Feeling stretched: Parents' narratives about challenges to resilience when their child has a tracheostomy.

This study aimed to examine how parents develop personal resilience when facing the challenges of caring for a child with tracheostomy. This study employed a longitudinal qualitative design. Unstructured narrative interviews with 12 parents (from nine families) whose child had a new tracheostomy were undertaken at three time points over 12 months. Data were analysed using a socio-narratology method. Findings reveal the journey parents experienced, how their feelings changed and the processes involved in developing resilience over the first 12 months of their child having a tracheostomy. Stories told by parents early in their journey revealed emotional upheaval, negative emotions, stress and shock. Due to medical need, parents had little or no choice for their child to have a tracheostomy. Once their child's life was out of danger, parents started to reframe their experiences and beliefs. Resilience played a major part in how parents perceived and faced their situation, allowing them to deal with what came their way and to move forward with their lives. Different aspects of resilience such as self-awareness, grit, gratitude, internal locus of control and reframing came to the fore at different time points. Parents talked feeling stretched by the challenges they faced and how they reframed their perspectives about their child's tracheostomy. Parents' resilience and reframing is discussed in relation to the ABC-X model. This study identifies a theoretical model that explains this process of change, this results in transferable knowledge, useful for understanding and explaining the experience of other parents and families.

Predictors of Mother and Infant Emergency Department Attendance and Admission: A Prospective Observational Study.

OBJECTIVE: To explore the predictors of emergency department attendance and admission for mothers and their infants. METHODS: Self-reported emergency department (ED) attendance and admission, sociodemographic, mental health, and other measures were recorded at baseline and at 12 months at 4 sites in England between May 2017 and March 2020. RESULTS: Infants' gestational age (OR 0.73, 95% CI 0.61 to 0.88, p = 0.001), mothers' mental health (OR 2.40, 95% CI 1.30 to 4.41, p = 0.005) and mothers' attendance at ED (OR 2.34, 95% CI 1.13 to 4.84, p = 0.022) predicted infant ED attendance. Frequency of attendance was predicted by ED site (IRR 0.46, 95% CI 0.29 to 0.73, p = 0.001) and mothers' age (IRR 0.96, 95% CI 0.92 to 1.00, p = 0.028). Infant hospital admissions were predominantly for respiratory (40%) and other infectious diseases (21%) and were predicted by previous health problems (OR 3.25, 95% CI 1.76 to 6.01, p < 0.001). Mothers' ED attendance was predicted by mixed or multiple ethnic origin (OR 9.62, 95% CI 2.19 to 42.27, p = 0.003), having a male infant (OR 2.08, 95% CI 1.03 to 4.20, p = 0.042), and previous hospitalisation (OR 4.15, 95% CI 1.81 to 9.56, p = 0.001). Hospital admission was largely for reproductive health issues (61%) with frequency predicted by having attended the ED at least once (IRR 3.39, 95% CI 1.66 to 6.93, p = 0.001), and being anxious or depressed (IRR 3.10, 95% CI 1.14 to 8.45, p = 0.027). CONCLUSIONS FOR PRACTICE: Improving the reproductive and mental health of mothers may help to avoid poor maternal and infant health outcomes and reduce emergency service utilisation and hospitalisation.

Stuck in transit: A qualitative study of the transitional care needs of young people with epilepsy and juvenile idiopathic arthritis.

Transition services for young people with long-term conditions often fall short. This qualitative study explored perspectives on service features that enable effective transition in epilepsy and juvenile idiopathic arthritis. Patients, parents, clinicians and service commissioners took part in semi-structured interviews (n = 18). Thematic analysis was used to identify key features, barriers and facilitators of effective transition across participant groups. Analysis led to the development of nine sub-themes which mapped to overarching domains of communication, capability, continuity and capacity. Findings include the need for age appropriate communication, the link between parental dependence, self-care and patient knowledge, the value of service integration for continuity and the impact of capacity on flexible and age appropriate transition services.

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

Not applicable.

Barriers and facilitators in the delivery of a proportionate universal parenting program model (E-SEE Steps) in community family services.

