Being orientated towards social justice: Learning for health visitor practice.

Not applicable.

"Health for All" in England and Brazil?

This article discusses the achievements and challenges that England and Brazil face in relation to their capacity to address inequalities in health through health promotion and public health policies. Using secondary data (policy texts and related documents), this article contextualizes, explains, and critically appraises health promotion and public health efforts for the reduction of inequalities in health in the 2 countries. A historic documentary analysis was undertaken, with hermeneutics as the methodological framework. The global economic crisis has prompted the so-called developed economies of Europe to reconsider their economic and social priorities. England represents a state facing this kind of challenge. Equally, Brazil is assuming new positions not only on the world stage but also in terms of the relationship it has with its citizens and the priorities it has for state welfare. The United Kingdom continues to finance a health care system allowing universal access in the form of the National Health Service, and state concern about the public health task of reducing inequalities has recently been underlined in policy. For Brazil, although there have been recent achievements related to population access to healthcare, challenges continue, especially with regard to the quality of care.

Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: a narrative review of the literature.

INTRODUCTION: There is increasing international interest in universal, health promoting services for pregnancy and the first three years of life and the concept of proportionate universalism. Drawing on a narrative review of literature, this paper explores mechanisms by which such services might contribute to health improvement and reducing health inequalities. OBJECTIVES: Through a narrative review of empirical literature, to identify: (1) What are the key components of health visiting practice? (2) How are they reflected in implementing the universal service/provision envisaged in the English Health Visitor Implementation Plan (HVIP)? DESIGN: The paper draws upon a scoping study and narrative review. REVIEW METHODS: We used three complementary approaches to search the widely dispersed literature: (1) broad, general search, (2) structured search, using topic-specific search terms, (3) seminal paper search. Our key inclusion criterion was information about health visiting practice. We included empirical papers from United Kingdom (UK) from 2004 to February 2012 and older seminal papers identified in search (3), identifying a total of 348 papers for inclusion. A thematic content analysis compared the older (up to 2003) with more recent research (2004 onwards). RESULTS: The analysis revealed health visiting practice as potentially characterized by a particular 'orientation to practice.' This embodied the values, skills and attitudes needed to deliver universal health visiting services through salutogenesis (health creation), person-centredness (human valuing) and viewing the person in situation (human ecology). Research about health visiting actions focuses on home visiting, needs assessment and parent-health visitor relationships. The detailed description of health visitors' skills, attitudes, values, and their application in practice, provides an explanation of how universal provision can potentially help to promote health and shift the social gradient of health inequalities. CONCLUSIONS: Identification of needs across an undifferentiated, universal caseload, combined with an outreach style that enhances uptake of needed services and appropriate health or parenting information, creates opportunities for parents who may otherwise have remained unaware of, or unwilling to engage with such provision. There is a lack of evaluative research about health visiting practice, service organization or universal health visiting as potential mechanisms for promoting health and reducing health inequalities. This paper offers a potential foundation for such research in future.

Home visitors and child health in England: advances and challenges / Visitadores domiciliares e saúde infantil na Inglaterra: avanços e desafios / Visitantes domiciliarios y salud infantil en Inglaterra: avances y desafíos

There is increasing interest in the early years as a focus for reducing health inequalities as well as one that is important for the children themselves. This paper describes the introduction in England of Sure Start Local Programmes, which included home visiting within a community development approach, and an intensive home visiting programme, the Nurse-Family partnership, for disadvantaged teenage mothers. It reflects on changes and challenges in service provision to mothers and their pre-school children in England, explaining that a long tradition of home visiting was, paradoxically, reduced as attention focused on the newer initiatives. This is now being addressed, with attention to a range of evidence based programmes and a specific focus on heath visitor provision.

