities, equity offers a solution to narrow those inequalities. Equity and equality are terms often used interchangeably, although there are distinct differences between the two. Equality is based in equal access to services which promote and support good health, regardless of level of need. Equity recognises that some individuals or communities have greater needs, and therefore need more or greater intensity of interventions to improve health and wellbeing. This may lead to unequal distribution of resources, favouring more deprived, disadvantaged or marginalised groups in society (Figure 2.5). It is important that practitioners actively consider equity in the planning, implementation and evaluation of community-centred interventions to avoid the widening of health inequalities. Often, widening of inequalities happens without intent due to the unintentional failure to consider services in their widest context, including accessibility—the uptake and availability for those who have the greatest need. Achievement of this often requires innovative thinking and service design. Empowerment Empowerment approaches seek to support individuals and communities to identify their own health priorities and then to upskill and support changes needed to improve the health needs identified (Naidoo and Wills, 2016). Empowerment is often used as a
In the first image, it is assumed that everyone will benefit from the same supports. They are being treated equally.
In the second image, individuals are given different supports to make it possible for them to have equal access to the game. They are being treated equitably.
In the third image, all three can see the game without any supports or accommodations because the cause of the inequity was addressed. The systemic barrier has been removed.
FIGURE 2.5 Equality vs. equity. Source: City for All Women Initiative (2015).
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mechanism for meeting the principles of the WHO (WHO, 1986) definition for health promotion, specifically relating to maximising an individual’s control over their life (Lindacher et al., 2018). Systematic reviews of empowerment approaches to health improvement have shown statistically significant positive impacts on health (Lindacher et al., 2018). Empowerment approaches can be used with individuals or communities; further, empowerment can be considered as a ‘process’ through which health is promoted or a ‘state’ in which a person is able to find optimum health (Tengland, 2016). It is widely agreed that empowerment approaches are ‘bottom-up’ rather than ‘top-down’ processes (Spencer, 2016), and this can cause some challenges in agenda matching between priorities for health as defined by public health professionals and the priorities of individuals and communities (Lupton and Tulloch, 2002; Katainen, 2006; Spencer, 2013).
Community-centred approaches and practical application in child and family public health The practical steps for undertaking community-centred approaches in public health are complex and diverse, depending on the specific approach being applied. However, most approaches involve a common underlying process of which practitioners should be aware to maximise the potential success of any activity being undertaken. The following outlined model (Table 2.1) builds on those previously developed by Craig (Craig and Lindsay, 2000) and Dalziel (2008), adding stages of change (Prochaska and DiClemente, 1983) and diffusion of innovation (Rogers, 2010) theories, whole systems approaches (PHE, 2015) and the author’s own practice experience within the emerging health and social care landscape. Health visitors and school nurses should play both a leadership role in strategic development of the work, whilst concurrently developing the front-line, operational relationships and activities required to empower and support community-centred health improvement. The Public Health England guide to community centred approaches for health and wellbeing (PHE and NHS England, 2015) presents a framework of potential approaches when working with communities for population health improvement (Figure 2.6). This guide acknowledges the growing evidence base for a range of interventions, which can be applied and used as stand-alone or multifaceted approaches by public health workers. Many of these rely on and are strengthened by multi-agency and integrated systems opportunities as previously discussed. Strengthening communities Strengthening communities’ approaches seek to identify and build on existing community strengths, assets and capacity to facilitate collective action for health improvement. This approach is most closely linked to traditional community development approaches to health improvement, and in fact includes this specific mechanism as a potential approach. Empowerment of individuals and communities is particularly important for this group of approaches, and as such, outcomes are entirely dependent on the successes or failures of the communities themselves. Intended outcomes of these approaches are listed in Table 2.2.
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TABLE 2.1 Practical application of community-centred public health practice Process Stage
Strategic
Stage 1: Information gathering and planning
Understanding local systems
Operational
Evaluation
Building individual and Ongoing evaluation: organisational reputation within a • Identification of routinely collected outcome community through relationships measures and those which with individuals and groups need to be captured before Identifying Networking with local people, and after intervention community leaders formal and informal social groups, • Use of validated and potential religious groups, third-sector evaluation and outcome partners and services organisations, stakeholder measurement tools mapping • Ongoing review of data to support evaluation of the Identification and Community mobilisation and impact on health outcomes understanding of identifying potential early and health inequalities local plans, policies, adopters within the community. strategies and This may include formalisation of • Feedback to key stakeholders and the priorities a group within the community community who will take a leadership role (early majority).
Stage 2: Health needs assessment, and identification of community assets for health
Review of local Joint Strategic Needs Assessment
Working with community members to informally gather an understanding of locally expressed health needs and community assets to address these. This might involve the use of community workshops, community asset mapping, delivery of interactive health education sessions. To achieve high levels of participation, best practice would be to include a core group of community members in the planning and delivery of these activities.
Stage 3: Developing a strategy and planning
Facilitation of community-led planning to prioritise manageable health needs to be addressed and create a SMART (specific, measurable, achievable, realistic, time limited) (Yemm, 2012) action plan to address these. Where possible, community assets will be maximised to address health needs, with the practitioner offering the coordination, facilitation and leverage of other local multi-agency resources to meet needs that cannot be addressed by the community. (Continued)
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TABLE 2.1 Practical application of community-centred public health practice—cont’d Process Stage
Strategic
Operational The practitioner needs to carefully agenda match with the community during this stage, presenting what is known from epidemiological data about community health needs, with those experienced and expressed by the community themselves.
Stage 4: Supporting community-driven change
The role of the practitioner in this stage is to lead, facilitate and ensure momentum for community delivery of the action plan. This may include networking and integrated working with other local services, both health and those which impact on the wider determinants. For many practitioners, finding a balance between making successfully progress with a project, without imposing their professional power over the community, is somewhat of a challenge. Reflective practice can help to supporting learning and professional development which will benefit ongoing and future community-centred interventions. Aside from the community-level changes, the practitioner should ensure that community members have the opportunity to influence local strategy and policy relating to their identified health needs. Evaluation and monitoring of the project are essential at this time, and true participatory methods would include the community in the design and collation of this too.
Stage 5: Celebrating community success
Reporting to Health Community led celebration and and Wellbeing Board dissemination of success. Reporting to commissioners
Involvement of community members in feedback of findings, successes and areas for further work to key stakeholders and local decision-makers.
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Models and approaches for community-centred public health practice
Community-centred approaches for health & wellbeing
Strengthening communities
Volunteer & peer roles
Collaborations & partnerships
Access to community resources
Community development
Bridging roles
Community-based participatory research
Pathways to participation
Asset-based methods
Peer interventions
Area-based Initiatives
Community-based
Peer support
Community engagement in planning
Community-based commissioning
Peer education Peer mentoring
Coproduction projects
Social network approaches
Volunteer health roles
FIGURE 2.6 Family of community-centred approaches. Source: Public Health England and NHS England (2015).
TABLE 2.2 Intended outcomes of community-strengthening approaches Community outcomes
Individual outcomes
Environmental outcomes
Increased social capital
Increased self-esteem
Improvements in the wider determinants of health (e.g. housing)
More confident, active communities
Greater empowerment
Improved community infrastructure
Increased social engagement
Improved health literacy
Increased funding and resources
Adapted from Public Health England (Public Health England and NHS England, 2015).
These approaches are separated into three main categories: 1. Community development: Defined as ‘a long-term value-based process which aims to address imbalances in power and bring about change founded on social justice, equality and inclusion’ (Federation for Community Development Learning, 2009). An example of this in child and family health practice might include the School Health Needs Assessment cycle, which empowers school leadership and students to identify their school community health needs and create and implement school health action plans to address them. School nursing leadership can support the technical aspects of the needs assessment process and facilitate integrated solutions with partners to support the school community to improve population health.
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2. Asset-based approaches: Including asset mapping and asset-based community development. These approaches focus on what is strong, not what is wrong in communities, seeking to empower individuals and communities to mobilise and maximise their assets to improve health. In child and family public health, asset mapping might provide a useful tool for empowerment of a particularly disempowered community, to build trust and rapport as part of a bigger programme of work. 3. Social network approaches: These approaches focus on the relationships between people and their social networks that form communities. These approaches can be especially empowering in health visiting and school nursing practice, where practitioners can support the informal networks of parents in similar circumstances through the creation of new structures or enhancement of existing networks that benefit health, such as time banking schemes, informal baby or toddler meets, Parent Connectors (Duppong Hurley and Huscroft-D’Angelo, 2018) or mutual aid groups, including those which existing online through social media. Volunteer and peer roles Volunteer and peer role approaches focus on the development and empowerment of individuals to provide advice, support, information and organised activities in their own communities to the benefit of community health and wellbeing. These community members may need training and support to undertake this role safely and effectively. One of the main challenges for practitioners in developing this approach is the balance between ensuring safety and being comfortable enough to let peer workers take an autonomous role within their own community, letting go of professional control. Peer support can offer some of the best opportunities to reach the most vulnerable parts of society, who might not otherwise engage with professionals or services, and therefore it offers a real opportunity to reduce health inequalities. There are also benefits to individuals who undertake these roles including pathways to employment and education (Sheffield Well-being Consortium, no date). These approaches are separated into three main categories: 1. Bridging roles: Volunteers play a signposting role, connecting community members into local services and groups. An example of this in child and family health might include the development of community connectors at well-baby clinics, or ‘Making Every Contact Count’ training for community members or non-health professionals. 2. Peer-based interventions: These interventions are directed at the recruitment and training of people who might find themselves sharing similar characteristics to a target group. There are numerous examples of this in child and family health through Breastfeeding Peer Supporters, but this approach could also be carefully developed to support families of babies, toddlers, children or young people (Home-Start) with any locally identified health need that is not met effectively within a specific community through traditional services. 3. Volunteer health roles: These roles might link more closely to professional service delivery, enhancing the breadth of the offer and encouraging increased access and uptake by marginalised groups. Through new integrated ways of working in health
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and social care, health visitor and school nursing services might consider recruitment and training of volunteers to reduce health inequalities in current streams of work, assuming roles such as befriending and accompany patients to appointments. Partnerships with third-sector organisations can support practitioners to develop this offer. Collaboration and partnerships These approaches focus on coproduction of service design and delivery with communities. The approaches within this group perhaps seem the least naturally applicable to child and family public heath practice as they are grounded in research (community-based participatory approaches) and in wider systems integration and strategy (local area initiatives). It is important for practitioners to be aware of the benefits of community-centred approaches in this type of work so that they can identify and influence opportunities for participation and empowerment as part of wider integrated workings in which they might be involved. However, two approaches within this group have been attempted within health and care services for many years; community engagement in planning and coproduction. The Public Health England model specification for 0-19 services (PHE, 2018a) established the expectation that services will engage with service users to support the design, performance monitoring and evaluation of provision. An understanding and appreciation of the challenges of good community-centred engagement will support the meaningful achievement of these requirements. Access to community resources This group of approaches focusses most closely on the integrated working opportunities with third-sector groups and community resources. Practitioners might find these approaches a natural progression from the asset-based approaches described earlier in this chapter. The importance of integrated working in the current public health context has already been established, and these approaches focus on the mechanisms and means of enhancing integrated working with community resources: referral pathways, reducing barriers to service access and social participation. Intended outcomes of these approaches are shown in Table 2.3. TABLE 2.3 Intended outcomes from integrated working opportunities with third-sector groups and community resources Community outcomes
Individual outcomes
Health service outcomes
Shared resources
Reduced social isolation
Reduced demand
Increased capacity through volunteers
Increased social connectedness
Increased resource knowledge to manage presenting health complaints
Increased health knowledge and improved health behaviours Better access to services
Adapted from Public Health England (Public Health England and NHS England, 2015).
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These approaches are separated into two main categories: 1. Pathways to participation: Strengthening opportunities for participation in non-health activities which improve health through the wider determinants. Examples of opportunities for health visitors and school nurses include application of social prescribing principles or the development of local activity and resource guides. 2. Community hubs: Community venues which bring together integrated services which improve health and wellbeing. Health visitors might look for opportunities to co-locate with children’s centres for all or some service delivery, whereas school nurses could explore opportunities to develop community hubs for health for young people outside the traditional school environment, such as youth centres and sports clubs.
Evaluation of community-centred approaches It is acknowledged that community-centred practice is time-consuming and requires the long-term involvement of practitioners, or teams of practitioners, to develop effective solutions with the community of focus. These approaches require the commitment of both individual practitioners and wider provider organisations to advocate for their benefits to population health on behalf of the communities they serve. Programmes should be evaluated both quantitatively and qualitatively to demonstrate the achievement of improved individual and community-level health outcomes. As with all public health programmes, providing evidence of the impact for communitycentred approaches is a challenge; systematic review has demonstrated heterogeneity in the designs and methods for community-centred and empowerment approaches to health improvement, leading to a lack of consensus in evaluation methods (Lindacher et al., 2018). The impacts on health and wellbeing may not be apparent for many years. With many other potential influences on health and wellbeing, it is difficult to attribute changes to one single activity (Naidoo and Wills, 2016). However, public health practitioners can use epidemiological data and outcomes frameworks (Public Health Outcomes Framework, Child Health Profile) (PHE, 2018d, 2018e) to demonstrate changes to population health over time, including the impact on health inequalities. Comparative analysis at the local level before and after intervention, including wellness scores (Warwick-Edinburgh Mental Well-Being Scale) (Tennant et al., 2007), routine screening for maternal mental health (Edinburgh Postnatal Depression Scores, Patient Health Questionnaire-9 and/or Generalized Anxiety 7-item scores) (National Institute of Health and Care Excellence and NICE Pathways, 2018) and child development monitoring (Ages and Stages Questionnaires for national reporting) (PHE, 2018c), are examples of additional and routinely collected data sources which can be used at a population level to demonstrate the impact of community-centred interventions. Local authority public health teams can support efforts to obtain and analyse these types of data. In times of scarce public health resource and with the focus on innovation and integrated working in health and social care systems, demonstration of impact on health outcomes and inequality to commissioners (New Economics Foundation, 2014) and systems leaders is growing increasingly important.
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Discussion Questions • Are health professionals best placed to undertake community-centred approaches? • Should the social determinants of health set the agenda for community health practitioners? • What are the barriers and facilitators for practitioners seeking to undertake communitycentred approaches to public health? • Is the public health workforce ready and skilled for the shift towards asset-based ways of working in communities? • Is community-centred working driven by need and evidence or through lack of resource and challenges in the health and social care system? Does it matter?
References Abma, T., Banks, S., Cook, T., Dias, S., Madsen, W., Springett, J., et al., 2019. Participatory Research for Health and Social Well-Being. Springer International Publishing, Cham, Switzerland. Acheson, D., 1988. Report of the Committee of Inquiry into the Future Development of the Public Health Function and Community Medicine. HMSO, London. Arnstein, S.R., 1969. A ladder of citizen participation. J. Am. Inst. Plan. 35, 216224. Barrett, G., 2015. Deconstructing community. Sociol. Ruralis. 55, 182204. Campbell, F., 2010. The Social Determinants of Health and the Role of Local Government. Local Government Association, London. Children’s Commissioner for England, 2016. Lightning Review: School Nurses—Children’s Access to School Nurses to Improve Wellbeing and Protect them from Harm. Children’s Commissioner, London. City for All Women Initiative, 2015. Advancing Equity and Inclusion. A Guide for Municipalities. City for All Women Initiative, Ottawa. Craig, P., Lindsay, G., 2000. Nursing for Public Health: Population-Based Care. Churchill Livingstone, London. Dahlgren, G., Whitehead, M., 1991. Policies and Strategies to Promote Social Equity in Health. Institute for Futures Studies, Stockholm, Sweden. Dalziel, Y., 2008. Community development as a public health function. In: Cowley, S. (Ed.), Community Public Health in Policy and Practice: a Sourcebook, 2nd edition. Bailie`rre Tindal, Kent, UK. Day, G., Murdoch, J., 1993. Locality and community: coming to terms with place. Sociol. Rev. 41, 82111. Department of Health, 2010. Healthy Lives, Healthy People: Our Strategy for Public Health in England. The Stationary Office, London. Department of Health, 2011. Health Visitor Implementation Plan 201115: A Call to Action. Department of Health, Crown, London. Department of Health, 2012. Health and Social Care Act. Department of Health, London. Department of Health, 2017. Local Authority Circular. Circular No LAC(DH)(2017) 2. Public Health Ring Fenced Grant 2018/19. Department of Health Public Health Policy and Strategy Unit, London. Department of Health, 2018. Public health local authority allocations 2018 to 2019 and indicative allocations 2019 to 2020. Department of Health, London. Dooris, M., 2005. Healthy settings: challenges to generating evidence of effectiveness. Health Promot. Int. 21 (1), 5565. Duppong Hurley, K., Huscroft-D’Angelo, J., 2018. Parent connectors: a parent-to-parent support program feasible for rural settings. Rural. Spec. Educ. Q. 37, 251256. Federation for Community Development Learning, 2009. A summary of the 2009 Community Development Occupational Standards. FCDL, Sheffield. Foot, J., Hopkins, T., 2010. A Glass Half-Full: How an Asset Approach can Improve Community Health and WellBeing. Great Britain Improvement and Development Agency, London.
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Garces-Ozanne, A., Kalu, E.I., Audas, R., 2016. The effect of empowerment and self-determination on health outcomes. Health Educ. Behav. 43, 623631. HM Government, 2011. The Localism Act. London. Katainen, A., 2006. Challenging the imperative of health? Smoking and justifications of risk-taking. Critical Public. Health 16, 295305. Lindacher, V., Curbach, J., Warrelmann, B., Brandstetter, S., Loss, J., 2018. Evaluation of empowerment in health promotion interventions: a systematic review. Eval. Health Prof. 41, 351392. Local Government Association, 2017. Prevention. How Do You Know That Your Council is Doing All it Can to Deliver on Prevention? Local Government Association, London. Lukes, S., 1974. Power; a Radical View. Macmillan, London. Lupton, D., Tulloch, J., 2002. ‘Life would be pretty dull without risk’: voluntary risk-taking and its pleasures. Health Risk Soc. 4 (2), 113124. Marmot, M., Allen, J., Goldblatt, P., Boyce, T., Mcneish, D., Grady, M., 2010. Fair Society, Healthy Lives. The Marmot Review, London. Marmot, M., Allen, J., Boyce, T., Goldblatt, P., Morrison, J. 2020. Health equity in England: The Marmot Review 10 years on. Institute of Health Equity, London. Marshall, G., 1998. A Dictionary of Sociology. Oxford University Press, Oxford. Morgan, A., Ziglio, E., 2007. Revitalising the evidence base for public health: an assets model. Int. J. Health Promot. Educ. 14, 1722. Naidoo, J., Wills, J., 2016. Foundations for Health Promotion. Elsevier, London. National Institute for Health and Care Excellence, 2016. Community Engagement: Improving Health and Wellbeing and Reducing Health Inequalities. NICE, London, ,https://www.nice.org.uk/guidance/ng44. (accessed 25.09.19). National Institute for Health and Care Excellence & Nice Pathways, 2018. Identifying and Assessing Mental Health Problems in Pregnancy and the Postnatal Period. NICE, London. New Economics Foundation, 2014. Commissioning for outcomes and co-production. a new model for commissioning public services, ,https://neweconomics.org/2014/06/commissioning-outcomes-co-production. (accessed 10.12.18). NHS, 2014. Five Year Forward View. The King’s Fund. NHS, 2019. The NHS Long Term Plan. Crown, London. Oxford English Dictionary, 2019. ‘Community’. ,https://en.oxforddictionaries.com/definition/community. (accessed 10.12.18). Prochaska, J.O., Diclemente, C.C., 1983. Stages and processes of self-change of smoking: toward an integrative model of change. J. Consult. Clin. Psychol. 51 (3), 390395. Public Health England, 2015. Promoting Children and Young People’s Emotional Health and Wellbeing. A Whole School and College Approach. Crown, London. Public Health England, 2018. Health matters: community-centred approaches for health and wellbeing, ,https:// www.gov.uk/government/publications/health-matters-health-and-wellbeing-community-centred-approaches/ health-matters-community-centred-approaches-for-health-and-wellbeing. (accessed 12.06.18). Public Health England, 2018a. Best Start in Life and Beyond: Improving Public Health Outcomes for Children, Young People and Families. Guidance to Support the Commissioning of the Healthy Child Programme 0-19: Health Visiting and School Nursing Services. Commissioning Guide 2: Model Specification for 0-19 Healthy Child Programme: Health Visiting and School Nursing Services. Crown, London. Public Health England, 2018b. Best Start in Life and Beyond: Improving Public Health Outcomes for Children, Young People and Families. Guidance to Support the Commissioning of the Healthy Child Programme 0-19: Health Visiting and School Nursing Services. Commissioning Guide 1: Background Information on Commissioning and Service Model. Crown, London. Public Health England, 2018c. Children’s Public Health 0 to 5 Years—Interim National Reporting Process for the Universal Health Visiting Service: Full Guidance for Local Authority Members of Staff 2018/19. PHE Publications, London. Public Health England, 2018d. Fingertips. Public Health England, ,https://fingertips.phe.org.uk/. (accessed 30.11.18). Public Health England, 2018e. Public Health Outcomes Framework. ,https://fingertips.phe.org.uk/profile/ public-health-outcomes-framework . (accessed 30.09.19). Public Health England, 2019. Public Health Skills and Knowledge Framework as a Tool for Line Managers. London.
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Public Health England & NHS England, 2015. Health and Wellbeing: a Guide to Community-Centred Approaches. Public Health England, London, ,https://www.gov.uk/government/publications/health-andwellbeing-a-guide-to-community-centred-approaches. (accessed 29.09.19). Public Health England & The Association of Directors of Public Health, 2016. Guidance on the Ringfenced Public Health Grant Conditions and Mandated Functions in England. A Co-Production between PHE Centres and Regions and the Association of Directors of Public Health. Public Health England, London, ,http://www.adph.org.uk/wp-content/ uploads/2016/09/Interpreting-the-ringfenced-grant-conditions-and-mandateGATEWAY.pdf. (accessed 18.03.20). Rogers, E.M., 2010. Diffusion of Innovations. Simon and Schuster, New York. Rose, G., 1985. Sick individuals and sick populations. Int. J. Epidemiol. 14 (1), 3238. Sheffield. Well-Being Consortium no date. Health champions case studies. Sheffield Well-being Consortium, Sheffield. Spencer, G., 2013. Young people’s perspect. Health: empowerment, risk? Health Educ. 113 (2), 115131. Spencer, G., 2016. ‘Troubling’moments in health promotion: unpacking the ethics of empowerment. Health Promot. J. Aust. 26, 205209. Tengland, P.-A., 2016. Behavior change or empowerment: on the ethics of health-promotion goals. Health Care Anal. 24, 2446. Tennant, R., Hiller, L., Fishwick, R., Platt, S., Joseph, S., Weich, S., et al., 2007. The Warwick-Edinburgh Mental Well-Being Scale (WEMWBS): development and UK validation. Health Qual. Life Outcomes 5, 6375. The King’s Fund, 2018. Making sense of integrated care systems, integrated care partnerships and accountable care organisations in the NHS in England. ,https://www.kingsfund.org.uk/publications/ making-sense-integrated-care-systems. (accessed 10.12.18). Townsend, P., Davidson, N., 1982. Inequalities in Health: the Black Report. Penguin, Harmondsworth. Walmsley, J., 2006. Putting community in place. Dialogue 25 (1), 512. Wellman, B., 2001. The persistence and transformation of community: from neighbourhood groups to social networks. Report to the Law Commission of Canada 45, 436. Welsh Government, 2018. A Healthier Wales: Our Plan for Health and Social Care. Crown, London. World Health Organization, 1986. Ottowa Charter for Health Promotion. Geneva. ,https://www.who.int/ healthy_settings/about/en/. (accessed 10.04.1919). World Health Organization, 1978. Alma Ata 1977. Primary Health Care. WHO, UNICEF, Geneva, Switzerland. World Health Organization, 2002. Community Participation in Local Health and Sustainable Development: Approaches and Techniques. WHO, Geneva, Switzerland. World Health Organization, 2006. Constitution of the World Health Organization. WHO, Geneva, Switzerland. World Health Organization, 2019. Introduction to Healthy Settings. ,https://www.who.int/healthy_settings/ about/en/. (accessed 29/04/2020). Yemm, G., 2012. Essential Guide to Leading Your Team: How to Set Goals, Measure Performance and Reward Talent. FT Publishing International, Upper Saddle River, NJ. Yphantides, N., Escoboza, S., Macchione, N., 2015. Leadership in public health: new competencies for the future. Front. Public. Health 3, 2424.
Further reading and resources For more detailed information about community engagement and community-centred approaches for public health, you might like to read the following:
• NICE Guideline: Community engagement: improving health and wellbeing and reducing health inequalities (NICE, 2016) • A guide to community-centred approaches for health and wellbeing (Public Health England and NHS England, 2015) and ‘health matters’ (PHE, 2018) A useful text for participatory research methods for community empowerment:
• Participatory Research for Health and Social Well-Being (Abma et al., 2019) Finally, for innovative and contemporary evidence of community interventions for public health:
• What Works Centre for Wellbeing: www.whatworkswellbeing.org
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C H A P T E R
3 Complex place-based interventions for health Robert Nettleton KEY ISSUES • Why improving health is complex • Place-based interventions in the UK
• Examples of place-based interventions in the UK
• Theories of change and logic models for place-based interventions
• Finding my place within place-based approaches
Everything should be made as simple as possible, but not simpler. Attributed to Albert Einstein
Introduction Health is a commonplace concern that belies an extremely wide range of meanings, attributes, objective measures and subjective experiences. It is therefore not surprising that improving health presents a complex challenge. It is not immediately obvious what we are trying to improve. Health may be defined narrowly, for example, in terms of the absence of disease or widely as a positive and holistic ‘state’; or it can be defined objectively by authoritative measures applied to the individual or a population or by subjective measures of wellbeing or suffering. Such are some of the dimensions of health that can be unpacked from the famous definition of health as ‘a state of complete physical, mental and social. well-being and not merely the absence of disease or infirmity,’ in the World Health Organisation’s (1946) constitution. In addition, when considering population health—for example, the health of a particular community (however defined)—health (and illness and/or disease) are typically not distributed evenly throughout the population under
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consideration. This being the case, improving population health may either reduce, maintain or even exacerbate disparities in the distribution of health. The impact of measures or ‘interventions’ intended to improve health may have differential effects for different health issues and groups depending on a wide range of other influencing factors as demonstrated in detail by Marmot as the chair of the Strategic Review of Health Inequalities in England (Marmot et al., 2010, 2020) and others since (Pearce et al., 2019). The interaction between these factors has long been recognised—for example, in Dahlgren and Whitehead’s graphic representation of the determinants of health (see Figure 2.2, page 38). Within this complex field, contemporary health and social policy seeks to identify the ‘wicked issues’ or challenges that are particularly resistant to change by engaging the determinants of health beyond the individual, by reckoning with complexity and finding a focus around which to mobilise such interventions. This chapter identifies recent attempts to do this within the United Kingdom (UK) described as ‘place-based’. It outlines developments in policy that give impetus to the approach as well as some of the theoretical frameworks and methods that inform them. Further, it describes how these developments are manifested in current interventions before finally reflecting on how practitioners can find their place within place-based approaches.
‘Wicked issues’ in contemporary UK society An excellent summary of the health challenges facing the UK is provided by the King’s Fund (2015) challenges that will have been exacerbated by the far-reaching nature of the Covid-19 pandemic (see Shonkoff 2020, for example). ‘Wicked’ issues are those ‘complex and multifaceted issues that have no single solution, and are perceived by different stakeholders through contrasting views. . . . [Other] examples in the social context include climate change, poverty, energy production, sanitation, sustainable cities, pollution and homeland security’ (Elia and Margherita, 2018). A good way to identify the wicked issues and define a focus for action is to ask the following question: ‘If we continue doing what we do now, what scenario can we expect in x years from now?’ Such questions are routes to tackling the inertia that often applies to the ‘status quo’. For example, in 2002 Sir Derek Wanless projected the future for health in the UK and outlined three scenarios in relation to health care expenditure and productivity. What he could not have predicted was the economic crisis of 2008 and subsequent ‘austerity’ policies, which substantially reduced spending on the public sector (Reeves et al., 2013). Since then, the Five Year Forward View (National Health Service (NHS) England, 2014) noted that Sir Derek Wanless’ (2002) warning about the necessity of taking prevention seriously had not been heeded. Therefore, in setting out priorities for the NHS in England it stated that, without a ‘radical upgrade in prevention’, health spending would be unsustainable to meet the growing demands for health care for a population that was living longer with more predictable ill heath attributable to many factors, notable amongst which are obesity as a risk factor for many long-term health issues. The nature of these ‘issues’ is that they are not susceptible to the solutions offered by health care alone, but by concerted interventions, ‘upstream’ of these downstream effects. Otherwise stated, the focus should be on the determinants of health, as mentioned earlier, or as Sir Michael Marmot puts it, the ‘causes of the causes’ (Marmot et al., 2010).
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A simplified, if metaphorical, way to formulate the current challenge is: Challenge 5
Austerity economics Ageing demographic 3 comorbidities 3 ðcostlyÞ new treatments
The challenge amounts to the shared acknowledgement amongst policy makers and strategists that the imbalance of demand on health services (created by ageing, comorbidities and new treatments) cannot be met by the level of funding to health and other services as presently conceived. The recognition of the essential contribution of nonhealth care provision to meeting the demand on services helps to mitigate this imbalance. This is exemplified by attempts to move towards more ‘integrated health and social care’, although social care is not funded across the UK by the same method and, since the introduction of ‘austerity economics’ from 2008, has been subjected to public spending cuts more than the NHS. While initiatives to integrate health and social care in some form are not new, in England, integrated care systems (previously known as sustainability and transformation partnerships) were developed on a ‘place-based’ geographical footprint to give impetus to this. Indeed, Ham and Alderwick (2015) argue that ‘Place-based systems of care are the way forward for the NHS in England.’ However, a public health approach moves its perspective further upstream from care to recognising that care systems are insufficient in themselves as they are more-of-the-same solutions to a problem that requires focus on the causes of the causes that manifest downstream. From this perspective, demand management is properly seen as a failure to prevent. Therefore, on the demand side of the equation—the age of the demographic of the population, the trajectory in the development of multiple long-term health conditions (often attributed to lifestyle choices and behaviours) and the types of interventions (or treatments)—need to be reconceived. The sustainability and transformation partnerships published in England have a conspicuous emphasis on the older demographic within the population responsible for the greatest demands on health and social care. While this is understandable, analysis of the epidemiology and demography of health and disease shows with remarkable consistency that (1) the greatest inequalities in health correlate with a ‘social gradient’ related to inequalities in social and economic advantage, and (2) that inequalities in childhood are persistent in their effects over the life course (Marmot et al., 2020). Recent research on Adverse Childhood Experiences (ACEs) (Bellis et al., 2014) has shown that these have particular potency, fuelling patterns of disease into later life. Conversely, the economist James Heckman (2007) has demonstrated that the greatest return on investment in health and social outcomes is investment in childhood health and education programmes, especially in the earliest years. See Hinkley et al. (2020) for recent example offering later health benefits. Indeed, the WAVE Trust (2013) summarises this by stating that ‘early years’ interventions are a rare opportunity to spend money in a way that delivers social and economic benefits at the same time’ (p. 101). (For further discussion, see Chapter 11: The economics of prevention in the early years.) While ‘complex community-based interventions’ in the 1990s, such as Sure Start, Health Action Zones and Education Action Zones (Houston, 2007), are all consistent with these insights, they have not been sustained under austerity economics. However, there is a strong case for rediscovering the priority of childhood, especially in the earliest years, for prevention
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before the onset of health problems and interventions that offer the greatest return on investment. The NHS Long Term Plan, previously referred to as the 10-year plan (NHS England, 2019) adds to the priorities of the Five Year Forward View a renewed focus on childhood, prevention, inequalities and mental health, possibly signalling such a rediscovery. The supply side of the equation, dominated by austerity economics, provides an insight that health is not the product of health care or health care plus social care. Rather, health care is the management of failure to prevent. Health is the product of healthy environments and the lifestyles that they sustain. Moreover, the public cannot be just the funders and consumers of health care. A salutogenic model of health considers what creates health rather than pathology (pathogenic model) and the active role that people have in creating and sustaining health. (See Chapter 1 for further details.) Having outlined in the most general terms the key components of the wicked equation, we now turn to the problem of complexity. The equation described is a simplification, not to say an oversimplification, of the myriad of issues and processes involved in health in a given place or population. To say that the aforementioned factors interact with each other is one thing, to say how they interact in given circumstances and with what effects is another.
Complexity Reflecting on the persistence of wicked issues in health care, Braithwaite (2014, p. 1) states: We need to understand why system-wide progress has been so elusive and to identify the kinds of initiatives that have made positive contributions to date. Then we can ask what new solutions are emerging that may make a difference in the future and start to change our thinking about healthcare systems. Braithwaite suggests that we need to recognise that attempts to re-engineer health systems or, by extension, to change the highly resistant health behaviours of the community fail to connect with the experience and meaning attributed to these interventions ‘on the ground’. Many practitioners and managers within organisations share the experience of reflecting that ‘this has been tried before’, ‘what goes around comes around’ or ‘the more things change, the more things stay the same’. Braithwaite explains that the conservatism or inertia of complex systems results from the total of the negotiations, trade-offs and positioning of stakeholders: ‘No one person or group is to blame; but a complex system clearly does not change merely because someone devises and then mandates a purpose-designed solution’ (Braithwaite, 2014, p. 1). A way of understanding this is to draw on complexity theory that positively engages with these processes of change and circularity, the messiness of health experience and organisational life, and the practicalities of working with complexity. Following Byrne and Callaghan (2014), Davidson-Knight et al. (2017, p. 7) summarise three key concepts from complexity theory as follows: 1. Unpredictability and emergence. The elements of a complex system interact in ways which produce unpredictable results. Tiny variations in the starting conditions of a
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system and minute fluctuations from external influences mean that identical-looking systems can produce wildly different results. The results produced by an intervention in one place and time may be different if tried in another place or time, and in complex systems, outcomes cannot be reliably and robustly attributed to particular interventions. 2. Path dependence. Complex systems are unpredictable but not totally random. What happens next is strongly influenced by what went before. The patterns that complex systems produce have histories which must be understood to understand the results they produce. 3. The importance of context and being humble about our knowledge claims. Because tiny (often unmeasurable) variations and external fluctuations influence results so dramatically, context becomes very important. What works in one place may fail in another, and what works now may not be repeatable later. We must therefore be humble about what we can claim to know about how such systems work and what evidence is telling us. It is not that evidence is unimportant, but that the answers it gives us are only ever partial. Davidson-Knight et al. (2017, p. 2) translate these insights into their finding about how place-based interventions should be commissioned: ‘Our places are recognised as complex systems, influenced by many but controlled by none. . . . Outcomes are created by people’s interaction with whole systems, not by particular interventions or organisations.’ This can seem rather paradoxical; on the one hand, the language of systems can seem impersonal and mechanistic, while on the other hand, outcomes are said to be dependent on human interactions, how people make sense of their situation and how they adapt to it. ‘Personalised public health’ is a term that seems to combine these contradictions. Personalisation can mean drawing on the knowledge of individual susceptibility to disease due to advances in genomics and the interaction of genetic endowment and the environment (epigenetics) (National Scientific Council on the Developing Child, 2010). More broadly, we might recognise personalised public health as a mode of practice that takes seriously the lived experiences of individuals and families within the wider context of their ‘place’ or ecology. To do so in reflective manner, here we introduce two authors to each other.
Case Study 3.1 A reflection on two perspectives Professor Sir Michael Marmot Michael Marmot is recognised internationally for his work, including chairing the World Health Organization Commission on the Social Determinants of Health (2008) and key publications, including Fair Society, Healthy Lives and a follow-up to the review ‘10-years on’ (Marmot et al., 2010, 2020) and The Health Gap: The Challenge of an Unequal
World (Marmot, 2015). In these and other publications, he details the evidence that charts the consistently close relationship between health inequalities and the social gradient. The steepness of the social gradient exacerbates the health inequalities independently of the collective wealth of any given society. In other words, inequality is bad for everyone’s health, although
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Case Study 3.1 A reflection on two perspectives—cont’d especially so for the most disadvantaged. On this reckoning, the overwhelming evidence suggests that the most effective placebased intervention would be to reduce the social gradient between the most and least well-off. Marmot is insistent that his appeal is to evidence and not to ideology. The nature of his evidence is overwhelmingly in the form of large-scale demographic and epidemiological data displayed in tables and graphs or expressed through formulae such as the Gini coefficient that ranks the most to the least unequal nations. However, in The Health Gap he also introduces the reader to individuals (real or imagined) from a variety of cultures and life situations whose place has an impact on their health and who seek to make sense of their place. Darren McGarvey Darren McGarvey (2017) (aka Loki) is a rapper, activist and writer whose autobiographical book, Poverty Safari: Understanding the Anger of Britain’s Underclass, details his upbringing and young adulthood in a towerblock council estate in Glasgow. In his early life he is exposed to a host of what, in recent years, have been coined adverse childhood experiences (ACEs), including domestic
violence, mental illness, substance abuse, neglect and so on. He describes vividly the personal toll on his physical and mental health, including his capacity to sustain relationships. He is drawn into socialist local political activism fuelled by anger against ‘the system’. Despite his ‘trainspotting’ lifestyle as a youth, over time he somehow reaches beyond the systematic denigration and indignities that he has experienced to find self-expression through his music, writing and forming more empathic relationships with others whom he had previously lashed out at as hostile figures of authority, the establishment or capitalism. Darren could easily be one of the characters introduced by Sir Michael Marmot (2015) to illustrate the impact of extreme social inequality. Professor Marmot’s research evidence supports Darren’s worldview shaped by his traumatic childhood of the systemic harm produced by such an environment. Although they come from very different backgrounds, perhaps they would have much to appreciate from each other. Personalised public health is, perhaps, what takes place in the dialogue between these two testimonies to the complexities of health inequalities as it is lived in many places.
Place-based interventions in practice There is a strong rationale for place-based approaches to focus on primary preventative interventions for families with young children. The Centre for Community Child Health (2011, p. 11) in Melbourne sums up the approach as follows: Families are often faced with a range of different, complex health and psychosocial problems. Place-based approaches aim to address these complex problems by focusing on the social and physical environment of a community and on better integrated and more accessible service systems, rather than focusing principally on the problems faced by individuals. A place-based
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approach targets an entire community and aims to address issues that exist at the neighbourhood level, such as poor housing, social isolation, poor or fragmented service provision that leads to gaps or duplication of effort, and limited economic opportunities.
Theories of change and logic models for place-based interventions Theory of change is an approach to planning and developing interventions that seeks to surface the explicit theories or assumptions about the nature of the problems to be solved, their causes and likely solutions. Assumptions may be more or less implicit or explicit and, likewise, they may be more or less evidence based. An example of this could be as follows: ACEs are likely to be associated with a range of poor health and other social outcomes for children over their life course. ACEs are also associated with socioeconomic deprivation (see Chapter 13). If both of these propositions are thought to be applicable, consideration should be given to implications for intervention: • Should intervention aim to reduce ACEs and thereby contribute to improved life chances, greater social mobility and reduced inequalities? • Or should intervention seek to reduce poverty, thereby reducing the prevalence and intensity of ACEs? Or perhaps interventions should focus on both the event(s) (ACEs) and the circumstances that support or exaggerate the effect of the event—for example, the child witnessing regular domestic violence, living in a household with little economic resource that, if available, might support access to supportive community facilities. One way of progressing with developing the theory of change would be to ask: what theory can explain how children can thrive even under adverse circumstances? A theory may utilise the concept of resilience and assets, building on the concept of salutogenesis (Antonovsky, 1979). It might take into account research evidence from Anne Masten (2014), who coined the term ‘ordinary magic’ for what children need to thrive despite their poverty: a loving parent or caregiver; an additional caring adult standing by the child; and connections to opportunity—even modest opportunities—at crucial times in a child’s life. By combining these elements it is not difficult to propose how interventions may be supportive of these ingredients of ordinary magic or, for example, to identify how in 2017, Darren McGarvey’s life story these were present and fulfilled a protective function for him (see Case Study 3.1). Logic models are techniques that can be used to map in greater detail the components of a programme of intervention, specifying the inputs (resources), outputs (activities) and outcomes (results) with the underlying assumptions (theory and evidence) and, crucially known unknowns—acknowledging that the precise mechanisms of change may be opaque. Having mapped such a logic model, indicators can be proposed to capture data about how the intervention is being implemented to evaluate effectiveness and to learn how it may be improved. This is a very simplified summary of theory of change and logic modelling. Paradoxically, they aim to reckon with complexity by simplifying it. In doing so, there is the obvious danger
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of oversimplifying the complexity, and in particular, of specifying logical pathways of causality beyond what can be supported by evidence or that can be open to a myriad of other influences. For example, teenage pregnancies have declined in the UK since the 1990s, but this cannot be exclusively attributed to ‘strategy’ but also to changes in wider social norms, meaning a simple cause-and-effect relationship between interventions and outcomes is unrealistic (Hill, 2016). The Healthy Child Programme (HCP) (Department of Health, 2009) is a wellestablished child and family public health programme rolled out nationally in England (with similar programmes in the other three home nations of the UK). It is commissioned locally and runs alongside other child health and welfare services with which it may be relatively well or otherwise aligned. In recent years, the leading function of health visiting in the HCP has been presented in ways that can be mapped as a logic model (Table 3.1). This logic model is potentially more enduring and generalisable than nation-based child health programmes, as the headings remain unchanged, but the examples that follow can be amended or updated as new approaches are proposed. The levels of service are based on the principle of proportionate universalism (Marmot et al., 2010; Center on the Developing Child, 2007). Proportionate universalism summarises the understanding that to reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage (Marmot et al., 2010, p. 10). The child and family health reviews are scheduled to take place in the first 5 years of life at key stages of development and/or transition that can be predicted as time-sensitive in terms of identifying and responding the health needs. The number of reviews varies across the UK. The high-impact areas are a set of relatively wicked issues which are, nevertheless, sensitive to health visitor input and that can therefore be predicted to contribute to health outcomes. An example of a high-impact area that has been stubbornly resistant to sustained improvement is the uptake and duration of breastfeeding. Stephenson (2016, p. 10) reports the evaluation of breastfeeding networks in terms of a theory of change leading towards ‘mothers being empowered to breastfeed for as long as they choose’. In support of this aim, a logic model is specified and illustrated based on a combination of published evidence, expert opinion and the experiences of people affected by this issue. The logic model was based on the assumption that a network approach could bring together partners and activities whose impact ‘will go beyond individual family situations, building a stronger network of mothers willing to become peer supporters, encouraging some mothers to pursue new learning opportunities and equipping communities with increased social capital and greater skills of breastfeeding for future generations’ (Stephenson, 2016, p. 7). In this TABLE 3.1 The function of health visiting as a simple logic model Inputs
Outputs
Outcomes
Continuum or levels of service provision (proportionate universalism):
Planned minimum health and development reviews at key development stages and transitions.
Areas of predicted high impact for the early years:
For example, universal, universal plus, universal partnership plus and community development for health
Community capacity building
For example, breastfeeding, hospital admissions
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respect, the logic model exemplifies a place-based approach. The schematic outline of such a model enables members of networks to identify the part that they play or their potential contribution alongside others. For example, health visitors can use their scheduled child and family health reviews from the antenatal period onwards to explore attitudes towards and knowledge of breastfeeding, facilitating access to and uptake of support tailored to the family and cultural experience of families. Building community capacity is integral to this logic model and could extend further to embrace wider cultural and commercial influences over health practices. The HCP as it stands cannot be viewed as a place-based intervention unless combined with a process of service development that involves all stakeholders, notably including the users of services and the wider community. The Aspen Institute’s (https://www .aspeninstitute.org/) approach to the theory of change places such stakeholder involvement as crucial, and recent research is now available on what service users value and how they can be involved (Donetto et al., 2013; Scottish Government, 2015). The Centre for Community Child Health (2011 p. 3) proposes that ‘At the heart of all successful place-based partnerships are communities that provide maximum practicable input in all decision making’ and investment in community capacity building as well as for staff. The evidence also suggests that a place-based approach is only one feature of a comprehensive community-based service framework that can respond more effectively to the wicked problems that affect communities, families and children. Other features include the following: 1. A strong universal service system backed by a tiered set of additional supports for families experiencing particular stresses (i.e. proportionate universalism) 2. An integrated service system providing holistic support to families 3. Multilevel interventions to address all factors that directly or indirectly shape the development of young children and the functioning of their families 4. A partnership-based approach based on partnerships between families and service providers; between different service providers; and between government and service providers 5. A robust governance structure that allows different levels of government, different government departments, nongovernment services and communities to collaborate in developing and implementing comprehensive place-based action plans. (Centre for Community Child Health, 2011) These characteristics provide criteria for evaluating the implementation of the HCP within the wider place-based systems in the UK with their varied levels and forms of development. The following case study exemplifies how outcomes are linked to system change and leadership.
Case Study 3.2 A Better Start A Better Start (ABS) is a large-scale, 10-year programme funded by the Big Lottery Fund to fundamentally change support services for
young children and their families living in five different geographical areas in England and to share learning more widely to tackle
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Case Study 3.2 A Better Start—cont’d inequality and improve outcomes throughout childhood and beyond. It does not fund the services as such but supports service development and integration through evidence-based approaches and processes. It focusses on three key outcomes: 1. Improving children’s diet and nutrition to support healthy physical development and protect against illness in later life. 2. Supporting children to develop social and emotional skills so they can develop positive relationships and cope with difficult situations. 3. Helping children develop their language and communication skills so that they can engage with the world around them. (ABS, 2018)
These three outcomes do not exclude other important outcomes, such as improved perinatal mental health or children’s oral health, but these and other important outcomes can be linked to the identified priority outcomes. A fourth intended outcome ‘is to bring about “systems change”—that is, to change, for the better, the way that local health, public services and the voluntary and community sector work together with parents to improve outcomes for children’ (ABS, 2018, p. 8). Arguably, this is the largest difference from ABS areas and other places, as in England from 2015 commissioning of the HCP was transferred from the NHS to local authorities at the same time as major cuts in funding were implemented.
ABS exemplifies a ‘leadership paradigm for collective impact’, as set out by Cabaj and Weaver (2016) (Table 3.2) building on the work of Kania and Kramer (2011). The five conditions for achieving collective impact on the left side of the table are extended in a move from managerialist strategic leadership towards embracing a social movement approach, which is captured in the following quotation:
TABLE 3.2 Leadership paradigm for collective impact (Source: Cabaj and Weaver, 2016). From
To
The leadership paradigm Management
Movement building
The five conditions Common agenda
Community aspiration
Shared measurement
Strategic learning
Mutually reinforcing activities
High-leverage activities
Continuous communication
Inclusive community engagement
Backbone
Containers for change
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Creating and managing collective impact requires a separate organization and staff with a very specific set of skills to serve as the backbone for the entire initiative. Coordination takes time, and none of the participating organizations has any to spare. The expectation that collaboration can occur without a supporting infrastructure is one of the most frequent reasons why it fails. (Kania and Kramer, 2011, p. 40) The ABS place-based approach is a good example of such ’supportive infrastructure’ that can be described as a ’container for change’ for multiple organisations rather than a single organisational ’backbone’. This commitment to creating collective impact at system level is what the ABS initiatives supply as an extra ingredient to increase the likelihood of success. A feature of this leadership paradigm is that the term ‘intervention’ is not entirely appropriate if it implies that there is a unilateral relationship between the expert, powerful strategists (cast as the chief actors in defining and solving wicked problems) and the object of the intervention, cast as the passive, problematic recipients. The following case study (3.3) illustrates this shift in the paradigm of leadership.
Case Study 3.3 The Wigan deal As in other parts of the country, partner organisations in Wigan are attempting to work together in a more integrated way, working flexibly across organisational boundaries within local neighbourhoods, ‘place’ and ‘system’ seeking to establish a new ‘deal’ at a collective level between residents and services and agencies. Kate Ardern, director of public health for Wigan Council, reflects in a blog on placebased working and the qualities NHS leaders need to consider as they develop the neighbourhood, place and system vision for integrated care system working described by the NHS Long Term Plan. She states ‘real place-based leadership then is more than just professional expertise, it’s about bringing together small communities and big personalities and working hard at forging a sense of shared ownership where we can celebrate all of our successes and learn from all of our mistakes’. Key issues highlighted are as follows:
1. Recognising a sense of place, thereby understanding the geography and history of territory and rivalry, capitalising on pride in place to grow 2. Valuing the expertise—both professionally and equally—of local leaders. Supporting system leadership that can bring the right people together to make the right thing (relevant thing) happen 3. Bottom-up and accommodating learning from mistakes and learning as an endeavour for growth and improvement Each of these three points bears further detailed contextualisation. For example, place can be understood and experienced differently within and between communities themselves and service providers. Some expertise can be valued or discounted more than others. And improvement is not guaranteed to be linear but can undergo reversals (Ardern, 2015). A more detailed description and critique is provided by Naylor and Wellings (2019).
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Finding my place within place-based approaches The language of complex place-based interventions can seem rather remote from the practitioner delivering services to families and communities. Mapping logic models and specifying indicators can seem to cast the practitioner as a mere cog in the wheel. However, the case studies indicate that more participatory approaches are possible. Complexity theory suggests that overly controlling approaches to intervention are as unrealistic as trying to control the climate or indeed the weather. There are some broader structural interventions (such as controlling carbon dioxide emissions, reforestation and so on) within which individual and localised action makes more sense and can make a difference. In the context of place-based health improvement, relationships are key at strategic and frontline levels. At the level of frontline practice, Cowley et al. (2018b, p. 411) report research evidence, which indicates that Highly developed skills, flexibility and autonomy in practice are necessary to enable health visitors to tailor provision to need and maintain client-sensitive care, particularly where there are complex needs or tensions between public health expectations, official requirements and parental beliefs and context. This chimes with the ordinary magic alluded to earlier by which children and young people are supported to access consistent caring relationships within or beyond their families and to have modest opportunities to use the assets available to them in their communities. In short, magic does not just happen either at the strategic level or at the frontline of service delivery, but ensuring that necessary ingredients are present is an essential first step. Davidson-Knight et al. (2017, p. 1) propose that commissioning of services needs to move to a culture and practices much more in line with the centrality of human relationships to effective relationship based practice valued by service users and that motivates practitioners. Welcoming the knottiness of the world feeds into a more equitable relationship between funders and communities—valuing learning and improving, rather than proving; asking what matters, not what’s the matter; and putting people in the lead, instead of prescribing the solution. . . . It takes time to build relationships and trust. It requires us to be people-driven rather than focused on process, and to take decisions which require professional judgement and empathy, instead of relying on the safety of detailed criteria. We’ll need to reassess how we ensure accountability. And we need to create a more community-led response to the challenges we face. Cowley et al. (2018a, p. 358) cite Marmot et al. (2010) when they describe health visiting in terms that reflect this personalised or relationship-based public health approach: By using this core service ‘offer’ to tailor information specific to each family’s individual needs, health visitors can draw on particularist principles (Carey & Crammond, 2017), provide differentiated help at the level of each family, acknowledging health,
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cultural and social situations to achieve a service that is proportionate to need (Carey et al., 2015). This enables health visitors to work towards reducing the social gradient of health inequalities by delivering services based on ‘proportionate universalism’, which is argued to be the key to reducing health inequalities.
Critique and summary The language of intervention can sound heavy-handed or even authoritarian as strategists determine what is best for the ‘needy’ (hence McGarvey’s book title Poverty Safari), with attempts to engender a more participative approach (as in Wigan) being potentially merely ways of gaining legitimacy for those who remain in power—that is, it is a hegemonic enterprise (Moini, 2011). Practitioners may feel that they are mere cogs in the machine, although equally they may be spanners in the works, with the capacity to make or break strategic interventions. Determining what counts as place can likewise be called into question, as illustrated by the Wigan case study: a town of many townships, administratively within Greater Manchester although historically and culturally aligned with Lancashire. This chapter takes its starting point as place-as-system through the lens of complexity, but a critical perspective from the frontline of practice and the lived experience within places invites reflection on other perspectives and approaches such as community development (see Chapter 2) and relationship-based skills (see Chapter 7). If complexity theory alerts us to the reality that we cannot control all the variables when it comes to intervention and change, then theories of change, especially when developed collaboratively, can be used to propose logic models. Through logic models signature outcome indicators can be proposed and evaluated (such as the three key outcomes for ABS) along with some limited but powerful process indicators such as those associated with the quality of relationships (ordinary magic). The latter can be applied as collective leadership at the strategic level (West et al., 2014); engagement at the community level; quality and continuity of practitioner/client relationships at the professional level and, for families, parent or carer/child relationships. The power of the quality of relationships lies in the receptivity to (or reactivity against) any intervention. The complexity of health and society is such that attempts to simplify it inevitably fall foul of oversimplification. Health and society are not only complex, but they are also adaptive systems, and so are practitioners. Thus, practitioners can and do work at the frontline of services, communities and families to create health in adaptive ways through their adaptive interactions.
Discussion Questions • What does ‘place’ mean to the community you work with? Are there different meanings and associations with place within the community? How do these compare with the meaning of place to professionals in your sector? • Can you identify any strategic documents that refer to ‘place-based’ intervention or strategy where you work?
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• What is your place within the place-based approaches you are aware of? What is your contribution? • Can you identify the ‘wicked’ complex health issues that are resistant to change in the communities where you work? What assumptions do people have about these issues? How could dialogue be facilitated to develop a theory of change?
References A Better Start, 2018. Knowledge and learning programme briefing. ,https://www.tnlcommunityfund.org.uk/ media/documents/a-better-start/A-Better-Start-briefing.pdf?mtime520181207102227. (accessed 02/04/2020). Antonovsky, A., 1979. Health, Stress and Coping. Jossey-Bass Publishers, San Francisco. Ardern. K., 2015. Bottom up working for effective place-based leadership. ,https://www.nhsconfed.org/blog/ 2019/03/bottom-up-working-for-effective-place-based-leadership. (accessed 02/04/2020). Bellis, M.A., Lowey, H., Leckenby, N., Hughes, K., Harrison, D., 2014. Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. J. Public. Health 36, 8191. Braithwaite, J., 2014. Changing how we think about healthcare improvement. BMJ 2018;361:k2014. Cabaj, M., Weaver, L., 2016. Collective Impact 3.0: An Evolving Framework for Community Change. Tamarack Institute for Community Engagement, Waterloo, Ontario. ,http://www.tamarackcommunity.ca/ collectiveimpact. (accessed 02/04/2020). Carey, G., Crammond, B., De Leeuw, E., 2015. Towards health equity: a framework for the application of proportionate universalism. Int. J. Equity Health 14, 81. Carey, G., Crammond, B., 2017. A glossary of policy frameworks: the many forms of ‘universalism’ and policy ‘targeting’. J. Epidemiol. Community Health 71, 303307. Center on the Developing Child, 2007. InBrief: early childhood program effectiveness. ,https://developingchild .harvard.edu/resources/inbrief-early-childhood-program-effectiveness/. (accessed 02/04/2020). Centre for Community Child Health, 2011. Place-Based Approaches to Supporting Children and Families. Policy Brief no. 23. The Royal Children’s Hospital, Melbourne, Centre for Community Child Health, ,https://www .rch.org.au/ccch/publications-resources/policy-brief/. (accessed 02/04/2020). Commission on Social Determinants of Health, 2008. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. World Health Organization, Geneva. ,https://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng. pdf;jsessionid55E2B8DB9EAB0C9FA015CAF9F58EBFBAD?sequence51. (accessed 08/04/2019). Cowley, S., Whittaker, K., Malone, M., Donetto, S., Grigulis, A., Maben, J., 2018a. What makes health visiting successful—or not? 1. Universality. J. Health Visiting 6 (7), 352360. Cowley, S., Malone, M., Whittaker, K., Donetto, S., Grigulis, A., Maben, J., 2018b. What makes health visiting successful—or not? 2. The service journey. J. Health Visiting 6 (8), 404412. Davidson-Knight, A., Lowe, T., Brossard, M., Wilson, J., 2017. A Whole New World: Funding and Commissioning in Complexity. Collaborate, Newcastle University Newcastle. ,http://wordpress.collaboratei.com/wp-content/ uploads/A-Whole-New-World-Funding-Commissioning-in-Complexity.pdf. (accessed 10/09/2019) Dejours, C., 2006. Subjectivity, work, and action. Crit. Horiz. 7 (1), 4562. Department of Health, 2009. Healthy Child Programme: Pregnancy and the First 5 Years of Life. Department of Health, London, ,https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/167998/Health_Child_Programme.pdf. (accessed 02/04/2020). Donetto, S., Malone, M., Hughes, J., Morrow, E., Cowley, S., Maben, J., 2013. Health Visiting: the Voice of Service Users Learning from Service Users’ Experiences to Inform the Development of UK Health Visiting Practice and Services. Kings College, London, https://www.kcl.ac.uk/nmpc/research/nnru/publications/index (accessed 03/04/2020). Elia, G., Margherita, A., 2018. Can we solve wicked problems? A conceptual framework and a collective intelligence system to support problem analysis and solution design for complex social issues. Technol. Forecast. Soc. Change 133, 279286.
