Chapter 4
Approaches to Supporting Families
Karen I. Chalmers
The University of Manchester, Manchester, UK
Karen A. Whittaker
University of Central Lancashire, Preston, UK
Introduction
Health visitors are well positioned to contribute to the public health system and improve the health of the nation (DH & Public Health England, 2015). Improving the social determinants of health is critical if health inequalities are to be reduced across social groups (Marmot et al., 2010). The Department for Work and Pensions (DWP) social justice team estimates that the gap in educational attainment for disadvantaged children aged 4 is 9%, and that it escalates throughout childhood (HM Government, 2013). Disadvantages include having no parent in the family in work, living in poverty or overcrowded housing, having no parent with educational qualifications, having a mother with mental health problems, and living in a family with low income. The impact of poverty is seen in the 35-fold increase in the number of people relying on emergency food provided by the UK-wide network of Trussell Trust Foodbanks (Perry et al., 2014). Research funded by the Economic Social Research Council (ESRC) and published by Poverty and Social Exclusion UK (2013) reports that over 3.5 million adults are unable to feed themselves properly and that over half a million children (4%) live in food-insecure households. Worryingly, children who regularly experience hunger are likely to have poorer health and thus increased vulnerability (Ke & Ford-Jones, 2015). Additionally, there is increasing evidence of the impact of the home environment on the neurological development and physical and psychosocial health of infants and young children, and these impacts can have a long-lasting effect on children’s health and development. Building resilience and well being in young children across the social gradient is critical to improving the health of the population (Marmot et al., 2010). Supporting families with young children is seen as an important approach to improving the social determinants of a population. Furthermore, nurse-led home visiting programmes modelled to some extent on UK health visiting are promoted (e.g. by UNICEF, working with Eastern European countries (Whittaker & Bowne, 2014)) as a viable mechanism for improving early child development and thereby later health.
Supporting families to improve health and prevent ill health, particularly families with young children, has been the cornerstone of health visiting practice since the inception of the service. This chapter explores approaches and programmes in which health visitors support families with young children with the goal of improving family health. The specific objectives of the chapter are to:
- Assess some models of intervention in family life and their application to health visiting practice.
- Explore the role of policies influencing health visitors’ work in supporting families.
- Examine programmes to support families with young children.
- Examine the role of the health visitor–client relationship in providing supportive care to young families.
- Reflect on the challenges when planning services for and working with families.
Models of intervention in family life
The ‘family’ is viewed as an important institution in our society, not only for individual welfare but for society as a whole. The family is used as a symbol in all discussions of social life and social welfare, and it is seen as a necessary function of the state that it intervene in family life through the provision of services and benefits and by controlling behaviours through policies and laws (e.g. the use of infant and child car seats). Health visitors are, more than most other health workers, involved in visiting families in their homes, and they provide a unique service by working with families across all social classes and during periods of family transition and crisis. To work with families in this way gives health visitors considerable experience of family life and the tensions which are a normal part of living, placing them in a privileged position to monitor social and economic policies affecting health. Working with individuals and families in this personal and important sphere of their lives is a also a great responsibility. The notion of intervening in family life to assess need is a complex one, and it has within it tensions based on the relationships between the state and the family. On the one hand, the family is seen as being a private and personal unit, especially when there are no children and the dominant values of society are being upheld. On the other hand, due to the importance of the family, particularly in relation to the well being of children, intervention is seen by many as a legitimate action of the state. Governments recognise the need to develop policies on many fronts in order to increase the life chances of children living in poverty, including policies to support child rearing, improve nutrition, and help parents access work (HM Government, 2014a).
The state often first intervenes in the family when a woman becomes pregnant and almost always when the child is born. Pregnancy and childbirth result in the private family being scrutinised by professionals. Doctors often legitimise when a woman is pregnant and decide on the availability of abortion, if that is requested. The medical profession tends also to control contraception, at least in part. Social workers, and more recently health visitors, have a major role in deciding if children are being adequately cared for and when, or if, they should be taken into care, and parents may perceive that they have to ‘measure up’ to professionals’ expectations. The focus on child-rearing skills objectifies parenting as caring labour and hides the fact that it has a gendered status and is largely undertaken by women in the family. Also, it is women who usually find themselves on the interface with social and health services, particularly if they are caring for children or aged or disabled family members (Carers UK, 2014). Of concern is the substantial number of children and young people in England who find themselves in caring roles and the damaging impact this has on education and life chances (The Children’s Society, 2013). Campaigning by charity groups has facilitated increased recognition of the social costs imposed on carers, and increasingly carers’ needs are being identified by governments (e.g. DH, 2014; HM Government, 2014b), although the impacts of this remain to be seen.
