Health Visiting: Context and Public Health Practice

Chapter 2
Health Visiting: Context and Public Health Practice


Martin Smith


Liverpool City Council, Liverpool, UK


Introduction


Health visiting has long been recognised as providing a model for public health nursing in the UK. However, for a number of decades it has found itself having to respond to a fast-moving world of policy change and contrasting political views of public health, which has left the profession constantly having to adapt to the prevailing political ideology in order to ensure its survival. To its credit – if not relief – the profession has responded well to these challenges. Indeed, since the late 1990s there has been an implicit assumption in UK policy that health visitors have a key public health role to play in the support of children and families (Home Office, 1998; DH, 1999, 2010, 2011; HM Government, 2006). It could be argued that such policies arose less in the interests of health visiting and more as a means of securing the economic potential of the future adult population, as Glass (1999) suggested was the case with Sure Start. Nevertheless, these and a plethora of other policies at both the global and national level have resulted in health visiting becoming increasingly associated with an early years intervention model for practice and framed within a public health context through working with individuals, families, and communities (DH, 1999, 2003, 2011; NHSE 2014).


What is less clear is exactly what the public health context means for health visiting. The origins of health visiting are said to be firmly rooted in a public health approach (Adams, 2012), and indeed, its beginnings as an occupation are said to have aligned closely with the public health movement (Cowley & Frost, 2006; Cowley et al., 2013). However, public health itself is recognised as a contested concept (Verweij & Dawson, 2009; Dawson, 2011), with different and often conflicting interpretations of its meaning. This chapter aims to articulate the concept of public health for the practice of health visiting. To do so will expose public health as a social construct, with a range of perspectives on what it means and on some of the consequent tensions and ambiguities that exist between policy and practice. It is therefore an analytical text rather than a description of ‘how to do’ public health nursing. This is important for two reasons. First, as Craig (2000) highlighted and Dahl & Clancy (2015) have shown, the range of perspectives on the nature of public health nursing has a direct impact on how it is practised. Second, it is essential for practitioners to consider these tensions, because their own understanding of public health, and of their role as specialist community public health nurses (SCPHNs), will frame the decisions they make concerning their own health, the approach they take to the interpretation of policy, and the promotion of health with others.


This exploration of the connection between health visiting and public health is particularly relevant for contemporary practice and a policy context which focuses the role on families and young children. This analysis will therefore take account of a broad child health policy framework that covers both international and national policy and legislation. Globally, UNICEF has reported continuing concerns over the plight of children subjected to the forces of poverty and inequities in health (UNICEF, 2009). This comes 20 years after the United Nations Convention on the Rights of the Child (UNCRC) (UNICEF, 1989), which highlights children’s right to life and health, and yet globally 1 billion children are still deprived of food or shelter, clean water or healthcare, with thousands under the age of 5 dying every day from preventable causes (UNICEF, 2009). More recently, UNICEF has highlighted the continuing – and in some respects, widening – inequities for children from the poorest households compared to those from the most affluent (UNICEF, 2015). The UNCRC is the world’s most ratified convention, with the UK government among its signatories. The UK government was also a signatory, along with other UN member states, to the Millennium Declaration in 2000 (UN, 2000), which set out eight goals to be achieved by 2015, two of which were concerned with reducing child mortality (reduce by two-thirds between 1990 and 2015) and improving maternal health (reduce maternal mortality by three-quarters between 1990 and 2015). A more recent worldwide consultation undertaken by the UN has reconfirmed how central ‘health’ is to any future development agenda (UNDG, 2013). As the 2015 limit on the Millennium Development Goals (MDGs) beckoned, and with poverty and inequality still very evident for many nations, there were moves by the UN to build on these goals through the promotion of a more inclusive, sustainable development approach (UNDP, 2015a). It is clear that despite the goal-setting aspirations of governments, and perhaps as a consequence of the limited power and authority of the UN, there is still much work to be done.


