"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.

A survey of parental self-efficacy experiences: maximising potential through health visiting and universal parenting support.

AIMS AND OBJECTIVES: To examine parental self-efficacy experiences for users of a parenting support programme and consider the pertinence of self-efficacy theory to health visiting (public health nursing) practice. BACKGROUND: Commonly, successful parenting training programmes are underpinned by social learning principles and aim to strengthen parental self-efficacy. However, research examining programme effectiveness rarely discusses how self-efficacy outcomes are achieved. DESIGN: A descriptive survey was completed as the first part of a realistic evaluation study examining how a UK parenting support programme worked. METHODS: The first part of the realistic evaluation involved validating outcome measures (the Parenting Self-Agency Measure and Self-Efficacy for Parenting Tasks Index subscales) and administering a questionnaire survey. The questionnaire was completed by adults accessing a parenting support programme during a 10-month period (n = 168). Data were analysed using descriptive and inferential statistics. RESULTS: Women were the main users of the programme, which included informal drop-in groups as well as more formalised health visiting services and parenting training courses. The Parenting Self-Agency Measure results indicated good general parental self-efficacy; however, the task-specific Self-Efficacy for Parenting Tasks Indexes scales suggested that parents were less self-efficacious in disciplining children. Lower self-efficacy scores correlated with high ratings for 'feeling tired', 'receiving negative comments' and 'giving-in to a child's demands'. CONCLUSIONS: Study results indicate that the domain general and task-specific measures provide different, but helpful, insights into parental self-efficacy experiences. By identifying factors associated with the levels of general and task-specific parental self-efficacy, health visitors can gain a fuller appreciation of support needs. RELEVANCE TO PRACTICE: To maximise potential through parenting support, attention should be given to addressing factors associated with poorer self-efficacy experiences, including parental tiredness. Equally, practice should be directed at developing community environments that offer exposure to positive praise and the opportunity to practice new skills without facing criticism.

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

Not applicable.

Social rehabilitation in long-term conditions: learning about the process.

AIM: This paper is a report of a study of the process of social rehabilitation, and the analysis of the main elements and influencing factors which are important in the process. BACKGROUND: The process of social rehabilitation lacks conceptual and empirical understanding in Neurology because most rehabilitation programmes have focused on cognitive and physical recovery. METHODS: An action research project was undertaken in two neurological wards of a highly specialized hospital in Spain, and was completed in 2006. A social rehabilitation programme based on the assessment of social needs and individualized social education was planned with health professionals, and implemented and evaluated with patients and carers. Several instruments were used to explore how patients and carers perceived the process of social rehabilitation before and after the programme: semi-structured interviews, socio-demographic forms, field notes, participant observations, and scales of activities of daily living, social impairment and adjustment. Comparative content and statistical analyses were undertaken. FINDINGS: Social rehabilitation was identified as a dynamic process in which the environment, activities, social interaction, self-recognition and awareness of social problems, coping and satisfaction played an essential role. Some defining criteria for social rehabilitation related to patients' and carers' attitudes, behaviour and the external implications that the socialization process had for them. CONCLUSION: This study shows the advantages of multidisciplinary work, and user and family involvement in social rehabilitation and provides in-depth knowledge about how patients and carers experience and could face barriers to develop a role in their family environment, social groups and society.

Working the way up in neurological rehabilitation: the holistic approach of nursing care.

AIM: To provide understanding of the nurses' role in neurological holistic rehabilitation and identify strategies for the enhancement of rehabilitation services. BACKGROUND: Although acute and chronic neurological patients and relatives experience emotional and social changes, most rehabilitation programmes do not deal with non-physical needs or involve nurses, leading to a poor definition and specialisation of the nursing role. DESIGN: Action research. METHOD: The project took place in two neurological wards of a highly specialised hospital in Spain and lasted 30 months. An individualised nurse-led social rehabilitation programme was planned, implemented and evaluated. The nursing role and care in rehabilitation were explored with 37 nurses and 40 neurological patients and 40 relatives (convenience sampling). Semi-structured interviews and participant observations were developed. Content (QSR NUDIST Vivo v.2.0) and statistical (SPSS v. 13.0) analyses were run. RESULTS: The lack of time, knowledge and experience, the poor definition of the nursing role and ineffective communication with users limited holistic care in the wards. Some enhancing nursing strategies were proposed and explored: promotion of acceptance/adaptation of the disease through education, reinforcement of the discharge planning and planning of emotional and social choices based on the assessment of individual needs and resources at home. CONCLUSIONS: Nursing professionals are in a privileged position to deal with neurological patients' and carers' holistic needs. Several attributes of the advanced nursing role in rehabilitation teams have been proposed to deal with non-physical aspects of care. RELEVANCE TO CLINICAL PRACTICE: • Rehabilitation needs of neurological patients and carers at hospital have been described. • Nurses' perceptions of their work and role in rehabilitation have been presented. • Clinical strategies to develop the advanced nursing role in holistic neurological rehabilitation have been highlighted.