Three models relevant to health visiting practice in families with young children
Historically, the focus of health visitors’ work was on families, specifically families with infants and pre-school children. Although individuals, social groups, and ‘the community’ were also cited in health visitor texts and position statements, in practice, the dominant focus was usually children and women in the mothering role. In England, the current service vision introduced by the Health Visitor Implementation Plan 2011–15 (DH, 2011b), updated as The Plan (DH, 2013), reintroduces health visitors’ wider public health roles, although there remains a dominant emphasis on working to support young families.
Articulating the theoretical underpinnings of practice may assist practitioners in clarifying what actually or potentially influences their day-to-day work. This section outlines three models or approaches to health visitors’ work in supporting young families: the child-centred model, the family-centred model and the ecological model. These models have not been generated strictly from empirical research, although there is some research which supports how health visitors work with young families (see later). Rather, they have been synthesised from the health visitor literature.
The child-centred model
This model has been the dominant model of health visiting practice for many years. Within it, the proper focus of services is seen to be the well being of the young child, with other family members – especially fathers – playing secondary roles. Health visitors work primarily with mothers in their homes and clinics, with the goal of promoting the healthy development of children. They have contact at designated times to carry out development assessments (as advocated by the Healthy Child Programme (HCP) (DH, 2009; Public Health England, 2015)), and provide health teaching and support. All families receive the home visiting service; the universality of the service is seen as eliminating the stigma of professionally perceived needs or problems, permitting intervention ‘upstream’ (Marmot et al., 2010: 155) to prevent health and behavioural problems (primary prevention) or to detect these problems early, before they become entrenched (secondary prevention).
Health visitors have no statutory right of access to the home, but negotiate their entry based on the universality of the service (‘everyone receives it’). Because the focus is on the child, the well being of other family members is perceived to be secondary or is minimally considered. There is currently strong research evidence of the importance of prenatal and early childhood development, including neurological development, as a determinant of health and health equalities (Center on the Developing Child at Harvard University, 2010). Interventions to promote healthy child development are critical. While health teaching to parents related to child development remains important, the means to promote healthy child development are also now seen as entailing a wider focus than just the child within the family.
The family-centred model
The family-centred model also recognises the importance of children’s health; however, the means of securing enhanced child health is viewed within a holistic ‘family lens’. This approach has the satisfactory health and functioning of the family as its main aim. It tends to be concerned with resolving difficulties and conflicts within the family and thus improving the overall functioning and well being of the family as a whole, as well as those of its members. The underpinnings of this model are influenced by family theories, primarily family systems theory, but also structural-functioning theory and family development theory (Wright & Leahy, 2013). These theories were developed in social science disciplines and adapted by some applied disciplines, such as clinical psychology and specialty fields within social work. Aspects of them are now taught in nursing and health visiting courses. For example, genograms of families (see Figure 4.1) are used as a pictorial means of viewing the family holistically (McGoldrick et al., 2008), particularly when considering safeguarding practice issues (Calder et al., 2012). To build on information provided by a genogram and so understand parents’ wider personal social networks, an eco-map can be created (Whittaker, 2014). This extended visual map (see Figure 4.2) illustrates community resources and connections within the reach of families. As in the genogram, both the quantity and quality of relationships can be depicted (Feeley & Gottlieb, 2000). Activity 4.1 provides further information about the symbols used, as well as the opportunity to create your own genogram and eco-map. Creating these visuals with a family can be a useful means of highlighting the circumstances surrounding them. Within safeguarding contexts, professional practice has been criticised for concentrating focus on the parents and giving insufficient attention to the circumstances surrounding the child (Munro, 2011). Thus, genograms and eco-maps are included in child protection resource packs, such as that produced on behalf of the Scottish Government (Calder et al., 2012), as tools for detailing the child’s situation and thereby keeping their needs in mind whilst working with adult carers.