Há um crescente interesse, nos últimos anos, objetivando reduzir as desigualdades na área da saúde, bem como uma desigualdade específica infantil. Este artigo descreve a introdução, na Inglaterra, de programas locais chamados Sure Start, que incluem visitação domiciliar, dentro de uma abordagem de desenvolvimento da comunidade, e um programa intensivo de visitas domiciliares, a parceria com a Nurse-Family, para mães adolescentes em condições desfavoráveis. Isso reflete nas mudanças e desafios da provisão de serviço as mães e filhos em idade pré-escolar, na Inglaterra, explicando que uma longa tradição de visitas domiciliares foi, paradoxalmente, reduzida, conforme a atenção concentrava-se em novas iniciativas. Isso está sendo, agora, tratado, atentando para uma variedade de evidências com base nos programas e com um foco específico na provisão de visitantes da área da saúde.

Existe un creciente interés en los años tempranos de la infancia para reducir inequidades de salud, tratándose de algo de alto impacto para los propios niños. Este artículo describe la introducción en Inglaterra de los Sure Start Local Programmes (Programas Locales de Inicio Seguro), los cuales incluyen visitas domiciliarias insertas en una aproximación al desarrollo comunitario, y un programa intensivo de visitas, el Nurse-Family partnership (Asociación Enfermera-Familia), para madres adolescentes en situación desventajosa. Se reflexiona acerca de cambios y desafíos en provisión de atención a madres y sus hijos en edad preescolar en Inglaterra, explicando que una larga tradición en visitas domiciliarias fue reducida, paradójicamente, por enfocarse la atención en las iniciativas más actuales. Todo esto está siendo direccionado, atendiendo a una serie de programas basados en la evidencia y a un foco específico en la percepción del visitante de campo.

Home visitors and child health in England: advances and challenges.

There is increasing interest in the early years as a focus for reducing health inequalities as well as one that is important for the children themselves. This paper describes the introduction in England of Sure Start Local Programmes, which included home visiting within a community development approach, and an intensive home visiting programme, the Nurse-Family partnership, for disadvantaged teenage mothers. It reflects on changes and challenges in service provision to mothers and their pre-school children in England, explaining that a long tradition of home visiting was, paradoxically, reduced as attention focused on the newer initiatives. This is now being addressed, with attention to a range of evidence based programmes and a specific focus on heath visitor provision.

Controversial questions (part two): should there be a direct-entry route to health visitor education?

This is the second paper in a series of three, drawing on the experience of providing evidence to the Health Select Committee's 2008 inquiry into health inequalities. Material submitted has been adapted and expanded according to three common and often controversial questions. One member of the committee enquired about the relevance of education and training to recruitment issues in health visiting, asking why it is necessary to be a nurse and what would be the barriers to changing this arrangement, which has been in force since the 1960s.This paper summarises some of the longstanding discussions about this issue, which has rarely been off the agenda, and proposes that, since health visiting is no longer in statute, the time has come to take a radical approach and to change current arrangements.

Controversial questions (part one): what is the right size for a health visiting caseload?

Questions asked by managers, commissioners and policy makers to find out what is, or should be, happening within health visiting services can seem immensely helpful in focusing the mind or clarifying key points. Alternatively, they may feel hostile and accusative, if their starting assumptions are alien to the everyday experience of health visitors. This paper is the first in a short series of three that draw on the experience of providing evidence to the Health Select Committee's 2008 inquiry into health inequalities. A formal process of seeking written evidence was followed up with specific questions in oral session, asked by committee members, trying to find out about how health visiting services relate to health inequalities. This line of questioning reflects concerns expressed elsewhere about the variability of health visiting services across the country and the lack of clear alignment to areas of deprivation, leading to calls for an increase in targeted services, instead of universal ones. This paper explores the notion of 'caseload', the distribution of services according to levels of deprivation and delivery of a universal or targeted health visiting service.

Health visiting assessment processes under scrutiny: a case study of knowledge use during family health needs assessments.

