ARTIGO ORIGINAL
Principles of British health visiting
PRINCÍPIOS DO MODELO BRITÂNICO DO VISITADOR EM SAÚDE
LOS PRINCÍPIOS DEL MODELO BRITÁNICO DEL VISITADOR DE SALUD
Sarah CowleyI
1 Professor of
Florence Nightingale
School of Nursing at
King's College of
London, UK. Master
in Education. PhD in
Health and
Community Studies.
Visiting Professor of
Collective Health
Nursing Department
of School of Nursing
at São Paulo
University, 2007.
Sponsored by
FAPESP.
sarah.cowley@
kcl.ac.uk
756
ABSTRACT
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.
RESUMO
Em um contexto internacional,
muitas vezes, é importante considerar como os conceitos são compreendidos nos diferentes países
e explorar algumas de suas distintas funções. Esse conhecimento
raramente pode ser transferido de
um país ou de uma localidade para
outra, mas ouvir outras experiências de desenvolvimento, de
quaquer parte do mundo, pode
despertar idéias e pensamentos
que sejam úteis ao desenvolvimento local. Este artigo apresenta
um breve histórico sobre como a
profissão de visitador em saúde
se desenvolveu na Grã-Bretanha,
explicando os valores e princípios
que, atualmente, servem de base à
sua prática, estabelecendo-se alguns paralelos com a atual situação
da saúde no Brasil contemporâneo.
RESUMEN
En el contexto internacional, muchas veces es importante considerar como los conceptos son
comprendidos en los diferentes
países y explorar algunas de sus
diferentes funciones. Ese conocimiento raramente puede ser transferido de un país o de una localidad para otra, no obstante, escuchar las experiencias de desarrollo, de cualquier parte del mundo,
posibilitan despertar ideas y pensamientos que pueden ser útiles
para el desarrollo local. Este artículo presentó un breve histórico
sobre como la profesión de visitador de salud se desenvolvió en
Gran Bretaña, explicando los valores y principios que actualmente
sirven de bases para su práctica
y estableciendo algunos paralelos
con la actual situación de salud
de Brasil contemporáneo.
KEY WORDS
Delivery of health care.
Great Britain.
Needs assessment.
DESCRITORES
Assistência à saúde.
Reino Unido.
Determinação de necessidades de
cuidados de saúde.
DESCRIPTORES
Prestación de atención de salud.
Reino Unido.
Evaluación de necesidades.
Rev Esc Enferm USP
2007; 41(Esp):756-61.
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Recebido:
05/09/2007
Principles
of British
Aprovado:
health 11/06/2008
visiting
Cowley S
HEALTH VISITING:
BACKGROUND
Health visiting is a profession that began in 19th century
England, which was a period of rapid industrialization and
migration from rural to urban areas(1). We might speculate
about the parallels with today, when we are seeing similar
phenomena internationally, with some 80% of the world’s
population now living in towns and cities. At that time,
there were terrible slums in British cities; both homes and
the factories where people worked were unsafe, and there
was dreadful poverty. In some cities, one in four babies died
before reaching their first birthday, mainly as a result of the
poverty and adverse living conditions, which fostered
epidemics, malnutrition and injuries to adults and children
alike
It was a very gender-divided period, with women and
men each having their own spheres of influence: men in the
world of work, and women in the home. Many public health
initiatives and laws were passed, to control the state of
buildings, factories and food, alongside municipal
developments, such as the installation of water treatment
works, sewers and town planning. In Salford, an industrial
town in the north of England, a women’s public health
organisation used this to advantage, believing that the
influence of the home and family were paramount. In 1862,
they began employing local women to visit homes and
families, to offer help and advice about how best to feed the
family, care for the sick and improve the chances of their
children growing up healthily.
The profession of health visiting as we know it today
developed from this small start. Since 1962, 100 years after
the start of the profession, health visitors all must hold a
nursing qualification, which is still controversial. Health
visitors still focus mainly on family health and home visiting,
practices that are supported, now, by a large body of research
evidence. Early child development has been shown to be a
key social determinant of both health and health
inequalities(2 ), and home visiting is a particularly effective
strategy for health improvement(3 -4). However, the way in
which home visiting is implemented varies widely from one
study to another, and in practice, which influences the extent
of its effectiveness.
The British health service started in 1948, but until 1974,
health visitors were employed by the local (municipal)
boroughs. In that year, the public health and primary care
services joined the National Health Service, which had
formerly been concerned only with hospital care, a move
that was similar to the recent unification of the Brazilian
health service. Health visitors were worried about this move,
and felt the need to explain themselves in this different, more
medically focused workplace, so they held an investigation
into the principles and process of their work(5).