Figure 4.1 Family genogram. The dotted lines denote the current family arrangement. The scenario is a mother (separated) living with her current partner and three children: Sarah (from her previous husband), Tom, and Molly. She is expecting her fourth child. Her current partner was previously married and is now divorced with one child, Katie, who lives with her mother. Sarah has a half-brother, Ben, as her father is in a new relationship.
Figure 4.2 Family eco-map of the same family as shown in Figure 4.1.
It is important, though, that theories developed and applied by other disciplines are not ‘imported’ into health visiting without careful consideration of the practice context. These theories may assist health visitors to view families holistically, expand their ‘lens’ of practice from ‘child’ to ‘family’, and direct them to view the influences on the child’s health from a broader perspective.
Ecological model
This model has its origins in Bronfenbrenner’s (1979) ‘person in context’ framework. This is an integrated framework which recognises the interrelationship and interdependence of all aspects and levels in society. For example, the young child can be viewed as nestled within a family, which is viewed within the neighbourhood and community and the larger sociopolitical and cultural environments. The model outlines four distinct levels: the microsystem, mesosystem, exosystem, and macrosystem. Viewing children’s health through this approach acknowledges the various immediate and more distant environments as major impacts on children’s health and development. It also provides additional ‘targets’ for legitimate health visitor interventions. This might involve meeting with extended family members and parents to discuss the child’s health needs (i.e. mesosystem) or developing groups to support young families in the community (i.e. exosystem) or influencing governments to implement child health promotive policies (macrosystem).
This model recognises the transitions of families and communities and helps to provide a means of viewing today’s families within the context of the many influences on their lives. For example, it would direct the health visitor to recognise the diversity of family units (e.g. sole parent, same-sex parents, adoptive families) and assess the strengths, resources, and stressors coming from the different systems which influence individual and family health.
This model also resonates with the Health Visitor Plan for England (DH, 2013) which supports health visitor fulfilment of public health roles with families in the context of their community through building community capacity (BCC) activities. The ecological feature of recognising the person-in-situation is understood as a key feature of health visiting (Cowley et al., 2014), and thus the model is advocated as a promising approach for the health visiting service. However, further research is needed to test directly the utility of the framework in practice (Bryans et al., 2009: 564). Bronfenbrenner’s (1979) ecological model is also one of the theoretical underpinnings of the Family Nurse Partnership (FNP) and Maternal Early Childhood Sustained Home Visiting (MECSH) programmes (see ‘Current Home Visiting Programmes’, later in the chapter).
Application of the models in practice
Although these models are presented separately, there is little empirical evidence that, in actual practice, health visitors in the past or at present function solely within one conceptual perspective. Health visitors’ practice with young families is also influenced by many other factors, such as the numbers of other health visitors in the community and other available resources. One of the most important factors is the policy initiative under which the service is offered. For example, policies might direct health visitors’ service provision to all under-5s or to a targeted group of young children who are deemed to be at particular risk for poor health and development. (The influence of policy on health practice is outlined in more detail in the next section and in Chapter 2.)
Understanding of how practice is actually delivered is gleaned from empirical research. Research studies that gather information through observation and interviews with health visitors and clients are particularly helpful. For example, Cowley et al.’s (2014) narrative review of published literature on health visiting practice identified interventions which may contribute to positive outcomes in families and outlined the ‘conceptual orientation’ underpinning health visitors’ practice, which may contribute to benefits. Across studies, health visiting practice was found to emphasise key principles such as valuing the person, a strengths- and solution-based approach to practice, and viewing the client within his/her wider environment The review also noted that in delivering a service underpinned by these principles, health visitors appear to engage in three core activities when making contact with families: home visiting, relationship formation, and continual needs assessment.
By operating within conceptual models, health visitors place more or less emphasis on particular aspects of their work. For example, in an early study of health visiting practice in the North of England, health visitors were interviewed about aspects of their practice (Chalmers, 1992a). At that time, all health visitors in the study were carrying out universal home visiting to families with children from the early postnatal period to age 5. Although the focus of the study was not directly on how health visitors worked with fathers, this could be seen from the analysis of their descriptions of practice. The particular approach that the health visitors used was influenced by their conceptualisation of men/fathers as important (or not) in promoting the family’s health, including the health of young children, and also by factors in the actual client–health visitor situation which enhanced or restricted their work with the fathers. There was considerable variation in the approach to promoting the health of the children and in involvement with the fathers in these households. Some health visitors, for example, did not appear to conceptualise men as particularly important in their work with the families, but did seek them out (i.e. worked with them) when they assessed the mother to be incompetent in some way in the mothering role. Some health visitors were clearly working from a child-centred model, while others were more family-focused.