A concern for the health and well being of children is also important nationally at a time when the UK government grapples with recovery from a global recession and implements a political strategy to stimulate economic growth through a reduction in public services and the institution of welfare reforms. Indeed, recession or not, the constant pressure for cost-efficiency within health and social care services means that the ongoing political rhetoric around reducing child poverty and improving the health and life chances of children presents significant challenges – as well as opportunities – for health visiting. This was clearly evident in the Marmot Review of health inequalities, which laid out the disproportionate impact of poverty on the lives of children and called for a policy objective of ‘Giving every child the best start in life’ (Marmot et al., 2010 p. 15) as the highest priority, with health visitors having a key role. From a policy perspective, health visitors are clearly at the forefront of supporting this goal, both by leading the Healthy Child Programme (DH, 2009) and through strong links to Children’s Centres (Lansley, 2010). There is a requirement for there to be ‘A named health visitor on every Children’s Centre Management Board’ (NHSE, 2014: 21). Additionally, in October 2015 the movement from the National Health Service (NHS) to local authorities of the commissioning responsibility for services for children aged between 0 and 5 years, which includes health visiting and Family Nurse Partnership (FNP), is clearly focused on a role designed to give children and their families a healthy start (DH, 2015).


In addition to analysing public health as a construct, this chapter will also provide an analysis of the health visiting role in relation to children and families and will consider how this sits within a public health approach to practice. This is important as it has been argued that a focus on children rather than the whole population does not fit a public health approach (Symonds, 1991). However, children are a distinct population and, as will be demonstrated from a lifecourse perspective, poor social circumstances in early life can have lasting influences on population health (Davey Smith et al., 1997; Blair et al., 2010). Lifecourse theory suggests that exposure to the cumulative impact of health and environmental factors during childhood is connected to the development of disorders, disability, and death in adults. Health visitors are in a prominent position to maximise the health and well being of this future adult population, which will one day have children of its own.


The Marmot Review (Marmot et al., 2010) recognised this and saw health visitors as critical to the success of any programme that aimed to improve the life chances of children, highlighting concerns over the falling numbers of health visitors. The review was not a lone voice in this regard, with calls for significant investment (HSC, 2009; UKPHA, 2009; Unite, 2009). However, despite these calls and an expedient political rhetoric on the importance of health visiting (DH, 2007, 2009; DH/DCSF, 2009), future prospects remained bleak.


The advent of a new UK coalition government in 2010 brought significant changes for health visiting and the subsequent policy direction has seen the commissioning of health visiting and family nurse partnership becoming the responsibility of local government since 2015 (DH, 2015). At a time of economic and social austerity, the profession found itself at the dawning of a new era, with significant investment from 2011 resulting in a major increase in the workforce of more than 4000 additional health visitors (Bennett, 2015a). However, this investment comes at a price, with health visitors facing challenges in enacting government policy which, it will be argued, diverges from the four principles that underpin health visiting (CETHV, 1977; Cowley & Frost, 2006). Meeting these challenges will mean making full use of each of the principles in order to gain any possibility of success. These four principles are explored in detail later in the chapter.


Throughout the discussion, the terms ‘health visiting’ and ‘public health nursing’ will be used interchangeably. This is not to assume that the terms mean exactly the same thing. Indeed, Craig (2000) has already given an enlightening deconstruction of the concept of ‘public health nursing’ and what it means for UK health visiting. However, for the purposes of this chapter, the analysis will remain focused on the context of health visiting for a public health role and not on the relationship between health visiting and nursing per se.


Public health


Before examining the relationship between health visitors and the public health function, it is important to consider and understand what is meant by ‘public health’ and the language and frameworks commonly used to describe it. ‘Public health’ is widely recognised to be a contested concept (Orme et al., 2007; Verweij & Dawson, 2009; Baggott, 2011). As a result, several terms are used to describe or help explain the need for it. In the first instance, and to support the analysis, it may be useful to consider the two underlying terms separately: ‘public’ and ‘health’.


Defining ‘public’


Verweij & Dawson (2009) suggest the term ‘public’ may be interpreted in two ways. First, as an aggregate (sum) of the experiences of individuals within a given population. Examples of populations in this context are given in Box 2.1. You may also find Activity 2.1 useful. And second, as collective and organised action either by the state or by groups of people. Therefore, ‘both the interventions and objectives of public health are “public” and go beyond the level of individuals’ (Verweij & Dawson, 2009: 21). The concept of ‘public’ is important for health visitors as much of their work is with individuals, and an understanding of the health of those individuals can be aggregated to a population level to support a broader understanding of health need and the social context within which they live their lives.