BACKGROUND: Accurate assessment of family health need is a core health visiting skill, requiring considerable knowledge and expertise. To date, there has been only limited empirical examination of the types of knowledge and ways of knowing which are likely to influence health visiting practice during family health needs assessments. OBJECTIVES: This paper will present a detailed analysis of health visiting assessment processes and will explicate some of the many elements associated with the processes of identifying and assessing family health needs. DESIGN: An in-depth case study was undertaken to explore health visiting practice across three study sites. The focus of interest was to attempt to understand the factors that may influence a health visitor in making a professional judgement to offer a family extra support. SETTINGS: The study was conducted in three community Trust case sites in England, UK. METHODS AND PARTICIPANTS: The study was informed by a constructivist methodology. Data collection took place during 56 observed home visits to families receiving increased health visiting support and intervention. Following the home visits separate in-depth interviews were undertaken with the health visitors and the clients. RESULTS/CONCLUSIONS: This paper will explicate some of the many elements associated with the processes of identifying and assessing family health needs. It endeavours to unravel some of the complexity and intricacies of these processes and provide insights into health visitors' practical 'know-how'.

Health visiting assessment--unpacking critical attributes in health visitor needs assessment practice: a case study.

BACKGROUND: Assessment of family health need is a central feature of health visiting practice in which a range of skills, knowledge and judgements are used. These assessments are pivotal in uncovering need, safeguarding children and in determining levels of health intervention to be offered to children and their families by the health visiting service in the UK. OBJECTIVES: The central focus of this paper is to outline the critical attributes of the basic principles that underpin health visiting assessment practice that emerged as part of a case study enquiry. DESIGN: A case study design informed by a constructivist methodology was used to examine health visitors' professional judgements and use of formal guidelines in identifying health needs and prioritising families requiring extra health visiting support. SETTINGS: The main study was conducted in three community Trust case sites in England, UK, with pilot work being undertaken in a fourth site. METHODS AND PARTICIPANTS: Fifteen health visitors participated in the main study and data were collected during 56 observed home visits to families receiving extra health visiting support. Separate in-depth interviews were conducted with the health visitors, pre- and post-home contacts, while 53 client interviews also took place. RESULTS/CONCLUSIONS: The analysis suggests that there are certain fundamental elements associated with the majority of health visitor assessments and these have been termed assessment principles. These characteristics are integral to, and provide the basis upon which health visitors' assessments are conducted and professional judgement is formed. They reflect the basic principles of health visiting assessment practice, which exist despite the constraints and realities of the practice context and can be differentiated from the activity centred methods of assessment processes.

A funding model for health visiting: baseline requirements--part 1.

A funding model proposed in two papers will outline the health visiting resource, including team skill mix, required to deliver the recommended approach of 'progressive universalism,' taking account of health inequalities, best evidence and impact on outcomes that might be anticipated. The model has been discussed as far as possible across the professional networks of both the Community Practitioners' and Health Visitors' Association (CPHVA) and United Kingdom Public Health Association (UKPHA), and is a consensus statement agreed by all who have participated.

Busting the bureaucracy: lessons from research governance in primary care.

This paper provides a critical discussion of the research governance approval processes faced in a nationally-funded primary care health service survey. The study is investigating how a range of English primary care organisations are addressing child protection and safeguarding children responsibilities in the light of a wealth of policy directives following publication of the report of Lord Laming's inquiry into the death of Victoria Climbié in 2003. The principal investigator is a member of a local research ethics committee and has a good working knowledge of the Research Governance Framework. However, following multi-centre research ethics committee approval, a whole catalogue of difficulties emerged in gaining research governance approval for this study from primary care organisations. These challenges and our lessons for primary care are outlined in an organisational case study with the intention of generating debate around this fundamental stage in the research process. With the current restructuring of primary care, we believe the time is right to streamline research governance procedures.

Working on person-centred planning: from amber to green light?

This article reviews the practice and policy based literature on person-centred planning in learning disability services in England. Its aim is to identify the implications for the workforce in practice.The analysis found that implementation is often described as partial or slow and characterizes reasons for this at a number of levels, including the slow pace of change in service culture and power relations, immutable funding structures, services' inflexible infrastructures, high levels of staff turnover and lack of training, inexperience among service management, inadequate staff supervision, and ambiguity among some stakeholders. Little substantial critique exists of the model itself. Analysis of the literature further reveals that the implementation of person-centred planning in practice is assisted by policy encouragement, service development and investment, favourable case reports and personal accounts, practitioner enthusiasm and positive evaluations. This article explores these to consider what facilitates the adoption of new elements of practice.