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Cowley S
THE PRINCIPLES OF
HEALTH VISITING
The results of the investigation provided a framework to
organize the knowledge and skills required for health visiting
practice, and a touchstone for continuing development. The
profession is frequently under threat, partly because of
funding crises within the British national health service
(NHS); also because there are different political opinions
about whether a health visiting service should continue, as
now, to be offered as a universal service to all families with
young children. So, last year, an updated version of the
principles document was published(6), to clarify the particular contribution made by health visitors to public health and
explain why health visitors claim this approach is still needed.
There was agreement across the profession that health
visiting is implemented by using four enduring processes,
which are known as the principles of health visiting. These
are:
•
•
•
•
The search for health needs
The stimulation of an awareness of health needs
The influence on policies affecting health
The facilitation of health-enhancing activities
There are three things to note about these principles.
They 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. These will be considered in more detail,
in turn
HEALTH PROMOTION
The Principles are not concerned with doing things
directly to or for someone who is unable to perform essential
activities of daily living. Providing help and assistance is a
common focus of nursing practice, so this is the first big
change for nurses when they enter the additional training
needed to become a health visitor. Families being visited in
the community are not ill just because they have a new baby,
or are living in a very deprived area, and it would undermine
them if the health visitor were to offer expertise from a highly
professional perspective. Instead, which is much harder than
just giving advice and information, the challenge is to enable
families to find ways of improving their health for themselves,
drawing on their own strengths, knowledge and the expertise
developed by living in their own particular circumstances.
To take one example: the relationship between expectant
mothers smoking, living in poverty and the birth weight of
their babies is very strong in Brazil, as in the UK. Yet, there
is also seminal research that explains why young mothers
who live in poverty smoke(7). It is not because they do not
know it is bad for them. It is because it helps them to cope
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with stress and violent relationships, and the caring responsibilities they face. When money is short, smoking a cigarette stops them feeling hungry. Simply advising them to
stop smoking, or even offering a support group or education
to help them stop smoking, just makes them feel bad. Then
their stress rises and they smoke even more. First, we must
deal with their stress, give them some support to cope with
their relationships and respect for the way they are coping
with difficult circumstances. Then, when we have a strong
relationship, we might ask them what they think will help
their baby to be healthy; before long they identify smoking
as a problem. That is the time to offer them nicotine patches
and support groups; they are more likely both to succeed in
stopping smoking, and to feel good about themselves.
An integrated framework
The second thing to note about the principles is that
they are not separate skills or activities to be learnt. Instead,
they provide an integrated and interlinked framework for
implementing the knowledge base of health visiting in the
interests of public health (Figure 1).
One principle or another may predominate as activities
and interventions are carried out, but any aspect of health
visiting practice is informed by all the principles, with public
health as the central pivot and focus. Public health is a social and political concept aimed at improving health,
prolonging life and improving the quality of life among whole
population through health promotion, disease prevention
and other forms of health intervention(8).
The principles of health visiting reflect the need for what
has been called the nutcracker effect of both top-down,
strategic policies for whole populations (like the provision
of a national health services, for example), and bottom-up,
grass roots activities to engage individuals, families and
communities in their own health(9). Our society is no longer
as segregated as when health visiting first began, but there
is still a very strong division between those who have power,
with the right to speak and be listened to, and those who do
not. Practitioners who are in daily contact with the most
vulnerable and excluded populations often know best
how to describe their real health needs. They need to work
in both directions of the nutcracker (bottom up and top
down), first by explaining and supporting people to make
best use of services and policies designed to help them.
Then, because they can also see how, when and why those
policies go wrong, they need to explain where the barriers
lie, and help policy makers to see what further changes are
needed to policy.
The value of health
The third point to note is that the word ‘health’ features
in each of the principles. This focuses attention on both the
way this term is understood, and the value afforded to health,
rather than (for example) health care, or concerns about
illness. Health visitors placed a value on health for its own
sake, and a broad understanding of this underpins the
principles and practice of health visiting(5).
Figure 1 - Principles in practice
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Even though it has been declared a right for all, enshrined
in the Brazilian constitution, health is a phenomenon that is
fraught with ambiguity, and it defies objective definition and
quantification(10). In accepting that everyone has a fundamental right to the best possible state of health, health visitors
take on a responsibility to do something about the present
inequalities and inequities in health and health care. Instead
of trying to define the value of health in philosophical terms,
therefore, they decided to emphasise its practical application
through health promotion, identifying seven key, underpinning beliefs that informed their practice (Box 1)(6).