In a study on health visiting practice in central Scotland, carried out in 2003–04 (Bryans et al., 2009), the actions of the health visitors in their day-to-day work with families were analysed from an ecological perspective. This study used a mixed-method design, involving audio-recorded interviews with health visitors and clients, observations of health visitor–client interactions during home visits, and a review of documents and workshops with health visitor participants. The findings illustrated considerable work by the health visitors at the micro-, meso-, and exosystem levels. The researchers articulated that Bronfenbrenner’s (1979) framework captured how health visitors worked with individuals and families in a culturally sensitive, person-focused, and context-specific way (Bryans et al., 2009: 571). Thus, research on actual practice can help to uncover what ‘informal’ models may be influencing health visiting practice, regardless of the policies operating at the time.
Policies
As already noted, health visitors’ practice with young families is highly influenced by government policies. Governments attempt to direct social change by various policy instruments, including programmes to benefit specific groups, such as children. It is governments which develop, implement, revise, and retire polices. In addition, other nongovernmental organisations, such as professional associations, unions, and voluntary associations, attempt to influence government policies by lobbying, making presentations at government committee meetings, and producing position statements or other reports on topics of interest to their agendas.
Health visiting is increasingly seen at the forefront of government plans to deal with health inequalities and improve public health (Department of Health, Social Services and Public Safety (Northern Ireland), 2010; NHS Scotland, 2011; Public Health England, 2015). Several government policies over the past few decades have been directed at supporting families and improving children’s health. A notable early publication was Supporting Families by the Home Office (1998), which introduced the Sure Start programme.
The Green Paper, Every Child Matters (HM Government, 2003), proposed the development of a national Common Assessment Framework (CAF) (see Chapter 5), which is now widely used across England (Collins & McCray, 2012). Research examining its impact indicates that the CAF is a useful means of assessing families’ needs and delivering services. Parents and carers generally report satisfaction with the CAF related to support in assessing their needs and emphasise the importance of the lead professional (Holmes et al., 2012).
The Every Child Matters report was followed by the National Service Framework for Children, Young People and Maternity Services report (DH, 2004) and set out the framework for delivering requirements of the Children Act 2004. An outcome of this report was the initiation of the Child Health Promotion Programme (DH, 2008), now the HCP (DH, 2009), aimed at providing preventative services tailored to the individual needs of children and families. Of note is that a body of research evidence was also published to support the HCP (Barlow et al., 2008), which has since been updated and published by Public Health England (2015).
Health visitors are the identified leads for the HCP. Since its publication in 2009, health and social care services have undergone immense change, as political influences have shifted with changing governments. Similarly, in Scotland, the health visitor is the named person for the 0–5 age group and is understood to be the key provider of universal services in the early years as part of the Getting it Right for Every Child (GIRFEC) programme (NHS Scotland, 2011).
In England, the Health Visitor Implementation Plan (DH, 2013) supported an unprecedented expansion in the size of the health visitor workforce to enable comprehensive and targeted delivery of the HCP, and set out a new model for service delivery. Described as the ‘family offer’ (DH, 2011a), this model informed – by principles of proportionate universalism (Marmot et al., 2010) – ensures universal provision to all parents, with additional, targeted help for those with more complex needs.
Health visiting services in England are now based on the Health Visitor Implementation Plan ‘family offer’ (DH, 2013) and are detailed in the NHS England (2014) health visiting service specification as operating on four levels: the community, universal, universal plus, and universal partnership plus. The community level recognises the importance of strengthening the community and ensuring the availability of community resources. The universal level includes services available to all families with young children, such as breastfeeding guidance, health and development assessments for infants and children, support for parents, and access to a range of community services/resources. Universal plus level services provide additional support and a rapid response when specific expert help is needed (e.g. to assist with postnatal depression, a sleepless baby, or weaning, or to answer any concerns about parenting). Universal partnership plus is designed for families that need support from a range of services working together to deal with complex issues over time (e.g. services from Sure Start children’s centres, other community services (including charities), and, where appropriate, the FNP programme (NHS England, 2014)). By ensuring a range of services based on need and connections with community capacity, the England service model takes a public health approach to improving the health of young families.