BACKGROUND: A proportionate universal (PU) approach to early years' service provision has been advocated to improve children's health and development and to reduce health inequality, by ensuring that services provide timely and high-quality parenting support commensurate with need. Process-oriented research is critical to examine the factors that contribute to, or hinder, the effective delivery/implementation of such a model in community-based family services. This study aimed to assess the delivery, acceptability and feasibility of a new PU parenting intervention model (called E-SEE Steps), using the Incredible Years® (IY) parent program, when delivered by trained health/family service staff in three "steps"-one universal step (the IY Babies Book), and two targeted steps (group-based IY Infant and Toddler programs). METHODS: An embedded mixed-methods process evaluation within a pragmatic parallel two-arm, assessor blinded, randomized controlled trial was conducted in community services in four local authorities in England. The process evaluation used qualitative data gathered via interviews and focus groups with intervention arm parents who were offered the targeted steps (n = 29), practitioners (n = 50), service managers (n = 7) and IY program mentors (n = 3). This was supplemented by quantitative data collected using group leader pre-training (n = 50) and post-delivery (n = 39) questionnaires, and research notes of service design decisions. RESULTS: The E-SEE Steps model was acceptable to most parents, particularly when it was accompanied by engagement strategies that supported attendance, such as providing childcare. Practitioners also highlighted the positive development opportunities provided by the IY training and supervision. However, participant views did not support the provision of the IY Babies book as a standalone universal component, and there were barriers to eligible parents-particularly those with low mood-taking up the targeted programs. Service providers struggled to align the PU model with their commissioned service contracts and with their staff capacity to engage appropriate parents, including tackling common barriers to attendance. CONCLUSIONS: Despite general enthusiasm and support for delivering high-quality parenting programs in community services in the England, several barriers exist to successfully delivering IY in a proportionate universal model within current services/systems.

A randomized controlled trial of a proportionate universal parenting program delivery model (E-SEE Steps) to enhance child social-emotional wellbeing.

BACKGROUND: Evidence for parenting programs to improve wellbeing in children under three is inconclusive. We investigated the fidelity, impact, and cost-effectiveness of two parenting programs delivered within a longitudinal proportionate delivery model ('E-SEE Steps'). METHODS: Eligible parents with a child ≤ 8 weeks were recruited into a parallel two-arm, assessor blinded, randomized controlled, community-based, trial with embedded economic and process evaluations. Post-baseline randomization applied a 5:1 (intervention-to-control) ratio, stratified by primary (child social-emotional wellbeing (ASQ:SE-2)) and key secondary (maternal depression (PHQ-9)) outcome scores, sex, and site. All intervention parents received the Incredible Years® Baby Book (IY-B), and were offered the targeted Infant (IY-I)/Toddler (IY-T) program if eligible, based on ASQ:SE-2/PHQ-9 scores. Control families received usual services. Fidelity data were analysed descriptively. Primary analysis applied intention to treat. Effectiveness analysis fitted a marginal model to outcome scores. Cost-effectiveness analysis involved Incremental Cost-Effectiveness Ratios (ICERs). RESULTS: The target sample (N = 606) was not achieved; 341 mothers were randomized (285:56), 322 (94%) were retained to study end. Of those eligible for the IY-I (n = 101), and IY-T (n = 101) programs, 51 and 21 respectively, attended. Eight (of 14) groups met the 80% self-reported fidelity criteria. No significant differences between arms were found for adjusted mean difference scores; ASQ:SE-2 (3.02, 95% CI: -0.03, 6.08, p = 0.052), PHQ-9 (-0.61; 95% CI: -1.34, 0.12, p = 0.1). E-SEE Steps had higher costs, but improved mothers' Health-related Quality of Life (0.031 Quality Adjusted Life Year (QALY) gain), ICER of £20,062 per QALY compared to control. Serious adverse events (n = 86) were unrelated to the intervention. CONCLUSIONS: E-SEE Steps was not effective, but was borderline cost-effective. The model was delivered with varying fidelity, with lower-than-expected IY-T uptake. Changes to delivery systems and the individual programs may be needed prior to future evaluation. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number: ISRCTN11079129.

