Chapter 2. Developing programs for the child, young person and family
Gay Edgecombe and Karen McBride-Henry
Learning outcomes
Reading this chapter will help you to:
» understand what constitutes a program
» understand program planning and development
» understand how programs support government health policy
» understand how programs can impact on health outcomes for children, young people and families
» identify the role of key stakeholder groups in program development
» identify the knowledge and skills required for nurses and midwives to engage in program development
» understand program evaluation, and
» appreciate the importance of collaboration between related service systems and the key roles nurses and midwives can play for families by integrating their care.
Introduction
This chapter explores the development of healthcare programs for the child, young person and family, within the context of policy frameworks that guide national health priorities. The World Health Organization (WHO) defines a program as ‘an organised aggregate of activities directed towards the attainment of defined objectives and targets’ (1984a p. 4). These objectives and targets are generally expressed in terms of health policies or strategies established by international organisations, national and state governments, and regional health service providers. Programs are the frontline, or operational, mechanism through which we attempt to implement these policies; therefore, they must address policy aims while at the same time serving the target community.
Nurses and midwives working in the community have many opportunities to become involved in the public policy-making process that may lead to program development, program implementation and ongoing evaluation. The majority of nurses and midwives, however, are involved in translating policy into practice (Hennessy 2000 p. 1). A recent example of the key role nurses and midwives can play was the development of discharge protocols for midwives and maternal and child health nurses to ensure continuity of care for women during antenatal care, childbirth and discharge into a maternal and child health service. This work was carried out in Australia during 2003–04 by a multidisciplinary team of policy makers, maternal and child health nurses and midwives. The protocols were launched in Victoria in 2004 (Department of Human Services 2004 p. 1) and are now being used across the state by public hospitals and the Maternal and Child Health Service.
Many early childhood programs have been developed in New Zealand and Australia over the past decade, reflecting the integral role that successful early childhood policy has played in the development of new programs. See Table 2.1 for examples in both countries. These successes have been supported by evidence-based research (Lumley et al. 2003) and a response to informed community need (Keating & Hertzman 1999). This chapter explores program development as it relates to midwives and nurses working with children, young people and families. It discusses how government health policies set the context in which such programs exist, and presents a range of issues surrounding program planning and implementation, illustrated with examples drawn from the authors’ experience in both Australia and New Zealand.
| Policy | Government or sector level | Program |
|---|---|---|
| New Zealand examples | ||
| Ten steps to successful breastfeeding (World Health Organization & UNICEF 1989) | Ministry of Health New Zealand, 2001a The Ministry of Health New Zealand consulted with key stakeholders and subsequently developed the DHB tool kit: to improve nutrition (2001a) to educate healthcare professionals about the Baby Friendly Hospital Initiative. | Different District Health Boards (DHBs) and small maternity hospitals began to develop strategies and programs to assist them in implementing the Baby Friendly Hospital Initiative. |
| Ottawa charter for health promotion (World Health Organization, 1986World Health Organization 1986) | The Primary health care strategy was created by the Ministry of Health New Zealand (2001b). Its key aims are to provide population-based healthcare and promote the role of the community in health promotion and preventive care. DHBs respond by adjusting organisation visions, and aligning planning and funding with the policy. | A Policy and Guidelines Group in a Child Health Service embrace a philosophy of ‘seamless care’, which emphasises integrated, interdisciplinary collaboration to improve healthcare delivery. This results in a program that crosses traditional tertiary and community healthcare boundaries (see Box 2.3 Practice highlight). |
| Ottawa charter for health promotion (World Health Organization 1986) | In 1999, the new state government of Victoria planned to establish a secondary school nursing program with a strong emphasis on health promotion. | A new secondary school nursing program is implemented in 2000–01. Each school nurse is allocated two state-funded secondary schools. The following program goal illustrates the influence of the Ottawa charter: ‘Goal 1: Play a key role in reducing negative health outcomes and risk-taking behaviours among young people, including drug and alcohol abuse, tobacco smoking, eating disorders, obesity, depression, suicide and injuries’ |
| Building healthy public policy is a goal of the Ottawa charter (look this up on the internet). Such policy is designed to integrate all aspects of the healthcare system providing services for families. | In 2003, the state government of Victoria established a working party to develop protocols for state maternity services and the state’s Maternal and Child Health Service to assist the care of newborn infants and their families by improved discharge processes. | The protocols were published and distributed in 2004 to midwives (employed by midwifery programs) and maternal and child health nurses employed by Maternal and Child Health (MCH) programs. A key principle underlying the protocol is: ‘… enhance continuity of care for recent mothers and their babies from pregnancy through early parenthood, as provided by maternity and MCH services (this aim will be realised through improved care planning supported by effective communication and collaboration)’ |
Setting the scene: a program development scenario
Developing and implementing healthcare programs generally relies on funding from a government agency, which implies that, if a proposed program is to proceed, it must be well supported at the state, regional, local government and/or national level. This is likely to be achieved only if the program is aligned with the priorities set out in current national or state/regional healthcare policy. However, it is important to recognise that effective policy development also requires input and support from frontline staff, which may be achieved, for example, through the participation of nurses and midwives in multidisciplinary teams.
