The Community Dimension
Rosamund M. Bryar
City University London, London, UK
Health visitors are fundamentally community public health workers – they work in communities, they work with communities, and they are part of communities. In 2004, the Nursing and Midwifery Council (NMC) opened the Specialist Community Public Health Nursing (SCPHN) Register, emphasising in its title and in the qualification both the community and the public health role of the practitioners – including health visitors – on that register. In Chapter 2, the case was made that in undertaking community work, health visitors are essentially working with individuals who are part of a community to address the health of that community (that community’s public health) at the level of individual behaviour change. Draper et al. (2010) cite O’Dwyer et al.’s (2007) systematic review of area-based interventions and comment that the differentiation between these two approaches to working with communities is not often acknowledged:
The distinction between community-based interventions (programmes that are based in communities, but focus on achieving change in individuals) and community-level interventions (programmes that seek to achieve change in a whole community via participation and other community wide changes) is also rarely made.
(Draper et al., 2010: 1104)
Hogg et al. (2013) discuss the tension in health visiting between the individual-level and community-level approaches to public health in a study of the views of parents and health visitors about parents’ need for support in parenting. This distinction is further demonstrated in the model or ‘family of community-centred approaches’ (South, 2015a: 4) in guidance from Public Health England, which includes roles that develop individuals (‘volunteer and peer roles’) and processes that ‘strengthen communities’, including community development and social network approaches.
Health visitors, in putting into practice the principles of health visiting (Cowley & Frost, 2006), are seeking through such work to influence community-level health (through both community-based and community-level interventions), wider public health policies, and the main determinants of health (Dahlgren & Whitehead, 1991; Morgan & Cragg, 2013).
In working with and in communities, health visitors are responding to the identification within the Declaration of Alma-Ata (Health for All by the Year 2000) (WHO/UNICEF, 1978), reiterated in Primary Health Care – Now More Than Ever (WHO, 2008) and in the Primary Health Care Performance Initiative (www.phcperformanceinitiative.org), of the importance of communities to the health of individuals, populations, and countries. The Health for All declaration identifies that communities should be involved in the development, provision, and monitoring of health services and sees health care as contributing to overall community development. This focus was reinforced in the primary health care reforms proposed by the World Health Organization (WHO) in 2008, which sought to move health systems towards health for all through making services more people-centred, promoting and protecting the health of the public, and improving health equity: ‘reforms that secure healthier communities, by integrating public health actions with primary care and by pursuing healthy public policies across sectors…’ (WHO, 2008: xvi).
This focus on the development and involvement of communities was reinforced in 2015 by the adoption by the UN General Assembly of 17 sustainable development goals, to be achieved by 2030, which are concerned with five Ps: people, planet, prosperity, peace, and partnership. The UN is one form of community, bringing together 193 of the 196 countries in the world, and the ‘world’ community focus is evident in the resolution which records the adoption of the goals:
All countries and all stakeholders, acting in collaborative partnership, will implement this plan. We are resolved to free the human race from the tyranny of poverty and want and to heal and secure our planet. We are determined to take the bold and transformative steps which are urgently needed to shift the world onto a sustainable and resilient path. As we embark on this collective journey, we pledge that no one will be left behind.
(UN, 2015: 1)
The launch of these sustainable development goals was accompanied by the launch of the Primary Health Care Performance Initiative (phcperformanceinitiative.org), which identifies the value of interventions in communities through actions in primary health care, including, for example, improving equity in health and supporting people to become active decision makers with regard to their health – which is fundamental both to the sustainable development goals and to public health.
Lang & Rayner (2012: 4) support the need for the multisectoral approach evident in the UN and WHO documents: ‘Today public health requires multilevel action, coordinated across not just the state but private spheres, commerce and civil society.’ In the UK, the National Health Service (NHS) Five Year Forward View (NHS England, 2014a: 4) emphasises the need for integrated working and the importance of prevention and public health, proposing that ‘the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain now depend on a radical upgrade in prevention and public health’ (emphasis in original). Health visitors as front-line public health workers working with local communities are in a prime position to contribute to this urgent agenda.
The aim of this chapter is to examine the role of health visitors in communities, the value of community-level activities, and the skills needed to undertake this type of work. The focus will be on working with groups or populations within communities, while acknowledging that this may often be achieved through engagement with individuals. Many of the skills health visitors make use of in working with individuals, such as health promotion theories (Stockdale et al., 2011; Cragg et al., 2013), motivational interviewing (Miller & Rollnick, 2012), and nudge methods (see Chapter 2), are also utilised in working with communities.
Chapter 2 provided a definition of public health and found it to be concerned with improvement in the health of populations: ‘through action with populations that take account of the wider social determinants of health’ (p. 60). The wider social determinants of health (Dahlgren & Whitehead, 1991; Morgan & Cragg, 2013) provide one of the many frameworks for considering public health practice. In this chapter, the underpinning approach taken is that of ecological public health proposed by Rayner & Lang (2012). This framework recognises the complex interrelationships between human beings and the world which impact on human (and world) health. Rachel Carson’s (1962) famous Silent Spring, in which she discusses the impact of pesticides on the food chain, leading to the death of birds and the ‘silent spring’, illustrates this ecological approach to considering public health. Rayner & Lang (2012) identify four dimensions of existence which interrelate and contribute to prevention and public health:[
- ‘the material, which refers to the physical and energetic infrastructure of existence;
- the biological, which refers to the bio-physiological processes and elements, not just ‘blood and bodies’ but all that grows;
- the cultural, which refers to the importance of how people think and to the formation of collective consciousness;
- the social, by which we mean interactions between people, and their mutual engagement in collectivities, in the form of institutions through which societies operate.’