Evaluation of birth companions perinatal and peer support provision in two prison settings in England: a mixed-methods study.

PURPOSE: This paper reports on insights from an evaluation of Birth Companions (BC) (a UK-based charity) perinatal support in two prison settings in England. The initiative involved the provision of group and/or one-to-one perinatal support and training women prisoners as peer supporters. DESIGN/METHODOLOGY/APPROACH: A mixed-methods study was undertaken that involved observations of support groups and peer support supervision sessions (n = 9); audio recorded interviews (n = 33) with prison and health-care staff, women in prison, peer supporters and BC staff; analysis of existing routinely collected data by BC and notes undertaken during regular meetings (n = 10) with the BC Project Manager. Thematic analysis was undertaken supported by MAXQDA qualitative data analysis software. FINDINGS: BC provided instrumental/practical support, emotional support, information support, signposting to services and advocating for women to the prison concerning their perinatal needs and rights. Key themes revealed that support had an impact on the lives of perinatal women by creating a safe place characterised by meaningful interactions and women-centred approaches that facilitated access to wider care and support. The service made a difference by empowering women and providing added value for peer supporters, prison, health-care and BC staff. Key enablers and strategies for the care of perinatal women and the delivery of perinatal support are also detailed. ORIGINALITY/VALUE: Through longitudinal data and the involvement of a range of stakeholders, this study evidences the subtleties of support provided by BC and the potential it has to make a difference to perinatal women in prison and those volunteering or working within the prison system.

Non-profit breastfeeding organisations' peer support provision in areas of socio-economic deprivation in the UK: A meta-ethnography.

In many high-income countries such as the United Kingdom, inequalities in breastfeeding initiation and continuation rates exist, whereby socio-economically advantaged mothers are most likely to breastfeed. Breastfeeding peer support interventions are recommended to address this inequality, with non-profit breastfeeding organisations providing such support in areas of deprivation. As these organisations' roots and membership are often formed of relatively highly resourced women who have different backgrounds and experiences to those living in areas of deprivation, it is important to understand their practices in this context. In order to explore how UK non-profit organisations practice breastfeeding peer support in areas of socio-economic deprivation, a systematic review and meta-ethnography of published and grey literature was undertaken. Sixteen texts were included, and three core themes constructed: (1) 'changing communities' reveals practices designed to generate community level change, and (2) 'enabling one to one support', explains how proactive working practices enabled individual mothers' access to supportive environments. (3) 'forging partnerships with health professionals', describes how embedding peer support within local health services facilitated peer supporters' access to mothers. While few breastfeeding peer support practices were directly linked to the context of socio-economic deprivation, those described sought to influence community and individual level change. They illuminate the importance of interprofessional working. Further work to consolidate the peer-professional interface to ensure needs-led care is required.

The challenges of assessing sample representativeness within community-based evaluations of parenting programmes delivered in England and Ireland.

The findings from evaluations of parenting programmes can help inform policy and practice decisions, including how best to allocate scarce resources designed to support families. However, studies often fail to consider the extent to which the findings can be generalised to other settings or populations. One, yet unexplored solution, is to compare study findings and large-scale data sets including publicly available population data. The aims of this study were to assess the feasibility of assessing sample representativeness using publicly available data and to identify the challenges involved in considering the generalisability of study findings. Sociodemographic data from two community-based evaluations of parenting programmes conducted in England and Ireland between 2015 and 2018 were used in the study (N = 395 parent-infant dyads). The results indicated some differences between the trial samples and the wider population. However, it is difficult to reach definitive conclusions about these findings due to the limitations associated with using the comparative data sets. Our study revealed three key challenges, including: (1) how best to define and conceptualise representativeness; (2) the availability of comparative data sets; and (3) the quality of the available data. Our study suggests that there is a need for up-to-date, good-quality comparative data sets to allow for the assessment of representativeness. Further work is required to identify parameters for making claims about representativeness, specifically regarding the acceptable level of difference between the target population and the study sample. This is the first study to explore the feasibility of using publicly available population data in two jurisdictions, for the purpose of making judgements about the representativeness of the findings from parent programmes. It is hoped that our results will encourage further investigation around the reporting of trial external validity to enable effective decision-making at policy and practice level.

