FEB 2013 Volume 86 Number 2 Volume

OLDER WOMEN LIVING AND COPING WITH DOMESTIC VIOLENCE

TACKLING PARENTAL ALCOHOL ABUSE: A PRACTICAL APPROACH

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Unite/CPHVA Existing Unite/CPHVA members with queries relating to their membership should contact: 0845 850 4242 or see: www.unitetheunion.org/contact_us.aspx for further details. To join Unite/CPHVA, please see: www.unitetheunion.org Unite/CPHVA is based at: Transport House, 128 Theobald’s Road, London WC1X 8TN 31 Tel: 020 3371 2006

Community Practitioner journal 3 Editorial 18 Professional 34 A practical approach Unite/CPHVA members receive the This is the year.... and research to tackling parental journal free each month and have free By Rachael Maskell Building community alcohol abuse access to all content from 2004 onwards capacity using web- Thomas Cornwallis via the online archive. 4 News round-up supported work-based Non-members of Unite/CPHVA and The latest in policy learning 36 Taking action against institutions may subscribe to the journal and practice Pauline Pearson, poverty: Unite to receive it every month and access the Lesley Young-Murphy, Community online journal archive. Jonathan Yaseen, Ellie O’Hagan Non-member subscription rates: 10 Association Gillian Shiel Individual (UK) £125 Conference poster Individual (rest of world) £145 winner: families with 38 CPHVA 121 Campaign Institution (UK) £145 multiple births; NHS 23 Supporting women with for School Nursing Institution (rest of world) £195 Leadership Academy; perinatal mental health Rosalind Godson Institution online access: Public health nursing of problems: the role of Up to five users £195 school-aged children the voluntary sector 39 Reflection: the student Six to 10 users £390 Chris Coe, Jane Barlow learning curve 11 to 20 users £780 12 Antenna Natasha Morris-Day 21 to 50 users £1560 Looked after young 27 Older women living and Subscription enquiries may be made to: people and mental coping with domestic 40 Look after yourself in Community Practitioner subscriptions, health stigma; Book violence 2013! Ten Alps Subscriber Services review: A guide Anne Lazenbatt, John Ruth Oshikanlu Abacus e-Media Limited Devaney, Aideen Gildea Bournehall House, Bournehall Road to practical health Bushey WD23 3YG promotion 41 Practice: peer Tel: 020 8950 9117 32 Features reviewed [email protected] 15 CPHVA Awards Ending the placement Common surgical www.cphvabookshop.com of children under three problems in children The journal is published on behalf of 16 News feature in institutions Siba Prosad Paul, Meera Unite/CPHVA by: Northern Ireland: fit Obi Amadi Thayalan, Andrew Ten Alps Creative and well? Michael Fernando One New Oxford Street By Herpreet Kaur London WC1A 1NU Grewal 47 Diary & Tel: 020 7878 2300 Noticeboard

For editorial contacts, please see the panel over the page. Advertising queries: CRS OVE Tory: Claire Barber Tel: 020 7878 2319 perinatal mental health: [email protected] a volunteer support Sponsorship/supplement queries: Sunil Singh Tel: 020 7878 2327 project [email protected] Production: Ten Alps Creative – Design and production Williams Press – Printing Community © 2012 Community Practitioners’ and Health Visitors’ Association Practitioner ISSN 1462-2815 The journal of the Community Practitioners’ and The views expressed do not Health Visitors’ Association (Unite/CPHVA) necessarily represent those of the editor nor of Unite/CPHVA. Paid advertisements in the journal do not imply endorsement of the products or services advertised.