Furthermore, the notion of collective or organised action can mean two things for health visitors:



  • The organisation of a response for care, based on the health visitor understanding the aggregate need within the ‘population’ of clients (e.g. the development of a postnatal support group in response to an increasing demand for postnatal mental health support).
  • Facilitating and supporting collective action either with or on behalf of groups or communities to tackle local issues that affect health (e.g. supporting a resident’s association in articulating the health impact of poor housing in a community or seeking political support to prevent the closure of a nursery).

Understanding the concept of ‘public’ through work that is substantially with individuals presents challenges for health visitors. The process of contact and care with one individual or family followed by another fragments the perception of population in day-to-day practice. SmithBattle et al. (2004) found such difficulty among inexperienced public health nurses (PHNs) in Canada1 as they came to terms with the transition from nursing to public health nursing. This finding arose from a qualitative study of knowledge and skill acquisition among PHNs, which demonstrated how, through experiential learning, the PHNs developed a perceptual grasp of the ‘bigger picture’. There was a shift from a reliance on a nurse-focused agenda, with predetermined frameworks and protocols to follow, to a ‘situated understanding of practice’ (SmithBattle et al., 2004: 96). In other words, through their experiences with individuals and families, the PHNs were increasingly able to recognise the larger patterns and subtle cues embedded within the social context of their clients’ lives. They demonstrated a shift from viewing client contact as a narrow, clinical situation to one in which there were patterns that required a community response. As one of the PHNs stated, ‘Individuals in a community are as healthy as their community is, and vice versa…You can’t address one without addressing the other’ (SmithBattle et al., 2004: 99). The study was therefore clear in its view that ‘individual and family level experience was a crucial foundation for aggregate-level practice’ (SmithBattle et al., 2004: 99). The challenge of taking a population approach for those entering health visiting is still very real, as illustrated in guidance from the Royal College of Nursing (RCN, 2012) which encourages all nurses to work ‘upstream’ and provides illustrative cases studies to help them recognise and participate in ‘public’ health work.


So, for health visitors, the concept of ‘public’ as something that reflects collective and organised action (Verweij & Dawson, 2009) may develop with experience, as they gain a perceptual understanding of and readiness to respond to the broader issues surrounding complex situations within families.


Defining ‘health’


Defining ‘health’ is equally complex. It depends on the underlying perspectives and values of those that seek to explain what it is. Earle (2007) highlights how health can be categorised into three broad areas:



  • Health as the absence of disease. This reflects a negative (i.e. absence of disease) narrow biomedical interpretation of health.
  • Health as well being, in its widest, most positive sense. For example, the World Health Organization (WHO) defines health as a ‘state of complete physical, social and mental wellbeing, and not merely the absence of disease and infirmity’ (WHO, 1946).
  • Health as a resource. This suggests that health is embedded in the processes and actions of everyday life. For example, the WHO (1986) defines health as ‘a resource for everyday life, not the object of living. It is a positive concept emphasising social and personal resources as well as physical capabilities’.

Cowley & Frost (2006) note the challenges of attempting to define the value of health. They refer to work by health visitors in 1992 that considered the value of health and its practicability through health promotion from a health visiting perspective. This working group identified seven underpinning beliefs informing health visiting practice:



  1. 1. Rights and responsibilities: As everyone has a fundamental right to an optimum state of health, health visitors take on a responsibility to address health inequality and inequity.
  2. 2. Health in context: Health cannot be separated from the socioeconomic and cultural context in which it is experienced. It is the health visitor’s understanding of individuals, their families, and their communities that takes account of the wider influences on health.
  3. 3. Choice and blame: Health must be regarded in broad holistic terms, encompassing individuals and families within their personal situations. Health visitors need to utilise their skills to promote an environment in which individuals, families, and communities are able to make healthy choices. They will need to consider who in society has responsibility for health beyond the individual, in order to minimise the risk of ‘blaming the victim’ (Ryan, 1976).
  4. 4. Positive health: Health promotion involves finding ways to create resources for health. This requires health visitors to think innovatively with families and communities about how to maximise their social and personal resources in order to effect health improvement.
  5. 5. Health improvement: Health visitors work to enable people to make full use of their physical, emotional, and social capacities to improve health. The focus is on working with the active participation of clients to address those factors that influence their health in the broader context.
  6. 6. Empowerment: Health visitors enable people to recognise that through active participation, they have the power to achieve health for themselves and to shape their own lives and those of their families. They therefore need to recognise the importance of facilitating people to engage in decision making about their health, particularly those groups who are frequently marginalised and excluded and are known to make less use of services (e.g. those on low incomes, from ethnic minority groups, or with mental illness).
  7. 7. Community partnership and participation: Healthcare services should be readily acceptable and accessible, and involve full community participation. This requires health visitors to work together with individuals, families, and communities and alongside other professionals in order to maximise their opportunities and capabilities to improve health.