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Ham, C., Alderwick, H., 2015. Place-Based Systems of Care: A Way Forward for the NHS in England. The King’s Fund, London. Heckman, J.J., 2007. The cconomics, technology and neuroscience of human capability formation. Proc. Natl Acad. Sci. 104 (3), 1325013255. Hill, A., 2016. How the UK halved its Teenage Pregnancy Rate. Guardian 18 June 2916. ,https://www.theguardian. com/society/2016/jul/18/how-uk-halved-teenage-pregnancy-rate-public-health-strategy. (accessed 03/05/2019). Hinkley, T., Timperio, A., Watson, A., Duckham, R.L., Okely, A.D., et al., 2020. Prospective associations with physiological, psychosocial and educational outcomes of meeting australian 24-hour movement guidelines for the early years. Int. J. Behav. Nutr. Phys. Act. 17 (1), 36. Houston, A., 2007. Complex community-based interventions. In: Cowley, S. (Ed.), Community Public Health in Policy and Practice: a Sourcebook, second ed. Baillie`re Tindall, London. Kania, J., Kramer, M., 2011. Collective impact. Stanford Soc. Innov. Rev. Winter 9 (1), 2011, ,https://ssir.org/ articles/entry/collective_impact. (accessed 02/04/2020). Masten, A.S., 2014. Ordinary Magic: Resilience in Development. Guilford Press, New York. Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., et al., 2010. Fair Society, Healthy Lives: The Marmot Review. Strategic Review of Health Inequalities in England Post-2010. Marmot Review, London, ,http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review. (accessed 08/04/2019). Marmot, M., 2015. The Health Gap: the Challenge of an Unequal World. Bloomsbury, London. Marmot, M., Allen, J., Boyce, T., Goldblatt, P., Morrison, J., 2020. Health Equity in England: The Marmot Review 10 Years On. Institute of Health Equity, London. Available at: , http://www.instituteofhealthequity.org/ about-us/the-institute-of-health-equity/our-current-work/collaborating-with-the-health-foundation- . (accessed 07/04/2020). McGarvey, D., 2017. Poverty Safari: Understanding the Anger of Britain’s Underclass. Luath Press, Edinburgh. Moini, G., 2011. How participation has become a hegemonic discursive resource: towards an interpretivist research agenda. Crit. Policy Stud. 5 (2), 149168. National Scientific Council on the Developing Child, 2010. Early experiences can alter gene expression and affect long-term development: Working paper No. 10. ,https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna ssl.com/wp-content/uploads/2010/05/Early-Experiences-Can-Alter-Gene-Expression-and-Affect-Long-TermDevelopment.pdf. (accessed 03/05/2019). Naylor, C., Wellings, D., 2019. A Citizen-Led Approach to Health and Care: Lessons from the Wigan Deal. The Kings Fund, London, ,https://www.kingsfund.org.uk/projects/lessons-wigan-deal. (accessed 08/07/2019). NHS England, 2014. Five Year Forward View. ,https://www.england.nhs.uk/publication/nhs-five-yearforward-view/. (accessed 09/04/2019). NHS England, 2019. The NHS Long Term Plan. NHS England. Available at: , https://www.longtermplan.nhs .uk/publication/nhs-long-term-plan/ . (accessed 07/04/2020). Pearce, A., Dundas, R., Whitehead, M., Taylor-Robinson, D., 2019. Pathways to inequalities in child health. Arch. Dis. Child. 104, 9981003. Reeves, A., Basu, McKee, M., Marmot, M., Stuckler, D., 2013. Austere or not? UK coalition government budgets and health inequalities. J. R. Soc. Med. 106, 3236. Scottish Government, 2015. Tackling Inequalities in the Early Years: Key Messages from 10 years of the Growing up in Scotland Study. Scottish Government, Edinburgh, ,http://www.gov.scot/Resource/0048/00486755 .pdf. (accessed 09/08/2016). Shonkoff, J., 2020. Stress, Resilience, and the Role of Science: Responding to the Coronavirus Pandemic. Center on the Developing Child at Harvard University. Available at: , https://developingchild.harvard.edu/stressresilience-and-the-role-of-science-responding-to-the-coronavirus-pandemic/ . (accessed 03/04/2020). Stephenson, B., 2016. Evaluation of breastfeeding network: final report. The Breastfeeding Network Paisley. ,https://www.breastfeedingnetwork.org.uk/wp-content/uploads/2016/06/BfN-Blake-Stevenson-Evaluationreport-V5-1Apr.pdf. (accessed 09/09/2019). Wanless, D., 2002. Securing our Future Health: Taking a Long-Term View: Final Report. HM Treasury, London, ,http://image.guardian.co.uk/sys-files/Society/documents/2002/04/17/contentsp1.pdf. (accessed 09/04/2019). WAVE, 2013. Conception to Age Two: the Age of Opportunity. The WAVE Trust, London.
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West, M., Eckert, R., Steward, K., Pasmore, B., 2014. Developing Collective Leadership for Health Care. The King’s Fund & Center for Creative Leadership, London. World Health Organisation, 1946. Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946. , https://www.who.int/governance/ eb/who_constitution_en.pdf . (accessed 02/04/2020).
Further reading and resources Bottom-up working for effective place-based leadership. https://www.nhsconfed.org/blog/2019/03/bottom-upworking-for-effective-place-based-leadership (accessed 02/04/2020). More information about Case Study 3. Kate Ardern, director of public health for Wigan Council, reflects on place-based working and the qualities NHS leaders need to consider as they develop the neighbourhood, place and system vision for integrated care system) working described by the NHS Long Term Plan. Davidson-Knight, A., Lowe, T., Brossard, M., Wilson, J., 2017. A Whole New World: Funding and Commissioning in Complexity. Newcastle University, Newcastle, This challenges the ‘markets’ approach to commissioning of services. Dejours, C., 2006. Subjectivity, work, and action. Crit. Horiz. 7 (1), 4562. Christophe Dejours provides an insight into the nature of work from a psychological view and what he calls the ‘double bind’ of ‘prescribed flexibility’—the requirement to be compliant with imperatives prescribed by the organisation (such as achieving key performance indicators) and the requirement to be flexible, because our work is in unpredictable, even messy, environments. Jones-Devitt, S., Smith, L., 2007. Critical Thinking in Health and Social Care. Sage, London, This resource provides a number of critical thinking tools, see especially Chapter 9 ‘Chaos and Complexity Theories’. Local Government Association & District Councils Network, 2019 (Shaping Healthy Places, Exploring the district council role in health. https://www.local.gov.uk/shaping-healthy-places-exploring-district-council-rolehealth) (Accessed 02/04/2020). Explains the role of local councils in creating healthy environment and has several case studies of place-based initiatives. Naylor, C. (Ed)., 2019. Creating Healthy Places: perspectives from NHS England’s Healthy Towns programme. ,https://www.kingsfund.org.uk/publications/creating-healthy-places. (accessed 02/04/2020). The King’s Fund, London. Provides a comprehensive collection of short case examples from the NHS Healthy Towns Programme conceived with Public Health England. These illustrate how healthy places can be created with close working across diverse but related sectors, including: the NHS, local authority planning teams, developers, public health departments, third sector organisations and local communities.
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C H A P T E R
4 Planning public health strategies Louise Condon and Amanda Jane Thomas KEY ISSUES • What are public health strategies?
• Planning for Gypsies, Roma and Travellers’ immunisations
• The policy context of public health planning • Two case studies • Planning for the health of asylum seekers
• Applying public health planning to your own practice
Introduction Until fairly recently, health policy in the United Kingdom (UK) was thought to be about how the health service is funded and the provision of medical care. However, health is not just the realm of the health service but engages all sectors of society. Inequalities and health outcomes are reliant on community and individual resources as well as an individual’s genetic blueprint, and it is the reduction of health hazard that can help reduce the burden of disease. Changes in philosophy in the past few years acknowledge that it is not just the state of being in good or bad health that influences mortality and morbidity, but also the social determinants of health (Wilkinson and Marmot, 2003). Increasingly it is recognised that health is closely related to status within society, and the more socially and economically favoured people are, the better their health (Marmot, 2010). Public health is about population health, and its origins lie in economic, social, environmental and ecological aspects of health and disease. It is both a collective and an individual issue, and the health of the population is affected by the policies of many government departments, such as those responsible for agriculture and food production, the fiscal system and transport. Thus, health is highly reliant on wider influences outside the control of
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the NHS. Dahlgren and Whitehead’s diagram (see Figure 2.2, p. 38) depicts the determinants of health, which have a profound effect on individuals’ health and wellbeing. The World Health Organization (2008) defines the social determinants of health as the conditions in which children and families grow, live, work and age.
What are public health strategies? The broad-based National Health Service (NHS) and local authority strategies are set by the government and are based on assessments of need, party ideologies and, indirectly, what the electorate has mandated. The past few years have seen a plethora of policy changes that have centred on the community, with the focus on public health, partnerships and public participation. In 1985, the World Health Organization identified international public health principles, which include peace and freedom from fear of war, equal opportunity for all, social justice, satisfaction with basic needs, public commitment and public support. These principles are based on values of preserving human dignity, enhancing social justice and community responsibility, maintaining health and wellbeing, and improving quality of life (Levy, 1998). It is apparent when one considers recent global conflicts, as well as increasing health inequalities between and within countries, that these core public health principles are difficult to uphold, but they continue to form the basis of public health practice. A strategy is a corporate plan, which can be developed at a local or national level. Strategies can be developed to encompass a geographical area or to focus on a specific aspect of health. Where there is a health issue or problem for a specific condition or population group, the public health expertise is concentrated around the problem. A team of public health workers are needed to bring together the necessary skills and expertise to address the specific health issue. Team members come from very different agencies and either assume an advisory role or become the ‘hands-on’ practitioners, working to a strategic plan that has a common aim and focus. The team must evaluate and review the outcomes. The reality of teamwork is that it is not easy and involves complex relationships. Although it is often thought to be a panacea for good practice, it involves commitment and time to make it work. A vital part of team working is that team members share goals and vision, values and aspirations.
The policy context of public health planning This chapter provides examples of public health strategies that have been planned and implemented by public health workers. This approach has been taken to demonstrate how such initiatives are put in place to address pressing health needs, and to stimulate readers to consider how this can be applied to their own practice. Before moving on, it is necessary to consider the framework within which public health initiatives take place. Many public health workers are not familiar with the process by which policies are formed at a national level, but this process has a profound impact on the resources and capacity available to workers to meet public health challenges at a local level.
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One framework describes four steps of the policy process which can be applied to national and local policy making (Green and Thorogood, 1998): 1. Setting the agenda—How some social problems come to the fore of government and public attention and become the objects of policy making 2. Formation—How possible responses to these problems are identified and which groups in society claim a legitimate role in forwarding solutions 3. Implementation—How policy initiatives are decided on and put into practice 4. Evaluation—How the outcomes of policy are evaluated, whether it meets its implicit objectives and what unintended impacts it has had and upon whom Tackling health inequalities among disadvantaged groups is a major focus of policy across the UK (Department of Health, 2004; Marmot et al., 2010). In 2015, Public Health England suggested that the gap in inequalities is unlikely to close in light of the current political climate, which adds weight to the need for inclusivity and a ‘whole of society’ approach to achieving health goals. At the national level, a landmark act in policy making is the Wellbeing of Future Generations (Wales) Act (Welsh Government, 2015a). This proposes ambitious long-term goals for sustainable development by 2030, putting the onus on both professionals and the public to contribute to wellbeing with a strong emphasis on empowering individuals to take the lead in caring for their own health. Under this Act, public bodies in Wales are required to (1) consider the long-term impact of their decisions; (2) to work better with people, communities and each other; and (3) to prevent persistent problems such as poverty, health inequalities and climate change. This Act is attracting interest from countries across the world as it offers a new opportunity to make a longlasting, positive change to the health of current and future generations. While professional and expert views on major public health issues are important, so also are the views of those who use services. It can be seen from Green and Thorogood’s (1998) framework that, all too easily, the agenda of interest groups can dominate policy making, and those who use services can be excluded from forming responses to problems and influencing solutions. When planning public health strategies, it is important to take into account innate resourcefulness, and the ability of individuals to meet their own needs using their social networks and the capacity and resources of local communities (Social Care Institute for Excellence, 2015). The challenge is to respect the strength and skills of service users and work alongside them to effect change. ‘Alongsideness’ is founded on human worth, and belief that all people are valuable (Pound and Grant, 2008 and see Chapter 15). Working collaboratively promotes opportunity for individuals to participate in planning and become coproducers of services and support (Social Care Institute for Excellence, 2015). These concepts are demonstrated in the following case studies.
Public health planning case studies To demonstrate the work of public health practitioners, we look at two case study examples. In both case studies public health planning was needed to address an issue which affects both individual and population health. Both case studies are concerned with
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the health of marginalised groups who experience major health inequalities in comparison with the majority population. These inequalities include access to health services, as well as poverty and frequent exposure to racism and discrimination.
Case Study 4.1: Public health planning for asylum seekers Migration is a growing issue in the 21st century. There are many reasons why people migrate from their country of origin. First, many move to improve their life chances in a country in which they are entitled to live and work. Most people who migrate to the UK fall into the category of ‘economic migrants’ and are more likely to be employed than the general population, and have a higher standard of education. Economic migrants do not usually require specialist health services, but they do experience barriers to accessing health care due to unfamiliarity with health systems, inflexible work and language difficulties. Additionally, recent research has shown that positive health behaviours, such as exclusive breastfeeding in the first 6 months, not smoking and avoiding alcohol, can be lost once settled in the UK (Hawkins et al., 2008; Condon and McClean, 2016). It is therefore important for public health practitioners to take into account the health needs of new arrivals to the UK by thorough assessment and targeted health promotion. Asylum seekers most commonly come to the UK after fleeing from war or persecution in their own counties. The United Nations reported in 2015 that across the world, 1 in 113 people are displaced, more than after the Second World War. Thus forcibly displaced people comprise 1% of the global population, which is more than the entire population of the United Kingdom. An asylum seeker is defined as a person who has not yet achieved refugee status, while a refugee has been granted permission to stay in the UK due to fear of persecution in their homeland, arising from their race, religion, nationality, social group or political opinion. Refugees can be resettled from a country in which they have sought protection to a third country which has agreed to admit them as refugees so they can rebuild their lives (Refugee Council, 2019). This has happened in the UK under the Syrian resettlement scheme, by which the government agreed in 2015 to resettle 20,000 of the most vulnerable Syrian asylum seekers (survivors of torture, people with serious medical conditions and women with children) by 2020. Otherwise to apply for asylum in the UK, applicants must be on UK territory and therefore some people resort to dangerous means to arrive on British soil. In 1999, the UK government made the decision to disperse asylum seekers away from London and South East England. Until this time most people seeking asylum arrived in the South East, but they now travel to a variety of nominated destinations through the UK after assessment in a regional centre (Scottish Refugee Council, 2019). As a result, asylum seekers are frequently housed in the poorest parts of the UK, such as in Glasgow, Northern England and Wales, primarily due to the availability of more affordable housing. One analysis showed that 57% of asylums seekers are accommodated in the poorest third of the UK, while only 10% are placed in the richest third (Lyons and Duncan, 2017). Local authorities are then responsible for the provision of services such as education and basic health care to asylum seekers.
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Once in their new town or city, asylum seekers are provided with Home Office commissioned accommodation, basic furniture and a weekly allowance for food and travel (approximately d37 per week per person in 2019). An HC2 certificate allows asylum seekers to access dental treatment, sight tests and free NHS prescriptions. Asylum seekers cannot choose where they wish to live in the UK and can be moved with very short notice if alternative accommodation is needed. Currently only women who are due to have a baby within a few weeks are protected from being moved to a new area of settlement. A recent report highlighted the detrimental effect of unexpected short-notice relocation of asylum seekers, particularly for those with chronic conditions or during pregnancy (Russell et al., 2019). Swansea, a city in South Wales, has a well-established public health strategy for providing health services to asylum seekers who are settled in the area. A key provider of health care is the Health Access service which is provided by a small team of public health workers. This service was set up in 2001 by a public health consultant and lead health visitor, in response to the dispersal policy adopted by the UK government. There are four dispersal centres in Wales which have different models of health provision for asylum seekers; these vary from general practitioner (GP)-led services to a nurse-led service just for adults. The public health nursing team in Swansea consists of four community nurses, three of whom are registered health visitors. Since before the start of the NHS health visitors have been recognised for their public health role, and these skills are fully used in working with asylum seekers. The Swansea Health Access team provide a range of public health services for adults and children. Children younger than 5 years are referred to their local health visitors and receive the Healthy Child Wales Programme (Welsh Government, 2015b). Once notified of asylum seekers arriving in Swansea, the Health Access team make contact within 1 week to assess, share information and refer as appropriate to secondary or third sector services. The assessment usually takes an hour, and if necessary, follow-up is provided in the clinic or at home. With clients’ consent, copies of health assessments are sent to GPs, health visitors and midwives to avoid duplication of work. The team continue to act as advocate for clients, who can attend the daily drop-in clinic for assistance and signposting to other agencies. Services offered to adult asylum seekers by the Health Access team include the following: • • • • • • •
Assessment of physical and mental health Height and weight, blood pressure and urinalysis Immunisation Screening for bloodborne viruses Screening for tuberculosis GP registration Referral to primary and secondary services (including maternity, dental, sexual health, female genital mutilation clinic) • Health promotion and information on accessing health care in the UK • Referral for social support and mentorship • Joint assessment with looked after children nurse for unaccompanied asylum seeker children.
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The Health Access service has evolved over time in response to changing client needs and the policy context of service provision. Since 2005, almost all GP practices in the city have developed enhanced services for asylum seekers. Many asylum seekers have been the victims of trafficking and sexual exploitation, which has increased the complexity of initial assessments conducted by the Health Access team, and referrals to statutory and third-sector mental health agencies. The team must be flexible in their work and able to adapt to a constantly changing clientele with high health needs. The nationality of those using the service changes according to where conflict is in the world, with service users most commonly from Iraq, Iran, Turkey and Syria in 2019. Language and literacy difficulties are commonplace in any asylum seeker client group. In addition to being proficient in working across language barriers (often using online concurrent translation services), the team are highly creative in developing resources to assist people new to the area. These include maps and photographs of the outside of buildings on referral letters. All new asylum seekers are offered a mentor who is a refugee or asylum seeker themselves. This performs the dual purpose of supporting new arrivals and offering volunteering opportunities to those with experience. The mentoring scheme is part of the ‘A Better Welcome to Swansea Project’ for 2018-2020 (for information, access https://swansea.cityofsanctuary.org/what-we-do/a-better-welcome-to-swansea-project), which has the aim of building confidence and reducing isolation. It is a short-term intervention, typically consisting of two to eight sessions (depending on assessed needs) to help new asylum seekers ‘find their feet’ in their new community. This scheme exemplifies how community assets can support health and wellbeing, ranging from professional skills, knowledge and competencies, local groups through to voluntary organisations, public, private and third-sector assets.
BOX 4.1
What Is a City of Sanctuary? City of Sanctuary is a national movement where local people and communities work together to make their cities places where new arrivals are welcomed and where they can begin to feel safe from war and persecution. City of Sanctuary support can include community centres, charities, social clubs, schools, local services and businesses, as well as refugee organisations and volunteers.
Supporting organisations promise to welcome and include people seeking sanctuary in their activities. City of Sanctuary UK enjoys close partnerships with all the major refugee organisations and is committed to working with them to build a united voice to advocate for people seeking sanctuary in our nations and worldwide.
In May 2010, Swansea became the UK’s second official City of Sanctuary (see Box 4.1). This demonstrates how public health planning has been taken beyond a simplistic focus on the health need of the individual and has extended to community and policy levels of involvement to address the social determinants of health. In addition to encouraging
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interaction between a range of supportive agencies, efforts are made to reduce societal prejudice against asylum seekers, refugees and migrants as a whole—for instance, by encouraging the reporting of hate crimes. Plans are now in place for Wales to become a Nation of Sanctuary for those fleeing war and persecution. The voice of asylum seekers themselves also needs to be heard when planning targeted health initiatives. This has been reflected in the evaluations that have been carried out of the provision for asylum seekers in Wales. In 2017, the report ‘I used to be someone’: Refugees and Asylum Seekers in Wales found that refugees and asylum seekers’ experiences of service provision across Wales generally lacked consistency (Equality, Local Government and Communities Committee, 2017). In 2019, a report on the health experiences of migrants in Wales was published (Russell et al., 2019). This concluded that specialist services play a valuable role in building trust and helping people navigate through unfamiliar systems. However, mainstream services often lacked the resources and training to tailor services to asylum seekers’ needs. Recommendations were made for health professional training on the social and legal issues affecting those seeking sanctuary, as well as on cultural issues and health systems in countries of origin (Russell et al., 2019). Providing access to interpreting services and translation of resources was identified as a key factor in raising health literacy among people who migrate to the UK.
Case Study 4.2: Public health planning for Gypsies, Roma and Travellers The second case study is concerned with immunisations for a marginalised group. Immunisation is an important part of public health planning because it is an effective, cost-effective and well-established means of reducing risks to population health. In 2013, the National Institute for Health Research commissioned a large-scale qualitative study to explore the barriers and facilitators to immunisation among Gypsy and Traveller communities in the UK (Jackson et al., 2016). This means that at a national level, the reasons for lower uptake of immunisations in Gypsy and Traveller communities were a pressing policy concern. Therefore, the National Institute for Health Research decided to invest in public health research to address this health issue. The research team that won the funding included public health workers in addition to researchers and members of Gypsy/Traveller communities. Public health workers were able to bring their knowledge of public health planning to the research team. Working in partnership with Gypsies and Travellers was also centrally important, and community members contributed to the design of the study, conducted interviews with peers and assisted with interpreting the data. Public involvement is important in research to ensure that research is done with people, rather than to people. In this way, solutions can be found to pressing public health problems which are relevant to communities. Gypsies and Travellers are an ethnic group included in the 2011 UK census. In this census 58,000 people (0.1% of the usual resident population of England and Wales) identified themselves as Gypsy or Irish Traveller; however, this is thought to be an underestimate of overall numbers. Gypsies and Irish Travellers are on average younger than the general population (39% are younger than 20 years), more likely to have no qualifications and to
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have dependent children. Approximately a quarter of Gypsies and Travellers lived in a caravan or chalet, with the rest living in bricks-and-mortar housing (Office of National Statistics, 2014). Scotland’s 2011 census showed that 0.1% of the population self-identified as ‘White: Gypsy/Traveller’ (Scottish Government, 2015), and in Ireland 0.6% of the population were Irish Travellers (Irish Government, 2012). Barriers to accurate data collection include low literacy levels and reluctance to identify as a Gypsy or Traveller due to stigma and fear of discrimination. Also related to the Gypsy and Traveller ethnicity are New Age Travellers, Boat People, Showpeople and Roma people from a variety of European counties (Van Cleemput, 2010); however, these groups were not included in the 2011 census ethnic classification of Gypsy/Traveller. Roma people have a Gypsy heritage, and it is estimated that 10 to 12 million live in Europe. They are the largest ethnic minority in the European Union and experience social exclusion, discrimination and unequal access to employment, education and health (European Commission, 2017). Many Roma people live in highly deprived circumstances before migrating to the UK; for instance, almost 100% of Roma in Italy, France and Portugal are at risk of poverty (European Union Agency for Fundamental Rights, 2014). The number of Roma people moving to the UK increased from the mid-2000s when some Eastern European countries with significant Roma populations acceded to the European Union. In the UK, Roma people are likely to live in multi-occupancy rented accommodation. Roma people experience the challenges of being recent migrants, such as unfamiliarity with the UK health system. The rationale for commissioning this research was increasing concern about low and variable immunisation rates are among Gypsies and Travellers. Finding exact figures is difficult, as the NHS dataset does not include Gypsy/Traveller ethnicity. However, a number of studies suggest low rates of immunisation (Dar et al., 2013; Feder et al., 1993), with one reporting a 100-fold higher risk of measles (Maduma-Butshe and McCarthy, 2013). Significantly, there was a lack of knowledge about the reasons for low uptake of immunisation. Generally in the UK, there has been an increase in the number of measles outbreaks linked to suboptimal levels of measles, mumps and rubella immunisation from the mid1990s. For instance, a measles outbreak started in Wales when 4 children returned from a holiday camp with the virus and led to more than 1000 cases of measles, resulting in 88 people being admitted to hospital and the death of a 25-year-old man (Public Health Wales, 2013). In areas with pockets of low immunisation in the population, outbreaks of disease can occur (see Chapter 14 for fuller discussion on immunisation). The first aim of the UNITING (Understanding uptake of immunisations in Travelling and Gypsy communities) study (Jackson et al., 2016) was to explore the reasons why Gypsies and Travellers either receive or do not receive immunisations. In the first phase of the study, 174 interviews were conducted with community members and then 39 interviews with service providers in 4 UK cities. Community members were all older than 16 years and included young people, mothers, fathers and grandparents. They came from the following groups: • Romanian Roma • Slovakian Roma • English Gypsies
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• Irish Travellers • Scottish Showpeople Service providers were a mix of front-line workers, such as health visitors, and those in strategic roles, such as commissioners. The main findings were that most Gypsy, Roma and Traveller communities are broadly accepting of vaccination and believe it to be a positive way of maintaining good health (Jackson et al., 2016, 2017). All communities valued trusting relationships with health professionals, and it was evident that some service providers were expert in tailoring their approach for Travellers despite challenges such as funding cuts. A minority of Englishspeaking participants were concerned about multiple or combined childhood vaccines, particularly the measles, mumps and rubella vaccine. Some communities mentioned cultural beliefs as a barrier to immunisation. For instance, one Irish Traveller father said of antenatal vaccines: ‘These are needles that women don’t take when they are pregnant because to them it’s God’s fate’. HPV vaccination was also potentially contentious, and an Irish Traveller mother said: ‘We’re not into . . . giving that one to the young ones, our girls aren’t promiscuous’. Accessing immunisation services was often a problem for service users. This could be due to school attendance (particularly for human papillomavirus), poverty, housing and discrimination. One major barrier to accessing immunisation services in all communities was problems with literacy and language (Box 4.2). This study provided clear guidance about how to make immunisation services more accessible to Gypsies, Roma and Travellers. In the final phase of the study, community members and professionals came together in workshops in Glasgow, London, Bristol and York to discuss what interventions might be feasible and acceptable to help community members access the immunisations they want. To do this they considered what was known about barriers and facilitators to immunisation from phase 1 interviews. In the workshops, five interventions were identified as most important; all were related to the public health values of preserving human dignity, enhancing social justice and community responsibility, maintaining health and wellbeing, and improving quality of life (Levy, 1998). The five priority interventions agreed by the Gypsies, Roma, Travellers and health professionals who participated in workshops were as follows: 1. Training for health professionals to understand Traveller ways of life 2. Identification of Travellers in health records to tailor support and check uptake 3. Provision of a named front-line person in GP practices to provide a respectful and supportive service 4. Flexible systems for booking appointments, recall and reminders 5. Protected funding for health visitors specialising in Traveller health Since the study was completed, the findings have been used as evidence in significant reports such as the House of Commons report, ‘Tackling the inequalities faced by Gypsy, Roma and Traveller communities’ (Women and Equalities Committee, 2019). This demonstrates the importance of community nurses engaging in research and adding to public health knowledge. The Women and Equalities Committee report stated that, ‘Gypsy, Roma
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BOX 4.2
Language and literacy barriers to accessing immunisations for Gypsies, Roma and Travellers
Roma It would be better if they could send a letter . . . in Romanian because some people can’t, don’t understand what it’s all about . . . some people who don’t know how to write and read it’s difficult, and then they don’t understand what the letter is about so then they don’t turn up for vaccination or they think it’s something worse, being scared. —Romanian Roma, grandfather, Bristol They can’t read the letters to start with, all they want is an appointment to know when they can go. —Health visitor, Bristol I mean we routinely hear about receptionists being rude to people, and doing the kind of shouting at people as if raising their voice could help with the communication . . . when in fact all they need to do is type a number into their phone, pick it up and it’s a speak phone system. —Social Services team leader, Glasgow
Irish Travellers and Gypsies Half of these women can’t read or write and they’re embarrassed, and not to talk ‘big talk’ with the big words, to make it basic so as a
Traveller woman can understand what they’re on about. —Irish Traveller, young woman with no children, Bristol Like you go up to the hospital you see all these leaflets . . . about needles . . . if you could read, you could sit and read them. But you go up to a GP they’ve got nothing up like that in . . . the waiting room. . . . They’ve got leaflets but it’s got no pictures of what they mean. —English Gypsy, mother, York And the other thing . . . that’s really important is the level of literacy and literacy expectations, that isn’t considered quite often at commissioning level, because people don’t understand functional literacy and they don’t understand the sort of ideas about literacy and the truth of text embedded in a nongraphical, still a non-graphical society; it’s still not focused on text in the same way as the majority culture in the UK which means that giving information [on] posters or that sort of public health campaign, isn’t as appropriate . . .. and that’s a sociological anthropological thing that often isn’t taken into account when you’re trying to engage people with information. —Practice nurse, London Adapted from Jackson et al., 2016.
and Traveller people feel that they are, at best, ignored and, at worst, actively discriminated against in public services and policy making’ (p. 3). A strong recommendation was made that data be collected by the NHS about people of Gypsy, Roma and Traveller ethnicity to facilitate policy making and resource allocation and tackle inequalities. Including Gypsies, Roma and Travellers in the NHS dataset is a prerequisite for public health planning (Women and Equalities Committee, 2019). In order to decide that any health issue is a priority, information must be collected nationally and locally. This data then informs an agenda for action, and is therefore a crucial part of public health strategy planning.
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Applying public health planning to your own practice A key feature of each of the case studies was empowerment. For both asylum seekers and Gypsy/Traveller communities it was important to involve members of the target groups in sharing their experience and working with service providers to raise the quality and accessibility of the services offered. Opportunities for health promotion activities allow us to empower families. An in-depth understanding of empowerment is needed for public health workers to understand how relationships operate in order to guide and influence further practice (Aston et al., 2006). If empowerment relies solely on sharing expert knowledge, the effect will be minimal and less likely to make a difference (see Arnstein’s ladder of participation in Chapter 2, p. 42). This is particularly so in areas of deprivation where the priority may just be to meet basic needs (McKee et al., 2011). Strengthening communities through community development and community regeneration strategies involves a more integrated approach. Working in partnership highlights the issue of power and implies sharing power with individuals, families and communities, and participation on an equal level (Green et al., 2015). This is a prime consideration when planning public health initiatives.
Conclusion This chapter has been concerned with planning public health strategies. Both case studies were concerned with groups which are marginalised in society and experience severe health inequalities. It is a public health priority to address these health inequalities to improve the health of the whole population. Use of Dahlgren and Whitehead’s (1999) model makes it possible to see how the social determinants of health need to be taken into account to meet the health needs of the most disadvantaged. Front-line public health workers have a core role in the planning, delivery and implementation of public health strategies.
Discussion Questions • What are the priority public health issues in the area in which you work, and what is currently being done to address these? • Looking at the demographic data produced by your local public health department, which groups of people experience the greatest health inequalities in the area in which you work? Is this linked to geographical area or to issues of ethnicity, culture, age or gender? • How do service user views contribute to the planning and evaluation of public health strategies in your practice? • What other agencies do you work with, and how could you develop this interdisciplinary practice to address the health needs of local people?
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Acknowledgements The authors thank Jean Saunders and the Swansea Health Access team for sharing their expertise, and all researchers and participants in the UNITING study. The UNITING project described in Case Study 2 was funded by the National Institute for Health Research Health Technology Assessment Programme (12/17/05). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Health Technology Assessment Programme, NIHR, NHS or the Department of Health.
References Aston, M., Meagher-Stewart, D., Sheppard-Lemoine, D., Vikic, A., Chirop, A., 2006. Family health nursing and empowering relationships. Paediatric Nurs. 32 (1), 6167. ,https://search.proquest.com/docview/ 199457220?accountid514680. (accessed 30/03/2020). Condon, L., McClean, S., 2016. Maintaining pre-school children’s health and wellbeing in the UK: a qualitative study of the views of migrant parents. J. Public. Health (Oxford) 39 (3), 455463. Available from: https://doi. org/10.1093/pubmed/fdw083 (accessed 30/03/2020). Dahlgren, G., Whitehead, M., 1999. Policies and Strategies to Promote Equality in Health. Health 21: Health for all Policy Framework for the European Union. WHO, Copenhagen. Dar, O., Gobin, M., Hogarth, S., Lane, C., Ramsay, M., 2013. Mapping the gypsy traveller community in england: what we know about their health service provision and childhood immunization uptake. J. Public. Health (Oxford) 35 (3), 404412. Department of Health, 2004. National service framework for children, young people and maternity services. ,https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/199952/ National_Service_Framework_for_Children_Young_People_and_Maternity_Services_-_Core_Standards.pdf . (accessed 30/03/2020). Equality, Local Government and Communities Committee, 2017. “I used to be someone”: Refugees and asylum seekers in wales. ,http://www.assembly.wales/laid%20documents/cr-ld11012/cr-ld11012-e.pdf. (accessed 30/03/2020). European Commission, 2017. EU and Roma. [online] , http://ec.europa.eu/justice/discrimination/roma/ index_en.htm . (accessed 30/03/2020). European Union Agency for Fundamental Rights, 2014. Poverty and employment: the situation of Roma in 11 EU Member States. European Union Agency for Fundamental Rights, Luxembourg. Feder, G., Vaclavik, T., Streetly, A., 1993. Traveller gypsies and childhood immunization: a study in east London. Br. J. Gen. Pract. 43 (372), 281284. Green, J., Thorogood, N., 1998. Analysing Health Policy: A Sociological Approach. Longman, London. Green, J., Cross, R., Woodall, J., Tones, K., 2015. Health Promotion, Planning and Strategies, third ed. SAGE, New York. Hawkins, S., Lamb, K., Cole, T., Law, C., 2008. Influence of moving to the UK on maternal health behaviours: prospective cohort study. Br. Med. J. 336 (7652), 10521055. Irish Government 2012 Census, 2011. Profile 7 religion, ethnicity and irish travellers—ethnic and cultural background in Ireland. ,https://www.cso.ie/en/census/census2011reports/census2011profile7religionethnici tyandirishtravellers-ethnicandculturalbackgroundinireland/. (accessed 30/03/2020). Jackson, C., Dyson, L., Bedford, H., Cheater, F.M., Condon, L., Crocker, A., 2016. Understanding uptake of immunisations in travelling and gypsy communities (UNITING): a qualitative interview study. Health Technol. Assess. 20 (72), 1176. Jackson, C., Bedford, H., Cheater, F., Condon, L., Emslie, C., Ireland, L., et al., 2017. Needles, jabs and hags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among gypsies, travellers and roma. BMC Public. Health 17 (1), 254. Levy, B., 1998. Creating the future of public health: values, vision and leadership. Am. J. Public. Health 88, 188192.
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Lyons, K., Duncan, P., 2017. ‘It’s a shambles’: data shows most asylum seekers put in poorest parts of Britain. Guardian. 9 April. ,https://www.theguardian.com/world/2017/apr/09/its-a-shambles-data-shows-mostasylum-seekers-put-in-poorest-parts-of-britain. (accessed 13.09.18). Maduma-Butshe, A., McCarthy, N., 2013. The burden and impact of measles among the gypsy-traveller communities, thames valley, 200609. J. Public. Health Oxford 35 (1), 2731. Marmot, M., 2010. Fair society, healthy lives. ,http://www.instituteofhealthequity.org/resources-reports/fairsociety-healthy-lives-the-marmot-review. (accessed 30/03/2020). McKee, M., Sim, F., Pomerleau, J., 2011. Inequalities in health. In: Sim, F., McKee, M. (Eds.), Issues in Public Health, second ed. Open University Press, New York. Office of National Statistics, 2014. What Does the 2011 Census Tell us About the Characteristics of Gypsy or Irish Travellers in England and Wales? Office for National Statistics, London. Pound R., Grant R., 2008. Leadership Through Alongsideness. In Community Public Health: Policy and practice (Ed. S. Cowley) 2nd edition, pages 284304. Elsevier, London. Public Health England, 2015. A Guide to Community-Centred Approaches for Health and Wellbeing. Briefing. Crown Copyright, London ,https://assets.publishing.service.gov.uk/government/uploads/system/uploads/ attachment_data/file/402889/A_guide_to_community-centred_approaches_for_health_and_wellbeing__briefi___ pdf. (accessed 30/03/2020). Public Health Wales, 2013. Outbreak of measles in wales: report of the agencies which responded to the outbreak (Abertawe Bro Morgannwg University Health Board, Powys Health Board, Hywel Dda Health Board and Public Health Wales. Available at: ,http://www.wales.nhs.uk/sitesplus/888/news/29688 . (accessed 30/03/2020). Refugee Council, 2019. Refugee resettlement. ,https://www.refugeecouncil.org.uk/our-work/refugee-resettlement/. (accessed 30/03/2020). Russell, I., Khanom, A., Richardson, G., Russell, D., Scott, R., Snooks, H., 2019. Health experiences of asylum seekers and refugees in wales. Br. J. Gen. Pract. 69 (Suppl 1), bjgp19X703121. Scottish Government, 2015. Gypsy/Travellers in Scotland—a comprehensive analysis of the 2011 census. ,https://www.gov.scot/publications/gypsy-travellers-scotland-comprehensive-analysis-2011-census/pages/ 6/. (accessed 30/03/2020). Social Care Institute for Excellence, 2015. Care act guidance on strengths-based approaches. ,https://www.scie. org.uk/strengths-based-approaches/guidance. (accessed 30/03/2020). Van Cleemput, P., 2010. Social exclusion of gypsies and travellers: health impact. J. Res. Nurs. 15 (4), 315327. Welsh Government, 2015a. Wellbeing of future generations (Wales) act (2015). ,https://www.publichealthnetwork.cymru/en/topics/policy/well-being-of-future-generations-wales-act-2015/. (accessed 30/03/2020). Welsh Government, 2015b. An overview of the Health Child Wales Programme. ,https://gov.wales/sites/ default/files/publications/2019-05/an-overview-of-the-healthy-child-wales-programme.pdf. (accessed 30/03/2020). Wilkinson, R., Marmot, M. (Eds.), 2003. Social Determinants of Health: The Solid Facts. second ed. WHO Regional Office for Europe, Copenhagen. Women and Equalities Committee, 2019. Tackling the Inequalities Faced by Gypsy, Roma and Traveller Communities. House of Commons, London ,https://publications.parliament.uk/pa/cm201719/cmselect/ cmwomeq/360/report-summary.html. (accessed 30/03/2020). World Health Organization, 1985. Targets for Health for all. WHO, Geneva. World Health Organization, 2008. Closing the gap in a generation. Health equity through action on the social determinants of health. WHO, Geneva. ,https://apps.who.int/iris/bitstream/handle/10665/43943/ 9789241563703_eng.pdf?sequence 5 1. (accessed 30/03/2020).
Resources Condon, L, Ford, J., 2016. Institute of health visiting good practice points: working with minority groups. Working with migrant families ,http://ihv.org.uk/for-health-visitors/resources-for-members/resource/ minority-groups/working-with-gypsies-and-travellers/. (accessed 30/03/2020). Beach, H, Condon, L, Lally, S., 2014. Institute of health visiting good practice points: working with minority groups. Working with Gypsies and Travellers ,http://ihv.org.uk/for-health-visitors/resources-for-members/ resource/minority-groups/. (accessed 30/03/2020).
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C H A P T E R
5 Leadership development for public health practice Karen Stansfield KEY ISSUES • There is an abundance of leadership theories, but what are the main underpinning leadership theories in nursing and health? • How does health care policy direct the leadership role of public health practitioners?
• A new leadership model for public health practitioners that identifies the different components that are important to consider when developing your leadership role is discussed.
Introduction The development of leaders and leadership skills at all levels of the National Health Service (NHS) is perceived as central to the modernisation agenda of the NHS and other health care organisations across the United Kingdom (UK) (Department of Health Northern Ireland (DHNI), 2016; NHS Scotland, 2017a; Welsh Government, 2018a; NHS England, 2019). This is because developing leaders and leadership has been seen by governments as the key to establishing high-quality, safe and compassionate health care (NHS England, 2016; NHS Scotland, 2017b; Welsh Government, 2018b). Further, health care organisations are reminded of their ‘responsibility to provide compassionate leadership, ensuring that staff can understand what is expected of them and that they are supported and educated to fulfil their roles’ (NHS England, 2016, p. 124). Leadership has been described as an abstract concept that is ambiguous, difficult to define and continuously debated (Parry, 1998; Jackson and Parry, 2011; Northouse, 2018). Despite these challenges, however, leadership is a concept that shows no sign of waning within health care (Hartley et al., 2008).
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There is a lack of research examining how public health nurses understand leadership. The leadership development model presented in this chapter was developed through a research project as part of a doctorate in business administration programme (Stansfield, 2017). It focused on exploring how health visitors understand leadership in their practice, perceive their leadership role and how leadership is demonstrated in the delivery of the health visiting service in the NHS in England. First, this chapter explores the most effective approaches to leadership in nursing and health. The implications of health policy on leadership for public health practitioners are considered. Then, an explanation of the leadership development model is detailed, including its component parts and how it has been applied in practice through the Institute of Health Visiting (iHV) leadership development programme.
Underpinning leadership theories in nursing and health Who the leader is has been examined through the trait approach (Jackson and Parry, 2011). This was popular until the late 1940s and is based on the premise that leaders have specific personality traits that differentiate them from non-leaders. Thus one is seen as a born leader (Parry and Bryman, 2006). However, research into this approach examining consistent and unique personality traits showed no definite pattern (Yukl, 2013). What the leader does has been explained by the style approach (Northouse, 2018). This approach was prominent until the late 1960s. It emphasises the personal behaviour of the leader and what they do rather than their personal characteristics (Parry and Bryman, 2006). This implies that leaders’ behaviours can be changed through training (Northouse, 2018). Criticism of the style approach focuses on the lack of evidence to show how leadership styles are associated with performance outcomes, and it is suggested that there is no one best style of leadership that works in every situation (Yukl, 2013; West et al., 2015; Northouse, 2018). Transactional leadership is focused on transactions between leaders and others. It is driven by exchanging compliance/performance for reward (Bass and Avolio, 1993; Cummings et al., 2010; Curtis and O’Connell, 2011). It works within an existing culture by basing decisions and actions on the organisation’s norms and procedures (Bass and Avolio, 1993). Transformational leadership has evolved and has been viewed as a different way of understanding leadership. In this approach the leader is viewed as a manager of meaning, somebody who can make sense of the situation in which leadership is occurring, particularly in relation to the culture of the organisation (Parry and Bryman, 2006; Paterson et al., 2010; Parry et al., 2014).
Transformational leadership Transformational leadership (Bass, 1990) has been characterised by four factors: • Idealised influence—the followers’ needs are put ahead of the leaders’ needs • Inspirational motivation—leaders motivate by providing meaning and creating a vision
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• Intellectual stimulation—the leader encourages followers to be innovative • Creative and individualised consideration—the leaders acts as a coach or mentor (Bass et al., 2003; Yukl, 2013). Articles exploring leadership and nursing have found transformational theory to be the most effective and frequently used approach to leadership in nursing (Cummings et al., 2010; Paterson et al., 2010). This is because transformational theory has been found to link nursing leadership to positive patient outcomes in several studies and results in increased staff satisfaction and better unit or team performance (Pearson et al., 2007; Wong and Cummings, 2007; Wong et al., 2013). The premise of transformational leadership is that through leading by example, also referred to as role modelling (Paterson et al., 2010; Yukl, 2013; Bowers et al., 2015), public health nurses influence and change what individuals do within an organisation, which in turn impacts on the relationships between those individuals across the organisation. This is done by inspiring and connecting to their motivations and transforming them by appealing to their values, beliefs, ideals, attitudes and emotions (Bass and Avolio, 1993; Curtis and O’Connell, 2011; Yukl, 2013), thereby supporting the development of followers into leaders (Burns, 1978; Avolio and Gardener, 2005). This values-based approach, when coupled with the offer of a clear vision, helps individuals feel safe in processes of change (Bowers et al., 2015; Stansfield, 2017). In the leadership literature, role modelling is cited as a means of understanding and learning about leadership (Brigham et al., 2012; Bowers et al., 2015), and influencing is recognised as a key leadership behaviour of leaders (Parry, 1998; Yukl, 2013; Northouse, 2018). See Box 5.1 for an outline of transformational leadership. Moreover, for practitioners to follow, there must be something about the leader that motivates followers to act and to be influenced (DeRue and Ashford, 2010). Being fair, knowledgeable, passionate, compassionate, credible, inspiring and motivating is considered particularly important attributes for leaders to demonstrate through role modelling in order to influence followers (Pearson et al., 2007; Paterson et al., 2010; Stansfield, 2017). It has been found that leadership role modelling is demonstrated most effectively through actions and not words (Avolio and Gardener, 2005; Wong et al., 2010) and the importance of making individuals feel the action of the leadership, through providing meaning and sense making (Jackson and Parry, 2011; Parry et al., 2014). There is a strong theme of courage/bravery linked to having a vision and doing things even when the activity is unpleasant. Practising in this way has been found to help practitioners feel safe, even when working in difficult practice environments with competing demands (Brigham et al.,
BOX 5.1
Guidelines for transformational leadership (Yukl, 2013) • • • •
Articulate a clear and appealing vision Explain how the vision can be attained Act confident and optimistic Express confidence in followers
• Use dramatic symbolic actions to emphasise key values • Lead by example
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2012). Seeing what a leader can achieve through observing leadership in action can inspire followers that they can also do it and provides an example of how to make the change (Curtis and O’Connell, 2011; Bowers et al., 2015; Stansfield, 2017). Inspirational motivation includes the behaviour of articulating an inspirational vision to achieve the change required (Bass and Avolio, 1993; Curtis and O’Connell, 2011; West et al., 2015). Public health practitioners do this by communicating a clear vision so that staff are able to understand and implement the change. This could be a vision developed by the public health practitioner at a team level or the strategic vision of the organisation articulated by strategic leaders. By communicating clearly through their role, public health practitioners strengthen the existing vision or build commitment to a new one (Brigham et al., 2012; Yukl, 2013). For health visitors and school nurses this relates to knowing what they need to do to deliver the vision in the workplace. They need to have a clear understanding of what the vision is and what their role is in delivering it. They do this by having a shared understanding and agreement about the direction of the organisation. They are also specific about the key priorities to be achieved and how achievements are measured (NHS Leadership Academy, 2013; West et al., 2015). Working in this manner, with support from the organisation, enables others with whom the health visitors and school nurses are working to feel safe, reassured and motivated. This practice lays the foundation for a vision to develop as courage and commitment to achieve a goal is realised, even in the face of adversity.
Collective leadership Relationships have been perceived as a key factor in understanding leadership irrespective of how scholars conceptualize leadership (Curtis and O’Connell, 2011; Wong et al., 2010; Bowers et al., 2015). The importance of relationships in producing effective leadership in nursing has been reported as central to how nurses engage with leadership (Cummings et al., 2010), as leadership has been defined as a way of establishing meaning (Jackson and Parry, 2011). It has been suggested that nurses and health visitors experience and construct leadership through professional relationships, specifically role modelling (Brigham et al., 2012; Wong et al., 2010; Stansfield, 2017). This shift in viewing leadership as relationship-based and shared across the organisation has resulted in leadership being perceived as a much more collective, more egalitarian, less hierarchical process (Brigham et al., 2012; West et al., 2015). The idea of leadership centred at a collective system level has grown in popularity in health care organisations (NHS Scotland, 2014; NHS Leadership Academy, 2015; DHNI, 2016; Welsh Government, 2018a). This is a direct result of the need to foster cooperation across health and social care organisations, as the two are so entwined in terms of delivering an effective overall health care system (West et al., 2015). Achieving an effective overall health care system requires a different understanding of leadership that must focus on the purposes of leadership as opposed to the needs of the leader (Day, 2001; Hartley and Benington, 2011). The focus must be on teams, not individuals, with a focus on the cultural context of leadership rather than the leader (Brigham et al., 2012; West et al., 2015). This theory views leadership as a widely dispersed activity
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BOX 5.2
Definition of collective leadership (West et al., 2017) Collective leadership: leadership of all, by all, for all. This means: • Everyone taking responsibility for ensuring that there is high-quality, continually improving and compassionate care • Shared rather than dominating leadership in teams • Continual development of teamworking (West, 2012)
• Interdependent leadership with leaders working together across boundaries, prioritising patient care overall, not only in their area of responsibility • A consistent approach to leadership across organisations, characterised by authenticity, openness, curiosity, kindness, appreciative and, above all, compassion (West et al., 2014)
and not the sole responsibility of one individual (Parry and Bryman, 2006). See Box 5.2 for a definition of collective leadership. In summary, the array of leadership theories and approaches can be confusing, because there is not one definitive approach that works in every situation. Therefore, practitioners have to consider what works in their particular situation, taking into account the culture of the organisation within which they work. There has been a move away from the notion of leadership as leader-follower-goal, which is the most common view of leadership and is evident in transformational theory, to a collective approach based on shared/distributed leadership in which any member of staff can emerge as the leader depending on their knowledge and skills. In this approach leadership is seen as a task—that is, that leadership should create direction, alignment and commitment to make the changes required in complex organisations working through a team approach (Drath et al., 2008). This does not mean that an organization has no formal leader; rather, it means that the role between leaders and followers is much more fluid, and the leader is not considered to have all the knowledge and expertise. In addition, there is now much more emphasis on the culture of the organisation, as it is recognised that the culture has a major impact on the leadership approaches that staff are encouraged or indeed able to undertake.
Leadership in public health nursing policy The need to undertake and strengthen leadership in public health nursing has been voiced in health care policy for the past 20 years (NHS England, 2016; Welsh Government, 2016; DHNI, 2016; NHS Scotland, 2017b). All pre- and postregistration programmes approved by the Nursing and Midwifery Council (NMC) in the UK, including health visiting/school nursing, must include leadership in the curriculum (NMC, 2004, 2018). It has continually been found that effective leadership in nursing can improve patient outcomes
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and thus save lives (Wong et al., 2010) by reducing mortality outcomes (Wong and Cummings, 2007). Historically, the term ‘leadership’ was given to a nurse/health visitor in an assigned leadership or management role. More recently the term has taken on a more universal meaning to apply to all nurses/health visitors at all levels (NHS Scotland, 2014; NHS England, 2016; Welsh Government, 2016; DHNI, 2016). The specificity of the public health nursing context with respect to leadership demands in successive health policies has been confusing for several years (Haycock-Stuart et al., 2010; Department of Health (DH), 2011; Royal College of Nursing, 2017). Government policies, strategic and local leaders have repeatedly asserted that health visitors and school nurses are senior public health professionals and leaders (DHNI, 2016; Welsh Government, 2016; NHS Scotland, 2017b; Public Health England, 2018). However, the public health role and the related leadership role of health visitors and school nurses are not as clearly defined as that of the nurse working in an acute care setting with larger teams and steeper hierarchies. In addition, public health practitioners are often less visible, as they work in the community and for health visitors mainly with families in the home setting (Cameron et al., 2011). The national framework for leadership in England incorporates the following capabilities: ‘systems leadership skills, improvement skills, compassionate inclusive leadership skills and talent management’ (NHS Improvement, 2016, p. 2). This latest direction regarding leadership for health care organisations in England applies equally to other countries and clearly supports the move away from a transactional approach to leadership to a more collective/shared one (NHS Scotland, 2014; NHS Leadership Academy, 2015) that engages staff and followers (NHS England, 2016) with a strong focus on the culture of leadership within organisations being compassionate (West et al., 2015; DHNI, 2016; West et al., 2017). This approach to leadership fits well with the professional model undertaken by public health nurses that is not hierarchical. Being non-hierarchical, it also fits well during the moment of crisis created by Covid-19. This pandemic provides ‘an opportunity to collectively improve the leadership culture of the NHS’ (Bailey and West 2020) through compassion for all health professionals, whether they occupy formal leadership positions or not. All leadership training within NHS England refers to the competency framework (called the Healthcare Leadership Model; NHS Leadership Academy, 2013; Storey and Holti, 2013), which defines the nine dimensions of leadership behaviours required by NHS staff at all levels to increase leadership capabilities. This framework has been used to self-assess individual leadership competencies and to support the mapping of such competencies to team and organisational development and success (West et al., 2015). This is the most common framework used to develop leadership programmes for public health practitioners in England. NHS Scotland developed a similar model, NHS Scotland Leadership Qualities Framework (2014), which identifies a set of leadership qualities and behaviours that all leaders should demonstrate.
Leadership development model This model (see Box 5.3 for the content) was developed because of a lack of clarity about how best to develop leaders and leadership in health care (West et al., 2015), specifically health visiting. There is no systematic process for recognition and reinforcement of
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BOX 5.3
Content of the iHV Leadership Development Programme • Introductions, setting the scene and expectations • Leadership development model • Compassionate resilience • Building resilience in the health visiting and school nursing workforce • Developing leadership identity through cognitive behavioural techniques • Compassionate/courageous conversations • Leadership of the Healthy Child Programme; evidence for the 4-5-6 model
• Health visiting/school nursing policy and leadership • Discovering the power of influence • NHS Leadership Academy: Healthcare Leadership Model (2013) • Business skills • Dragons Den—Pitching the Business Case • How we make a difference to children and families through leadership—Next steps • Action pledging
health visitors’ leadership roles. This lack has been found in other studies, particularly with regard to public health leadership (Poulton, 2009; Haycock-Stuart et al., 2010; Cameron et al., 2011). The leadership model represents the understanding and meaning given to leadership by health visitors in England. Therefore, it is context specific, and although the model cannot be generalised in an objective sense, it can be applied to a wider audience whose lived experience and constructed realities are similar.
Overview of the leadership development model component parts The model consists of four components. These components are interrelated and mutually reinforcing aspects of health visiting leadership practice (Figure 5.1). The leadership development model can be used with any leadership theory, as it takes into account the situation in which public health practitioners are working (context). It can be used at an individual, family, team or organisational level. It is intended to make sense of the array of leadership approaches into a manageable model that helps practitioners think about their own leadership role within the area that they work as part of their professional practice. The four components are discussed in the following text in terms of how they relate to each other and develop leadership. Context of leadership. Leadership is situated in specific contexts, which help to explain what it means (Parry et al., 2014). It is, therefore, difficult to separate the context of leadership from the historical and social surroundings that exist in the situation where leadership occurs (Drath et al., 2008). Recognising the situation and social context that exists within the health visiting service, and how health visitors interact with both the context and each other, is thus key to understanding how they view leadership in the
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FIGURE 5.1 The leadership development model (Stansfield, 2017).
Leadership Ide nti ty
Lea
d e r s h i p I d e n t it y
H e a lt h
tity r Iden isito hV alt He
Leadership Behaviour
Making a Difference
dentity hip I ers ad Le
Health Vis itor Ide ntit y
Context of Leadership
Purpose of Leadership
V i s i t or I d e n t i t y
workplace and how they can influence the context that they work in (Day and Harrison, 2007). The context for health visitors is very much dependent on their professional background (e.g. either as a nurse or midwife), the professional boundaries that they work across, health policies that direct the role, their health visiting model of practice, how the service is commissioned and the culture of the organisation. The context of their leadership focuses on the situation in which the leaders work—that is, their workplace/practice environment—and relates to where and who they are actually leading (e.g. a family, a team or an organisation). Purpose of leadership. The importance of the leadership role in providing purpose for organisations is well documented (Hartley et al., 2008; Jackson and Parry, 2011; NHS Leadership Academy, 2013). Purpose in leadership is commonly understood to mean a sense of direction (Day and Harrison, 2007), as direction provides an alignment around strategies, which is seen as a key part of effective leadership (Yukl, 2013). The purpose for health visitors depends on how they are engaged in change by colleagues and the managers of the service and how they are assisted to contribute to taking the vision forward, including influencing and creating an environment that is safe to follow by them as leaders. Such an environment should allow a two-way process where leadership is fluid and leaders can be followers and vice versa, and where practitioners and the public
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are allowed a right to reply. The latter point is particularly important, as a right to reply provides an opportunity to challenge the vision in a constructive way that allows other views to be considered. Understanding the context in which practitioners work (as described earlier) allows them to make realistic goals and gain support to achieve the goals and make the change they aim for with measurable outcomes. Leadership behaviour. How leaders behave is important to the leadership culture of an organisation because the leadership style they adopt within the organisation reflects the vision and beliefs of the organisation. In essence, what leaders say is not as important as how they act because those actions transmit more than the words of the leader, about what they consider important and, therefore, how they influence followers to act (Avolio and Gardner, 2005; Wong and Cummings, 2007). The leadership behaviour for health visitors depends on their recognition of the impact of their behaviour on other colleagues and those they are leading, in addition to the impact of their behaviours as role models on the clients with whom they work. Due to the nature of their role, public health nurses need to have the confidence to behave autonomously in their role and through their leadership approach. They also need to recognise which leadership skills and training they require; the model helps them to do this by recognising their leadership strengths and what they need to further develop. ‘Making a difference’ is a term commonly applied by health professionals to denote the intrinsic rewards that motivate them in their work to be able to deliver high-quality care and actions that will result in better health outcomes (Maben and Griffiths, 2008; Whittaker et al., 2017). Fundamentally, making a difference demonstrates the outcome of the leadership activity undertaken by the health visitor that can be measured and seen in relation to improving the health of children, families and communities. For an example of how the Leadership Development Model can be applied in practice, see Case Study 5.1.
Case Study 5.1
Applying the Leadership Development Programme and model in practice (Stansfield, 2018)
Sarah* is a health visitor working with a family with complex needs. Sarah will consider context—the situation that she is leading on in the work environment (i.e. family, team or organisational level), the nature of the family situation means that Sarah needs to work across professional boundaries, and therefore needs to consider the leadership culture of the organisation she is working in and how different services work together. Then the purpose of the intervention is considered, why Sarah is doing what she is
doing—that is, what goal she is working towards with the family. Working from her model of practice, she agrees with the family and other services that the goal is to strengthen the family’s assets and increase their wellbeing. This includes working in partnership through a parenting programme. Sarah encourages the family members to build their parenting skills and be engaged in the decision making. In addition, Sarah has a coordination role that involves liaising with other services that are also contributing to the support of the family
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Case Study 5.1 Applying the Leadership Development Programme and model in practice (Stansfield, 2018)—cont’d and children, ensuring that all involved are clear about the goal of the intervention and how the outcomes will be measured. Sarah then needs to consciously consider which leadership behaviours she needs to demonstrate as a leader in this situation. Sarah realises the importance of role modelling in that how she behaves towards the family must convey her value for the family by treating them with respect and recognising their input as central to the work that she and other services are providing. This can be done by role modelling positive interactions with the children in the family whilst challenging parenting that could be harmful to the children and ensuring the children are safe. Sarah is also demonstrating her leadership role to the organisations involved by making clear transparent decisions in consultation with the family and other services on a plan of action with the
family and then communicating this to other agencies through a partnership approach that recognises the expertise of all involved to achieve the goal. Sarah will then review to discern whether she has made a difference through her actions by reviewing the agreed-on goals and outcomes set at the start of the intervention. By working through the model Sarah can articulate succinctly what her leadership intervention has been in the family to other services and managers, including those who commission the service, thereby recognising her leadership role and in so doing strengthening her leadership identity. The model supports Sarah’s development in that she can then consider through reflection or supervision which further opportunities she needs to develop her leadership skills. *pseudonym
Identity The final part of the model relates to building a leadership and professional identity. In the study by Stansfield (2017), all participants had a professional identity developed from their model of practice, referred to by many as the four-tier service delivery model (DH, 2011), that allows them to deliver the Healthy Child Programme (DH/Department of Children, Schools and Families, 2009) and the Principles and Practice of Health Visiting (Council for the Education and Training of Health Visitors, 1977) embedded in the NMC (2004) standards for specialist community public health nurses However, leadership identity was not found to be well developed in health visiting practice. In the study by Stansfield (2017), all participants viewed leadership as part of the health visiting role; however, overwhelmingly they thought that not all health visitors (band 6) (DH, 2004)—even those with years of experience—considered themselves as leaders. This has been found in other studies, particularly regarding the public health leadership role of the health visitor (Poulton, 2009; Brigham et al., 2012). Yet when asked which leadership activities health visitors undertook, all groups in the study provided an abundance of examples in line with leadership definitions in the literature (Yukl, 2013; NHS Leadership Academy, 2013; Northouse, 2018), and all agreed that leadership was inherent in the health visitor’s role.
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From the literature it is apparent that what ‘identity’ provides for leaders is a sense of knowing who they are (Zheng and Muir, 2015). The leadership model helps the health visitor to understand that many of the activities they continually undertake have a component of leadership, as would be expected of a specialist community public health nurse (NMC, 2004). In many cases health visitors would just consider this as part of professional practice, which of course it is. However, noticing the parts of the activity that demonstrate leadership helps the health visitor to develop a leadership identity as well as a professional one. It brings their leadership role to the forefront and therefore helps them to see themselves as leaders. Day and Harrison (2007) applied identity theory to leadership and noted the importance of having a leader identity if the individual is to develop as a leader. The rationale behind this theory is that the more an individual perceives themselves as a leader, the more they are likely to look for ‘experiences to enact and develop that aspect of’ their identity (Day and Harrison, 2007, pp. 353356). Day and Harrison (2007, p. 365) suggest that an individual’s identity ‘develops as a result of challenging environments and the integration of experiences with the self’. It follows, therefore, that how one thinks of oneself as a leader will make this a more conscious and more cognitive decision. This should help leaders to (1) recognise their leadership identity to understand who they are, see Case Study 5.2, and (2) be clear about their goals and objectives along with personal strengths and limitations (Komives et al., 2005; Day and Harrison, 2007; Zheng and Muir, 2015).
