The potential of ecological theory for building an integrated framework to develop the public health contribution of health visiting

In line with recent UK and Scottish policy imperatives, there is increasing pressure for the health visiting service to assume an enhanced role in improving public health. Although health visiting has so far maintained its unique position as a primarily preventive service within the UK health service, its distinctive contribution now appears under threat. The continuing absence of a comprehensive and integrated conceptual basis for practice has a negative impact on the profession’s ability to respond to current challenges. Establishing an integrative framework to conceptualise health visiting practice would enable more sensitive, focused and appropriate research, education and evaluation in relation to practice. Work in this area could thus usefully contribute to the future development of the service at a difficult time. Our paper aims to make such a contribution. In support of our conceptual aims, we draw on a study of health visiting practice undertaken within a large conurbation in central Scotland. The study used a mixed method, collaborative approach involving 12 audio‐recorded and observed health visitor–client interactions, semi‐structured interviews with the 12 HVs and 12 clients, examination of related documentation and workshops with the HV participants. We critically consider prevalent models of health visiting practice and describe the more integrative conceptual approach provided by Bronfenbrenner’s ecological, ‘person‐in‐context’ framework. The paper subsequently explores relationships between this framework and understandings of need demonstrated by health visitors who participated in our study. Current policy emphasises the need to focus on public health and social inclusion in order to improve health. However, if this policy is to be translated into practice, we must develop a more adequate understanding of how practitioners work effectively with families and individuals in a sensitive and context‐specific manner. Bronfenbrenner’s framework appears to offer a promising means of building on the current strengths of the health visiting service to further develop a ‘person‐in‐context’ approach to health improvement that is mindful of and responsive to multiple, inter‐related influences on health. We therefore recommend further research to directly test the utility of this framework.     

Benefit or burden: introducing paraprofessional support staff to health visiting teams: the case of Starting Well

With increased public-sector funding to expand and improve frontline services, pre-existing skill shortages within key professional workforces have become more acute. One response to this has been to encourage the development of skill-mix approaches which allow tasks previously undertaken by professional staff groupings to be assumed by new paraprofessional employees. Within the UK National Health Service, one group of professionals who are being challenged to change their way of working in this way are health visitors. Starting Well, one of Scotland's four health demonstration projects, which was established in 2000 to bring about a step-change in child health within deprived communities in Glasgow, operated as a pilot for such a skill-mix model of health visiting. The project was evaluated using a multimethod approach that encompassed the study of both processes and outcomes. The present paper reports on a process evaluation of the project's implementation that addressed the rationale underlying the development of Starting Well's skill-mix approach and the challenges which this model faced in practice. The perceptions of both managerial staff (n=18) and those working in practice (n=33) were gathered using semistructured interviews which sought to elicit and test Starting Well's theory of change in relation to the use of paraprofessional staff. Two sets of interviews were conducted with each group of staff between 2001 and 2003. Two main types of challenge were identified: deploying potentially vulnerable members of staff; and co-management of paraprofessionals by the health service and a voluntary-sector organisation. A potential challenge identified from the literature, i.e. that of implementing a new role within an existing team, proved to be less problematic within Starting Well. These issues are discussed in relation to current policy and practice debates.     

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.     

The process of health visiting and its contribution to parental support in the Starting Well demonstration project

Significant resources are being directed at interventions designed to attenuate the effects of deprivation on children's health and development. The Starting Well demonstration project, established in two deprived areas within a Scottish city, aimed to show that a programme of planned activities to support families could improve child health. The project was subject to a main quantitative evaluation and several additional qualitative and mixed-method evaluations. The present paper draws on findings from one of the qualitative studies that sought to gain insight into how interventions provided by health visitors were operationalised and how they were perceived by parents. The particular focus of this paper is how the process of health visiting resulted in parents' perceptions of being supported. A longitudinal design captured variation in work undertaken by health visitors and temporal changes in maternal experiences of child rearing. Semi-structured interviews were conducted with 20 mothers and their health visitors at two time points, i.e. when infants were 3-4 and 9-10 months old. Sampling was 'purposive', and included first-time and experienced mothers. The findings reported here are based on 59 interviews carried out during 2002 and 2003. The analysis involved a thematic approach focused on programme implementation, and participant perceptions about process and benefit. Parental perceptions of being supported were exemplified by increased confidence in infant care, reduced anxiety regarding infant care needs, increases in knowledge and sense of personal competence in parenting practices, reduced isolation, and advocacy for those experiencing problems. A selection of the interactional processes that resulted in these forms of perceived support are reported, including methods of providing information, cautious and tactful questioning of maternal decision-making, and encouragement of successful parenting practice. The implications for practice, service delivery and targeting at the individual level are noted.     