(adapted from Cowley & Frost, 2006: 13–14)


From the analysis undertaken by the working group to which Cowley & Frost refer, it is evident that the concept of health requires health visitors to be adaptable and responsive to the needs of the most disadvantaged and socially excluded in society. In a review of research literature concerning health visiting, Cowley et al. (2013) found evidence supporting a health creating or salutogenic approach to health visiting practice. The health visitor role becomes one that seeks out ways to promote health, taking account of the environment in which people live and enabling people to actively participate in and shape their own lives. Activity 2.2 may be useful in helping you to explore your own underpinning values concerning health promotion.


Defining ‘public health’


Recognising the diverse natures of ‘public’ and of ‘health’ and the competing perspectives that can occur in their explanations, it is not surprising that to interpret ‘public health’ presents significant challenges. Verweij & Dawson (2009) highlight how interpretations of public health fall into two main categories – narrow and broad – much as the definitions of health do. The narrow perspective sees public health in terms of how long people can remain free from disease. In contrast, the broad perspective sees public health not only in terms of protecting the health of the population but also in a broader role of health promotion and disease prevention (Verweij & Dawson, 2009). This broader view is said to be ‘anticipatory, geared to the prevention of illness rather than simply the provision of care and treatment services’ (Baggott, 2011: 1). However, taking a broad approach presents a key difficulty for the concept of public health. Perspectives that are packaged to be inclusive and capture the broad issues across society result in a concept that is so ambiguous they risk collapsing into a confusing set of ideas that are devoid of any useful purpose. The temptation to define public health in narrow terms – to address a specific problem or disease – is strong, but this risks focusing on treatment and provision of care without taking account of the broad range of factors that can influence health. You may wish to undertake Activity 2.3 at this point.


Different perspectives on public health will reflect what society sees as the prevailing priorities for improving the health of the public (Baggott, 2011). Baggott highlights that ‘Different interests favour their own particular interpretations of public health and their interplay establishes its meaning…it is essentially a political process’ (Baggott, 2011: 2). As mentioned in the introduction, the political process of public health has clearly had an impact on health visitors and their health promoting work with children and families in recent decades. Baggott goes on to suggest a number of broad ideological perspectives on public health that reflect the key debates surrounding freedom and responsibility between the individual and the state. You may wish to undertake Activity 2.4 at this point.


It is clear from these perspectives that the prevailing political environment has an impact upon how services for families with children are delivered. Indeed, current UK policies are designed to cope with the global recession through a reduction in welfare and public sector spending. This will have an impact on children and families, with cutbacks in services and benefits. Health visitors will therefore increasingly be working with families with reduced or limited incomes who have no access to family support. It is important at this point to consider public health more specifically in relation to health visiting.


A frequently cited definition of public health is that of the UK Commission for Inquiry into the Public Health Function, undertaken in the late 1980s: public health is ‘The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’ (DH, 1988; Faculty of Public Health, 2010). This is often referred to as the ‘Acheson definition’, as Sir Donald Acheson, the Chief Medical Officer at the time, chaired the committee. It clearly presents a broad interpretation of public health and encompasses some of the difficulties in interpretation highlighted in this section. It also reflects a collectivist ideology (Baggott, 2011). Beaglehole & Bonita (1997) have suggested that it emphasises the main components of public health:



  • population perspective;
  • collective responsibility for health and prevention;
  • the role of the state, linked to a concern over underlying socioeconomic determinants of both health and disease;
  • a multidisciplinary basis, incorporating quantitative and qualitative approaches;
  • an emphasis on partnership with the populations served.