The transformed health visiting service that has resulted now includes mandated times at which the health visitor will have contact with families during the child’s early years. These are the antenatal visit, the new birth visit, 6–8 weeks, 12 months, and 2 to 2.5 years (DH & Public Health England, 2015). The DH (2013) health visiting implementation plan also outlines six high-impact areas (areas of focus for health visitors’ work): transition to parenthood and the early weeks; maternal mental health (perinatal depression); breastfeeding (initiation and duration), healthy weight, healthy nutrition, and physical activity; managing minor illness and reducing hospital attendance and admission; health, well being, and development of the child age 2–2.5 years (integrated review); and support to be ‘ready for school’ (https://www.gov.uk/government/publications/commissioning-of-public-health-services-for-children). These initiatives are sometimes referred to as the 4-5-6 Plan (4 levels, 5 contacts, 6 impact areas). It is important to note that the work emanating from the DH (2013) health visiting implementation plan addresses policies in England only. In Scotland, there have been similar developments, although on a smaller scale, with the Scottish Health Secretary announcing in 2014 that there would be an expansion of the health visitor workforce of 500 people by 2018. It is anticipated that this will support the GIRFEC approach and allow fulfilment of the named-person role for the 0–5 age group, now required following the Children and Young People (Scotland) Act 2014 (Scottish Government, 2014). Other policy initiatives focus on meeting certain health indices for various groups in the population. For example, the policy Reducing Obesity and Healthy Eating (DH & Ellison, 2013) addresses, among other issues, the growing problem of obesity in children: the UK government aims to achieve a sustained downward trend in the levels of excess weight in children by 2020, from the estimated 28% of children between the ages of 2 and 15 who are overweight or obese today. To assist commissioners and practitioners in working towards this goal, Public Health England (2014) has published an electronic Children and Young People’s Health Benchmarking Tool, which provides health outcomes data for different communities, highlighting key statistics that can be used to support discussions and planning, http://fingertips.phe.org.uk/profile/cyphof.
Clearly, from this brief review of current policy documents, the well being of children is an increasing government concern, and health visitors are seen as contributing to the support of families with young children. Regardless of the approach or the programme which directly structures health visitors’ work, health visiting is situated within broader policy, social, and community contexts. These influences may provide additional supports with which to assist families. Whittaker (2014) outlines the influences on and facilities for parenting education and details the multiple sources of support – formal, semi-formal, and informal – which health visitors may draw upon in order to assist families. In the following sections, the evidence for family support programmes is explored.
The contemporary policies influencing health visiting practice remain consistent with the Council of Education and Training of Health Visitors’ (CETHV’s) original principles, which addressed searching for health needs, stimulating an awareness of health needs, influencing policies that affect health needs, and facilitating health-enhancing activities (CETHV, 1977).
Evidence for interventions to support families
Over the years, several home visiting and other child health programmes have been developed to address the needs of families with young children. Most of the interventions are home visiting programmes or group programmes specifically developed for work with young families. Other interventions focus more on an ‘approach’ to practice with parents, rather than a specific programme. For example, the Family Partnership Approach, based on a ‘parent advisor’ model, developed by Davis et al. (2002) and evaluated through a European programme of research (Puura et al., 2005) and a UK randomised controlled trial (RCT) (Barlow et al., 2007a), aims to equip health visitors to invest in strengthening the practitioner–parent relationship using a structured helping process. Training in this approach is used for health visitors working with the MECSH programme (discussed later) and the HENRY childhood obesity preventive programme (Brown et al., 2013). Another example is the Solihull Approach (www.solihullapproachparenting.com), now used widely across the UK. Preparation in the Solihull Approach enables health visitors to work with a model for enhancing parent–child relationships that draws on psychoanalytic, child development, and behaviourist theories. Support for parents can be offered in group and one-to-one situations, helping them learn to understand their child and apply principles of containment, reciprocity, and behaviour management to support emotional development throughout the child’s life (Douglas, 2010). This approach can sensitise health visitors to the importance of promoting emotional well being in infants and children, regardless of the programme focus in their work setting. Although widely adopted, with favourable parent and practitioner feedback, evidence for the outcomes resulting from the Solihuill Approach has only been generated using small-scale evaluations (Douglas & Brennan, 2004; Johnson & Wilson, 2012; Brown, 2014).