Rayner & Lang (2012: 315)
These four dimensions provide a focus for action by individuals, governments, communities, and public health practitioners, which Rayner & Lang (2012: 320–1) illustrate through an application to the obesity epidemic. Taking just the material dimension, local authorities can use planning laws to build physical activity into people’s lives (e.g. by developing cycle paths); governments can pass laws which link food producers’ profits to the production of healthier food ranges; and the public can seek to live more healthily by demanding increased access to public space and making use of play spaces for children in streets and parks (e.g. through schemes such as Play Streets) (Gill, 2015; Play England, 2015).
The ecological public health approach is based on the interaction between human health and the health of the environment – both local and global. The model also suggests, therefore, that the responsibility for improving the health of the public is multidimensional:
The complexity and multiple interactions which Ecological Public Health assumes mean that no one or few institutions, bodies or professions can resolve public health problems on their own. Public health is inevitably about teams, about the collective of actors, not the intrinsic superiority of one profession.
(Rayner & Lang, 2012: 314)
This framework emphasises the need for collective action to improve individual health and the health of communities. This is recognised as one of the key messages of Public Health England:
local government and the NHS, together with the third sector, have vital roles to play in building confident and connected communities as part of efforts to improve health and reduce health inequalities
(South, 2015a: 3)
Health visitors, with their unique access to all of the families within a community, therefore have a key role to play as part of the team of health and social care practitioners working with the community to improve health. In England, this role has been specified as occurring at the community level within the 2011 service model of health visiting (DH, 2011), but as illustrated in Box 3.1, health visitors need to make use of their community-work skills at all four levels of provision. Working with local communities, they can help to develop the community’s skills and knowledge to address local health issues. Working with professional communities, such as midwives and social workers, in providing universal and universal plus services, they need to know and understand local services and have relationships with people within those services in order to make appropriate referrals.
The idea of community is central to the provision of health care, to public health, and to the description of social life in general, but there are very many different interpretations of what it denotes. Community is one of the traditional concepts in sociology, and Delanty (2003) argues that:
The idea of community, which perhaps explains its enduring appeal, is related to the search for belonging in the insecure conditions of modernity. The popularity of community today can be seen as a response to the crisis in solidarity and belonging that has been exacerbated and at the same time induced by globalization.
Delanty (2003: 1–2)
Activity 3.1 will help you explore your understanding of ‘community’.
‘Community’ is a complex term, as captured in the definition used by the National Institute for Health and Care Excellence (NICE):
A community is defined as a group of people who have common characteristics. Communities can be defined by location, race, ethnicity, age, occupation, a shared interest (such as using the same service) or affinity (such as religion and faith) or other common bonds. A community can also be defined as a group of individuals living within the same geographical location (such as a hostel, a street, a ward, town or region).
(NICE, 2008: 38)
The word ‘community’ originates from the Latin communis, which can mean ‘affable’, ‘collective’, ‘common’, ‘open’, ‘public’, ‘social’, and ‘universal’ (www.wordhippo.com). In attempting to analyse the word further, Tonnies (published 1887; cited in Harris, 2001) contrasted the concepts of Gemeinschaft and Gesellschaft. Gemeinschaft is described as the most basic form of human grouping, characterized by rich and satisfying relationships. Gesellschaft, on the other hand, describes those relationships which are essentially superficial and impersonal. The quality of relationships within a community is identified as a defining characteristic in a discussion of the term on the Resilience website (www.resilience.org), where the following definition is proposed: ‘A community is a network of social and economic relationships and the places where those relationships interact’. This definition, in using the word ‘places’ rather than a defined geographical location as a characteristic of a community, allows for other types of locations of interaction, such as digital locations and Internet communities (e.g. Facebook, WhatsApp, the Health Visiting Community of Practice Evidence Hub). As McNaught (2009: 167) comments, ‘What gives the notion of community its strengths is the self-perception and awareness of its members that they are a “community”.’
Communities and theories about communities are not static (Crow, 2002). The changes that can occur in one community over time are made very clear by the case of the East End of London. In 1957, Young & Willmott (2007) published a classic study entitled Family and Kinship in East London, which showed the value of the strong relationships in that community in supporting its resilience. Almost 50 years on, a new study of the area, revealingly entitled The New East End: Kinship, Race and Conflict (Dench et al., 2006), found that the community had changed radically and that tensions between different groups characterised relationships in the area.
The various meanings and confusions surrounding the concept of ‘community’ occur because the word is used in both descriptive and evaluative terms. Just think of the many ways we use it: we talk of community nursing, community spirit, community policing, the European Community, community education, and so on. In addition, it often not only describes a range of features in social life but puts these features in a favourable perspective. As Hawtin & Percy-Smith (2007: 39) note, definitions of community ‘are almost always positive, evoking feelings of warmth and closeness.’ Unlike many other terms relating to social organization, such as ‘state’ or ‘society’, the term ‘community’ is seldom used in an unfavourable sense. However, as discussed in Chapter 2, considerable disparities and inequalities exist between and within communities, which have the potential to undermine a local community or wider society. Health inequalities, social disturbance (e.g. riots), and rapid changes in population composition suggest that the work of community building has the potential to impact on community health, social cohesion, and community capacity (Lawrence, 2008; Community Development Foundation, 2014).Health visitors work with a range of different communities, whether defined by location (e.g. a neighbourhood), by interest (e.g. new mothers), or by ethnicity (e.g. a Turkish women’s group), and interface with others, such as those on the Internet (e.g. Netmums: www.netmums.com). From the preceding discussion, it can be seen that communities play a central part in people’s lives, and it is therefore important to ask what impact they have on the health of individuals, families, and on the communities themselves.
The experience of community has a significant impact on well being, physical and mental health, and inequalities in health. South (2015b: 32) summarises the evidence on the impact of community-centred approaches on health, identifying improvements in health literacy, increased social capital, increased civic engagement by community members, and – at the organisational level – outcomes including increased uptake of preventive services. Health visitors’ work with local communities or neighbourhoods – including understanding, intervening in, and measuring the well being and health of these communities – contributes to the wider public health in an area.