Illustrating how the leadership development model can be used in practice A leadership development programme focusing on the leadership development model (Stansfield, 2017) was developed and delivered to health visitors and school nurses (Agenda for Change NHS Pay Scale Bands 6 and 7) (DH, 2004) within three NHS trusts in England over a 6-month period by the iHV. See Box 5.3 for the content that was identified for inclusion in the leadership programme. It became apparent through the programme that a way to support learning and application of leadership to practice would be to develop a board game, as a learning tool to support the discussion of complex leadership theories. Funding from the Burdett Trust for Nursing was secured, and ‘The Leadership Game’ was developed from the original research to explain the theoretical underpinnings identified through each component that makes up the leadership development model focused on collective leadership (Stansfield, 2017). This was developed in conjunction with the iHV and focus games. See Box 5.4 for the key findings from the evaluation of the iHV leadership development programme.
Case Study 5.2
Becoming like a meerkat
Use of the model in practice During the iHV leadership development training, the leadership model was considered as a way to contextualise the health visitor’s/school nurse’s role. Through relating
the role directly to a wide range of practice examples, the participants were able to understand that they were using leadership skills and capacity in their direct work with both families and their colleagues. They also
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Case Study 5.2 Becoming like a meerkat—cont’d used the model to analyse situations, such as (1) what was the context, (2) what was the purpose of their interaction and (3) what leadership behaviours did they require and what skills and attributes could they draw on. Understanding that if they were not clear or owning the purpose, they would find it harder to lead was useful insight. One practitioner shared how she had been working with a family for a significant period of time to try to support them in accessing services and support. The practitioner had been struggling to engage some of the support services with the family as they did not appear to recognise the needs that the health visitor was raising. Through direct application of the leadership model, the health visitor was able to recognise that the context of her interaction with the support services was creating a barrier to their shared understanding of the problem. She had been emailing the duty manager and connecting with
different people each time; she had made contact and then had given up trying. After reflecting on the situation, she then made face-to-face contact and was able to move the referral forward. This, she reflected, was a better approach; she felt empowered to make direct contact again recognising the need for a collective approach. Greater awareness of the impact of context on the ability to lead was important learning. By understanding that leadership was about their own sense of purpose and not losing sight of this in all they do has helped practitioners build confidence in their own leadership skills and to ‘look outside the box’, be inquisitive and challenge constructively. The participant described herself as a meerkat with her head now up, scanning the horizon and seeing things from a different perspective. Walking in others’ shoes helped her understand why some things were a barrier and to look for shared solutions.
BOX 5.4
Evaluation of the iHV Leadership Development Programme (Stansfield, 2018) • One hundred per cent reported an increase in their knowledge and confidence immediately after training. • This confidence was sustained when working with individual families, colleagues and teams providing evidence-based leadership 6 months after the initial training. • Participants reported positive feedback from the training and how it supported
their work with families, colleagues and teams by increasing their confidence in their leadership identity and feeling empowered to lead. • Participants reported they have been able to influence local service provision through working with commissioners and service leads.
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Conclusions This chapter has explored how health policy directs the leadership role of all public health practitioners. Transformational leadership, an approach based on relationships, has been found to be the most effective in nursing. However, collective leadership—an approach to leadership that is not perceived as embedded in one person but instead is shared across teams and organisations—is growing in popularity. This theory offers much for public health practitioners who want a more egalitarian approach to leadership. It is recognised that leadership is often an invisible activity for public health practitioners. In addition, they can lack a leadership identity. Therefore, it is suggested that a model of leadership development devised from research undertaken with health visitors can provide a way to recognise and reinforce the public health practitioner’s leadership role and make these activities more visible.
Discussion Questions • What kind of leadership is demonstrated in your organisation? • What behaviours have you observed that have led you to your answer? • Thinking about the four components, how might you apply the leadership development model in your daily practice? • How can you use the principles outlined in this chapter to develop your leadership identity?
Acknowledgement The author acknowledges the Burdett Trust for Nursing, which provided a grant to develop, implement and evaluate the Leadership Development Programme for health visitors and school nurses to strengthen collective clinical leadership. The author would also like to thank Vicky Gilroy (Projects and Evaluation Lead, iHV) and the health visitors and school nurses from Mersey Care NHS Foundation Trust for using the Leadership Development Model and Leadership Game as part of the iHV Leadership Development Programme, and for providing inspiration and feedback used for the Case Studies.
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Brigham, L., Maxwell, C., Smith, A., 2012. Leading in practice: a case study of how health visitors share and develop good practice. Community Pract. 85 (5), 2428. Burns, J.M., 1978. Leadership. Harper and Row, New York. Cameron, S., Harbison, J., Lambert, V., Dickson, C., 2011. Exploring leadership in community nursing teams. J. Adv. Nurs. 68 (7), 14691481. Council for the Education and Training of Health Visitors, 1977. An Investigation into the Principles and Practice of Health Visiting. CETHVA, London. Cummings, G., MacGregor, T., Davey, M., Lee, H., Wong, C.A., Lo, E., Muise, M., Stafford, E., 2010. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Int. J. Nurs. Stud. 47, 363385. Curtis, E., O’Connell, R., 2011. Essential leadership skills for motivating and developing staff. Nurs. Manag. 18 (5), 3235. Day, D.V., 2001. Leadership development: a review in context. Leadersh. Q. 11 (4), 581613. Day, D.V., Harrison, M.M., 2007. A multilevel, identity-based approach to leadership development. Hum. Resour. Manag. Rev. 17, 360373. Department of Health, 2004. Agenda for Change. The Stationery Office, London. https://www.nhsemployers .org/-/media/Employers/Documents/Pay-and-reward/AfC-Handbook-Version-1.pdf (accessed 21/06/2019). Department of Health, 2011. Health Visitor Implementation Plan 20112015: A Call to Action. The Stationery Office, London. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/213759/dh_124208.pdf (accessed 05/03/2020). Department of Health/Department of Children, Schools and Families, 2009. The Healthy Child Programme: Pregnancy and the First Five Years of Life. The Stationery Office, London. https://assets.publishing.service .gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf (accessed 05/03/2020). Department of Health Northern Ireland, 2016. Health and wellbeing 2026: delivering together. https://www.healthni.gov.uk/sites/default/files/publications/health/health-and-wellbeing-2026-delivering-together.pdf (accessed 05/04/2020). DeRue, D.S., Ashford, S.J., 2010. Who will lead and who will follow? A social process of leadership identity construction in organisations. Acad. Manag. Rev. 36, 627647. Drath, W.H., McCauley, C.D., Palus, C.J., Van Velsor, E., O’Connor, P.M.G., McGuire, J.B., 2008. Direction, alignment, commitment: toward a more integrative ontology of leadership. Leadersh. Q. 19 (6), 635653. Hartley, J., Benington, J., 2011 Recent trends in leadership. The King’s Fund, Commission on Leadership and Management in the NHS, 143. Hartley, J., Martin, J., Benington, J., 2008. Leadership in Healthcare: a Review of the Literature for Health Care Professionals, Managers and Researchers. Commissioned by the National Institute for Health Research (NIHR) Service Delivery and Organization (SDO) Programme. Haycock-Stuart, E., Baggaley, S., Kean, S., Carson, M., 2010. Understanding leadership in community nursing in Scotland. Commun. Pract. 83 (7), 2428. Jackson, B., Parry, K., 2011. A Very Short, Fairly Interesting and Reasonably Cheap Book about Leadership. Sage, London. Komives, S.R., Owen, J.E., Longerbeam, S.D., Mainella, F.C., Osteen, L., 2005. Developing a leadership identity: a grounded theory. J. Coll. Stud. Dev. 46, 593611. Maben, J., Griffiths, P., 2008. Nurses in Society: Starting the Debate. National Nursing Research Unit. King’s College, London. NHS England, 2016. Leading change, adding value. https://www.england.nhs.uk/publication/leading-changeadding-value-a-framework-for-nursing-midwifery-and-care-staff/ (accessed 05/04/2020) NHS England, 2019. NHS long term plan. https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ (accessed 05/04/2020). NHS Improvement, 2016. Developing people—improving care. https://improvement.nhs.uk/documents/542/ Developing_People-Improving_Care-010216.pdf (accessed 05/04/2020). NHS Leadership Academy, 2013. Healthcare leadership model. https://www.leadershipacademy.nhs.uk/wpcontent/uploads/2014/10/NHSLeadership-LeadershipModel-colour.pdf (accessed 05/04/2020). NHS Leadership Academy, 2015. Developing systems leadership. https://eoe.leadershipacademy.nhs.uk/wpcontent/uploads/2019/04/Developing-Systems-Leadership-July-2017.pdf (accessed 05/04/2020).
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NHS Scotland, 2014. NHS Scotland leadership qualities framework. https://www.nes.scot.nhs.uk/media/3399300/ scottish_leadership_qualities_framework_-_guidance_notes_july_2014_-_copy.pdf (accessed 05/04/2020). NHS Scotland, 2017a. Everyone matters: 2020 workforce vision. https://www.gov.scot/collections/everyonematters-plans/ (accessed 05/04/2020). NHS Scotland, 2017b. Everyone matters: 2020 workforce vision. Implementation Plan 2018-2020. ,https://www .workforcevision.scot.nhs.uk/wp-content/uploads/2017/12/Everyone-Matters-2020-Workforce-VisionImplementation-Plan-2018-20.pdf. (accessed 05/04/2020). NHS Scotland, 2017b. Nursing 2030 vision. https://www.gov.scot/publications/nursing-2030-vision9781788511001/pages/6/ (accessed 05/04/2020). Northouse, P.G., 2018. Leadership Theory and Practice, eighth ed. Sage, London. Nursing and Midwifery Council, 2004. Standards of Proficiency for specialist community public health nurses. https://www.nmc.org.uk/standards/standards-for-post-registration/standards-of-proficiency-for-specialistcommunity-public-health-nurses/ (accessed 05/04/2020). Nursing and Midwifery Council, 2018. Standards for pre-registration nursing programmes. https://www.nmc.org .uk/standards/standards-for-nurses/standards-for-pre-registration-nursing-programmes/ (accessed 05/04/2020) Parry, K.W., 1998. Grounded theory and social process: a new direction for leadership research. Leadersh. Q. 9, 85105. Parry, K.W., Bryman, A., 2006. Leadership in Organizations. In: Clegg, S.R., Hardy, C., Lawrence, T.B., Nord, W.R. (Eds.), The Sage Handbook of Organisation Studies, second ed. Sage, London. Parry, K., Mumford, M.D., Bower, I., Watts, L.L., 2014. Qualitative and historiometric methods in leadership research: a review of the first 25 years of The Leadership Quarterly. Leadersh. Q. 25, 132151. Paterson, K., Henderson, A., Trivella, A., 2010. Educating for leadership: a programme designed to build a responsive health care culture. J. Nurs. Manag. 18, 7883. Pearson, A., Laschinger, H., Porritt, K., Jordan, Z., Tucker, D., Long, L., 2007. Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in healthcare. Int. J. Evidenced Based Healthc. 5, 208253. Poulton, B., 2009. Barriers and facilitators to the achievement of community-focused public health nursing practice: a UK perspective. J. Nurs. Manag. 17 (1), 7483. Public Health England, 2018. Best start in life and beyond: improving public health outcomes for children, young people and families. Commissioning Guide 1: Background information on commissioning and service model 118. Royal College of Nursing, 2017. The best start: the future of children’s health. Stansfield K.J., 2017. Making a difference: how health visitors understand the social processes of leadership. Unpublished thesis, Sheffield Hallam University. Storey, J., Holti, R., 2013. Towards a new model of leadership for the NHS. NHS Leadersh. Acad. 132. Welsh Government, 2016. Nursing and midwifery in Wales: key priorities 2016-2021. ,https://gov.wales/sites/ default/files/publications/2019-03/nursing-and-midwifery-in-wales-key-priorities-2016-2021.pdf. (accessed 05/04/2020). Welsh Government, 2018a. A healthier Wales: our plan for health and social care. ,https://gweddill.gov.wales/ docs/dhss/publications/180608healthier-wales-mainen.pdf. (accessed 05/04/2020). Welsh Government, 2018b. The parliamentary review of health and social care in wales. A revolution from within: transforming health and care in Wales. ,https://gweddill.gov.wales/docs/dhss/publications/180116revie wen.pdf. (accessed 05/04/2020). West, M.A., 2012. Effective Teamwork: Practical Lessons from Organizational Research, third ed. Blackwell Publishing, Oxford. West, M.A., Eckert, R., Steward, K., Pasmore, B., 2014. Developing Collective Leadership for Healthcare. The King’s Fund, London. West, M.A., Armit, K., Loewenthal, L., Eckert, R., West, T., Lee, A., 2015. Leadership and Leadership Development in Health Care: The Evidence Base. The King’s Fund, London. West, M.A., Eckert, R., Collins, B., Chowla, R., 2017. Caring to Change: How Compassionate Leadership can Stimulate Innovation in Health Care. The King’s Fund, London. Available from: https://www.kingsfund.org .uk/publications/caring-change (accessed 05/04/2020).
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Whittaker, K.A., Malone, M., Cowley, S., Grigulis, A., Nicholson, C., Maben, J., 2017. Making a difference for children and families: an appreciative inquiry of health visitor values and why they start and stay in post. Health Soc. Care Community 25 (2), 338348. Available from: https://doi.org/10.1111/hsc.12307 (accessed 05/04/2020). Wong, C.A., Cummings, G.G., 2007. The relationship between nursing leadership and patient outcomes: a systematic review. J. Nurs. Manag. 15, 508521. Wong, C.A., Laschinger, H.K.S., Cummings, G.G., 2010. Authentic leadership and nurses’ voice behaviour and perceptions of care quality. J. Nurs. Manag. 18 (8), 889900. Wong, C.A., Cummings, G.G., Ducharme, L., 2013. The relationship between nursing leadership and patient outcomes: a systematic review update. J. Nurs. Manag. 21, 709724. Yukl, G., 2013. Leadership in Organisations, eighth ed. Pearson, Essex. Zheng, W., Muir, D., 2015. Embracing leadership: a multi-faceted model of leader identity development. Leadersh. Organisational Dev. J. 36 (6), 630656.
Further reading Northouse, P.G., 2018. Leadership Theory and Practice, eighth ed. Sage, London. This book discusses the different theories of leadership and how each one has developed in a sequential manner over the years. West, M.A., Armit, K., Loewenthal, L., Eckert, R., West, T., Lee, A., 2015. Leadership and Leadership Development in Health Care: The Evidence Base. The King’s Fund, London. In 2015, the King’s Fund along with the Faculty of Medical Leadership and Management and the Centre for Creative Leadership undertook a review of the leadership evidence surrounding leadership and leadership development in health care. This resource provides a comprehensive overview of how the evidence on leadership is applied in health care practice. Yukl, G., 2013. Leadership in Organisations, eighth ed. Pearson, Essex. This book provides an oversight of the different leadership theories and their effectiveness within organisations.
Resources The Leadership Game. https://www.nhsleadershipgame.co.uk (accessed 05/04/2020) The Leadership Game has been developed as a learning tool to support the understanding of the leadership development model (Stansfield, 2017) and the theoretical application of collective leadership. Institute of Health Visiting. https://ihv.org/uk Further information regarding the Leadership Development Programme can be found on the iHV website, a key learning resource for health visitors and other public health nurses. The King’s Fund. https://www.kingsfund.org.uk The King’s Fund website provides a wealth of information about health and social care policy and practice in England. It has excellent resources on leadership and information on the latest developments in leadership in health and social care. The NHS Leadership Academy. https://leadershipacademy.nhs.uk The Leadership Academy provides information on the leadership framework in England. It has a range of information on programmes available for health care professionals to undertake regarding leadership. It also contains several resources, including the Healthcare Leadership Model, that can be downloaded. NHS Education for Scotland. https://nes.scot.nhs.uk This website provides information on leadership and management initiatives in Scotland. It also provides access to the NHS Scotland Leadership Qualities Framework. NHS England and NHS Improvement. https://improvement.nhs.uk NHS England and NHS Improvement came together as one organisation in April 2019. This website provides a wide range of information and resources on improving health care and leadership. Specific information can be found on Developing People—Improving Care, the national framework for improvement and leadership development.
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Working to create health: salutogenesis Introduction to Section 2 Practitioners choosing to move to public health roles often cite the experience of witnessing ill health conditions—such as obesity, coronary artery disease or diabetes—that may have had early origins in childhood. Rather than treating and managing ill health, there is a motivation to be involved in care practices directed at creating good health (salutogenesis) and starting early enough in life to maximise people’s health potential. Section 2 includes topics pertinent to system- and practitioner-level actions necessary to support the generation of good health. Community public health workers often provide a link between the system and the recipients of the service provided. Therefore this section starts with health needs assessment (Chapter 6), a process crucial for determining the public health activities and priorities for each population and individual or family. The process necessarily involves working with others to (1) determine what information should be collected, (2) to share what is known and (3) how it is understood. Achieving this requires partnership and cooperation, which in turn provide a sound basis for establishing relationships that are used as a vehicle for public health practice. Chapter 7 provides detailed consideration of this next topic: relationships and partnership working between colleagues and with service users. As already noted, the desire to create circumstances for and the experience of good health is in part motivated by the knowledge and experience of ill health later in life, but which had earlier origins. Chapter 8 presents the case for early action, particularly with regard to supporting parents and family life, using life course evidence to explain what can be prevented and highlighting the critical moments when early intervention can pay dividends. This argument is extended in Chapter 11, which addresses the economics of investment in the early life stages to enhance existing potential or counteract known risks. These risks are unpacked and matched against the economic cost of interventions directed at treating ill health or behavioural discord that poses risk to individuals, families and/or communities. The modes of public health action also need consideration, and Chapter 9 focuses on how new technologies and digital means of communication are making their mark on the
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functioning of public health systems and services. Further, to make the most of what is known about public health action, an appreciation of how to implement new knowledge and translate it into viable action, based on empirical evidence, is a key skill for public health practitioners who need to be able to make decisions they can justify (see Chapter 10). Use of digital communication technologies is frequently relied on to access information by practitioners so they can implement evidence-informed practice, and by the public, who need to know what and where they can access a service to address their needs. In some quarters, digital technology is an important solution for reaching populations who might otherwise be seldom catered to or even heard to understand their needs. Many new modes of delivery were tested urgently when the COVID-19 pandemic closed down standard face-to-face methods of provision. But of course, any permanent expansion of services enabled by technology needs to be tested by research methods to determine (1) the effective modes of practice and (2) how they should be implemented when extended to wider populations. Health needs assessment. Sarah Cowley Relationships and partnership working for public health. Sarah Cowley & Christine Bidmead (new title) 8. Public health and the life course: supporting parents and families. Karen Whittaker (new title) 9. Public health practice in a digital world. Toity Deave 10. Health programme decision making and implementation science. Lynn Kemp 11. The economics of prevention in the early years. Gabriella Conti
6. 7.
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6 Health needs assessment Sarah Cowley KEY ISSUES • The nature of need and needs assessment is contested and controversial. • The policy background provides constraints and drivers
• Needs assessment approaches in these situations vary according to different circumstances and purposes:
• The question is always: need for what?
• Assessment for universal prevention: strengths-based practice
• Needs assessment is a basis for public health
• Assessment for targeted services: indicated and selective needs • Early Help Assessment
• Community needs assessments
• Screening
• Defined populations • Deciding the focus • Which data to collect and how • Policy priorities: explains the reason for the focus on children and families
• Needs assessments do not answer the moral question of who should receive public resources to meet their needs
Health needs The idea of ‘health need’ is relatively recent in historical terms, particularly with respect to health promotion or public health. The British National Health Service (NHS) was first established in 1948 in response to a wartime policy document that focused largely on the need for social insurance to combat widespread poverty (Beveridge, 1942). In one part of this document, the Beveridge Report recognised the need for ‘universal comprehensive medical treatment and rehabilitation’ to be provided for ‘all persons capable of profiting by it’ (para 19, xi). Whilst this founding brief was largely achieved through the NHS Act 1946, two issues raised by the quotes were to recur through subsequent legislation.
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First, it is clear that the NHS was originally conceptualised as a service to treat illness and disability and to provide medical care. Public health and community health services (health visitors, school and district nurses, community midwives) were provided by local government until 1974. After this ‘unification’ of health services, the idea of prevention began to be formally incorporated into NHS policy, but the terminology remains quite limiting. The Health Act 1999 (section 18.4) defines ‘health care’ as ‘services for or in connection with the prevention, diagnosis or treatment of illness’. The legislation refers back to the NHS Act 1977 (section 128 (1) c) for a definition of illness, which ‘includes mental disorder within the meaning of the Mental Health Act 1959 and any injury or disability requiring medical or dental treatment or nursing; “medical” includes surgical’. The idea of health as a positive state, or public health as an important function of the health service, is not, therefore, widely established in NHS legislation. However, a specific duty was introduced in the Health and Social Care Act 2012 to secure continuous improvement in the prevention, diagnosis or treatment of illness as well as in the protection or improvement of public health (Part 1, section 2: 1A). The second issue raised by Beveridge’s qualifying remark that the service should be provided to ‘persons capable of profiting by it’ raises the question of who should decide whether profit is possible or not, and based on what criteria. Similar subjectivity was incorporated into the NHS Act 1977, in which Section 34a (i) required provision of ‘the number of medical practitioners required to meet the reasonable needs of their areas and the different parts of those areas’ (added emphasis). Rising public expectations, increasing costs of health care and different political views about what constitutes a ‘reasonable need’ have underpinned many subsequent policy changes. More recently, a duty to reduce inequalities was introduced in the Health and Social Care Act 2012 (Part 1.4) ‘with respect to the benefits that they can obtain from the health service’, in terms of access to services and outcomes achieved. The main drivers of health inequalities lie outside the health service, but clarifying which organisation is responsible for meeting particular needs is an important purpose of policies.
Health and social care The National Health Service and Community Care Act 1990 first introduced the notion of an ‘internal market’ into the NHS in England, stressing that services should be planned strategically within one organisation, then purchased from a different provider service to meet needs in the area. The Act was based on two separate white papers. The first, Caring for People (Department of Health (DH), 1989a), acknowledged the importance of providing support for people experiencing a range of needs that were regarded as ‘social’ rather than medical. This included people with long-term mental health needs and those with intellectual and physical disabilities for which (it was argued) help might be needed by family and friends or be provided from local authority sources if informal support was not sufficient. Needs arising in old age as part of a normal life course were included, but support required by mothers and families with young children were not. Whilst the legislation stipulated that individuals had a right to receive care where an assessment showed that ‘social needs’ existed, local authorities could make a charge for any services they
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provided. This was distinct from ‘Working for Patients’ (DH, 1989b), the second white paper concerning the provision of health services, which continued to be free at the point of delivery. Deciding which services would be either free at the point of delivery or be charged to the recipient remains highly contentious, leading to many debates about what constitutes a ‘need’ to be met by one service or another. Whilst health and social care services were expected to collaborate to provide a seamless service, distinguishing between ‘health needs’ and ‘social needs’ became a source of much confusion for care providers and service users alike (Bergen et al., 1996). The strategic planning requirement in the Health and Community Care Act 1990 legitimised public health activities within the NHS and specifically enjoined the different organisations to work together to ensure that prevention and public health remain key aspects of health service planning. Even so, it tended to reinforce the earlier focus on illness and service provision, instead of wider factors that contribute to health, such as environment or lifestyle. More recently, the Health and Social Care Act 2012 provided for Directors of Public Health to be appointed as officers of local authorities. Funding to commission public health services, such as school nursing, health visiting, sexual health and stop smoking services, followed this change, although the costs are administered separately from the main NHS budget.
Need for what? Given this background, it is clear that the notion of ‘health need’ is highly political, complex, value-laden and far from problem-free. However, interest in the use of the term and in different approaches to assessing needs has never waned. Needs assessment processes are considered an essential precursor to the planning of services, on both an individual and population-wide level. It is clear that needs must be assessed with the question in mind always of ‘need for what?’ In clinical terms, this usually means making an assessment before prescribing a treatment; a population-wide assessment may lead to the ‘prescription’ of public health strategy, including the provision of general health services as well as prevention. The definition of health needs in respect of health improvement is rather more complex than its clinical counterpart, as it concerns whole populations and determinants of health. The Beveridge ideal of being ‘capable of profiting by it’ might, in the case of public health interventions, not apply to single person or individual, or outcomes may be so long term that it is hard to discern immediate changes. The mechanisms used for both assessing needs, and evaluating services, in such circumstances, need to take a population-wide approach.
Need and needs assessment The nature of need Whether at a clinical or population-wide level, it is clear that the nature of ‘need’ is highly contested, and there is general agreement that need is a ‘deceptively tricky concept’ (Asadi-Lari and Gray, 2005, p. 295). It is problematic as an operating concept (Sheppard
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and Woodcock, 1999) and value laden in that someone has to decide whether or not a need exists, which is an evaluative judgement (Endacott, 1997). Needs were famously distinguished by Bradshaw (1972) under four headings: • Normative need is that which the expert or professional defines as need, usually using previously designated criteria. • Felt need is equated with ‘want’ and is often denigrated as being not a ‘real’ need, as it is dependent only on the perceptions of the individual. • Expressed need is defined as felt need turned into action—for example, as reflected in waiting lists for services. • Comparative need is primarily used to establish the gap in provision between areas or individuals. Bradshaw’s typology is long established but has a clear bias towards professional definitions of need, which has been largely superseded by a focus on individual experience. In a study conducted in the mid-1990s, the question of what the term ‘need’ meant to them was put to a series of focus groups of, first, service users, then professionals (district nurses and health visitors), then managers and those who commissioned and organised both NHS and local authority social services, and then finally practice teachers and lecturers (Cowley et al., 1996). They all had different views, and many found it very difficult to think about what ‘need’ might mean, unless it was attached to something else, such as ‘health need’, ‘needs assessment’ or ‘clinical need’. Most service users were somewhat unhappy with the term, as it had connotations of ‘being needy’, which they felt was stigmatizing. A detailed analysis across the focus group responses revealed many contradictions within the concept, and a conclusion was reached that need is a dual concept, in that it has some very contrasting meanings (Cowley et al., 1995). It is possible to describe needs quite objectively, at least in part. Needs are recordable, and can be measured, observed and made explicit, to some degree. It is possible, for example, to assess someone’s blood pressure, their mobility, or whether they have postnatal depression by using a carefully developed and validated instrument. Such assessment tools provide a good degree of what researchers call ‘interrater reliability’, which basically means that if two or more people take the measurement, they will reach the same conclusion. But needs are also very variable and personal, in that the same issues—for example, a child or young person’s behaviour or limited mobility in an older person—may each lead to different views of whether it is a problem or not. In this respect, needs are very subjective and changeable according to context. This is the polar opposite of interrater reliability, where completely different conclusions are reached about what, on the surface, may appear to be the same thing. Some needs are very obvious, particularly those associated with clear physical diagnoses, perhaps with an obvious wound or a rash, or in a desperately run-down area that clearly displays its deprivation through graffiti, neglected or derelict buildings, and lack of facilities. Other needs—physical as well as social, emotional and mental health needs—are more hidden, perhaps where genteel poverty and pride go hand in hand, where emotional distress is seen as a source of shame or where the mental trauma is so severe that clients may hide their needs from an assessor, or simply not reveal things that are worrying them
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because they cannot formulate the words. Indeed, people may experience a level of anxiety or difficulty, without fully realising what lies beneath their worries. For example, they may be quite genuine in stating that their childhood was happy because the ‘family secrets’ of sexual or emotional abuse that lay behind a fac¸ade are too deeply hidden for them to recognise themselves. Does that mean they are not needs? Or not needs until they are revealed, or only if experienced as problems? These were the kinds of very complex questions asked in the study referred earlier about what constituted a ‘need’ (Cowley et al., 1995, 1996).
Needs assessments A whole taxonomy of needs assessment was developed after carrying out a series of observations in practice and interviews to develop the ideas voiced in the focus groups described earlier (Bergen et al., 1996; Cowley et al., 2000a, 2000b). Needs assessments can be considered under three main headings, each with different, interlinked elements. These headings are as follows: 1. Ideals In policy—Discipline-specific— Ascribed worth 2. Timing Client issues—Service issues—Practice issues 3. Types Purpose— Formality, Specificity—Complexity
Ideals Formal policies and laws set out whose assessment counts in particular situations, and the rights and responsibilities that flow from the assessment. These constitute a specific set of values and ideals, agreed in the particular society that approves them and made real as they are enacted. The difference between health and social need, for example, is clear only in the duties placed on different public services to meet identified needs. Expectations of the rights, responsibilities and choices available to service users are set out in policy, as well as the duties of service providers. Despite the policy commitment and frequent use of the terms ‘need’ and ‘needs assessment’, they tend to be used very differently by different disciplines, including economists, epidemiologists, policy makers and professionals. Apart from differences between considering needs at an individual or service level, each profession has a distinct underlying philosophy, which influences their understanding of the term ‘need.’ For doctors, reaching a diagnosis is a central part of their professional work, which influences both their communication style (ten Have, 1991) and their interest in disease-specific needs assessments (Asadi-Lari and Gray, 2005). Nurses, too, traditionally tended to concentrate on deficits and difficulties, with Endacott (1997) also emphasising the importance of prioritising and the ability to meet needs. Much social work literature focused on deficits in the past,
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although this has changed to a more strengths-based focus recently. White et al. (2009) argue that assessments are constrained by the language on forms such as the Common Assessment Framework (a standard assessment tool introduced across England in 2006, but no longer in use nationwide). Guidance stemming from implementation of the Care Act 2014 has specified that a strengths-based approach is central to social work practice (Department of Health and Social Care, 2019). Health visitors have also updated their practice and aim to promote public health and positive health using a salutogenic (health-creating) approach (Whittaker et al., 2017), so concentrating on deficits or problems would negate their main purpose. Community development workers, too, avoid focusing on deficits, preferring instead to highlight the capacity, strengths and resources found in the local population (see Chapters 1 and 2). The different uses of the term ‘need’ can create difficulties, for example, when a problem focus is used to determine needs assessment schedules for use by health visitors, resulting in a medicalized approach to the work (Cowley et al., 2004). The extent to which an assessment is valued in an organization varies according to who carries it out (ascribed worth) and how important particular needs seem within an organisation. When individual nurses and health visitors had assessed needs in their caseloads, for example, Bergen et al. (1996) found their profiles tended to be disregarded, because they were not sufficiently senior in the organization for their assessment to count for much. In contrast, local needs assessments made by senior public health doctors usually overruled those of everyone else.
Timing People need to be ready to talk about things that are bothering them, so timing is important from the client’s perspective. Also, practitioners need the time to carry out assessments sensitively. Cowley and Houston (2003) found that clients were either bemused or offended when rushed practitioners read through a list of questions without listening to responses, because their organisation required the assessment form to be completed by the time an infant reached a certain age—usually at the first or only visit. Quality or ‘key performance’ indicators requiring certain topics to be introduced or discussed before a child reaches a particular age inevitably influence the timing of when needs assessments are carried out. Time is one element of the model of service quality outlined by Hanafin and Cowley (2006) and Hanafin (2008). The timing of an assessment is also related to the level of prevention; once a problem has become manifest, it is of no use aiming to achieve primary prevention, nor to offer anticipatory advice about a developmental stage once it has passed.
Types Some assessments are much more formal than others. Typically, the most formal assessments are those that have financial implications, such as those carried out at a strategic level to inform decisions about which services to fund or prioritise. At the grass-roots level, information may be gathered to feed into those decisions, either by collecting one or two particular types of information (perhaps the weight of school-aged children, for
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example, to feed into a strategy about obesity prevention) or may be collated into a community profile, considered further in later text. The informal and non-specific assessments are no less important and sometimes help to complete a complex picture; a mother struggling to introduce solids to a reluctant baby might make a throwaway remark about power battles in the home around mealtimes when she was a child herself, for example, that will be far more telling than a whole battery of behavioural tests. Also, the purpose of the assessment influences both how and when it is carried out. In practice, assessments rarely fall neatly into a single format, with the different types and timing issues involved being intertwined with policy priorities and specific professional perceptions about what constitutes ‘need’. Overall, needs assessments carried out for purposes of preventive care and health promotion on a well population, whether at the level of the community, child, family or individual, are less widely documented than approaches used for planning either acute services or treatment.
Assessing community health needs The terms ‘local health needs assessment’ and ‘health profile’ tend to be used interchangeably. Billings (2002) distinguishes between them, regarding ‘health needs assessment’ as a broad term concerned with a description of those factors which must be addressed to improve the health of the population. This definition allows for the delineation of the range of factors which make up the concept of need, whereas the health profile is a method by which needs are assessed (Billings, 2002). It was identified in its widest sense as ‘the systematic collection of data to identify the health needs of a defined population, and the analysis of that data to assess and prioritise strategies in health promotion’ (Twinn et al., 1990, p. 2). Health profiles use mainly quantitative health data, such as statistical information, but qualitative health data, such as individual assessments and client perceptions, can also be incorporated to form a more holistic picture (Billings, 2002). Health profiling may be carried out as a search for specific, prioritised needs that have been identified as important at a national, international or local level. Alternatively, a bottom-up approach may be used to allow the local population to discern for themselves what they consider to be their own needs. This is a more common approach in community development and community practice, as explained in Chapters 2 and 15. Often, the two are used to some extent in combination. Either way, there are four questions to be considered before planning to assess needs at the level of grass-roots practice, summarised in Box 6.1.
Defined populations The first stage of identifying health needs is deciding which population is under consideration. Public health practitioners usually have responsibility for working with a defined population of some kind, which is often called their ‘caseload’. This differs from the caseload held by clinicians, where the numbers on the caseload equate to the files held, indicating contact with a person. In terms of prevention and public health, it is necessary to be aware, even without having necessarily met a person, of what their needs might be. So, a
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BOX 6.1
Local health needs assessments 1. What is the population to be considered? a. Level: caseload, practice, neighbourhood? b. How is the population defined? 2. What is the purpose and scope of the assessment? a. Service planning? b. Evaluation? c. Multidisciplinary and/or multiagency? 3. Which data are readily available?
a. Data from medical (general practitioner) practice? b. Census data? c. Local public health department? d. Local, national and international statistics? 4. Which data must be collected specifically for the assessment? a. Local survey b. Rapid participatory appraisal? c. Audit and monitoring information?
public health caseload might include the whole school population, for example, even though a school nurse might never have the opportunity to meet all of the many thousands of children enrolled in the schools for which she has responsibility. In some places, the idea of ‘whole school population’ may include staff as well as children and their families, or specifically indicate enrolled children only. Similarly, an occupational health nurse may have responsibility for a defined population of employees, or this may extend to incorporate prospective staff (through pre-employment medical checks, for example), and ex-employees, such as those who have retired from an organisation, and possibly the local population, through staff clubs and family facilities. Those working within primary care in Great Britain often have their population defined in terms of the practice list identified by registration with a general medical practitioner. Other services are defined by geographical area, particularly where they are either led by local authorities or developed in collaboration with them. In either case, there may be subdivisions of the whole population, such as those living in a particular area, as well as being on a general practitioner’s list, or belonging to a particular age range. These days, for example, health visiting work is commonly restricted to preschool children and their families, whereas it was once more usual for it to incorporate a wider age range. Some specialists may be appointed to focus on particular population groups, such as homeless families, the travelling community, refugees and asylum seekers, or looked-after children.
Wider context It is usually preferable to have a ‘core population’ for which services are to be planned, but nevertheless to look at the context within which that group lives, so as to determine the needs of the defined group more clearly. Focusing only on homeless families without looking at the wider population where they live, for example, would give no indication
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about the root causes of their housing problem. Seeing the needs of employees only whilst they are at work would limit the extent of preventive activities in which they might be engaged, whereas focusing on a wider community may give an indication of local leisure patterns, food behaviour and so on, all of which have an influence on health. Timelines are important, particularly for children. Eating patterns in the preschool years may set the scene for later healthy weight (see Wright, 2019), for example, or a child’s inability to develop self-control may indicate a risk of later delinquency, if help is not forthcoming (Nofziger and Rosen, 2017). This form of ‘nesting’ of information is used in community, neighbourhood and caseload profiles, with the overall title being determined by which level is foremost. These levels of health needs assessment are not separate from each other. Community profiles, for example, may include general practice and caseload information. Practice profiles will need some community-wide information for comparison purposes. At the level of strategic planning, there is an increasing tendency to try to match service boundaries so they are coterminous. It helps if boundaries match electoral wards or boundaries, because most data sources are collated in those formats. Figures are traditionally collected according to mortality (rates and causes), gathered mainly from birth and death certificates and morbidity (Box 6.2). Morbidity is the extent of illness and disease, gleaned from a range of sources, such as general practice or hospital data (attendance, admissions, investigations and treatments) and surveys and censuses. As far as possible, definitions are standardised nationally and internationally so that comparisons can be made. International comparisons are particularly
BOX 6.2
Gathering information: epidemiology basics
Definition • Epidemiology is the study of how often diseases occur in different groups of people and why.
Key features • Epidemiology involves the measurement of disease outcomes in relation to a population at risk. • Epidemiological observations may guide decisions about individuals, but they relate primarily to groups of people.
• Clues to aetiology come from comparing disease rates in groups with differing levels of exposure. • Epidemiology is concerned with monitoring or surveillance of time trends to show which diseases are increasing or decreasing in incidence and which are changing in their distribution.
Measurement • Measuring disease frequency in populations requires the stipulation of diagnostic criteria, sometimes known as ‘defining the case’. Continued
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BOX 6.2
Gathering information: epidemiology basics—cont’d
Measurement—cont’d • The International Classification of Diseases, Injuries, and Causes of Death, published by the World Health Organization, assigns a three-character alphanumeric code to every major condition. This is regularly updated to ensure international consistency in data collection. • For epidemiological purposes, the occurrence of cases of disease must be related to the ‘population at risk’ giving rise to the cases. • Measures of disease frequency in common use are: • The incidence of a disease is the rate at which new cases occur in a population during a specified period (i.e. once a person is classified as a case, he or she is no longer liable to become a new case) • The prevalence of a disease is the proportion of a population infected with the disease at a point in time. • Mortality is the incidence of death from a disease • Direct standardisation entails comparison of weighted averages of ageand sex-specific disease rates, the weights being equal to the proportion of people in each age and sex group in a convenient reference population (e.g. measures of testicular cancer related to males in the population). • A comparable statistic, the standardised mortality ratio, is widely used by the registrar general in summarising time trends and regional and occupational differences. • To analyse time trends, as with the cost of living index, an arbitrary base year is taken.
• A crude incidence, prevalence or mortality death rate is one that relates to results for a population taken as a whole, without subdivision or refinement. Occurrences such as the death rate would be higher in certain populations (e.g. a retirement village where there is a higher elderly population), so standardised mortality rates adjust for such variation.
Some special rates, usually related to 1 year Birth rate 5 Number of live births to midyear population Fertility rate 5 Number of live births to number of women aged 1544 years Infant mortality rate 5 Number of infant (,1 year) deaths per number of live births Stillbirth rate 5 Number of intrauterine deaths after 28 weeks compared with total number of births Perinatal mortality rate 5 Number of stillbirths 1 deaths in first week of life compared with total number births Neonatal mortality rate 5 Number of stillbirths 1 deaths in first month of life (28 days) compared with total number births Post-neonatal mortality rate 5 Number of deaths from first month of life (28 days) to end of first year, compared with total number births Source: Coggan, D., Rose, G., Barker, D.J.P., 1997, Epidemiology for the uninitiated (4th edition). British Medical Journal Publishing Group, London. https:// www.bmj.com/about-bmj/resources-readers/ publications/epidemiology-uninitiated (accessed 19/05/2019)
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BOX 6.3
Useful sources of information about health
International statistics World Health Organization gathers and publishes statistics by country and by health topics, including urgent health-related data, such as epidemic or pandemic alerts and advice. Also has a range of research and epidemiological tools, publications on key issues and monitors progress towards selected health improvement goals http://www.who.int/en/ [accessed 27/03/2020]
UK national statistics Demographic information from latest census, neighbourhood information about, e.g. deprivation, health inequalities and latest health surveys. http://www.statistics.gov.uk [accessed 27/03/2020]
Country information Information on key areas of immediate policy interest, including public health indicators, workforce and service provision.
England: https://www.gov.uk/govern ment/organisations/public-health-england [accessed 27/03/2020] Scotland: http://www.healthscotland. com/ [accessed 27/03/2020] Wales: http://www.wales.nhs.uk/ [accessed 27/03/2020] Northern Ireland: https://www.publi chealth.hscni.net/ [accessed 27/03/2020]
Public health Ireland: https://www.publichealth.ie/ about [accessed 27/03/2020] Scotland: https://www.scotpho.org.uk/ [accessed 27/03/2020] Wales: http://www.publichealthwalesob servatory.wales.nhs.uk/home [accessed 27/03/2020] England: https://fingertips.phe.org.uk/ profile/child-health-profiles [accessed 27/03/2020] https://www.gov.uk/topic/healthprotection [accessed 27/03/2020]
important when working with minority ethnic groups (to draw on home country information), to assess disease trends and treatment efficacy or service effectiveness (Box 6.3).
Clarify purpose of assessment Governments determine which services are to be funded through the public purse, which has a direct impact on the nature of needs that will be met, and which agency will meet them. In terms of public health, it is well recognised that multi-agency, collaborative services are necessary, since the root causes of health and illness are rarely the sole responsibility of the NHS or any other single agency. It is important to have some idea of the scope of services that could be deployed to meet the needs that are identified and to establish a joint planning group at the outset.
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Which data to collect? Readily available Some data are readily available, such as the number of children in a school or new births on a general practice list. Employers need and collect information about the number of staff with disabilities, which may prove useful when targeting groups for health promotion campaigns, for example. Census data are also readily available from the Office for National Statistics (www.ons.gov.uk), whilst other data are readily available from international, national or local sources (see Box 6.3). Ideally, demographic data collected in a local situation, such as a caselist, school roll or neighbourhood, needs to be compared to wider figures at the level of a borough, electoral ward or county. Collected specifically for the assessment Alternatively, information may be collected specifically for the assessment, perhaps through a local survey or community-based research. Grant (2005a,b) (see also Chapter 15) describes the methodology known as Community Participatory Appraisal, which she used to investigate lay perspectives on health in her local area. This methodology uses a variety of methods to triangulate information gathered. It involves the local population in determining their own needs through a process using a questionnaire survey, observations, interviews and focus groups. Jackson (Chapter 2) also details the essential place of community participation in researching the needs of a neighbourhood, explaining ways to involve local people, particularly where deprivation and disempowerment are features. Noting that good health intelligence is not automatically easy to achieve, Sir Muir Gray (cited in DH, 2006, p. 11) coined the metaphor that “Information is like water. It must be gathered from where it falls, channelled, cleaned, treated and tested before being stored in reservoirs. It must then be made available on tap to those who need it, wherever and whenever they need it.” A national framework for health information and intelligence was proposed to set a standard for collating information (Box 6.4). A series of Public Health Observatories were set up across England to strengthen the availability and use of information about health at the local level (DH, 1999a). The observatory model has been adopted internationally and has continued in Scotland and Wales, but in England they have been largely absorbed into Public Health England, along with health protection information and child and maternal health statistics. Since public health functions were transferred to local government in England, some local councils have established urban observatories (Aspinall et al., 2016). Their key features are summarized in Box 6.5. Grass-roots public health workers are often in a position to gather information that is useful for health intelligence, but it is not ideal to make it ‘routine’ to ask everyone a series of questions about issues of concern to service commissioners rather than allowing families the opportunity to discuss their health needs in their own preferred way. Instead, practitioners need time to analyse and synthesise the (anonymised) information they have at hand before passing it on. It is not feasible to develop a single instrument suited to both family health needs assessment and the purposes of health intelligence (Cowley and
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BOX 6.4
A national framework for health information and intelligence
Data collection • Data should be collected as a by-product of routine public or private sector activity as far as possible. • Data should be of known validity and completeness. • Available data should cover the causes of health and illness, including wider determinants as well as health outcomes and quality of services provided. • Sources of data should include primary, secondary and community National Health Service care, local public sector sources, private sector and voluntary sector sources.
Data management • Data should be efficiently shared, collated, validated, linked, anonymised and archived as appropriate, using secure systems. • Person-level data should be handled in such a way that the rights and interests of the individuals concerned are acknowledged and respected, while striking a proportionate balance with the public benefit.
Analysis Systems should allow a range approaches to analysis, including:
of
• Ad hoc, query-based analysis • The regular production of specified indicators • Surveillance for unexpected trends and outcomes • Modelling of health outcomes against targets • Data feeds for disease registers including cancer registries • Area-based analyses from national to small area with comparisons.
Interpretation in context The results of the analysis must be interpreted in the context of: • Statistical and methodological issues, including data quality • Evidence from research • Experience of practice • Local knowledge
Communication of messages • The messages derived from the interpretation of the information and evidence must be communicated to relevant audiences using a range of media appropriate to the target audience or audiences. Source: Department of Health, 2006. Informing healthier choices: information and intelligence for healthy populations. Department of Health, London, p. 10.
Houston, 2004), partly because routine questioning may be out of step with the service user’s readiness to answer. This point is explained further later in the text, along with details about how advice, support and intervention are routinely intertwined with health visiting assessment practices.
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BOX 6.5
Functions of observatories
Public health observatories
Urban health observatories
• The turning of health data into
• A primary focus on the urban setting and
intelligence to support decision making on commissioning health and health care
local priorities, using a social determinants of health approach
• Monitoring, forecasting and assessing
• Coordination across multiple sectors,
health policy impacts and providing a regional health intelligence service including trajectories and inequalities targets
disciplines and levels of government
• Signposting health intelligence
• Collation of data which is disaggregated
at the intra-urban (small area) level to reveal health inequalities • Analysis and interpretation of data to
• Producing national web-based tools,
knowledge and services to support local action; working actively with key partner organizations (such as local health service providers and local councils) • Acting as a source of expertise in health
intelligence, indicator development and inequalities measurement • Building regional analytic capacity in the
workforce through teaching and training.
understand health patterns in the city and their underlying causes, to detect gaps in existing policies and programmes, and to identify new priorities for intervention • Production of relevant, timely,
understandable and actionable local health intelligence to promote use of research evidence in strategic planning, policy formulation and performance review • Dissemination and outreach to policy
makers, the scientific community and the general public • Research and capacity building in urban
health Source: Aspinall et al., 2016. Establishing and sustaining health observatories serving urbanized populations around the world: scoping study and survey. Eur. J. Public Health 26(4): 681686.
Need for prevention Focus on children and families The importance of maternal and child welfare as the basis for public health programmes is increasingly clear. Historically, and currently in much of the developing world, this focus has been of direct importance, because high rates of mortality or morbidity during pregnancy, childbirth and in the early years of life inhibit the development of nations. The inception of a
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universal health visiting service, mainly focused on the health and welfare of women and young children, was an early response to high maternal and infant mortality rates in the United Kingdom in the late 19th and early 20th centuries. The World Health Organisation (WHO) (2005) reports similar services developing early in France, later spreading to various other countries and still needed where poverty is rife and basic health care lacking. Kazakhstan, for example, has recently developed home visiting services to address child and maternal health needs, using United Nations Children’s Fund (UNICEF) Europe and Central Asia training modules based on nurturing care resources (UNICEF and ISSA, 2016). As mortality rates have fallen in developed countries, continued support for promoting the health of mothers and infants might, at first glance, seem less important. However, the links between a mother’s health and that of her infant, and between children’s health and their later health in adulthood, have become increasingly clear (Center on the Developing Child at Harvard University, 2016; Black et al., 2017). The impact of the child’s early life course has a particular and strong effect, not only on an individual infant, but also on health inequalities across the nation (Marmot et al., 2010, 2020). The effect is so strong that early child development (that is, from conception to aged 8 years) has been described as a ‘powerful equalizer’ (Irwin et al., 2007). The WHO et al. (2018, p. 1) describe investment in early child development as ‘one of the best ways a country can boost shared prosperity, promote inclusive economic growth, expand equitable opportunity, and end extreme poverty’, pointing to the excellent return on investment, which is at least $13 for every dollar spent. They describe a Nurturing Care Framework for the early years, which highlights the importance of having both universal and targeted services. Nurse home visiting for addressing child and maternal health needs has recently been established in Central Asia. In Kazakhstan, as described above, home visitors are trained in the UNICEF Europe and Central Asia modules on nurturing care for home visitors (UNICEF and International Step by Step Association, 2016). Universal or targeted services Policy responses to evidence about the links between children’s socioeconomic circumstances and adult health can take two different forms (Graham and Kelly, 2004), which have different implications for the assessment of needs. One approach is to focus on the most socially excluded, those with the most risk factors and who are the most difficult to reach. These are often called ‘targeted’ approaches and include the provision of various specialist services for named vulnerable or excluded groups, such as the homeless population, asylum seekers or looked-after children, or geographically targeted measures such as the provision of A Better Start or similar complex initiatives (see Chapters 3 and 8). This type of approach fits into the form of prevention called ‘selective prevention’ in the typology proposed by Mrazek and Haggerty (1994) and the WHO (2004) (Box 6.6). The second policy approach responds to the broader social gradient in health and the large numbers of people who, while they may not be formally regarded as socially excluded, are relatively disadvantaged in health terms. This approach recognises the need for more universally available services, even if they are not delivered in a uniform way. All pregnant women in the UK, for example, are deemed to need midwifery support starting early in the antenatal period, continuing through the delivery until after the birth. This universally available service also acts as a conduit through which women can access other
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BOX 6.6
Definitions of universal, selective and indicated prevention Universal
Universal prevention is defined as those interventions that are targeted at the general public or to a whole population group that has not been identified on the basis of increased risk.
Targeted: two forms
1. Selective prevention targets individuals or subgroups of the population
whose risk of developing a disorder is significantly higher than average, as evidenced by biological, psychological or social risk factors. 2. Indicated prevention targets high-risk people who are identified as
having minimal but detectable signs or symptoms indicating predisposition for disorder, but who do not meet diagnostic criteria for disorder at that time. Adapted from Mrazek, P.J., Haggerty, R.J. (eds) (1994). Reducing risks for mental disorders: frontiers for preventive intervention research. National Academies Press, Washington, DC.
primary and secondary care services if needed, whether by referral or through information giving, following needs assessment, which is a form of ‘indicated prevention’ (see Box 6.6). This is another form of targeting, which is generally more individually focused and may be delivered in conjunction with a universal service. More recently, the realisation that needs follow a social gradient across the whole population has led to emphasis on prevention through ‘proportionate universalism’ (Marmot et al., 2010; Cowley et al., 2015; see Chapter 1). This approach recognises (1) that everybody needs some support and (2) that reaching out to all families provides a platform from which to identify those who need more than the minimum provision. The late epidemiologist Geoffrey Rose emphasised that ‘a large number of people at small risk may give rise to more cases of disease than a small number of people at high risk’ (Rose et al., 2008 p. 5), which has been cited as a strong reason to continue universal provision (e.g. Elkan et al., 2001; Cowley and Bidmead, 2009). Both health visiting and school health services aim to promote health for all children and to reduce health inequalities by identifying other needs through individual child and family health assessments. The processes involved in needs assessment vary widely, depending on whether they are being used for targeting (whether through selective or indicated prevention) or for purposes of health promotion in a universal service (Cowley and Houston, 2004).
Universal prevention: assessment for health promotion Universal services focused on health improvement through promotion and prevention are delivered with three major aims in mind. First, they provide for the public health imperative of improving health across the whole of the population to whom the service is delivered. Second, by destigmatizing and normalizing service provision, universality
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enables those who are the most disadvantaged—and usually hardest to reach—to accept initial offers of provision, which is key to the reduction of health inequalities. The third major aim is to jointly differentiate and target individuals, children or families who have a need for additional services, so they can have access to appropriate support and early interventions. Needs assessment processes are central to all three aims and are intertwined with delivery of a preventive, health-promoting service. Empowerment is viewed as a ‘flagship’ value for health promotion (Woodall et al., 2012), despite definitional difficulties and problems with measurement (Cross et al., 2017). Empowerment is regarded as an essential basis for health, which can only be developed internally by individuals, families or community groups (Rissell, 1994). It cannot be prescribed or dispensed by an outsider, but a facilitator might encourage or assist that development by working in a genuine, respectful partnership (Davis and Day, 2010). To achieve health, people need to own it themselves, in the sense of exercising full autonomy and choices in the way they live their lives (Rijke, 1993). Universal services, therefore, use the assessment process as an opportunity to promote and develop ‘participatory competence’ on the part of the client, whose position Kieffer (1984) describes in terms of citizenship and empowerment. The assessment process should not inhibit their primary purpose of health promotion (Cowley and Houston, 2004). A narrative review of health visiting literature showed needs assessment to be a core element of health visiting practice, which is intricately linked with home visiting and developing a relationship with parents (Cowley et al., 2015). Table 6.1 summarises the key elements involved in a universal assessment process that also aims to promote health through empowerment (Houston and Cowley, 2002, Mitcheson and Cowley, 2003). Clientcentredness, needs assessments and enabling access to services are all intertwined and interdependent rather than following a linear process (Cowley et al., 2000a; Appleton and Cowley, 2003; Cowley and Houston, 2004), as shown in Table 6.1. Overall, the research paints a picture of assessment that is bound up with the whole of practice, rather than being a separate, preliminary stage, as occurs in selective prevention or when assessing needs before developing services. Luker and Chalmers (1990) detail the embedded processes and time needed to accomplish what they call ‘entry work’, treating problems as if they are ‘normal’ rather than ‘deviant’, which is an essential prerequisite to the main body of activity, the ‘health promotion work’ (Chalmers, 1992). Appleton and Cowley (2004) showed that, even when given lists of questions or aides memoire to guide their assessments, health visitors tended to use their own professional judgement about when to ask questions or follow up perceived cues from parents. Rather than going in with a fixed agenda or a closed choice of predetermined needs to be ratified by clients, they aim, instead, to explore how families can harness their own health-creating potential and capacity. This contrasts strongly with needs assessment protocols that list ‘problem areas’ for possible discussion, thus denying clients the opportunity to raise their own concerns and placing firm boundaries around the remit of the service (Cowley et al., 2004). This undirected and open conversational style is used to ‘search for health needs’, which is a foundation principle of health visiting (Council for the Education and Training of Health Visitors, 1977; Chalmers, 1993; Cowley and Frost, 2006). Bearing in mind that health visiting is a proactive, unsolicited service, its practitioners need to be prepared to accept and follow shifts in the direction of conversation, responding
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TABLE 6.1 Empowerment approach to needs assessment Relevant health visiting research
Health visiting practice
Intent for client
1. Enabling relationships (Pearson, 1991; Chalmers and Luker, 1991; de la Cuesta, 1994) 2. Gaining access/entry work (Luker and Chalmers, 1990) 3. Health promotion work (Chalmers, 1992) 4. Client-centredness; ‘fringe work’ (de la Cuesta, 1993) 5. Development: changing expectations (Pearson, 1991) 6. Shifting focus in conversation (Cowley, 1991) 7. Unpredicted needs/therapeutic prevention (Cowley, 1995a) 8. Actively promoting resources for health (Cowley, 1995b)
1. Health visitor as facilitator and resource 2. Assessment is integral to practice 3. Flexible view of what constitutes ‘need: 4. Encourages client-centred approach to practice 5. Allows professional judgement 6. Fosters acceptance of the client’s view 7. Proactive search for health needs
1. Client in the lead 2. Promotes ‘participatory competence’ 3. Nonprescriptive: permitted needs not predetermined 4. Validation of client’s perspective/opinion 5. Inclusive of contextual and sociocultural issues 6. Nonstigmatising 7. Assessment as an opportunity to discuss health, not a condition for receiving service
to cues which may be quite minimal, and either verbal or nonverbal. This shifting focus follows and stimulates awareness of any health needs mentioned in the conversation (Cowley, 1991). The shifting directions are purposeful, being used to maintain open agreement between health visitor and client about the purpose of the contact, enabling topics relevant to the client to be central. This approach may be equally relevant in other health-promoting services that are offered, whether requested or not. Proactive, health-promoting services need to be client-centred, requiring the ‘fringe work’ (de la Cuesta, 1993) that lies outside normal organisational agendas, such as arranging appointments at times to suit the client rather than the clinic and maintaining mobile role boundaries to maintain relevance of the service for clients. Relationship skills appear critical in determining the degree to which health visitors (Machen, 1996; Normandale, 2001) or any other practitioners are acceptable to clients (Davis and Spurr, 1998; Davis and Day, 2010). Interpersonal relationships between parents and professionals lie at the core of all health visiting provision (Cowley et al., 2018). They are purposeful and facilitative in that they enable health promotion work to be initiated and accomplished (Chalmers and Luker, 1991; de la Cuesta, 1994; Bidmead et al., 2016; Axford et al., 2015). Relationships form the basis for a great deal of public health work (see Chapter 7) and endure over time, whereas an assessment undertaken at one point in time is likely to yield quite different results if undertaken with the same family at another time (Elkan et al., 2000). A versatile service helps practitioners to provide valued help in an acceptable or timely manner, perhaps with an apparently small query in the first instance, which helps to build trust in the service. A combination of trust in the professional as a person and in their ability to respond appropriately helps to build confidence and understanding about the purpose of the service (Collinson and Cowley, 1998a). In turn, this helps clients to feel able to reveal and discuss otherwise hidden, possibly more relevant and deep-seated, health needs (Collinson and Cowley, 1998b) (see Figure 6.1).
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Need for prevention
LEVEL ONE
DEMAND
• pseudo-medical/mostly physical • legitimate • child-oriented • visible/tangible • expressed verbally (e.g. by asking questions) visible
• manifest • public/professional sphere • relatively simple (i.e. single components) • quantifiable (i.e. measurable outcomes)
LEVEL TWO
NEED
• mostly mental and emotional • exposes vulnerability • adult/family or mother-oriented • invisible/intangible • expressed nonverbally
hidden
• latent • private/lay sphere • complex/multifaceted • nonquantifiable outcomes
LEVEL THREE Unmet need possibly due to:
UNMET NEED
• needs unrecognised by health visitor or mother • lack of knowledge regarding the service
unknown
• no actual need to access the service
FIGURE 6.1 Iceberg of need (family health). Adapted from Collinson and Cowley, 1998a.
Assessments, therefore, often occur over a period time and at an unpredictable pace set by clients as they come to recognise their own needs and seek support. This is the mechanism through which universal service provision achieves the major priorities of identifying and enabling access to services by those with specific needs, particularly by individuals and families who traditionally find services difficult to access.