These interventions and approaches build on a long tradition of child health services delivered by health visitors (in the UK) and public health nurses (in the USA, Canada, and other countries). With the growing number of well-designed longitudinal studies, there is increasing evidence – primarily from North America – that home visiting programmes contribute to several improved outcomes in mothers and children. Many of these studies have been critiqued and reported in a number of systematic reviews and meta-analyses (e.g. Elkan et al., 2000; Bull et al., 2004; Public Health England, 2015). While the focus of the programmes and the variables used to assess outcomes may vary, all of the studies are designed to gather evidence as to ‘what works’ in supporting young families. From reviews, the evidence suggests that home visiting programmes are associated with improved parenting, improvements in some child behaviours, improved cognitive development (particularly in some subgroups, such as low-birth-weight or premature infants), reductions in accidental child injuries, and improved detection and management of postnatal depression. Other studies have also shown prevention of postnatal depression in women receiving health visitor intervention (Brugha et al., 2011) and short-term improvement in the emotional and behavioural adjustment of young children (Barlow et al., 2010), although longer-term benefits are not known.
A recent extensive review of the literature on health visiting interventions and outcomes by Cowley et al. (2013a) concluded that there was specific benefit for families and children in the prevention, identification, and treatment of postnatal depression and in the provision of parenting support by specialist health visitors or through structured home visiting/early intervention programmes (Cowley et al., 2013a: 20). Christie & Bunting (2011) also showed increased service satisfaction and reduced reliance on emergency care, although these benefits were not found in some groups (e.g. low-risk mothers parenting young infants). The strongest evidence for the benefit of health visitor support to families is found in studies in which health visitors have received additional training and education on the delivery of specific interventions (Puura et al., 2005; Cowley et al., 2013a).
Despite the promising findings from evaluation studies and reviews, the variation in their design, sample characteristics, data collection periods, and many other factors makes it difficult to ‘tease out’ the critical features of the home visiting programme that are contributing to their outcomes. In an earlier meta-analysis of 60 home visiting programmes, no one characteristic was found to be a significant influence across outcomes (Sweet & Applebaum, 2004). However, while programmes and approaches may vary, there are several key elements in most, including the provision of support for parenting, parental education (informal or formal), and the transmission of practical skills.
Characteristics of services and programmes to support families with young children
Programmes and approaches to support young families can vary in many important characteristics. Some questions that need to be considered when examining and evaluating programmes are outlined in Box 4.1. Whilst this list is not exhaustive, it may assist you in thinking about the number of factors which will influence the development, implementation, and evaluation of programmes to support families. Use this list to complete Activity 4.2.
The following sections examine several programmes delivered in the UK and the evidence available to evaluate their outcomes. Similarities and differences in the conceptual underpinnings of programmes are identified, where possible, as are how the programmes were operationalised or put into actual practice. Also outlined are the key elements of the programmes and what variables or criteria were used to evaluate them. Where possible, information is provided on the programmes’ evaluated findings, with additional recommendations for changes or future development.
Early home visiting programmes
First Parent Health Visiting Programme
Home visiting is now recognised globally as an important public health approach for supporting and nurturing care giving practices that buffer the effects of toxic stress and associated threats to infant development (Garner, 2013). The first and major structured home visiting programme in the UK was the Child Development Programme (also called the First Parent Health Visiting Programme), which originated at Bristol University under the leadership of Professor Walter Barker and was supported by the Bernard Van Leer Foundation at The Hague (Barker, 1984; Barker & Anderson, 1988). This was a large-scale programme intervention and evaluation project, which focused on altering the human environment surrounding the child during the earliest years of life and on supporting parents to make positive changes.
The First Parent health visitor visited antenatally and postnatally at monthly intervals (or more frequently, if necessary, in the early months), by appointment. The home visits focused on seven fields of child development: language, social development, cognitive development, pre-school educational development, nutrition, health, and general development. The health visitors’ work was specialised in that they did not engage in other health visiting duties. The programme stressed the importance of working in partnership with parents, recognising their expertise. Health visitors acted as guides rather than authorities on child care, providing help to enable parents to seek their own solutions to child-rearing challenges.