These components see health improvement through action with populations that take account of the wider social determinants of health, much as Cowley & Frost’s (2006) seven beliefs underpinning health promotion in health visiting seek to demonstrate. One of the key phrases within the Acheson definition is the ‘science and art of preventing disease’. This not only reflects a scientific perspective that uses epidemiological evidence and research to determine the causes of ill health, but also suggests that public health is concerned with innovation and action through health delivery. For health visitors, this is a key aspect of practice, involving understanding not only the needs of the population through the process of health needs assessment (HNA) (see Chapter 3), but also how to ‘create’ a response to those needs in practice at a local level (e.g. following cuts within the welfare system, working jointly with local welfare rights agencies to make welfare rights and benefits information accessible in a local clinic).


Human rights and public health


Beaglehole & Bonita’s (1997) analysis of the Acheson definition highlights collective responsibility, concern over socioeconomic determinants of health, and the importance of partnerships for public health. It also suggests human rights have an underlying significance for health. Sirkin et al. (2005: 538) are very clear that healthcare professionals ‘have a responsibility to protect and promote human rights’. The reasons for this are twofold. First, those human rights that are violated (e.g. being subjected to torture or deprived of an education) can have health consequences. And second, the process of promoting and protecting human rights can be the most effective means to securing health (Sirkin et al., 2005). Health visitors therefore have a responsibility to protect and promote human rights as a means of optimising the health of communities and reducing the impact of health inequalities. Indeed, as employees of a public service, health visitors are required to comply with the UK Human Rights Act 1998 and with international legislation ratified by the UK government. This includes:



  • the Universal Declaration of Human Rights (UDHR) (UN, 1948);
  • the International Covenant on Economic, Social and Cultural Rights (ICESCR) (UN, 1966);
  • the European Convention on Human Rights (ECHR) (Council of Europe, 1950);
  • the UNCRC (UNICEF, 1989).

These declarations of human rights contain series of ‘articles’ that reflect rights of freedom and rights of protection – what Fromer (1981) refers to as option rights and welfare rights, respectively. As Sirkin et al. (2005) allude to, if the ideal health outcomes in the WHO definition of health are to be acknowledged, then health will underpin all human rights. Conversely, there could be an occasion when, in the interests of public health, other human rights might be restricted (e.g. when someone is detained against their will because they have a highly infectious disease or are at risk of causing harm to themselves or others).


Despite the UK government having ratified these conventions, the Human Rights Act 1998 is the only agreement relating to human rights that has been enshrined in UK law, and this is therefore the framework that makes the government directly accountable for human rights. Recently, a repeal of the Human Rights Act has been suggested (Conservative Party, 2014). Whether repealed or not, international covenants of human rights are referred to in legal processes and are accepted as part of legal argument in determining case law. Interestingly, the UK Human Rights Act and its parent human rights framework, the ECHR, do not contain a specific article on the right to health, meaning there is no explicit accountability for that right in the current national legislation. If health visitors wish to use any human rights legislation to argue the right to health, therefore, they need to articulate that right in terms of deprivation of other rights under a range of available articles, much as Sirkin et al. (2005) highlight in the process of promoting and protecting human rights.


In the case of the UN declarations, member states are required to submit reports to the UN of their performance against the articles in the declarations. Again, however, without explicit national legislation, accountability is limited. There is further discussion of human rights legislation and its impacts on health visiting in Chapter 5, particularly in relation to the UNCRC. Suffice it to say at this point that the UNCRC does contain a specific article (Article 24) on the right to health of children that has relevance to health visiting and a public health role (see Box 2.2). This article sets out a comprehensive statement of the rights of children to health, taking account of wider determinants and, in particular, the right of access to healthcare. The article also makes reference to the concept of ‘progressive realisation’: this is an acknowledgment of governmental obligations to the UNCRC, and of the fact that the rights may be difficult to achieve on a short timescale, but it does mean that governments are required to demonstrate through their reporting to the UN that they are taking steps towards ‘realisation’ of the right to health (Gruskin & Tarantola, 2004). It is also clear that achievement (or otherwise) of the remaining articles of the UNCRC will have a profound impact on securing the health of children. You may wish to explore this further through Activity 2.5.