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Assessment for targeted services Cowley and Houston (2004) argued that targeting of preventive interventions is essentially driven by an organizational agenda. That is not to be understood as a criticism; effective and efficient organizations are central in driving forward the public health agenda and overall preventive effort, as long as the objectives serve a health improvement purpose. Having an objective or a minimum result to aim at, which is what ‘target’ means, is immensely helpful in terms of organizational efficiency. Targeting the service, or aiming the resources more precisely, is not only a mechanism through which costs can be contained; it is also concerned with responding effectively to particular problems or causes of problems (‘social determinants of health’) that have been identified as needing attention. However, conflicts may arise for practitioners when targeting is planned to limit or replace universal provision, rather than expanding where additional needs exist. Proportionate universalism (Marmot et al., 2010) presumes that families or vulnerable groups with additional needs can be identified through a universal service and offered more than the minimum provision that everyone receives. Targeting is, therefore, an essential requirement in a universal service that is to be delivered proportionately, and which will help to reduce health inequalities. Once an assessment that a specific need exists has taken place, then a prescribed treatment or (to use terminology that is more familiar to nurses and health visitors) a ‘programme of care’ can be initiated. Targeted prevention takes two forms: selective and indicated, as explained above (see Box 6.6). Selective prevention is used with individuals or subgroups of the population who have been identified as having a higher than average risk of developing problems. The FamilyNurse Partnership programme (known as Nurse-Family Partnership in the United States) (Olds 2006) is one example. It is delivered in England to young (younger than 24 years), single, first-time mothers, because they are a population known to be at higher risk of developing difficulties in the early years of parenting. Assessment for indicated prevention Universal services are offered at a minimal level in England, working on the assumption that additional services will be offered to those individual children or families who are identified, through assessment, as needing an additional service over and above the minimum. This includes individuals who have minimal signs, symptoms or factors suggesting a risk may be present, even if they do not meet a threshold or diagnostic criteria for disorder at that time. Assessment using professional judgement may identify early vulnerability, such that additional service provision appears necessary or further formalized assessment using appropriate instruments. In many cases, the need is such that a single professional, or a colleague working in the same sector, is able to provide sufficient support to meet the need. Most health visiting services, for example, include a range of group- or clinic-based activities to meet common needs, such as child behaviour problems, postnatal depression or breastfeeding support (Cowley and Caan, 2005). Likewise, school health services often incorporate drop-in facilities, including family planning or support for relationship problems, or run parenting groups (see Chapter 8). Instruction within the Scottish Universal Health Visitor Pathway (Scottish Government, 2015) illustrates how the apparently informal (albeit highly skilled) assessments undertaken
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BOX 6.7
Useful resources for specific assessments • Edinburgh Postnatal Depression Scale Questionnaire • Domestic Abuse Risk Assessment Checklist (DASH RIC) • National Risk Assessment Tool • Getting It Right for Every Child (GIRFEC) Practice Model • Ages & Stages Questionnaires: (ASQ:3) • Parents Evaluation of Developmental Status (PEDS) • Parents Evaluation of Developmental Status: Developmental Milestones • Questionnaire (PEDS:DM) • Ages & Stage Questionnaire: Social-Emotional (ASQ:SE 2) • Strengths & Difficulties Questionnaire (SDQ) • The Sure Start Language Measure (SSLM) • Modified Checklist for Autism in Toddlers (M-CHAT) Source: Scottish Government, 2015. Universal Health Visitor Pathway in Scotland. https://www.gov.scot/ publications/universal-health-visiting-pathway-scotland-pre-birth-pre-school/ accessed 27-03-20
when first meeting a family, can shift to incorporate a more formal assessment, possibly involving use of specific, structured or validated instruments in developing an individualised health plan. It lists a series of useful resources that may be used routinely (Box 6.7). The guidance emphasizes the importance of a trusting relationship between the health visitor and family members as a requirement for assessment, particularly when carrying out routine enquiries about sensitive issues, such as domestic abuse, for example. Use of the Getting it Right for Every Child (GIRFEC) national practice model is emphasised, with strengths-based practice and assessment at the heart (Figures 6.2 and 6.3). Resources to support GIRFEC are available from https://www.gov.scot/policies/girfec/wellbeing-indicators-shanarri/. The model was designed for all health professionals to use to support collaboration between services (Healthier Scotland, 2010). Assessment for selective prevention At an individual level, assessment for selective prevention is a form of screening, aiming to achieve early interventions or offer programmes of care once a difficulty has been identified. To be valid, a needs assessment activity performed for the purpose of targeting should have the same attributes as any useful diagnostic test. Such a test should (1) be sensitive, picking up people who have the condition; (2) be specific, excluding people who do
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Assessment Appropriate, Proportionate, Timely
Suc ce ss fu
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My Wider World
Me
MY WORLD
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ens
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Resilience matrix used when required for more complex situations Resilience Observing and Recording Events/concerns/observations/ other information
Planning, Action and Review Adversity
Proactive environment Vulnerability
Gathering Information and Analysis
FIGURE 6.2 Wellbeing Wheel. Source https://www.gov.scot/publications/shanarri/ (accessed 27/03/2020)
not have the condition; and (3) be accurate, revealing the correct result, not false positives or negatives (Power et al., 2013). In many instances, this will involve use of a structured instrument, validated for a particular condition. In other cases, the tests may be simple assessments, such as identifying high risk for obesity through raised maternal weight antenatally, for example, perhaps leading to a referral to a local HENRY (Health, Exercise and Nutrition for the Really Young) group (Willis et al., 2016) before the infant is weaned. Other examples include referral of teenage single mothers to the local Family Nurse Partnership programme, or expectant mothers of any age facing social stress to a Maternal and Early Childhood Sustained Home-visiting programme (Kemp et al., 2011; Goldfeld et al., 2018). Introducing a general screening test for any specific condition is likely to have the effect of directing the service towards that area of interest, and away from others. In this respect, the process of targeting can be seen to overlap with that of prioritising at a population level, so the choice of which screening activities to use could be made in the light of anticipated health needs identified at an overall, neighbourhood or locality level.
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Conclusion
Everyday care and help
Being healthy
De vel op
ple o Wh
Being there for me
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Play, encouragement and fun Understanding my family’s history, background and beliefs
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Becoming independent, looking after myself
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Confidence in who I am
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Being able to communicate
Learning to be responsible
Gr ow an d
Learning and achieving
Guidance, supporting me to make the right choices
My World Triangle
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MY WORLD My Wider World
School Support from family, friends and other people
Enough money Local resources
Work opportunities for my Comfortable family Belonging and safe housing
FIGURE 6.3 My World triangle. Source https://www.gov.scot/publications/shanarri/ (accessed 27/03/2020).
In public health terms, it is a disadvantage that screening activities tend to focus attention on individuals (whether mothers or children) with specified problems, instead of on the underlying social and contextual causes of the problems. If a need (such as delayed language development) has been deemed so prevalent in an area that all families are to be screened for this condition, some parallel community-wide activities are needed to challenge and change the underlying causes of the problem (e.g. Turner et al., 2004).
Conclusion This chapter has concentrated on describing the key features of needs assessments for individuals, children and families when preventive interventions are required. Despite its importance in terms of public health and improving health inequalities, there has been much less interest in this activity than in needs assessments for service planning, or for planning individual programmes of care once a diagnosis, deficit or problem has been
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identified. In part, this reflects the perceptions of need held by professionals delivering care, and how they view their responsibilities in relation to policy priorities. Difficulties arise when the forms of assessment needed for health promotion and empowerment are overshadowed by those more suited to different situations, like service planning or prescribing treatments. Cowley and Houston (2003), for example, found that a schedule of questions drawn from instruments better suited to community profiling was unacceptable to clients and unhelpful in identifying needs at the level of the family. Welldeveloped communication skills and a commitment to working in an empowering way are both essential, as shown by two other studies in which the assessment processes were considered unhelpful (Mitcheson and Cowley, 2003; Roche et al., 2005). In most instances, an established relationship between client and professional helps to promote a positive atmosphere and fruitful assessment, although partnership working of the kind described in Chapter 7 can be developed at the first meeting (Bidmead et al., 2015). If organisational requirements limit the assessor to asking only about predetermined needs, or to avoid identifying some needs because of service restrictions (perhaps because of lengthy waiting lists, or staff shortages), then practitioners become disempowered. In turn, their practice is more likely to be disempowering. Client perceptions need to be paramount and needs assessments, although intertwined with care delivery, should be open, not covert (Cowley et al., 2004). There is no single mechanism for needs assessment. It is not a purely technical task, but requires skill to negotiate the basically complex and contested nature of the concept of health need. Neither choosing a needs assessment approach nor ensuring the skills to carry it out can answer the moral questions about which of the many competing needs should be met by health services. But a good assessment of needs is the cornerstone of service provision, offering a sound starting point for universal and targeted prevention, integrated working and health improvement. The potential rewards are such that it is worth grappling with the complexity of the task.
Discussion Questions • What professional skills are most important for assessing health needs of communities? • What professional skills are most important for assessing health needs of individuals and families? • Can information about health needs in an area be used to plan service delivery and service configurations? How? What are the barriers? • Consider how knowledge of health needs could be used to advocate for additional services, or to disinvest from specific provision. How are such dilemmas best resolved?
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Recommended reading and resources Appleton, J., Whittaker, K., 2019. Assessing the health needs of children. In: Horwath, J., Platt, D. (Eds.), The Child’s World the Essential Guide to Assessing Vulnerable Children, Young People and their Families, 3rd edition, Jessica Kingsley Publishers, London. Coggan, D., Rose, G., Barker, D.J.P. (Eds.), 1997. Epidemiology for the Uninitiated. 4th edition British Medical Journal Publishing Group, London. Available from: , https://www.bmj.com/about-bmj/resources-readers/ publications/epidemiology-uninitiated . (accessed 19/05/2019). World Health Organization, 2018. Nurturing Care for Early Childhood Development: a Framework for Helping Children Survive and Thrive to Transform Health and Human Potential. WHO, Geneva, Switzerland, ,https:// apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf. (accessed 19/09/2019). See also https://nurturing-care.org/ for nurturing care resources.
Community public health in policy and practice
C H A P T E R
7 Relationships and partnership working for public health Sarah Cowley and Christine Bidmead KEY ISSUES • Partnership working has long been regarded as central to achieving public health outcomes, particularly for those working in the community. • Partnership working has some defining attributes and requirements, which contribute to relationship-centred public health.
• Relationships, important in all of health care, are central to efforts to work in partnership. • Key features of parenthealth visitor relationships, and the way they are affected by organisational arrangements, are identified. • Relationships and partnership working are purposeful and need to be outcomes-oriented.
Introduction Relationships matter at all levels. They matter in high-level dialogues, global negotiations and in diplomatic services—and amongst individuals on an intimate, interpersonal level and at all levels in between. They underpin collaboration and partnership working, which have long been viewed as enabling services to be better delivered and organised, with greater success and more work satisfaction when relationships are positive and potentially worse outcomes when they are negative. There are ingredients in common between professional ways of working in partnership between agencies, colleagues and teams, and relationships between service users and the practitioners engaging with them. In turn, those ways of working can mirror and model ways of being in intimate, interpersonal relationships. This chapter begins by explaining the basics of partnership working, which has long been regarded as central to public health, then explaining why and how the dialogue has turned to a consideration of relationships in recent times. Second, the term ‘partnership’ is examined
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more closely, with particular reference to professional work with families and individuals. Third, research about parenthealth visitor relationships are introduced, along with the way that organisational arrangements may help or hinder their formation, to illustrate some of the complexity and skill needed to develop and maintain positive professional relationships.
Partnership working Partnership working is said to offer mutual benefit for health through the sharing of expertise, skills and resources (World Health Organization, 1997). Sometimes known as interagency cooperation, cross-disciplinary collaboration or, in a more advanced form, integrated working, it has long been proposed as a mechanism for dealing with the multifaceted and complex nature of the foundations of health and early intervention. In England, all National Health Service (NHS) bodies were expected to form sustainability and transformation partnerships as a means of delivering the NHS Five Year Forward View (NHS England, 2015) in a time of financial austerity. In all, 44 sustainability and transformation partnerships were established and are now giving way to integrated care systems (ICS), described as an ‘even closer form of collaboration’ (NHS England, 2019a). In an integrated care system, NHS organisations work in partnership with local councils and others, taking collective responsibility for managing resources and delivering NHS standards, with a view to improving the health of the population they serve. The NHS Long Term Plan (NHS England, 2019b) suggests that every area will be served by an ICS by 2021, with general practitionerled primary and community networks developing expanded teams covering a local area. These proposed developments come with large aspirations. The new ICSs will focus more on population health and partnerships with local authorityfunded services to support more people. Breaking down traditional barriers between care institutions, teams and funding streams everywhere is intended to help ensure a shift towards more person-centred care. However, there is some recognition in the Long Term Plan that creating genuine partnerships requires professionals to work differently, as well as a systematic approach to engaging patients in decisions about their health and wellbeing. This caution is reflected in research about partnership working. Most partnerships fall into one of three categories (Hunter and Perkins, 2012). Facilitating partnerships are concerned with managing long-standing strategic policy issues, whilst coordinating partnerships are concerned with the management and implementation of policy based on broadly agreed priorities. Finally, implementing partnerships are pragmatic and concerned with specific, mutually beneficial projects. Hunter and Perkins (2012) identify some clear principles for partnership working, which are the need to • • • • •
Have a clear purpose with common aims, goals and objectives Bring together the right partners who can contribute most and commit Be able to have an honest dialogue about each partner’s contribution Invest in building trust and relationships Invest in leadership of the right sort, which demands working across ‘silos’
Evans and Killoran (2000) used realistic evaluation to examine local health improvement partnership projects, clarifying key factors that enabled progress. The necessary shared
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strategic vision was aided by joint development work and co-terminosity of agencies—for example, a history of having worked together helped to develop good interpersonal relationships and organisational readiness. The extent of policy turbulence at a national level and organisational turbulence locally were cited as factors that required good leadership and management, with the ability to be responsive to a changing environment. Complexities of fluid and multiple accountabilities in partnership projects could create tensions likely to affect relationships; local ownership and local champions were identified as helpful in maintaining positive relationships. Indeed, relational factors such as trust and goodwill are described as the ‘glue that made partnerships work’ by Hunter and Perkins (2012 p. 50), who suggest they can be enabled by adopting a complex adaptive systems perspective, rather than focussing so much on rigid structures. Drawing on an extensive review of community-based research aimed at improving public health, Israel et al. (1998) noted a number of factors that may either facilitate or challenge the approach (Box 7.1). Despite its many advocates, partnership working can be a challenging route to follow. Furthermore, its effectiveness has been questioned, with Smith et al. (2009) finding in their
BOX 7.1
Partnership approaches to improve public health
Challenges, barriers and tension
Facilitating factors and recommendations
• Lack of trust and respect
• Jointly developed operating norms
• Inequitable distribution of power and
• Identification of common goals and
control
objectives
• Conflicts associated with differences in
perspective, priorities, assumptions, values, beliefs and language • Conflicts over funding • Conflicts associated with different
emphases on task and process • Time-consuming process, e.g. time
required to establish and maintain trusting relationships • Challenges and conflicts about who
represents the community and how community is defined
• Democratic leadership • Presence of community organizer • Involvement of support staff/team,
who may or may not be university based • Researcher role, skills, and
competencies and recognizing the expertise of others • Prior history of positive working
relationships • Identification of key community
member Source: Israel et al. (1998)
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systematic review little evidence that public health partnerships have a direct effect on health. In part, that may be because the very complexity of partnership projects creates difficulties in evaluation, but systemic barriers and differences are a major part of the problem, and leaders trained to deal with whole systems change are needed (Hunter, 2009). Furthermore, long-term stable relationships, regarded as a key element of success, have become increasingly difficult to maintain because of the cycle of continuous change in public services (Hunter and Perkins, 2012). Focussing on society as a whole, or even large population groups, can seem somewhat impersonal and removed from the everyday activities of community public health practitioners, who usually work with local groups, families or individuals. However, according to Nundy and Oswald (2014), care providers need to develop and maintain the comprehensive set of relationships that lie at the centre of population health services. They draw on the paradigm of relationship-centred care, indicating that it is equally relevant to the delivery of health care services and population services. Relationship-centred care is understood to have four key dimensions (Tresolini and the Pew-Fetzer Task Force, 1994), which have been expanded by Nundy and Oswald (2014) to show their relevance to public health. 1. Relationships between the patient and practitioner need to also account for all service users, such as parents and families. 2. Relationships between the practitioner and other colleagues need to encompass the whole care team and the entire health care delivery system. 3. Relationships between the practitioner and the community need to be extended to include family and peer patient support as well as community health resources. 4. The practitioner’s relationship with him or herself needs to include professional and personal development and self-awareness as a health professional. Overall, partnership working is clearly closely entwined with developing relationships and relationship-centred public health.
Partnership with individuals and families There is evidence of benefits from working in partnership with individuals and families. The Family Partnership Model (FPM) (Davis and Day, 2010; Day and Harris, 2013), which was developed over many years, is one example of a well-studied approach. It provides an accessible guide to the processes involved in helping families for all potential helpers, to enable their practice, and as the basis of system design and training. Originally known as the ‘Parent Advisor Approach’ (Davis et al., 1997; Davis and Spurr, 1998), it was renamed as the Family Partnership Model to better reflect the underlying philosophy and basic tenets, which will be explored in more detail below. FPM draws on Kelly’s (1991) theory of personal constructs and many of the tenets of helping relationships identified by Egan (1998) and has been widely adopted across the United Kingdom (UK) and internationally. Feedback after training in the FPM approach has been consistently positive, with practitioners reporting overall satisfaction, learning and relevance to their work (Davis et al.,
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1997; Brocklehurst et al., 2004). Course participants have routinely demonstrated improved helper self-efficacy (Rushton and Davis, 1992; Davis et al., 1997; Lea et al., 1998; Bidmead and Cowley, 2005) using the Constructions of Helping Questionnaire, which involves participant ratings of the qualities and skills they bring to helping parents (e.g. empathy). Local trusts have also found the approach helpful in initiating positive change (e.g. Department of Health (DH), 2012). Papadopoulou et al. (2005) trained 52 primary care professionals to work on the European Early Promotion Project (EEPP) (Davis and Tsiantis, 2005) with families in five different European countries and found close to maximum ratings for overall satisfaction (mean 4.5; maximum 5) and professional relevance (mean 4.3; maximum 5). The process of the training was also validated by highly positive ratings (mean 3.6; maximum 4) of the style of teaching, which is intended to mirror the helping situation (e.g. listening to participants and treating them with respect). Significant improvements in the qualities (e.g. empathy) and skills of helping have been demonstrated in a number of studies as a result of the course as assessed— for example, by ratings and observational measures taken from videotaped interactions (Rushton and Davis, 1992; Davis et al., 1997; Lea et al., 1998; Bidmead and Cowley, 2005). Health visitors trained in the FPM for the EEPP also showed higher and more accurate levels of need identification (Papadopoulou et al., 2005). The EEPP evaluated a new universal primary health care approach for families with young children in five countries (Davis et al., 2005). Based on the FPM, the intervention aimed to promote the psychological wellbeing of children through the prevention of psychosocial difficulties. There were statistically significant improvements in parentchild relationships, an increase in the levels of responsiveness and involvement shown by parents with their children and a decrease in the level of control used by parents (Puura et al., 2005). Overall, parents’ perceptions of the relationships with their workers improved. This was particularly relevant for the UK, where mothers initiated contact with their health visitors significantly more frequently than the comparison group, suggesting that they were able to use services more effectively owing to the positive parentworker relationship (Puura et al., 2005). Several studies have shown increased parental self-esteem as a result of intervention by FPM-trained personnel. Evidence of decreased parental stress has been found in families when workers were trained in the FPM approach (Davis and Spurr, 1998; Davis et al., 2005). Similarly trained primary care workers were shown to enhance parental perception of support and to increase their satisfaction with services (Davis and Rushton, 1991; Davis and Spurr, 1998; Davis et al., 2005). Maternal anxiety and depression have been shown to improve in parents working with staff trained in the model (Davis and Rushton, 1991; Davis and Spurr, 1998; Davis et al., 2005). Several studies have shown improved parentchild relationships and actual interaction as a result of intervention by trained personnel, as measured by how positively parents construe their children, the HOME Inventory (Bradley and Caldwell, 1979) and other observational measures (Davis and Rushton, 1991; Davis and Spurr, 1998; Puura et al., 2005). Although workers trained in the FPM may not necessarily focus specifically on the behaviour and development of the children in the families with whom they work, studies have shown both improved developmental progress as measured by the Griffiths (Davis
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and Rushton, 1991; Avon Premature Infant Project, 1998) and the Bayley Scales (Davis et al., 2005) and improvements in behavioural and emotional functioning (Davis and Rushton, 1991; Davis and Spurr, 1998; Davis et al., 2005). The Oxfordshire Home Visiting Study (Barlow et al., 2007) used a randomised controlled trial to evaluate the effectiveness of an intensive home visiting programme for stressed, complex families having their first or subsequent child. The programme aimed to improve parent and child outcomes in families at risk of abuse and neglect, and was delivered by heath visitors, all of whom had received training in the FPM. Results at 12 months showed improvements in parenting (specifically, maternal sensitivity and infant cooperativeness) and an increased identification of infants at risk of abuse and neglect in high-risk families. To complement parental benefits, the Somerset Partnership NHS Foundation Trust reported that health visitors can also gain from training in partnership approaches (DH, 2012). The case study example illustrates how the experience of working with the FPM assisted advanced health visitor practice, helping them to develop a greater critical awareness of a situation, have improved confidence in working in a focussed way and to manage difficult, but respectful, conversations with parents. The evidence presented indicates that the relationship with parents is the key to producing effective outcomes, which is explored further in later text. First, the intricacies of partnership working are explored further as this is demonstrably fundamental to working in public health.
Unpacking the Family Partnership Model In the FPM, helping is seen as a series of steps, stages or tasks (processes), which are required to produce a set of designated changes (outcomes). It is assumed that the process starts by establishing a relationship between the client and practitioner, so there is a need to define the nature of the relationship that will be most effective in facilitating the process and hence in achieving the desired outcomes. To enable a partnership relationship—and therefore the process as a whole—it is further assumed that the practitioner must have a small number of basic human characteristics and a larger set of communication skills by which these qualities may be demonstrated to the client. To work effectively, it is argued that potential helpers need to be explicit about the changes they are attempting to produce, using a holistic view of people as thinking, feeling beings always operating within a social context. This chimes with the tenets of an ‘orientation to practice’ identified by a review of health visiting research (Cowley et al., 2015), which included valuing each individual within an ecological framework, as described in Chapter 1. Anticipated outcomes of the helping process Anticipated outcomes need to mirror the aims of any helping process (Box 7.2). At the very least, the helper should do no harm. There is evidence, for example, that using a closely structured health needs assessment tool can lead to an emphasis on professional expertise and subsequent reduction in parent participation, so that parents may be harmed by feeling disempowered (Mitcheson and Cowley, 2003; Cowley et al., 2004). Previous bad
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BOX 7.2
Outcomes of working in partnership with families • Do no harm • Help parents identify, clarify and manage problems • Enable parents • Enable wellbeing and development of children
• Facilitate social support and community development • Enable access to appropriate services • Predict and manage future difficulties • Compensate where necessary • Improve the quality of future care
experiences with professionals may mean that they are reluctant to engage with services that may potentially benefit them and their children (Barlow et al., 2005). The relationships that health visitors have with clients are complex, and their professional power may inhibit the exercise of their supportive role, which has been documented in the field of domestic violence (Peckover, 2002, 2003). Parents need to be valued and understood, treated as capable human beings and to be facilitated in their role as carers (Attride-Stirling et al., 2001). Sensitive exploration by the practitioner is required to help the client express what is relevant to them and their circumstances in order to identify, clarify and manage specific problems. This might mean discussion of issues pertaining to themselves, their children or their family generally, as they may be all closely related. Problems may be raised that are beyond the expertise of the practitioner, who will need to acknowledge this as well as help clients to become clearer about themselves. A key aim is to enable parents to take power and control so as to face life more confidently, being more effective in meeting their own needs and those of their children. It is about working with them to reduce their vulnerabilities and working from their strengths—that is, through ‘strengths-based practice’ (Department of Health and Social Care, 2019). Raising parents’ self-efficacy and self-esteem helps to enhance their understanding of the helping processes and their own problem-solving abilities. One of the most powerful ways of doing this is through a respectful relationship between the parent and practitioner. When working with parents, the wellbeing and development of their child will need to be kept in mind even if the main focus of the work is not on the children and their problems. Whatever the work entails, parents can be helped to relate appropriately to their children so as to understand them more effectively and meet their needs. Social support has been found to be health-enhancing (Oakley et al., 1994; Wiggins et al., 2004, 2005), so a major aim of working with clients should be to build on and enhance existing social support networks. Relationships between parents might be an important focus for the work (Coleman et al., 2013; Institute of Health Visiting, 2019) but
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not to the neglect of other potentially supportive relationships with extended family, friends, neighbours and communities. Some families will require further support from other services. It is therefore important that adequate information be provided to them to facilitate the use of these services as appropriate. It is helpful to facilitate parents to be able to look to the future and to be able to predict their future needs. Helping them to use a problem-solving approach to their difficulties in the here and now may be useful to them in the future. Enabling parents to look forward to children’s transition points, for example, may be empowering in allowing them to anticipate future events and deal with them more effectively. For preference, work with parents should aim to foster their own self-efficacy and selfesteem, but occasionally this may be ineffective or even unsafe, particularly if it is an exclusive focus in situations when children are at risk of abuse and in need of protection. If parents or carers are unable to meet the child’s needs for any reason, then the aims of the worker must include the provision of whatever support and resources are necessary to compensate (see Chapter 13 for further discussion of actions to safeguard children). Service delivery systems need to have two-way communication and partnership relationships built in at all levels (e.g. child to parent, parent to practitioner, practitioner to supervisor). All workers should be responsible or have a right to attempt to change systems of care within any sector when they are inappropriate or inadequate. This is not just the responsibility of senior, managerial staff and/or government, but of all personnel, who should be working in partnership with their managers and in two-way communication to facilitate service development. Understanding the characteristics of the kind of relationship involved partnership working—the partnership relationship—helps to clarify what is aimed for and whether or not it has been achieved. These characteristics are listed in Box 7.3. It is assumed that the
BOX 7.3
Requirements for working in partnership
Characteristics
Qualities
Skills
• Working together/
• Respect
• Attending and active
participation
• Empathy
• Complementary expertise • Power sharing
• Genuineness • Personal
• Agreed aims and process
integrity
• Mutual trust and respect
• Humility
• Open communication
• Quiet
• Negotiation
listening • Prompting and exploration • Empathic responding • Enabling change/challenging • Problem management
enthusiasm
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most effective relationship is one in which both service user and practitioner are participating, actively involved and working together. It is not possible for either the parent or the practitioner to carry out partnership work alone. Collaboration is required wherein both partners bring their own resources to the situation and their commitment to positive outcomes. Partnership working recognises the complementary expertise of both parties. It does not deny professional knowledge and skills, which are vital. However, professional expertise is most likely to be effective if the parents’ expertise is seen as equally important for understanding and ameliorating problems. The FPM acknowledges, therefore, that parents and professionals have different expertise and that it is the complementary nature of the two that is most effective in helping families, parents and their children. Openly acknowledging this at the beginning and throughout the relationship sets the stage for a true power-sharing relationship. In reality, the balance of power is likely to shift between them over time, but given that the practitioner is there to provide a service, the parent should be the senior partner in most circumstances. If the practitioner and parent are working in partnership, they are attempting to agree every step of the process together. Initially, there needs to be an explicit agreement to work together and then ongoing agreement about what they are trying to achieve and how. Both participants in a true partnership relationship will have mutual trust and respect. Practitioners need to work to earn this trust and respect and not assume it by virtue of their profession. This means that practitioners need to approach each relationship with complete respect for the parent, valuing their expertise and their ability to change. There is evidence that the old-fashioned ‘professional expert’ approach is unhelpful in medical practice. Britten et al. (2000) showed that when the relationship was experienced as not collaborative but as a paternalistic, expert relationship, it was associated with noncompliance and drop-out. The hallmark of partnership is clear and open communication. Both partners need to share all relevant information in ways that maximise the understanding between them and minimise misunderstandings. This also involves sharing the processes of helping, so that the client is as aware of the process as the helper and learns how it works. Openness also implies the need for each partner to be as honest as possible, paving the way for each partner to be able to challenge the other as necessary. No relationships are without a degree of disagreement or conflict at times, even though one attempts to work with openness, honesty and respect. Disagreements have to be managed. This means that sources of conflict have to be identified and deliberate attempts made to resolve them. Agreement is sought by respecting the parent’s views and indicating acceptance and a willingness to explore all possibilities with the aim of negotiating a way forward. If the practitioner is gentle, tentative and invitational in proposing alternative views, conflict is usually minimised. Working in partnership leads to a number of assumed benefits. Among these is the suggestion that the task of helping becomes less stressful for practitioners, as it may relieve them of the burden of needing to have all the answers to everyone’s problems. Evidence for positive effects on professional satisfaction and stress are suggested by Davis and Fallowfield (1991).
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Qualities for partnership working The FPM assumes that the process of helping as a whole is dependent on the personal qualities and skills of the practitioner, needed by practitioners to facilitate relationship building and the process as a whole. These qualities may be understood as general intrapsychic characteristics, which orientate the practitioner appropriately to the helping situation and the person with whom they are working and must be demonstrated in ways that are perceived by the client. These qualities are assumed to be additional to a body of professional knowledge that the practitioner must bring to the situation, including an in-depth and explicit understanding of the processes and ingredients involved in helping. The qualities, highly influenced by the work of Rogers (1959), are listed in Box 7.3. Respect is fundamental and involves a general belief that the client is valuable and important, able to cope and to change. Professionals can communicate this in many ways, such as by being punctual, introducing themselves, and being courteous at all times. Perhaps the most powerful demonstration, however, is by being interested in, concerned for and listening to parents and children. Empathy involves a willingness and ability to try to enter the other’s world and see it from his or her point of view. If successfully demonstrated it gives parents a sense of being understood and valued. Developing a clear understanding of the thoughts, feelings and behaviour of another person requires in-depth concentration and careful listening, both to what the person is saying and to what they are implying. Genuineness or congruence is a complex quality that was used by Rogers (1959) to denote the importance of openness to one’s own and others’ experience. When exploring problems or difficulties, it is crucial that parents’ ideas are not coloured too much by practitioners’ own experiences, constructions and prejudices. Practitioners need to know their strengths and their weaknesses and be at home with themselves so they can remain objective. Being oneself within the relationship implies openness and honesty in all communications. Personal integrity is closely related to genuineness and refers to the practitioner’s capacity to: 1. 2. 3. 4.
Be strong enough emotionally to support those who are vulnerable Tolerate the anxieties of the helping situation Retain an objectivity that enables careful thought about people Allow the practitioner to be able to challenge or disagree with clients when it is thought to be to their benefit.
Humility involves developing a realistic assessment of the practitioner’s own strengths and weaknesses, knowing their limitations and acknowledging the differences between themselves and others without assuming that they are superior by virtue of being a professional. It includes an accepting, nonjudgemental attitude and an explicit acknowledgement that they do not have all the answers but will try to work with the parent to facilitate their strengths and expertise.
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Quiet enthusiasm forms the basis for conveying warmth and positiveness to parents. Anyone who enjoys their work conveys enthusiasm, which is infectious in interactions, adding warmth and spontaneity to the relationship. Enthusiasm that is excessive is inappropriate as practitioners may be working with people who are dealing with very real and distressing difficulties. However, it is possible for the practitioner to take pride in a job well done. Although practitioners’ needs must not take precedence, they must derive satisfaction from their work or they may experience compassion fatigue, which is characterised by emotional and physical exhaustion, a decrease in the ability to empathise and nurture others (Spiegelhalter, 2018). Skills for partnership working The FPM is based on a belief that the practitioners’ personal qualities are demonstrated through a set of communication skills that, in turn, enable the process of helping, including relationship development. Box 7.3 includes a nonexhaustive list of the most important groups of necessary skills Underpinning all helping processes are the skills of attending and actively listening to the parent or other clients, to show respect, develop the relationship and enable the helping process. The practitioner needs to concentrate fully on the client, removing all other distracting thoughts from beyond the immediate situation, and to indicate this through eye contact, responsive facial expression, body orientation, openness of posture and all other aspects of verbal and nonverbal behaviour. It entails being visibly tuned into clients with the heart, mind and body. Attending carefully can encourage the client to be more open and to explore problems in a way that they have not done in the past. If, however, the practitioner is only partially present, with their mind on other things, then this will communicate itself to the client, who will be less than willing to trust and be open. Listening is not a passive process. It involves actively processing all the information the client provides, verbally or otherwise, including what is omitted. The intention is to make sense of it from the parents’ perspective, trying to discern what they really mean, constantly checking out this understanding. Thinking about the parents in a holistic way, attempting to register their thoughts, feelings and behaviour whilst being conscious of their own reactions, is a very demanding form of practice. Attending and listening are the basis of skills required for exploring any issues, concerns or problems. Additional skills that may enable parents to talk, elaborate and structure their thoughts and feelings and to derive a clearer understanding of their situation include careful questioning, appropriate use of pauses, highlighting significant issues by reflecting them back and summarising. The practitioner’s task is to help the parent tell their story (Egan, 1998). Some people need little prompting and will tell a coherent tale and all the practitioner has to do is to summarise from time to time to ensure that they have grasped the detail. However, others may be less forthcoming for many possible reasons, including embarrassment, anxiety or depression; they will need time, patience and considerable skill to help them talk about their concerns. For some people there may be no resolution to their immediate problems (e.g. bereavement), but the role of the practitioner in these situations is to listen
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carefully, indicating that they are clearly with or ‘alongside’ the person in their distress (see Chapter 15). Empathic responding is an extremely important skill for facilitating a parent practitioner relationship, indicating listening and enabling change. It involves showing in words or in behaviour what the parent is feeling, thinking and/or doing. Many people who enter the caring professions do so because they care about others and want to help them with their problems. This sometimes means that they attempt to take the problem away or make it better with immediate advice. This approach risks failing to acknowledge the parent’s feelings at the cost of minimising the problems and ignoring the person’s own role in dealing with the issues confronting them. It may be more helpful to begin by indicating an understanding of the person and his or her situation, so as to build trust, on the basis of which the resources of both client and practitioner can be brought to bear. There are times when a person may be fixed on an understanding of their situation that may be unhelpful to them. Parents may, for example, view themselves negatively, attribute inappropriate feelings to their children or have a limited understanding of their children’s development and needs. In such circumstances, there is a need to help them change their perceptions, even though there may be extreme resistance to change and even feelings of considerable threat and conflict. Working in partnership, therefore, sometimes means that practitioners need the strength to acknowledge unhelpful constructions and the skills to challenge these (i.e. invite the person to change). These skills include the ability to request permission to consider such difficulties, to negotiate a way of tackling them and to do so using a tentative, invitational style, which is nonjudgemental, does not put down the parent, but acknowledges their strengths and elicits these in dealing with the issues involved. A variety of potential skills and techniques may be used here, including sharing the model of helping with the client—and particularly, the process and the notion of construing—providing new information, using advanced empathy (e.g. drawing unacknowledged conclusions or implications from what the parent has said) or immediacy (i.e. using the practitionerclient relationship itself to make points about how the client relates to others and the difficulties that might be involved in this). The use of these skills, within the context of a respectful and trusting relationship and a strong concern for the good of all the family, is more likely to enable the parent to change without feeling alienated. There is a set of skills related to the problem management steps in the helping process (i.e. setting aims and goals, planning strategies, implementation and review). These include, for example, the skills of sharing the model with the parent, involving her or him in the decision-making processes, prioritising the problems, negotiating aims, generating and evaluating goals and strategies, and exploring the outcomes. Such skills are the essence of problem-solving/management, but they are also crucial in motivating clients, increasing compliance, enhancing their own skills and understanding of the processes involved and raising the client’s sense of self-efficacy and their self-esteem. Case Study 7.1 highlights the success of one Trust in implementing and documenting these and other FPM skills, after learning to use the antenatal and postnatal promotional guides used in the EEPP study described above (Davis and Tsiantis, 2005; Day et al., 2014).
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Case Study 7.1 Health visitors and school nurses in the Southern Health Foundation NHS Trust were all trained to use the FPM and Promotional Guides (Day et al., 2014). The Trust used a routine audit to reinforce the importance of care planning to their staff, then demonstrate the success of this approach to commissioners and—more importantly—to the parents with whom they worked, using data collated through the RiO electronic patient record (Figures 7.1 and 7.2). A paper record of the plan is routinely offered to parents to hold, whilst a duplicate is used by the health
visitors back at base to transfer data into the electronic patient record before shredding. The record includes boxes in which to record the goal and plan, along with a straightforward 0 to 10 scale on which parents are asked to rate their view of where they are at the outset. This numerical scale is key to evaluation of parent-experienced outcomes. There are also boxes to note what is working already (strengths), next steps for parents, including support from family and friends, and what the professional team will do to help, along with a review date.
Name: ................................................... NHS Number: ....................................... Date my plan started: Today’s date: Lead professional: Healthy Child programme care plan:
My goal:
Where am I now? Goal rating As far away from my goal as I could be My strengths (what’s working well already):
0
10
GOAL!
My next steps (including support from family and friends): Practitioner: Role: Review date: How will the health visiting or school nursing team help me?
SH01322 - January 2017 © Southern Health NHS Foundation Trust
FIGURE 7.1 Parent-held Child Health Record.
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Children’s Services - Care Plan Reporting Care Plan Outcomes Recorded Outcomes
Care Plans Concluded by Primary Reason Aug 19
Sep 19
Oct 19
Nov 19
Dec 19
Jan 20
35 33
34 34 2 18 123 8 22
24 41 2 9 96 9 34 2 11 2 38 5 1 16
28 22
36 23 2 15 66 6 35
3 9 1 4 58 2 10 2 3 1 13 1 1 9 1 3 1 122
Behaviour Breast feeding Care Review Complex Health Need, SEN & Disability Development/Health Review Emotional & Psychological Support Healthy Weight HENRY 1:1 Infant Mental Health Introducing Solids Maternal Mental Health Minor Illness and accident prevention Multiple Needs Sleep Teenage Pregnancy Toilet Learning Support Transition to parenthood Grand Total
27 84 6 34 8 2 31 3 1 14 1 7
13 1 54 8 1 29 1 4 3 355
286
13 119 6 27 1 6 1 44 4 2 21 3 2 4 303
6 3 299
Score Difference - All Completed Care Plans
7 1 43 6 1 20 8 2 271
Goal achieved- no further action
1,144
Partially achieved- no further action
179
Goal not achieved- no action
97
Goal achieved- refer
59
Goal not achieved- refer
56
Noncompliant with care plan
54
Moved out of area
45
Service user deceased
2 1,636
Grand Total
Score Difference - Distribution by Primary Reason Primary Reason
Number of Completed Scores: 1321
Behaviour Breast feeding Care Review
No. Children
200
Complex Health Need, SEN & Disabi.. Continence Development/Health review
100
Emotional & Psychological Support Emotional Health
–10 0 –6
–4
–2
0
2
4
6
8
–5
0
5
10
Score Difference
10
i
FIGURE 7.2 RiO data. Disabi, disability; HENRY 1:1, Health, Exercise and Nutrition for the Really Young, https://www.henry.org.uk/; SEN, special education needs.
Case Study 7.1—cont’d The RiO system (https://www.servelec. co.uk/product-range/rio-epr-system/) was set up to collate data about the most common problems encountered (such as breastfeeding, sleep, behaviour problems, toilet training, infant and maternal mental health) and an electronic care plan maintained for all parents needing extra support on the ‘universal plus’ or ‘universal partnership plus’ levels of health visiting or school nursing. At follow-up, parents are asked ‘where are you now?’ along the 0 to 10 scale;
experience showed that parents generally regarded even apparently small shifts as helpful. Most improved by 2 to 5 points along the scale, with fewer than 10% feeling their situation was not resolved and around 5% referred to another service. Collating data across all the care plans on an annual basis provided helpful information for commissioners and practitioners, demonstrating the value and success of the local service. r Southern Health Foundation NHS Trust.
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ParentHealth Visitor Relationships
ParentHealth Visitor Relationships Partnership working, whether between organisations or between service users and professionals, all have relationships at their heart. There is a good deal of overlap between the two terms, as shown in the brief summary of thesaurus synonyms shown in Figure 7.3. However, partnerships are explicitly a way of working with one or more people, organisations or agencies, whilst relationships connote a way of being together. The phenomenon has been widely described in health visiting, including consumer studies showing that parents (like health visitors) greatly appreciate a relationship based on trust and mutual respect (Chalmers, 1992; de la Cuesta, 1994; Normandale, 2001; Donetto and Maben, 2015). The idea of ‘relationship-centred care’ was boosted by the influential Pew-Fetzer Report, which recognised the long-standing nature of the approach, across health care. They wrote: [W]e feel that a primary focus on ways to enhance and enrich the relationships that are relevant to health care through both education and practice is of critical importance. Our focus on relationships as a central feature of health care builds on the traditions of the nursing profession (Benner and Wrubel, 1989; Peplau, 1952) and the concepts of the biopsychosocial and patient-centered care models (Engel, 1988; Levenstein, 1988; McWhinney, 1989). While acknowledging that these models have influenced our thinking substantively, we also assert the need for a new phrase, relationship-centered care. (Tresolini and the Pew-Fetzer Task Force, 1994, p. 10) Relationships were widely regarded as important within health visiting since the beginning of health visiting in the mid-19th century, although the approach has been considered unnecessary at times. Bidmead (2013), for example, noted long-standing discussions about whether health visiting serves its purpose best through a relationship-centred or problemoriented approach (Orr, 1980; Robinson, 1982), a debate that has resurfaced in current practice in two ways.
Partnership A way of working with with one or more other people Includes: alliance, collaboration, interest, cooperation
Shared Attributes: Affiliation Association Connection
Relationship A way of being with one or more other people Includes: rapport, bond, liaison, link
FIGURE 7.3 Partnerships and relationships.
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First, the national shortage of health visitors has led to a plethora of different forms of team working and skill mix. These are broadly approved in policies that promote the idea of health visitors as leaders of teams, who delegate functions and families on their caseloads to team members (Lowe, 2007; DH, 2011). This approach may include teams with severe staff shortage, operating inappropriately as ‘health visitor led’ in name only (Institute of Health Visiting, 2019). It embodies the problem-oriented approach, assuming that the health visitor can identify an issue to address and then prescribe an intervention, which can be carried out by another team member. This mirrors a stereotypical medical model of assessment (diagnosis), care package (prescription) delivery of care (intervention) (Cowley and Houston, 2004). In this view, relationships based on continuity of care are considered necessary only when working with families with medium to complex needs. However, parenthealth visiting relationships are deemed important in models such as the Scottish Universal Health Visiting Pathway (Scottish Government, 2015), which mandates 11 home visits to be conducted by the caseload-holding health visitor. In Wales, too, relational continuity is prioritised, even though skill mix workers are named as possible substitutes in some of the universal scheduled contacts mandated in their Healthy Child Wales Programme (Welsh Government, 2016). Also, professionalclient relationships appear increasingly relevant, with raised awareness of the importance to mental health of the relationship between mothers, fathers and infants. Relational continuity appears particularly helpful for assessing the parentchild relationship (Wilson et al., 2008) and maternal mental health (Brugha et al., 2010). Parentprofessional relationships have been deemed significant in intensive home visiting programmes (Olds et al., 2007; Kemp et al., 2012). The second way a problem-orientated approach surfaces in modern dialogue is in influencing the approaches used in research about health visitor effectiveness for interventions to particular problems—for example, child safety (Kendrick et al., 2009) or childhood behaviour (Roberts, 2012). In these examples, investigators asked about the effectiveness of a specified health visitorled home safety intervention, or of delivering an Incredible Years parenting group for parents with mild to moderate concerns about childhood behaviour. Such evaluative research is concerned with establishing an evidence base for particular interventions, rather than clarifying the processes whereby the intervention is delivered. As suggested earlier, relationships are a way of being with (an)other, and partnership working is a way of working. Interventions are somewhat separate, being a specific goaldirected action or process of intervening. It is not always easy to distinguish between the concepts in practice or research. Complex interventions may specify the need for a relationship or partnership working—for example, in delivering the Solihull Approach (Bateson et al., 2008) or the Maternal and Early Childhood Sustained Home-Visiting Programme (Goldfeld et al., 2018). Unravelling the detail of what happens in partnership working, as explained earlier, helps this endeavour, but similar clarity was needed for relationship in health visiting. Bidmead aimed to identify key processes used in effective parenthealth visitor relationships with a view to developing valid instruments to measure these processes. Her research began by reviewing theories and measures of relationships used by other professionals to determine if their insights and instruments could be used for health visiting (Bidmead et al., 2015).
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Therapeutic relationships Many helping professionals recognise the importance of relationships—for example, in social work, nursing and medicine, amongst others—but the theories and research conducted by psychologists offered some of the most helpful insights into therapeutic relationships. In psychotherapy, therapeutic relationships have been the subject of intense scrutiny, where research has shown that it is crucial to positive outcomes for the client. Horvath (2000) explained that Freud, the founding father of psychoanalysis, first developed the idea that helping relationships might be therapeutic, although early behaviour therapists emphasised the importance of techniques rather than the relationships to change behaviour. Rogers (1959) developed these early theories further, asserting that the relationship itself was sufficient for therapeutic change, advocating the necessary conditions of unconditional positive regard, empathy and congruence. His client-centred approach implied that the therapist needed to be responsible for providing the conditions necessary for the client’s growth and development (Horvath, 2000). Rogers’ theory gave rise to research showing that the therapist-offered relationship is indeed the major means by which clients are helped and a positive relationship is correlated with positive outcomes. However, it seems that the client’s subjective evaluation of the relationship, rather than the therapist’s actual behaviour, has the most impact on the outcome of therapy. Objectively measured congruence, empathy and unconditional positive regard have a less powerful impact on therapy than the client’s perception of these qualities, which was shown to be key to the positive outcomes of the helping process (Horvath, 2000). Bearing in mind the importance of perceptions, Greenson (1963) and Bordin (1979) developed the concept of the ‘working alliance’, emphasising agreement and collaboration between the therapist and client so that the responsibility for the relationship became twoway (Horvath, 2000). It was understood that the concept was generalisable across all helping relationships and gave rise to the development of tools to measure the bond, tasks and goals of therapy. Subsequent research demonstrated that the strength of the relationship that is created between the professional and the client is associated with positive outcomes across a number of therapies and is a robust predictor of therapy outcome (Horvath, 2000; Martin et al., 2000). The ‘working alliance’ Bordin (1979), rather than the relationship itself, was thought to be what made it possible for the client to cooperate in therapy and follow the treatment plan. Even so, the therapeutic relationship continued to feature in research. Cahill et al. (2008) reviewed 83 therapist-patient measures of the relationship and identified three developmental processes necessary for the provision of an effective therapeutic relationship: establishing a relationship, developing a relationship and maintaining a relationship. However, it is not certain that Cahill’s therapeutic model translates into the health visiting context. Health visitors may, indeed, be required to establish a therapeutic relationship—for example, when a mother is suffering from postnatal depression or if a child is diagnosed with special educational needs or a serious medical condition. But there are differences. In psychotherapy, the relationship is predicated on continuity of care by one therapist over a number of sessions, whereas health visitors may see a parent on only one occasion and so
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needs to be able to establish a relationship very quickly. Further, a health visitor may not be working with the parent to address a particular problem as the contact may be purely promotional and preventive. In such circumstances, the relationship is not ‘therapeutic’ as such, because it is not being used intentionally as a vehicle of treatment for a particular problem. Finally, whilst confidentiality is always a prime concern, health visitors need to develop relationships with parents, even if other family members (including their children), friends and neighbours are present during a home visit. Identifying measurable factors To develop a suitable measure for parenthealth visitor relationships, Bidmead (2013) carried out a study in two phases. First, having identified six suitable parenthealth visitor dyads, she carried out a stimulated recall study (Gass and Mackey, 2000), which involved interviewing both the parent and the health visitor about what they thought was happening at salient points during video recordings of a home visit. These data were analysed to identify key markers of the relationship, using indicators identified in the relevant literature. The analysis was discussed further with two focus groups: one of health visitors and one of parents. Then, a set of questionnaire-type instruments was developed and piloted, similarly interviewing both parties in the parenthealth visitor relationship. Parents and health visitors in the study both identified trust, openness and honesty as essential qualities, with the health visitors also focussing on friendliness, respect and interest. Good communication skills and reciprocity were also highlighted (Bidmead et al., 2016a). Parents contribute actively to the parenthealth visitor relationship, but their input may need to be facilitated, particularly for the more vulnerable. Health visitors need advanced communication skills to help parents feel comfortable enough to be open and honest in their joint interactions. Bidmead and colleagues noted that previous studies of the relationship tended to concentrate only on health visitors’ skills, qualities and activities, but if health visitors and parents work in partnership, then both bear a responsibility for their relationship. Health visitors in the study were able to identify a number of necessary features, including key relational skills, such as active listening, remembering, exploring and challenging (Bidmead et al., 2016b), many of which mirrored the skills of working in partnership. Wider literature offered confirmatory data, and the overall analysis revealed that sound advice given by an experienced, knowledgeable health visitor helped to build trust and strengthen the relationship with parents. Health visitors demonstrating respect by showing interest in parents and their families, not just the baby, helped to raise parents’ self-esteem. When health visitors praised parents for their childcare, parents felt respected, which helped to build their confidence. Health visitors’ qualities, such as calmness and gentleness, were deemed important, as were their friendliness, sense of humour and trust in parents (Bidmead et al., 2016b). Overall, the analysis helped to clarify not just the basis of the relationship that underpinned partnership working by parents and health visitors, but also the steps in the health visiting process, which actively identified problems or issues and then worked towards a solution (Figure 7.4). This highlights the somewhat spurious nature of earlier
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Organisational factors
Health visitor qualities and skills
Parent qualities and skills
Parent–health visitor relationship Outcome/ending
Exploration
The health visiting process
Review
Implementation
Understanding and clarification
Aims and goals Strategy planning
FIGURE 7.4 Health visiting process. Source: Bidmead, Cowley and Grocott 2016c.
debates about whether a relationship-centred or problem-oriented approach would be best for health visiting effectiveness, since the relationship assists with both identifying and solving problems. Throughout the study, shortage of staff and barriers to relationship building were very evident, leading to a new focus for instrument-development— that of the organisational contribution to parenthealth visitor relationship (Bidmead et al., 2016c). Organisations may value relationship-centred work and actively support it, or not. Parents wanted continuity of care from one health visitor and, in the study by Bidmead et al. (2016a), preferred home visits above busy, often crowded clinics. Health visitors were concerned about caseload sizes and the bustle of clinics, which affected their ability to provide continuity of care. Community clinics were not all located in areas convenient for mothers on a health visitors’ caseload either, so busy clinics could adversely affect their ability to provide continuity of care, rather than providing opportunities for contact. Lack of time was a key factor, with the ability to provide continuity hampered by caseload sizes and the use of skill mix and corporate or team working. In the area where the Bidmead study was conducted, health visitors were expected to delegate follow-up of most families to a team member, such as a community nursery nurse or community staff nurse, after the first new birth visit. Where skill mix teams have been introduced, training, support and supervision by health visitors have been considered essential (McIntosh and Shute, 2007). Consideration of the effect on health visitor loss of face-to-face contact with parents, with
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resulting loss of time for establishing and maintaining relationships, seems equally important. Donetto et al. (2013) identified key facilitators for relational continuity, which parents in their study also deemed to be very important. Parents they interviewed appreciated health visiting outside the home as well as home visiting and were amenable to both team working and collaboration with children’s centres, as long as four key conditions were in place. Relational continuity was the first essential condition, along with clear coordination, usually by a health visitor. Other prerequisites were good communication and the importance of ‘knowing’ one person to whom they could turn and trust as well as ‘being known’— that is, a feeling that they were known personally by the health visiting team. When organisations support relational continuity, these conditions seem readily available. Measuring parenthealth visitor relationships A measure of the parenthealth visitor relationship is essential for research and practice, to test the view that health visitors have long asserted, which is that the relationship is central to the health visiting process (e.g. Chalmers, 1992; de la Cuesta, 1994; Condon, 2011; Pound, 2013a,b). The parenthealth visitor relationship is obscure, varied and personal to each situation, whereas measurement requires observable behaviours or activities (Bidmead et al., 2017). The observable behaviours and activities are indicators of something much deeper and felt at a personal level by the participants. The measure is not of the relationship itself, therefore, but is an indicator of it. The first phase of the Bidmead study (as described earlier) identified organisational factors, along with the qualities and skills of both parents and health visitors, showing how these all combined to achieve change through the health visiting relational process (Bidmead et al., 2016c). The analysis revealed what parents and health visitors believed to be important in their relationships, which was synthesised and compared with existing knowledge to ensure the content validity of the questionnaires. The new objective measure of parenthealth visitor relationships needed to reflect these key details. Some key factors, summarised in Box 7.4, were not found in any other measures of helping relationships. These appear essential for a successful parenthealth visitor relationship and may also be seen as defining features for the health visiting profession. These factors, and other key features from the first phase of the study, were distilled into three sets of two questionnaires, with each set including one for completion by the parent and one for the health visitor about their relationship. One set was designed to be suitable for the first meeting (usually the new birth visit) and one for further along in the relationship when the infant might be 3 to 4 months old. At this stage in the relationship, parents and health visitors were each asked to complete an organisational questionnaire as well. Boxes 7.5 and 7.6 summarise the constructs used in the questionnaires, which were piloted in use by parents and health visitors in two stages to ensure the questionnaires were easily completed (each had between 10 and 12 questions) and that the wording was acceptable and valid. The TELER (Treatment Evaluation by the Le Roux method) approach is a structured system for making and presenting clinical notes for an individual receiving treatment or care (Le Roux, 2003). It was chosen for the Bidmead et al.’s (2017) study, because its philosophy respects the individual and acknowledges the imperfect nature of measurement.
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BOX 7.4
Factors defining the parenthealth visitor relationship, not found in other helping relationship measures
Health visitor factors
Parent factors
Health visitor knowledge and expertise Nonjudgemental attitude Caring Friendly Ability to put parents at their ease Ability to relate to babies and children Skill of relating to other adults who may be present
Openness and honesty Friendliness Interest Trust Respect for health visitor
Organisational factors Continuity of care Home visiting
Source: Bidmead, Cowley and Grocott 2017.
The foundations of the measurement tool are clinical knowledge and expertise, brought to bear on the understanding as developed between health visitors and parents during the first phase of the study. The new questionnaires produced pilot data on the number of barriers experienced by each health visitor and parent during an interaction. It was hypothesised that barriers experienced by the health visitor or parent as measured by the items on the questionnaire would or would not constitute a problem in forming relationships. The questionnaires proved able to identify such barriers. The pilot studies showed that it was possible to use the instruments to measure the parenthealth visitor relationship and that the instruments were sensitive to differences in those relationships. The items on the relationship questionnaires also demonstrated differences in perception between parents and between health visitors, including differences between health visitors’ perceptions of organisational support for the building of relationships with parents. The data revealed important differences in the relationships formed, again demonstrating the sensitivity of the questionnaires towards these differences. The set of questionnaires could be used in practice to measure all relationships between parents and health visitors or as an aid to teaching and learning for students and novice practitioners. They could also be used to monitor the impact of organisational changes in an area to identify whether relationships are enhanced or adversely affected. Finally, they are suitable for use in research to potentially answer the question of whether or not a positive relationship between parents and health visitors leads to better health outcomes than working without attention to relationships.
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BOX 7.5
Constructs used in parent questionnaires
First visit
Established relationship
Health visitor introductions Health visitor openness Health visitor empathy Health visitor respect Health visitor information/ knowledge Health visitor listening Health visitor body language Health visitor relationship to baby
Health visitor empathy Health visitor encouragement Health visitor remembering Health visitor reliability/ trust in health visitor Health visitor information giving Health visitor respect/ punctuality Health visitor body language Health visitor ability to give time Continuity of contact
Organisational Continuity of health visitor contact Ability to identify health visitor from other professionals at clinic Social contact at clinic with other parents Welcoming approach of health visitor Ability of health visitor to give parent time Health visitor record-keeping in red book (Parent Held Child Record)
Source: Bidmead et al., 2017.
BOX 7.6
Constructs used in health visitor questionnaires
First visit Parent interest Parent welcome and friendliness Parental acceptance of service Parent body language
Established relationship Health visitor remembering Parental autonomy Parental acceptance of service Parental information seeking
Organisational Workload and its effect on provision of services Team leadership Size of health visitor team Record-keeping
Continued
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BOX 7.6
Constructs used in health visitor questionnaires—cont’d
First visit
Established relationship
Willingness to work in partnership Parent communication skills Health visitor trust of parent Parent openness
Parental openness Parental use of services Parental self confidence Health visitor trust of parent
Organisational Meeting attendance Clinical supervision Skill mix Ability to give follow-up care in clinic/home Professional autonomy
Source: Bidmead et al., 2017.
Conclusions The importance of partnership working has been asserted in public health circles for many decades, initially in reference to collaborative approaches between agencies. More recently, there has been a recognition of the need for partnership working between professionals and the public they serve. Research has driven and arisen from this wider recognition, so there is a clearer understanding of the essential elements of partnership working, although organisational reforms do not always take account of the need to enable them. Increased understanding of barriers to partnership working has focussed attention on aspects of interpersonal relationships, particularly trust, respect and good communication. This chapter has explained the essentials of partnership working between agencies and individuals, highlighting the centrality of relationship-centred working for public health as well as for practice between professionals and their clients. The development of a set of instruments designed to measure the relationship between parents and health visitors was described in detail, as it provides insight into the required elements and potential barriers to this form of practice. Relationships are essentially a way of being with people, whilst partnerships connote ways of working together, which may happen with or without a specific project or intervention. Good relationships lie at the core of all partnership working, and either relationships or partnerships may be specified as elements of complex interventions. They may be omitted from research protocols when interventions or treatments are more straightforward, but they appear essential in the process of delivering services. Organisational arrangements can help or hinder the development and continuity of relationship-centred care or public health. In conclusion, for everyday practice in community public health, good relationships can make the difference between a successful project, partnership or intervention. They need to be taught, encouraged, facilitated and treasured.
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Discussion Questions 1. Can relationships and partnership working be separated or are they two sides of the same coin? 2. Think about a time where a prior relationship with a colleague or a service user has made a potentially difficult situation easier. What skills and qualities did you bring into play? 3. Are there any barriers to developing relationships and partnership working where you practice? How might you help overcome them? For queries regarding use of the parenthealth visitor questionnaires and licensing, please contact Roger Young, Managing Director, Longhand Data, 1 Welburn Business Park, Greets House Road, Welburn, York YO60 7EP [email protected]
Acknowledgements The author thanks colleagues at Southern Health Foundation NHS Trust for sharing the case study details (contact Ginny Taylor, Head of Children and Family Services, [email protected]) and Dr Crispin Day at the Centre for Parent and Child Support, South London and Maudsley NHS Foundation Trust for the training described. The Parent Held Child Health Record page cited in the case study is available from Harlow Printing at http://www.harlowprinting.co.uk/products/. Sadly, Dr Christine Bidmead passed away towards the end of 2017, and this chapter is dedicated to her memory. Christine is credited as a co-author because the chapter is a revised and updated version of the one she wrote for the second edition of this text, and it includes much material from her publications and doctorate.