The programme was evaluated during 1986–92 (retrospective data on 2113 families) and 1993–98 (prospective data from 459 families) as part of the National Health Service (NHS) provision (Emond et al., 2002: 150). Evidence of outcomes when children were aged 1 and 2 years was disappointing, indicating few differences between intervention and comparison mothers and children; the only clear outcome was an improvement in breastfeeding rates in the first parent group. However, the programme was delivered simultaneously with universal home visiting to all new infants and children: it was possible that generic health visitors adapted their practice when working alongside First Parent visitors, thereby masking any potential differences between the services.
Despite the evaluation outcomes, this remains a seminal programme on health visiting. The concepts introduced – targeting the disadvantaged child, structured home visiting, an emphasis on positive parenting and parents as experts, respectful relationships between the health visitor and parent, and the importance of support – are the cornerstones of most home visiting programmes which followed.
Community Mothers Programme (CMP)
As part of the development of the First Parent Programme, the concept of a ‘Community Mothers’ Programme (CMP) was developed in Dublin in 1983 in response to limitations in resource provision for high-needs families. Community mothers visit families with first and (sometimes) second children monthly. Women are selected on the basis of being experienced and competent mothers with the ability to empathise with and empower others. The mothers are volunteers, although they are given nominal expenses for each visit. The emphasis is on support, encouragement, and guidance, rather than direct advice. The programme is run in the Republic of Ireland by the Health Service Executive (Molloy, 2008).
Evaluations indicate some successes likely attributable to the CMP. Mothers and children had improved diets, and improvements were seen in children’s receipt of primary immunisations and exposure to play and learning opportunities. Mothers were also reported to have reduced experiences of tiredness and depressive feelings (Johnson et al., 1993). What is more, follow-up research indicated that these child and maternal benefits were sustained 7 years later (Johnson et al., 2000), confirming that nonprofessionals can deliver a health promotion programme on child development effectively.
Modified versions of the CMP were initiated in some other communities in the UK. For example, the Essex-based charity Parents 1st (www.parents1st.org.uk) has developed community parent volunteers, and in Lanarkshire, Scotland there is a CMP specifically to support breastfeeding (www.nhslanarkshire.org.uk). It is also worth noting that the extensive Home Start programme operating across the UK and in other nations (www.home-start.org.uk) works with 16 000 volunteers to provide support in the home for 32 000 families with additional needs. First established in the 1970s in Leicestershire, Home Start has undergone several evaluations, offering mixed evidence for the value of family support provided by volunteers (McAuley et al., 2004; Barnes et al., 2006; Hermanns et al., 2013). Collectively, the evidence suggests that whilst cost-effective outcomes are hard to demonstrate, families perceive personal benefits from volunteer family support, and thus further research is warranted (Hermanns et al., 2013). Whilst there is evidence from other jurisdictions that substituting paraprofessionals for professional public health nurses in home visiting programmes results in less positive outcomes for children (Olds et al., 2007), the role of volunteers as an additional support was not studied. It is evident that the question remains as to the use of replacements for health visitors when families have additional needs.
Current home visiting programmes
Family Nurse Partnership (FNP) Programme
Background
The US Model
The FNP programme (sometimes referred to as the Nurse Family Partnership Programme) is supported by a National Unit commissioned jointly by licence holders the Department of Health and Public Health England. The national unit supports local organisations to implement this model of intensive, nurse-led home visiting for vulnerable, first-time, young parents in the UK. The concept was developed in 1977 by psychologist David Olds, who worked with nurses to test the idea of home visiting with disadvantaged mothers who had at least one of the following risk factors: being a teenager, being unmarried, or being of low socioeconomic status (Olds et al., 1986).
The intent of the programme is to provide support to the new mother as she learns to parent her infant, often in a very stressful environment. The nurses receive extensive training for the role, including in building therapeutic relationships. Nurses work with approximately 25 families during hour-long visits, beginning prior to the 29th week of pregnancy. Visits take place every 2 weeks. The mother’s participation in the programme is voluntary. The focus of the visits is on six domains: personal health, environmental health, friends and family, the maternal role, use of health care and human services, and ‘maternal life course development’ (which encompasses planning for future pregnancies, education, and employment) (Dawley et al., 2007).