If we focus on the neighbourhood, the usual workplace for health visitors, the Young Foundation suggests:
Neighbourhoods are ultra-local communities of place. Most people feel they intuitively understand what they mean, in the shape of neighbourly interactions, mutual support, gathering places and a friendly, attractive environment – or a ‘bad neighbourhood’, danger, anti-social interaction, exclusiveness, isolation and dereliction.
(Young Foundation, 2010: 9)
The Young Foundation (2010: 11) also mentions the rule of thumb of planners of new towns that ‘the overall size of a neighbourhood should be dictated by “the maximum walking distance for a woman with a pram”’. The neighbourhood – or a group of neighbourhoods – forms the usual area of practice of the health visitor and health visiting team, although in many rural areas neighbourhoods may be spread over a large area.
The Young Foundation (2010) suggests that our understanding of neighbourhoods has three aspects (see Figure 3.1): the administrative wards or geographic boundaries of an area; our personal identification and mental map of our neighbourhood; and the public realm, including open spaces, services, schools, and community centres. The interaction of these three aspects provides a description and understanding of the experience of a neighbourhood. From a health visiting point of view, it also indicates the role that local public services, such as health visiting, play in the experience of the community and raises questions concerning joint working between different public services to support a positive neighbourhood experience.
An individual’s experience of their neighbourhood includes feelings of mutual support and their relationships within the community, which help them cope with and enhance their health and the health of their families. These subjective elements go to make up what Moos (Kloos et al., 2012) terms the ‘social climate’, which affects the quality of life of individuals and of the community. The social climate in a particular setting results from the interplay of three elements: relationships and the support experienced by community members; personal development and the extent to which individuals are supported to grow and develop skills in a particular environment; and system maintenance and change, in which emphasis is put on maintenance of order and behaviour in the setting. Moos (1976) suggests that environments have unique personalities, just as people do: some are supportive, some competitive. This approach, using the environmental-social, rather than the environmental-physical, emphasises impressionistic elements of description, which are, however, measurable using various measurement scales, including the Family Environment Scale (Moos, 2002), used recently in a study of the German application of the Family Nurse Partnership (FNP) model (Sierau et al., 2015).
Historically, planners and policy makers have relied on objective measures of a community. They have measured such things as housing and unemployment, because it is argued that such factors influence people’s lives. These types of measure are useful because they enable comparisons to be made between areas and groups and can be a guide to changing socioeconomic conditions. The question, however, remains as to the meaning of these statistics and their relationship to the subjective experience. We can, for example, measure the housing density, but what does that tell us about the pleasures or problems of living in a particular estate? According to Campbell et al. (1976), who were early researchers in the field of quality-of-life measures, the use of social indicators alone is not sufficient: in order to know the quality of life experiences, one must go directly to the individual for a description of what their life is like. In a review of quality-of-life measures, Bowling (2014) discusses these wider measures (with reference to Campbell et al.’s (1976) work), which take into account people’s perceptions of the quality of their lives and the factors which matter to them and influence their feelings of well being. Krupat & Guild (1980) identified in their early research a number of factors which they suggest could be used to capture the social climate of a city or community. These factors can be seen now to inform the work being undertaken by the Office for National Statistics (ONS) to measure national well being: ‘We must measure what matters – the key elements of national well-being. We want to develop measures based on what people tell us matters most’ (ONS, 2015). Six factors which are meaningful to people and by which social climate can be described emerge in Krupat & Guild (1980)’s work:
- 1. Warmth and closeness: This first and most important factor contains items reflecting general feelings of security and support which an environment may provide, such as a relaxed atmosphere, a sense of intimacy, a safe, healthy, and peaceful place, and friendly people.
- 2. Activity and entertainment: This factor contains items such as activity, entertainment, diverse selection, dense population, and an atmosphere of culture. Density is seen as being related to the opportunity for activity and entertainment, and reflects positive aspects of urban life, rather than the isolation and anonymity that are often described.
- 3. Alienation and isolation: This factor contains items such as apathy, dirty surroundings, loneliness, distrust, confusion, and violence. It predominantly includes items referring to the characteristics of people, but it also refers to the physical condition of the environment, which is seen as something which fosters – or is a result of – a breakdown in interpersonal solidarity.
- 4. Good life: This factor contains items such as intellectual people, affluent people, liberal people, prestigious places, the valuing of old ways, and people who are interesting because they are not locals. It again refers to the characteristics of the people, and it may be seen as elitist. Different values will be important in different communities. Included here is the recognition of spatial mobility and innovation.
- 5. Privacy: This factor includes items such as gossip, intrusion, ignorance, and pettiness. It refers to a dimension of life involving privacy and carries a strong negative connotation, with the inclusion of items noting pettiness and ignorance on the part of people.
- 6. Uncaring: This factor includes items such as snobby people, a depressing environment, and insensitive people. It represents the uncaring aspects of social climate and includes aspects of people’s behaviour and feelings about the overall social life.
- 3. Alienation and isolation: This factor contains items such as apathy, dirty surroundings, loneliness, distrust, confusion, and violence. It predominantly includes items referring to the characteristics of people, but it also refers to the physical condition of the environment, which is seen as something which fosters – or is a result of – a breakdown in interpersonal solidarity.
It can be seen that the elements of the social climate of a community relate to the material, biological, cultural, and social framework discussed earlier (Rayner & Lang, 2012). These factors suggest areas which need to be addressed in developing the infrastructure of new communities. Current approaches to new developments aim to bring together those involved with the design of new houses and the physical environment of communities with members of the community and public health practitioners to build more healthy communities (Ross & Chang, 2012; House, 2015).
The level of support in a neighbourhood indicates the networks and relationships or social capital present there, which interact to reinforce a salutogenic approach to health and well being. Such relationships and networks enable people to manage and deal with the challenges in their lives, leading to the question – of great relevance to health visitors working with communities – posed by Antonovsky (1996):
What can be done in this ‘community’ – factory, geographic community, age or ethnic or gender group, chronic or even acute hospital population, those who suffer from a particular disability, etc. – to strengthen the sense of comprehensibility, manageability and meaningfulness of the persons who constitute it?