A funding model for health visiting (part 2): impact and implementation.

This is the second of two papers offering the information required to work out how to fund a health visiting service. The first paper gave the basic requirements, while this one identifies and explains the separate components of the service along with issues of scope and skillmix. In this way, it starts to describe the programmes embedded within a generic health visiting service, which is helpful in terms of what might be expected in terms of impact and outcomes. These are described with reference to the new Public Service Agreement targets and other relevant policy.

Quality in preventive and health-promoting services: constructing an understanding through process.

AIM: To develop a model of service quality for health-promoting services. In assessing quality, there are difficulties in taking account of the views of multiple stakeholders, the process of the service and the organizational context within which the service is provided. This study set out to address these difficulties. METHODS: A collective case study that incorporated national data from public health nurses (n = 946; response rate 54%) and public health nurse managers (n = 24; response rate 75%) and four case study sites which included data collected from 27 mothers with infants. RESULTS: A model of service quality that takes account of multiple stakeholder constructions, organizational context, service process and consequences was developed. CONCLUSIONS: Seven steps of process coupled with five concepts around which quality is judged can provide a basis for understanding service quality in a predominantly preventive and health-promoting type service.

Service configuration and quality of Irish public health nursing.

This paper presents findings from a national study of the Irish public health nursing service and focuses, in particular, on issues relating to service configuration. The findings are drawn mainly from a national questionnaire of public health nurses (PHNs) working with families with infants (n=613; response rate 54 per cent) and the data were gathered in 1999/2000. The average ratio of public health nurse (PHN) to population size was found to be 1:3997 with a range between 500 and 16,500. The vast majority of respondents (85 per cent) had responsibility for five or more client groups including the elderly, those requiring clinical nursing care, terminal nursing care, psychiatric care, school nursing and the organisation of the home help service. Statistically significant differences between and within health board areas in the extent to which other nurses were available to the service led to a conclusion that in these circumstances a standardised service across individual PHN areas is not possible. The findings highlight the importance of the principle of vertical equity where service configuration is determined by population composition and need.

Evaluating family partnership training in health visitor practice.

The second paper in this series of two on partnership examines the effects of family partnership (parent adviser) training which builds on health visitors' skills to facilitate partnership working with parents. This study was utilised as a pilot to identify a suitable method, to explore the interaction processes of health visitors who had undergone the training. The study draws together both quantitative and qualitative methods to seek to understand processes in depth. Three health visitors, who were part of a training group of 12, took part in the qualitative research using stimulated recall methodology. The quantitative data was collected from the whole training group using the Constructions of Helping questionnaire and the course evaluation form. The findings suggest that the family partnership training may be effective in enhancing partnership working in health visiting and that the stimulated recall methodology is an effective method of identifying the processes of interaction. The triangulation of methods led to an understanding that change in practice is dependent on the insight of the practitioner and that this may be able to be measured to some extent by the use of different methods.

The guideline contradiction: health visitors' use of formal guidelines for identifying and assessing families in need.

The aim of this paper is to examine health visitors' use of formal guidelines in identifying health needs and prioritizing families requiring extra health visiting support. With the increasing emphasis on targeted health visiting, a case study was used to explore the extent to which health visitors in three case sites use needs assessment guidelines in the assessment of family health need. The findings indicate how the presence of core visiting protocols hints at elements of control by managers, leading to conflicts in the relationship between professional judgements and official guidelines. Despite a management ethos of guideline formulation, several contradictions exist for which these guidelines are a focus. These include: little involvement of health visitors in guideline development, some staff not informed about the existence of formal guidelines, little evidence of guidelines contributing to improved client outcomes and their limited use by many health visitors in practice. Thus, even when guidelines exist, no accurate predictions can be made about health visitors' knowledge of or use of such guidelines in practice.