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Editorial Advisory Board Gaynor Kershaw (chair) – Health Visitor, Heywood, Middleton and Rochdale PCT This is the year …. Obi Amadi – Unite/CPHVA Lead Professional Officer ll of us who have worked in the Maggie Breen – Macmillan Clinical Nurse Specialist – Children and Young NHS come with an ideal that we People, The Royal Marsden Hospital NHS want to improve quality of life Foundation Trust A for those we serve. We work to a higher Toity Deave – Senior Research Fellow, ethic and seek to do all we can to achieve Centre for Child and Adolescent Health, University of the West of England, Bristol our objectives. Barbara Evans – Community Nursery Now in a climate of cuts, blame and Nurse, Leicestershire Partnership NHS damaging reforms we have to remind Trust ourselves precisely what has made Gavin Fergie – Unite/CPHVA Professional us make our journey through our Officer for Scotland and Northern Ireland chosen career paths and what our next Margaret Haughton-James – School Nurse Team Leader and practice nurse, Guy’s and St contribution will be to the precious lives Thomas’ Hospital of those under our care. Catherine Mackereth – Public Health 2013 will be the most difficult year for Lead, South Tyneside Primary Care Trust the NHS ever. Brenda Poulton – Emerita Professor As finances are stripped out of the NHS, of Public Health Nursing, University of Ulster and the remainder handed to newly appointed private consortia to dictate Editorial Team what their GPs can or can’t do we know Polly Moffat – Editor that service delivery will face tougher [email protected] challenges than ever. Jane Appleton – Professional Editor New providers of health services, such a different path through the chaos, which [email protected] as local authorities getting to grip with not only gives validity to each clinician, Tel: 020 7878 2404 public health – and private companies but most importantly reinforces the Naveed Khokhar – Designer grappling with the basics – will create [email protected] centrality of service users and how their further chaos in the NHS. aspirations for a life of good health and The reverberations of the Francis Unite/CPHVA Honorary Officers wellbeing is our core value. Report will dominate the scene and put Elizabeth Anionwu – Vice-President To attain our highest aspirations as Chris Cloke – Vice-President clinicians in the spotlight, while those the CPHVA we all have a part to play Alison Higley – Chair in governance, from chief executives to in overcoming the tsunami of challenges politicians, will be busy apportioning by setting the right agenda and resisting blame to all but themselves. Unite Health Sector Officers anything which could harm the progress At the same time, employers will be Tel: 020 3371 2006 we want to make. seeking to restrict pay progression and Obi Amadi – Lead Professional Officer If in 2013 all community health other terms and conditions through Rachael Maskell – Head of Health practitioners work together to set the regressive changes to Agenda for Change, Gavin Fergie – Professional Officer for rhythm for the NHS of the future, then Scotland and Northern Ireland where pay will not rise with inflation we have nothing to fear. Rosalind Godson – Professional Officer and pensions will demand further for School Health and Public Health contribution increases. Dave Munday – Professional Officer It is not a happy picture. Jane Beach – Professional Officer There comes a point where we have to Shaun Noble – Communications Officer stop and think about our raison d’être. [email protected] Throughout its history the CPHVA has Fiona Farmer – National Officer never been about complicity, but about Rachael Maskell Barrie Brown – National Officer driving a better alternative. 2013 will be Head of Health James Lazou – Research Officer a defining year for the CPHVA as it sets Unite the Union

February 2013 Volume 86 Number 2 Community Practitioner | 3 NEWS ROUND-UP Campaign to expose hidden ‘food nasties’ unveiled government advertising campaign Arevealing the levels of sugar, fat, and salt in everyday foods, including a cola bottle that contains 17 sugar cubes, was launched on television last month. The Change4Life campaign aims to help the public develop healthier eating habits. People are encouraged to sign up to the campaign online and by doing so they will receive healthy recipes ‘with enough combinations to eat a different daily menu every day for six years’. The campaign is working with big industry names like Asda, ALDI, Quorn, Uncle Ben’s, Minister, said: ‘Making healthier, balanced ‘There are only a few places where the the Co-Operative Food and Cravendale to meals on a budget can be a challenge for government has entered into deals; for spread the message. Hundreds of offers will families. This new Change4Life campaign example, supermarkets like Asda. They might be on at more than 1,000 Asda, ALDI and offers families free, healthy recipes and money take part in the campaign but will they also Co-Operative food stores across the country as off those much-needed cupboard essentials to still put Mars bars on buy-one-get-one-free a part of the campaign. encourage everyone to try healthy alternatives.’ offers? They have flagged up a few products The Change4Life campaign is a part of a Rosalind Godson, Professional Officer at to get people into their shops. If they were wider government drive announced in 2011 Unite, is sceptical about the campaign: ‘We serious they would hike up the prices of called the ‘Responsibility Deal’. It pledged to don’t object to manufacturers making food unhealthy goods and make healthy food work with businesses to play a larger role in healthier and reducing portion sizes; but if cheaper. Is this just a way of getting more tackling big health issues such as obesity they sell that food at the same price it will only people to go to these shops, or do they really and alcoholism. Anna Soubry, Public Health be of benefit to them,’ she said. want to help improve the health of the nation?’