(Antonovsky, 1996: 16)
One response to this question can be seen in the launch of the Big Society by Prime Minister David Cameron in 2010, which aimed to ‘give power back to the people, to involve us all in creating a fairer society’ (Civil Exchange, 2015: 4). The Coalition Government’s and the present Conservative Government’s policies can be seen to be promoting the three key areas underpinning the notion of the Big Society: community empowerment, opening up public services, and social action. In relation to health visiting, the increase in the number of health visitors achieved under the Coalition Government (2010–May 2015), which now, arguably, enables health visitors to fulfil the community level of the Health Visitor Service Model (NHS England, 2014b), has the potential to contribute to both building community capacity (BCC) and community empowerment, and promoting the health of communities. The University of Kansas Group for Community Health and Development, as part of its role as a WHO Collaborating Centre, has produced a free Community Tool Box (University of Kansas, 2015) to support work to build healthy communities and contribute to social change, which health visitors should find very useful in working towards delivering the community element of health visiting practice.
Well-being extends the idea of social climate (Krupat & Guild, 1980) and has been described by Layard & Dunne (2009) (cited by Roberts et al., 2009) as resulting from the interaction of seven factors:
- 1. family relationships;
- 2. financial situation;
- 3. work;
- 4. community and friends;
- 5. health;
- 6. personal freedom;
- 7. personal values.
Individual, subjective well-being is therefore impacted by a person’s health and feelings of being healthy. Mguni & Bacon (2010) define an individual’s feeling of well-being as a combination of subjective well-being and community well-being:
The focus of our work has been on individual ‘subjective well-being’, how people experience the quality of their lives, alongside community well-being – the extent to which local services and infrastructure has the capacity to support or reduce well-being. We see this as the most fundamental test of any area: does it provide its citizens with a good life?
(Mguni & Bacon, 2010: 11)
These authors illustrate the relationship between community well-being and an individual’s sense of well-being and health in a circular diagram (see Figure 3.2). When we consider the elements of this figure in relation to the discussion of the model of the main determinants of health (Dahlgren & Whitehead, 1991) in Chapter 2 (Figure 2.1), we can see how the experiences of individuals of, for example, poor access to quality education and thus a lack of job opportunities, interact to form a community with a reduced sense of wellness, a poorer sense of social capital (Gilchrist, 2007), and a greater need for inclusion in the Big Society (Mulgan, 2010).
Communities living close together can have widely different health experiences. The iconic map of the London Underground system provides a graphic representation of the different levels of community health within one small geographic area. As shown in Figure 3.3, communities located along the Jubilee Line from affluent Westminster in the centre of London to the more deprived Canning Town experience a loss of 1 year in life expectancy for each stop you move further east.
Evidence of the impact of the different factors on health and the identification of the needs of a local community enable us to identify where interventions (e.g. through children’s centres, parents’ sense of well-being, social networks, and relationships) have the potential to change communities, people’s experience of their neighbourhood, wellness, and health:
Even when families live in poor housing with inadequate income and experience unemployment and multiple deprivations, finding ways to enhance adult well-being can have positive repercussions on the whole family, giving all its members a better chance of constructing a different kind of future.
(Roberts et al., 2009: 13)
As long ago as 1971, Tudor Hart put forward the concept of the inverse care law: the availability of good medical (and nursing) care tends to vary inversely with the need for it in a given population (Tudor Hart, 1971; Watt, 2002). That is, people with greater health care needs have less access to good health care provision. One way to address this imbalance is through a reorientation of health care to an approach that is people-centred, includes a focus on health needs and enduring personal relationships, is comprehensive and continuous, takes responsibility for the health of the whole community across the life span, has responsibility for tackling the determinants of ill health, and integrates public health with primary care provision (Starfield 1996; WHO, 2008; Bryar et al., 2012), and in which ‘People are partners in managing their own health and that of their community’ (WHO, 2008: 43). Public health practitioners, as part of health systems, therefore have a role to play in improving the health of communities. The next section will consider the role of the health visitor in this regard.
There is a long history of community and public health work in health visiting. Since the establishment of health visiting in 1862, there has been an ongoing tension for health visitors and health visiting services between working at the community or public health level and working with individuals and families on a one-to-one basis (see Chapter 2). Craig (1995: 5), in A Different Role: Health Visiting in a Community Project, refers to both aspects in a description of the work of the first health visitor employed in Glasgow, who worked with the city’s first woman doctor in the early 20th century ‘to supervise the Milk Depot Scheme and undertake infant consultation sessions’. The tension between a public health/community focus and a focus on individuals is also reflected in public health policy: measures such as the ban on smoking in public places (Bauld, 2011) are aimed at changing the exposure of whole populations to tobacco smoke, while strategies such as Change4Life (www.nhs.uk/Change4Life/Pages/change-for-life.aspx) are aimed at changing individuals’ health behaviours to improve both their own health and that of the whole population.
The public health role has long been included in courses for student health visitors. One of the functions of the health visitor identified in 1967 was in the ‘Recognition and identification of need and mobilization of appropriate resources’ (Council for the Education and Training of Health Visitors, 1967; cited in Robinson & Elkan, 1996: 4). Robinson & Elkan comment that ‘The formalization of group and population-based health needs assessment (HNA) by nurses working in community settings can be traced from 1965, when a new syllabus of training for health visitors was introduced’ (Council for the Education and Training of Health Visitors 1965; cited in Robinson & Elkan, 1996: 4). The increasing emphasis on the community role of the health visitor at this time is illustrated in the earlier editions of the present volume (Luker & Orr, 1992; Orr, 1992) and evident in the principles of health visiting first defined in 1977 (see Chapter 2, p. 63).
