Supporting early family life: the importance of public health programmes

Globally, women are generally offered maternity-specific care during their pregnancy through obstetricians, gynaecologists, nurses and/or midwives. While this care extends into the postpartum period, guidelines currently do not recommend visits to the mother beyond 6 weeks (World Health Organization, 2014). However, in the Fair Society, Healthy Lives report, it is emphasised that the two first years of life represent a critical time point in which the obstacles to healthy brain development can lead to long-term disadvantages, and that interventions are required to prevent the emergence of health inequalities and to improve children’s life chances (Marmot et al., 2010). In attempts to prevent ill health in infants, a number of countries provide services that traverse both the antenatal period and the early years of life. Examples of such services include the Healthy Child Programme in the UK, the Maternal and Child Health Service in Australia, and the Comprehensive Child Development Service in Hong Kong. While these services differ, they are structurally similar in that they provide a universal preventative service with a programme of care that encompasses screening, immunisation, health and development reviews, supplemented by advice around health, well-being and parenting. In accordance with the principle of ‘proportionate universalism’, the scale and intensity of intervention is proportionate to the level of disadvantage to ensure more vulnerable families receive increased care and that safeguarding takes place for children at increased risk (Marmot et al., 2010).

While the role of the midwife has been explored in intervention research to enhance family well-being, less is known about the health visitors and health nurses who carry out these public health initiatives antenatally and postnatally, and the impact their interventions have on the health and well-being of women and their families. To a certain extent this may be due to a lack of clarity of their role. In attempting to summarise the international evidence in this field, authors of the ‘Why Health Visiting’ report state ‘there are continuing debates about its nature, form and purpose, and which terminology is most appropriate in describing it. Internationally, … there are different government policies about child and family health and well-being, and competing opinions about how services are best organised and delivered, including which sector or discipline should be responsible for the provision’ (Cowley et al., 2013, p. 30). Furthermore, a number of emerging services modelled upon programmes from other countries are in a state of transition as they are adapted to the health issues pertinent to their population, and as such still require appropriate evaluation (Ip, Chau, Thompson, & Choi, 2015). A further complication is that these services are designed to bridge multiple services, and as a result their format will vary according to the services they encompass. Consequently, summarising and generalising international evidence on these services becomes increasingly problematic.

Despite complexities in comparability across services, optimising the content, delivery and implementation of these services is ripe for further psychological research. To use the example of the Healthy Child Programme within the UK, the Department of Health (2009) introduced six high-impact areas where the work of the health visitors is key: (i) transition to parenthood, (ii) maternal mental health, (iii) breastfeeding, (iv) healthy weight, (v) managing minor illness and accident reduction and (vi) healthy 2-year-olds and school readiness. These impact areas touch upon issues of role identification, mental health, health behaviour change and infant cognitive development, which are all relevant to psychology researchers. For example, what effect may services have on these health outcomes and what are the barriers and facilitators to achieving positive outcomes across these areas? Alternatively, how do services draw on psychology and behaviour change evidence when helping mothers breastfeed or helping children be a healthy weight? How do services learn to effectively collaborate across multiple and varied health professionals and agencies, such as housing and early years education providers? As previously mentioned, while these services provide universal care programmes, within the remit of their roles is extra care and support for vulnerable families. This may entail further visits with more intensive intervention, referral to tertiary services and safeguarding responsibilities. Thus, there are instances where health visitors work particularly closely with some families. How do services support families with sensitive issues involving social complexity? How might services with vulnerable families be developed further? The approach taken by these professionals needs to be evidence-based to ensure care is appropriate and sensitive.

Another important consideration is the level of access these healthcare professionals have with young families. After the transition from maternity care services, most healthcare professionals typically only meet with a family if there is a problem (either health or social) and do so in a medical setting rather than the family home. On these occasions, the meeting with a healthcare professional is an indicator of ‘expressed need’ (e.g. attending A&E or GP). While social workers do enter the home, this is generally because of their targeted safeguarding role, and by the time a social worker becomes involved, problems are ingrained. However, prior to the observable expression of need, ‘felt needs’ are those perceived by the individual and these are contingent on an individual’s perceptions of their condition and their confidence in approaching healthcare services (Bradshaw, 1972). In the context of maternal mental health and caring for a newborn, mothers may find it difficult to interpret their own feelings, be unaware of the needs of their child, or unaware of the support services available (Megnin-Viggars, Symington, Howard, & Pilling, 2015). Within universal public health services, families are often met in their home in a preventative manner and as such contact with healthcare professionals is far less stigmatising and the practitioners have opportunity to implement services early. Furthermore, the opportunity to engage and support fathers has been cited as one of the key ways in which these public health services are unique (Burgess, 2014). But are we maximising this opportunity? A systematic review of experiences of care for women with (or at risk of developing) antenatal or postnatal mental health problems recently highlighted that confusion of the role of the health visitor made many fearful and apprehensive of their visits (Megnin-Viggars et al., 2015). Conversely, Jomeen, Glover, Jones, Garg, and Marshall (2013) asked health visitors about their experiences with assessing women’s perinatal psychological health and found a lack of services and clarity regarding referral pathways. The findings from these studies support conclusions from the Why Health Visiting review that ‘the nature of the health visitor–client relationship needs to be clarified, along with evidence for any therapeutic aspects of this or other aspects of the work of health visitors’ (Cowley et al., 2013, p. 35).

Irrespective of the title these public health services are given, they are comparable in that they are providing support and intervention in key clinical, psychological and societal outcomes in the critical developmental period of early life. Their visits can provide regular contact with families outside a clinical setting and they are commonly seen as a trustworthy source of information, and may be an untapped resource for health interventions. These visits may also potentially provide a unique continuity of care for women and their families during the perinatal period and beyond. Perinatal psychology needs to move beyond focusing on maternity services and the immediate postnatal period and to take advantage of the opportunity to develop and evaluate interventions within these frameworks to help directly influence public health.

James J. Newham
Institute of Health and Society, Newcastle University
Hazel Roberts
Centre for Maternal and Child Health Research, City University London, Homerton University Hospital, NHS Foundation Trust
Maria Raisa Jessica (Ryc) Aquino
Centre for Maternal and Child Health Research, City University London
Ellinor K. Olander
Centre for Maternal and Child Health Research, City University London