Department of Health, said: ‘In order to meet the needs of our aging population we have to New district nursing change the way we work and provide more care in the community. People are living longer and we need services that support strategy launched people to be as well and as independent as they can for as long as possible. District new strategy setting out to improve the current and future needs, including more nurses have the professional expertise and Aservice model for district nursing was productive use of community services; knowledge to lead and provide these services.’ launched last month by the Department of integrated working with health and social Obi Amadi, Lead Professional Officer for Health in England. care; delivering complex care such as Unite, said the document is ‘all good stuff Care in Communities: A new vision and chemotherapy at home; and new technology that is happening and should have been model for district nursing sets out solid to enhance this type of care in the home. happening. foundations for district nursing services, The strategy emphasises core elements: ‘The important bit is how it will get including strengthening trust between population and caseload management; implemented in practice. By the time some patients and carers, making sure GPs support and care for patients who are unwell, documents become a reality, what is possible and other services are working more recovering at home and at the end of life; and in practice can look quite different. In order collaboratively and supporting the transition support and care for independence. to move in accordance with the strategy phases of putting a patient into care in a The document seeks to build on the things will need to be done differently. It’s residential or hospice care. existing national strategy for nurses, midwives about making sure that change happens so It also outlines the developments and and care staff, Compassion in Practice. that staff get the support to change and the innovations that ensure services can meet Viv Bennett, Director of Nursing at the public understands that change.’

4 | Community Practitioner February 2013 Volume 86 Number 2 NEWS ROUND-UP

Former health visitor Sarah Cowley awarded a DBE

health visitor instrumental in leading Institute of Health Visiting, which became A research into modern health visiting operational at the end of 2012. was recognised in the New Year Honours Cowley told Community Practitioner list last month. that her 16-year career as a nurse had Professor Sarah Cowley has been emphasised the importance of promoting acknowledged as having a big influence health and reducing health inequalities – on the health visiting field. Most recently, especially the latter. ‘Getting justice into the she co-led a programme of research to system was always a major interest,’ support the government’s Health Visitor she said. of an honour. She said: ‘In that respect, Implementation Plan. Cowley said she feels ‘overwhelmed and this is an award for all of the health visiting She retired in 2012 after a 16-year career honoured to have received this award, profession.’ in nursing that turned into a focus on particularly because it was for ‘services In November 2012, Cowley was awarded a health visiting in 1980. She joined King’s to health visiting’, which is the first time lifetime achievement award by the CPHVA, College London in 1992 and was appointed I have seen such a citation – it helps to which she describes as ‘wonderful acclaim as Professor of Community Practice put health visiting on the ‘honours map’. from my professional colleagues’. She Development in 1997. Cowley is also a Cowley added that she was ‘delighted’ to added: ‘I feel that this honour from outside trustee and founding member of the new see health visiting as a category deserving the profession affirms that earlier award’. Scottish government framework to ‘bolster child protection concerns’

framework to help practitioners A improve their skills working across agencies, and new criteria to help identify when a child may be at risk, has been published by the Scottish government. The guidance, National Framework for Child Protection Learning and Development in Scotland 2012, is intended to act as a ‘practical reference point for all health care staff working within an adult and child service context’. The framework also outlines criteria to measure and evaluate practitioner performance. It emphasises a responsibility on organisational leaders to encourage different methods of learning and development. It highlights the specific roles and responsibilities of specialist staff working in particular settings wherever children and young people will usually be as ‘Version 12’, but takes into account the was not meant to be ‘a panacea’ for all issues seen. It also sets out the framework to aid complex nature of work carried out when around child protection. practitioners in their role in dealing with protecting children and young people and ‘Establishing more guidance may diminish child protection concerns. working with families, and the range of roles rates that are being reported’, he says. The framework builds on much of the that may be involved. ‘Perhaps it will assist de-escalation of work established in a previous document, Gavin Fergie, Professional Officer for bad situations and help to bring down Protecting Scotland’s Children and Young Unite, said the framework would ‘enforce incidences of neglect, emotional and People Training Framework (2005), known best practice and guide practitioners’ but physical abuse’.