The UNCRC needs to be viewed within the context of the WHO definition of health, the UDHR (UN, 1948), and the ICESCR (UN, 1966), which all also assert rights relating to health. The UDHR is noteworthy as the first articulation of the right to health, but the ICESCR holds particular significance for public health and health visiting. The Covenant under Article 12 ‘recognises the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ (UN, 1966) and makes specific reference to a reduction in child mortality and the healthy development of children under this article. The Covenant also places a particular emphasis on the social and economic context of people’s lives and reflects upon how, in the absence of rights of freedom and protection, the infrastructure for health is lost. The UN has affirmed this with a statement that under Article 12 of the ICESCR:



States must protect this right [to health] by ensuring that everyone within their jurisdiction has access to the underlying determinants of health, such as clean water, sanitation, food, nutrition and housing, and through a comprehensive system of healthcare, which is available to everyone without discrimination, and economically accessible to all.


(CESCR, 2000: para. 11)


The UN is very clear, therefore, through the ICESCR and the UNCRC, that not only do the underlying social and economic determinants of health need to be addressed in order to realise an attainment of health, but member states need to recognise the unfair distribution of those determinants and that they should take steps to reduce the impact of health inequalities, much as described in the UN’s 17 sustainable development goals (UNDP, 2015b). Health visitors must recognise how this international framework of legislation can be used to support their role as an advocate for local children, families, and communities.


Not only is there a legislative requirement for health visitors to uphold human rights, but it can also be argued from an ethical standpoint that health visitors have a moral duty to promote and protect human rights as a means of securing health. Indeed, The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives requires nurses, midwives, and health visitors to ‘pay special attention to promoting wellbeing, preventing ill health and meeting the changing health and care needs of people during all life stages’ (NMC, 2015: 5). This statement clearly resonates with the role of health visitors. Furthermore, from an ethical standpoint, health visitors need to have an understanding of how ethical health visiting practice links to a public health approach. Beauchamp & Childress (2001) identify four principles for ethical practice: autonomy, beneficence, nonmaleficence, and justice. Table 2.1 highlights the implications of these principles for health visitors in their role of protecting and promoting health.


Table 2.1 Principles for ethical health visiting practice


















Principle Implication for health visiting practice
Autonomy Supporting self-determination by building the self-esteem of clients and encouraging active participation in how they change their lives in order to improve their health
Beneficence Supporting health improvement with individuals, families, and communities by identifying health needs, taking account of the broader social determinants of health
Nonmaleficence Ensuring that health-visiting practice uses evidence-based approaches and is undertaken in a way that is cost-effective for disadvantaged populations. This is important for two reasons:


  • practice that is delivered inappropriately through outdated methods or without an evidence base may be harmful to clients
  • delivering care to populations with fewer needs entails time and opportunity costs for the health of those who need it the most
Justice Ensuring that health visiting practice is delivered equitably across the population and is focused on addressing the needs of vulnerable groups and seeking to reduce the impact of health inequalities

In summary, the process of defining the underlying concepts associated with public health has demonstrated clear associations with health visiting and the role of health visitors in promoting health and reducing health inequities. This is supported by an ethical and moral justification for promoting the health of children and their families, based on consideration of the broad social determinants of health. It is useful, therefore, with reference to the preceding discussion, to consider the underpinning principles of health visiting that enable an articulation of the public health role for health visitors.


The principles of health visiting


The Acheson definition also views public health in terms of disease prevention and health promotion. There are thus clear and direct parallels here with the role of health visiting defined as ‘The promotion of health and the prevention of ill health’ (CETHV, 1977). Such an approach clearly draws health visiting into the anticipatory and preventive nature of public health by seeking to prevent illness and improve the health and quality of life of whole populations of people. Health visitors undertake this work by focusing at various times on individuals, families, groups, or communities.


Health visiting itself is underpinned by four principles (CETHV, 1977; Baldwin, 2012). These principles were first articulated nearly 4 decades ago by the Council for the Education and Training of Health Visitors, the regulatory body for health visiting at that time, but they have since been reaffirmed, most recently by Cowley & Frost (2006). They are said to reflect the knowledge base and process of health visiting (UKPHA, 2009), as well as providing the framework for the Nursing and Midwifery Council (NMC) SCPHN Standards (NMC, 2004):



  1. 1. The search for health needs.
  2. 2. The stimulation of an awareness of health needs.
  3. 3. The influence on policies affecting health.
  4. 4. The facilitation of health-enhancing activities.