Of course, securing funding is not the end of the story—staff involved in a program will face a range of difficulties before reaching a successful outcome. Currently, one of the most significant of these is the ‘silo’ culture that exists in child, young person and family health services. This refers to the tendency for different sectors, such as primary healthcare, early childhood education and mental healthcare, to provide the community with specialised services without communicating with each other. If you reflect on your current workplace, you will recognise the frustration this creates for the families you are working with, as they negotiate their way through early childhood services. You will be frustrated by not being able to obtain all the information you need from other early years professionals to assist your work with families.
We present a simple scenario describing some of the key players and issues surrounding policy and program development in the context of child, young person and family health, related to healthy eating and obesity. The example presented demonstrates the problems of silo culture and the potential of thinking outside the square of individual departments.
The nurse or midwife
You are attending a monthly community health meeting of all staff in your region who are involved in early childhood care. The speakers are working on a program proposal for the local health department designed to reduce the incidence of childhood obesity. You decide to volunteer because you are very concerned about the number of children in your maternal and health nursing practice who are overweight. A close friend of yours is also interested. She is the school nurse in the local secondary school and has introduced a number of programs in her school designed to reduce obesity and prevent type 2 diabetes. You had not previously considered becoming involved in program development, because you thought such work was only undertaken by managers and policy makers from the health department.
The program proposal team
A multidisciplinary team is working on a program proposal related to childhood obesity, which has been increasing at an alarming rate over the past 10 years. Governments in a number of countries have recognised an urgent need to act. The team lacks sufficient input from frontline clinicians and is pleased that several nurses and midwives are keen to review the draft program proposal and provide feedback.
Program silo: nurses and midwives
Child and family nurses Elizabeth and Rani are concerned that their roles are becoming less relevant as childhood health services evolve. Their view is that: ‘We are always the ones left holding the baby. We must argue that some of the new childhood obesity funding should come our way in the form of additional staff, so we can spend more time with families working on childhood obesity prevention. Our program is designed to work with families for at least the first 5 years of the child’s life. What is the point in giving this program to agencies that do not understand child development?’
Program silo: policy makers
Ted and Bruce are involved in policy development at a regional health office, and are worried about the ‘silo culture’ associated with early childhood services. Ted is frustrated, and comments that ‘health services don’t talk to education services, the child and family nurses don’t work with the early childhood teachers, and the midwives do their thing and so on. They all do their own thing. How can we get them to work together on childhood obesity?’
Integrated programs: nurses and midwives
Farrokh and Ilsa are maternal and child health nurses working in an enhanced home-visiting program targeted to meet the needs of vulnerable families. They are pleased with the integrated aspects of their work. Their view is that: ‘We feel so supported in our practice. We have a great multidisciplinary team and the clinical supervision helps us keep up to date with best practice.’ Both have attended team meetings to plan for the introduction of a childhood obesity prevention initiative.
Integrated programs: policy makers
Bruce, a senior policy maker in the regional health office, is excited by the maternal and child health enhanced home-visiting program, and suggests to Ted that it could serve as the platform from which to deliver the childhood obesity initiative.
It might be useful at this point to map the people, organisations and policy and service levels involved in the scenario presented to develop a picture of the complexities of program development.
The next section examines health policy and its impact on program development. Policy makers in Australia and New Zealand are working closely with their existing early childhood programs to introduce programs designed to prevent and reduce population health problems such as childhood obesity.
Health policy and its effect on program development
Any regional child and family health program in Australia and New Zealand exists within the context of global and national health policies, which tend to determine health priorities such as reducing childhood obesity. While these factors may be quite removed from their day-to-day activities, nurses and midwives need to understand that they have a significant influence on health priorities, and the availability of funding for services, at regional and local levels.
Therefore, when proposing or establishing any program, consideration must be given to the relevant health policies that support it. For infants, children and young people, early intervention is vital. Therefore, it is also important to review the principles of health promotion, as prevention and early intervention represents the core practice of child and family nurses. This guidance is particularly important when planning to manage major public health issues such as childhood obesity. The following original principles of health promotion were prepared by a World Health Organization (WHO) working party (1984b p. 20) and remain an excellent starting point:
1. Health promotion involves the population as a whole in the context of their everyday life, rather than focusing on people at risk for specific diseases. It enables people to take control over, and responsibility for, their health as an important component of everyday life, both as spontaneous and organized action for health. This requires full and continuing access to information about health and how it might be sought by all the population, using, therefore, all dissemination methods available.