February 2013 Volume 86 Number 2 Community Practitioner | 5 NEWS ROUND-UP Doctors and nurses to help protect vulnerable children octors and nurses are to be given extra frequently attended emergency departments already listed as being at risk or if children Dhelp to identify children suffering or urgent care centres over a period of time – have been repeatedly seen in different from abuse and neglect under a new scheme which can be an indication of neglect or abuse. emergency departments or urgent care centres introduced by the government. This information will aid practitioners as with suspicious injuries or complaints, which Under the new system, to be launched in part of their overall clinical assessment. It will may indicate abuse.’ NHS hospitals from 2015, when a child arrives also assist them in forming a better picture Dr Amanda Thomas, Officer for Child and is logged in at an emergency department of what is happening in the child’s life so Protection at the Royal College of Paediatrics or urgent care centre reception, a flag will they can alert social services if they think and Child Health, said the new system was appear on the child’s record if they are subject something might be wrong – improving links ‘a positive step and an important part of the to a child protection plan or are being looked between the NHS and social services. overall solution’. She said: ‘The Report of the after by the local authority. The latter means Health Minister, Dr Dan Poulter, said: Children and Young People’s Health Outcomes a child has already been identified by the ‘Doctors and nurses are often the first people Forum, published in July 2012, highlighted that authorities as being at risk. to see children who are victims of abuse. professionals working in different care settings Doctors and nurses will also be privy to Up until now, it has been hard for frontline need to communicate better with one another information about whether the child has healthcare professionals to know if a child is on child protection issues.’

New NHS workforce figures show small rise in Health staff in north-east health visitor numbers Lincolnshire face ‘savage’ ore health visitors are in employment Mthan over a year ago, according to cuts to pay and conditions government figures published at the end of last year. are Plus, which provides adult health and social care in north east Lincolnshire, is Provisional monthly NHS Hospital and Ctrying to railroad though a ‘savage’ package of cuts to its 750 employees’ pay and Community Health workforce figures from the conditions. NHS show that in September 2012 the overall Care Plus, a so-called social business, plans to implement £800,000 of savings in the next headcount of employed qualified health visitors financial year, 2013/14, which would hit patient care. increased to 10,227 from 9,830 in 2011. Dave Monaghan, Unite regional officer, said: ‘Care Plus is intent on tearing up the More specifically, the number of full-time long-established Agenda for Change national agreement for staff. It is savage in its working health visitors rose from 7,941 in scope’. September 2011, to 8,386 in September 2012. Care Plus provides community nursing and specialist nursing services for conditions such This is the first annual rise in numbers as diabetes, drug and alcohol misuse, as well as home care, and learning disability and end of since 2004. The ‘baseline’ against which the life care. government’s aim is to build an additional Management has only allowed 28 days, from 7 January, to consult staff on the proposals 4,200 health visitors is 8,092, which was which could see cuts to overtime and unsocial hours payments; travel expenses for staff the figure for May 2010. Qualified school using their vehicles on business; maternity leave payments and to annual leave, as well as the nurse figures have also risen, albeit far less downgrading of posts. spectacularly, from 1,165 full-time equivalent The proposed £800,000 axe is on top of £865,000 of cuts demanded for the current nurses in 2011 to 1,174 in September 2012. financial year, 2012/13 – with even more cuts promised in future years. The figures include electronic staff returns – Dave Monaghan said: ‘This is one of the worst examples of attacking health service staff pay ESR (NHS) and non-ESR figures, ie, those in and conditions that I have seen. social enterprises who do not complete NHS ‘In a short period of time, when diaries are already full, Care Plus is attempting to railroad returns. through changes to our members’ contracts which will have a devastating effect on their Rosalind Godson from Unite says: ‘The remuneration packages. Management is refusing union representatives permission to address coalition government agreed to increase the their members at the consultation sessions – that’s disgraceful. number of health visitors and these figures ‘It is too early to assess the knock-on effect for patient care, but undoubtedly, it will be support this. That means currently lots and lots adversely affected. The NHS is being dissected before our very eyes. of health visitors are being trained so they can ‘This is not what staff were promised at the time of conversion to a social enterprise and meet their pledge. As far as we know progress is staff clearly feel very let down. Unite will be working with our members to strongly fight being made to make sure it happens’. these changes.’