In the 1970s to 1980s, there was a resurgence of interest in the community role of health visitors, as Drennan (1988) notes in Health Visitors and Groups: Politics and Practice:
While envisaging a role that responds to present-day society, health visitors have come to look increasingly to group and community work methods of practice, with their emphasis on consumer-expressed definitions of need. Health visitors are not alone in this change of emphasis. Increasingly, the philosophies of the provision of health care are now embracing the notion of partnership between the professional and individual and community at large. More emphasis has been given to client or community perceptions and definitions of need, participation in planning and active involvement in the provision and evaluation of care.
(Drennan, 1998: 8)
As previously discussed, the philosophy of partnership identified by Drennan almost 30 years ago has been given a new impetus in the NHS Five Year Forward View (NHS England, 2014b). Examples of this type of work are provided by the Stockport Model of Health Visiting (Swann & Brocklehurst, 2004), which enabled and required health visitors to engage with the public health elements of the role; the multifaceted public health/community development activities in Glasgow (Craig, 1995; Craig & Lindsay, 2000); the community-development approach used in work in a community health house set up on a council estate in the Welsh Valleys (Bryar & Fisk, 1994); and, more recently, the community projects initiated as part of the BCC developments (Pearson, 2013; McInnis et al., 2015), which form part of the delivery of the community level of the Health Visiting Service Model (NHS England, 2014a).
During the 1990s and into the 21st century, the focus of health visiting work reverted to one on individuals away from work at the community/public health level. This reorientation resulted from a number of changes, including the NHS focus on targets, the influence of evidence-based documents (which raised questions concerning the efficacy of some of the screening work undertaken by health visitors; Hall & Elliman, 2006), and changes in the regulation of health visitors. The development of Sure Start/children’s centres from the late 1990s further reduced the need for health visitors to lead or provide group- and community-level initiatives. The closure of the health visiting register by the NMC in 2002, which led to a reduction in the number of health visitors, further contributed to the decline. Given these pressures, managers of health visiting services required health visitors to prioritise work with individuals at the expense of community-focussed work. This dichotomy in provision has been perceived as a tension for many health visitors (Craig & Lindsay, 2000). Cameron & Christie (2007) interviewed health visitors in 2003, and one of the respondents, looking back over the previous 10 years of her practice (to 1993) in various parts of the UK, describes the lack of focus on community/public health work:
My early experience of health visiting was mainly crisis visiting and coping with a very large 0–5 caseload, with lots of problems and public health was a very small component of the work and only in relation to core under 5 work. I can’t remember doing any groups or development work.
(Cameron & Christie, 2007: 84)
At the same time, work on setting competency standards for the wider public health workforce was taking place, supported by public health organisations including the Community Practitioners and Health Visitors Association (CPHVA). This resulted in the publication of a framework identifying the 10 key areas of public health practice – with associated competencies – that could be applied to all public health practitioners (see Chapter 2, Box 2.3). Activity 3.2 will help you explore the use of one of these elements of public health practice in your work with a community. This framework was applied to the education of SCPHNs, including health visitors, in the Standards of Proficiency for Specialist Community Public Health Nurses (NMC, 2004), which aligns the standards of proficiency for the 10 areas of public health practice to the four principles of health visiting (termed ‘domains of practice’ in the document). All 25 NMC standards, which guide learning at university and in practice, can be seen to relate to the development by health visitors of skills in promoting the health of communities. Table 3.1 provides examples of standards in relation to each of the domains of practice (principles of health visiting) and its associated principle (area of public health practice). (As noted in Chapter 2, the use of the terms ‘principle’ and ‘domains’ in the NMC document is both ambiguous and confusing.)
Table 3.1 Selected NMC standards of proficiency for health visiting that relate to working with communities
|Principle||Domain: Search for health needs|
|Surveillance and assessment of the population’s health and well-being|
|Principle||Domain: Stimulation of awareness of health needs|
|Working with, and for, communities to improve health and well-being|
|Principle||Domain: Influence on policies affecting health|
|Developing health programmes and services and reducing inequalities|
|Principle||Domain: Facilitation of health-enhancing activities|
|Promoting and protecting the population’s health and well-being|
Since the publication of the NMC standards in 2004, there have been several refinements of the public health framework. The first, the Public Health Skills and Career Framework (Public Health Resource Unit/Skills for Health, 2008), refined the 10 areas of public health practice into four core areas and, in addition, identified five defined areas of practice. In 2013, a further review refined the four core areas of practice and five defined areas (Public Health Online Resource for Careers, Skills and Training, 2013). The four core areas of practice for all public health practitioners are central to the work of health visitors and to working with communities (see Box 3.2).
However, as identified by Cameron & Christie (2007), the low priority that has been given to public health/community skills in recent years has led to many health visitors feeling daunted by the prospect of re-engaging in community-level work, as required by the health visiting service model (DH, 2011) and the commissioning framework in England (NHS England, 2014a), which identifies the remit of the health visiting service as:
Leading, with local partners, in developing, empowering and sustaining families and communities’ resilience to support the health and well-being of their 0–5 year olds by working with local communities and agencies to improve family and community capacity and champion health promotion and the reduction of health inequalities.
(NHS England, 2014a: 12 para. 5.1)
This anxiety was recognised in the roll out of the Health Visitor Implementation Plan 2011–15 (DH, 2011) and led to the commissioning of the BCC module from a team headed by Professor Pauline Pearson of the University of Northumbria. This module provides a combination of online and work-based facilitation support for health visitors, allowing them to reinvigorate or develop new skills in community work by undertaking a community capacity-building project in their area of practice. It is available as an open access module on the e-Learning for Healthcare website (www.e-lfh.org.uk/programmes/building-community-capacity/). Through redevelopment of these skills, enabling health visitors to better connect with communities, it is anticipated that health outcomes for children and their families will be improved (Lynch et al., 2010; NICE, 2008). The BCC module is discussed further on p. 110. If health visitors are going to fulfil their role in working with communities and contributing to local Joint Strategic Needs Assessments (JSNAs) they need skills in learning about and working with communities. The next section discusses a range of ways in which they can develop such skills.