Principles of British
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Cowley S
Box 1 - Beliefs about health
1.
•
2.
•
3.
•
4.
•
5.
•
6.
•
7.
•
Rights and responsibilities
Everyone has a fundamental right to the best possible state of health.
Health in context
Health cannot be separated from the socio-economic and cultural context in which it is experienced.
Choice and blame
Health must be regarded in broad, holistic terms, encompassing individuals and families within their personal situation.
Positive health
Health is a positive concept, encompassing social and personal resources, as well as physical capacities.
Health improvement
A positive sense of health enables people to make full use of their physical, mental and emotional capacities, so they can
reach their full potential for achievement.
Empowerment
Achieving health means that people have the power to shape their own lives and those of their families.
Community partnership and participation
Health care services should be readily accessible and acceptable, and involve full community participation.
Box 1 - Beliefs about health
These underpinning beliefs are implemented by a focus
on health as a social rather than an individual construct, so
understanding the whole family and community perspective
is essential. In practice, health visitors appear to treat health
as a process (not a state of being to be obtained) and to
consider health in its overall socio-cultural context(11). It is
long term work, sometimes taking more than one generation,
with beneficial outcomes from home visiting showing up
many years later(3).
It is not necessarily the problem that individuals or families face, as such, which determines whether they need
support or not; the deciding factor may be the situation in
which they are living(12). Some people face enormous risks
without harm, and others come to grief with a lesser level of
risk. The extent to which individuals need support and the
nature of that support varies according to their own personal
resources, and those in the situation they are living in.
Personal resources include financial resources, but are by
no means only concerned with these. Resources for health
include emotional strengths, or physical or practical resources, or the ability to understand and reason about
what would help; strong faith or a supportive family or
stamina all help. However, families might be destructive as
well as helpful; some faith groups are damaging and
demanding, and a partner might be abusive and violent
instead of supportive. So, to determine whether they are
helpful or not, we need to know the extent to which resources
are immediately accessible to the individual, and under their
personal control. This means that health visitors need to
identify their clients’ strengths and resources, and how these
may change and develop over time, offering more or less
support at different periods in the process.
A longitudinal, process approach is unusual among
health professionals, who commonly aim to identify a specific diagnosis as soon as possible, since this provides a basis
from which a care pathway can be predicted. Communities
and family life are less predictable than a medical diag-
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nosis(13 ), but formal organisations like the health service
require predictability as a basis for their planning. If the
unpredictability of community and family life is not understood and accepted, health visitors may be regarded by their
colleagues as incompetent, because they cannot always
specify exactly what will happen.
Taking a longitudinal, process approach helps health
visitors to offer support in ways which are the most empowering for individuals and groups at different stages(10,14).
Empowerment is viewed as an essential basis for health, but
it can only be developed internally by individuals, families
or community groups(15). It cannot be prescribed or dispensed
by an outsider, but a facilitator might encourage or assist
that development by working in a genuine, respectful
partnership(16). There is a delicate balance between the need
to allow, enable and encourage people to own their health in
the sense of exercising full autonomy and choices in the
way they live their lives(17), and the individualistic approach
to health promotion which stresses personal responsibility
and blame.
Clients have reported that they did not feel subjugated
by health visitors if the interventions were based on acceptance and a professional caring approach(18), although the
opposite is true in that individuals can be further disempowered by their interactions with health visitors if practitioners do not accept individuals’ views or are shocked by
their situation(19).
Relationship skills appear critical in determining the
degree to which health visitors are acceptable to clients(20).
These communication skills can be learnt, but need to be at
a very high level, especially when engaging clients who are
deeply vulnerable and socially excluded. Such people may
include young mothers, those whose childhood was deeply
insecure, or who use drugs and other illicit substances. They
distrust authority in every form, and may reject the health
visitor or any offers of support or information as irrelevant.
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They may be unreliable in their use of services, perhaps setting out to shock to test the genuineness of respect and
concern being offered, or because they have never experienced a strong or positive interpersonal relationship before.
Basic attitudes and personal attributes of empathy,
warmth, personal integrity, humility and enthusiasm are all
tested by such encounters. They are not frequent, but they
show the importance of being open to the great variety of
perceptions and expectations about health, family life and
norms(14) and of acknowledging that the way people perceive
health and well-being affects the way they live their lives.
Participation by the whole community begins with partnership working with individuals.