6 | Community Practitioner February 2013 Volume 86 Number 2 NEWS ROUND-UP ADVERTISEMENT

Health should be at the centre of UK drug policy, says BMA

K drugs policy should have a stronger health focus to help reduce Uthe harm caused by illegal drug use, according to a report pubished by the British Medical Association (BMA). Drugs of dependence – The role of medical professionals has been produced by the BMA’s Board of Science to explore what can be done to reduce the damage caused by addiction to illegal drugs. The report acknowledges that UK drug policies are beginning to incorporate wider social and economic factors, but maintains that the focus on health remains inadequate. It says drug users may be discouraged from approaching drug services, contacting paramedics in emergency situations, or volunteering accurate or complete information to health professionals because they fear that policies are mainly focused on criminal justice. An expert reference group of specialists with a wide range of knowledge and experience in this field was set up to contribute and advise on the report. The report concludes that drug dependency is a medical condition as well as a legal problem and that alternatives to the current approach to UK drug policy should have health at the centre of the debate. NICE consults on BMI thresholds for ethnic minority groups

ICE is developing public health guidance on body mass index N(BMI) and waist circumference thresholds for intervening to prevent ill health among black, Asian and other minority ethnic (BAME) groups. Draft recommendations for practice and for research have been published on the NICE website for consultation. Professor Mike Kelly, Director of the Centre for Public Health Excellence at NICE said: ‘Our aim in developing this draft guidance is to help determine whether different BMI and waist circumference measures should be used to identify those at increased risk of conditions such as type 2 diabetes or cardiovascular disease in BAME groups. This would help ensure that people at risk of these conditions could be identified at the earliest opportunity to make sure they receive the right advice or preventative action for them. ‘There is evidence to suggest that BAME groups are at a higher risk of diabetes than white populations with the same BMI and waist circumference values. However, it has not been possible to determine a specific threshold to trigger further assessment or health promotion and prevention advice. We have, however, proposed recommending that those assessing BMI and waist circumference be aware that people from BAME groups are at equivalent risk for diabetes and mortality at a lower BMI than white people. We also plan to recommend that health professionals and managers work in partnership with existing BAME community initiatives to raise awareness of this risk’.