There are a range of approaches to gaining a picture of the health of your local community or neighbourhood. Knowing the local community is fundamental to working in an area, as Gilchrist (2007) notes:
Learning about other people’s cultures and histories is an important aspect of networking, enabling people to empathize with perspectives that are different from their own and to operate appropriately in different settings.
(Gilchrist, 2007: 146)
This section outlines three approaches which help move from a general understanding of the needs of your community to a more detailed picture of the needs of a particular section of that community:
- windshield survey;
- public health walk;
- health needs assessment.
The first activity a health visitor should undertake in a new area is to ‘walk the patch’ or drive around the area, undertaking a ‘windshield survey’ or ‘walking survey’. The purpose of this is to gain information on the obvious characteristics of the area and so identify potential strengths and challenges (Brown & Collins, 2015). Hunt (2013: 142) provides an outline assessment tool for collecting information on the people, places, and social systems evident in the community by making use of ‘the five senses and powers of observation’. Questions to ask while undertaking the survey include: Who are the people in the streets, parks, shops, and community centres? How are they dressed and what are they doing? What are the boundaries of the neighbourhood or area? What types of building are there, and how old are they? What condition are the houses in? Are there any open spaces, and if so, what are these used for? What types of shop are there? How many fast food outlets are there? What services are available? What health services are available? Is there a library, and if so, what types of health information does it provide? Are there any schools, religious buildings, or cinemas? (Hunt 2013: 142–3).
These questions suggest the need to consider carefully the main purpose of the survey, the area it will include, at what time of day to do it, and what the information gained will be used for – as discussed by Rabinowtiz (2015) in the University of Kansas Community Tool Box. Doing a windshield survey at different times of day or on different days will yield different information (e.g. a park might be used by older people on a health walk, younger people playing football, or pet owners exercising their dogs). Rabinowitiz (Rabinowtiz, 2015) provides detailed guidance on undertaking these surveys and the need to consider personal safety, but also suggests participation in community activities – go on the buses, shop in the shops, eat in the cafes, perhaps even walk around with a pram and experience the community from the perspective of a new mother.
Public health walk
A windshield survey may identify evidence of public health issues, such as local reservoirs linked to water supply, buildings which were once local hospitals, old industrial waste indicating possible health risks or unemployment, the use made of parks, the number of fast food outlets in the area, children’s centres, and the number of people in a shopping centre during the day. Identification of these elements can help in understanding the health issues impacting on the current population, as well as some of the attitudes of local people to health care provision.
Once these public health aspects have been identified, they can be examined in more depth through an exploration of the history of the area, examining the local public health reports, reading novels and other books about the area, and talking to local practitioners and residents. This exploration will provide information of help in understanding the relevance and impact of the different public health features identified, which can then be woven together to form a walk tracing the public health history of the area. In East London, one such walk has been developed by the lecturer and historian John Eversley, which provides an introduction for student health visitors to the public health history of part of the borough of Tower Hamlets. Some of the elements included in this walk are shown in Table 3.2. Activity 3.3 will help you construct your own public health walk.
Table 3.2 A public health walk in Tower Hamlets, London
|Evidence in the community||Relevance|
|The (former) Women’s Library (now part of London Metropolitan University)||Previously the local wash house|
|Tall Georgian houses with large windows on the top floor||Homes of the Huguenot weavers, providing light for their work – evidence of immigration|
|A mosque||Previously a synagogue – evidence of immigration|
|Signs on a building indicating a soup kitchen for Jewish immigrants||Immigration; poverty; community support|
Health needs assessment
An HNA involves the collection and analysis of information of relevance to the health of a particular population. The Health Development Agency (HDA) defines HNA as:
a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities.
(HDA, 2004a: 3)
HNA is therefore vital in terms of the commissioning of services and of supporting the direction of the activities of a particular health visiting team. This definition is expanded by the HDA to identify the key elements of HNA:
HNA is an approach that reviews systematically the health issues facing a given population. The starting point in HNA is a defined population. Health issues selected as priorities will usually be those that can help reduce health inequalities. The primary outputs are a set of recommendations, an action strategy based on the evidence gathered about that population, and the identification of effective and acceptable interventions. These should be used to influence policies and service delivery in order to improve health outcomes (highlight added, apart from ‘population’; bold in original)
(HDA, 2004b: 5)
It can be seen from this description that HNA involves the identification of a need, plans to address that need, and evaluation of the impact of the interventions put in place to meet the need. Hooper & Longworth (2002: 9) state that there are three underpinning principles to HNA: improvement, integration, and involvement.
- 1. Improvement of health and inequalities by making changes that improve the most significant conditions or factors affecting health…
- 2. Integration of this improvement in health into the planning processes…
- 3. Involvement of:
- people who know about the health issues in a community
- people who care about those issues
- people who can make changes happen.
- people who know about the health issues in a community
These definitions focus on the identification of needs. Stewart et al. (2009: 133) stress the importance of identifying health assets alongside needs: ‘The purpose of health needs assessment (HNA) is to identify the health assets and needs of a given population to inform decisions about service delivery to improve health and reduce health inequalities’.
Before examining the process of HNA, it is important to consider our understanding of need. Stewart et al. (2009) discuss a number of approaches, including Maslow’s hierarchy of needs (Maslow, 1954). Maslow identifies need from the perspective of the individual, ranging from the fulfilment of basic physiological needs through to self-actualisation (the individual’s fulfilment of their own potential). This approach may be contrasted with that of Bradshaw (1972, 1994), who categorises need from ‘the perspective of the person or organisation identifying the need’ (Stewart et al., 2009: 136). Although Bradshaw first proposed his taxonomy many years ago, Scriven (2010) notes that it is still of great use in distinguishing levels of need. Bradshaw’s fourfold classification is based on the derivation of the criteria adopted to recognize need, be they diagnostic or prescriptive. He identifies four types of need:
- 1. normative needs;
- 2. felt needs;
- 3. expressed needs;
- 4. comparative needs.
