Public health has been defined as ‘the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals’ (Wanless 2004: 27). The science and art of preventing disease in health visiting practice has been described by Twinn (1991), who discusses how health visitors combine a scientific approach with the art of health visiting. The scientific basis to their work encapsulates epidemiology, and the evidence base for practice is extracted from research. This is combined with the art of professional judgement based on intuition, the complexities of families and communities, past experiences and the unique situations health visitors find themselves in. There is an art in synthesizing this information, reflecting on and in action and understanding and helping clients to achieve health. Health visiting as previously mentioned is also concerned with ‘planned activities aimed at the promotion of health and prevention of ill health’ (CETHV 1977), which has a positive effect on the health of individuals and society.

The public health role of the health visitor is reaffirmed by the NMC in its standards of proficiency for specialist community public health nursing when ‘health visiting’ was renamed ‘SCPHN’ (NMC 2004). This is further supported by the QAA, who developed ‘benchmarking standards for health visiting education and practice’ that clearly articulate the public health dimension of their work (QAA 2001). The latter document uses the following health visiting principles developed in 1977 (CETHV 1977) to underpin professional practice, which provide a sound basis for public health and are now firmly rooted in research. The NMC adopted these principles and adapted them to support their standards for practice (CETHV 1977: 9, Cowley, Appleton, 2000 and Cowley, Appleton, 2000, Cowley, Frost, 2006 and Cowley, Frost, 2006, Twinn and Cowley 1992):

The stimulation of an awareness of health needs refers to helping people become aware of what may be possible to achieve in an effort to improve their personal health, or the health of the community (CETHV 1977, Twinn and Cowley 1992, UKSC 2001). This can also include working with disadvantaged groups in society who may have limited access to health information and resources (QAA 2001, UKSC 2001). Cowley, Frost, 2006 and Cowley, Frost, 2006 suggest that stimulating an awareness of health needs should be extended to three different levels:

In working with all of the above groups, the health visitor may stimulate an awareness of health needs through the provision of knowledge, recognizing that the way in which this is delivered is dependent upon the situation. When working with individuals and communities it is essential to take cognizance of social, educational and cultural backgrounds and people’s personal experiences, and consider how they affect individual perceptions of health. Empowering individuals and communities to gain control over factors that influence their health underpins the application of this health visiting principle in practice and demonstrates the approach used by health visitors when engaging in ‘health promotion’ as seen in its broadest sense. This is encapsulated in the definition given by the World Health Organization (1986), which states that ‘health promotion is about enabling people to increase control over and so improve their health’. The QAA (2001: 7) emphasizes this point when it describes health visiting as using a ‘partnership approach to practice, through which clients are empowered to address issues influencing their health’. This is an essential element of promoting health and preventing ill health and places health visitors in a central position to deliver a public health agenda, based on identified health needs.

It is worth exploring ‘empowerment’ in more detail in an effort to describe the way in which health visitors undertake practice. Empowerment is a two-way process between professional and client, where the client’s needs take priority, and goals are negotiated (Naidoo and Wills 2000). The principles revolve around fostering informed choice, supporting change rather than coercing clients, the provision of knowledge and allowing people to make up their own mind (Tones and Tilford 1994: 11). Persuasion, instruction or propaganda do not form part of the process; however, clarifying values, building self-esteem, and developing supportive environments and services to achieve well-being are essential ingredients of this approach (Cowley, Frost, 2006 and Cowley, Frost, 2006). It is important to consider that some families lead complex and deprived lives; these often hard to reach families have hidden needs which can be identified by the health visitor.

When working with politicians and policy makers to stimulate an awareness of health needs it is essential to ensure that links, whether overt or covert, are made with the political agenda. To inform this process health visitors need to ensure that health profiles are compiled based on epidemiological data and client experiences, and clearly identify the issues for the community, such as housing or safe play areas for children. Action taken to improve communities must be undertaken in partnership with other agencies, as no one agency can be effective alone.

Cowley, Frost, 2006 and Cowley, Frost, 2006: 32) suggest that this principle can be implemented through three interwoven mechanisms:

Health visitors influence policies on a national and local level and this is pivotal to promoting health and preventing ill health (QAA 2001, UKSC 2001). They are ideally placed in the heart of the community to identify health and social needs, by identifying problems early, and to develop policies to prevent these problems (Wanless 2004). Information about emerging health needs in the community should be disseminated to health commissioners; health visitors collate such information, and therefore it would make sense for health visitors to become actively involved in primary care trusts or local health boards to influence healthcare planning based on accurate needs assessments, ensuring that strategies include issues for prevention (SNMAC 1995). This would incorporate taking part in strategy development that may impact on the health of the community. Examples relate to influencing health improvement plans, health action zones (HAZs) or contributing to services in relation to healthy living centres. Working at an international and a national level with organizations such as the Community Practitioner and Health Visitor Association and the Royal College of Nursing is an effective way to influence policy development and the future profession of health visiting.

Facilitating health-enhancing activities is a major part of health visiting professional practice and includes the broad remit of public health inclusive of environmental changes, personal preventative activities and therapeutic endeavours (Cowley, Frost, 2006 and Cowley, Frost, 2006). This may take place through encouraging and enabling individuals to take responsibility for their own health, through facilitating health-enhancing activities which could be community or family based, or by influencing policy formation which positively affects health. Campaigning to establish services in deprived or disadvantaged areas such as nursery school provision, or activities for teenagers are examples of facilitating health-enhancing activities. Monitoring health needs and acting as an agent who mediates between agencies on behalf of families and individuals and promotes health-enhancing activities is another element of health visiting.

Sure Start, and more recently Flying Start, is the cornerstone of the government’s drive to tackle child poverty and social exclusion (Home Office 1998, Welsh Office 1999, Welsh Assembly Government 2005b), and provides excellent examples of health-enhancing activities by health visitors (Bidmead 1999, Daniel 1999). There is substantial evidence to support early interventions with children and much of the work in the United States by Olds, Henderson, Chamberlin, Tatenbaum, 1986 and Olds et al, 1997 and Kitzman et al (1997) demonstrated the benefits of home visiting in the pre- and postnatal period. The results of these studies indicate programmes can reduce child abuse and neglect, improve parenting skills and the quality of child interactions, reduce subsequent pregnancies and, in the long term, reduce criminal behaviour of mothers and children (Olds et al 1998). This evidence base has been used as the basis for Sure Start programmes, which are multiagency and set about to improve the health, intellectual and social development of children; pilot sites have been set up in England to implement parenting programmes using the Olds methods (Home Office, 1998 and Home Office, 1999).