February 2013 Volume 86 Number 2 Community Practitioner | 7 NEWS ROUND-UP

Newsinbrief Quit smoking service set up Forced marriage ‘app’ available A new smartphone app has been designed by the Metropolitan Police and the Freedom for young people in Wales Charity to help young people at risk of forced marriage. The app, which can be downloaded for free, includes a checklist he first quit smoking advice and support The Filter said: ‘In Wales research has shown of signs of forced marriage and links young Tservice dedicated to 11–25 year olds was that 14% of 15-year-old girls and 9% of people at risk to organisations that can help officially launched in Cardiff on 10 January, 15-year-old boys regularly smoke and we need them, including ChildLine. Aneeta Prem, with the aim of reducing the number of to get those figures down. There is a big gap in founder of Freedom Charity, said: ‘We are trying to stay on top of new technology and children who start smoking each year in Wales. smoking advice and support tailored to young the new methods by which young people Public health charity Action on Smoking people in Wales and we hope that this project are now communicating. and Health in Wales was awarded more than will reach out to those who are falling through ‘We have a new generation who have £850,000 from the Big Lottery Fund last May to the net. smartphones and by accessing the app they develop the project, ‘The Filter’, which aims to ‘Up to now, education about smoking has are just two buttons away from getting life- saving help.’ spread the message of the dangers of tobacco been very adult focused and usually delivered For more information visit: among children and young people. by authority figures. Quite often it’s seen as www.freedomcharity.org.uk The Young People’s Quit Smoking project will punitive as well. Our project will have young include online support, free tobacco education people at its heart; we will communicate with Birth to Five book petition and training for youth workers, teachers and them on their terms and, hopefully, what we do A petition has been launched for the DH ‘Birth to Five’ book’ to be republished and health professionals working with young will resonate with their everyday experiences. made available to all first-time parents who people, as well as a telephone ‘quitline’ tailored The project is generating support from across do not have access to wi-fi or the internet to teenagers. Wales including high-profile figures such as at home. The petition takes seconds to The Big Lottery funding has enabled ASH Olympic silver medalist rower Chris Bartley. complete and currently stands at 663 Wales to appoint a Programme Manager Chris, from Wrexham, said: ‘Smoking is an signatures – it needs 10,000 in total for the government to take notice. To sign the to run the project; two telephone advisers; addiction that causes huge damage and we petition visit: https://submissions.epetitions. two training and education officers who have to do everything we can to stop children direct.gov.uk/petitions/34517 will provide tobacco control training to taking up smoking. professionals working with young people; a ‘It’s great news that we’re going to have ‘Fulfilling Lives: A Better Start’ initiative web and social media officer, as well as a youth a dedicated service in Wales to help young A Big Lottery Fund £165m initiative for babies and young children aims to deliver development officer who will work directly people to quit and to offer advice and a step change in prevention for babies and with young people in their communities. information about smoking through young children from pregnancy to three Jamie Jones-Mead, Programme Manager for new ways.’ years of age. It focuses on outcomes in three main areas of child development: communication and language development, social and emotional development, and Professionals welcome study of children’s nutrition in the first years of life. The initiative is looking to make between three speech and language services and five awards to local authoritie areas, with their health and voluntary sector upils entitled to free school meals who are training for teachers, teaching assistants, early partners, of approximately £30–£50m each for up to 8–10 years in a specific geographic Pliving in deprived neighbourhoods are years practitioners and speech and language area of around 50,000 people. Grants will twice as likely as other children to be identified therapists to meet the varied needs of children be awarded for activities that focus on as having speech, language and communication with communication needs. It also advocates communication and language development, needs (SLCN), according to new research. a framework setting out the different levels of social and emotional development, and diet The ‘Better Communication’ research support required for different levels of need and nutrition. See: www.biglotteryfund.org.uk programme, the largest ever programme of and more systematic collection of evidence research into children’s SLCN and services about outcomes for children, including the Children’s rights annual report in the UK, also suggests that a black child perspectives of children and their parents. From being sentenced to death and life is almost twice as likely to be designated Kamini Gadhok, Chief Executive of the Royal imprisonment, to suffering repression for as having SLCN than a white British pupil. College of Speech and Language Therapists, participating in protests, children continue to suffer a wide variety of rights violations The odds of a pupil of Asian heritage having said: ‘The findings from this programme across the world. autism spectrum disorder are half those of a are of crucial importance for everyone who The Child Rights International Network white British pupil, say the findings. is concerned about the development of published its annual report for 2011–12 in Recommendations in the report suggest that children’s communication. They illustrate the January. Issues in focus include restrictions more effective collaboration is needed by health complexity of children’s communication and on the work of children’s rights defenders and children and international justice. and education services to make sure every child the need for all children with speech, language The report in full can be found at: gets the best and most tailored support. and communication needs to have access to www.crin.org/docs/CRIN_Annual_ The study also recommends a comprehensive appropriate services commissioned jointly by Report_2011-12_final.pdf programme of initial and post-qualification local authorities and local health services.’

8 | Community Practitioner February 2013 Volume 86 Number 2 32 CP Nov 11 Bookshop.qxd:Layout 1 10/10/11 11:36 Page 32

Unite/CPHVA Bookshop The bookshop of Unite/CPHVA provides members of the association and their colleagues with an invaluable source of key professional resources, often at reduced and discounted prices for members

Remember to quote your Unite/CPHVA membership number www.cphvabookshop.com during checkout to qualify for reduced prices

Infant mental health: effective prevention and early intervention by Maria Robinson ‘Dr Robinson’s book should be read by every experienced health visitor to affirm and update their practice, and by all students learning the craft. It deserves to become a classic text in this field’ (Professor Sarah Cowley, King’s College London). £17.50 Unite/CPHVA members £27.50 non-members