Each of the principles is interconnected with the others, and together they form the basis for health improvement in individuals, families, and communities. They reflect a philosophy of health visiting (rather than specific activities per se) that focuses intervention with those identified as in greatest need, and therefore aim to reduce health inequalities. The UK Public Health Association (UKPHA, 2009) highlighted the importance of these principles for children and families – particularly the most disadvantaged, who become socially excluded and suffer comparatively poorer levels of health. The principles of health visiting are also clearly action focused, which again reflects the art of preventing disease, prolonging life, and promoting health. A consideration of each of the principles demonstrates that they all have distinct features embedded within a public health approach.


The search for health needs


The search for health needs is viewed as an essential starting point for health improvement (South, 2015). While it forms the basis of an assessment process aimed at developing a plan to improve health, often in the form of an Health Needs Assessment (HNA), it also frames the search for health needs within a positive interpretation of health. HNA will be considered in more detail in Chapter 3, but suffice it to say at this point that searching for health needs broadens the horizons within which the health visitor views the people they work with and the factors they must take into account when making an assessment. The emphasis is on what needs can be fulfilled to maximise health, rather than what the health problem(s) is/are. Searching out need therefore goes beyond the individual client to the context within which they live their lives (e.g. their access to material resources and services, income, and employment2). Searching for health needs therefore aligns with a public health approach as a preventive process that takes account of the wider determinants of health.


However, it has to be acknowledged that meeting health needs will be a challenging area of health visiting practice, given the increasing pressures and cuts in public- and voluntary-sector services (Bawden, 2013; CPAG, 2015). There is a risk of minimising those health needs that the health visitor perceives may require additional assistance or referral and prioritising a focus on the client changing their individual behaviours. Given the earlier account of the client’s rights to health and the duty of the health visitor to respond to those rights, health visitors need to think creatively about how they respond to unmet health needs. For example, utilising an asset-based community-development approach (South, 2015) with peer- or group-based activities can be an empowering way for clients to find solutions to their needs. Searching out health needs is therefore a challenging but important process for opening up the social determinants of health in clients’ lives. This is in contrast, as Cowley & Frost (2006) point out, to other primary health care professionals, who will be framed by the presence of illness or disease and will be constrained by a focus on the health problem to be treated or rectified.


The stimulation of an awareness of health needs


The knowledge and understanding that health visitors gain from searching for health needs is a rich resource for gaining awareness of issues in need of a public health response. For example, the health visitor’s awareness of the extent of domestic abuse occurring in the community, and the associated impacts on families and the community as a whole, are important pieces of information that warrant some form of action. What is less clear is whose awareness is to be stimulated. Cowley & Frost (2006) suggest three different levels at which to engage in awareness-raising in order for an issue to be recognised as a priority. These can be applied to the issue of domestic abuse as follows:



  1. 1. With individuals and communities: Building trusting relationships and focusing on attributes and the capability to promote self-esteem in people suffering from domestic abuse, and exploring with them the unseen impact of domestic abuse on their own health and the health of their children. Such an approach can stimulate awareness of health as a positive resource.
  2. 2. With commissioners and providers of services: Raising awareness of the extent of domestic abuse as an often hidden and unmet need. The purpose is to give a richer understanding of the barriers and challenges that exist for health service managers and commissioners when attempting to meet key health improvement targets in local areas. For example, women experiencing domestic abuse are more likely to smoke, have an alcohol dependency, or suffer from depression. In this situation, the approach to improving health targets also means investing resources in tackling domestic abuse.
  3. 3. With politicians and policy makers: Raising awareness about proposed cuts in services for people experiencing domestic abuse and the subsequent impacts on individuals, society, and the economy.

Health visitors should be prepared to employ all of these levels in order to maximise the opportunities for improving the health of individuals, their families, and communities. To do so will require thinking critically and working in partnership with their service leaders and commissioners to determine the most appropriate audience with which to engage and to raise full awareness of health needs (see, for example, iHV, 2015).