Normative needs are defined in accordance with some agreed standard. A desirable standard is laid down by an expert or professional and is compared with a standard which already exists. If an individual or group falls short of the desirable standard, they are identified as being in need. A normative definition of need is by no means absolute. It may not correspond with other definitions, and, of course, different experts may have conflicting standards. It is relatively easy to lay down standards for housing – where, for example, inside plumbing and electricity may be accepted as two standards of adequate housing – but it is more difficult to set standards in less tangible areas such as health without becoming involved in making value judgments. Thus, normative definitions of need may differ according to the value judgments of different experts. Furthermore, the idea of normative need demonstrates a particular view of service delivery, in that it places the expert or professional at the centre of needs assessment.
A felt need is a need expressed by an individual or community. It is termed a ‘want’. Felt need alone may be an incomplete measure because it is limited by the perceptions and knowledge of the individual or community, who may express a desire for a service without needing it, fail to recognize their own need, or assume that no acceptable solution exists.
Expressed need, or ‘demand’, is a felt need turned into action. Under this definition, total need is defined as ‘those people who demand a service’. Commercial weight-management classes provide an example of a response by industry to an expressed need (Scriven, 2010). Expressed need alone is an unsatisfactory measure, however, because some people will not turn felt need into demand or, again, will not recognize their own need. Waiting lists are an insufficient measure of unmet need, for example, as some people will be pre-symptomatic. Other forms of information are also needed; for example, any self-help groups in an area or any demand for well women clinics or parenting information for fathers may be seen as examples of expressed need.
Comparative needs are the imputed needs of an individual or group not in receipt of services but similar in relevant characteristics to others receiving such services. For example, if a person receives a service because they have particular characteristics and another person with those characteristics is not receiving that service, then we can say that the second person has a comparative need. Note, however, that provision may not correspond with need: even if area A is receiving more resources than area B, area A may still be in need.
Using the Bradshaw taxonomy, we can consider the interrelations between these four definitions of need. For example, taking the example of fluoridation of water supplies, this need was accepted by public health experts (i.e. was a normative need) long before it was felt, demanded, or supplied. The application of Bradshaw’s taxonomy raises many issues for practice, not the least of which is the lack of clarity about what health visitors should determine to be a normative need and what criteria we should use in comparing provision in our area with what is available in other parts of the district or country. As Naidoo & Wills (2016: 273) conclude, ‘needs are not objective and observable entities to which we must just match our interventions. The concept of need is a relative one, and is influenced by values and attitudes and by other agendas.’ Such other agendas will, of course, also include access to resources and finance that can support services aimed at meeting the identified needs of the community. The process of HNA, in partnership with community members and public health colleagues, and with reference to evidence such as that provided by Marmot et al. (2010), is one way of seeking to address these dilemmas.
Steps to undertaking HNA
The HDA (which was joined with the National Institute for Clinical Excellence, forming the National Institute for Health and Clinical Excellence in 2005, now the National Institute for Health and Care Excellence (NICE)) has produced a guide (HDA, 2004a) and workbook (Hooper & Longworth, 2002) to support people in undertaking HNAs. A five-step process is provided in Table 3.3, and Activity 3.4 will help you to use these steps in undertaking an HNA in your locality.
Table 3.3 Steps in undertaking a health needs assessment (HNA)
|Step 1: Getting started|
|Step 2: Identifying health priorities|
|Step 3: Assessing a health priority for action|
|Step 4: Planning for change|
|Step 5: Moving on/review|
Source: HDA (2004a: 2).
An HNA may be undertaken by a range of different people, but involvement across different services and disciplines will enable collection and sharing of a wide range of information and will ensure that those participating are ready to be involved in the planning and implementation of change. Hooper & Longworth (2002) suggest that some or all of the following might be involved in an HNA: members of the community affected by the issue; community leaders; religious leaders; shop owners; teachers and social workers; police, probation, and community safety officers; GPs and members of the primary care team; local authority staff and elected members; service commissioners; and members of community organisations (e.g. allotment associations). They also suggest that the following questions will be helpful in deciding who should be involved in the HNA:[
- Who knows about the issue?
- Who cares about the issue?
- Who can make change happen related to the issue?
(Hooper & Longworth, 2002: 29)
An HNA may therefore be undertaken by such a cross-community team, or else a health visiting team may undertake an HNA of an area of its practice population to help plan the types of service it will provide and engage with members of the wider community as part of this. An HNA can cover a whole population (e.g. a neighbourhood) or be focused on a particular part (e.g. families with children over the age of 2). Such groups may or may not identify themselves as a community (refer back to Figure 3.1 in thinking about communities of interest). Once the focus of the HNA has been decided, the team undertaking it must develop a realistic time plan.
A major part of an HNA is the collection of information of relevance to the health needs of the population under study. This information will be both quantitative and qualitative. It will involve accessing information from local, national, and international sources and undertaking local forms of qualitative data collection, which might include interviews, focus groups, and observation of the use of services or spaces. Sources of information are shown in Table 3.4, while methods of identifying information with the local community are shown in Table 3.5 (other sources are provided in Chapter 7).