Skill mix in health visiting and community Record-keeping and documentation: nursing teams: principles into practice principles into practice by Maggie Fisher by Rita Newland At a time when spending in the NHS is An easy-to-use publication under scrutiny, it is important that all filled with practical information decisions are based on the best to help practitioners to evidence and knowledge of what works. establish and maintain Skill mix is a very under-researched area effective and efficient record- in the community, but Maggie Fisher keeping and documentation has successfully brought together the practice. A must for students available research and placed it within and qualified staff. a professional and policy context. £15 Unite/CPHVA members £17.50 Unite/CPHVA members £17.50 non-members £27.50 non-members

Getting it right: supporting the Tackling child obesity with HENRY: health of refugees and people a handbook for community seeking asylum and health practitioners by Cath Maffia and Steve Conway by Candida Hunt and Mary Rudolf How and why people come to the UK An approach to help practitioners in search of sanctuary, what happens engage successfully with parents to them when they arrive, and the and carers, and encourage them to likely health impacts of their unique give their babies and toddlers an and varied experiences. optimal start to life. £10 Unite/CPHVA members £10 Unite/CPHVA members £12 non-members £12 non-members

The principles of health visiting: Discovering the future of school nursing: opening the door to public health the evidence base practice in the 21st century by Diane DeBell and Alice Tomkins by Sarah Cowley and Marion Frost £10 Unite/CPHVA members £10 Unite/CPHVA members £12 non-members £15 non-members

Protecting babies’ heads: a teaching Community development: toolbox for preventing shaking and new challenges, new opportunities head injuries in babies by Catherine J Mackereth by Lisa Coles £10 Unite/CPHVA members £8 Unite/CPHVA members £15 non-members £10 non-members

Community nursery nurse (CNN) handbook Unite/CPHVA handbook with information on CNN members: get your free handbook subjects including leadership, record- If you are a CNN member, contact Unite/CPHVA for your free keeping and lone working copy of the CNN handbook. Email your name, membership FREE to CNN members of Unite/CPHVA number, job title, hours per week and primary care trust or £10 otherwise employer name to: [email protected] CPHVA Awards advert:Awards 12/12/2012 11:13 Page 33

A CELEBRATION OF PROFESSIONALISM

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Make your nomination online at www.communitypractitioner.com