Adapting breastfeeding support in areas of socio-economic deprivation: a case study approach.

BACKGROUND: There are inequalities in breastfeeding initiation and continuation rates, whereby socio-economically disadvantaged mothers are least likely to breastfeed. Breastfeeding peer support (BPS) interventions are recommended as a solution, and in the UK non-profit organisations are commissioned to deliver BPS services in areas of socio-economic deprivation. BPS interventions have a mixed evidence base, offering limited knowledge about the interaction between context and intervention and how this affects women's experiences. METHODS: This interpretive study used a case study methodology to explore how and why two BPS services developed their services in socio-economically deprived contexts. Methods aimed to generate holistic understanding of BPS service development. Data collected across both cases comprised; observation (n = 1), and semi-structured interviews with: mothers who had (n = 10) and had not (n = 9) engaged with the BPS services, peer supporters (PSs) (n = 9), community health professionals (n = 5), infant feeding co-ordinators (n = 2), non-profit organisation managers (n = 3), and public health commissioners (n = 2). Inductive grounded theory analytic techniques of open coding and constant comparisons, followed by cross case comparisons, were used to analyse the data. RESULTS: The over-arching theme - 'the transcending influence of society' - offers insights into the underlying context and drivers impacting service development. It reflects how funding and data sharing arrangements determined service operation and the peer's access to women. Four underpinning themes explain how: peer supporters were resourceful in adapting their services ('adapting and modifying the support'); BPS organisations worked to enable women's access to supportive breastfeeding environments, but did not necessarily focus service development on the needs of women living in areas of deprivation ('supporting women's journeys to access'); the BPS-professional connections for supporting access and how BPS could result in more supportive community environments ('embedding within healthcare practice'); and how management practices precluded meaningful use of data to provide context led service development ('ways of using knowledge'). CONCLUSIONS: Findings suggest that while PSs are commissioned to focus on those most in need, there is limited discussion, collection, or use of knowledge about women's lives to develop needs-led service delivery. The key recommendation is the development of a social ecological tool to facilitate the use and application of contextual knowledge.

Holding Their Own and Being Resilient: Narratives of Parents over the First 12 Months of Their Child Having Tracheostomy.

Caring for a child with a tracheostomy can be challenging for parents and learning to safely manage their child's airway can be frightening due to their child's breathing issues, complex diagnosis and the difficult decisions they have to make. The aim of this longitudinal narrative study was to tell the stories of parents whose child had a new tracheostomy. Twenty three narrative interviews were conducted with twelve parents from nine families at three time points over a 12 month period. Data were analyzed using a socio-narratological approach. The stories told how parents were able to 'hold their own' despite experiencing shock, emotional upheaval and uncertainty during the period of their child's surgery. 'Holding their own' was possible for parents because resilience played an important part of their journey. Parents continued to be resilient as they adapted to being at home and dealt with ongoing challenging and stressful circumstances. All of the parents told stories reflecting on and recognizing that there were times when they exhibited higher levels of resilience and times when their resilience was lower. Looking back on their experiences parents appreciated that they reframed their initial often negative views about their child's need for a tracheostomy into more positive understandings and a future orientated perspective.

Violence exposure and young people's vulnerability, mental and physical health.

OBJECTIVES: To analyse the impact of being affected by domestic and/or relationship violence in early adolescence on indicators of health and well-being. METHODS: Secondary data analysis of a cross-sectional survey of 13-14 year-old pupils attending schools in north-west England, with variables relating to vulnerability, violence and mental and physical health, was performed. The sample of 9626 represented 71% of the eligible population. Chi-squared tests and logistic regression were used to analyse demographic exposure to violence and outcomes. RESULTS: Pupils affected by domestic and/or relationship violence had significantly worse outcomes and experiences than non-affected peers. Odds ratios demonstrated higher risks of being lonely, being bullied or having deliberately self-harmed. They were also more likely to report an enduring health condition, poorer health practices and worse access to and experiences of health services. CONCLUSIONS: Exposure to violence in domestic and/or relationships is detrimental to children and young people's mental and physical health and vulnerability. Health risks and inequalities reported by CYP in this study provide compelling intelligence for renewed strategic policy-level consideration in the design and delivery of young peoples' health services.