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Department of Health, 2011. Health Visitor Implementation Plan 2011–15 A Call to Action. London Department of Health, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/ file/213759/dh_124208.pdf (accessed 29/03/2020) Department of Health, 2012. Delivery of the Family Partnership: a case study explaining the changing way we work with families through delivery of the Family Partnership. ,https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/210772/ S4_Delivery_of_the_family_partnership_Somerset_SHACS.pdf. (accessed 27/08/2019). Department of Health and Social Care, 2019. Strengths-based Practice. DHSC, London, ,https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/778134/stengths-basedapproach-practice-framework-and-handbook.pdf. (accessed 10/10/2019). Donetto, S., Maben, J., 2015. ‘These places are like a godsend’: a qualitative analysis of parents’ experiences of health visiting outside the home and of children’s centre services. Health Expect. 18 (6), 25592569. Donetto, S., Malone, M., Hughes, J., Morrow, E., Cowley, S., Maben, J., 2013. Health Visiting: The Voice of Service Users—Learning from Service Users Experiences to Inform the Development of UK Health Visiting Practice and Services. National Nursing Research Unit, King’s College, London, https://www.kcl.ac.uk/nmpc/ research/nnru/publications/index (accessed 29/03/2020).. Egan, G., 1998. The Skilled Helper. A Problem Management Approach to Helping, sixth ed. Brooks/Cole Publishing, Pacific Grove, California. Engel, G.L., 1988. How much longer must medicine’s science be bound by a seventeenth century world view? In: White, K.L. (Ed.), The Task of Medicine: Dialogue at Wickenburg. The Henry J. Kaiser Family Foundation, Menlo Park, California, pp. 113136. Evans, D., Killoran, A., 2000. Tackling health inequalities through partnership working: learning from a realistic evaluation. Crit. Public. Health 10 (2), 125140. Gass, S., Mackey, A., 2000. Stimulated Recall Methodology in Second Language Research. Lawrence Erlbaum Associates, Mahwah, New Jersey. Goldfeld, S., Price, A., Kemp, L., 2018. Designing, testing and implementing a sustainable nurse home visiting programme: right@home. Ann. N. Y. Acad. Sci. 1419 (1), 141159. Greenson, R.R., 1963. The Working Alliance and the Transference Neurosis. Department of Psychiatry, University of California School of Medicine, Los Angeles. Horvath, A.O., 2000. The therapeutic relationship: from transference to alliance. J. Clin. Psychol. 56 (2), 163173. Hunter, D., 2009. Leading for health and wellbeing: the need for a new paradigm. J. Public. Health 31 (2), 202204. Hunter, D., Perkins, N., 2012. Partnership working in public health: the implications for governance of a systems approach. J. Health Serv. Res. Policy 17 (Suppl 2), 4552. Institute of Health Visiting, 2019. Health Visiting in England: A Vision for the Future. Institute of Health Visiting, London, ,https://gallery.mailchimp.com/6d0ffa0c0970ad395fc6324ad/files/a36ba975-1396-4e98-adfb7173c269e5cb/9.10.19_Health_Visiting_in_England_FINAL_VERSION.pdf. (accessed 29/03/2020). Israel, B.A., Schulz, A.J., Parker, E.A., Becker, A.B., 1998. Review of community-based research: assessing partnership approaches to improve public health. Annu. Rev. Public. Health 19, 173202. Kelly, G., 1991. The Psychology of Personal Constructs: Volume 1: A Theory of Personality. Routledge, London. Kemp, L., Harris, E., McMahon, C., Matthey, S., Vimpani, G., Anderson, T., et al., 2012. Benefits of psychosocial intervention and continuity of care by child and family health nurses in the pre- and postnatal period: process evaluation. J. Adv. Nurs. 69 (8), 18501861. Kendrick, D., Mulvaney, C., Watson, M., 2009. Does targeting injury prevention towards families in disadvantaged areas reduce inequalities in safety practices? Health Educ. Res. 24 (1), 3241. Lea, S., Clarke, M., Davis, H., 1998. Evaluation of a counselling skills course for health professionals. Br. J. Guid. Couns. 26, 159173. Le Roux, A.A., 2003. The TELER Handbook. TELER Ltd, Sheffield. Levenstein, J.H., 1988. Family medicine and the new science. South. Afr. Fam. Pract. 9 (1), 1117. Lowe, R., 2007. Facing the future: a Review of the Role of Health Visitors. Queen’s Nursing Institute, London. Martin, D.J., Garske, J.P., Davis, M.K., 2000. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J. Consult. Clin. Psychol. 68 (3), 438450. McIntosh, J., Shute, J., 2007. The process of health visiting and its contribution to parental support in the starting well demonstration project. Health & Soc. Care Commun. 15 (1), 7785. McWhinney, I.R., 1989. A Textbook of Family Medicine. Oxford University Press, New York.
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Mitcheson, J., Cowley, S., 2003. Empowerment or control? An analysis of the extent to which client participation is enabled during health visitor/client interactions using a structured health needs assessment tool. Int. J. Nurs. Stud. 40, 413426. NHS England, NHS Improvement (Monitor and the NHS Trust Development Authority), Care Quality Commission, Health Education England, National Institute for Health and Care Excellence, Public Health England, 2015. Delivering the Forward View: NHS Planning Guidance 2016/17 -2020/21. ,https://www.england.nhs.uk/publication/delivering-the-forward-view-nhs-planning-guidance-201617-202021/. (accessed 22/07/2019). NHS England, 2019a. Sustainability and Transformation Partnerships. ,https://www.england.nhs.uk/integratedcare/stps/view-stps/. (accessed 22/07/2019). NHS England, 2019b. NHS Long Term Plan. ,www.longtermplan.nhs.uk. (accessed 22/07/2019). Normandale, S., 2001. A study of mothers’ perceptions of the health visiting role. Commun. Pract. 74 (4), 146150. Nundy, S., Oswald, J., 2014. Relationship-centered care: a new paradigm for population health management. Healthc. (Amsterdam, Neth.) 2 (4), 216219. Oakley, A., Rigby, A., Hickey, D., 1994. Life stress, support and class inequality. Eur. J. Public. Health 4, 8191. Olds, D.L., Sadler, L., Kitzman, H., 2007. Programs for parents of infants and toddlers: recent evidence from randomized trials. J. Child. Psychol. Psychiatry 48 (3-4), 355391. Orr, J., 1980. Health Visiting in Focus. Royal College of Nursing, London. Papadopoulou, K., Dimitrakaki, C., Davis, H., Tsiantis, J., Dusoir, T., Paradisiotou, A., et al., 2005. The effects of the european early promotion project training on primary health care professionals. Int. J. Ment. Health Promot. 7, 5462. Peckover, S., 2002. Supporting and policing mothers: an analysis of the disciplinary practices of health visiting. J. Adv. Nurs. 38 (4), 369377. Peckover, S., 2003. ‘I could have just done with a little more help’: an analysis of women’s help-seeking from health visitors in the context of domestic violence. Health Soc. Care Commun. 11 (3), 275282. Peplau, H.E., 1952. Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing. Putnam, New York. Pound, R., 2013a. Influences on relationship-based health visiting, part 1: reflecting on contradictions in practice. J. Health Visiting 1 (9), 516520. Pound, R., 2013b. Influences on relationship-based health visiting, part 2: discovering the need for balance through a new epistemology. J. Health Visiting 1 (9), 522528. Puura, K., Davis, H., Ma¨ntymaa, M., Tamminen, T., Roberts, R., Dragonas, T., et al., 2005. The outcome of the european early promotion project: mother-child interaction. Int. J. Ment. Health Promot. 7, 8294. Roberts, D., 2012. An evaluation of a community-based basic parenting programme: a two-year follow-up. Community Practitioner 85 (2), 2731. Robinson, J., 1982. An Evaluation of Health Visiting. Council for the Education and Training of Health Visitors, London. Rogers, C., 1959. A theory of therapy, personality and interpersonal relationships as developed in the client-centered framework. In: Koch, S. (Ed.), Psychology: A Study of Science, third ed. McGraw Hill, New York. Rushton, R., Davis, H., 1992. An evaluation of the effectiveness of counselling training for health care professionals. Br. J. Guid. Couns. 20, 205220. Scottish Government, 2015. Universal Health Visiting Pathway in Scotland. Pre-birth to Pre-school. ,https:// www.gov.scot/publications/universal-health-visiting-pathway-scotland-pre-birth-pre-school/. (accessed 30/ 08/2019). Smith, K.E., Bambra, C., Joyce, K.E., Perkins, N., Hunter, D.J., Blenkinsopp, E.A., 2009. Partners in health? A systematic review of the impact of organizational partnerships on public health outcomes in England between 1997 and 2008. J. Public. Health 31 (2), 210221. Spiegelhalter, K., 2018. Cultivating Compassion: Who Cares for NHS Staff? [Blog]. Institute of Employment Studies, Brighton, ,https://www.employment-studies.co.uk/news/cultivating-compassion-who-cares-nhsstaff. (accessed 23/08/2019). Tresolini, C.P., Pew-Fetzer Task Force, 1994. Health Professions Education and Relationship-Centered Care. Pew Health Professions Commission, San Francisco, California. Welsh Government, 2016. An Overview of the Healthy Child Wales Programme. ,https://gov.wales/sites/default/ files/publications/2019-05/an-overview-of-the-healthy-child-wales-programme.pdf. (accessed 22/08/2019).
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Wiggins, M., Oakley, A., Roberts, I., Turner, H., Rajan, L., Austerberry, H., et al., 2004. The social support and family health study: a randomised controlled trial and economic evaluation of two alternative forms of postnatal support for mothers living in disadvantaged inner-city areas. Health Technol. Assess. (Winchester, Engl.) 8 (32), 1133. Wiggins, M., Oakley, A., Roberts, I., Turner, H., Rajan, L., Austerberry, H., et al., 2005. Postnatal support for mothers living in disadvantaged inner city areas: a randomised controlled trial. J. Epidemiol. Commun. Health 59 (4), 288295. Wilson, P., Barbour, R., Graham, C., Currie, M., Puckering, C., Minnis, H., 2008. Health visitors’ assessments of parent-child relationships: a focus group study. Int. J. Nurs. Stud. 45 (8), 11371147. World Health Organization, 1997. Jakarta Declaration on Leading Health Promotion into the 21st Century. WHO, Geneva, Switzerland, ,https://www.who.int/healthpromotion/milestones_ch4_20090916_en.pdf. (accessed 15/07/2019).
Resources and further reading National Scientific Council on the Developing Child, 2015. Supportive relationships and active skill-building strengthen the foundations of resilience: Working paper No. 13. ,https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2015/05/The-Science-of-Resilience2.pdf. (accessed 10/10/2019). Explains how nurturing relationships enable babies to develop resilience as they grow up, including the science that underpins this centrally important issue. Ham, C., 2018. Making Sense of Integrated Care Systems, Integrated Care Partnerships and Accountable Care Organisations in the NHS in England. The King’s Fund, London. Available from: https://www.kingsfund. org.uk/publications/making-sense-integrated-care-systems (accessed 29/03/2020). Looks at accountable care systems and integrated care systems, describing and explaining how these different systems operate. Hearld, L.R., Alexander, J.A., Wolf, L.J., Shi, Y., 2019. The perceived importance of intersectoral collaboration by health care alliances. J. Commun. Psychol. 47 (4), 856868. The need for broad, multisectoral participation to address multifaceted issues such as health and health care in local communities is well recognised, but sustaining collaborations is complex. This study identifies some key, nuanced variations across different sectors of engagement. Department of Health and Social Care, 2019. Strengths-based Approach: Practice Framework and Practice Handbook. DHSC, London. Available from: https://assets.publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/778134/stengths-based-approach-practice-framework-and-handbook. pdf (accessed 10/10/2019). This handbook was written specifically for social workers implementing the Care Act 2014, but it is equally relevant to anyone working in community public health. However, it emphasises that strengths-based practice is holistic and multidisciplinary, is applicable to any client group, to any intervention and can be applied by any profession. Put simply, a strengths-based approach explores, in a collaborative way, the individual’s abilities and their circumstances rather than making any deficit the focus of the intervention.
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C H A P T E R
8 Public health and the life course: supporting parents and families Karen Whittaker KEY ISSUES • Early life and support for families as a ‘public health’ priority • Poverty and threats to children, parents and family life
• Policies that enable investment in human life through action on parenting and family support. • Varieties of parenting and family support and those involved to achieve a comprehensive service
Introduction Parenting practices and family life impact directly on social mobility through influencing how children and young people grow, function and later participate in society (Economic Social Research Council, 2012). Families are thus the basic building blocks of our society or, in Bronfenbrenner’s (2005, p. 260) words, ‘the heart of our social system’ into which children are born and parented. It follows that the public’s health is indelibly connected to how children are raised and parented, and therefore that parenting and family support is a critical feature of public health provision (Hanson et al., 2019). In this chapter, family support and its necessity for family health are considered, drawing on life course evidence, which explains why and when parenting support is important. As evidence evolves, so does the need for policy to enable action at the right time and at the best level. The chapter therefore illustrates types and forms of parenting and family support and policy requirements to address public health needs, in addition to giving consideration to how and who can deliver the range of interventions.
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Early life and public health Responsibility for raising children as fit citizens who can contribute to society has historically rested with families. Before the 1900s this responsibility extended to the provision of care and guidance in cleanliness and behaviour, to ensure good moral and spiritual standards could be upheld, as this was believed to prevent disorder and disease. The 19th-century Industrial Age brought greater urbanization and conditions for spread of communicable diseases that threatened the health of families who provided the workforce for industry. New knowledge and the science of prevention introduced an awareness of the impact of good sanitation and environmental conditions on health, early life and the life course that followed. The period, and attempts to manage infectious disease, provides an early example of an appreciation of life-course factors impacting later adult health (Scally and Womack, 2004). Families were a focus for civic action with mothers of infants, for example, targeted by ‘sanitary visitors’ to receive instruction and guidance in hygiene and infant nutrition. These early visitors, offering a form of family support in the home setting, were the prequel to United Kingdom (UK) health visitors (Davies, 1988).
Life-course evidence By the end of the 1900s and the start of the new century, life-course epidemiological evidence had grown exponentially, providing invaluable knowledge for understanding how to approach persisting national and global health inequalities (Boyce and Shonkoff, 2016; Boyce and Hertzman, 2018; Alderman et al., 2017). The life-course research is drawn on to develop a rationale for early intervention and prevention of conditions caused by either noncommunicable disease, so-called lifestyle factors, or more recently emotional and relational factors (Bundy et al., 2018). The whole body of life-course evidence brings together a number of fields, including neuroscience, genomics, developmental psychology, sociology and economics, which collectively explain effects of toxic stress and the introduction of risks for later life (Shonkoff et al., 2012). Box 8.1 illustrates the case for early life and later cardiovascular health. As a consequence of the growth of life-course evidence, there is good understanding on a global stage that human survival and the opportunity to thrive starts with exposures in the first 1000 days of life and continues for the next 7000 (Bundy et al., 2018). During the first 8000 days of life (to the age of 21 years), children and adolescents go through a number of sensitive periods of development that can benefit from intervention to support progression to healthy adulthood (Box 8.2 summarises life stages and areas of action). Others also note, that the cycle of human life exposes the significance of the preconceptual period (often coinciding with young adulthood), when optimal nutrition and lifestyle positively impact a woman’s health and thereby her ability to have a healthy pregnancy, birth and baby (Stephenson et al., 2018; Aagaard-Hansen et al., 2019). Committing to interventions based on life-course principles makes good sense due to the opportunity to triple-up on benefits (for the child in the present, in the future as adults and for their own children) (Aagaard-Hansen et al., 2019). Further, when actions are delivered at a time of neuroplasticity, recipients should have a huge capacity for change and, as a consequence, interventions will offer the public purse good value for money.
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BOX 8.1
The case of cardiovascular health and the life course An example of physical health directly impacted by earlier life events is cardiovascular disease (CVD). Early work by Barker (1998) explained a model of biological programming for fetuses in utero, infants and children when exposed to biological hazards, such as parental smoking, poor nutrition or early infection. These hazards interfere with subsequent maturation of cells and organs and create vulnerability in adults if later exposed to biological stressors, such as a high-fat, high-sugar and high-salt diet, smoking or infectious disease. Hardy et al. (2015) explain that many of the risk factors for CVD (a significant problem for health care systems worldwide) are ‘socially patterned’ and are evident across the entire life course. This means that the risks accrue from preconception, antenatally and then through infancy and childhood, depending on the parental circumstances. Negative socioeconomic circumstances faced by parents—and hence their children—contribute to mechanisms
of risk for vascular disease through the reinforcement of behavioural or biological pathways (Davey Smith and Lynch, 2004). Childhood states listed as contributing to risks for such pathways include the experience of sustained stress, poor diet, obesity and poor growth. More recent evidence about adult cardiovascular health and early life reinforces the powerful opportunity for actions during the preconceptual period and first 1000 days of life, through health behaviours such as adjusting to smoking and alcohol consumption (Stephenson et al., 2018), nutrition during pregnancy (Fraser et al., 2018) and breastfeeding (Umer et al., 2019). Play and interactions supporting large motor skills and young child physical activity may also offer later cardiovascular benefits given evidence regarding early physical activity and adiposity (Bell et al., 2019) and that regarding walking age and resting heart rate trajectories (O’Hare et al., 2018).
The family is an essential element in the ‘life-course story,’ given that it is through the family that a child’s development is shaped (Hanson et al., 2019) and a nurturing care environment (a stable, protective and stimulating environment, sensitive and responsive to children’s needs) can be experienced (Britto et al., 2017) (see Box 8.2 for some family focused actions). Within the family, parents and/or other adult caregivers play a central role, and to strengthen their capacity to support child development caregivers should themselves be recipients of nurturing care interventions before and during pregnancy, birth and thereafter (World Health Organization (WHO), 2018). A specific global impact to emerge from the life-course evidence is the WHO-endorsed framework for nurturing care (WHO, 2018). This framework sets out guidance for improving child development through policy that enables a whole system approach (at government and societal levels) to providing interventions designed to promote nurturing care. The WHO (2018) explains nurturing care as representing a set of conditions that support good health, adequate nutrition, responsive caregiving, security and safety and opportunities for early learning. All these features are important for thriving and managing
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BOX 8.2
Life stages and areas for actiona
Stage
Action areas
Preconceptual Antenatal
Optimal nutrition Exposures to toxins (e.g. tobacco smoke, alcohol) Nurturing care Safe sleeping Nutrition Responsive caregiving Social connections for neurocognitive development Healthy habits Self-regulation of emotions/behaviour Social connections for empathetic skills Healthy habits Weight control Cognitive stimulation Diet and nutrition Lifestyle Self-regulation of emotions/behaviour Social connections and education for self-agency development Executive functioning Nutrition Managing stressors and exposures to toxins (e.g. tobacco smoke, alcohol)
Infancy (within first 1000 days)
Early childhood (younger than 5 years) Middle childhood (510 years)
Adolescence (1120 years) Young adulthood (2025 years)
a
Examples supported by Aagaard-Hansen et al. (2019), Hanson et al. (2019), Bundy et al. (2018), Britto et al. (2017) and Center on the Developing Child at Harvard University (2016).
adversity that may present through adverse childhood experiences (ACEs), such as domestic violence, maternal depression, criminality and substance misuse in the home (Allen and Donkin, 2015) (see Chapter 13) or through community conditions of war, conflict, environmental disaster (WHO, 2018) and mass outbreaks of infectious disease on epidemic or pandemic proportions (Cluver et al., 2020).
Poverty and families Being poor matters to children, as it compromises the circumstances within which they are raised, limiting life chances and introducing greater risk of exposure to ACEs (Allen and Donkin 2015). Further, family poverty is of great consequence to society, as demands
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on public services, including the National Health Service, are increased creating greater pressure in a stretched system (Bramley et al., 2016). In 2016, the Social Metrics Commission (SMC) was established to design and use new metrics to understand more about UK poverty experiences and consider the extent below the poverty line (depth), length of time in poverty (persistence) and factors impacting on families that caused them to feel trapped by poverty (SMC, 2019). The metrics, based on 2017-2018 UK data, show poverty as a sizeable problem, with 4.6 million (34%) children living in poverty, and of these 2.3 million (17% of all children) live in persistent poverty. The picture revealed that children experiencing poverty are more likely than their nonpoor counterparts to live in a family with (1) a lone parent; (2) three or more siblings; (3) a disabled adult or child; (4) workless adults; (5) from an ethnic minority; and/or (6) adults with self-reported mental health concerns and low health satisfaction (SMC, 2019). These features often operate as disadvantages due to the limits on material and social resources or marginalising effects of discriminatory attitudes, causing those experiencing poverty to be at great risk of being ‘left behind’ and facing great health inequity (United Nations Development Programme, 2018). An international longitudinal study of child poverty, Young Lives, reports that the main impacts from poverty on children arise from food insecurity, the indirect costs from compromised education and household illness. All these features are strikingly evident in the lives of many UK children relying on food banks for family meals (Loopstra et al., 2018) or whose education is comprised due to taking on caring roles for less able household members (Scottish Government, 2017). The risks from poverty specific to child health are evidenced by large cohort studies, including the UK Millennium Cohort Study involving about 19,000 children born between 2000 and 2001 (Rougeaux et al., 2017). Impacts are seen on body weight, long-standing illnesses and mental health (Lai et al., 2019). Others considering the question of persistent poverty or repeated episodic poverty have also drawn on Millennium Cohort data and identified impacts on child cognitive development (Schoon et al., 2012; Dickerson and Popli 2016) and social relationships with peers and family members (Gibb et al., 2016). However, the direct and/or indirect effect of poverty makes a complex picture and to gain a clearer understanding, account must be taken of several factors, such as family background or circumstances, parental investment (e.g. activity to shape the home environment), parenting style and child ability. To illustrate the complexity, cohort data examined by Gibb et al. (2016) revealed that whilst children in persistent poverty fare poorly on several counts (e.g. they are less likely to talk to their friends or their mother about their worries, will fight more with their peers and will bully or be bullied more), child self-reports indicate greater happiness in their families. This unexpected result seems perverse, suggesting that in situations of persistent low income, the stability of the difficult situation supports positive feelings about family life. Less surprising is the evidence that the effects of poverty on children’s social relationships are mediated by other factors, including parental education, working hours, conflict, maternal depression and early parenting style (Gibb et al., 2016). Likewise, evidence concerning impacts of childhood poverty on cognition shows that parenting practices can have an important mediating role (Kiernan and Mensah, 2011), but disadvantaged circumstances place more demands on parents, making the practice of positive parenting, more difficult (Dickerson and Popli 2016) and equitable access to services a challenge (Woolfenden et al., 2020).
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To explain the effects of poverty on family life and generation of ACEs, the Early Intervention Foundation (EIF) (Stock et al., 2017) refer to the Family Stress Model (Conger and Conger, 2002). The model, developed from longitudinal data gathered over a decade, link the pressure of economic hardship experienced within families to conflict between parents or primary caregivers. Stress generated from conflict challenges parental mental health and creates an inhospitable situation for nurturant-involved parenting. As a result, children are more likely to be raised in an environment where harsh words and behaviours are used which would have a detrimental impact on their social and emotional development. Moreover, if in these circumstances, play opportunities are also reduced, then risks to child cognitive and motor development will also be seen (Milteer et al., 2012). The negative impact on child development compromises the individual’s ability to demonstrate what is now referred to as executive functioning: the ability to consciously self-regulate emotions and behaviour (Center on the Developing Child at Harvard University, 2016). The experience of coronavirus disease (COVID-19) pandemic and the social-distancing measures that required closure of workplaces, schools, leisure facilities and even public parks, was predicted to have enormous negative impacts on family stress (Cluver et al. 2020; Douglas et al., 2020). For children living in poverty, and confined to inadequate housing (Rosenthal et al., 2020) or within family units featuring violence (Cluver et al. 2020) the negative impacts on child development and mental well-being were predicted to be keenly felt, heightening existing child health inequalities (Shonkoff 2020). In short, poverty places an extra strain on family life (Economic Social Research Council, 2012; Cooper and Stewart, 2013). The limits to life chances through poverty, in combination with compromise to human development and exposure to risks, all add up to poor health outcomes and ultimately lead to health inequalities that have long-lasting effects into adulthood (Pearce et al., 2019). Being parented and then becoming a parent in poor circumstances introduces a cumulative effect of chronic stress. In these circumstances, the risks for harsh parenting are raised due to the impact of chronic stress on adult sensitivity to child emotional and social needs (Kim et al., 2018). Further, socioeconomic disadvantage limits the availability of material resources otherwise accessible through social networks and, therefore, the capacity for social ties or ‘bridging’ links to compensate for economic disadvantage (McCabe et al., 2013). Arguably the destructive impact of family poverty and experience in childhood also extends to expectations of young people and by young people of themselves as they move to adulthood. National statistics and epidemiological evidence as discussed so far would support expectations of failure due to the experience of multiple disadvantages. However, caution is needed, as holding and representing such expectations could be the very thing that seals a young person’s fate. Correcting life chances does require policy that addresses family poverty, and at the same those working with parents and families need to promote human potential and support enabling environments. Health visitors and school nurses have a duty to remember and communicate to others that children and young people are not ‘passive victims of their family’s low incomes, but active agents who craft[ed] their own experience’ (Farthing, 2016, p. 108). Taking a strengths-focused approach to practice and reinforcing positive expectations of young people is important and may make the difference as to whether a young person feels able to ‘beat the odds’ and sustain efforts for a positive life course (Crivello and Morrow, 2019).
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Policy initiatives promoting family and parenting support In its preamble, the United Nations Convention on the Rights of the Child (United Nations (UN), 1989) asserts that, The family, as the fundamental group in society and the natural environment for the growth and well-being of all its members, particularly children, should be afforded the necessary protection and assistance so that it can fully assume its responsibilities within the community. Article 18.2 goes on: For the purpose of guaranteeing and promoting the rights set forth in the present Convention, States Parties shall render appropriate assistance to parents and legal guardians in the performance of their child-rearing responsibilities and shall ensure the development of institutions, facilities and services for the care of children. ‘Wellbeing’ as applied here is surely health in its widest sense. The idea that raising children is a joint venture between the state and parents recognises that all citizens bear a responsibility for children. The UK is a signatory to the Convention on the Rights of the Child and should therefore recognise the state’s duty to provide assistance to parents, acknowledging the need for social support to enhance the opportunities for all children. Fulfilling duties by taking action on poverty should have been made more feasible through the UK Child Poverty Act 2010, which enshrined in law commitments to end child poverty by 2020. Sadly, this has not been realized, and the Act was repealed and renamed in 2016 as the Life Chances Act 2010. The newer Welfare Reform and Work Act 2016 has shifted the targets, which are now expressed as tackling worklessness, education, social mobility and supporting ‘troubled’ families. Whilst these areas impact on poverty, parallel challenges of zero-hour contracts, childcare costs, education fees and limited affordable housing, amongst others, mean that gaining access to education or employment is not a sure route to alleviating poverty. Of concern is the political apathy in seeing through pledges to address child poverty. The example of government failure to make use of allocated European Union funding (Fund for European Aid to the Most Deprived) for addressing the worst forms of poverty, including that experienced by children (Lords Select Committee, 2019), illustrates how policies and resources intended to support child wellbeing need careful guardianship if impact is to be achieved. Policy directed at supporting parents and families is the surest way a country can invest in the living standards of its communities and hence its future (Kim et al., 2018). Social progress in this regard can be measured against international Sustainable Development Goals (SDGs), a set of 169 targets over 17 dimensions (including poverty, health, education, gender equality and sustainable consumption) applicable to all countries regardless of income (UN, 2015). The family is a critical element in the achievement of the SDGs, and early comparative research evidence suggests that family-focused policies and resultant programmes in one goal area will also have impacts on other related goals (Richardson, 2018). For example, policy directed as addressing family poverty can have a positive spillover effect on family health, education and nutrition (hunger). As part of the strategic
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direction towards the SDGs, member countries have committed to the ‘leave no one behind’ pledge (UN, 2017), which includes the recognition that those most ‘left behind’ are often managing intersecting disadvantage caused by multidimensional poverty (United Nations Development Programme, 2018). Policies aimed at whole communities, therefore, need to accommodate the intersectionality of people—that is, the many aspects that make up humans and that impact on their interactions (Hankivsky et al., 2014). The term ‘intersectionality’, coined by Crenshaw (1989), has origins in activist, indigenous and black feminist writing. As a concept, intersectionality encourages thinking about policies that can reach beyond single categories of people—for example, ethnicity, gender, class, location, age and ability/disability—and reflect the social location of people and societal power structures (Hankivsky et al., 2014). Community public health practitioners, including health visitors and school nurses who work with individuals, groups and communities, are well placed to recognise intersecting disadvantage, and hence contribute to delivery of policies designed to improve health equity and leave no one behind. This requires health visitors and school nurses to be proactive, ensuring their capabilities are understood by those in seats of power within their communities, such as local government officers or commissioners, so that they can stimulate an awareness of the needs of parents and children and influence policies capable of addressing the broad spectrum of family need. To aid them in explaining arguments for investment and strategies for delivery of parenting and family support, reference can be made to the report of the Health and Social Care Select Committee (House of Commons Health and Social Care Committee, 2019) on the ‘First 1000 days of life’. This cross-government committee has set out in plain terms the folly of missing the opportunity that early life offers and therefore the need for local authorities to develop clear and ambitious action plans for supporting parents and families. This includes working through close intersectoral partnerships with health, community and voluntary organisations, to work through proportionate universalism, to ensure reach for all and additional help when required to prevent worsening the social gradient of inequality that a targeted-only approach would generate (see Chapter 1). This is the first of six key principles to work with to design support for families based on: 1 2 3 4 5 6
Proportionate universalism Prevention and early intervention Community partnerships A focus on meeting the needs of marginalised groups Greater integration and better multi-agency working Evidence-based provision.
The meaning of family support The term ‘family support,’ when used within UK culture, can immediately rouse ideas about responding to problems, and a common misconception is to assume that inadequacy must exist if support is required. Within health and welfare services, The Children Act 1989 (since modified by The Children Act, 2004) and Children and Families Act 2014
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particularly lent credence to this view with its emphasis on the implementation of family support becoming synonymous with identified need. This legislation required local authorities to respond to a child as deemed in need and make available ‘family support’ to compensate for that need. Arguably this paved the way for the undesirable identity of family support as inevitably linked with neediness and inadequacy. This history, however, distorts perceptions and blinds us to the full extent of family support and understanding it as not just as a response system, but also as a fundamental component of a healthy society. As already discussed in the opening sections of this chapter, societies actually need family support to ensure and maintain human development. To appreciate what constitutes family support, it is perhaps first helpful to consider what we understand of the modern family and hence parenting roles. Bronfenbrenner developed a bioecological understanding of human development, where environment plays a part in person development. He explains in his edited collection (Bronfenbrenner, 2005) that there now exist new family forms that operate in an era where the family retains moral and legal responsibilities for children but often lacks the opportunity to do the job properly. This, Bronfenbrenner argues, is due to the changed conditions of life, where children and parents spend little time together, and instead each is in the company of peers. Indeed, current political drives to encourage increased paid employment for families operating through a system of universal credit, tax-free childcare (Department for Work and Pensions, 2019) and breakfast and after-school clubs extending the school day means that parents and young children will continue to spend more and more time in their separate worlds (see Rowe [2019] for action on this in Bicester as part of NHS England’s Healthy Towns programme). The existence of economic migration, secular adult partnerships, young motherhood and longer life span are some of the influences affecting the contemporary family that exists in various sizes, gender, ethnic and age combinations. With change comes an altered parental role where; for example, the loss of one parent may force the other to become breadwinner and carer, or indeed, the loss of both parents may bring grandparents back into primary caregiver roles for children. Family support can be easily misunderstood, especially when it is so well integrated into daily patterns and, sadly, may only be recognised when it disappears. Different forms of social support, including that which easily becomes invisible, can be captured within a threefold model developed by Ghate and Hazel (2002). The model is based on a study of parents’ experiences when living in economically harsh circumstances and is composed of the following: • Informal support arising from pre-existing personal social networks • Semi-formal support arising from community organised activities • Formal support made available by statutory services, sometimes in partnership with the third sector. This model fits with Bronfenbrenner’s notion of human ecology, which identifies the existence of social structures, sitting within one another as if nested like Russian dolls. Each nested structure is influenced by and, indeed, influences the other (see Chapter 1). When applied to Ghate & Hazel’s model, the informal support is nested around the immediate environment of the person. Semi-formal supports are an extension of informal support but have more order to them. Within the model, semi-formal support influences the
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personal social network used by the person as opposed to the person directly. Likewise, formal support structures organised by statutory and officially sanctioned agencies operate as part of public policy and culture, shaping the environment within which communityorganised activities (semi-formal structures) take place. Thus, each affects the other and trickles down to influence the individual at the centre of the nest. This conceptualisation usefully encourages questioning about our understanding of the relationships between the levels of support and, indeed, the consequences when deficiencies exist. For example, if the semi-formal support is absent, can the person at the centre of the informal support reach support at the formal level? Or is semi-formal support, in fact, a mediator or a gateway to formal services? These questions are pertinent to the debate about place-based interventions, social capital and whether, indeed, social capital as a commodity can be generated by formal support systems (for wider discussion, see Chapter 1). To take a public health approach to supporting families, there is an argument that this should mean a focus on the places where families spend their time and live their lives as families, including the home (Hanson et al., 2019). An illustration of the settings for parenting support and the diversity of arrangements is provided in the flow chart shown in Figure 8.1. The boxes in the flow chart show separate formal and informal support systems that coexist through shared settings, including intimate home environments, public community venues and virtual spaces accommodated by information technology and media facilities. The purpose Parenting and Family Support
Formal & Semi-formal
Informal
Health Visiting, Early Help family support services, volunteer/lay visiting
Home
Visits and contact with family and friends
Programmed courses, Healthy Child Programme services, support groups
Statutory premises (Clinics, hospitals, schools, libraries)
Opportunistic meetings at groups, school events and sports/leisure clubs
Programmed courses, drop-in groups, parent-led groups
Community (Church halls, community & cultural centres, parks)
Planned social contact at community groups
NHS Choices, Parentchannel.tv, websites, call lines, reality television, mass media campaigns
Virtual environments (Telephone, web and television)
Web-based chat rooms, blogs, social media, text and telephone communication
FIGURE 8.1 The intersections of parenting and family support illustrating varieties and locations.
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of the flow chart is to highlight the multifaceted nature of parenting and family support, showing the intersections across formal and informal care structures. The parent who meets others through attending a formal group at the health centre may on other occasions meet these same people opportunistically. In addition, he or she might use self-directed parenting resources for advice accessed via a mobile app, website, reading popular press or by watching the latest parenting television programme. The point is that each person accessing formal interventions delivered by professionals is also exposed to less formal ideas, advice and explanations about parenting whether through personal social networks (face to face or virtually) or the popular media. Suggestions offered about individual experiences could be perceived as criticism or praise and hence could either undermine or encourage a willingness to commit to formalised programmes of education and/or support. This means that to understand any local parenting and family support service, there needs to be an appreciation of the wider community context and different settings, while remembering that the unpredictable features of a community (real or virtual) could be important determinants in the success of formalised strategies.
The availability of parenting and family support Since the turn of the century major initiatives have been introduced by UK governments to address family needs, particularly support for early child development (Powell, 2019). These initiatives include former government investment in the delivery of area-based Sure Start Local programmes targeted at disadvantaged communities (introduced in 1999 after the Home Office Supporting Families consultation) and then more widely available Sure Start children’s centres as part of the Every Child Matters policies (see Bidmead and Whittaker, 2008). These existed alongside UK-wide universal provision of child health programmes (Emond, 2019) involving health visitors and school nurses as key professionals, but who now work to a slightly different programme in England, Scotland, Wales and Northern Ireland (Appleton and Whittaker, 2019). Previous and existing area-based programmes have championed the ideal of better joined-up working across health, education, social care and the third sector. Since 2010, Local Authority austerity measures have hampered availability of parenting and family support, with declining numbers of children’s centres and reduced children and young people’s services reliant on Local Authority funding (The Children’s Society et al., 2019). Service reduction challenges the ability to meet the continuum of need that will be evident within each community and poses risks to an ability to safeguard children’s welfare (see Chapter 13). To remedy this need, central government action is required to address, amongst other things, the d3 billion funding gap to enable fulfillment of statutory and nonstatutory duties (e.g. provide early help to families and safeguard the welfare of children) (House of Commons Housing, Communities and Local Government Committee, 2019). Large community-wide programmes developed in more recent years are often supported by the third sector—for example, the National Lottery Community Fund investment in five test and learn programmes known as A Better Start (ABS) for promoting early child development through services for families delivered by community partnerships. Parents are at the heart of these initiatives. A Better Start programmes have built on and extended the previous work of Sure Start, by involving parents as individual
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volunteers or as representatives of parent and family organisations, in service design, provision and evaluation (Dickerson et al., 2016; Barlow et al., 2017).
Service delivery During the late 1990s and early 2000s, provision of services for parents and parenting was a strong political focus, and as a result there was a proliferation of various parenting programmes and interventions (Daly et al., 2015). Health visitors, school nurses and others were often involved in developing and delivering parenting programmes (e.g. the Solihull model) being quick to recognise the need and to innovate, working in partnership with parents. Often this has been dependent on the enthusiasm of the few and has lacked strategic support, direction and coordination. An important aspect of service delivery is the approach of the practitioner, who needs to be sufficiently skilled to move beyond ‘surface’ issues, forming a strong enough relationship to address underlying challenges (Whittaker et al., 2014). Nationally there is a huge variation in services and with respect to those dedicated to supporting parent-infant relationships, specialist teams have been identified as ‘rare jewels’ across all four UK nations (Parent Infant Partnership UK, 2019). The patchiness of services offered to parents is likely to continue when services are commissioned locally and national priorities for parenting are only expressed in broad terms. That said, there are many different ways in which parents can be supported, and the variety of possible interventions or ways of working with parents can be confusing. To help to clarify the situation, consideration is now directed to some of the most popular and evidence-based modes of intervening for parenting education and support.
Home visiting The universal provision of home visiting following the birth of a baby by a health visitor has been the envy of other countries, such as the United States, which have sought to replicate this provision (Daro et al., 2019). Hanson et al. (2019) fervently argue for familyfocused public health with action in the home, explaining that it is in this setting where the family, as a unit, plays out its behaviours and influences each other’s health. Home visiting allows for an identification of need and then targeting of services as appropriate. Benefits are seen when contact in the home starts early (i.e. in the antenatal period) as this is the optimal time to identify risk and resilience factors and establish the partnership relationship with the parent/coparent so necessary for future service delivery (Kemp et al., 2013). Sadly, this contribution of the parenthome visitor relationship is rarely mentioned within the home visiting literature when discussing effective outcomes. When conducted by trained health visitors, an antenatal visit that incorporates the parent’s expectations of the infant and of themselves as mothers and fathers can be most effective in thinking about the transition to parenthood (Deave et al., 2008). It provides a forum to address psychosocial issues that may impinge on parenting ability, taking a problem-solving approach. It can build on the strengths and the resources that the parents-to-be have to enhance their parenting ability, and can be of considerable help to families and services alike in order to identify
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areas of need and concern (Puura et al., 2005). Realist evaluation evidence of parenting support identifies that access to one form of help (e.g. home visiting) enables parents to know about and make informed decisions about engaging with other services (e.g. parenting training) (Whittaker, 2008). Thus, systems of home visiting for parents should be part of a wider comprehensive system, and service designs should be based on principles of human ecology, respecting the family context and wider determinants of health. A successful example of which is the Maternal and Early Childhood Sustained Home-Visiting model (Kemp et al., 2011; Goldfeld et al., 2019), which although Australian developed, operates in a number of countries, including the UK (Kemp et al., 2017). The benefits of home visiting have been shown (Filene et al., 2013) and incorporated into many initiatives such as A Better Start, so that those most in need can be identified, as it has been demonstrated that intensive home visiting to those in most need is most effective (Nygren et al., 2018). Research shows that effective home visiting for child health outcomes needs to be carried out by professional home visitors (often nurses); however, better birth outcomes may be achieved when clients are matched for ethnicity with nonprofessional home visitors (Filene et al., 2013).
Volunteer and lay visiting programmes As noted previously, volunteer and local parent partnerships have been a cornerstone of area-based programmes, including Sure Start and latterly A Better Start. Examples of previous volunteer programmes include Community Mothers Schemes, Home Start and Newpin (New Parent and Infant Network) (Cox et al., 1991; Oakley, 1995) with Home Start standing the test of time in the UK. In a review of the effectiveness of volunteer schemes, Munns et al. (2016) report benefits of improved positive parenting attitudes, confidence and coping skills. These schemes all build on self-help ideals.
Parenting groups Many parenting programmes are offered in the community to help parents either relate more effectively to their children or manage their children’s behaviour (Barlow and Stewart-Brown, 2001). Many of these programmes have either not been assessed or do not fit the criteria for the EIF (2019) Guidebook, but nevertheless have been found to be acceptable by parents who engage with them. Examples include Family Links Nurturing Programmes, which works with parents and with children in schools, Mellow Parenting Programmes, and so on. They often use a combination of video clips of parents in situations with children, discussion, role play and homework tasks in which they try out various strategies at home with their own children. Very often parents will train to become parent leaders of the groups and work alongside the health professional, thus contributing to the building of social capital in the local area.
Educational/parenting programmes These programmes have been fuelled by a desire in the UK to increase children’s school readiness. However, parentchild interaction is enhanced by the parents being
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encouraged to help their children learn by enjoying early play together, sharing books and talking together from the earliest weeks. Examples of these education-based initiatives are Delta in Northern Ireland (Gillespie and McClean, 2004), Parents as First Teachers in Berkshire (EIF, 2019), PEEP in Oxfordshire (Evangelou and Sylva, 2007; Barlow and Coe, 2011) which also have been developed for working with parents who are in prison. These programmes, which are gaining in popularity, have evidence of effectiveness with health visitors often taking the lead.
Referred parenting groups for children with disruptive behaviour Here a number of evidence-based approaches are suitable, often informed by social learning and attachment theories: The Incredible Years (Webster-Stratton and Hammond, 1997) and Triple P (Sanders, 1999). These programmes are manualised, requiring facilitators to adhere to prescribed content for supporting positive behaviour management. Empowering Parents, Empowering Communities (Day et al., 2012) is informed by the Family Partnership Model (see Chapter 7) and as a peer-led programme, differs from others mentioned.
Traditional antenatal and postnatal classes/groups These classes and groups may be delivered by health visitors or midwives or together in a combined approach and are to be found in most areas of the UK. Groups available in community settings can provide an opportunity for supporting transition to parenthood, though their reach with fathers is less good than with mothers (Deave et al., 2008). Prenatal and postnatal support of this kind is also provided by the National Childbirth Trust to parents who pay to attend. When commissioning arrangements permit, health visitors offer postnatal support groups to the new parents on their caseloads. These are not the same as parenting groups, as they offer, for the most part, information about infant feeding, child development, childcare, toys, first aid and a variety of practical issues, and one of their aims is to reduce social isolation among women with babies. Groups that extend from the antenatal through to the postnatal period are thought to be most successful at achieving this particular outcome.
Support for fathers The importance of fathers’ roles, their significance on child outcomes (Amato and Rivera, 1999; Kroll et al., 2016) and the skewed nature of existing parenting support and education facilities (which shows a mother bias), was noted during the early period of UK growth in parenting support interventions (Ghate et al., 2000) and, sadly, continues to be apparent (Barlow et al., 2014; Hogg, 2014; Baldwin et al., 2019). An emerging international body of evidence research seeking to understand the needs of fathers (Asenhed et al., 2014; Thomas et al., 2011; Baldwin et al., 2019) and address the challenge of programme engagement (Tully et al., 2017, 2018; Lechowicz et al., 2019) collectively makes a number of recommendations for services. These include approaching fathers ‘as men’, rather than just as fathers; advertising and increasing awareness of support for fathers and transition to fatherhood interventions; ensuring that parenting Community public health in policy and practice
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intervention content and delivery is father inclusive; and ensuring workforce access to father engagement training. Hogg (2014) details a comprehensive list of top 10 tips for those working with parents in the perinatal period.
Perinatal mental health support The provision of listening visits to mothers with postnatal depression has been shown to be an effective intervention for mothers and babies (Segre et al., 2015). Health visitors report a desire to provide listening visits, and when appropriately prepared, they can use nondirective listening to support women deal with complex biopsychosocial issues (Cummings and Whittaker, 2016). However, Healthwatch (2019) report contrasting parental views about professional help, including that provided by health visitors, for new parents. This finding is consistent with health visitor (Cummings and Whittaker, 2016) and public health nurse reports (Higgins et al., 2018) about the need for better access to perinatal mental health training and education. Good practice in this regard would be to access the Multi-Agency Perinatal & Infant Mental Health Champions training available through the Institute of Health Visiting, an international award-winning education programme for health visitors and other practitioners (https://ihv.org.uk/training-and-events/training-programme/pimh-training-programmes/). Other means of supporting parenting and mental wellbeing in the family can be achieved through community groups. To test the effectiveness of a universal proportionate approach to early parenting support in the UK, the Enhancing Social-Emotional Health and Wellbeing in the Years randomised controlled trial has been established (Bywater et al., 2018) and is due to be reported in 2021. This model of parenting support offered on a proportionate basis by health visitors and early years practitioners includes the Incredible Babies book (as a universal resource) and the Incredible Years infant and toddler parenting groups (a selective prevention element, see Chapter 6) for parents assessed as needing further support.
Relationship support Research has shown how distressing it is for children to experience the breakdown of their parents’ relationship (Coleman and Glenn, 2010). Disconnecting ‘parenting from partnering’ is a mistake (Clulow and Donaghy, 2010), though an understandable error when parenting support interventions have largely focused on parenting skills development (Tavistock Relationships, 2015). There has been a considerable movement to encourage health visitors and other community health services to offer support for relationships when problems first start to occur, though these services are not defined as ‘relationship support’, which on the whole remain underdeveloped in the UK (Doubell et al., 2017). The One-Plus-One Brief Encounters programme (see the resources section) offered by health visitors has been identified as a promising means of providing couples with early help (Doubell et al., 2017), providing health visitors with critical skills in approaching and handling conversations when parents show signs of distress (Coleman et al., 2015). In situations when parents have experienced violent and damaging couple relationships, support with parenting needs to also consider the safety issues of family members. Early evidence is being developed for a life coaching approach, known as Parent Vision, which could show promise in improving self-efficacy and quality of parentchild relationships for women who have had previous trauma following domestic abuse (Berry et al., 2019). Community public health in policy and practice
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One-to-one approaches to supporting parentchild interactions It is clear that not all parents want to attend groups for a number of different reasons (Whittaker and Cowley, 2012). However, there are several different approaches that health visitors and school nurses might use that do not involve the use of parent groups. Examples of these include the Solihull Approach (Brigham and Smith, 2014) and the Parent Adviser/Family Partnership Model (Davis et al., 2002) (see Chapter 7) and the Brazelton Neonatal Behavioural Assessment (Nugent, 2015) that place emphasis on parents understanding and relating to their baby/child.
Conclusions and implications for practice The grounds for supporting early life—and thereby parents and families—have been well established by life-course research evidence. Such evidence, drawn from life and social science fields, explains how exposures to different factors (environmental, biological, psychosocial or genetic) can impact on human development and longer-term health. The experience of poverty plays its part too and is an area of much debate with different policy actions recommended by national and international organisations. A global strategy for addressing human flourishing across a range of dimensions, including health, is work towards transforming the world by fulfilling sustainable development goals set by the UN (UN, 2015). Problem areas recognised by the SDGs are not unique to emerging economies (poorer countries), as features such as food insecurity, poverty, environmental disaster, violence and inequality in access to education are evident in UK communities. These challenges are especially experienced by families with fewer economic and social resources and place additional demands on parents. Health visitors and school nurses have key roles in working with children and families, and with acknowledgement of the wider context of families’ lives, can make a real difference by provision of child and family-focused support based on nurturing care principles. However, individual practitioner work with families does not and should not happen in isolation. Meeting parenting and family support needs requires comprehensive service provision (incorporating home visiting, community, group-based and virtual/digital facilities), so parents can access the right thing, at the right time and from the right person. Universal early help should be available before a baby is born, enabling prevention activities to be put in place to minimise exposure to factors harmful to health. Importantly, early health visitor contact with parents opens the way for promoting the universal child health service, improving the reach of parenting support and investing in emerging relationships with families. From this basis, health visitors and school nurses can role model nurturing care and thereby help shape the environment necessary for fulfillment of the SDGs and healthy beginnings for children.
Discussion Questions • What conversations can health visitors and school nurses have and with whom to address shortfalls in provision of parenting and family support?
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• How should health visitors and school nurse proceed to ensure continuity of service provision for parents and families? • What community partnerships can be developed to review and strengthen local availability of comprehensive family support that reaches across community intersections? • What areas of additional education and training can community public health professionals access to enhance service provision that can achieve improved perinatal and infant mental health outcomes?
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The Children’s Society, Action for Children, Barnardo’s, National Society for the Prevention of Cruelty to Children, the National Children’s Bureau, 2019. Children and young people’s services: funding and spending 2010/11 to 2017/18. ,https://www.childrenssociety.org.uk/what-we-do/resources-and-publications/children-and-youngpeople%E2%80%99s-services-funding-and-spending. (accessed 02/04/2020). Tavistock Relationships, 2015. Health visiting workforce and early relationship support. Available at: ,https://www. tavistockrelationships.org/. (accessed 02/04/2020). Thomas, J.E., Bone´r, A.K., Hildingsson, I., 2011. Fathering in the first few months. Scand. J. Caring Sci. 25 (3), 499509. Tully, L.A., Piotrowska, P.J., Collins, D.J., Mairet, K., Black, N., Kimonis, E.R., et al., 2017. Optimizing child outcomes from parenting interventions: fathers experiences, preferences and barriers to participation. BMC Public. Health 17 (1), 550. Tully, L.A., Piotrowska, J., Collins, D.A.J., Frick, P.J., Anderson, V., Moul, C., et al., 2018. Evaluation of ‘the father effect’ media campaign to increase awareness of, and participation in, an online father-inclusive parenting program. Health Commun. 34 (12), 14231432. Umer, A., Hamilton, C., Edwards, R.A., Cottrell, L., Giacobbi, P., Innes, K., et al., 2019. Association between breastfeeding and childhood cardiovascular disease risk factors. Matern. Child. Health J. 23 (2), 228239. United Nations, 1989. United Nations Convention on the Rights of the Child. Office of the United Nations High Commissioner for Human Rights, Geneva, ,http://www.childrensrightseducation.com/un-convention-onthe-rights-of-the-child1.html . (accessed 30/01/2020). United Nations, 2015. Transforming our World: the 2030 Agenda for Sustainable development. United Nations, New York. United Nations, 2017. UNDP Strategic Plan, 20182021. Publication DP/2017/38. United Nations, New York. Available at: ,http://strategicplan.undp.org/. (accessed 02/04/2020). United Nations Development Programme (UNDP), 2018. What does it mean to leave no one behind? A UNDP discussion paper. United Nations, New York, ,https://www.undp.org/content/undp/en/home/librarypage/poverty-reduction/what-does-it-mean-to-leave-no-one-behind-.html. (accessed 30/01/2020). Webster-Stratton, C., Hammond, M., 1997. Treating children with early onset conduct problems: a comparison of child and parent training interventions. J. Consulting Clin. Psychol. 65, 93109. Welfare Reform and Work Act, 2016. HMSO, London. Whittaker KA, 2008. A realistic evaluation of how parents experience the process of formal parenting support. Unpublished PhD dissertation. King’s College, London. Whittaker, K.A., Cowley, S., 2012. An effective programme is not enough: a review of factors associated with poor attendance and engagement with parenting support programmes. Child. & Soc. 26 (2), 138149. Whittaker, K.A., Cox, P., Thomas, N., Cocker, K., 2014. A qualitative study of parents’ experiences using family support services: applying the concept of surface and depth. Health Soc. Care Community 22 (5), 479487. Woolfenden, S., Galea, C., Badland, H., Smithers Sheedy, H., Williams, K., Kavanagh, A.M., et al., 2020. Use of health services by preschool-aged children who are developmentally vulnerable and socioeconomically disadvantaged: Testing the inverse care law. J. Epidemiol. Community Health. Available from: https://doi.org/ 10.1136/jech-2019-213384. World Health Organization, United Nations Children’s Fund, World Bank, 2018. Nurturing Care for Early Childhood Development: A Framework for Helping Children Survive and Thrive to Transform Health and Human Potential. World Health Organization, Geneva.
Further Reading For information on parenting programme delivery with specific subgroups of parents, (e.g. parents with intellectual disabilities, teenage parents, parents who are incarcerated, parents of young children with autism), the Cochrane Library hosts a number of evidence reviews. ,https://www.cochrane.org/. (accessed 02/04/2020) Specific programmes suited to different areas of need can be searched via the Early Intervention Foundation (EIF) online guidebook. ,https://guidebook.eif.org.uk/. (accessed 02/04/2020) A selection of learning materials available for home visiting and supporting families for nurturing care have been developed by a UNICEF and International Step by Step Association (ISSA) partnership recruiting consultants globally to write materials. ,https://www.issa.nl/modules_home_visitors. (accessed 02/04/2020)
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Good practice in work with fathers and available training is offered by key charities and interest groups (e.g. The Fatherhood Institute, the Institute of Home Visiting, the NSPCC and Family Lives). The NSPCC, Babies Count: Dad’s Project Resource offers ideas on parent programme planning, design and delivery Example case studies illustrating parenting programme delivery in prisons across the UK see the PEEPLE website: ,https:// www.peeple.org.uk/prison-case-studies. (accessed 02/04/2020). The One-Plus-One designed ‘Brief Encounters’ video resource, recommended by The Relationships Alliance, demonstrates communication skills used within a brief intervention approach, and can be seen via YouTube. ,https://www.youtube .com/watch?v=cbSz5RBP57E/. (accessed 02/04/2020) Family Lives, a national family support charity. ,https://www.familylives.org.uk/. (accessed 02/04/2020) Think Baby online training from Oxford Brookes University to support student health visitor skills in observing parent-baby communication. ,https://www.brookes.ac.uk/osnm/research/centre-for-nursing--health-and-social-care/children-and-fami lies/think-baby/. (accessed 02/04/2020) The Parent-Foundation in 2019 produced a toolkit for commissioners and providers wishing to develop and set up services supporting parent-infant relationships. ,https://parentinfantfoundation.org.uk/. (accessed 02/04/2020)
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C H A P T E R
9 Public health practice in a digital world Toity Deave KEY ISSUES • The rising use of technology within the context of public health
• Safeguarding; is this an issue when using apps and social media?
• Varieties of apps, social media and ‘digital technologies’
• Case studies: users’ experience and effectiveness
• Advising and signposting clients to information and advice: issues to consider
Introduction to the use of apps and social media within the context of public health In recent years the process of information finding has changed to one of using online search engines, social media, mobile applications (apps) and other online sources. Whilst this increases greater accessibility to information, the quality and accuracy of much of this intelligence have not been reviewed or assessed. Research that focuses on mobile health app users and non-users is scarce, and this is partly because of the methodological challenge in measuring mobile app use (Box 9.1). Both individuals’ motivations to use health apps and their actual use of their mobiles vary widely. Therefore research has primarily measured health app use by exploring the use of a specific health app or by, for example, assessing general usage of health apps as one outcome variable (e.g. Carroll et al., 2017). Although there are many health apps that appear similar, they tend to offer particular features that focus on different goals and target different groups which, in turn, could affect usage (Bol et al., 2018).
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BOX 9.1
Useful definitions key terms Mobile health (mHealth) is a generic term for the practice of medicine and care delivery supported by the use of mobile phones and other wireless technology. There are many potential applications including, but not limited to, education, diagnostic support, helplines as well as remote monitoring and data collection (Digital Health & Care Institute, Scotland, n.d.). E-health ‘The use of information and communications technology in support of health and health-related fields’ (WHO, 2019). Telehealth includes a broad spectrum of technologies and systems that enable the remote exchange of data between a patient and their health care professional. They can assist in diagnosis and monitoring and are typically used to support patients with long term conditions (Digital Health & Care Institute Scotland, n.d.).
Digital health definition: ‘The cultural transformation of how disruptive technologies that provide digital and objective data accessible to both caregivers and patients leads to an equal level doctor-patient relationship with shared decision-making and the democratization of care’ (Mesko et al., 2017). In other words, it includes many subsectors such as e-health, m-health, tele-health and health information technology. Digital health technologies include ‘a wide range of products used in the health and care system including apps, software and online platforms that are intended to benefit people or the wider health and care system. They may be standalone or combined with other products such as medical devices or diagnostic tests’ (NICE, 2018).
A person’s gender, age, education and e-health (see Box 9.1) literacy skills are associated with their use of apps, but they also predict the use of different types of health apps (Bol et al., 2018). E-health literacy is often a strong predictor of technology use (Neter and Brainin, 2012). Younger, more highly educated people are more likely to use mobile health apps than older, less educated people, but older populations are more at risk of chronic diseases (e.g. hypertension), and health apps that enable monitoring of such diseases are more likely to be used by them (Lorenz and Oppermann, 2009). For children and young people, digital technologies have been developed to address unmet needs within the National Health Service (NHS). This includes the development of speech recognition software to support those with speech impairments and neuro-rehabilitation within the home being supported by virtual reality systems. This younger generation uses technology in their everyday lives and are likely to be open to its use in management of their health care at a time when health care resources are increasingly limited (Dimitri, 2019). A significant
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proportion of the NHS budget used to manage disease in adulthood has its origins in childhood, thus making a case for a life-course approach to technology, with an attention on early life. This was promoted by the Chief Medical Officer’s report (HM Government, 2012), which emphasised the need for a greater focus on health innovations for child health and young people’s health. That said, when the coronavirus pandemic (COVID-19) precipitated countrywide lockdown, there was a step change in who was routinely using electronic media. Across the world the implemented social distancing measures caused routine healthcare appointments to be shifted to telehealth systems, requiring people of all age groups to make use of ehealth (Zerunyan, 2020). A move in the UK was supported early on by medical Royal Colleges to manage the spread of infection (Gunasekera, 2020) and reduce the risk of healthcare providers themselves becoming ill (Royal College of General Practitioners, 2020). Digital health interventions include digital technology (hardware and/or software) that is used to support the delivery of health or social care. The ‘interventions’ element includes introducing or changing the technology so that it can be used by health and social care staff, patients and the public. There is huge potential for digital interventions, but for these to be realised, their impact on health, care and society needs to be robustly evaluated, including the barriers and facilitators to their implementation. Important questions around how best to use and evaluate many of these technologies also remain. In the recently published Topol Review (Health Education England, 2019), it is acknowledged that technologies have the potential to assist in redressing inequalities but may also add to them—for example, if the use of technology advantages some people’s access to health. However, at present there is a lack of evidence about the impact of health technologies on health. In the Topol Review, it is assumed that the patient is at the centre and, when assessing and implementing any new technologies, that these technologies improve patient care and the effectiveness and efficiency of care being delivered. The patient or client chooses to use them, to opt in to use these technologies. This supports the user to have more control over their own health and care, and, as a result of the earlier assumptions, there is likely to be an improvement in the patienthealth care practitioner relationship, which will likely result in greater trust and better communication. However, this is dependent on health professionals being cognisant of new technologies, being confident in their use and being aware of their advantages, disadvantages and aspects to be aware of when using them, whether in their own practice or recommending to patients and the public. The public health workforce need to be aware of who routinely uses apps and health-related technologies in the populations that they service so that they can keep pace with their clients. The NHS Long Term Plan placed technology at the centre of a number of its commitments, with a particular emphasis on patients being able to access primary care in different ways (NHS England, 2019). A prevention green paper highlights prevention opportunities for the 2020s that will be proactive, predictive and with personalised interventions (HM Government, 2019). Data held by the NHS and those data generated by smart devices worn by members of the public will form the beginning of ‘intelligent public health’ (HM Government, 2019, p. 3). There is also a commitment to build on the digital infrastructure in the NHS. A King’s Fund report that studied the impact of technology on the NHS estate highlighted that the two are interlinked and that technology changes will alter the way that
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locations are used, to make more efficient use of space, but the size of the estate will not be reduced (Wenzel and Evans, 2019). A World Health Organization (WHO) report (Kringos et al., 2015) discusses the challenges faced by primary care, one of which is the changing technology, and the implications of this change, with respect to not only the ageing population and multimorbidity associated with this but also the shrinking workforce and financial constraints.