The public health workforce, 2006: new challenges

Efforts to develop the public health workforce since 2001 have benefited from increased funding resulting from concerns over terrorism and other public health threats. This largesse has been accompanied by the need for greater accountability for results. The size, composition, and distribution of the public health workforce have long been policy concerns. Production and retention of public health workers remain important issues, although new dimensions of readiness are also taking center stage. We offer here policy recommendations in the areas of assessing the public health workforce and its needs, organizing development efforts around essential competencies for public health practice, credentialing workers, and accrediting agencies.     

Multi-sectoral health promotion and public health: the role of evidence

BACKGROUND: Evidence-informed health promotion and public health is an emerging and ever-changing theme in research and practice. A collaborative approach to gathering and applying evidence is crucial to implementing effective multi-sectoral health promotion and public health interventions for improved population outcomes. This paper presents an argument for the development of multi-sector evidence and discusses both facilitators and challenges to this process. METHODS: Sector-specific contacts familiar with decision-making processes were selected from referrals gained through academic, government and non-government networks and interviewed (in-person or via telephone) as part of a small scale study to scope the use of evidence within non-health sectors where decisions are likely to impact on public health. RESULTS: The views gathered are preliminary, and this analysis would benefit from more extensive consultation. Nonetheless, information gathered from the interviews and literature search provide valuable insights into evidence-related decision-making paradigms which demonstrate similarities with, and differences from, those found in the health sector. CONCLUSIONS: Decisions in health promotion and public may benefit from consideration of the ways in which disciplines and sectors can work together to inform policy and practice.     

Health visiting and public health: back to our roots or a new branch?

The term 'public health nursing' has been introduced within the last decade into the UK without being adequately defined. In consequence, confusion has arisen over the use of the term 'public health' in relation to health visiting. It is not yet clear whether the introduction of the term 'public health nursing' into the UK is a positive step for health visiting, or if it threatens its core functions. The historical developments of the public health movement and health visiting were traced, in particular, the main strands that have led to current confusion over role identity. Analysis of the literature led to one suggestion as to the nature of the public health role for health visitors. This was examined within a social policy framework in order to understand its relevance to current NHS practice. Finally, the contemporary link between health visiting and public health is explored in order to assess whether the public health role represents a new development within health visiting, or an attempt to rediscover mainstream support from public health departments.     

Collaborative work in public health? Reflections on the experience of public health networks

This paper aims to stimulate critical reflection and debate on the future development of multidisciplinary and collaborative public health practice. Focusing on the early experience of public health networks, it suggests that various processes of professional boundary maintenance combined with perceptions of public health amongst the wider community of practitioners may constrain the establishment of new ways of collaborative working between specialist public health practitioners and the wider public health workforce within and beyond the NHS.     

Public health in Thailand: emerging focus on non-communicable diseases

Over the past three decades, the public health landscape in Thailand has shifted remarkably. Currently chronic non-communicable diseases represent the largest cause of mortality in the Thai population. In light of the current situation, this paper synthesizes what is known about the chronic non-communicable disease situation in Thailand and analyzes current policy responses. Relevant contextual factors such as socio-economic transitions, health systems development, and health workforce capacities are also considered. Primary data for this study were collected by a review of policy documents, government statements, and statistics reported by the Thailand Ministry of Public Health. Secondary data were obtained by a thorough review of the existing literature. The paper finds that while current policy responses to chronic non-communicable diseases in the health sector have focused on improving prevention and control of risk factors, a stronger emphasis on chronic disease treatment and management may be needed in the future. The paper concludes with an exploration of the potential for developing and implementing realistic public health responses to the growing burden of chronic non-communicable diseases in a Southeast Asian country context by utilizing existing capacities in research, policy, and health workforce development.     

Learning practice: a new model of health visitor intervention to drive outcomes

Although there is a body of literature related to how hospital nurses develop skill, judgement or expertise there is little empirical work that focuses on understanding and developing health visiting expertise. The aims of this paper are: to identify a typology of health visitor skills, knowledge and cognition in use and the nature of health visitor expertise; to present an expert model of practice as a practice learning tool; to locate this model in context of my 2007 empirical research. This explored the problems of families and children in need and how they were supported by health visitors. This new practice model is timely in view of the need to train more health visitors, educators and practice facilitators as set out in the Health Visitor Implementation Plan.     