The influence on policies affecting health


Influencing policy development has been perceived as the most challenging of the principles for most health visitors (Cowley & Frost, 2006; Laverack, 2015). The political nature of public health suggests that perspectives on public health and healthcare policy should be challenged to recognise the needs of the most vulnerable in society. In effect, the practitioner becomes an advocate for those with health needs, challenging and supporting policy making in order to ensure that policies have a positive health impact. Cowley & Frost (2006) suggest that this principle has three underpinning mechanisms for health visiting:



  1. 1. Health intelligence: A recognition of timely local population evidence, often ahead of official statistics, can be useful in determining a local policy response or service development. For example, health visitors are able to use their up-to-date knowledge of the community, through HNA and other processes (see Chapter 3), to gather qualitative information highlighting health needs.
  2. 2. Innovation and change: Being an active participant in change, challenging current practice, and becoming involved in new approaches (e.g. as a member of a project steering group, developing a breastfeeding policy in a local authority children’s centre).
  3. 3. Acting as a resource: Either:

    • directly undertaking and disseminating robust research to support policy makers in identifying best practice to underpin new policies;
    • getting involved in policy development, which may include redesigning local service delivery;
    • informing or responding to policy proposals;
    • indirectly enabling community groups or pressure groups to access and interpret information on health and health services; or
    • enabling colleagues and other services to interpret the health impact of policies, in order to ensure their actions are conducive to good health (e.g. raising awareness within a local community cafe of the unhealthy nature of foods high in refined sugar or saturated fat content – and getting them to consider alternatives).

The political nature of public health and the extent to which it is dependent upon the values of those that make policy means that this is arguably one of the most important areas of health visiting practice to become involved in. It is the capacity to influence service redesign and policy making that will determine the extent to which the population will be able to maximise its health potential.


The facilitation of health enhancing activities


Milio (1986) coined the phrase ‘making the healthier choice the easier choice’, which became an underlying principle of the Ottawa Charter for Health Promotion, adopted in the same year (WHO, 1986; de Leeuw & Clavier, 2011; Naidoo and Wills, 2016). It suggests a focus on addressing the environment within which families and communities live as a means of achieving improvements in their health. Clearly, there are strategies that individuals can be supported to adopt in order to change their health behaviours, but to do so leaves untreated the underlying factors that may be contributing to those behaviours. Focusing on individual behaviour also places clients under substantial pressure to change their lifestyles when they may not have the capacity or resources to do so. Indeed, estimates suggest that only 10–30% of the gap in health outcomes between the most and least wealthy may be explained by differences in health-related behaviours (Lantz et al., 1998). This suggests that the remaining 70–90% is determined by other factors in an individual’s social environment. There is therefore a high risk of failure with the individual behaviour approach, which can stifle health enhancement.


Facilitating health focuses on multidisciplinary approaches to enabling people to actively participate in and shape their own futures. Giddens (2006: 8) highlights how the ‘social contexts of people’s lives are not just random assortments of events or actions; they are structured, or patterned in distinct ways’. This social patterning across populations is built on access to income and employment, cultural and community patterns and norms, adequate housing, education, and healthcare services. Tackling inequalities in health is therefore at the core of facilitating health-enhancing activity. Health inequalities will be discussed further later in the chapter, but at this point, the key issue is for health visitors not to focus solely on the health behaviours of clients but to see their role within the broader context of social determinants of health. Activity 2.6 may help you explore the principles of health visiting further.


Summary


The four principles described in this section set out the values and processes underpinning health visiting. They resonate with public health principles and form the basis for viewing the practice of health visiting in a broad context that can promote health enhancement for the most disadvantaged. The common emphasis in all four principles is on a population understanding of health and the wider determinants that impact upon people’s lives. Success is best achieved, this suggests, through a process of enabling people and communities to determine how they can shape their lives to maximise their health experience by prioritising the issues that matter to them. The principles themselves have endured for over 30 years and, whatever the political landscape, they have remained as the bedrock for health visiting practice and will need to continue to do so into the foreseeable future.


The principles of health visiting are also included in the current Standards of Proficiency for Specialist Community Public Health Nurses produced by the NMC (2004). As the regulatory body for health visiting, the NMC sets the standards for entry to that part of its register that is concerned with public health nursing and provides the framework that regulates health visitors. Health visitors are not alone in this part of the register, which includes school nurses, occupational health nurses, family health nurses in Scotland, and nurses practising in a variety of settings, including sexual health and health protection. The four principles (referred to rather ambiguously as ‘domains’ in the NMC document) are mapped against 10 key areas developed as national occupational standards for public health practice (Skills for Health, 2004) (see Box 2.3). The purpose of the 10 areas is to identify those standards within

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Jun 17, 2017 | Posted by in NURSING | Comments Off on Health Visiting: Context and Public Health Practice

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