Apps, social media and ‘digital technology’ The use of websites to provide easy access to information, including health-related subjects, is now commonplace. The use of mobile phone apps and social media is relatively new, even though a majority of the population now use these for purposes other than health-related ones. Mobile health interventions previously relied on voice or text-based short message service, but the easier access to the internet, ease of use of apps, greater functionality of apps as well as the austerity cuts to health and social care services (Karanikolos et al., 2013) have led to a significant growth of smartphone apps that can be used to change health-seeking behaviour. With burgeoning digital technologies, these now include apps that enhance the service user’s experience by delivering personalised care and advice; others collect data and feed back to the patient/user the need—for example, a change in medication (e.g. for diabetes, Kollmann et al., 2007). For practitioners (including health visitors and school nurses) who aim to keep abreast of assistive technologies and the development of new apps, the challenge is enormous, especially for those who offer care to children and young people who view technology as part of everyday life (Dimitri, 2019). It is estimated that more than 200 apps are added daily to the leading app stores (https:// liquid-state.com/mhealth-apps-market-snapshot/). Mobile apps are very popular, but they can be developed by anyone who has an interest in the subject area with little, if any, regulation required before making the app publicly available. Many people download those that are free and find that they can be fun and are a convenient resource; however, before downloading, some apps require payment, and it is up to the user to decide whether they consider it worthwhile. Little consideration is likely to be given to how the development of the app has been paid for, what information might be gathered from their mobile device or what happens to that information. The developers of free apps are likely to make money by, for example, selling advertising space or trying to interest the user in the app developer’s other products. Basic versions of apps may be available free of charge, but the user has to pay for a version that has more features, or there are in-app purchases that the user may be encouraged to make. Few apps have been assessed for their effectiveness in changing their specified outcomes (McKay et al., 2018). Many do not have any specified outcomes, and the majority have not been evaluated. Despite the growth in apps designed to support behaviour change and encourage good health, little research has been undertaken to investigate the accuracy or suitability of the health or medical advice provided, the theory underpinning the app or the effectiveness of these apps in effecting the change they set out to make (Lau et al., 2016; McKay et al., 2018). In the UK, the NHS Apps Library uses a set of digital assessment questions to ensure that only safe and secure apps and digital tools are published on the library (https://
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www.nhs.uk/apps-library/). These include questions that relate to the target population, whether the device links into a variety of different networks (such as NHS Mail and the Health and Social Care Network), the type of information it is providing or data it is going to collect, whether the product processes any data of the NHS or Social Care service users and, finally, questions about the effectiveness of the app. These questions are followed by a technical assessment that the app developers must reply to and satisfy. Only after these are all satisfied will the product be accepted onto the NHS Apps library and be made publicly available. ORCHA is one of the major organisations that, worldwide, appraises health apps and helps governments as well as health and social care organisations to choose and deliver apps that have the greatest effect on improving health outcomes. There is also an app library that can be accessed on their website (https://appfinder.orcha.co.uk/). It conducts reviews for NHS England and for NHS Digital, and the NHS has placed ORCHA in its National Innovation Accelerator programme. This programme supports uptake and spread across England’s NHS of proven innovations that have impact. The National Institute for Health and Care Excellence (NICE) has developed an evidence standard framework for digital health technologies that have been developed in the UK health and care system (NICE, 2018). It sets out requirements that need to be met by different types of health technologies (e.g. apps). The framework is aimed at developers, funders of research and evaluators (including commissioners) and sits amongst other standards, regulations and guidance (https://tinyurl.com/yxksyu9h). There is also an initial code of conduct to enable the development and adoption of safe, ethical and effective data-driven health and care technologies. It outlines 10 key principles (Box 9.2) that set out the behaviours expected from those developing, deploying and using
BOX 9.2
Ten key principles 1. Understand users, their needs and the context. 2. Define the outcome and how the technology will contribute to it. 3. Use data that are in line with appropriate guidelines for the purpose for which it is being used. 4. Be fair, transparent and accountable about what data are being used. 5. Make use of open standards: ensure the technology can communicate easily with existing national systems.
6. Be transparent about the limitations of the data used. 7. Show what type of algorithm is being developed or deployed. Aim to show in a clear and transparent way how outcomes are validated. 8. Generate clear evidence of the effectiveness and economic impact of a product or innovation. 9. Make security integral to the design. 10. The commercial strategy needs to be defined. Source: Department of Health and Social Care, 2019
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data-driven technologies for safe and effective digital innovations (Department of Health and Social Care, 2019). Whilst these principles are not necessarily of direct use to health care practitioners, it is important to know that there are regulations and guidance for the development of digital health technologies that are to be used in the NHS. The actual safety of digital health technologies is the remit of the medical device regulations or the NHS digital clinical safety regulations (https://digital.nhs.uk) in the UK. Using the definition that ‘a medical device is any device intended to be used for medical purposes’, the Medicines and Healthcare Products Regulatory Agency (MHRA) (2012) makes decisions on what is a medicine or medical device (borderline products). These are the digital health technologies that fit the NICE (2019) criteria of tier 3btype devices. For example, these might include those products that provide treatment for a diagnosed condition but not those that provide general advice for that particular condition (NICE, 2019). In Europe, the European Commission Medical Devices Directorate covers the regulations for the European Union for Medical Devices (MDD) (European Union for Medical Devices, 1993, 2017). This agency clears and places medical devices into one of four classes which pertain to the level of risk to the patient, according to the characteristics, functions and intended purposes of the product. In the United States, the Food and Drug Administration, an agency within the Department of Health and Human Services, produces regulations on medical device approval (US Food and Drugs Administration (FDA), 2019). In April 2019, the WHO (2019) published recommendations for ways that countries can use digital health technologies to improve people’s health and essential services, highlighting that they are ‘vital tools to promote health, keep the world safe, and serve the vulnerable’. The main target groups for this guideline are public health practitioners and decision makers who will benefit from an understanding of which digital health interventions have an evidence base to address health system needs. Social media software is quite varied and used by an increasing proportion of society for channels of communication; online networks provide a rich internal structure whereby users can decide which types of interaction they want to use. Some interactions may have evidence-based information and advice, but many are opinion-based and/or may be commercially motivated. The social value of online interactions, in respect of whether they are evidence of real social activity, has been and continues to be debated (Grabowicz et al., 2012). Facebook is the type of social media software used quite commonly by groups of health care practitioners, children’s centres and other organisations to promote their services and advertise events, and many permit the beneficial exchange of views, ideas and advice. For example, online support groups for women experiencing postnatal depression provide a safe place to connect with others (Evans et al., 2012). Care is still needed in accessing these pages because most will be accessible to the public, but there are likely to be some pages that are closed and/or private so that just those signed in can access them. If professionals want to set up or contribute to group pages, familiarity with the privacy settings is important to ensure confidentiality. There may also be some form of messaging system that is confidential. Blogging is thought to increase social networks by enhancing the connection with extended family and friends, which in turn has a positive impact on maternal wellbeing (McDaniel et al., 2012). Some professional organisations have published guidance and recommendations on the use of social media (e.g. Nursing and Midwifery Council, 2019; Royal College of Nursing,
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2015; Royal Society for Public Health (RSPH), 2017, 2018). These set out broad principles and advice for practitioners to enable them to think through issues, to act professionally, to promote trust, to ensure public protection at all times, to know how to safely use social media to improve their care and reputation, and to have an awareness and knowledge of how to protect children and young people from the pitfalls of social media. The RSPH also established an All-Party Parliamentary Group in 2018 to drive policy change that might minimise the negative effects of social media use for young people’s mental health and wellbeing and to promote the positive aspects (RSPH, 2018). Digital health technologies help patients and families better manage their conditions, promote their own health and address health problems. Within health care these are usually applications that have been made accessible to the patient by a health care professional and will not be publicly available. For example, Changing Health, a lifestyle coaching programme for people with type 2 diabetes, requires a referral by a general practitioner for patients to access it. There are also likely to be publicly available apps that seem to perform similar functions but that are unregulated, may be inaccurate and ask for personal data with little information as to how it will be used (see later text). In addition to being used by patients and staff, digital health technologies are used in research to address many challenges to evaluating health care interventions, including patient retention and engagement. There are novel technologies such as artificial intelligence (which aims to mimic tasks normally requiring human intelligence, such as visual perception, speech recognition) and machine learning (e.g. algorithms) which enable richer data generation and collection and can assist making real-time alerts for health risks and predictions for health outcomes (Jiang et al., 2017). Whichever mode of digital technology is being accessed, the following section highlights some important aspects to consider.
Advising and signposting clients to information and advice: issues to consider When accessing a website, a social media platform and/or downloading an app, it is commonplace to be asked for further details, some more personal than others. An e-mail address is the minimum that will be requested, but when downloading an app, for example, permission may be requested to let the app access information that is on the phone/ mobile device. This might include the phone and e-mail contacts, a log of phone calls, internet data, data about the phone/mobile device’s location, unique identification numbers of the device and/or the information about the use of the app that has been downloaded. Some apps access only the data they need to function; others access additional data that are not related to the purpose of the app. This information might be shared with other companies, so the privacy settings on the device need to be checked to look for ways to opt out of the data collection in the app’s privacy policy. However, this may mean that some of the functions of the app are limited, so a decision needs be made about what to prioritise—privacy or being able to use the whole functionality of the app. The market of mobile health applications is directed toward patients, those with health concerns, clinicians and health care professionals. These particular apps are for one or
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more of the following three purposes: point-of care use, health care professional education or patient education. They are mainly suited for disease management, self-monitoring and, possibly, drug control, as well as other clinical and educational/health promotion applications. Several important and complex questions about these medical applications should be asked, such as those regarding security, reliability, efficiency and quality of service. The following question can be asked, if relevant to the subject area and purpose of the app: Can they really perform a reliable, secure and efficient diagnosis? Many apps make statements about what they will achieve—for example, ‘this app will help you to lose weight’. Is this realistic? For any apps or downloads that are meant to be secure, the user needs to be able to learn whether they are indeed so. Aspects to consider include determining the motivation for the development of that particular intervention, who funded it, whether there was a commercial aspect to it, looking for any reference to there being an evidence base to it and, if so, what sort of evidence was referred to. It should be evident from the description of the app if it is endorsed by any health organisation, royal college or health trust; who funded it; its purpose; the target population; and who has access to any information that the user provides (Federal Trade Commission, 2017; NICE, 2018). Information on the app intending to take personal information from the user when signing in, and what it will be used for, is found in the terms and conditions accompanying the download, but these are rarely read because they are in small print, usually very lengthy, and users do not take the time to do so. There is scant evidence about the effectiveness of apps or the accuracy of the information provided, and on whether or not they are publicly available (Tomlinson et al., 2013; Chen et al., 2018). For example, a systematic review of evaluations of apps for parents during pregnancy and early infancy included just one that related to breastfeeding and one that focused on women’s health (Derbyshire and Dancey, 2013; Overdijkink et al., 2018). Another systematic review that evaluated apps for health behaviour change found that evaluations were generally of limited methodological quality; they included content analysis of the information provided and appraisal of the evidence base and of the underpinning theory. Only one study used an experimental methodology, a case-control study (McKay et al., 2018). For publicly available apps, it is more complex to undertake a rigorous evaluation of the effectiveness of a particular app. Ideally, a control group is needed, and the members of this group should not have accessed or explored the app; when an app is available to anyone, it is challenging to find such people. One method to try to overcome this is comparing frequent users of an app with those who do not use it much. However, accurately defining a ‘high’ user compared with a ‘low’ user and how this information is collected is complex, especially if there are several elements to the app. For example, a user may open an app several times but may not use it or may just spend a very short time looking at it; many apps do not automatically stop when the user closes their screen, so when this is the case, the amount of time on the app cannot be assessed accurately. In relation to any information or knowledge gained from accessing online information or downloads, it may not be possible to link the content and action of what you read or see with the intended outcomes. For example, if you look at an app that provides advice about correct first aid, when you next injure yourself, it may be difficult to judge whether your actions directly related to that advice or whether it was something else that you had
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read, seen or been told, either before or after looking at the app, that impacted on your actions. To explore a user’s utilisation of an app, the data from the app analytics are needed—in other words, information about what elements of the app were used, how often the app was opened, the times of day this occurred and so on. To gain this information, the user’s consent is needed, which may be tricky to obtain, partly because the researcher needs to identify who the users are and partly because the users might not want their personal data shared (even if it is anonymised). Those people who do consent for their information to be made available might do so because they might like the app or use the app quite a lot, and therefore be different in some way from others who do not agree to share their data. Some guidance has been developed by the WHO; it produced a guide to conducting research and assessment of digital health interventions (WHO, 2016) to assist the user of these interventions to navigate through the claims made by that particular technology, including suggestions about how to assess the quality and availability of the data collected by that intervention. The guide takes the reader through the technical requirements for the development of the technology, early implementation, to reporting the impact of it.
Safeguarding: an issue when using apps and social media Social media has permeated nearly every aspect of day-to-day life, and greater consideration is being given to the importance of mental health and wellbeing within the health debate, especially the relationship between social media and mental health. Social media has become a place where relationships are developed; it shapes self-identity, representing a means by which we express ourselves and how people learn about the world; and it is intrinsically linked to mental health. This specifically relates to 16- to 24-year-olds who are the most active users of social media (RSPH, 2017). Whilst social media platforms can promote a sense of community and enable the universal provision of emotional support, there are also risks that can cause significant harm to children and young people—for example, cyberbullying. Childhood and early adulthood is a potentially vulnerable time for the development of social and emotional health. In early 2017, the RSPH undertook a UKwide survey of 14- to 24-year-olds to explore the impact of the (then) five most commonly used platforms on their health and wellbeing (YouTube, Twitter, Facebook, Snapchat, Instagram) (RSPH, 2017). The survey found that the most negative impacts on young people’s health and wellbeing related to sleep, depression and anxiety, body image, bullying and feeling of missing out on something. Safeguarding relates to oneself as well as others when referring to the use of websites (Nursing and Midwifery Council, 2019), the apps used and the information provided when using a phone or mobile device. It is important to remember that someone may be collecting data when children and young people and/or parents access these sites and apps, and this information may be shared with other companies, such as the developer of the app or the website, the app store itself, any advertiser or the network of the app. If there are concerns about anyone’s information being used or shared (for example, a child, young person or vulnerable user), check the privacy settings on their device and be aware of ways to opt out of data collection in the app privacy policy. However, as stated earlier, this might interfere with the functionality of the app.
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It is not always easy to find out what information is accessed by each app or how it will be used. The app stores may include a website or e-mail address for the app developer; if such is not provided, one may want to question the integrity of the app. For Android systems, users have the opportunity to read the permissions. This might seem cumbersome, but the permissions outline what data will be accessed from the app, and reading it enables the user (practitioner, parent, carer) to make a judgement as to whether they are happy with the permissions and that they make sense. An app may want a phone’s location to provide advertisements that link with the user’s interests and location. To prevent this, the location settings will need to be changed on the device’s settings. The location setting may be particularly important for vulnerable people (those with special needs, elderly, children and so on) for them not to receive inappropriate advertisements or similar information. For further information, see https://www.consumer.ftc.gov/articles/0018-understanding-mobile-apps Before downloading apps for children or vulnerable people, it is important to know that apps might collect and share information, link to any social media, allow them to spend money and include advertisements shown to the user (Federal Trade Commission, 2012). One way to ensure that children and other vulnerable people are using apps safely is to try them personally and talk to the users about their use of it. Several websites provide guidance, advice and support to parents, carers and professionals in relation to online safety, including gamification. The Childnet International website provides a wealth of information and advice on internet use. Childnet works directly with children and young people, 3 to 18 years old, parents, teachers and other professionals to help them stay safe online and to inform the resources that they develop (https://www.childnet.com/ resources). Common Sense Media rates and reviews a variety of different media, including films, books and technology (www.commonsensemedia.org). They provide a breadth of tools and guides for parents by age group, topic or media type—for example, on privacy and internet safety. There are also lists of best apps, best games and those for best learning. In relation to safe and sensible gaming, the Ask About Games website provides advice on how to play games safely; the app offers families tips to help them to maximise the number of games they can enjoy together (https://www.askaboutgames.com). The previously mentioned apps are some examples of investment to promote children’s and young people’s online safety. There are also some examples of investment in developing suitable digital health technologies in child health, but they predominantly concern child disease-oriented services (https://www.cypmedtech.nihr.ac.uk). There is a need for the universal child health approach, which is integral to community child health services, to develop evidence-based technologies that support child health and development used by parents and children.
Case studies One example of a widely used interactive app has recently been evaluated and is described in the Case Study 9.1. Other digital health technologies involve county councils working with their public health partners to innovate and pilot new ways of working. These include using a text messaging service (ChatHealth, 2017) for children and young people to contact school nurses (Local Government Association, 2018) (Case Study 9.2).
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Case Study 9.1 Baby Buddy app case study The Baby Buddy is a freely available app that was developed by the national child health and wellbeing charity, Best Beginnings. Its public health purpose is to provide evidence-based, professionally validated information to pregnant and new mothers, empower women’s positive pregnancy and early parenting health behaviours, promote contacts with health care professionals and increase mothers’ self-efficacy with regard to pregnancy, baby care and early parenthood. Professionals’ views collected in a national evaluation of the app (Deave et al., 2018) indicated that the app was a good fit when communicating public health and lifestyle choices to first-time mothers. The professional used the app as a reinforcement tool for information given in practice and further reassured first-time mothers that the information they were reading from the app was correct. Some actively adopted the app into some of their service delivery which, they felt, had had a positive effect on their relationship with some of the first-time mothers. They used the app to signpost to information, especially practical examples of breastfeeding, that were available from the films linked to the app. This suggests that the Baby Buddy app worked well for both health care professionals and first-time mothers and that the app helped them to build on information shared in appointments, in line with Every Contact Counts (Public Health England, NHS England, Health Education England, 2016). For both mothers and health care professionals, it was important that the app was endorsed by many of the royal colleges and relevant institutions. Nevertheless, many needed reminders to make sure that they used the app and to keep them motivated to use it: ‘like with everything, it needs that constant, every few months
or so reminder, because there are new things coming out and new things in the booking packs etc’ (Health Care Professional). Mothers also liked the app; they liked its accessibility and that the information was concise and easily found, but they also used other apps like a pick and mix, choosing specific apps for different aspects they wanted to know about. Some mothers were using five or more different apps related to the perinatal period. Despite this, they said they still preferred in-practice support from a health care professional. In contrast, the quantitative element of the evaluation to determine whether the app achieved its aim to increase mothers’ self-efficacy and mental wellbeing found that it made no difference for the first-time mothers who took part in the evaluation (Deave et al., 2018). The main lesson learnt from this evaluation related to the use of other publicly available apps is that, whilst the user might like using the app and feel that it is helpful, use of the app might not achieve the outcome(s) that the app specified that it would. Whilst this might not appear to be important, users of apps should not be under the impression that the app will do something that it cannot or will not accomplish, but that it might help in other ways. The professional endorsement of the app was very important to both health care professionals and mothers/users. Staff may well need reminders about an app because, in the everyday bustle of work, it is not a top priority. Whilst an app might be helpful, mothers and other user groups are likely to use many apps, not just one, and therefore, exploring or monitoring the information that users access is complex. The qualitative element of this work was undertaken by J. Coad, E. Bailey, S. Nightingale, D. Coleby and N. Ashley of Coventry University and T. Goodenough and T. Deave of University of West England, Bristol.
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Case Study 9.2 ChatHealth case study ChatHealth (2017) is a confidential text messaging service that is one method by which children and young people (ages 11 to 19 years) can easily contact their local public health nursing (school nursing) team. The service started in the Leicestershire Partnership NHS Trust (Local Government Association 2018) but is now available in several areas of the country. There are individual text numbers for each area. Children and young people can contact the service for advice about any aspect of their physical or emotional health. They can send a text at any time (day or night) and, during the weekday, know that it will be responded to within working hours specified by each particular trust. The service is particularly relevant in the current financial climate with small numbers of employed school nurses. It is second nature for children and young people to access social media and use text messaging to communicate rather than via face-to-face contact. Nevertheless, ChatHealth complements and promotes the face-to-face contact, making those contacts more efficient and beneficial to both the child or young person and the school nurse. The Southern Health NHS Trust started using the app in 2017 with a group of self-
selected school nurses who had received training from the Leicestershire Partnership NHS Trust and purchasing the relevant number of licenses to use it. The issue of safeguarding was the element that needed to be addressed, and staff felt reassured how this was dealt with. For example, if a text is received from a child who is at risk, then, if need be, the mobile telephone number can be identified by the police and usual safeguarding processes followed. Lessons were also learnt from trusts that had already started using ChatHealth. There is a rota of on-call staff to ensure coverage. The number of texts received gradually increased, and more staff were trained and are now part of the offer that commissioners purchase. The benefits to staff have been a more efficient method of working; the initial contact from the child or young person tends to be earlier on in the progress of the problem, and therefore it can be caught before it is magnified. In addition, there has been some useful intelligence about children and young people’s health who have used the service, particularly regarding emotional health and wellbeing—for example, bullying and exam stress. Specialist Community Public Health Nursing team, Southern Health NHS Trust.
Conclusions Telemedicine, mobile phones and applications, wearable devices, robotics, virtual reality and artificial intelligence all come under the umbrella of digital health technologies. Longer life expectancies, increasing numbers of people living with chronic conditions and rising costs of health care are pressuring health systems around the world. For many people, access to health services can be improved by the use of digital health technologies, which may also reduce costs, improve the quality of health care service a patient receives and enhance the efficiency of health systems. Digital health technologies offer
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opportunities for self-management—for example, those with chronic health conditions— which may be via wearables or remote monitoring devices. Many health applications are publicly available and are not regulated, and care must be taken when downloading and using them, especially in relation to reading the permissions and examining the privacy settings. Information accessed and used by the app may not only relate to the subject and functioning of that app but may also be used by third parties. Few apps have been evaluated for the effectiveness of their stated impact, but this may not detract from the support that some patients, families and young people might gain from using a particular app. Before using it or recommending an app to your client group, it is important to learn whether the information and advice provided by that app is evidence-based, who funded the development of the app and how they benefit from doing so. It is anticipated that these technologies will not replace health care professionals but will enhance the services provided, giving health care staff more time to care for patients, families and young people (Health Education England, 2019).
Discussion Questions • What dilemmas do community practitioners face when recommending digital health care interventions to their patients, clients and/or young people and families? • Before recommending an app or other digital intervention, what aspects might you consider? • If downloads and/or apps are meant to be secure, what aspects do you need to explore to see if this is true or not? • Many apps make statements about what they will achieve—for example, ‘this app will help you to lose weight’. Do you think this is realistic? If not, why not? • For an app or other digital intervention that you use or might have recommended, what aspects of it might you be able to evaluate and how?
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Derbyshire, E., Dancey, D., 2013. Smartphone medical applications for women’s health: what is the evidence-base and feedback? Int. J. Telemed. Appl. Available from: https://doi.org/10.1155/2013/782074. Digital Health and Care Institute, n.d. Digital Health and Care. Available from: , https://www.dhi-scotland. com/about-dhi/what-we-do/ . (accessed 13/04/2020). Dimitri, P., 2019. Child health technology: shaping the future of paediatrics and child health and improving NHS productivity. Arch. Dis. Child. 104 (2), 184188. European Union for Medical Devices, 1993. Council Directive 93/42/EEC concerning medical devices. EUR-Lex31993L0042 - EN-EUR-Lex. ,https://eur-lex.europa.eu/legal-content/en/ALL/?uri 5 CELEX%3A31993L0042. (accessed 23/07/2019). European Union, 2017. Regulation (EU) 2017/745 of the European Parliament and of the Council on medical devices, amending Directive 2001/83/EC, Regulation (EC) No 178/2002 and Regulation (EC) No 1223/2009 and repealing Council Directives 90/385/EEC and 93/42/EEC. Available from: , https://eur-lex.europa.eu/ eli/reg/2017/745/2017-05-05 . (accessed 11/04/2020). Evans, M., Donelle, L., Hume-Loveland, L., 2012. Social support and online postpartum depression discussion groups: a content analysis. Patient Educ. Couns. 87 (3), 405410. Federal Trade Commission, 2012. Mobile apps for kids: disclosures still not making the grade. ,https://www.ftc .gov/reports/mobile-apps-kids-disclosures-still-not-making-grade. (accessed 23/07/2019). Federal Trade Commission, 2017. Understanding mobile apps. ,https://www.consumer.ftc.gov/articles/0018understanding-mobile-apps. (accessed 23/07/2019). Grabowicz, P.A., Ramasco, J.J., Moro, E., Pujol, J.M., Eguiluz, V.M., 2012. Social features of online networks: the strength of intermediary ties in online social media. PLoS One 7 (1), e29358. Gunasekera, C., 2020. Royal College of Ophthalmologists. Near Telemedicine during Covid-19 using iPads and iPhones to minimise face-to-face contact. 19 March 2020. Available at: , www.rcophth.ac.uk/wp-content/ uploads/2020/03/Norfolk-and-Norwich-Near-iPad-Telemedicine-during-Covid.pdf . (accessed 16/04/2020). Health Education England, The Topol Review. ,https://topol.hee.nhs.uk/. (accessed 23/07/2019). HM Government Chief Medical Officer annual report, 2012. Children and young people’s health. ,https://www.gov .uk/government/publications/chief-medical-officers-annual-report-2012-our-children-deserve-better-preventionpays. (accessed 23/07/2019). HM Government, 2019. Advancing our health: prevention in the 2020s—consultation document. ,https://www .gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s. (accessed 23/07/2019). Jiang, F., et al., 2017. Artificial intelligence in healthcare: past, present and future. Stroke Vasc. Neurol. 2 (4), 230243. Karanikolos, M., Mladovsky, P., Cylus, J., Thomson, S., Basu, S., Stuckler, D., et al., 2013. Financial crisis, austerity, and health in Europe. Lancet 381 (9874), 13231331. Kollmann, A., et al., 2007. Feasibility of a mobile phonebased data service for functional insulin treatment of type 1 diabetes mellitus patients. J. Med. Internet Res. 9 (5), e36. Available from: https://doi.org/10.2196/jmir.9.5.e36. Kringos, D., Boerma, W., Hutchinson, A., Saltman, R., 2015. Building Primary Care in a Changing Europe. World Health Organization Regional Office for Europe, Geneva. Lau, Y., et al., 2016. Efficacy of e-technologies in improving breastfeeding outcomes among perinatal women: a meta-analysis. Matern. & Child. Nutr. 12 (3), 381401. Local Government Association, 2018. Using Digital Technology to Improve the public’s Health: A Guide for Local Authorities. Local Government Association, London, https://www.local.gov.uk/sites/default/files/documents/ 1%2077%20Digital%20public%20health_02%201.pdf (accessed 13/04/2020). Lorenz, A., Oppermann, R., 2009. Mobile health monitoring for the elderly: designing for diversity. Pervasive Mob. Comput. 5 (5), 478495. McDaniel, B.T., Coyne, S.M., Holmes, E.K., 2012. New mothers and media use: associations between blogging, social networking, and maternal well-being. Matern. Child. Health J. 16 (7), 15091517. McKay, F.H., Cheng, C., Wright, A., et al., 2018. Evaluating mobile phone applications for health behaviour change: a systematic review. J. Telemed. Telecare 24 (1), 2230. Medicines and Healthcare Products Regulatory Agency (MHRA), 2012. A guide to what is a medicinal product. MHRA Guidance note no. 8. ,https://assets.publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/380280/guide_8_what_is_a_medicinal_product.pdf. (accessed 23/07/2019). ˝ Mesko´, B., Drobni, Z., Be´nyei, E´., Gergely, B., Gyorffy, Z., 2017. Digital health is a cultural transformation of traditional healthcare. mHealth. 3, 38. Available from: https://doi.org/10.21037/mhealth.2017.08.07.
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National Institute for Health and Care Excellence (NICE), 2018. Evidence standards framework for digital health technologies: user guide. ,https://www.nice.org.uk/Media/Default/About/what-we-do/our-programmes/ evidence-standards-framework/user-guide.pdf. (accessed 16/05/2020). National Institute for Health and Care Excellence (NICE), 2019. Evidence standards framework for digital health technologies. ,https://www.nice.org.uk/Media/Default/About/what-we-do/our-programmes/evidence-standardsframework/digital-evidence-standards-framework.pdf. (accessed 16/05/2020). Neter, E., Brainin, E., 2012. eHealth literacy: extending the digital divide to the realm of health information. J. Med. Internet Res. 14 (1), e19. Available from: https://doi.org/10.2196/jmir.1619. NHS Apps Library. ,https://www.nhs.uk/apps-library/. (accessed 23/07/2019). NHS England, 2019. The NHS Long Term Plan. ,https://www.longtermplan.nhs.uk/wp-content/uploads/ 2019/01/nhs-long-term-plan-june-2019.pdf. (accessed 23/07/2019). Nursing and Midwifery Council, 2019. Guidance on using social media responsibly. Nursing and Midwifery Council, London. https://www.nmc.org.uk/standards/guidance/social-media-guidance/ (accessed 13/04/2020). Overdijkink, S.B., et al., 2018. The usability and effectiveness of mobile health technologybased lifestyle and medical intervention apps supporting health care during pregnancy: systematic review. JMIR mHealth uHealth 6 (4). Available from: https://doi.org/10.2196/mhealth.8834. Public Health England, NHS England, Health Education England, 2016. Making Every Contact Count (MECC): Consensus statement. Available from: , https://www.england.nhs.uk/wp-content/uploads/2016/04/makingevery-contact-count.pdf . (accessed 13/04/2020). Royal College of General Practitioners, 2020. COVID-19 (coronavirus). Available from: , http://www.rcgp.org. uk/policy/rcgp-policy-areas/covid-19-coronavirus.aspx . (accessed 16/04/2020). Royal College of Nursing, 2015. Use of Digital Technology: Guidance for Nursing Staff Working with Children and Young People. Royal College of Nursing, London. Royal Society for Public Health, 2017. #StatusofMind. ,https://www.rsph.org.uk/our-work/campaigns/statusof-mind.html. (accessed 23/07/2019). Royal Society for Public Health, 2018. APPG on social media. ,https://www.rsph.org.uk/our-work/campaigns/ status-of-mind/appg.html. (accessed 23/07/2019). Tomlinson, M., et al., 2013. Scaling up mHealth: where is the evidence? PLoS Med. 10 (2), e1001382. US Food and Drugs Administration (FDA), 2019. Policy for Device Software Functions and Mobile Medical Applications Guidance for Industry and Food and Drug Administration Staff. Available from: , https:// www.fda.gov/media/80958/download . (accessed 11/04/2020). Wenzel, L., Evans, H., 2019. Clicks and Mortar: Technology and the NHS Estate. The King’s Fund, London, ,https://www.kingsfund.org.uk/publications/technology-NHS-estate. (accessed 23/07/2019). World Health Organization, 2016. Monitoring and Evaluating Digital Health Interventions: A Practical Guide to Conducting Research and Assessment. WHO, Geneva. Available from:,https://apps.who.int/iris/bitstream/ handle/10665/252183/9789241511766-eng.pdf;jsessionid5AF702975BE1442A785705AB1B8B6B5E2? sequence51. (accessed 23/07/2019). World Health Organization, 2019. WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening. WHO, Geneva. Available from: ,https://apps.who.int/iris/bitstream/handle/10665/311977/ WHO-RHR-19.8-eng.pdf. (accessed 23/07/2019). Zerunyan, F.V., 2020. Coronavirus: Telemedicine is great when you want to stay distant from your doctor, but older laws are standing in the way. The Conversation, 2 April. Available from: , https://theconversation .com/coronavirus-telemedicine-is-great-when-you-want-to-stay-distant-from-your-doctor-but-older-laws-arestanding-in-the-way-134885 . (accessed 16/04/2020).
Suggested reading and resources Dimitri P, 2019. Child health technology: shaping the future of paediatrics and child health and improving NHS productivity. Arch. Dis. Child. 104(2): 184188 Greaves, F., Joshi, I., Campbell, M., Roberts, S., Patel, N., Powell, J., 2018. What is an appropriate level of evidence for a digital health intervention? Lancet 392 (10165), 26652667. This is a short comment in the Lancet that raises the advantages and disadvantages of digital technologies. For digital health interventions, it introduces the framework that provides standards for the evidence of effectiveness, dependent on
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the amount of functionality that the digital intervention involves. This is especially helpful for developers, commissioners and evaluators. Greenhalgh, T., Shaw, S., Seuren, L., Wherton, J., 2020. Video consultation information for GPs. IRIHS research group, University of Oxford. Available from: , https://bjgp.org/sites/default/files/advanced-pages/ 20Mar_COVID_VideoConsultations.pdf . (accessed 15/04/2020). This guidance written during the COVID-19 pandemic for general practitioners is relevant for other public health practitioners working remotely to support patients and clients in the community. Murray, E., Hekler, E.B., Andersson, G., Collins, L.M., Doherty, A., Hollis, C., et al., 2016. Evaluating digital health interventions: key questions and approaches. Am J Prev Med 51 (5), 843851. The article by Murray and colleagues examines the challenges of undertaking evaluations of digital health interventions and outlines and evaluation strategy. Even if you are not interested in undertaking an evaluation, it is useful to read so that when you use or recommend them, you have some idea of the difficulties in evaluation of digital health interventions. Royal Society for Public Health, 2017. #StatusofMind. ,https://www.rsph.org.uk/our-work/campaigns/statusof-mind.html. (accessed 23/07/2019). This report is an interesting read around the link between social media and children and young people’s mental wellbeing. It was published in 2017 but is still current, and some of the issues highlighted and discussed are relevant to not only all children and young people but may also be relevant to adults/parents. World Health Organization, 2016. Monitoring and evaluating digital health interventions: a practical guide to conducting research and assessment. ,https://www.who.int/reproductivehealth/publications/mhealth/digitalhealth-interventions/en/. (accessed 13/04/2020). Yardley, L., Morrison, L., Bradbury, K., Muller, I., 2015. The person-based approach to intervention development: application to digital health-related behavior change interventions. J. Med. Int. Res. 17 (1), e30. This article describes an approach the authors have developed for successful digital interventions to help people manage their health or illness.
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C H A P T E R
10 Health programme decision making and implementation science Lynn Kemp KEY ISSUES • Health programme decision making and implementation science describe a series of sequential strategies and processes necessary for health programme sustainability. • Decision making is an important first process, which should be guided by questions and tools that ensure that programmes selected for implementation are fit for the purpose within the local context. • Programmes need to be translated into locally implementable forms. Attention should be given to the mode of translation
that will allow adaptation and change whilst managing the risk of programme drift, dilution and consequent disappointment at lack of outcomes or delusion that outcomes are being achieved when they are not (the 4 D’s). • Dynamic and quality implementation strategies are needed to ensure that the selected and translated programme will sustainably achieve effective outcomes. • Tools can be used to support proactive and structured processes that ensure effective interventions are effectively implemented to achieve effective outcomes.
Introduction [P]atients might benefit even more—and more patients might benefit—if the health care system performed better in delivering existing treatments than in producing new ones. Woolf (2008 p. 212) For many decades (or even centuries), health care has focussed on the development and testing of new evidence-based practices. Consequently, health services are presented with
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BOX 10.1
Key processes for programme implementation and sustainability Health programme decision making and implementation science describe three key processes for achieving outcomes and sustainability:
1. Guided decision making 2. Translation of the chosen programme into a locally implementable form 3. Dynamic and quality implementation strategies
an extensive selection of rigorously tested products, tools, programmes and policies that may confer benefit on individuals or populations (Ben Charif et al., 2017). The research focus on methods such as randomised controlled trials and other forms of efficacy and effectiveness trials has skewed investment to the ‘new’, with resultant lags in and underuse of evidence to achieve population-wide improvements in health (Milat et al., 2015). Attention has not been paid to either the development and implementation of strategies that can support the decision-making processes needed to identify effective practices that could improve the public’s health or to the implementation strategies needed to ensure that chosen practices are translated into routines and delivered sustainably with quality to achieve the planned outcomes (Chambers et al., 2013; Milat et al., 2015). The field of implementation science is beginning to detail the processes by which evidence can be put into operation to achieve improved outcomes. Fixsen et al. (2013 p. 214) describe a simple formula for this: ‘Effective interventions 3 effective implementation 5 improved outcomes’. The multiplicative effect is such that if neither the intervention nor the implementation is effective (that is, given a value of 0), then improved outcomes cannot be achieved. This chapter guides readers through the process of selecting quality, evidence-based programmes and the subsequent implementation strategies and processes (summarised in Box 10.1) to ensure that selected programmes are implemented with quality to achieve improved outcomes. The text details the tasks and tools to support making decisions about programmes (1) shown to be efficacious, or even better effective (but perhaps not in the same context), and (2) deciding what and whether this programme will achieve the same results in the local context and then (3) ensuring that the implementation of the chosen programme is conducted in such a way as to increase the likelihood that it will be effective and sustainable.
Health programme decision-making strategies In their seminal early work on implementation approaches, Greenhalgh et al. (2004, p. 593) bemoaned the lack of active approaches to the processes of intervention decision making and implementation, criticizing the approach by which researchers produce evidence and then fail to engage with active approaches to implementation: adopting a ‘letting it happen’ or at best ‘helping it happen’ approach. They advocated for an active ‘making it happen’
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approach to ensure optimal implementation to achieve outcomes. An oft-missed process, however, is applying active strategies to deciding what the ‘it’ should be. Sometimes the ‘it’ is decided at a policy level (for example, by the government or by service commissioners) and imposed on services without consideration of the appropriateness and capacities needed for implementation in a local context. Sometimes slick marketing by programme developers can be of influence. The next section presents strategies and tools for ensuring that the decision about the ‘it’ is both considered and contextualised—that is, undertaken with due thought given to the external validity of the evidence (i.e. applicability and adaptability to other and different contexts), rather than the internal validity which characterises evidence generation methods such as randomised controlled trials (Chambers et al., 2013). This point is particularly important in the context of community public health programme decision making, which takes place within contexts that are usually much more complex than the controlled environments of research. In community public health it is difficult, for example, to separate the potential beneficiary of an intervention (e.g. a family member) from the broader context in which they live and the other actions within their complex social system that may influence their engagement or response (see Chapter 1). Very recently, Moore et al. (2019) have suggested readjusting focus from exploring the singular impacts of interventions (as focussed on in research) to thinking about interventions within complex social systems. Here, interventions are thought of ‘as “events within systems” which aim to disrupt the functioning of complex systems through changing relationships, displacing entrenched practices, and redistributing and transforming resources’ (Moore et al., 2019, p. 24). Such an approach suggests that knowledge of the system, practices and resources into which an intervention or programme may be introduced—and anticipatory thought about the impacts of a new intervention on the system—should be central, rather than peripheral, to intervention programme decision making. The active process of making decisions about which programme or intervention would be the most effective—that is, most likely to achieve the desired public health outcomes (with effective implementation)—is best undertaken by methods that support making comparisons between different options with the local context and system. Comparative effectiveness research describes the processes of comparing potential interventions (including the ‘no change’ option) to determine which may work best within the context. It can encourage reconsideration of change for change’s sake, where new programmes may perform no better than current practice (Saver, 2011). Such analyses can be undertaken using complex simulation techniques, including computer modelling, to explore implementation scenarios and the impacts over time. However, such computer modelling tools, and the data needed to support them, are often not easily available to the community public health policy maker or practitioner. In the absence of these, a number of tools can be easily used.
Frameworks and tools to assist in selection of evidence-based programs Useful tools for decision making are those that assist the policy maker or practitioner in assessing the generalizability and adaptability of the evidence-based programme research to the local context.
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Hexagon tool This tool facilitates comparison of multiple programmes on the domains of need, fit, evidence, readiness, resources and capacity (Blase et al., 2013) (Figure 10.1). The tool provides a 5-point rating scale that supports comparisons and can support the use of collaborative processes, including decision-making teams undertaking individual rankings and agreeing on processes for concurrence, as illustrated in Box 10.2.
RE-AIM model The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) model (RE-AIM, 2017) encourages decision makers to evaluate potential programmes with a
The Hexagon Tool Exploring Context The Hexagon Tool can be used as a planning tool to evaluate evidencebased programs and practices during the Exploration Stage of Implementation. See the Active Implementation Hub Resource Library http://implementation.fpg.unc.edu EBP: 5-Point Rating Scale: High = 5; Medium = 3; Low = 1. Midpoints can be used and scored as a 2 or 4. High Med Low
Ca p • S acity ta t qua ff me o Imp • S lifica et mi lem ust t ion nimu ent a m • S inabi s t l • O aff Co ity • L rganiz mpet ead enc ati • ies • B Fina ershi on p uy nc ope -in pr ial o ra c • P tiona ess r l • F actitio ized am n ilie ers s CAPACITY
Need in school, district, state • Academic & socially significant Issues • Parent & community perceptions of need • Data indicating need ent urr hc t, wit ves t i tric F iati dis Init hool, orities l i c r • S ate p ationa st aniz s lue rg es • O ructur nity va t u s m om •C
NEED
FIT
Need Fit Resource Availability Evidence Readiness for Replication Capacity to Implement Total Score
Re s sup ource READINESS RESOURCES s p for • s Cu orts f and s e r n n • Te ricul or: di yor chn a & Rea licatio purve ailable e Cla olo v (IT Rep alified TA av obser • S dept gy su ssroo r u taff .) ppo m • Q per t o ites to ions of i • n r ts s t T x g s ra • E ture eplica inition • D ining EVIDENCE a f r e l s M a t d ns a • • C ta Sy ver nal nen o oa st • Se eratio functi ompo c l p Su ching ems • O sentia tation • A pervi & dm sio es leme lized: ncy n in &s a te p yst istrat • Im eration ompe t em ion op taff C ppor S • Su ip rg. h Evidence • O aders • Outcomes-Is it worth it? • Le • Fidelity data • Cost-effectiveness data • Number of studies • Population similarities • Diverse cultural groups • Efficacy or Effectiveness
FIGURE 10.1 The hexagon tool. EBP, evidence-based programme; IT, information technology; Org., organizational; TA, technical assistance. Source: Blase et al. (2013).
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BOX 10.2
Hexagon tool example A health district was considering where best to invest to improve reductions in smoking in pregnancy. A process was undertaken using the Hexagon tool to compare different evidence-based approaches, to aid investment decision making. Note particularly that the ‘evidence’ score does not reflect simply the quality of the evidence, but also how
applicable that evidence was to the local population, including their cultural diversity. Health education, whilst ranking lower on ‘evidence’, scored highly on the other categories, compared with Incentives, which although having a higher ‘evidence’ ranking, was adjudged to have lower capacity to implement.
What could we be doing? Summary of Smoking in Pregnancy Intervention Options using the Hexagon Tool.
Intervention
Need
Fit
Evidence
Readiness for Replication
Health Education Counselling Incentives Social Support Feedback Nicotine Replacement Therapy with Behavioural Support
5 5 5 5 5 5
5 5 4 5 4 5
2 4 5 1 2 4
5 4 4 3 3 4
Resource Availability
Capacity to Implement
TOTAL
5 3 3 2 3 3
5 5 3 3 3 5
26 26 24 19 20 26
focus on population health impact. The acronym includes consideration of the factors included in the following list. Reach
Will/does the programme reach a large and representative proportion of the target population, particularly underserved and those most in need?
Effectiveness
Will/does the programme produce robust positive effects in the target population with minimal negative effects?
Adoption
Is it feasible to implement the programme in the context and in realworld and less ideal contexts?
Implementation
Can the programme be consistently implemented with reasonable costs?
Maintenance
Is the programme likely to support long-term and sustainable improvement?
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This tool has many similarities with the hexagon tool but does not benefit from a scoring system, albeit one could easily be applied.
Practical, Robust Implementation and Sustainability Model The Practical, Robust Implementation and Sustainability Model (Feldstein and Glasgow, 2008) asks decision makers to consider four key elements: 1. Programme/intervention, which should be viewed from both the organisational and client perspective, including organisational concerns such as readiness and adaptability, and client concerns such as access and choice 2. External environment, which includes consideration of the funding, regulatory and resource environments 3. Implementation and sustainability infrastructure, including data, training and systems for sustainability 4. Recipients, again from both an organisational and client perspective, including organisational capacity in management and leadership, and client demographics, knowledge and beliefs
Business research methods Business research methods can be useful in supporting decision making and are increasingly relevant to commissioning of health services. Business research encourages the asking of questions such as the following: • Demand. Is there a demand for the programme, will the programme meet that demand and what may impact on demand and the capacity to meet it? • End user analysis. Who are the likely users, how much will they use the programme and will that use change or be stable over time? • Market strategy. What is the best mix of programmes, how will users be encouraged to use the programme and will that use and provision be sustainable? • Product delivery planning. What are the specific elements of the programme, what is needed to deliver them, is there capacity to deliver and how can this be planned?
Summary Health programme decision making should be a process by which policy makers and practitioners actively and collaboratively consider the available evidence and its applicability to the local context—client, community and organisational. As illustrated in the hexagon tool example, the best evidence in research terms may not be the best programme to choose in any particular context. A key element of decision making must be the ‘implementability’ of the programme—how good the fit is between intervention and context (Lau et al., 2016). Even the most effective intervention will not result in improved outcomes if the local context cannot support effective implementation (Fixsen et al., 2013).
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Failure to consider implementability in programme decision making can result in significant investment, both financial and human, in interventions that are poorly implemented with low uptake and inadequate quality. The use of the suggested tools, either individually or collectively, can support careful and measured investment in community public health programmes and improved population outcomes. A limitation in the desire to undertake structured decision making is that commonly research literature focusses on providing the evidence on whether or not the intervention was effective and includes very little detail on the components of the intervention, the programme theory of change or implementation processes (Kemp et al., 2019). The programme or intervention is often presented as a ‘black box’ (McNaughton, 2004, p. 217) that is impossible to unpack to determine the factors for consideration suggested by the decision-making tools, or the answers to the questions the tools pose. This creates a risk that the decision-making processes may incorporate unfounded assumptions about the intervention. This can lead to a ‘pick and mix’ approach wherein the more understood, or familiar, elements of multiple programmes are chosen and put together to create a non evidence-based programme for implementation, with considerable risk to the achievement of the desired outcomes. This is not meant to preclude processes of local translation and adaptation, which are discussed in the next section.
Translating programmes for implementation The previous section provided the rationale and tools for assisting decision making about what programme/s (that is, the ‘it’) could be implemented to achieve the community public health outcome. Having chosen the programme or intervention to implement, there follows a series of decisions about how to translate the evidence into the local context. As with programme decision making, translation processes benefit from being proactive, considered and purposeful, to improve implementability of the intervention within local contexts (Castro et al., 2004; Lee et al., 2008; Moore et al., 2013; Stirman et al., 2013). Reactive translation, as can occur in response to implementation difficulties, can results in ‘a misapplication or mistaken application of the model, often involving either technical error, abandonment of core and requisite components, or introduction of counterproductive elements’ (Aarons et al., 2012, p. 2).
How to translate Decisions about how to translate the chosen programme into the local context require an understanding of some key terms that are often poorly defined, undertheorised and not often researched: adoption, adaptation, spread and scale-up (Ilott et al., 2013). Table 10.1 provides definitions of these terms and the outcomes of the process.
Issues in translation Regardless of the mode of translation that is used, there are issues to be considered to optimise the likelihood of positive community public health outcomes, as summarised in
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TABLE 10.1 Translation terms, meanings and outcomes. Term
Meaning
Outcome
Adoption
The endpoint of the programme decision-making processes: the decision to implement a particular evidence-based programme or intervention (Bowen and Zwi, 2005; Ilott et al., 2013).
A programme or intervention is implemented in a specific site without any adaptation—that is, as described in the research with no changes. May result in problems of implementability.
Assumes that the programme or intervention is optimally designed in the research process and can be effectively delivered independent of context (Chambers et al., 2013) Adaptation The process of customizing the chosen programme or intervention to suit local conditions and settings.
Spread
Scale-up
A bespoke programme that has increased potential to meet the needs of clients, communities and organisations, but may be at risk of loss of quality.
Results from accepting the premise that the benefit of any programme or intervention can only be achieved through a process of refinement to meet the contextual needs of diverse populations and systems (Aarons et al., 2012; Chambers et al., 2013. Ilott et al., 2013).
Adaptation processes and the benefits and risks are discussed further below.
‘Horizontal’ diffusion using a somewhat organic (albeit it can be planned and resourced) process by which evidence-based programmes, interventions and practices are shared within or across a service pathway or system (Ben Charif et al., 2017; Ilott et al., 2013).
Can result in widespread take-up of the programme, intervention or practice.
Spread can be achieved through many strategies as outlined in the Stanford Social Innovation Review’s Many Ways to Many website and resources (McCannon et al., 2016).
However, if undertaken without appropriate and adequate planning and resourcing, can result in loss of programme quality as the spread expands.
A strategically planned ‘vertical’ diffusion into With appropriate strategic planning, results in broader policy and practice, with an explicit aim embedded, large-scale change. and systematic strategy to expand the programme or intervention to new groups or sites regionally, nationally or even internationally (Ben Charif et al., 2017; Ilott et al., 2013; Milat et al., 2015). This usually involves specific strategies of system The programme, intervention or practice development to sustainably integrate, embed and becomes institutionalised— that is, it becomes ‘just what we do’. institutionalise the programme or intervention into policy and/or practice (May et al., 2007). Fixsen et al. (2013) suggest that scale is achieved when at least 60% of service units within a system are implementing the programme with quality and outcomes; at 60% system and organisational change will have necessarily occurred to sustainably support the programme.
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Table 10.1. Failure to proactively identify the potential risks in subsequent implementation of the translation mode can result in a number of serious implementation consequences, characterised here as the 4 D’s: • • • •
Drift Dilution Disappointment Delusion
Drift refers to the unintended process whereby the effectiveness of at-scale programmes dissipates over time due to failure to adhere to, or deviation from, programme protocols (Aarons et al., 2012; Moore et al., 2013). This results from the assumption that programmes have already been optimised for implementation through spread or scale-up during the development and research trial phase, that context is irrelevant and that adherence to the research protocols in real-world delivery will deliver the desired outcomes, when such expectations are unachievable and unreasonable (Chambers et al., 2013). Dilution refers to the reduced strength of the outcomes delivered to each participant as the programme is delivered to more and more diverse people (also known as ‘voltage drop,’ (Chambers et al., 2013; Glasgow and Riley, 2013), and is an almost expected and often tolerated consequence of the added complexity of delivery in real-world settings, by a range of providers and practitioners in multiple settings. Chambers et al. (2013), however, argue to reject this inevitability, suggesting that continuous quality improvement processes that support adaptation and adjustment of programme delivery protocols in response to systematic monitoring and learning processes can result in not just outcomes consistent with research, but even improved outcomes. Disappointment refers to the frustrations experienced by key stakeholders when the outcomes demonstrated in an experimental trial of the programme are not seen when the programme is spread or taken to scale. When unintended drift or dilution occur and desired outcomes are not achieved, potentially as a result of issues such as lack of resources or staffing needed for effective implementation, or lack of managerial or system support for effective implementation, organisations may negatively value the programme (Wiltsey Stirman et al., 2012). Delusion refers to the misconception that an outcome is being achieved when it is not. As such, it could be considered the antithesis of disappointment, as the failure to achieve the desired outcomes is unrecognised and may be caused by (1) failure to measure outcomes, and/or (2) problems with outcome measurement tools. The following section addresses the continuous quality improvement processes needed to ensure that achievement of the desired outcomes (or not) is recognised and acted on to prevent delusion. Proactive strategies—making it happen—are needed to address the 4 D’s and ensure that translated programmes are successful. Fixsen et al. (2013) note that programme success rates of 80% in 3 years can be achieved when active methods of translation and implementation are used. Quality leadership and partnership working with service partners, community and clients (see Chapter 7) that support positive adaptation processes, change management strategies and quality implementation (see later text) can support implementation that avoids the 4 D’s.
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Adaptation processes Adaptation is the process by which a programme is changed to improve the fit for purpose and/or context. Adaptation is most effective when it is conducted proactively and collaboratively, using two-way processes that consider both evidence-based practice and practice-based evidence in a reflexive learning cycle. By valuing local understanding of context and practice, evidence-based programmes can be codesigned locally in ways that can improve implementation and sustainability. This process can include adaptations to the programme or changes to the context—for example, policy change or system redesign (Chambers et al., 2013; Durlak and DuPre, 2008; Kemp, 2016). Accepting the need for adaptation to support implementation and sustainability in local contexts entails rejecting the idea of adoption, whereby the research-developed programme is placed in new or diverse contexts with active rejection of the notion of any potential contextual impact (Chambers et al., 2013). Programmes that promote rigid adherence to research-developed protocols place unrealistic expectations on implementers to control the real-world context. Adaptation also needs to be an ongoing process as context changes over time. Failure to recognise this temporal quality can result in programmes that reject adaption becoming increasingly irrelevant over time (Chambers et al., 2013; Glasgow et al., 2012). There is an increasing recognition that adaptation is both necessary and desirable to quality implementation. For example, Bopp et al. (2013, p. 204) argue that ‘Programs designed to be adaptable (versus those that have strictly-defined fidelity criteria) are more likely to be sustained and have public-health impact’. Adaptation, however, will only achieve these positive ends when the programme theory of change is clearly articulated by the programme developer (as noted previously, an all too rare occurrence), and it is a planned and proactive process—that is, it is a process of making it happen, rather than one of letting it happen (Greenhalgh et al., 2004). Without planning, adaptation can occur at the individual level, where each practitioner implementing the programme changes it according to their personal understanding of the context, and ‘without developer consultation; without any knowledge of the theoretical/ conceptual rationale for the programme and they typically involve dropping entire components, levels of required training, and dosage levels’ (Elliott and Mihalic, 2004, p. 51). Adaptation thus needs to be balanced with quality. There is ongoing and considerable debate about whether programme adaptation and quality are compatible, and whether adaptation diminishes or enhances programme outcomes. For some, ‘successful implementation of a programme is defined by lack of modification to manualized content’ (Lee et al., 2008, pp. 290291). Others have argued that careful adaptation can be advantageous, both supporting implementation quality and enhancing local engagement (Moore et al., 2013). Others have argued for a blend of both quality and adaptation where ‘core components of the intervention serve as a foundation for the adapted programme while the programme also incorporates the values of the target population to aid in refining the core components and to develop new components’ (Castro et al., 2004, p. 44). Adaptation that is planned, dynamic, investigated and encouraged but monitored and guided by evidence may support both quality and adaptation (Chambers et al., 2013; Lee et al., 2008; Moore et al., 2013), through using what Chambers et al. (2013) call a dynamic sustainability framework where quality monitoring processes
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BOX 10.3
Example of planned and codesigned programme adaptation: the Maternal Early Childhood Sustained Home-visiting (MECSH) programme The MECSH programme has a clearly articulated core and adaptation model called the ‘cake recipe’ (Kemp, 2016). The core recipe describes the key ingredients, equipment and methods required to achieve the core outcomes of improved child, maternal and family health and development. However, the real-world implementation to achieve these outcomes is adapted to local context through a codesign process between implementing sites and the MECSH programme developers. This supports identification of client, community and organisational needs, strengths and resources, and capitalises on these in implementation, enhancing local ownership and institutionalizing of the programme. MECSH-based programs also use a range of focus modules to support addressing of local priorities. Focus modules aim to bring particular areas of the core comprehensive MECSH intervention to ‘front of mind’ and provide added/consistent training, delivery and resources for practitioners. Appropriate content is evidence-based, consistent with the
MECSH delivery model and underpinning theories. Local resources are incorporated into the modules. Outcome measures appropriate to the focus modules are included in programme monitoring. Examples of focus modules implemented in the MECSH sites worldwide include the following: Parent care of the child • Sleep and settling • Household safety • Obesity prevention • Oral health Promoting parent attunement and responsivity • Parent-child relationship and attachment • Video feedback (compulsory MECSH module) • Learning to communicate (compulsory MECSH module) Maternal/family wellbeing • Antenatal smoking cessation • Maternal mental health • Family violence
capture the impact of adaptations on programme implementation and outcomes (Kemp, 2016). Box 10.3 shows of an example of these adaptation processes in practice.
Change management Translating an evidence-based programme into the local context, whether by adoption, spread or scale-up, and whether involving adaptation or not, creates a change in policy and practice. Key to translating the evidence and implementing with quality is management of the change processes. Implementation of new or changed practice on the basis that it is ‘evidence-based’ can challenge the practitioners who feel that the work they have been doing is good. Nevertheless, modern health service policy and practice is characterised by change; as the ancient Greek philosopher Heraclitus observed, ‘The only
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constant is change.’ The challenge here is to identify and enact processes to manage the change to prevent change resistant behaviours that can negatively impact on the implementation of the programme with quality. As with adaptation, change management requires that the implementing organisation adopts the culture of a ‘learning organisation’, with learning cycles, assessment and feedback loops to support the change process (Chambers et al., 2013). May et al. (2007) identified four constructs that can support change and implementation of evidence-based programmes, including the following • Understanding and seeking congruence between the practitioners, their practice and goals and the practice and goals of the new programme • Relating the new programme to existing knowledge and relationships, through understanding what knowledge is held by whom, and practitioners’ beliefs and confidence about that knowledge • Relating the new programme to current skill sets and divisions of labour, through understanding which tasks are, and need to be done by whom, the allocation and distribution of resources and authority, and how performance is managed • Understanding and relating the programme to organisational contexts, including decision making and allocation of responsibility for implementation. Lau et al. (2016) and Milat et al. (2015) similarly identified factors impacting implementation and potential sources of resistance to change that require active management, including the nature and implementability of the programme; professional competency, roles, attitudes to change and practice philosophy; organisational involvement, culture, resources, skill mix, relationships, processes and systems; and the external context such as policy and legislative frameworks and requirements, and economic climate and financing.
Summary Once a programme is chosen, the pathway to successful and sustainable implementation requires active decision making about how the programme is best translated—through adoption, spread or scale-up, with or without adaptation—to achieve the public health change desired. Decisions about, and processes of, adaptation should be proactive, collaborative and dynamic, paying respect to context rather than futilely seeking to control it. Active change management processes are needed to prevent resistance to new programmes, within a learning and engaging organisational culture. Two-way, codesigned processes that actively engage clients, communities and practitioners within the context can encourage a learning culture and support ownership of and investment in evidence-based programmes.
Implementation strategies The final stage in health programme decision making and the implementation pathway is the implementation itself. That is, once a programme is chosen, and the mode and processes of translation are attended to, the programme must be implemented with quality and
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Implementation strategies
FIGURE 10.2 The Drivers triangle. Source: Fixsen et al. (2005).