Accelerated programmes in children's nursing to tackle the workforce gap in the United Kingdom: A cost-consequences analysis.

BACKGROUND: With alarming vacancy rates and dipping availability of European nurses, remedies for the shortage of nurses in the UK are urged. To accelerate the registration of new children's nurses, a health education funder commissioned two education programmes within its region. The first is a 1-year programme designed for UK-registered nurses in adult or mental health. The second is a 2-year programme for individuals, not registered as nurses, who are child or social care graduates with experience of working with children and young people. OBJECTIVES: To evaluate the economic effectiveness of two accelerated children's nursing education programmes. DESIGN: Economic evaluation. SETTINGS: Two accelerated children's nursing education programmes in two sites in England. PARTICIPANTS: Nursing students enrolled in both programmes (N = 20). METHODS: We adopt a cost-consequences analysis to analyse the programmes' costs and outcomes. RESULTS: All graduates were heading for posts within the region where they studied, a favourable outcome for the funder. However, the first programme would deplete the workforce in other nursing fields, whereas the second, by quickening the graduates' career progression, would not dent the long-term shortage in entry roles. Given our small sample size, these impacts may differ if the programmes have wider implementation. CONCLUSIONS: Our evaluation measures the effectiveness of two novel accelerated education programmes in tackling the nurses' shortage. Concurrently, it contributes to developing a standardised approach for future economic evaluations in nursing education.

Psychometric Properties of Parent-Child (0-5 years) Interaction Outcome Measures as Used in Randomized Controlled Trials of Parent Programs: A Systematic Review.

This systematic review sought to identify observational measures of parent-child interactions commonly implemented in parenting program research, and to assess the level of psychometric evidence available for their use with this age group. Two separate searches of the same databases were conducted; firstly, to identify eligible instruments, and secondly to identify studies reporting on the psychometric properties of the identified measures. Five commercial platforms hosting 19 electronic databases were searched from their inception to conducted search dates. Fourteen measures were identified from Search 1; a systematic search of randomized controlled trial evaluations of parenting programs. For Search 2, inclusion/exclusion criteria were applied to 1327 retrieved papers that described the development and/or validation of the 14 measures identified in Search 1. Seventeen articles met the inclusion criteria, resulting in five observational measures for the final review. Data were extracted and synthesized using the COSMIN rating system to describe the methodological quality of each article alongside the overall quality rating of the psychometric property reported for each measure using the Terwee checklist. Measure reliability was categorized into four domains (internal consistency, test-re-test, inter-rater, and intra-rater). Measure validity was categorized into four domains (content, structural, convergent/divergent, and discriminant). Results indicated that the majority of psychometric evidence related to children aged from birth the three with internal consistency, inter-rater reliability, and structural validity the most commonly reported properties, although this evidence was often weak. The findings suggest further validation of the included measures is required to establish acceptability for the whole target age group.

Evaluating a telehealth intervention for urinalysis monitoring in children with neurogenic bladder.

Telehealth as a community-monitoring project within children's urology care is an innovative development. There is limited evidence of the inclusion of staff and parents in the early-stage development and later adoption of telehealth initiatives within routine urological nursing care or families' management of their child's bladder. The aim was to explore the experiences of key stakeholders (parents, clinicians, and technical experts) of the proof of concept telehealth intervention in terms of remote community-based urinalysis monitoring by parents of their child's urine. A concurrent mixed-methods research design used soft systems methodology tools to inform data collection and analysis following interviews, observation, and e-surveys with stakeholders. Findings showed that the parents adopted aspects of the telehealth intervention (urinalysis) but were less engaged with the voiding diary and weighing. The parents gained confidence in decision-making and identified that the intervention reduced delays in their child receiving appropriate treatment, decreased the time burden, and improved engagement with general practitioners. Managing the additional workload was a challenge for the clinical team. Parental empowerment and self-efficacy were clear outcomes from the intervention. Parents exercised their confidence and control and were selective about which aspects of the intervention they perceived as having credibility and which they valued.