CONTINUING AREAS
FOR DEBATE
Even though it is more than 30 years since public health,
primary care and hospital services were unified in the British
health, there are still many debates about the way that health
visitors work, and how their approach fits with that of other
colleagues, like nurses and public health medicine(21). The
discussions seem to reflect some of the debates taking place
in Brazil as well.
First, there is a continuing issue about whether to improve
public health by working with individuals or focusing on
whole populations. Most health care costs arise from hospital services, and from delivering care to sick individuals;
this is commonly seen as the main purpose of the health
service. Yet, to improve public health, we must focus on the
whole population, and to think about prevention. For epidemiologists, this often means focusing on population health
indicators and planning at a high strategic level. There is a
danger that this can lead to a greater emphasis on professionally defined, normative health needs: looking at those
needs that professionals think are important, rather than
those our clients think are important.
Health visitors are public health practitioners who hold a
caseload, that is, one that exists for purposes of prevention
and health promotion. They work with individuals, assessing and acknowledging needs in the way their clients see
them, rather than through normative indicators. It has been
suggested, in Brazil, that infant immunisations, offered to
everyone, can provide a starting point and opportunity for
engaging clients in an overall assessment and conversation
about their particular needs(22). This would help to contribute
to the health of all infants, which is a key public health indicator, so this work with individuals is also working at the
collective level.
Health inequalities arise mainly from social class and
other social determinants of health. Health care when sick is
essential, but the key to reducing health inequalities lies in
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providing preventive services. However, if we focus only
on those people who are living in poverty, we would miss
most health needs, which are widely spread across the
population. Issues like domestic violence, mental health
problems and child sexual abuse all occur across the social
gradient. Health visiting services are offered to everyone
who has a baby in the UK, but this doesn’t mean they all
receive the same service. If their health needs are quite
small, they might just see the health visitor once, then be
asked to come to clinic for immunisations and checks, or to
get in touch if they have any worries. But for others, they
can have their needs identified and be pointed in the
direction of other services, or supported in sorting them out
for themselves.
Health visitors are fighting hard to keep this universal
service, because delivering a service only to people whose
needs have identified according to social class, or where
they live, will inevitably lead to stigma. Also, the middle
classes pay most of the taxes to fund the services, so they
need to believe it is a service worth paying for; if they are
dissatisfied, they fight to improve service quality. Professionals may hate the criticism, but it helps to improve the service for everyone.
The public-private question is now broader than when
only men were allowed into the world of work, and women
had to stay at home. Gender issues are still important, but
now the main question is about which services should be
funded from the public purse, and which remain the
responsibility of the family: private and personal. It is widely
acceptable in our culture to talk about going to see the doctor
or the nurse for physical symptoms, and there is a clear
expectation that tax-payers money should be used to fund
this. But there are many grey areas that arise during a home
visit: mental health problems, sexual matters, marital and
relationship problems, children’s misbehaviour and so on.
These all contribute to the social environment in which
children are growing up, so will greatly affect their future
health, but there is no consensus that support for dealing
with them is legitimately funded by the health service. Nor
is it widely acceptable to speak about them in public; so
people may not feel they can ask for help or support around
such contested matters, or they may not even realise that
these are health needs. They remain very private, and also
they are largely women’s matters. In most of health care, the
problem is that people seem to ask for too much. In these
areas, we have the opposite difficulty; people ask too little.
Finally, there is the issue of social or bio-medical models
of health. Illness is easier to measure than health and risks
are better understood than strengths, yet we know that
focusing on strengths is the best way to engage clients in
the early prevention that is needed. Also, focusing on early
childhood can help in many fields; it helps to reduce crime,
improves children’s ability to learn, which in turn makes
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Cowley S
them more employable as adults, so helps economic productivity and their income once they are adults. Health is
improved in long term, by these social outcomes. Longitudinal research from the USA has shown the value of this,
over and over(3, 4). Health service organisations require
immediate returns, and may not be interested in outcomes
that apply in other public services. So, we need to work
across agencies, something that we are beginning to do
again. This is a paradox, because by unifying the health
service in 1974, we lost unity with social, education and
housing service, run by our local (municipal) authorities.
The key to coping with these four aspects is to realise
that they are not in opposition; instead they are a continuum
of need across the service. Not everyone can do everything;
health service provision is like a jigsaw, in which everyone
has their part to play. Multi-disciplinary working, or even
working with colleagues of the same profession who work
in a different speciality, is helped by understanding and respecting the different contribution each has to play. Hopefully, this overview of the practice and values of one group
of professionals on the other side of the world will help
to stimulate discussions between professionals in Brazil,
about the issues of importance to them, in their quest to
promote good health.
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Correspondência:
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27
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- Essex - UK
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S
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