Improved outcomes
Consistent uses of innovations
Fidelity
tio za n
Integrated & compensatory
Facilitative administration
rs ive
Selection
Co
Training
Dr
m pe te nc yD
Systems intervention
ni ga Or
riv er s
Coaching
Decision support data system
Leadership
sustainability (recalling the formula ‘Effective interventions 3 effective implementation 5 improved outcomes [Fixsen et al., 2013, p. 214]). Often organisations are surprised by the preparation and ongoing work needed to ensure effective implementation. A common belief, somewhat perpetuated by researchers and programme designers, that evidence-based programmes are able to be adopted, in what could be described as a ‘plug-and-play’ mode, means that organisations are unprepared for the work required (Fixsen et al., 2005). In the seminal and oft-depicted Drivers triangle (Figure 10.2), Fixsen et al. (2005) outline the drivers of implementation that need to be addressed to achieve consistent programme implementation and improved outcomes: organisational, competency and leadership drivers, together with performance assessment (Fixsen et al., 2013). Similarly, Milat et al. (2015) identified the adequacy of human resources, leadership and investment in implementation infrastructure, such as training and monitoring systems, as key to successful implementation, particularly in scale-up. Identification of the areas requiring investment and attention in implementation can also be viewed as using an ecological system approach, considering the processes that need to be addressed and reliably and continuously monitored at the programme implementer/practitioner level, team, managerial and organisational levels to ensure success (Chambers et al., 2013). This section first considers the continuous quality improvement processes in implementation and then the specific issues and tasks of measurement of quality.
Continuous quality improvement processes Just as adaptation should be an active learning process (see earlier text), quality improvement approaches should involve ongoing learning about ways to adjust and refine the programme. This process, Chambers et al. (2013) argue, should result in more effective
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FIGURE 10.3 Implementation cascade model. Source: Berkel et al. (2011).
Participant Behaviours
Fidelity Quality
Responsiveness
Programme outcomes
Adaptation
implementation and outcomes than processes focussed on strict adherence to researchdefined or initial protocols. Contemporary implementation science has thus been predominantly grounded in Berkel et al.’s (2011, p. 25) theoretical cascade model (Figure 10.3), which has been subsequently tested in practice (Berkel et al., 2018, 2019). This model assumes that various elements of programme delivery (quality (training and clinical skills), fidelity and participant responsiveness), together with adaptation behaviours, interact to determine the effectiveness of implementation which then directly and consequently determines the type and strength of outcomes (Durlak and DuPre, 2008). The cascade model, together with the Drivers triangle, make clear that quality improvement processes are required that continuously monitor and provide feedback on the quality of training and coaching, administrative, data, technical and adaptive systems. Processes such as PlanDoStudyAct (also known as PlanDoCheckAct) cycles and other structured activities, perhaps more common in businesses that are adhering to a cultural vision as ‘lean and agile’ organisations, can be useful (see the suggested reading and resources for these methods). PlanDoStudyAct cycles have perhaps been the most common within health organisations and services. Recent studies, however, have shown that the cycles are often poorly implemented, and additional work and support are needed to ensure that quality improvement processes are themselves performed with quality to achieve the desired implementation outcomes (Dawson, 2019; Knudsen et al., 2019; McNicholas et al., 2019). A major shortcoming with models for quality monitoring in implementation, including the Implementation Cascade Model (Berkel et al., 2011), is that they generally assume that by enacting processes to ensure quality programme delivery and participant responsiveness, effective outcomes will naturally and consistently follow (Olswang and Prelock, 2015). Even the Drivers triangle (see Figure 10.2) could be perceived as suggesting that good implementation drivers together with performance assessment will inevitably result in improved outcomes (Fixsen et al., 2005). This assumption has been problematic as it has meant that quality monitoring processes have traditionally focussed on enhancing programme delivery at the expense of developing better mechanisms for understanding outcomes (Green, 2009). A rapid literature review conducted by the author and colleagues of 102 studies evaluating at-scale programmes in the field of implementation science found that 75 (74%) studies evaluated programme delivery, whereas only 27 (26%) studies evaluated programme outcomes (Bunde et al., 2019). This may be because the focus on quality activities has been on minimizing drift and dilution (voltage drop) by ensuring that programmes are delivered as planned. However, in the absence of outcomes monitoring,
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disappointment and/or delusion may result. The next section considers what and how to measure quality.
Measuring quality As noted earlier, most development in measuring of quality has focussed on implementation quality rather than outcomes. However, as noted in the Implementation Cascade Model (Berkel et al., 2011) and the Drivers triangle (Fixsen et al., 2005), quality implementation is the precursor to successful outcomes. Ensuring that programme implementation is accompanied by establishing quality measurement systems has been associated with larger programme effect sizes, where outcomes have been measured (Durlak and DuPre, 2008; Fixsen et al., 2005). In choosing what to measure in implementation, two forms of quality (or fidelity—that is, adherence to the programme implementation expectations) should be considered: dynamic fidelity, which is adherence to the way it is done (that is, the processes of programme delivery) and structural fidelity, which is adherence to the what you do (that is, programme content) (Daro et al., 2014). In addition to questions of what should be measured and monitored, attention to how it should be measured, using what tools or metrics, is needed. Too often implementation quality monitoring is inhibited by use of metrics that were developed in the context of research, which may be less usable and of limited function benefit once the programme is implemented in real-world settings (Chambers et al., 2013). Glasgow and Riley (2013) have proposed a solution to the implementation quality measurement problem: the development of pragmatic measures that meet the following required criteria: • Meaningful to stakeholders; addressing their priorities in a way they consider meaningful, which is achieved through involving stakeholders in all phases of programme design and implementation • Actionable; can be feasibly used in a busy, real-world setting (easy to administer and interpret) • Low burden to staff and respondents (referring to both time and cost) • Sensitive to ongoing change measured over an infinite period of time Other recommended criteria are that the measures (1) should be broadly applicable, (2) have benchmarks, (3) are unlikely to cause harm, (4) are psychometrically strong and (5) are clearly related to the programme theory or model. Hansen, Fleming and Scheier (2019) agreed that psychometrically strong and pragmatic measures of implementation outcomes are key to quality monitoring, but they also highlighted the importance of assessing effect modifiers that may point toward mechanisms of action to avoid disappointment and/or delusion. They emphasised that participant engagement, not only in programme activities but also in evaluation processes, is a key moderator of programme effectiveness, suggesting a mechanism to enhance engagement in outcome measurement processes should be activated to maximise outcomes. Participant engagement in quality monitoring can be enhanced by identifying and using pragmatic measures that capture participant-reported
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BOX 10.4
Example of comprehensive implementation and outcome measures: the Maternal Early Childhood Sustained Home-visiting (MECSH) programme The MECSH programme extends its codesign processes to include exploration of existing site data systems supported by the MECSH technical assistance team, and seeks to use, and where necessary support, enhancement of routine and administrative Measure Quality measures Uptake, retention, dose, content Parent-reported measures PR experience M PR impact M PR outcome M Outcomes measures Breastfeeding Child development
Quality of the home environment to support child development
data systems to source the data needed for quality monitoring. When systems do not support parent-reported measures, pragmatic online tools are available for parents to use. Below is an example of the quality monitoring data in one MECSH site.
Tool
Data source
Occasions of service
Health service administrative data system
Parent Satisfaction Questionnaire Parent Enablement Index Adapt and Self-Manage
Online survey
Feeding mode at each contact Nurse or health visitorled assessment ASQ-3, ASQ-SE IT HOME-SF
Online survey Online survey Health service administrative data system Health service administrative data system Health service administrative data system
ASQ-3, Ages & Stages Questionnaires, third edition; ASQ-SE, Ages & Stages Questionnaires: social-emotional; IT HomeSF, Infant-Toddler Home Observation Measurement of the Environment - Short Form; M, measures; PR, parent-reported.
experiences, participant-reported impacts and participant-reported outcomes. Quality monitoring using pragmatic measures is further enhanced when the measurement is built into sustainable and user-friendly systems and when the adaptation of the programme includes adaptation of data systems to provide continuous monitoring. Box 10.4 shows an example of routine and pragmatic measures in a home visiting programme. Programme implementation and outcome quality monitoring processes are best achieved when supported by technical assistance both locally, with knowledge of existing local systems and practices, and from programme developers, with knowledge of the implementation processes that achieve the desired outcomes. As noted in the hexagon tool (Blase et al., 2013) (see Figure 10.1), readiness of the programme for replication, including
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the availability of expert and technical assistance, should be a key factor in the programme decision-making processes. Ensuring that the implementing organisations and practitioners have access to—and collaborative engagement with—the programme developer and technical assistance to support implementation and quality monitoring system development and use can be another critical component of quality. In the absence of engagement between developer technical assistance and implementers, risk of the 4 D’s is heightened as local practice drifts or dilutes quality processes.
Sustainability The final stage, and ultimate goal of health programme decision making—translation and implementation—is that the programme is sustainable—that is, institutionalised within the organisation and/or community. As noted throughout this chapter, considerable organisational and human resource investment is needed to undertake the processes necessary to determine effective interventions and establish effective implementation to achieve effective outcomes (Fixsen et al., 2013); such investment is poorly used if the programme implementation does not result in long-term use (Chambers et al., 2013). The National Health Service Institute for Innovation estimate that less than 30% of organisational change survives over time, wasting scarce resources (Ilott et al., 2013). Sustainability starts with the decision-making process by ensuring that the chosen programme is clearly assessed, preferably in structured, collaborative and transparent ways, as fit for purpose and context (Wiltsey Stirman et al., 2012). Chambers et al. (2013, p. 2) further argue that sustainability “integrates the themes of adaptive, contextually sensitive continuous quality improvement (CQI) and a learning healthcare system”. Established and ongoing processes of assessment of the fit between the programme and its organisational and community context, are critical, “where participants can continue to learn and adapt to ever changing circumstances” (Fixsen et al., 2013, p. 216), requiring dynamic systems and rapid learning, including ongoing processes of change management (see earlier text) (Glasgow et al., 2012).
Summary Implementation is a complex process that includes establishing ongoing and sustainable quality improvement processes and quality measurement. Too often implementation processes, particularly quality measurement, are limited to assessing whether the programme is being provided according to the planned or prescribed protocol, without establishing processes to monitor and support the quality of organisational, leadership and competency drivers of the implementation. Also, often missing from implementation strategies is quality measurement of the outcomes, based on the assumption that if ‘effective intervention 3 effective implementation’ is achieved, this will necessarily equal effective outcomes, risking disappointment and/or delusion and potentially impacting the sustainability of the programme. Finally, sustainability of the programme must be the starting goal of the decision making, translation and implementation and guide these processes to ensure that the significant investment needed realises sustained and large-scale community public health outcomes.
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Conclusion This chapter has led the reader through the three sequential processes needed to ensure that community public health programmes achieve the desired outcomes, inspiring an active ‘make it happen approach’. The tools presented are not a definitive list of those that can be used in each stage—decision making, translation and implementation—but are designed to guide the policy maker and practitioner towards the structured and proactive processes needed. Further tools and readings are provided in later text. The strengths, challenges and debates associated with the processes in each stage are presented to encourage a more critical approach, and limit poorly thought through, reactive and researcher- or marketing strategyled processes that can lead to the 4 D’s: drift, dilution, disappointment and delusion, and subsequent wasting of precious community public health financial and human resources.
Discussion Questions • What processes does your organisation use to explore new evidence-based programmes and make decisions about whether the programme is fit for purpose or context? How can the decision-making processes in your organisation be improved? • How are new programmes translated into your organisation? What active strategies can be used to ensure that the translation processes used will achieve the community public health reach and outcomes desired within the needed timeframe? • How comprehensive are the quality monitoring and measurement strategies in your organisation? How can they be improved? • Is there evidence of the 4 D’s—drift, dilution, disappointment and delusion—in the implementation of evidence-based programmes within your organisation? What strategies could be put in place to rectify these?
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Lee, S.J., Altschul, I., Mowbray, C.T., 2008. Using planned adaptation to implement evidence-based programs with new populations. Am. J. Community Psychol. 41 (3-4), 290303. May, C., Finch, T., Mair, F., Ballini, L., Dowrick, C., Eccles, M., et al., 2007. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Serv. Res. 7, 48. Available from: https://doi.org/10.1186/1472-6963-7-148 (accessed 06-04-20). McCannon, J., Rashad Massoud, M., Zier Alyesh, A. (2016). Many ways to many. A brief compendium of networked learning methods. ,https://ssir.org/articles/entry/many_ways_to_many. (accessed 8 October 2019). McNaughton, D.B., 2004. Nurse home visits to maternal-child clients: a review of intervention research. Public. Health Nurs. 21 (3), 207219. McNicholas, C., Lennox, L., Woodcock, T., Bell, D., Reed, J.E., 2019. Evolving quality improvement support strategies to improve Plan-Do-Study-Act cycle fidelity: a retrospective mixed-methods study. BMJ Qual. Saf. 28 (5), 356365. Milat, A.J., Bauman, A., Redman, S., 2015. Narrative review of models and success factors for scaling up public health interventions. Implement. Sci. 10, 113. Available from: https://doi.org/10.1186/s13012-015-0301-6 (accessed 06-04-20). Moore, J.E., Bumbarger, B.K., Cooper, B.R., 2013. Examining adaptations of evidence-based programs in natural contexts. J. Prim. Prev. 34 (3), 147161. Moore, G.F., Evans, R.E., Hawkins, J., Littlecott, H., Melendez-Torres, G.J., Bonell, C., et al., 2019. From complex social interventions to interventions in complex social systems: future directions and unresolved questions for intervention development and evaluation. Evaluation 25 (1), 2345. Olswang, L.B., Prelock, P.A., 2015. Bridging the gap between research and practice: implementation science. J. Speech, Lang, Hear Res. 58 (6), S1818S1826. RE-AIM., 2017. Applying the RE-AIM framework. ,http://re-aim.org/about/applying-the-re-aim-framework/. (accessed 8 October 2019). Saver, R.S., 2011. The new era of comparative effectiveness: will public health end up left behind? J. Law, Med. Ethics 39 (3), 437449. Stirman, S.W., Miller, C.J., Toder, K., Calloway, A., 2013. Development of a framework and coding system for modifications and adaptations of evidence-based interventions. Implement. Sci. 8, 65. Available from: https:// doi.org/10.1186/1748-5908-8-65 (accessed 06-04-20). Wiltsey Stirman, S., Kimberly, J., Cook, N., Calloway, A., Castro, F., Charns, M., 2012. The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implement. Sci. 7 (1), . Available from: https://doi.org/10.1186/1748-5908-7-17 (accessed 06-04-20). Woolf, S.H., 2008. The meaning of translational research and why it matters. J. Am. Med. Assoc. 299 (2), 211213.
Further reading and resources Many Ways to Many The website https://www.billionsinstitute.com/tools2/ (accessed 07-04-20) provides a useful decision-making tool to aid selection of appropriate processes for spreading or scaling-up a programme, intervention or practice. Global Implementation Initiative The Global Implementation Initiative (https://globalimplementation.org/) (accessed 07-04-20) provides several resources that further knowledge and practice of implementation science. Further resources can be accessed through membership in the Global Implementation Society. Quality improvement methods The following websites provide tools, guidance and examples of quality improvement methods that may be useful. Plan Do Study Act https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool2b. html (accessed 07-04-20) Continuous Improvement Tools and Techniques https://leankit.com/learn/kanban/6-continuous-improvement-tools-and-techniques/ (accessed 07-04-20)
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C H A P T E R
11 The economics of prevention in the early years Gabriella Conti KEY ISSUES • Gaps in different dimensions of child development—such as physical, cognitive and socioemotional—arise very early in life and, once they appear, tend to persist and widen over time.
• The cost of failing to intervene through early childhood programmes is high. • Governments bear the burden of the costs associated with crime, low education and labour productivity, social exclusion, and poor physical and mental health, among many others.
• Inequalities are not inevitable. Public or private investments that are intended to prevent or reduce inequalities should focus on the early stages of child development.
Introduction It is now recognised that factors operating since the early phases of life are important determinants of long-term socioeconomic and health outcomes (see Chapter 8; Almond and Currie, 2011; Almond et al., 2018; Conti et al., 2019). Children from low-socioeconomicstatus (SES) households are more likely to receive insufficient early stimulation and to be exposed to adverse social and environmental factors that prevent them from reaching their full developmental potential. As in many other countries, in the United Kingdom (UK), gaps in different dimensions of child development arise very early in life, and once they appear, they tend to persist and widen over time. This chapter explains the importance of child development from the perspective of economics. According to the latest developments in the field, it describes child development as a multidimensional, dynamic and cumulative process that can be improved (through public or
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private investments, by parents or other caregivers) or worsened (by exposure to adverse factors, lack of parental time investments or poor parenting). We focus on centre-based and home visiting programmes that have been implemented in the UK; we also refer to relevant international examples when evidence for the UK is missing. One key message of this chapter is that early (preventive) interventions are cost-effective policy tools, as opposed to late interventions.
Inequalities emerge early Large differences in development between children from more and less advantaged backgrounds emerge early, well before entry into school. The existing evidence supports two important facts. First, gaps in different dimensions of child development, such as physical, cognitive and socioemotional, arise very early in life, and once they appear, they tend to persist and eventually widen over time. Second, these gaps are also widening across generations, in line with the increase in income inequality that is observed worldwide (Corak, 2013). Feinstein (2003) wrote one of the first articles studying inequalities in cognitive ability in the UK. He shows that family background plays a large role in influencing the mobility of children within the distributions of ability at different ages, using data from the British cohort study. Most children of poor backgrounds display very low mobility; most of those who are in the bottom quartile at 22 months of age remain there at age 10. High-SES children show considerably more upward mobility and are more likely to be in the top quartile by age 10, even if they were in the bottom quartile at 22 months. Importantly, he finds no evidence that entry into schooling reverses this pattern. Ermisch (2008) uses the Millenium Cohort Study data to show that much of the difference in child development (at age 3) by parents’ SES can be explained by parents’ actions in terms of educational activities and parenting style. Kelly et al. (2011), using the same data (for ages 3 and 5), also show that much of the gap in child development by household income can be explained by the home learning environment, family routines and psychosocial environment, more so for non-cognitive development than for cognitive development. Along the same lines, Dearden et al. (2011) document substantial differences in cognitive development between children from rich and poor families in the UK at age 3, which widen by the age of 5. These authors find that differences in the home learning environment (as measured by a composite index that includes the frequency of various activities, such as reading to children, library visits, playing with ABCs/letters, teaching numbers/shapes, songs/nursery rhymes, drawing/painting) at age 3 explain a sixth of the gap in cognitive outcomes. The authors also notice that the home environment affects cognition at age 5 by improving cognition at age 3, a finding which highlights the cumulative nature of human capital development and the importance of intervening early to boost this process. Not only do the gaps in early development seem to widen during childhood, but there is also recent evidence that they are widening across generations. Attanasio et al. (2020) find that inequality in socioemotional skills at age 5 has increased between 1975 and 2005/2006 in the UK, especially for boys and in the bottom half of the distribution. The authors show that the gap for both externalizing and internalizing skills between the 90th and the 10th percentiles has increased by approximately half a standard deviation for boys.
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Research has also shown that child development in the early years influences several outcomes across the life course, ranging from education to health and socioeconomic outcomes. Conti et al. (2010) and Conti and Heckman (2010) show, using data from the 1970 British Cohort Study, that factors present before the age of 10 explain on average half of the inequalities by education in health and health behaviours at age 30. In particular, childhood traits developed by early investments, such as self-regulation and physical health, explain a greater proportion of adult health inequalities than do parental conditions such as income or education. Conti and Hansman (2013) show, using data from the 1958 National Child Development Study, that child behavioural development contributes to the education-health gradient to an extent comparable to cognitive development. Joshi et al. (2016) present evidence that social and emotional skills in childhood (as collected in the British Birth Cohort studies) are significant predictors of educational attainment and other adult outcomes. Blanden et al. (2007) further show that childhood development is also a significant determinant of intergenerational mobility, with cognitive ability accounting for 10% and non-cognitive variables accounting for 10% of the persistence of income from fathers to sons.
How economists think about child development Child development is conceived as a dynamic and cumulative process through which children develop a multidimensional set of capabilities—also known as human capital— including cognitive ability, socioemotional skills, personality and physical and mental health, that will allow them to generate economic value. These capabilities develop over time in a possibly non-linear fashion (e.g. growth can be faster in some periods than others), and can be promoted (or hampered) by positive (or negative) investments made by parents or other caregivers (so that the process is not deterministic). Different capabilities can also cross-foster each other (e.g. a healthier child may be better able to learn, so health can foster cognition). Although genetics plays a role in the intergenerational transmission of human capital, the traditional naturenurture distinction is now obsolete, and it is now recognised that genes and environments interact in complex ways in producing it (Heckman & Mosso, 2014). Hence, economists develop models that clarify the inputs in the production of child development, and how modifying them (e.g. through a parenting intervention) would increase child human capital, through a multistage process beginning early in life. A key object in the economics of child development is the production function for human capital (Fig. 11.1). This shows how each dimension of human capital (e.g. cognitive, socioemotional or health) evolves over time, as a function of all the stock of human capital in the previous period (which in part may depreciate. So, for example, cognitive development at time t is also affected by socioemotional development and health at time t 2 1.) and of investments (by parents or other caregivers) of a positive (e.g. time spent playing with the child) or negative nature (e.g. smoking in pregnancy). How do parents choose how much to invest in their children? The study of child development in economics dates back to Becker and Tomes (1979, 1986), who assume that parents are altruistic toward their children and that they make choices to ‘maximize household utility’ (i.e. wellbeing), subject to the production function (described earlier), the budget constraint (i.e. labour and nonlabour income have be to at least equal to the
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Human Capital (time t)
FIGURE 11.1
Human Capital (time t-1) Investment (between time t-1 and t)
Schematic representation of the production function for child development.
cost of the goods bought) and the time allocation constraint (i.e. leisure, work and childrearing time have to be less than or equal to the total time available in the day).a In the simplest model, parents have only one child, childhood lasts for only one period (followed by one period of adulthood, both encompassing several years) and child human capital is unidimensional. In the simple case of perfect information (on the production function—i.e. how to promote child development) and no market imperfections (so that poor parents can borrow money), parents will invest in children’s human capital if the rate of return to human capital is larger than the market return for their savings. Cunha and Heckman (2007) broke new ground in the economics of child development by developing a multiperiod model of human capital formation, where investments occur during different periods of childhood and human capital has multiple dimensions (such as cognitive and socioemotional). In each period, the production of child human capital is a function of human capital in the previous period (the stock which has not depreciated) and the intervening investments. One important aspect that this economic model allows economists to study is deciding the optimal timing for intervening. This is linked to the question of substitutability or complementarity between late and early investments. If they are substitutes, remediation is possible later in life (to a certain extent, depending on the degree of substitutability), but if they are complements, then late investments are more productive if they are preceded by early investment (again depending on the degree of complementarity; in the case of perfect complements, no late investment can make up for the lack of early ones). Although it is possible to examine this question in the data, direct empirical estimates are scarce owing to the difficulties in estimating the parameters of interest. The first study which attempted to do so is Cunha et al. (2010), who report (based on US data) that the degree of substitutability between cognitive skills and investments is relatively high early in life, which means that compensatory investments can be effective in improving cognitive outcomes mostly during early childhood. This is not the case at later stages of development, for which there is less evidence of malleability and substitutability for cognitive skills. This means that, after a certain age, additional investments will be less effective in raising cognition. On the other hand, the authors find that substitutability is roughly constant across stages of childhood in the production of non-cognitive skills. Finally, they show that for most configurations of disadvantage, it is optimal to invest relatively more in the early stages of childhood than in later stages. Figure 11.2 provides a a
In economic jargon, parents ‘maximize a utility function’ that includes their own consumption and the wellbeing of their children, subject to a set of constraints (production, budget and time).
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Determinants of investments: resources (income and prices), information, preferences and beliefs.
Genes
It0
HCt0
PRENATAL
It1
HCt1
BIRTH
HCt2
EARLY CHILDHOOD
HCt3
LATE CHILDHOOD
HCt4
ADULT HOOD
It2 It3
223
FIGURE 11.2 Schematic representation of model of human capital (HC) development across the life cycle.
It4
Socioeconomic outcomes
Health outcomes
It = Investment
schematic representation of the human capital model across the life cycle, which shows how it evolves over time and the interrelationships with investments. In the case of complementarity of investments across different stages, early ones increase the productivity of later ones, so that investing in disadvantaged young children can be both socially fair and economically efficient, whereas later-stage investments in children with lower stocks of skills may not yield as high returns (Heckman & Mosso, 2014). Lee and Seshadri (2019) explicitly incorporate multiple periods in the Becker and Tomes (1986) model and study the importance of borrowing constraints that poor parents face and the relative effectiveness of different government interventions on the persistence of economic status across generations in the United States. They find that the most effective policies at reducing the intergenerational transmission of poverty in the long run are the ones targeted to children from birth to age 5 years. The reason is that small differences early in life generate large differences later in life (and young parents are more likely to be borrowing-constrained). Caucutt and Lochner (2020) build on the work by Cunha et al. (2010) and show that when investments are sufficiently complementary over time, they will move together, so that policies that encourage investments in one period will tend to increase them in other periods as well. They emphasise the importance of life
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cycle borrowing constraints, which reduce investments in children in poor families. Importantly, they show that subsidies (or loans) for higher education alone provide little benefit to families who are financially constrained when the children are young (based on US data). Given the degree of intertemporal complementarity, the inability to make early investments also make later investments unproductive. Government interventions are motivated by equity or efficiency concerns. On the one hand, it is ethically fair for all children to have equal opportunities right from conception. On the other hand, the economic models show clearly the rationale for government interventions in terms of efficiency considerations. Parents may be unable to make the best choices for their children, and invest suboptimally, either because of time or liquidity constraints (e.g. poor parents cannot borrow to send their children to a high-quality childcare) or because of informational constraints (either because they do not know, for example, the quality of the services for children provided, or because they do not know that investing in children matters, or because they do not know how to interact with their children). Understanding the constraints faced by lower-SES parents is crucial in designing effective policies able to relax them, or in general to remediate for the lack of inputs, and to effectively promote child development. In general, the presence of these ‘market failures’ leading to parental suboptimal investment constitutes the rationale for government intervention. Before describing the main interventions in the next section, Table 11.1 describes some key inputs in the production of childhood development at the early stages that have been studied in the economics literature, with a focus on the UK.
Impacts of early interventions Early exposure to unstimulating environments, negative shocks or poor parental investments has detrimental effects on a variety of outcomes across the life course, ranging from SES to physical and mental health (Almond et al., 2018; Conti et al., 2019). Preventive or remediation interventions in the early years of life, which promote children’s development across its various dimensions by supplementing the parental inputs and the home environment, have the potential to reduce the development gaps that arise early on and reduce socioeconomic inequality in the long run. The type of interventions and their potential impacts on early childhood outcomes depend on the underlying factors that are causing poor developmental outcomes in children. This section reviews the main evidence on UK home visiting and centre-based programmes, but it also refers to international evidence from the United States when appropriate. There are several challenges to be overcome in the study of early interventions. The first one is to choose the appropriate method to evaluate them. Economists frequently use randomised controlled trials (RCTs) (or quasi-experimental designs that allow the identification of causal effects) in which they randomly assign some children to participate in a particular early childhood intervention and some children not to participate or act as a control group, to study the treatment effect on the outcomes of interest. In relation to this, the choice of the appropriate control group is key. Elango et al. (2016) argue that researchers should evaluate the effectiveness of a particular early childhood intervention under two scenarios: compared to no treatment at all, and as one more alternative to the set of
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TABLE 11.1
Inputs in the production of early childhood development at different stages
Developmental stage
Input
Investments/shocks and their effects
Mechanism
Reference (Year)
Prenatal
Nutrition
In utero exposure to Ramadan in early pregnancy lowers test scores at age 7 (by 0.050.08 of a standard deviation) for Pakistani and Bangladeshi students.
Effects due to impaired maternal nutrition.
Almond et al. (2015)
England
Prenatal
Influenza
In utero exposure to the Asian influenza pandemic of 1957 worsens cognitive test scores for all children, and negatively affects birth weight and height for the children of smoking mothers.
Effects on cognitive development likely related to inflammation; effects on growth to impaired maternal nutrition.
Kelly (2011)
England
Prenatal
Alcohol Maternal alcohol consumption consumption during pregnancy worsens child academic achievement.
The alcohol effect runs through maternal intake and metabolism.
Von Hinke Kessler Scholder et al. (2014)
England
Prenatal
Smoking and maternal work stoppage before birth
Maternal smoking during Engaging in healthier pregnancy reduces birth behaviours is beneficial to weight and foetal growth, maternal and foetal health. whereas stopping work up to 3 months before birth improves both outcomes.
Del Bono et al. (2012)
UK
Postnatal
Nutrition
Breastfeeding is associated with higher cognitive test scores, by 0.10 of a standard deviation.
Borra, Iacovou & Sevilla (2012)
UK
Postnatal
Pollution
Exposure to the Great Pollutants compromise Smog of London in 1952 in lung development. the first year of life increases the likelihood of childhood asthma (by 19.87 percentage points).
Bharadwaj et al. (2016)
England
Postnatal
Parental investments
Parental investments significantly improve child cognitive and behavioural development at 3 and 5 years of age.
Polyunsaturated fatty acids accumulate in the brain and retina, and may affect cognitive development. Sensory stimuli associated with contact between mother and infant contribute to the development of the nervous system.
Reading to the child, taking Hernandezthe child to the library, Alava and having regular bedtime, Popli (2017) watching less TV improve child development.
Country
UK
Continued
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TABLE 11.1 Inputs in the production of early childhood development at different stages—cont’d Developmental stage Postnatal
Input Parental investments
Investments/shocks and their effects Educational and recreational time inputs have a positive relationship with child cognitive and emotional skill development at ages 3 through 7.
Mechanism Reading to the child, helping with the homework and engaging with the school activities (educational time inputs), and outdoor recreation, indoor games, drawing and singing (recreational time inputs) improve child development.
Reference (Year) Del Bono, Francesconi, Kelly and Sacker (2016)
Country UK
programmes available to parents. Once the efficacy of a certain intervention is established (for example in a small-scale trial or in a local implementation), the next challenge is to replicate successful results at scale. A related challenge is the transferability across countries of programmes which have been developed in contexts with different baseline provision of health and social services. A well-known example of a successful home visiting programme is the Nurse-Family Partnership (NFP, Olds, 2006), which targets first-time mothers, starts prenatally and continues until the child is 2 years old for a maximum of 64 home visits delivered by highly skilled trained nurses, who provide information and support on various dimensions of child and maternal wellbeing. The NFP was designed by David Olds and evaluated in three randomised controlled trials, which have shown consistent improvements across a variety of child and maternal outcomes in repeated follow-ups. The most recent evidence from the Memphis RCT shows improvements in child cognitive skills and reduction in disability at age 18, and lower government welfare expenditures (Kitzman et al., 2019; Olds et al., 2019). The NFP is now delivered at scale in the United States, England, Scotland, Northern Ireland, Norway, Bulgaria, Canada and Australia.b In England the programme was introduced in 2008 as the FNP (Family Nurse Partnership), scaled up, and at the same time evaluated with the Building Blocks RCT. The first trial results (Robling et al., 2016) show that, although the FNP did not have effects on smoking in pregnancy, birth weight, subsequent pregnancy and hospital admissions for the children (the primary outcomes), it significantly improved several secondary outcomes, such as intention to breastfeed, levels of social support, partner relationship quality, general self-efficacy and especially maternally reported child cognitive development (at 24 months only) and language development (at 12, 18 and 24 months).c These results have spurred a significant amount of debate and emphasise the importance of understanding the value added of specific programmes imported from other contexts over and above the usual care. This is particularly important in countries like England, where health visiting is b
For details, see http://nfpinternational.ucdenver.edu/international-program.
c
Follow-up evaluations are ongoing.
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universally provided to all children beginning in the prenatal period. Recent evidence from the Pro Kind programme in Germany (a home visiting programme inspired by the NFP, starting prenatally up to age 2 of the child) also shows limited impacts on physical health but substantial improvements in mental health (also of the mother) and in child cognitive development (Sandner et al., 2017; Sandner et al., 2018). A recent study also shows how the programme worked by improving motherchild interactions (Conti et al., 2020). A more recently developed intervention is the Maternal and Early Childhood Sustained Home-Visiting (MECSH) programme, which consists of 25 scheduled home visits from pregnancy until the child is 2 years old. It has three defining features. First, instead of being a stand-alone programme, it is designed to be delivered within a universal home visiting service, such as the Child and Family Health Nursing service in Australia where it originated, or the British health visiting service. Second, the home visitors work actively towards ‘meshing’ home support with community-based support, helping parents to become connected with local networks and community services (a feature present also in the NFP/FNP). Third, as well as a sound theory of change, the programme has built-in flexibility, so it can be readily adapted to a variety of settings (see Chapter 10 for more detail). The programme was developed and tested in an RCT in Sydney, which showed improvements in some outcomes, such as breastfeeding duration and emotional and verbal responsiveness (measured via the Home Observation for Measurement of the Environment [HOME] Scale) (Kemp et al., 2011). A recent large arms-length (independent) trial has shown more regular bedtimes, increased home safety and improved parenting and home learning environment in the intervention group (Goldfeld et al., 2019). The programme has been implemented at scale across Australia, and it is being piloted in a number of sites in England and the Channel Islands, as well as in South Korea and the state of Vermont in the United States. Another home visit intervention starting prenatally is the Preparing for Life (PFL) programme in Ireland (Doyle, 2019). This programme has a longer duration than the NFP; it continues until the child starts school at age 4 or 5. The PFL incorporates home visiting for 5 years, as well as group-based baby massage in the first year and parent training classes in the second year. Group sessions are important to foster the creation of support networks that are more beneficial to disadvantaged parents who lack that support. A recent evaluation of the PFL shows that the programme shifted the entire distribution of cognitive skills to the right and also improved children’s socioemotional skills, although the effects were mainly concentrated among those most at risk of developing clinical problems. As per the mechanisms involved, parents in the treatment group were found to spend more time interacting with their children and to be more involved in their learning activities. They were also more understanding of their children’s behaviours and less likely to punish them unnecessarily; their houses and routines were more organised and their children spent less time watching television (Doyle, 2019). In addition to the above-mentioned programmes targeted to specific subgroups, in England home visiting is delivered at scale through one of the oldest universal health programmes in the world: health visiting. Health visitors are public health professionals who in England deliver the Healthy Child Programme. Although a formal evaluation of this programme has not been conducted,d evidence from comparable universal programmes d
An evaluation of the impacts of health visiting is ongoing (Conti, 2020).
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implemented at the inception of the welfare state in Scandinavian countries (in particular, Denmark, Norway and Sweden) show their potential in reducing infant mortality, improving health across the life course and preventing premature mortality, in particular from metabolic and cardiovascular diseases (Conti et al., 2019). Figure 11.3 shows a schematic representation, based on the human capital model, of how health visiting could improve child outcomes by improving maternal health and through this maternal investments. We now turn to review the evidence on the main centre-based programmes. Among them, one of the most iconic is the Perry Preschool Project (PPP) in the United States. The PPP is a small-scale randomised trial that targeted 123 disadvantaged, low-IQ African American children aged 3 to 4 years during the 1960s. Heckman et al. (2010) and Conti et al. (2016) show that the PPP significantly enhanced adult outcomes, including better education, employment, earnings and health, and reduced criminal activity. The most recent follow-up (Heckman and Karapakula, 2019) shows that the PPP has positive intragenerational and intergenerational effects that also benefit individuals who did not directly participate in the intervention. Heckman et al. (2013) further show that changes in child personality caused by the intervention are the main mechanism through which the PPP improved adult outcomes, especially crime. Conti et al. (2016) additionally compare possible childhood and adulthood mechanisms, and show that improvements in child development in the early years
Mother Healtht1
Investments t1
Foetal HC
PREGNANCY
Child HCt2
BIRTH
Child HC
POSTNATAL Age 0-2
t1
Health Visiting
Mother Healtht2
Mother Healtht3
Investments t2
Investments t3 t3
Mother Healtht4
Investments t4 Child HC
t4
Mother Healtht5
Investments t5
Child HC
t5
CHILDHOOD Age 2-12
CHILDHOOD Age 12-18
FIGURE 11.3 Schematic representation of the mechanisms through which health visiting can improve child human capital (HC).
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(especially reductions in externalising behaviour at ages 7 to 9), rather than in later SES, are the main drivers of the treatment effects on adult health outcomes. Another flagship, small-scale centre-based intervention in the United States is the Abecedarian (ABC) program, which included 111 low-income children, mostly African American. Treated children received year-round, full-time centre-based care for 5 years, starting in the child’s first year of life. The programme included individualised educational activities, primary health care and provision of nutritious meals. By age 5, the treated children’s IQ scores were 10 points higher than the scores of comparable children who did not participate in the programme (Duncan and Magnuson, 2013). Treated children also earned significantly higher scores on academic tests by age 21, attained significantly more years of education, were more likely to attend a four-year college (Campbell et al., 2002) and were in significantly better health in their mid-30s (Campbell et al., 2014). As found with the PPP, Conti et al. (2016) show for the Abecedarian program that improvements in child development in the early years (especially improvements in task orientation and reduction in body mass index at ages 1 to 2), rather than in later SES, are the main drivers of the treatment effects on adult health outcomes. Another preschool programme that has received much attention in the economics literature is Head Start (HS), which started in the 1960s as part of President Lyndon Johnson’s War on Poverty and is now implemented at scale in the United States. Some early studies estimated the effects of HS by comparing programme participants to their non-participant siblings. Results from this research design showed positive short-term effects on test scores (Currie & Thomas, 1995; Deming 2009) and long-term effects on educational attainment and earnings (Garces, Thomas & Currie, 2002). However, whether one of the siblings is sent to a HS centre is not random; it is the result of parental choice, and as such can be correlated with other factors unobserved to the researchers that can also affect the outcomes of interest. Hence, more recent studies use either the randomised evaluation of HS (the Head Start Impact Study) or quasi-experimental variation in programme assignment to show that HS had positive impacts on test scores (Kline & Walters, 2016), problem behaviour (Carneiro & Ginja, 2014) and health (Ludwig & Miller, 2007; Carneiro & Ginja, 2014). Loosely inspired by HS is the UK programme Sure Start (SS), a major early-years initiative which provides a variety of services to promote the development of children (ranging from child care and parenting classes to public health services and signposting for employment services) into a ‘one-stop shop’ for parents. SS was first introduced as a flagship programme of the New Labour government in 1999 and grew rapidly until 2010; however, since the removal of the funding ring fence in 2011, many centres have been closed or scaled down. A recent evaluation (Cattan et al., 2019) has provided the first causal evidence that SS significantly improved the health of children. In particular, greater access to SS reduced the likelihood of hospitalisation among children of primary school age (by 18% of its baseline level at age 11). At younger ages, a reduction in infection-related hospitalisations plays a large role in driving these effects; at older ages, the biggest impacts are felt in admissions for injuries. Importantly, children in the poorest neighbourhoods benefit more than those in the richest ones from having more access to SS; the impact is equivalent to closing 56% of the gap in the probability of hospitalisation between rich and poor at age 11.e e
A follow-up evaluation to quantify the impacts on other outcomes is ongoing.
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Although spending on SS has been declining since 2010, government expenditure on free childcare has been increasing (Belfield et al., 2018). Blanden et al. (2016) conducted the first evaluation of this policy and found that a 10-percentage point increase in the proportion of 3- to 5-year-olds covered by free entitlement improves cognitive and socioemotional outcomes up to age 5 by 2% of a standard deviation. However, there are no apparent benefits at age 11. Although increased availability of income might have been a mechanism, the positive effects at age 5 seem to be driven by increases in formal childcare use, particularly among lower SES children. However, disadvantaged children do not benefit substantively more from the free entitlement than their more affluent peers, possibly because the new places were created in the private sector, which is subject to less regulation than publicly provided childcare, and so it is of lower quality. In addition to studying each intervention in isolation, another important question is that of the optimal sequence of interventions before compulsory schooling starts, and especially how home visiting and childcare interact in the production of child development. Given the stringent data requirements and the difficulties in developing a robust design, there is very limited evidence to date on this important question. One of the few existing articles is by Rossin-Slater and Wust (2019), who studied the impact of preschool targeted at children from low-income families and examined its interaction with an infant home visiting intervention implemented over the years 19331960 in Denmark. They found lasting benefits of access to preschool on adult educational attainment, earnings and survival beyond age 65, including intergenerational benefits on the education of the children of women exposed to preschool. However, exposure to a nurse home visiting program in infancy reduces the added value of preschool, implying that the programmes serve as partial substitutes. Another important issue is understanding the extent to which early interventions can shield children from adverse shocks. Although the evidence on this aspect is scant for the UK, there is an emerging body of international evidence (Conti et al., 2019). Finally, it is also crucial to study the complementarity or substitutability of interventions before and after the start of formal schooling. Johnson and Jackson (2019) studied how increased access to preschool education complemented increased public spending in K-12 years (the years between kindergarten and the 1st through the 12th grades) in the United States. They found that having a HS centre, coupled with a 10% increase in K-12 spending, increases high school engagement by 14.87 percentage points, completed education by 0.599 years, wages by 17% and reduced adult poverty by 12 percentage points. In the only available evidence to date for the UK, Conti and Heckman (2010) show evidence of both complementarity and substitutability, depending on the dimension of child development considered: postcompulsory education has higher health returns for the children with higher cognitive abilities and worse behavioural development.
Costs and benefits of early interventions Although robustly estimating the causal impacts of early interventions is an important task, quantifying the benefits and assessing them against the cost is critical to support a cost-effective allocation of government resources, and indeed it is being increasingly done.
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Before reviewing the main existing evidence, it is worth pointing out the key issues to tackle when evaluating early childhood interventions. First, the key challenge is the missing data problem arising from the fact that long-term outcomes are not (yet) observed. One common approach is to analyse the effects of the intervention on a short-term outcome (a proxy or “statistical surrogate”), and then use existing evidence or another dataset to estimate the relationship between the short-term outcome observed and the long-term outcome of interest. For example, a child cognitive test could be a short-term outcome for which the impact of a home visiting programme can be directly estimated, and university education could be the long-term outcome. Recent work has developed more sophisticated methods to combine several short-term outcomes and improve the accuracy of this technique. Other possibilities adopted involve building up decision analytic frameworks of varying degrees of complexity, up to rich life course microsimulation models (see, for example, Layard et al., 2014). Other crucial aspects concern (1) converting in money metrics the benefits across a variety of domains, ranging from increased education and wages to averted health care costs and improved quality of life; (2) avoiding double-counting (e.g. in case of an improvement in education and wages, to the extent education mediates part of the treatment effects on wages); and (3) discounting, because most benefits of early programs accrue years after the intervention; to account for this delay, future benefits are discounted to the present.f For concerns about costs, the primary emphasis in the literature is on the costs of providing the interventions, which include the salaries of the individuals (health visitors, childcare workers), any costs of the materials which can vary with the program scale (e.g. a laptop or tablet computer for the home visitors) and fixed costs such as program-related infrastructure. There may also be relevant private costs, such as the financial and time costs that families incur for their children to benefit from the intervention (e.g. to bring the child to the childcare centre). Further cost considerations are involved when considering the outcomes which might be improved—for example, in the case of increased education, one should consider the cost of one additional year of schooling (including the opportunity cost of time). Often the main costs considered are only the costs of implementing the programme. The allocation of public resources should then be based on the present discounted value of benefits relative to that of costs. The current available evidence for the United States suggests high returns to early interventions. Hendren and Sprung-Keyser (2020) conducted a comparative welfare analysis of 133 historical policy changes in the United States and found that investments in the health and education of low-income children provide the highest marginal value of public funds (defined as the ratio of benefits to costs). Heckman et al. (2010) estimated the rate of return to the PPP, accounting for the benefits on education, training, employment, earnings, crime and use of the welfare system. They found that the estimated annual social rates of return fall between 7% and 10%, which are above the historical return to equity of about 5.8%; the benefit/cost ratios are between $6 and $9 for each $1 spent. Garcia et al. (2019) estimated the combined social costs and benefits of two related interventions: the Carolina f
The National Institute for Health and Care Excellence (NICE) recommends using a discount rate of 3.5%. Guide to the methods of technology appraisal, 2013, https://www.nice.org.uk/process/pmg9/resources/ guide-to-the-methods-of-technology-appraisal-2013-pdf-2007975843781
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Abecedarian Project (ABC) and the Carolina Approach to Responsive Education (CARE); both programmes were launched in the 1970s, started in the first weeks of life and lasted until age 5 of the child. The authors find a 13.7% per annum tax-adjusted internal rate of return and a 7.3 tax-adjusted benefit/cost ratio. Favourable estimates of the benefits have also been computed for programs implemented at scale in the United States. Ludwig and Miller (2007) calculated that the impact of HS on wages via schooling (an increase by about 0.5 years per child) is enough to recoup the costs. Deming (2009) estimated that HS participants gain 0.23 standard deviations on a summary index of young adult outcomes, and calculate an internal rate of return of 7.9% (with an average cost of 1 year of the program of about $6000). Klein and Walters (2016) account for the fact that HS draws roughly a third of its participants from competing preschool programmes which also receive public funds, and find a benefit/ cost ratio well above 1 (1.1, with $5513 the marginal benefit net of taxes and $5031 the marginal cost of HS enrolment for 1 year). Wu et al. (2017) used simulation methods to calculate the cost-effectiveness of the NFP, which costs approximately $9600 per family in 2015 dollars. They found that when the program is targeted towards lower-risk clients, it produces a gain in health at a cost of about $15,000 per quality-adjusted life years (QALY) gained, which is cheaper than other health interventions (Medicaid costs about $62,000 per QALY gained), and is under the cost-effectiveness threshold used by the U. S. Food and Drug Administration. Miller (2015) reviewed the evidence to date on the NFP and calculated that the reduction in spending on Medicaid, Temporary Assistance for Needy Families and Supplemental Nutrition Assistance Program (food stamps) alone will amount to $3 billion (present value), against a cost of $1.6 billion. He concludes that the NFP appears to be a sound investment. The most recent follow-up of the Memphis trial (Olds et al., 2019) computes that, over the 18-year follow-up, the nurse-visited women incurred $17,310 less in public benefit costs, against a program cost of $12,578. A more limited set of cost-benefit analysis of early interventions is available for the UK, but the literature has increasingly recognised the importance of adding them to estimates of effectiveness. Three cost-benefit analyses have been conducted for SS to date. Meadows et al. (2011) calculated that the Sure Start Local Programmes (SSLPs) cost approximately d1300 per eligible child per year at 2009-2010 prices. They found that, by the time children had reached the age of 5, SSLPs had already delivered benefits to the public purse valued at between d279 and d557 per eligible child (coming from a reduction in workless households), which is 6% to 12% of the total cost of the programme (a large impact, given the early stage at which it is measured). Gaheer and Paull (2016) collected very detailed cost data on different types of services delivered in 24 of the SS Children Centres that participated in the ECCE (Evaluation of Children’s Centres in England) study: baby health, child play, parent support, specialist child support, specialist family/parent services, childcare, finance and work support, and training and education. The average hourly cost per user (the value of resources used to deliver 1 hour of a service to a child or parent) ranged from d6 for childcare to d55 for finance and work support (in 2014 prices). The mean cost per family using the service (which includes both the hourly cost and the hours of usage) ranged from d958 for parent support to d8454 for childcare. The authors then combined estimates on the associations between the use of different types of children’s centre services and improved family outcomes (from the ECCE impact study) with existing
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evidence from the literature on long-term effects. They found that some services (such as general and specialist parent support) provide benefits to the taxpayer that exceed the cost of delivery. Cattan et al. (2019) quantified the monetary benefits associated with averted hospitalizations—distinguishing averted direct health care costs (extrapolated up to age 18), averted indirect costs (e.g. the cost of parents’ time) and averted lifetime costs (e.g. consequences of brain injuries). They used a measure of cost of SS per eligible child (overall government spending in SS/number of eligible children in areas with a SS centre), which ranges between a minimum d267 in 2014-2015 and a maximum d550 in 2009-2010. They found that total averted costs amounted to d65 million, against total incurred costs of d1055 million. The financial benefits from reducing hospitalisations offset only 6% of the cost of SS provision—a significant amount, given that it is only computed on the basis of the improvements in one outcome.g For the FNP, a cost-utility analysis alongside the Building Blocks trial has found that the probability of FNP being cost-effective is less than 20% given the current NICE willingness to pay a threshold amount of d20,000 per additional QALY. This study computed that the FNP intervention costs on average d1812 more per participant compared with usual care, but it only considered as the primary outcome QALYs, based on the EQ-5D-3L (a widely used instrument to measure health-related quality of life) reported by the mothers. In general, there are few good-quality economic evaluations of home visiting programmes for young vulnerable women, as a recent review has concluded, emphasizing the need for well-designed economic evaluations which follow the appropriate methodological guidelines and also account for the complexities of such interventions (Stamuli et al., 2015). On the other hand, not intervening or intervening late is expensive. Conti et al. (2017) have quantified for the first time the economic costs of child maltreatment in UK in relation to several short-, medium- and long-term outcomes, ranging from physical and mental health problems to labour market outcomes and welfare use. They have estimated that the discounted average lifetime incidence cost of nonfatal child maltreatment by a primary caregiver was d89,390 (with a wide uncertainty interval); the largest contributors to this were costs from social care, short-term health and long-term labour market outcomes. They have also estimated the discounted lifetime cost per death from child maltreatment as d940,758, comprising health care and lost productivity costs. In England and Wales, the cost of late interventions in 2016 was close to d17 billion per year—nearly d300 per person—to remediate the consequences of domestic violence, maltreatment, mental health problems, youth crime and exclusion from education and the labour market (Chowdry and Fitzsimons, 2016). For example, the fiscal cost associated with cases of domestic violence and abuse was d5.2 billion in 2016, whereas the amount spent on benefits for young people who are not in education, employment or training (NEETs) was estimated to be d2.7 billion. Notwithstanding all the previously mentioned evidence, public health is considered a politically soft target for budget cuts, as demonstrated by the recent and repeated major budget reductions experienced in UK (Finch et al., 2018). More than one review has shown that local and national public health interventions are highly cost-saving endeavours (see, g
Work is ongoing to update the impact analysis and the cost-benefit analysis.
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for example, Masters et al., 2017), so it is unlikely that the current allocation of public resources is optimal.
Conclusion This chapter has reviewed the economic approach to child development. Recent evidence shows that gaps in child development arise very early in life and once they appear, they tend to persist and eventually widen over the life cycle. Compensatory investments intended to prevent the formation of these gaps or remedial investments aimed at correcting them should focus on the early stages of development, in line with the existing theoretical and empirical literature in economics which argues that it is more productive to invest in disadvantaged children early in life than to remediate disadvantage later in life. This is also consistent with the high benefit/cost ratios observed in recent economic evaluations of multicomponent early childhood interventions.
Discussion Questions • Consider the features of your service that constitute costs and discuss with colleagues the factors that either increase or reduce costs. • Which local public health programmes have the potential to deliver a return on the investments made? • What contribution can public health practitioners make to achieve returns on investment from the work with individuals, families and communities?
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Gaheer, S., Paull, G., 2016. The Value for Money of Children’s Centre Services: Evaluation of Children’s Centres in England (ECCE) Strand 5. Research brief, Department for Education, London. Garces, E., Thomas, D., Currie, J., 2002. Longer-term effects of Head Start. Am. Econ. Rev. 92 (4), 9991012. Garcia, J.L., Heckman, J.J., Leaf, D.E., Prados, M.J., 2019. Quantifying the life-cycle benefits of an influential early childhood programme. J. Pol. Econ. ,https://doi.org/10.1086/705718. (accessed 20/02/2020). Goldfeld, S., Price, A., Smith, C., Bruce, T., Bryson, H., Mensah, F., et al., 2019. Nurse home visiting for families experiencing adversity: a randomized trial. Pediatrics 143 (1), e20181206; Available from: https://doi.org/10.1542/peds.2018-1206. Heckman, J.J., Karapakula, G., 2019. Intergenerational and intragenerational externalities of the Perry Preschool Project. National Bureau of Economic Research Working Paper 25889 ,https://www.nber.org/papers/ w25889. (accessed 20/02/2020). Heckman, J.J., Moon, S.H., Pinto, R., Savelyev, P.A., Yavitz, A., 2010. The rate of return to the HighScope Perry Preschool Program. J. Public Econ. 94 (12), 114128. Heckman, J.J., Mosso, S., 2014. The economics of human development and social mobility. Annu. Rev. Econ. 6 (1), 689733. Heckman, J.J., Pinto, R., Savelyev, P., 2013. Understanding the mechanisms through which an influential early childhood programme boosted adult outcomes. Am. Econ. Rev. 103 (6), 20522086. Hendren, N., Sprung-Keyser, B., 2020. A Unified Welfare Analysis of Government Policies. Accepted at the Quarterly Journal of Economics. Herna´ndez-Alava, M., Popli, G., 2017. Children’s development and parental input: evidence from the UK millennium cohort study. Demography 54 (2), 485511. Johnson, R.C., Jackson, C.K., 2019. Reducing inequality through dynamic complementarity: Evidence from Head Start and public school spending. Am. Econ. J.: Econ. Pol. 11 (4), 310349. Joshi, H., Nasim, B., Goodman, A., 2016. The measurement of social and emotional skills and their association with academic attainment in British Cohort Studies. In: Khine, M.S., Areepattamannil, S. (Eds.), Non-Cognitive Skills and Factors in Educational Attainment. Contemporary Approaches to Research in Learning Innovations. Sense Publishers, Rotterdam, pp. 239264. Kelly, E., 2011. The scourge of Asian flu in utero exposure to pandemic influenza and the development of a cohort of British children. J. Hum. Res. 46 (4), 669694. Kelly, Y., Sacker, A., Del Bono, E., Francesconi, M., Marmot, M., 2011. What role for the home learning environment and parenting in reducing the socioeconomic gradient in child development? Findings from the Millennium Cohort Study. Arch. Dis. Child. 96 (9), 832837. Kemp, L., Harris, E., McMahon, C., Matthey, S., Vimpani, G., Anderson, T., et al., 2011. Child and family outcomes of a long-term nurse home visitation programme: a randomised controlled trial. Arch. Dis. Child. 96 (6), 533540. Kitzman, H., Olds, D.L., Knudtson, M.D., Cole, R., Anson, E., Smith, J.A., et al., 2019. Prenatal and infancy nurse home visiting and 18-year outcomes of a randomized trial. Pediatrics 146 (6), e20183876; Available from: https://doi.org/10.1542/peds.2018-3876. Kline, P., Walters, C.R., 2016. Evaluating public programs with close substitutes: The case of Head Start. Quart. J. Econ. 131 (4), 17951848. Layard, R., Clark, A.E., Cornaglia, F., Powdthavee, N., Vernoit, J., 2014. What predicts a successful life? A lifecourse model of well-being. Economic J. 124 (580), F720F738. Lee, S.Y., Seshadri, A., 2019. On the intergenerational transmission of economic status. J. Pol. Econ. 127 (2), 855921. Ludwig, J., Miller, D.L., 2007. Does Head Start improve children’s life chances? Evidence from a regression discontinuity design. Quart. J. Econ. 122 (1), 159208. Masters, R., Anwar, E., Collins, B., Cookson, R., Capewell, S., 2017. Return on investment of public health interventions: a systematic review. J. Epidemiol. Community Health 71 (8), 827834. Miller, T.R., 2015. Projected outcomes of nursefamily partnership home visitation during 19962013, USA. Prev. Sci. 16 (6), 765777. National Evaluation of Sure Start Team led by Pam Meadows. Research report DFE-RR073. Department for Education, London. Olds, D.L., 2006. The nursefamily partnership: an evidence-based preventive intervention. Infant. Ment. Health J. 27 (1), 525.
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Olds, D.L., Kitzman, H., Anson, E., Smith, J.A., Knudtson, M.D., Miller, T., et al., 2019. Prenatal and infancy nurse home visiting effects on mothers: 18-year follow-up of a randomized trial. Pediatrics 144 (6), e20183889; Available from: https://doi.org/10.1542/peds.2018-3889. Robling, M., Bekkers, M.J., Bell, K., Butler, C.C., Cannings-John, R., Channon, S., et al., 2016. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet 387 (10014), 146155. Rossin-Slater, M., Wu¨st, M., 2019. What is the added value of preschool for poor children? Long-term and intergenerational impacts and interactions with an infant health intervention. Am. Econ. J.: Appl. Econ. Forthcoming. https://www.aeaweb.org/articles?id510.1257/app.20180698&&from5f (accessed 12/05/2020). Sandner, M., Jungmann, T., 2017. Gender-specific effects of early childhood intervention: evidence from a randomized controlled trial. Labour Econ. 45, 5978. Sandner, M., Cornelissen, T., Jungmann, T., Herrmann, P., 2018. Evaluating the effects of a targeted home visiting program on maternal and child health outcomes. J. Health Econ. 58, 269283. Stamuli, E., Richardson, G., Duffy, S., Robling, M., Hood, K., 2015. Systematic review of the economic evidence on home visitation programmes for vulnerable pregnant women. Brit. Med. Bull. 115 (1), 1944. Stephenson, J., Vogel, C., Hall, J., Hutchinson, J., Mann, S., Duncan, H., et al., 2019. Preconception health in England: a proposal for annual reporting with core metrics. Lancet 393 (10187), 22622271. von Hinke Kessler Scholder, S., Wehby, G.L., Lewis, S., Zuccolo, L., 2014. Alcohol exposure in utero and child academic achievement. Economic J. 124 (576), 634667. Wu, J., Dean, K.S., Rosen, Z., Muennig, P.A., 2017. The cost-effectiveness analysis of nurse-family partnership in the United States. J. Health Care Poor Underserved 28 (4), 15781597.
Further Reading Conti, G., Heckman, J.J., 2013. The economics of child well-being. In: Ben-Arieh, A., Frones, I., Casas, F., Korbin, J.E. (Eds.), Handbook of Child Well-Being. Springer, New York, pp. 363401. Available from: http://ftp.iza.org/ dp6930.pdf (accessed 15/04/2020). Dyakova, M., Ashton, K., Stielke, A., Bellis, M.A., 2019. How to Make the Case for Sustainable Investment in Well-Being and Health Equity: A Practical Guide. Policy and International Health Directorate, Public Health Wales, Cardiff, https://ihcc.publichealthnetwork.cymru/files/7915/6223/7713/WHO_CC_Investment_Guide_ Summary_English.pdf (accessed 12/02/2020). Elango, S., Garcı´a, J.L., Heckman, J.J., Hojman, A., 2005. Early childhood education. In: Moffitt, R.A. (Ed.), Economics of Means-Tested Transfer Programs in the United States, vol. 2. University of Chicago Press, Chicago, pp. 235297. https://www.nber.org/chapters/c13489.pdf (accessed 15/04/2020). Heckman. Why early investment matters. The economics of investment in early life are explained in a series of videos and short downloads on the Heckman: Economics of Human Potential website. https://heckmanequation.org/resource/why-early-investment-matters/ (accessed 10/02/2020). Marshall, L., 2018. Building the Evidence Around the Social and Economic Value of Health [blog]. The Health Foundation. https://www.health.org.uk/blogs/building-the-evidence-around-the-social-and-economic-valueof-health (accessed 10/02/2020). Miller, T.R., 2015. Projected outcomes of nursefamily partnership home visitation during 19962013, USA. Prev. Sci. 16 (6), 765777.