Enhancing Social-Emotional Health and Wellbeing in the Early Years (E-SEE): a study protocol of a community-based randomised controlled trial with process and economic evaluations of the incredible years infant and toddler parenting programmes, delivered in a proportionate universal model.

INTRODUCTION: Behavioural and mental disorders have become a public health crisis and by 2020 may surpass physical illness as a major cause of disability. Early prevention is key. Two Incredible Years (IY) parent programmes that aim to enhance child well-being and development, IY Infant and IY Toddler, will be delivered and evaluated in a proportionate universal intervention model called Enhancing Social-Emotional Health and Wellbeing in the Early Years (E-SEE) Steps. The main research question is: Does E-SEE Steps enhance child social emotional well-being at 20 months when compared with services as usual? METHODS AND ANALYSIS: E-SEE Steps will be delivered in community settings by Early Years Children's Services and/or Public Health staff across local authorities. Parents of children aged 8 weeks or less, identified by health visitors, children's centre staff or self-referral, are eligible for participation in the trial. The randomisation allocation ratio is 5:1 (intervention to control). All intervention parents will receive an Incredible Years Infant book (universal level), and may be offered the Infant and/or Toddler group-based programme/s-based on parent depression scores on the Patient Health Questionnaire or child social emotional well-being scores on the Ages and Stages Questionnaire: Social Emotional, Second Edition (ASQ:SE-2). Control group parents will receive services as usual. A process and economic evaluation are included. The primary outcome for the study is social emotional well-being, assessed at 20 months, using the ASQ:SE-2. Intention-to-treat and per protocol analyses will be conducted. Clustering and hierarchical effects will be accounted for using linear mixed models. ETHICS AND DISSEMINATION: Ethical approvals have been obtained from the University of York Education Ethics Committee (ref: FC15/03, 10 August 2015) and UK NHS REC 5 (ref: 15/WA/0178, 22 May 2015. The current protocol is Version 9, 26 February 2018. The sponsor of the trial is the University of York. Dissemination of findings will be via peer-reviewed journals, conference presentations and public events. TRIAL REGISTRATION NUMBER: ISRCTN11079129; Pre-results.

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.

Health visitor education for today's Britain: Messages from a narrative review of the health visitor literature.

OBJECTIVES: This paper draws on a narrative review of the literature, commissioned to support the Health Visitor Implementation Plan, and aimed at identifying messages about the knowledge, skills, and abilities needed by health visitors to work within the current system of health care provision. DESIGN: The scoping study and narrative review used three complementary approaches: a broad search, a structured search, and a seminal paper search to identify empirical papers from the health visitor literature for review. The key inclusion criteria were messages of relevance for practice. DATA SOURCES: 378 papers were reviewed. These included empirical papers from the United Kingdom (UK) from 2004 to February 2012, older research identified in the seminal paper search and international literature from 2000 to January 2016. REVIEW METHODS: The review papers were read by members of the multidisciplinary research team which included health visitor academics, social scientists, and a clinical psychologist managed the international literature. Thematic content analysis was used to identify main messages. These were tabulated and shared between researchers in order to compare emergent findings and to confirm dominant themes. RESULTS: The analysis identified an 'orientation to practice' based on salutogenesis (health creation), human valuing (person-centred care), and viewing the person in situation (human ecology) as the aspirational core of health visitors' work. This was realised through home visiting, needs assessment, and relationship formation at different levels of service provision. A wide range of knowledge, skills, and abilities were required, including knowledge of health as a process and skills in engagement, building trust, and making professional judgments. These are currently difficult to impart within a 45week health visitor programme and are facilitated through ad hoc post-registration education and training. The international literature reported both similarities and differences between the working practices of health visitors in the UK and public health nurses worldwide. Challenges related to the education of each were identified. CONCLUSIONS: The breadth and scope of knowledge, skills, and abilities required by health visitors make a review of current educational provision desirable. Three potential models for health visitor education are described.