2. Health promotion is directed towards action on the determinants or causes of health. Health promotion, therefore, requires a close cooperation of sectors beyond health services, reflecting the diversity of conditions that influence health. Government, at both local and national levels, has a unique responsibility to act appropriately in a timely way to ensure that the ‘total’ environment, which is beyond the control of individuals and groups, is conducive to health.
3. Health promotion combines diverse, but complementary, methods or approaches, including communication, education, legislation, fiscal measures, organizational change, community development and spontaneous local activities against health hazards.
4. Health promotion aims particularly at effective and concrete public participation. This focus requires the further development of problem-defining and decision-making life skills, both individually and collectively.
5. While health promotion is basically an activity in the health and social fields, and not a medical service, health professionals—particularly in primary health care—have an important role in nurturing and enabling health promotion. Health professionals should work outwards, developing their special contributions in education and health advocacy’ (emphasis in original).
More recently, the scope for nurses to enable populations not only at the coalface of healthcare delivery but also through participation in policy and service development is gathering momentum. Edelman and Mandle (2006 p. 613) are of the view that nurses need to consider three principal goals with respect to health promotion:
1. Participate in health promotion policy development.
2. Influence public expectations about health promotion.
3. Promote equitable access to preventive health care.
These principles underpin global, national and local policies, which in turn inform program development.
The global perspective
Global health organisations such as the WHO and the United Nations Children’s Fund (UNICEF) provide guidance on global health issues, which informs the decision makers in individual countries who are responsible for setting health priorities and policies. These organisations attempt to focus the attention of individual nations on healthcare issues that are considered to be of the utmost importance from a global perspective.
For example, the United Nations Convention on the Rights of the Child or UNCROC (1990 article 24) states that supporting nations must ‘recognise the rights of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation’. It also states that governments should ensure that children be given the right to access appropriate healthcare, which means that governments must embrace this right when planning child and family health policy at a national level. An example of the flow-through of prioritisation at a global level to national policy and service initiatives is set out in Box 2.1.
Box 2.1
Global policy
In 1990, WHO and UNICEF produced the Innocenti declaration: breastfeeding in the 1990s—a global treatise (World Health Organization & UNICEF 1990). It aimed to promote breastfeeding globally, enable women to practise exclusive breastfeeding and to pressure governments to implement policies that would support women to breastfeed. The declaration argued the optimal nutritive qualities of breastfeeding for growth and development, its role in reducing infant morbidity and mortality, enhancing women’s health, and producing economic benefits. It stipulated exclusive breastfeeding for all infants to 6 months of age and that breastfeeding be maintained to age 2.
The declaration sets out targets for individual countries to achieve, and strategies to help meet targets. These include:
1. the appointment of a national breastfeeding coordinator
2. the establishment of a multisector national breastfeeding committee
3. ensuring hospitals support the ‘10 steps to successful breastfeeding’, and
4. compliance with the ‘International code for the marketing of breast-milk substitutes’, and legislation to protect breastfeeding women.
National policy
In New Zealand, the Department of Health (now called the Ministry of Health) signalled its support for the Innocenti declaration (Gordon 1998, Vogel & Mitchell 1998) and a meeting was convened in 1991 to reconsider the code’s place within New Zealand. Little unifying action was taken. In 1999, the Ministry of Health established clear breastfeeding definitions and, in 2002, established national breastfeeding targets and a breastfeeding action plan (Ministry of Health New Zealand 2002).
Programs
In 1992, a ‘breastfeeding kit’ was developed by the then health department to educate healthcare professionals about the code for breast-milk substitutes and the Innocenti declaration. In 1998, the New Zealand Breastfeeding Authority (n.d.) was established to coordinate the many breastfeeding stakeholders and oversee the Baby Friendly Hospital Initiative (see Ch 6 for more information), a program promoted by WHO and known to increase breastfeeding rates.
Outstanding issues
1. A national breastfeeding coordinator has never been appointed.
2. No legislation requiring compliance with the code has been developed and, while monitored, compliance remains voluntary.
3. Breastfeeding rates have shown little change in the last decade.
Health literacy is an aspect of policy and program development that also filters through global, national and program levels to be relevant in the everyday work of nurses with families. Leaders in the field are providing useful global challenges for us all. For example, Nutbeam and Kickbusch (2000 p. 183) provide guidance in their editorial, ‘Advancing health literacy: a global challenge for the 21st century’. They argue for the need to ensure that people have access to education in order ‘to improve the health literacy of persons with inadequate or marginal literacy skills’.
Going beyond the notion of information dissemination, health literacy seeks to achieve more than information dissemination. Rather, it seeks to increase the accessibility of information and motivation for engaging in health-seeking behaviours. This is an issue that nurses and midwives deal with daily in New Zealand and Australia in our multicultural communities.
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