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S E C T I O N
3
Working with individuals and families: human valuing Introduction to Section 3 Section 1 explained how public health practice involves working with people as individuals, as group members, with families and with entire communities. Section 2 focused on a core purpose of public health: the creation of good health. The final section illustrates this purpose as applied to individuals and families, demonstrating the value of all humanity whether through investment in healthy practices—for example, to support good nutrition—or by delivery of actions to protect individuals from harm and disease. A human valuing approach to public health places the person at the centre of service provision, but it also acknowledges the human dimension of those working with families and communities. As highlighted by the World Health Organization Nurturing Care Framework, creating an environment for families to care for each other and raise healthy children who can fulfil their potential requires that care also be extended to those providing services to families. Chapter 12 focuses on the issue of breastfeeding as a healthy start to life. This chapter provides evidence of how valuing a woman’s potential to feed her baby and investing in education and skills for public health practitioners to support breastfeeding yields dividends for babies and families and communities. Investing in breastfeeding is one of several means to safeguard the interests of babies, given that the close and sensitive handling required during breastfeeding will help the infant to develop a secure attachment and the mother to become attuned to her infant’s needs. Chapter 13 considers the broader domain of safeguarding children and the actions necessary to identify and protect children at risk from harm and injury. An important feature of service provision in the United Kingdom is that all children are valued in terms of their right to access health provision, a system feature that is critical if their needs are to be identified and safeguarded. Acting to protect children, families and wider communities from harm caused by infectious diseases is addressed in Chapter 14, where it is shown that value for the health of individuals is inextricably linked to that of the wider community. Here the part played by organisational systems is also established because without good system-level processes, the mass protection of communities would be at risk. Respectful, collegiate working environments provide a positive context for service provision, affecting how information is shared, learnt and communicated across teams,
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disciplines and with families. This impacts on service continuity and can make a difference to the timeliness of interventions to enable children to be protected from risks and harms. Working collegially alongside communities is a theme attended to in Chapter 15, which addresses leadership and ‘micro-public health’ within single caseloads. This concluding chapter provides examples of compassionate leadership, delivered in different ways, through the perspectives of two health visitors who were both highly experienced and permitted the opportunity to practice innovatively to deliver public health goals relevant to local needs. It invites the reader to reflect on how working with individuals and communities in different ways and settings to support health creation can also be valuable to one’s own professional development. By committing to the potential for human growth, practitioners become involved in learning themselves as they support and witness change in others. The use of reflective practice enhances this experience, enabling public health practitioners to become attuned to their own needs, moving their practice forward to the benefit of themselves and the communities they serve. 12. 13. 14. 15.
Breastfeeding for a healthy start. Sally Kendall & Rowena Merritt Safeguarding children: a public health imperative. Jane V. Appleton, Jayne Harrison & Kathy Mumby-Croft Immunisation: ethics, effectiveness, organisation. Helen Bedford Leadership through alongsideness. Robyn Pound & Ruth Grant
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12 Breastfeeding for a healthy start Sally Kendall and Rowena Merritt KEY ISSUES • Breastmilk and breastfeeding as a public health resource.
• Families and partners are important in influencing breastfeeding practices.
• Breastfeeding remains a poorly appreciated activity within the United Kingdom, and the need to support mothers remains high.
• Health visitors working with professional and lay partners have an opportunity to make a real difference to women and infants’ breastfeeding experiences.
Introduction If a new vaccine became available that could prevent one million or more child deaths per year, and that was moreover cheap, safe, administered orally, and required no cold chain, it would become an immediate public health imperative. Breastfeeding can do all of this and more, but it requires its own ‘warm chain’ of support—that is, skilled care for mothers to build their confidence and show them what to do, and protection from harmful practices. If this warm chain has been lost from the culture or it is faulty, then it must be made good by health services. Nelson (1994, p. 1701) The warm chain of human milk from a mother’s breast to a baby, building the baby’s growth and strength, developing their brain, protecting them from infection and disease, signals the awareness of the safety and warmth of the mother, the nourishment of love and the bond between them. From mother to child, from child to adult, the chain stretches like a rabbitproof fence into a far distant future that will keep the growing individual whole in body and mind, secure, contained and able to pass on this precious and complex gift of nature. Breastfeeding is probably one of the most available and easiest ways to promote public health; if every baby were breastfed from birth to 6 months with milk that is free, sterile, warmed to blood temperature and packed with nutrients and immunoglobulins that are
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specific to every motherbaby dyad, we would see rates of obesity, asthma, diabetes, infectious diseases such as gastroenteritis and otitis media, and maternal cancers such as ovarian and breast fall significantly (Victora et al., 2016). Scaling up breastfeeding globally can prevent an estimated 823,000 child deaths and 20,000 breast cancer deaths annually (Victora et al., 2016). The impact on emotional and mental health for both mothers and infants could also be transformative (Britton, 2018). As the Lancet editorial (Nelson, 1994) suggests, if this were a vaccine, we would aim for 100% coverage, and yet in the United Kingdom (UK) in 2020 we struggle to achieve 42% at 6 to 8 weeks after birth (The Lancet series 2016). We have one of the lowest breastfeeding rates in the world, and yet there is so much that could be achieved through public health measures to scale up the breastfeeding environment to support, promote and protect breastfeeding. In this chapter, we aim to present the evidence surrounding the low prevalence of breastfeeding in the UK. This includes the latest evidence that supports the public health benefits of breastfeeding for mothers and babies, and potentially the wider family. We also discuss the cost-effectiveness of interventions that can support breastfeeding mothers and mothers-to-be. We explore the reasons why mothers do not breastfeed from a social and cultural perspective, and consider the ways in which health visitors, and other members of the primary health care team, can support families and communities to value breastfeeding and offer them the care they need to both start and continue to breastfeed. Box 12.1 provides a summary of the issues covered. It is important that we share our core values—that breastfeeding is the most natural way to feed a baby and that babies have a right to human milk. For a small minority of mothers, breastfeeding is not possible (e.g. effects of chronic illness, chemotherapy or a very premature or sick neonate). And for those mothers who do not breastfeed, we have no moral imperative to judge or make them to feel guilty. We want to throw light on the evidence that a breastfeeding-friendly environment would support and enable more mothers, who say they want to breastfeed and more babies to receive human milk. We aim to continue and provoke the debate that the warm chain could well exceed 42% with the political will, resources and education that could support health professionals to support women and families in their infant feeding decisions and ability to breastfeed.
The First 1000 Critical Days Since the second edition of this book in 2008, there has been growth in our knowledge and evidence of the importance of the first 1000 critical days of an infant’s life, from conception to 24 months (Wave Trust, 2013). It is increasingly recognised that (1) it is during this period that a baby’s brain development is critical and (2) the link between neurological development, cognitive function, communication, social and emotional adjustment and physical growth and development is highly related to immediate and future outcomes (Quigley et al., 2012). Breast milk is a vital component of the brain’s development immediately after birth, as it provides the nutritive environment of essential fatty acids and proteins necessary for neural pathways to grow and expand exponentially (Martin et al., 2016). Breastfeeding between mother and infant provides the additional benefit of bonding and attachment that we now begin to understand are not only warm and comforting
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BOX 12.1
Key issues important to understanding breastfeeding as a public health concern • Breastfeeding is one of the most available
• Fathers also have an influence; the more
and cost-effective ways to promote good public health, impacting positively on the health of both child and mother, improving health outcomes in the short and longer term. • United Nation agencies, the World Health Organization and UNICEF advise that a baby should be exclusively breastfed for the first 6 months of life and should continue to receive breast milk to the age of 2 years and beyond. Despite these recommendations and the emotional and physical health benefits of breastfeeding, prevalence remains low in the UK when compared globally. • The reasons women do not breastfeed are complex and may be an interaction of physical, social and psychological factors. A few of the most commonly cited reasons include unrealistic expectations; perceived insufficient milk; painful feeding; the desire for more sleep; embarrassment feeding in public; and prioritising immediate family wellbeing.
fathers know about breastfeeding, the more likely they are to support it. However, fathers can also have a negative influence on breastfeeding rates, caused by the father’s desire to be a part of the feeding process. • In the UK, only 1% of women maintain exclusive breastfeeding to 6 months. However, 80% of women stop breastfeeding before they want to. Health visitors have a role in encouraging continued breastfeeding. • Health visitors should have the unique opportunity to be with a mother in pregnancy and the early postnatal period and to use their skills of empathy and communication to support parents, and their knowledge of the practical and anatomical aspects of breastfeeding as well as research evidence to underpin their guidance. Health visitors can also work closely with other health professionals and breastfeeding peer supporters.
feelings but are also essential to neurological development and the future emotional development of the growing child and adult (Britton, 2018; Weaver et al., 2018; Kim, 2019). The mechanism that has been shown to predict this relationship is maternal sensitivity (consistency, promptness and appropriateness) that, together with touch, gaze and breastfeeding, appears to strengthen secure attachment. This contributes to the foundations for future psychological well being discussed in a later section. It is widely argued that babies fed with formula milk tend to be well fed, grow and develop within the normal range and do not have ill health or attachment issues any more than a breastfed baby. This, of course, depends on a wide range of variables that include the maternal profile and her own childhood experiences, as well as the nutrient content of the formula; how the formula is prepared in terms of volume and dilution; the addition of other content such as cereal; the length of time and frequency of feeding compared with breastfeeding; as well as the social support and the physical and cultural environment (access to clean water,
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for example). It is ethically difficult to design studies that control for all these factors and randomly assign babies to either being breastfed or not. Therefore we have to rely on observational studies that can retrospectively or prospectively analyse differences within cohorts over time. We discuss some of these studies in the next sections. Victora et al. (2016) have argued that on the basis on all the global evidence, formula milk cannot substitute for breast milk on either the public health outcomes or economic grounds: There is a widespread misconception that breast milk can be replaced with artificial products without detrimental consequences and that the benefits of breastfeeding only relate to poor countries. Nothing could be further from the truth. The importance of tackling this global issue is greater now than ever before. (Ce´sar Victora, quoted in UNICEF UK 2016a, p. 4)
The incidence and prevalence of breastfeeding in the UK The incidence of breastfeeding can be defined as the percentage of babies who initiate breastfeeding immediately after birth, whereas the prevalence is the percentage of babies who are breastfed at certain time points. Duration is the length of time a baby is breastfed. All categories include expressed breast milk and donor breast milk. This can be complicated by several factors: in relation to incidence, how is a first feeding defined, and who decides that a baby has actually received colostrum or breast milk? In previous UK surveys of infant feeding, this has been self-reported by mothers (McAndrew et al., 2012), and these selfreports are probably the most accurate data available, as mothers will know if they have put the baby to the breast. Even if the first feeding does not provide colostrum, the baby does have the benefit of skin-to-skin contact, and the sucking action will produce oxytocin and stimulate milk production. Other approaches, such as observation of the first feeding by a midwife, might provide more accurate data, but this is time consuming and difficult to rely on in an environment where the maternity workforce is diminished (Royal College of Midwives, 2018). Midwives rarely have time to observe a feeding, although this is more likely where UNICEF Baby Friendly UK standards have been implemented and accredited (Renfrew et al., 2012). Incidence can also be analysed in relation to the prenatal intention to breastfeed, and differences have been observed between mothers’ intentions and actual initiation of breastfeeding (Claesson et al., 2019). A Swedish cohort study of more than 700 women showed that there is a significant relationship amongst nulliparous women between their prenatal intention to breastfeed and their actual initiation and continuation of breastfeeding at 5 months. Prevalence is based on a number of temporal parameters; it can be defined as ‘ever breastfed’—that is, if the baby has ever had a breastfeeding, then this can be included. Prevalence is also observed at time points such as 6 to 8 weeks after birth, 4 months, 6 months, 1 year and 2 years. Within these time points breastfeeding can be exclusive (i.e. breast milk only) or a combination of breast and breast milk substitutes, and in older babies solid foods. It is therefore important to consider all of these factors in thinking about the available data and understanding the breastfeeding rates within a country or local area. The World Health Organisation (WHO, 2017, 2018) advise that a baby should ideally be exclusively breastfed for the first 6 months of life and should continue to receive breast
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milk to the age of 2 years and beyond. Although there is some controversy about the benefits of breastfeeding up to and beyond 2 years, some studies have shown some benefits, such as the study by Victora et al. (2015), which has shown that increased intelligence and educational attainment are positively related to breastfeeding longer than 12 months. There is also some evidence that the composition of human milk has nutritive value when breastfeeding continues into the second year of life (Perrin et al., 2017). Based on the available evidence, this prevalence rate would promote optimal health and wellbeing for both mothers and babies. So how do the UK countries compare with the rest of the world in terms of the incidence and prevalence of breastfeeding? The most recent national survey available is the Infant Feeding Survey from 2010 (McAndrew et al., 2012). The survey was comprehensive and based on large samples of women and babies, but although it had been conducted every 5 years since 1975, providing usefully comparative data over time, the survey was ceased by the Department of Health in 2012. From a public health perspective, the survey was essential because it provided data from all social strata across the UK and all geographies at a range of prevalence points up to 2 years. It could therefore tell us not only overall rates but also where the differences lie across the country and the associations between differences and other factors, such as employment, education and income. These relationships open the debate to how social determinants can affect health inequality, a core element of public health policy and practice. By knowing about differences and understanding the role of social determinants in whether a baby is breastfed or not, practitioners and policy makers can direct their efforts towards the most deprived communities and look for ways to enable and promote breastfeeding for all babies. However, the termination of the Infant Feeding Survey for the UK as a whole means that our most recent internationally comparable data are based on data collected in 2010, which are now outdated and should be regarded with some caution. A summary of the incidence of breastfeeding for the UK from the 2010 survey is shown in Figure 12.1. The graph shows that across the UK there has been a gradual increase in the incidence of breastfeeding since 1995 and 2005, and that this has varied between the
Incidence of breastfeeding (%)
Incidence of breastfeeding by country (1995 to 2010) 100%
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FIGURE 12.1 Incidence of breastfeeding by country (1995 to 2010). From McAndrew et al. Infant feeding survey 2010.
80% 60% 40% 20% 0% England
Wales Scotland
Northern Ireland
United Kingdom
Country Base: All Stage 1 mothers in the UK 2010 (15724), 2005 (12290), 2000 (9492), 1995 (9130)
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four countries, with England having the highest incidence of 83% in 2010 and Northern Ireland the lowest at 64%. The incidence for Wales was 71% and for Scotland 74%. However, although these increases in incidence can be considered encouraging, the prevalence at 1 week dropped to 69% and to 55% at 6 weeks for all of the UK. This figure does not represent exclusive breastfeeding, so the proportions of babies who are being breastfed at 1 week and 6 weeks after birth might also be receiving breast milk substitutes. An important and key message from the Infant Feeding Survey was that there was no change in the prevalence of exclusive breastfeeding at 6 months, which for the UK remained at 1%, indicating that mothers across the UK were not able to follow the WHO guidance on exclusive breastfeeding for reasons that are discussed later. This is one of the lowest exclusive breastfeeding rates in the world. Since the cessation of the UK Infant Feeding Survey there has been no cross-country comparable data collection for breastfeeding or other infant feeding methods. To understand the patterns of infant feeding within and between countries, we now turn to the public health digital platforms that have been developed and evolved to collect data at local authority or health board levels, which are amalgamated at the national level to show both the aggregated breastfeeding rates and the disaggregated figures. These are available at the country level through—for example, Public Health England and Public Health Wales but not at the UK level—whilst Scotland continues to conduct its own Infant Feeding Survey. These data rely on the mandatory upload of data from staff working in public health, such as health visitors, which are then checked and approved by public health analysts in local authorities or public health departments and analysed for local purposes but also available to Public Health nationally for analysis. These data for England can be found at https://fingertips.phe.org.uk/profile/child-health-profiles. It is notable that in England, breastfeeding data are only collected on initiation and at 6 to 8 weeks. So although these are of importance to public health as the variation can be seen between local authorities and compared within England, there are no data on (1) exclusive breastfeeding at 6 months, (2) breastfeeding at 1 and 2 years, and (3) the introduction of solid food. Therefore the data do not show the international comparison with the WHO recommendations. In Wales, data are collected nationally at 10 days, and in Scotland, a national survey continues to be conducted with data points for ‘ever breastfed’ at the first health visitor visit and at 6 to 8 weeks. In Northern Ireland, the data are collected at more time points, including 3 and 6 months. These data make national and international comparison very difficult, although at the country level, decision makers and public health practitioners can observe variation and identify areas of greater need. The most recent broad comparison that can be made is breastfeeding initiation across the UK is based on 2018 figures: England: 74.5% (initiation and 68 weeks) (Public Health England 2019) Wales: 63% (intention to breastfeed) (Public Health Wales, 2018) Scotland: 75% (ever breastfed at first health visitor visit) (NHS Scotland 20172018) Ireland: 53.4% (breastfed at birth) (Public Health Agency Northern Ireland, 2018) As is obvious, these data are not directly comparable within the UK or with other countries. This makes evaluation of any kind of intervention across the UK very difficult, as the
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baselines all vary and are impossible to compare with global data as they emerge from ongoing systematic reviews and new research.
The public health benefits of breastfeeding In 2016, a landmark series of papers were published in the Lancet (Victora et al., 2016; Rollins et al., 2016) that assembled the international evidence on the health and economic benefits of breastfeeding. The Lancet series was hailed as the most comprehensive and methodologically robust analysis of global research on breastfeeding to date, and has been used across the world by policy and practice to promote the benefits of breastfeeding. Importantly, the evidence was taken up in the UK by the UNICEF Baby Friendly Initiative UK call to Action (UNICEF UK, 2016) and by the National Institute of Clinical Excellence (2015) in its guidance. This has now translated to some extent into the NHS Long Term Plan (NHS England, 2019) and has been extensively drawn on in the Becoming Breastfeeding Friendly project that assesses the readiness of a country to scale up its breastfeeding environment (see later text). More recent evidence from further studies has been added (for example, evidence on the effects of breastfeeding on childhood obesity (Rito et al., 2019)), but as yet the synthesis of evidence that formed the Victora et al. (2016) article has not been updated. Evidence synthesis through systematic review provides a more robust evidence base for policy, as the findings from a number of similar highquality studies are pooled and the results are weighted to demonstrate whether there is an unequivocal case for implementing specific actions to achieve particular outcomes. This provides confidence levels ranging between 90% and 98% that the evidence is robust and likely to result in the required outcome, known as the odds ratio. The United Nations (UN, 2016), the UK chief medical officer (Davies, 2013, 2014), National Institute of Clinical Excellence (2010, 2014, 2015) and the Lancet series (Victora et al., 2016) identify that the UK has some of the lowest breastfeeding rates in the world and call on government to promote, protect and enable breastfeeding in all relevant policy areas. The UN also advocates for early life interventions that limit adverse childhood experiences and support self-regulation, as they can boost adult health and thereby generate a return on investment and benefits for society. Scaling up breastfeeding globally can prevent an estimated 823,000 child deaths and 20,000 breast cancer deaths annually (Victora et al., 2016). UK economic analysis shows that if half of the mothers who currently do not breastfeed were to do so for up to 18 months, this would result in incremental benefits of over d31 million across the lifetime of each annual cohort of first-time mothers (Renfrew et al., 2012). Increasing breastfeeding rates to a level compatible with reducing rates of early years obesity by 5% would result in annual health care savings of more than d1.6 million (Renfrew et al., 2012). US economic evidence (Rollins et al., 2016) suggests that a 10% increase in exclusive breastfeeding up to 6 months or continued breastfeeding up to 2 years would result in decreased treatment costs for childhood disorders of at least $7.8 million in the UK. These savings are in addition to an estimated d17 million annual savings in cost of treatment of four acute diseases in infants (Renfrew et al., 2012). In the Lancet studies, the following aspects of maternal and infant health were found to confidently improved by either mixed or exclusive breastfeeding.
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The cost-effectiveness of breastfeeding As noted earlier, there are many benefits of breastfeeding for both children and mothers, making breastfeeding one the most cost-effective preventative public health actions available (Rollins et al., 2016).
Cost benefits to babies and children Breastfeeding has been found to be protective against a number of health conditions in babies and children, although the strength of the evidence varies by health condition. There is strong evidence that breastfeeding reduces incidents of gastrointestinal and lower respiratory tract infections, acute otitis media and necrotising enterocolitis (NEC) in preterm babies (Pokhrel et al., 2015). An extensive review commissioned by UNICEF (Renfrew et al., 2012) estimated that moderate increases in UK breastfeeding rates (if 45% of women exclusively breastfed for 4 months, and if 75% of babies in neonatal units were breastfed at discharge), every year there could be estimated savings of the following: • 3,285 fewer gastrointestinal infectionrelated hospital admissions and 10,637 fewer general practitioner (GP) consultations, with more than d3.6 million saved in treatment costs annually • 5,916 fewer lower respiratory tract infectionrelated hospital admissions and 22,248 fewer GP consultations, with approximately d6.7 million saved in treatment costs annually • 21,045 fewer acute otitis mediarelated GP consultations, with more than d750,000 saved in treatment costs annually • 361 fewer cases of NEC, with more than d6 million saved in treatment costs annually The study calculated that this increase in breastfeeding would result in more than d17 million saved annually by avoiding the costs of treating four acute diseases in infants. Other studies have found similar positive cost savings. A 2016 study which modelled the cost-effectiveness of human milk and breastfeeding in preterm infants in the UK concluded that increased levels of human milk usage and breastfeeding in the neonatal intensive care unit could save the NHS d30.1 million (d583 per infant) over the course of a year from fewer episodes of NEC and sepsis and 190 fewer deaths. The total discounted lifetime savings to the NHS for premature infants born each year from increased levels of human milk consumption in the NICU would be d46.7 million. The analysis estimates that with the introduction of exclusive breastfeeding, there would be 190 fewer deaths due to neonatal infections and 48 fewer deaths due to sudden infant death syndrome annually (Mahon et al., 2016).
Cost benefits for mothers There is less high-quality evidence in relation to the impact of breastfeeding on mothers. This does not mean that there is no association, only that the evidence is currently weaker (Pokhrel, 2018). However, using the available data, if half of the mothers who currently do not breastfeed were to breastfeed for up to 18 months in their lifetime, for each annual UK cohort
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of around 313,000 first-time mothers, it is estimated that there could be 865 fewer breast cancer cases, with cost savings to the health service of more than d21 million. This would result in 512 breast cancerrelated quality-adjusted life years gained, equating to a value of more than d10 million. Overall, this could result in an incremental benefit of more than d31 million over the lifetime of each annual cohort of first-time mothers (Renfrew et al., 2012). Calculating the cost-effectiveness of breastfeeding Breastfeeding provides short-term and long-term health advantages to children and women. However, to realise these gains, financial investment is needed to promote and support breastfeeding. To support Public Health England and Local Authorities in their investment decisions, a series of return-on-investment tools have been developed. The Best Start in Life return-on-investment tool examines the cost-effectiveness of public health interventions aimed at infants and pregnant women (Public Health England, 2018). The tool emphasises the strong case to be made for investment in breastfeeding support, both in terms of cost saving and positive health outcomes. Offering mothers financial incentives to breastfeed There is increasing interest in the role of financial incentives to meet the health needs of children and maternal and newborn health (Glassman et al., 2013; Fiszbein and Schady, 2009; McNamara, 1995). A UK-based study called NOurishing Start for Health (NOSH) gave shopping vouchers worth d40 to mothers five times based on infant age (2 days, 10 days, 6 to 8 weeks, 3 months, 6 months), conditional on the infant receiving any breast milk. The study found that financial incentives may improve breastfeeding rates in areas with low baseline prevalence (Relton et al., 2018).
The Becoming Breastfeeding Friendly Project The Becoming Breastfeeding Friendly (BBF) Project is a global study led by Yale University in the United States (https://publichealth.yale.edu/bfci/bbf/). The aim of the project is to work with countries and to empower them with their policy makers to explore the current status of the breastfeeding environment in a country and how it can be scaled up to promote, support and protect breastfeeding. During 20172019, England, Wales and Scotland have been evaluated through the BBF study process, which has led to a series of recommendations for policy in each country. The recommendations, if fully implemented, could lead to real changes in the breastfeeding environment and long-term improvement in both breastfeeding rates and health outcomes for mothers and babies. The process is based on an assessment of a country using the Breastfeeding Gear Model (Perez-Escamilla et al., 2018) (see Figure 12.2). The model itself was developed based on global evidence and provides a framework for scoring countries against 54 benchmarks related to eight interlocking gears (Perez-Escamilla et al., 2012). The scores for the gears are determined through the work of an expert committee in each country, led by an independent BBF academic lead. This has followed a systematic, globally evidenced process to ensure that the scoring is standardised and reliable across countries and that the expert groups arrive at a consensus in their deliberations towards priority
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FIGURE 12.2 Breastfeeding gear model. Adapted from Pe´rez-Escamilla, et al. (2012). Advocacy Research & Evaluation
Political Will
Coordination Goals and Monitoring
Promotion
Legislation & Policies
Training & Programme Delivery
Funding & Resources
recommendations for a country (Perez-Escamilla et al., 2018). In Britain, the three committees have worked independently because of devolved responsibilities, led by the University of Kent as a collaborative partner with Yale, and overseen by a wider Great Britain Committee (Kendall et al., 2019). The findings for England and Wales have been published (Pe´rez-Escamilla et al., 2018). The recommendations for Scotland can be found on the Scottish Government website and have been summarised in Box 12.2 (https://www.gov. scot/publications/becoming-breastfeeding-friendly-scotland-report/).
BOX 12.2
Summary of recommendations from the Becoming Breastfeeding Friendly Scotland study Recommendation 1: Develop and implement a breastfeeding advocacy and promotion strategy which brings together and builds on activity at local, regional and national levels to build awareness of and
support for breastfeeding at multiple levels from community to government. Recommendation 2: To gain and maintain support from policy officials as well as other influential officials (for example, councils and Continued
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BOX 12.2
Summary of recommendations from the Becoming Breastfeeding Friendly Scotland study—cont’d the relevant Royal Colleges) to collaborate and formalise efforts for legislative change and advocacy for breastfeeding. Recommendation 3: To build on the advances in Scotland’s breastfeeding rates and provision to date by ensuring ongoing and adequate funding is prioritised and protected for breastfeeding activities, coordination and maternity protections through core Scottish government funding structures. Recommendation 4.1: Extend and strengthen the opportunities for promoting best practice in supporting women to breastfeed when returning to the workplace and ensuring a fair deal for women returning to work in Scotland. Recommendation 4.2: Empower women to be aware of their rights regarding breastfeeding in the workplace, employment provisions and in all areas of child care Recommendation 5: Establish a long-term plan of work to strengthen the formula and follow on milk regulations, including full adoption of the International Code of Marketing of Breastmilk Substitutes and subsequent relevant WHO resolutions (the Code) into legislation by strengthening and monitoring Infant Formula and Follow-on Formula (Scotland) Regulations 2007 (Scottish Statutory Instruments, 2007 No. 549) Recommendation 6: There are nationally coordinated, consistent learning outcomes
for all groups who care for mothers and babies, both in service and before registration, in addition to volunteers and lay supporters. These outcomes are based on a competency framework for each group and underpinned by training and mentorship, supervision and monitoring. Together these will ensure consistency for each group and appropriate, quality-assured and standardised provision. Recommendation 7: Women have equitable access to high-quality, evidencebased models of care through sufficient coverage, spread and awareness of audited and registered core, peer and specialist support providers. Well-developed and maintained referral structures are in place to ensure women receive the right information and support where and when they need it. Recommendation 8.1: Continue to collect and publish data on initiation and duration of breastfeeding up to 2 years, which includes exclusive breastfeeding and the initiation of complementary food (solids), in line with international standards. Recommendation 8.2: Establish a mechanism to monitor women’s experiences which is based on a quality improvement agenda and will assess the impact of interventions. Adapted from Scottish Government 2019.
The recommendations are important for health visitors to read and understand, as they provide a strong advocacy tool for breastfeeding. They also provide a platform for prioritisation of funding and commissioning decisions and for further research.
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Why don’t more women breastfeed in the UK? As already discussed, breastfeeding has significant benefits for both the mother and the child, as summarised in Box 12.3, and in the UK breastfeeding is now largely culturally accepted and promoted. However, despite these positive changes and policy initiatives at both a national and international level, breastfeeding rates remain low.
The Mother’s Perspective The reasons women do not breastfeed are complex and may be an interaction of physical, social and psychological factors (Renfrew et al., 2000). A few of the most commonly cited reasons include the following. • Unrealistic expectations. Idealistic images and messaging regarded breastfeeding during the antenatal period may result in women not being prepared for the realities and demands of breastfeeding (Trickey and Newburn, 2014). New mothers sometimes feel they have been given unrealistic expectations and a ‘rose-tinted’ view of breastfeeding by professionals keen to promote the practice. This results in women being unprepared for the physical challenges of early breastfeeding (Fox et al., 2015; Redshaw and Henderson, 2012; Kelleher, 2007) and feelings that formula
BOX 12.3
Summary of benefits of breastfeeding • Infant health: It reduces children’s from a range of illnesses including infections, diarrhoea and vomiting, otitis media, gastroenteritis, diabetes, asthma, heart disease, as well as Sudden Infant Death Syndrome (Cot Death). • Child health: Reduction in childhood obesity (Rito et al., 2019). • Maternal health: It protects mothers from breast and ovarian cancers, heart disease, osteoporosis and obesity (NHS, 2020). • Relationship-building: Breastfeeding strengthens the mother-baby relationship and reduces the risk of post-natal depression (Borra et al., 2015)
• Worldwide benefits: The benefits are seen in both high, middle and low income countries: a study published in The Lancet in 2016 found that increasing breastfeeding rates around the world to near universal levels could prevent 823,000 annual deaths in children younger than five years and 20,000 annual maternal deaths from breast cancer (Victora et al., 2016). • Cost savings: Breastfeeding contributes to significant savings to the NHS and is one the most cost-effective preventative public health actions available (Rollins et al., 2016).
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milk is the ‘easier’ option. This belief that formula offers an easy solution is often more prominent in younger mothers, as they feel using formula milk allows them to share the burden of feeding with other family members (Condon et al., 2013; Lee, 2007). Insufficient milk. Concern that the baby is not receiving sufficient milk is commonly reported as a fear by mothers (Public Health England, 2017). This issue is exacerbated by mothers not being able to tell how much milk their child is drinking from the breast as opposed to from a bottle. Mixed advice given by health care professionals—for example, supplement with formula milk when the baby is not gaining adequate weight (Fox et al., 2015)—can increase this fear. Painful feeding. Some women discontinue breastfeeding early over concerns about difficulty latching and painful nipples (Berridge et al., 2005). A study in 2012 (AhnfeldtMollerup et al., 2012) also found that postpartum infections, including breast infections, prevented women from breastfeeding. Prioritising immediate family wellbeing. We value immediate benefits greater than longerterm ones (Smith and Strand, 2008), which can result in breastfeeding being discontinued early or disregarded as an option altogether when competing goals of immediate family wellbeing take precedence over the long-term health benefits of exclusive breastfeeding (McInnes et al., 2013). The desire for more sleep. It is often assumed that mothers who feed their infants formula can sleep for longer periods because they can share feeding duties with their partner and function better in the daytime as a result. There is also a misconception that infant formula milk helps the baby to be more settled and sleep through the night (Brown and Davie, 2014). Despite several studies, there is still no evidence to indicate any benefit of formula feeding on maternal sleep, either exclusively or in combination with breastfeeding, compared with exclusive breastfeeding (Montgomery-Downs et al., 2010). However, being able to share the feeding duties with others is a motivation for formula feeding (Kent et al., 2006; Casiday et al., 2004). Embarrassment. Anxiousness about breastfeeding in public remains a barrier for some mothers (Public Health England, 2017), despite the UK Equality Act, 2010 making it illegal for anyone to ask a breastfeeding woman to leave a public place (Equality Act, 2010). This issue can be heightened by the attitude that the breast is primarily a sexual object (Pain et al., 2001).
Influence of family members Although social norms overall appear to support breastfeeding, for some households breastfeeding is not the social norm. A long history of UK formula feeding means that many women do not have had firsthand exposure to breastfeeding. No personal experience of watching friends or family members breastfeeding and having fed formula with a previous child are important barriers to women initiating and then continuing breastfeeding; this lack of experience often results in women believing that breastfeeding is too difficult or embarrassing (Brown et al., 2011a,b; Pain et al., 2001; Hoddinott and Pill, 1999). There is also the attitude with some mothers that ‘well, I wasn’t breastfed, and I’m healthy’. This attitude again can affect mothers’ perception of the promoted health benefits of breastfeeding.
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Fathers also have an influence. On a positive note, the more fathers know about breastfeeding, the more likely they are to support it (Ingram and Johnson, 2004; Wolfberg et al., 2004; Pisacane et al., 2005; Tohotoa et al., 2009). However, fathers can also have a negative influence on breastfeeding rates, caused by more emotion-led factors, including the following: • The father’s desire to be a part of the feeding process (Earle, 2000; Rempel and Rempel, 2011) • Fathers feel unprepared and unable to help their partner if they were having issues with breastfeeding, leading to frustration and the suggestion of ‘giving the baby a bottle’ (Merritt et al., 2019) • The desexualisation of the mother as a result of breastfeeding (Pontes et al., 2009; Henderson et al., 2011) • Embarrassment of their partner breastfeeding in public (Freed et al., 1992; Henderson et al., 2011).
Infectious disease Another threat to continued breastfeeding is the occurrence of infectious disease and parental concerns about passing on infection. Disruptions to feeding patterns have a detrimental impact on milk supply, and so mothers need reassurance in how to manage this, as cessation may not prevent pathogen exposure and will likely reduce the benefits gained from maternal antibodies within breastmilk (UNICEF, 2020). On 11 March 2020, WHO officially declared the outbreak of COVID-19 a pandemic. The number of new infectious diseases such as SARs, Swine Flu and Covid-19 has increased by nearly fourfold over the past century (BBC, 2020). WHO state that, even if a mother has COVID-19, she should be encouraged to touch and hold her baby, breastfeed safely with good respiratory hygiene, hold the baby skin-to-skin and share a room with the child, whilst taking precautions, including: • Practicing respiratory hygiene during feeding, including wearing a mask covering mouth and nose. • Washing hands with soap and water for 20 seconds before and after touching the baby. • Routinely cleaning and disinfecting surfaces they have touched (WHO, 2020). A very small number of babies have tested positive for the virus shortly after birth. However, it is unknown if these babies got the virus before or after birth, and currently the virus that causes COVID-19 has not been detected in breastmilk, although the evidence is limited (CDC, 2019).
The ‘Competition’ Breastfeeding faces strong ‘competition’ from the infant formula milk industry which positions formula milk as similar to breast milk by reassuring mothers it is developed based on ‘30 years’ research in breastmilk’ (Aptamil, 2013). This is despite the introduction of the International Code of Marketing Breast-milk Substitutes, published by WHO in
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1981. The UK’s legislation, named ‘The Infant Formula and Follow-on Formula’ regulations, incorporates some but not all of the code into law (UNICEF, 2019). These regulations forbid advertising and promotion of infant formula intended for babies younger than 6 months. However, they do not cover the numerous products for babies older than 6 months. This means that UK mothers are exposed to widespread follow-on formula advertising. Marketing influences people’s purchasing behaviour (Hawkes, 2009) through increasing attention to and the appeal of a product (Chandon and Wansink, 2012; Chandon et al., 2000), although they often operate at a subconscious level to influence consumer choices (Chandon and Wansink, 2012; Dijksterhuis et al., 2005). Infant formula milk companies currently position their brands alongside the responsible and hard-working mother who wants to try to do their best for their child. The companies use aspirational images and messages, empathising with the mother how hard raising a child can be, reassuring them that they are doing a good job and thereby reducing the feeling of guilt. For example, a recent SMA advert in the UK stated, ‘At SMA our follow-up milk is supported by 90 years of advancing baby nutrition and over the years we’ve really got to know mums, so take it from us, you’re doing great’ (SMA, 2013). This is important for new and tired mothers to hear, as struggling with breastfeeding can lead of feelings of failure (Mahon-Daly and Andrews, 2002; Schmied and Lupton, 2001) and guilt (McInnes et al., 2013; Marshall et al., 2007). Therefore, these reassuring messages can reduce the guilt felt. The competition also seeks to reassure mothers that there are little differences between formula and breast milk. The brand Aptamil tell mothers their ‘baby milk’ is inspired by ‘40 years of breastmilk research’ (Aptamil, 2019). With these messages, the companies reassure mothers that their baby milk is as good as, if not better than, breast milk—with the aim of reducing any concerns or guilt associated with choosing to feed formula.
What can health visitors do to support, promote and protect breastfeeding? The challenge for public health and health visitors is to address the persistently low rates of sustained breastfeeding in the UK to improve maternal and child wellbeing, infant nutrition, decrease maternal and child morbidity, improve life chances, reduce health inequality and prevent ill health in both infants and women. In the UK, only 1% of women maintain exclusive breastfeeding to 6 months as recommended by WHO and the UK governments. In the UK, only 34% of babies receive any breast milk at 6 months compared to 49% in the United States and 71% in Norway (Victora et al., 2016; Beake et al., 2012). Eight of 10 women stop breastfeeding before they want to (McAndrew et al., 2012). What can health visitors do to address this challenge? Supporting and enabling breastfeeding is one of the key high-impact areas of the health visitor’s role within the Healthy Child Programme (Department of Health and Social Care and Public Health England, 2018). Faced with these cultural and social challenges, it can feel difficult to support a mother who wants to breastfeed, perhaps when her partner or friends are advising her to stop. Or perhaps the mother is struggling with lack of sleep, pain or depression. For example, many parents believe that babies sleep better with
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formula milk, and that therefore their own sleep will be of better quality. The evidence is showing that breastfed babies do sleep well, but other factors also influence sleep quality (Brown and Harries, 2015). Changes in family structure, social mobility and the employment environment often leave mothers alone, unsupported by the extended family. Without the family or professional help to advise, guide and provide the emotional support needed to initiate or continue to breastfeed, exhausted and sometimes depressed mothers often find it too challenging to sustain breastfeeding (Miller et al., 2007; Entwistle et al., 2010). Health visitors should have the unique opportunity to be with a mother during pregnancy and the early postnatal period and use their skill of empathy and communication to support parents, and their knowledge of the practical, physiological and anatomical aspects of breastfeeding as well as research evidence to underpin their guidance. However, the reduction in the health visiting workforce since Local Authority commissioning was introduced in 2015, and the need to prioritise child protection in an already challenging caseload (Institute of Health Visiting Position Statement, 2019) make the consistency and continuity of the health visitorclient relationship required for one-to-one support of breastfeeding increasingly difficult. Health visitors can also work closely with breastfeeding peer supporters. There is good evidence that women appreciate the support to breastfeed from another mother who can be both a role model and provide emotional and practical support (Trickey and Newburn, 2014). Health visitors will know which mothers are confident breastfeeders in the community and how to use the skill of bringing mothers together through group work, networking and buddying approaches. More widely, as public health practitioners, health visitors can also follow the principles of health visiting: • • • •
The search for health needs The stimulation of an awareness of health needs The influence on policies affecting health The facilitation of health-enhancing activities (Council for Education and Training of Health Visitors, 1977; Cowley and Frost, 2006).
The NHS Long Term Plan (NHS England, 2019; https://www.england.nhs.uk/long-termplan/) commited to commencing the accreditation process for evidence-based infant feeding programmes such as the UNICEF UK Baby Friendly Initiative across maternity settings from 20192020. It can be hoped that the strength of evidence and the impact on mothers and babies would also lead to the initiative being extended to community settings over the next decade. This provides an opportunity for health visitors to draw on the principles to extend and promote good breastfeeding practice. Health visitors can identify and monitor breastfeeding activity in their caseloads, record the data and determine where the need is greatest and extend their support, advocate for families and promote the benefits of breastfeeding, and facilitate breastfeeding through one-to-one and group support. In particular, the principle of influencing the policies affecting health is how health visitors can act collectively and actively campaign at a population level to support, promote and protect breastfeeding and in so doing contribute to the future health of our children and the next generation. Community public health in policy and practice
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Discussion Questions • What conversations can public health practitioners have and with whom to promote awareness of the wider benefits of breastfeeding? • How can the needs of fathers and coparents be supported to create a positive home environment for breastfeeding? • What community partnerships can be developed to create healthy settings that enable women to breastfeed and/or express breast milk without fear of judgement? • What areas of additional education and training can health visitors and school nurses access to enhance their own practice with regard to supporting breastfeeding-friendly communities?
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UNICEF UK, 2016a: Protecting health and saving lives: a call to action , https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2016/04/Call-to-Action-Unicef-UK-Baby-Friendly-Initiative.pdf . (accessed 14/04/2020) UNICEF UK, 2016b. Breastfeeding saves lives and it’s time for action. [Blog]. ,https://www.unicef.org.uk/babyfriendly/baby-friendly-action-on-breastfeeding/. (accessed 14/04/2020). Unicef UK, 2019. Baby Friendly Initiative. Available from , https://www.unicef.org.uk/babyfriendly/ . (accessed 17/06/2019). UNICEF, 2020. Breastfeeding during the COVID-19 pandemic. Tips on keeping your baby healthy and safe. Available from: , https://www.unicef.org/eap/breastfeeding-during-covid-19 . (accessed 20/04/2020). United Nations Convention on the Rights of the Child, 2016. Concluding Observations on the Fifth Periodic Report of the United Kingdom of Great Britain and Northern Ireland. United Nations, Geneva. Victora, C.G., Horta, B.L., De Mola, C.L., Quevedo, L., Pinheiro, R.T., Gigante, D.P., et al., 2015. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: A prospective birth cohort study from Brazil. Lancet Glob. Health 3 (4), e199e205. Victora, C.G., Bahl, R., Barros, A.J.D., Franc¸a, G.V.A., Horton, S., Krasevec, J., et al., 2016. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet 387 (10017), 475490. WAVE Trust, Department of Education, 2013. From conception to age 2—the age of opportunity. WAVE Trust, Glasgow. Weaver, J.M., Schofield, T.J., Papp, L.M., 2018. Breastfeeding duration predicts greater maternal sensitivity over the next decade. Developmental Psychol. 54 (2), 220227. Wolfberg, A.J., et al., 2004. Dads as breastfeeding advocates: results from a randomized controlled trial of an educational intervention. Am. J. Obstet. Gynecol. 191 (3), 708712. World Health Organization, 1981. The International Code on the Marketing of Breast Milk Substitutes (with all resolutions). ,https://www.who.int/nutrition/netcode/resolutions/en/. (accessed 01/06/2019). World Health Organization, 2017. Guidelines on Protecting, Promoting and Supporting Breastfeeding in Facilities Providing New Born Services. WHO, Geneva. World Health Organization (WHO), 2018. Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: The revised Baby-Friendly Hospital Initiative. WHO, Geneva. Available from: , https://www.who.int/nutrition/publications/infantfeeding/ bfhi-implementation-2018.pdf . (accessed 14/04/2020). World Health Organisation, 2020. COVID-19 and breastfeeding - Position paper (2020). Available from , http:// www.euro.who.int/en/health-topics/Life-stages/maternal-and-newborn-health/publications/2020/covid-19and-breastfeeding-position-paper-2020 . (accessed 19/04/2020)
Resources and further reading The references to this chapter are up-to-date at the time of writing and can be useful further reading. Other resources including those listed can be found at the URLs provided. The UNICEF UK Baby Friendly Initiative provides evidence on breastfeeding and policy, as well as practical solutions to promoting breastfeeding (https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/breastfeeding-resources/). Public Health England ran a breastfeeding celebration week during June 2019 and many resources and practical ideas can be found on twitter: (https://twitter.com/search?q 5 breastfeeding&src 5 typed_query or https://www.nhs.uk/start4life/ baby/breastfeeding/extra-help-and-support/). NHS Health Scotland provides a range of practical resources (http://www.healthscotland.com/documents/120.aspx). First Steps Nutrition provides information and advice on breastfeeding and all aspects of infant and young child nutrition (https://www.firststepsnutrition.org/eating-well-infants-new-mums).
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C H A P T E R
13 Safeguarding children: a public health imperative Jane V. Appleton, Jayne Harrison and Kathy Mumby-Croft KEY ISSUES • Policy and legislation on safeguarding and promoting children’s welfare. • Safeguarding children incorporates all aspects of work with vulnerable children, children in need and children who are suffering, or at risk of suffering, significant harm. • Safeguarding and promoting children’s welfare includes early help, preventing impairment of children’s health and
development, child protection and contextual safeguarding. • Adopting a public health approach ensures that potentially vulnerable children can be identified early and receive the support and services that they and their families need to maximise the health and wellbeing of the child and potentially to prevent child maltreatment.
Introduction All children and young people have a right to be safeguarded and their welfare promoted. In its broadest sense ‘safeguarding’ encompasses a wide spectrum of activity to enable every child to have the best outcomes (HM Government, 2018). It includes the prevention of impairment of children’s health and development, the maximisation of children’s potential through stimulation, play and education, protection from disease via immunisation, prevention of harm from accidents, through to protection from abuse, neglect and exploitation. The terms ‘early help’, ‘safeguarding’, ‘vulnerable children’, ‘child(ren) in need’ and ‘child protection’ are used throughout the chapter as these reflect terms used in current practice. Identification of child welfare needs, through services that
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are developed from sound public health principles, is of paramount importance for the wellbeing of all children in our society. Themes are developed throughout the chapter to illustrate the public health basis of safeguarding work and its significance to health inequalities and childhood outcomes. These themes are examined within the context of current policy developments and contemporary community public health practice. Policy and the discourse pertaining to child welfare have been altered dramatically over the past four decades. In the 1980s and early 1990s, the concept of ‘protecting children’ came to the fore with much work centred around the child and family. There was a shift in emphasis to one of protection, from the narrower historical one traditionally associated with child abuse. ‘Child protection was not only concerned with protecting children from danger but also protecting the privacy of the family from unwarrantable state interventions’ (Parton, 2006, p. 36), with an emphasis on state agencies increasingly working in partnership with parents and carers. After publication of the Children Act (2004), the discourse shifted again, reflecting changes in law and policy to that of safeguarding and promoting children and young people’s welfare. The focus on safeguarding reflects a much broader focus and, as well as protection, encompasses prevention and an emphasis on all children’s safety, not just those in need and suffering or at risk of harm. In recent years there has been increasing interest in contextual safeguarding as an approach to understanding young people’s experiences of harm beyond their families (Firmin, 2017, 2018; HM Government, 2018).
Safeguarding Children and Public Health Public health interventions are principally societal and not focused solely on the individual. In safeguarding work, adopting a public health approach ensures that potentially vulnerable children can be identified at an early stage and receive the services and support that they and their families need to maximise the health and wellbeing of the child or young person and potentially to prevent child maltreatment. Policy reiterates the need for children’s interests to be viewed as paramount in our society. Internationally, a failure to safeguard children leads to significant public health problems and long-term individual suffering. Prevention should focus at all levels along a continuum of need to enable all children to have the best outcomes.
The world view The World Health Organization (WHO) has emphasised that investment in children’s health should include the prevention of abuse. They highlight the United Nations (UN) (2015) Sustainable Development Goal to ‘end abuse, exploitation, trafficking and all forms of violence against and torture of children’ by 2030 (World Health Organization, UNICEF, World Bank, 2018, p. 25), which was agreed by all UN Member States in 2015 (see Chapter 1 for more information about Sustainable Development Goals). Child maltreatment does not discriminate against gender, age, social class, community or country, which is illustrated by the international interest in this area and the existence of organisations such as the International Society for the Prevention of Child Abuse and Neglect (ISPCAN). This
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international society was founded in 1977 with the aim of ‘prevent[ing] cruelty to children in every nation, in every form. . . [ISPCAN is] committed to increasing public awareness of all forms of violence against children, developing activities to prevent such violence, and promoting the rights of children in all regions of the world’ (ISPCAN, 2019, p. 1). International organisations promoting children’s welfare and supported by world governments such as UNICEF and the WHO accept that child protection issues occur in all cultures and countries across the globe and across all social groups (WHO, UNICEF & World Bank, 2018). A number of initiatives emphasise children’s rights, such as the adoption in many countries of the UN Convention on the Rights of the Child (UN, 1989), which was ratified by the United Kingdom (UK) Government in December 1991. This international treaty has led to the increasing development of child-friendly and child-focused policies at a national level in many countries. Progress towards implementing the UN Convention varies from some countries where children are respected and viewed as an integral part of society to the other extreme where children are left to live on the streets or are exploited in war, as slave labour, through child sexual exploitation and trafficking. Several countries also have laws around mandatory reporting of child maltreatment concerns for health, education and social care professionals (McTavish et al., 2017). Increasing global migration has resulted in greater awareness amongst public health and social care professionals of different forms of child maltreatment, including separated and trafficked children (Rigby, 2011; Eccleston, 2014), modern slavery (HM Government, 2014) and female genital mutilation (HM Government, 2016). The WAVE Trust (Worldwide Alternatives to ViolencE) is an international charity, established in 1996, dedicated to raising public awareness of the root causes of violence and the ways to prevent and reduce violence in society (Hosking and Walsh, 2005). WAVE is particularly concerned with reducing child abuse and neglect because these are the major root sources of teenage and adult violence; they underlie much emotional suffering in adults who may never be violent; and violence and abuse are entirely preventable through implementing known, economically viable, and effective programmes to break the cycle of violence. (Hosking and Walsh, 2005, p. 4) The organisation is now working on its UK-wide 70/30 campaign to reduce adverse childhood experiences (ACEs), including abuse and neglect by at least 70% by 2030 (WAVE Trust, 2019).
Outcomes for children The most important public health aspect of safeguarding is the potentially long-lasting impact of abuse and neglect on a child’s social and emotional development and later health outcomes.
The impact of neglect on brain development There is now a large body of evidence showing that a lack of a positive nurturing environment in early childhood can have a damaging effect on brain development (see, for
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example, the National Scientific Council on the Developing Child, 2012). This lack of nurturing can have an impact on a child even before birth (Buss et al., 2012a,b), and neurological research demonstrates that increased levels of stress hormones in pregnant women can impair the brain development and size of the unborn baby (Charil et al., 2010). Persistent and prolonged periods of unresponsiveness from a primary caregiver during early childhood disrupts the normal stress response systems and impedes the formation of neurological pathways essential to communication in the brain (Perry, 2002). Many negative outcomes are caused by this disruption in brain development, including delayed language development, fine and large motor delays, impulsivity, disorganised attachment, attention deficit problems and hyperactivity. This in turn may lead to difficulties later in life, including long-term mental health and behavioural problems, poor self-esteem and an inability to make and maintain positive social relationships.
Adverse Childhood Experiences Our understanding of the impact of poor early childhood interactions has been further developed through recent work on adverse childhood experiences (ACEs). These are stressful or traumatic events in childhood that have an impact on later health and social wellbeing (Figure 13.1). The concept of ACEs was first described in a research study in the US by Felitti et al. (1998), with the data also being used in a larger-scale study which
Early death
Life Course
Disease, disability, social problems and low productivity Adoption of high risk behaviours and crime Social, emotional and cognitive impairment
Disrupted neurodevelopment and allostatic load
Adverse Childhood Experiences
FIGURE 13.1 Model of adverse childhood experiences impacts across the life course. (Based on the US Centers for Disease Control and Prevention ‘ACE Pyramid’: http://www.cdc.gov/violenceprevention/acestudy.) Diagram is from Bellis et al. (2015) and adapted from Felitti et al. (1998).
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looked at the experiences of over 17,000 adults (Anda et al., 2006). These experiences might include being subjected to physical, emotional or sexual abuse or neglect, or growing up in a household where there is domestic abuse, parental mental illness or drug abuse, or parental separation due to family breakdown or imprisonment. Further research studies have shown that experiencing multiple (at least four) ACEs is associated with increased risks of chronic ill health in later life, such as the development of heart disease, diabetes and cancer (Hughes et al., 2017). Evidence also suggests that children growing up in stressful environments are more likely to underachieve academically, develop antisocial and health harming behaviours, and become involved in crime, either as a victim or perpetrator. Whilst many people in the population may have experienced at least one ACE, research indicates that there is a cumulative effect: the more ACEs experienced, the more significant the impact. In the original American study, compared with an ACE score of 0, having four or more adverse childhood experiences was associated with “a 2- to 4-fold increase in smoking [and] poor self-rated health”, and a “4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt” (Felitti et al., 1998, p. 245). A study by Bellis et al. (2015) for Public Health Wales asked more than 2000 adults about their experiences of ACEs as children and their health and lifestyles as adults. The study found that 47% of adults in Wales had suffered at least one ACE as a child and 14% had suffered four or more. Individuals who had experienced four or more ACEs were 4.4 times more likely to be high-risk drinkers as adults and 4.7 times more likely to have low mental wellbeing compared to adults reporting no ACEs (Ashton et al., 2016; Bellis et al., 2015). Links between ACEs occurring in childhood or adolescence and later poor adult health and social outcomes are also confirmed by a study undertaken in England (Bellis et al., 2014) and a systematic review of research evidence (Hughes et al., 2017). Premature morbidity in adulthood by those who have experienced high ACE scores in childhood is a significant public health risk and the potential costs to wider society need to be considered. The follow-up work to the original American research study estimated that those with six or more ACEs are likely to die up to 20 years earlier on average than those individuals with no ACEs, and are approximately twice as likely to die before the age of 65 years (Brown et al., 2009) There is growing evidence to demonstrate the need for health visitors to be supported to engage with families living in complex circumstances (Bidmead, 2013; Whittaker et al., 2014), and public health professionals certainly consider a parent’s own childhood experiences as part of assessment.
Importance of early intervention and resilience work The evidence linking adverse childhood experiences to poor health outcomes highlights the importance of identifying abuse and neglect at an early point not only to safeguard the child at that moment in time but also to protect their future health, wellbeing and functioning in society. Evidence from practice tells us that in many families where children are experiencing neglect or abuse, the parents themselves had difficult childhoods. Hence a cycle may develop where those who have had poor-quality childhoods with a lack of emotional warmth go on to experience poor mental health, a lack of social skills and have
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difficulty forming positive relationships as adults; these factors impact on their own ability to parent successfully and provide a nurturing, stable environment for their own children. It is important to state that this does not mean that the prospects for all children who have experienced ACEs are poor. We know that some children are able to break away from a cycle of abuse and poor parenting and have successful futures. Very often, the factor that makes a difference is resilience. Resilience has been described by Kapoulitsas and Corcoran (2015, p. 87) as “a person’s capacity to overcome adversities that would otherwise be expected to have negative consequences (Kinman and Grant 2011).” Resilience theory focuses on the processes that promote wellbeing and protect against risk. For children in the general population, resilience is linked to high maternal and child self-esteem, good parental emotional health, adequate social support networks, quality parenting time and good academic performance (Cabaj et al., 2014). Those individuals who have experienced neglect or abuse as children may not have had the necessary parent factors to promote resilience but have still been shown to have developed resilience via other sources, including having a close bond with at least one trusted adult, positive sibling and peer relationships, having hobbies and interests outside the home to boost confidence and self-esteem, and having good relationships within the school environment. Ungar (2013) argues that resilience among children who have experienced maltreatment is the result of multiple factors, including the quality of the services provided to children exposed to chronic adversity. This is encouraging for practitioners working with families, as it indicates that positive work with children to build resilience can enable them to break out of a negative cycle and achieve a brighter future (Marriott et al., 2014). The eminent psychologist Urie Bronfenbrenner was a pioneer in research on the ecology of human development and how early relationships with children impact on their future pathways in life. He stated, “a child needs the enduring, irrational involvement of one or more adults in care of and in joint activity with that child. In short, somebody has to be crazy about that kid” (Bronfenbrenner, 2005, p. 262), and this quote is still widely referenced by child development experts today. For most children this ‘adult’ will, of course, be a parent. For others who are not in this fortunate position, it could be a grandparent, a close family member, a teacher or another professional who takes a genuine interest in that child and makes them feel that they have worth and value.
Intervening early Promoting resilience and reducing risk factors have the best chance of success if help and support are given at an early stage, as soon as problems are identified. Early help “can improve the quality of a child’s home and family life, enable them to perform better at school and support their mental health” (NSPCC Learning, 2019). Research indicates that early help can protect children from harm, improve their long-term outcomes, reduce involvement of child protection services and is more economical (Haynes et al., 2015; NSPCC Learning, 2019). The latest data show that as of March 2018, 53,790 children in England were subject to child protection planning, and of these, 25,820 had neglect as the primary concern, which
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BOX 13.1
Key factors for practitioners to consider when working with child neglect • Maintain a focus on the needs of the child and ensure that the voice of the child is heard within a potentially complex home situation where the parents have wide-ranging needs. • Maintain professional curiosity but do not allow empathy with the parent to detract from an understanding of the impact of their behaviour on the child. • Identify and name neglect early; be clear and transparent with parents about what the concerns are. • Ensure that there is robust communication with other professionals
and a shared understanding of the risks; compiling a joint chronology can support this. • Be clear about the roles and responsibilities of different professionals working with the family. • If a child is not attending health appointments, consider the reasons behind this. Think in terms of the child ‘was not brought’ rather than ‘did not attend’. (See, for example: Powell and Appleton, 2012; Appleton et al., 2016; Nottingham City Safeguarding Children Board, 2017).
is 48% of the total number of plans (Department for Education, 2018a). Many safeguarding children boards and local authorities across the country currently have a focus on neglect, which includes early identification and intervention. Learning from serious case reviews has shown that too often neglect is not identified soon enough; cases are allowed to drift, and children are left in neglectful circumstances for too long (Brandon et al., 2013). See Box 13.1 for key factors for practitioners to consider when working with neglect.
Safeguarding children: policy Key definitions Safeguarding children ‘Safeguarding children’ is an established term, and at its simplest, safeguarding is about ‘keeping children safe from harm, such as illness, abuse or injury’ (Children’s Rights Director, 2004, p. 3). The term was initially referred to in The Children Act (1989) in which a duty was placed on local authorities ‘to safeguard and promote the welfare’ of children in need (Section 17). Across the UK, each country has its own legislative framework for the safeguarding and protection of children. In England, safeguarding and promoting the welfare of children is defined in the multi-agency statutory guidance Working Together to Safeguard Children (HM Government, 2018, pp. 67) as follows: • ‘Protecting children from maltreatment • Preventing impairment of children’s health or development
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• Ensuring that children are growing up in circumstances consistent with the provision of safe and effective care • Taking action to enable all children to have the best outcomes’. It is important to recognise that much safeguarding work occurs before this point. The focus is on assessing need and providing early help and support to children and families as soon as a problem emerges. Defining child abuse and neglect Defining child abuse and neglect can be difficult. The relative nature of the concept is accentuated in Gil’s classic (1975, p. 346) definition: Any act of commission or omission by individuals, institutions or society as a whole, and any conditions resulting from such acts or inaction, which deprive children of equal rights and liberties, and/or interfere with their optimal development, constitute by definition abusive or neglectful acts or conditions. This broad yet complex definition emphasises society’s responsibilities and children’s rights, which are central features of the current safeguarding agenda. A child may be abused or neglected by someone inflicting harm on them ‘or by failing to act to prevent harm’ (HM Government, 2018, p. 103). The WHO uses the terms ‘child maltreatment’ and ‘violence against children’ to define abuse and neglect experienced by children younger than 18 years of age. This organisation highlights that most violence against children and young people ‘involves at least one of six main types of interpersonal violence that tend to occur at different stages in a child’s development’ as illustrated in Figure 13.2 (WHO, 2016, p. 14). In England, the Working Together to Safeguard Children (HM Government, 2018, p. 103) statutory guidance describes abuse as ‘a form of maltreatment of a child’ and outlines that children may be vulnerable to neglect and abuse or exploitation in a number of