Strengthening the public health workforce: An estimation of the long-term requirements for public health specialists in Serbia

At the beginning of the 21st century, planning the public health workforce requirements came into the focus of policy makers. The need for improved provision of essential public health services, driven by a challenging non-communicable disease and causes of death and disability within Serbia, calls for a much needed estimation of the requirements of the public health professionals. Mid and long-term public health specialists’ supply and demand estimations out to 2025were developed based on national staffing standards and regional distribution of the workforce in public health institutes of Serbia. By 2025, the supply of specialists, taking into account attrition rate of −1% reaches the staffing standard. However, a slight increase in attrition rates has the impact of revealing supply shortage risks. Demand side projections show that public health institutes require an annual input of 10 specialists or 2.1% annual growth rate in order for the four public health fields to achieve a headcount of 487 by 2025 as well as counteract workforce attrition rates. Shortage and poor distribution of public health specialists underline the urgent need for workforce recruitment and retention in public health institutes in order to ensure the coordination, management, surveillance and provision of essential public health services over the next decade.     

A qualitative study exploring parental perspectives and involvement in health visiting services during the Health Visitor Implementation Plan in the South West of England

Internationally, there is a strong interest in engaging the public more widely in both the development and governance of public services. This study aimed to explore family perspectives on the introduction of a new policy initiative called the ‘Health Visitor Implementation Plan’ (Department of Health [2011] Health Visitor Implementation Plan 2011–15: A Call to Action) and their experiences of the new health visitor service provision. The policy aimed to increase the health visitor workforce by 4200 additional practitioners between 2011 and 2015, in parallel with introducing a new service model to provide comprehensive and accessible support for parents with children 0–5 years. Using a qualitative approach, data were collected via semi‐structured interviews and focus groups with 22 parents between March 2013 and March 2014. Questions focused around the extent to which the new service met parental expectation and need. Participants were recruited through Children's Centres and interviewed during established group sessions. Analysis was conducted using thematic analysis and constant comparative methods. The participants were asked to share their experiences of the health visiting service and their views on this national policy initiative. Although asked to comment on the policy at nation and local level, their responses were predominantly around personal experience. Parents welcomed the increase in workforce capacity and positive experiences centred on health visitors who were caring, knowledgeable, skilled and facilitated positive outcomes. Many of the negative experiences were seen to be due to poor relationships between the parent and the health visitor. Parents were influenced by the communication skills and personal attributes of the individual health visitors, including time to listen. The strength of parental opinion indicated that parents are willing to contribute to service development, consequently policy makers and health visitors themselves need to have clarity around the purpose and mechanism of parental involvement if meaningful partnership is to become a reality.     

Well-being: its influence and local impact on public health

Objectives

To explore the emergence of the concept of well-being and examine its influences on the modernization of the public health structure at the local level.

Study design

The article applies a theoretical and policy orientated approach.

Methods

The article assesses the concept of well-being and applies its uses to local policy and practice.

Results

The concept of well-being has implications for the development of local public health structures, policy making and delivery.

Conclusions

In terms of local policy making, it enables public health professionals to develop locally based concepts and uses of well-being, engage communities, make links to social capital and consider wider determinants within them. In terms of delivery, it focuses attention on the need for collaboration between local statutory and voluntary organizations in applying local concepts of well-being to public health policy; and engaging with healthcare interventions grounded within local context and needs.     

Current educational challenges for specialist community public health nurses following a health-visiting pathway and the consequences of these challenges for public health

The UK Standing Conference on Specialist Community Public Health Nurse Education represents the interests of those most intimately involved with specialist community public health nurse (health visitor) (SCPHN (HV)) education in higher education institutions across the UK. This paper summarizes issues currently affecting the education of SCPHN (HV)s and the delivery of health visiting and public health nursing services across the UK. Difficulties in recruitment, numbers of practice teachers and tensions created by the gap between expected and actual practice roles for health visitors are discussed. This discussion takes place in the context of the Programme of Action on Health Visiting, which was launched in 2009 by the Department of Health in England. Recommendations for action by HEIs are made in response to the difficulties identified in particular. Although this paper applies to all the UK SCPHN education programmes the majority of these are in England, which has resulted in a focus being placed on challenges in England.     