Evidence from three large randomised trials carried out with participants in three participating cities in the USA (Elmira, NY, Memphis, TN, and Denver, CO) have shown that the programme provides significant and consistent improvements in the health and well being of the most disadvantaged children and their families in both the short and the long term. Benefits include: improved school readiness; better prenatal health; improvement in women’s antenatal health; fewer subsequent pregnancies; greater interval between births; reductions of between 50 and 70% in child injuries, neglect, and abuse; increases in employment; increases in the father’s involvement; reductions in welfare dependency; and reduced substance use initiation (Kitzman et al., 1997; Olds et al., 1997, 1998, 2007). More recent follow-up of the children, some to the age of 19 years, continues to find physical, emotional, and social benefits, including improved behavioural and language functioning (Olds et al., 2013); reductions in the number of girls entering the criminal justice system (Eckenrode et al., 2010); reduced mortality among mothers; and reduced preventable-cause mortality in first-born children living in highly disadvantaged settings (Olds et al., 2014).
The UK FNP Programme
The FNP programme was introduced in England in September 2006 as part of the government’s Social Exclusion Action Plan (Cabinet Office, n.d.). Initially, it was piloted at 10 sites in England; now there is extensive coverage, with FNP offered in more than 130 local authority areas as of March 2015 (FNP National Unit, 2015a).
FNP nurses (mainly health visitors with additional training, known as ‘family nurses’) visit parents from early pregnancy until the child is 24 months old, building a close, supportive relationship with the whole family and guiding mothers to adopt healthier lifestyles, improve their parenting skills, and become self-sufficient (FNP National Unit, 2015a). Families are referred to the FNP through Midwifery Services and other partner agencies, such as Leaving Care, Teenage Pregnancy Services, and general practitioners (GPs). The enrolment criteria are: age 19 and under at the point of conception; first-time mother; gestation 14–28 weeks; and not newly delivered (i.e. must be pregnant) (FNP National Unit, 2015a).
The programme is voluntary, and each highly trained family nurse works with up to 25 mothers, providing intensive support through home visiting, whilst liaising closely with other community health and local authority services. The family nurses work exclusively on the FNP programme and are all registered with the Nursing and Midwifery Council (NMC). They work in teams of up to eight, led by FNP supervisors.
Characteristics
While the FNP Programme is modelled after the US programme, it has been customised to the UK context. The programme entails weekly or fortnightly structured home visits. It is theoretically driven based on ecological (Bronfenbrenner, 1979), attachment (Bowlby, 1969), and self-efficacy (Bandura, 1977) theories. Ecological theory stresses social context and interactions among individuals and the environments in which they are situated (see earlier). Attachment theory highlights the importance of the mother–infant relationship, while self-efficacy theory focuses on the importance of individuals’ beliefs in achieving and directing behaviours. Self-efficacy in the parent role is encouraged by the strengths-based focus (i.e. focus on the parents’ strengths, not their limitations) (FNP National Unit, 2015b).
The curriculum is specific and detailed, with a plan for the number, timing, and content of the visits. There is ongoing supervision of the practitioner, and detailed records are kept. The core of the programme is the formation of a strong, therapeutic, empathetic relationship with the mother (FNP National Unit, 2015a).
The home visits, delivered during pregnancy, infancy, and toddlerhood, focus on five domains, with specific times allotted to address each one (Ball et al., 2012):
- personal health (35–40%);
- environmental health (5–7%);
- life course development (10–15%);
- maternal role (23–25%);
- family and friends (10–15%).
Evaluation and outcomes
Initial evaluations
The initial evaluation focused on the feasibility of the programme (prenatal and postpartum periods). It was important to know whether the programme, adapted from another jurisdiction (the USA), could be implemented in England; that is, could participants be recruited and retained in the programme and could the home visitors deliver the programme as outlined? The findings indicated that the programme was acceptable to the first-time mothers, as well as the fathers who participated. Participating practitioners valued the programme, although they found the work to be demanding. Some study sites found it challenging to meet recruitment and retention targets, and the number of visits to women was just over half (53%) of the targeted number. The evaluation was helpful in identifying best practice and barriers to working effectively with families, including how to strengthen the delivery of the service (Barnes et al., 2008; Ball et al., 2012).
Two follow-up evaluation studies addressed the implementation of the FNP Programme in 10 pilot sites in England. The first focused on the infancy phase (birth to 12 months; second-year evaluation) (Barnes et al., 2009) and the second on the toddler age group (12–24 months; third-year evaluation) (Barnes et al
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