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.

Explaining the principles of health visiting in Brazil.

Brazil is a rapidly developing country. Modern health services operate in a situation of extreme social change, which resembles some of the conditions that gave rise to health visiting in 19th century Britain. A visit there revealed much interest in the health visiting principles of the search for health needs, the stimulation of an awareness of health needs, the influence on policies affecting health and the facilitation of health-enhancing activities. Explaining these principles to an audience on the other side of the world highlighted three underlying themes. The principles of health visiting are about health promotion, not assistance; they provide an integrated framework, not a list of competences or skills; and they are all underpinned by a particular value and view of health. The explana-tion was met with great interest. We need to be both more aware and better able to explain these underlying themes in this country as well.

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.

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.

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.

Challenging the philosophy of partnership with parents: a grounded theory study.

BACKGROUND: Parent participation is viewed as a pivotal concept to the provision of high quality nursing care for children and their families. Since the 1990's, the term 'partnership with parents' has increasingly been reported in the literature and adopted as a philosophy of care in most paediatric units in the United Kingdom. OBJECTIVES: To explore children's, parents', and nurses' views on participation in care in the healthcare setting. DESIGN: Using grounded theory, data were collected through in-depth interviews, and participant observation. Sample consisted of eleven children, ten parents and twelve nurses from four paediatric wards in two hospitals in England. RESULTS: Most nurses assumed that parents would participate in care and viewed their role as facilitators rather than 'doers'. Nurses reported that the ideology of partnership with parents did not accurately reflect or describe their relationships with parents. Parents could never be partners in care as control of the boundaries of care rested with the nurses. Parents felt compelled to be there and to be responsible for their children's welfare in hospital. CONCLUSIONS: The pendulum of parent participation has swung from excluding parents in the past to making parents feel total responsibility for their child in hospital. It is argued that the current models or theories on parent participation/partnership are inappropriate or inadequate because they do not address important elements of children's, parents' and nurses' experiences in hospital.

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.

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.

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.

Principles of British health visiting.

In an international context, it is sometimes helpful to consider how concepts are understood in different countries, and to explore some different roles. Such knowledge rarely transfers directly from one country or place to another, but to hear about developments from elsewhere can spark ideas and thinking that may be helpful for local developments. This paper gives some brief background about how the health visiting profession developed in Great Britain, and then explains the values and principles that underpin its practice today. Some parallels are drawn with the health situation in modern Brazil.

Making a difference for children and families: an appreciative inquiry of health visitor values and why they start and stay in post.

The study aimed to develop an understanding of health visitor recruitment and retention by examining what existing staff and new recruits wanted from their job, their professional aspirations and what would encourage them to start and stay in employment. Following a period of steady decline in numbers, the health visitor workforce in England has recently been invested in and expanded to deliver universal child public health. To capitalise on this large investment, managers need an understanding of factors influencing workforce retention and continuing recruitment of health visitors. The study was designed using an interpretive approach and involved students (n = 17) and qualified health visitors (n = 22) from the north and south of England. Appreciative inquiry (AI) exercises were used as methods of data collection during 2012. During AI exercises students and health visitors wrote about 'a practice experience you have felt excited and motivated by and briefly describe the factors that contributed to this'. Participants were invited to discuss their written accounts of practice with a peer during an audio-recorded sharing session. Participants gave consent for written accounts and transcribed recordings to be used as study data, which was examined using framework analysis. In exploring personal meanings of health visiting, participants spoke about the common aspiration to make a difference to children and families. To achieve this, they expected their job to allow them to: connect with families; work with others; use their knowledge, skills and experience; use professional autonomy. The study offers new insights into health visitors' aspirations, showing consistency with conceptual explanations of optimal professional practice. Psychological contract theory illustrates connections between professional aspirations and work commitment. Managers can use these findings as part of workforce recruitment and retention strategies and for building on the health visitor commitment to making a difference to children and families.

Evaluating health visitor parenting support: validating outcome measures for parental self-efficacy.

Parenting support has become an increasing feature of child health services within the United Kingdom but typically, outcome measures available for testing the effectiveness of parenting interventions have been developed and validated elsewhere. This article reports the results of a feasibility study testing the Parenting Self-Agency Measure (PSAM) and subscales from the Self-Efficacy for Parenting Tasks Index (SEPTI) as outcome measures for UK-based parenting support programmes. Forty-six mothers and 10 fathers accessing routine health visitor and school nurse services participated in the test-re-test of the scales and commented separately on the acceptability of scale questions. Very large intra-class correlation results indicated good repeatability but alpha coefficient scores and factor analysis results suggest that UK respondents may not recognize SEPTI subscales items as measuring single dimensions. The PSAM was a more stable measure of parenting self-beliefs than the SEPTI subscales when tested with a UK sample of parents.