Establishing the validity and reliability of clinical practice guidelines used to identify families requiring increased health visitor support

One of health visitors' main roles is that of case finding and actively searching for health needs. This paper describes part of the findings of a study evaluating the clinical practice guidelines issued to health visitors to assist them in identifying families requiring increased health visitor support. A postal questionnaire was distributed to all Community Trust Chief Nurses in England (179), employing health visiting staff. The aim of the questionnaire was to assess the extent to which clinical guidelines are used throughout the country to identify families requiring extra health visiting support and to examine their validity and reliability. The survey results confirm the widespread existence of clinical guidelines in England to assist health visitors in identifying vulnerable families requiring extra support. The study provides evidence that the guidelines are largely subjective and invalid in nature. Questions are raised about the relationship between clinical guidelines and professional judgements.     

Developing the public health practitioner workforce in England: lessons from theory and practice

FOCUS: The paper focuses on public health practitioners who collectively represent one of three key workforce groups identified by England's Chief Medical Officer as critical to the successful delivery of national public health policy priorities. QUESTION: We report on two areas of work which attempt to address the following two-part question: in developing the public health practitioner workforce in England, what is needed, and how do we do it? APPROACH: First, we describe a five-component conceptual framework for developing the public health workforce which is grounded in data derived from a national Open Space event hosted by the University of the West of England in March 2005. The five components are (i) strategic support and oversight; (ii) national technical and professional support; (iii) national career building; (iv) local organisational development, and (v) sub-regional skills development. Key elements of each component are described in the paper. Second, we describe in some detail a new multidisciplinary skills development programme which illustrates one of the framework components (sub-regional skills development). The programme, established in January 2005, is aimed at three key groups of public health practitioners: health visitors (specialist community public health nurse), school nurses and environmental health officers. Its main features and some initial evaluation findings are presented. CONCLUSIONS: To be effective, activities aimed at supporting the development of the public health practitioner workforce should, where possible, aim to be congruent with core public health principles of self-determination and collective responsibility. We also conclude that leadership and vision at a national level, combined with local implementation of evidence-based training programme such as the one described could help to achieve much greater and more rapid progress in skilling up the existing public health practitioner workforce than has been possible up to now. But we note that this requires sustained investment, robust sector-wide delivery frameworks, and a group of committed local public health champions.     

Mapping the public health workforce I: a tool for classifying the public health workforce

We aimed to develop a tool to identify members of the public health workforce and classify them using categories developed for the Chief Medical Officer's project to strengthen the public health function. The tool was developed to gain a picture of London's public health workforce, and needed to be reliable and easy to use in many settings inside and outside the health service. We needed to be able to classify posts from brief information without interrogation of postholders, so that the entire workforces of large organisations could be classified from information provided by only a few key informants. Key questions and decision rules were defined by presenting interviewees in public health with brief information on nine jobs and discussing with them the process by which they determined whether each post was in the public health workforce, and if so, in which category. The questions and decision rules were refined into a classification tool which was presented as a flow diagram and a questionnaire. Application of the tool revealed that it was understood by key informants and resulted in classifications which were accepted by the researchers. The tool has now been applied extensively in London and yielded useful results. Many other applications in public health workforce planning and development are anticipated.     

Obesity, ergonomics and public health

Obesity within today's workforce is increasingly recognized as a challenge for both public health professionals and ergonomists. The two disciplines share a scientific, evidence-based approach to practice and now have the opportunity to address a common health issue, namely obesity. This paper shows, through an overview of the current literature, how and where obesity is impacting on the workplace and how the health of the workforce is being affected. Ergonomics and public health priorities have been mapped and challenges suitable for the application of existing knowledge and further research have been identified. Areas of common endeavour, for example how sedentary work may be exacerbating obesity, have been identified as candidate topics for joint activity by ergonomists and public health professionals.     

Enumeration of the public health workforce: developing a system.

Although it has been of interest to public health leaders, advocates, and policy planners for many years, decades have passed since the last organized count of public health workers. This article reports on methods used by the Columbia University School of Nursing, Center for Health Policy, to enumerate the public health workforce in 57 states and territories based on existing reports, summaries, and surveys. The complexity of public health workforce data is described and the scheme utilized to characterize the workforce using public agency categories is illustrated. The resulting "best current estimate" provokes many questions regarding future policy about a public health workforce database.