Table 3.4 Examples of sources of quantitative information on the health of a population
|SourceTypes of information|
|The local public health report (e.g. www.croydon.gov.uk/sites/default/files/articles/downloads/Annual%20Public%20Health%20Report%20for%202015.pdf)||Local health needs and current priorities|
|The local commissioning plan (e.g. www.northsomersetccg.nhs.uk/media/medialibrary/2014/07/North_Somerset_CCG_Five_Year_Strategic_Plan.pdf)||Plan of action across local organisations to meet health and social needs|
|Association of Public Health Observatories, www.apho.org.uk|
|UK National Statistics, www.gov.uk/government/statistics|
|NHS Evidence, www.evidence.nhs.uk|
Used to support high-quality health care
|Child and Maternal Health Observatory, www.chimat.org.uk|
|Birth cohort studies – Centre for Longitudinal Studies, www.cls.ioe.ac.uk|
|PEGASUS (Professional Education for Genetic Assessment and Screening), cpd.screening.nhs.uk/pegasus|
|Marmot Review, www.instituteofhealthequity.org|
|Joseph Rowntree Foundation, www.jrf.org.uk|
|World Health Organisation, www.who.int|
|Public Health England, www.gov.uk/government/organisations/public-health-england|
|Public Health Wales, www.wales.nhs.uk/sitesplus/888/home|
Table 3.5 Examples of sources of qualitative information on the health of a population
|Methods of gathering local information|
|Observation of the use of facilities and services in the local community|
Interviews with users of facilities and services
Interviews with key informants (e.g. informal group leaders, shopkeepers, religious leaders)
Public meetings and forums
Using local media, including radio phone-ins
Reviewing local newspaper content
Using Internet sites (e.g. a local community site, Facebook or Twitter groups)
Community health panels and citizens’ juries
Research techniques, including structured observation, rapid appraisal, and ethnographic studies
Source: Naidoo & Wills (2009: 264).
The information collected through these various methods may then be used to identify the extent of a health need in a particular population, the attitudes of people to that need, and the ability of the population to respond to the need. The health profiles on the Association of Public Health Observatories website will make a good starting point for identifying the health priorities in your area. Table 3.6 provides information from the health profiles of two contrasting areas of England, demonstrating the different focuses of health visiting intervention between them. Activity 3.5 will help you explore the information in the health profile relevant to your area.
Table 3.6 Comparison of health profile information
|Health profile information,||Health profile information,|
|June 2015||June 2015|
|The health of people in Hull is generally worse than the average for England|
Life expectancy is 12.1 years lower for men and 8.2 years lower for women in the most deprived areas compared to the least deprived
Early deaths from cancer, heart disease, and stroke and deaths from smoking are all worse than the England average
In Hull, breastfeeding initiation, smoking at time of delivery and teenage pregnancy are all worse than the England averages. However, the percentage of obese children (age 6) is close to the England average
|The health of people in Surrey is generally better than the England average|
Levels of deprivation are low and life expectancy is higher than average
Obesity in children (age 6) is below the England average
For all but 2 of the 32 indicators (road traffic accidents and malignant melanoma), health in Surrey is better than the England average
Source: www.apho.org.uk/default.aspx?QN=HP_FINDSEARCH2012 (last accessed 30 March 2016).
Organisations use a range of other approaches to identify needs, and the reports and strategies produced by local authorities and others as part of these processes provide valuable information about health needs in different areas. A health impact assessment: ‘enables the identification, prediction and evaluation of likely changes to health, both now and in the future, as a consequence of a policy programme or plan.’ (Naidoo & Wills, 2016: 187). It may be used to measure the impact of both health-related policies and of other strategies which are not directly related to health but have consequences for it (Lock, 2000) (see Table 3.6). Health equity audits are another way in which the health of populations can be assessed, usually by organisations such as health trusts or local authorities. Health equity is different to health inequality but may contribute to it: ‘health equity describes differences in opportunity for different population groups which result in different life chances, access to health services…’, which can lead to health inequalities (Hamer et al., 2003: 11). Hamer et al. (2003: 11) describe a health equity audit as focusing on ‘how fairly resources are distributed in relation to the health needs of different groups. (This may include resources such as services, facilities, and the determinants of health like employment and education.)’
Local authorities and local health commissioners were required under the Local Government and Public Involvement in Health Act 2007 to undertake a JSNA to identify the health and well-being needs of their local population and draw up plans to address them (DH, 2007). The Health and Social Care Act 2012 revised the requirement for the production of local JSNAs and associated Joint Health and Wellbeing Strategies (JHWSs) through health and wellbeing boards, led by the local authority and the local clinical commissioning groups (DH, 2013; NICE, 2014). JHWSs provide the means to address the needs identified through the JSNA process and guide commissioning of services. In England, the commissioning of services is led by clinical commissioning groups, which produce commissioning plans stating how local services will respond to identified needs (www.wellards.co.uk/papers/courses/diplomas_comms2014_TIER2/what_are_comm_plans2.html). Health visitors have responsibilities identified in the Health Visiting Service Specification (NHS England, 2014b) to contribute to the development of the JSNA and to the delivery of JHWSs. In relation to their role at the community level, they should be:
Providing and developing intelligence about communities’ assets in partnership with communities to support the health and well-being of 0–5 year olds, to inform the Joint Strategic Needs Assessment (JSNA)
(NHS England, 2014b: 13, 5.7.1)
Once evidence of the extent of health needs has been compiled, the HNA process moves on to the development of interventions and the creation of an action plan to address the health needs in the local commissioning plans (see Table 3.4). Discussion of the utilisation and evaluation of the BCC approach by health visitors will help demonstrate how health visitors and health visiting services can develop and implement these skills.
As previously discussed, recognition of the need to refresh and extend health visitors’ skills in working with communities led to the commissioning by the Department of Health of the BCC module developed by the University of Northumbria (Pearson, 2013). Some universities have also developed their own modules and learning resources (e.g. Sheffield Hallam University), while others have incorporated the e-learning module into their SCPHN programmes (e.g. University of West of England). A wide range of resources are now available to support health visitors in working with communities. Some have been specifically written for health visitors, including Building Community Capacity (BCC): An Introductory Toolkit for Health Visitors (Kenyon, 2015), while others are aimed at a wider audience, such as the guidance produced by the Scottish Community Development Centre for Learning Connections (2007) and the online Community Tool Box (University of Kansas, 2015) produced by the Work Group for Community Health and Development, University of Kansas, a WHO Collaborating Centre, as a worldwide free resource (see Box 3.3).