Thank you to our prestigious group of sponsors this year

DETTOL ' PAMPERS ' RECKITT BENCKISER ' FEEDING FOR LIFE ' JOHNSON'S BABY ' CPHVA CHARITABLE TRUST ' MOTHERCARE

The Awards luncheon takes place on Wednesday 13th March 2013 ASSOCIATION

Conference poster winner: Public health families with multiple births nursing of school- aged children t the CPHVA Annual Conference in births. They expressed that they are so ANovember, Merryl Harvey, Regender used to dealing with singleton births that s you may be aware, Unite/CPHVA has Athi and Elaine Denny were awarded the the complexities of multiple births are Arecently restructured the professional research poster prize, receiving £100. often overlooked’. forums into National Organising Professional The project was entitled Meeting the Committees (OPCs). We are now looking to Health and Social Care Needs of Families Delegates who viewed the poster said: populate these with a member from each with Multiple Births and aimed to explore ‘This supports the Healthy Child Programme’ region; currently only nurses from London and Kent have come forward. the lived experiences of families, including ‘I always called the twins “twins” and The professional officers will be working the impact of multiple births upon partners never thought that this may be upsetting for with the Health Regional Industrial Sector and children, and sources of support. parents’ Committees (RISC) to identify a public The project’s authors found interest from ‘There was a mum on my caseload who health nurse for school aged children from delegates at the conference in the research needed support. I often find that mothers of each Unite in Health area in your region was immense, with the qualitative findings twins are more tired, but what can I do to (about seven to 10 in each region), and relevant for frontline practitioners who have support these mothers? I didn’t know where then from those someone who would like to contact with parents with multiple births. to go’ represent public health and school nurses Author, Regender Athi, said, ‘The ‘I have more twins on my caseload now and at the National OPC. If you would like practitioners at the conference felt that they this information is really useful’ further information, or would like to put are coming across some of these problems ‘You don’t get any training on supporting yourself forward locally, please kindly get in touch. We need all our combined effort to but often do not know what to do or mothers with twins or multiples – this make sure that our voices are heard at this where to go to support people with multiple information is very useful’ crucial time. Community nursery nurses We also have similar gaps in our community nursery nurse representation, NHS Leadership Academy so please contact Ros Godson, Unite, for further information: rosalind.godson@ commitment of nine days, and the Ward he NHS Leadership Academy is unitetheunion.org Tlaunching a comprehensive approach Manager/Team Leader Programme a to leadership development. More than £46m commitment of seven days. Provisional dates will be invested in three core programmes, are programmed in for each cohort for both Institute of Health Visiting which will map to foundation, mid- and of the programmes which will run from e are writing to clear up any confusion that may exist in the minds executive-level leadership development. Part March 2013 to February 2014. Course details W of members about the distinctive roles of of this investment will initially be spent on confirmed so far are: Unite, which embraces the Community two programmes specifically for nurses and Practitioners’ and Health Visitors’ midwives, which are both due to commence in Aspirant Nurse Director Programme Association (CPHVA) and the fledgling March 2013. l Cohort One – 11, 12, 13 and 14 March 2013 Institute of Health Visiting. Both of these programmes are being and 4 July 2013 Unite/CPHVA celebrates a 116-year history developed with key organisations, including l Cohort Two – 15, 16, 17 and 18 April 2013 as the professional organisation for health Unite, the Royal College of Nursing and and 9 August 2013 visitors. This has not changed; we recognise the Royal College of Midwives, while the the importance of public health promotion main sponsors for the programmes will be Ward Manager/Team Leader and other professional issues and we have Jane Cummings, Chief Nursing Officer for the Programme the resources to campaign on both the industrial and professional agendas. The NHS Commissioning Board and Viv Bennett, l Cohort One – 25, 26 and 27 March 2013 CPHVA was the first women’s union to be Director of Nursing at the Department and 12 July 2013 affiliated to the TUC. l of Health. Cohort two – 29 and 30 April 2013 It was Unite/CPHVA that campaigned The process for selection/nomination to the and 1 May 2013 successfully for the 4,200 health visitors now programmes, and final content and course coming on stream. It is Unite that is fighting structure is currently being developed with the If you have any comments about what course the privatisation onslaught on NHS services key stakeholders and will undergo a validation content should look like, please visit: www. and the proposals by the NHS Employers to process over the coming weeks. leadershipacademy.nhs.uk/nurseleadership dilute the terms of Agenda for Change. Each of the programmes will have five Any questions about the nurse leadership The Institute is not part of Unite CPHVA – cohorts made up of 40 people. The aspirant programme should be directed to: it is part funded by the DH and housed at nurse director programme will require a [email protected] the Royal Society for Public Health.

February 2013 Volume 86 Number 2 Community Practitioner | 11 ANTENNA

Looked after young people and mental health stigma

ences within their placements, education and Most of the young people we spoke to per- Roger Catchpole support services. We asked young people to ceived mental health services with wariness and Training and Development Manager consider how they felt during different stages of attached negative meaning to the word ‘mental’. YoungMinds their placement journey and whether they were One of their biggest concerns was talking to able to express any worries and receive support. strangers about their most personal feelings. oungMinds is a child and adolescent men- Young people said that they were very anxious They stated that they were more likely to talk to Ytal health charity working to promote the moving in to new placements as they often foster carers, residential workers and participa- mental health of all children and young people did not know what to expect. The importance tion workers than professionals in a mental aged between 0 and 25. of pre-placement visits was reiterated so that health setting and stated that it was important One of the themes the charity is focusing on preconceived fantasies about placements could that all those working with looked after young is the mental health needs of looked after young diminish and young people could have realistic people had training in mental health. people. Our work aims to reduce mental health perceptions of what their future home might We asked young people about their experienc- stigma and to ensure that it is informed and be like. These visits need to be combined with es at school and these were quite varied. While underpinned by the experiences of looked after careful information sharing and opportunities most did not see this as the primary place to get young people. Creative workshops were set up for young people to feel safe asking questions emotional support, one young person explained that would enable participants to explore how and sharing their anxieties. A carefully planned that the reason he attended school throughout their emotional wellbeing was supported in placement move is a key factor in its success and was to see his counsellour. Participants said they different settings and to understand if young young people should be as involved as possible would like teachers to have a better understand- people were able to access the help they felt in the process. ing of what it might be like to be child in care they needed to support their mental health. Looked after young people’s access to and that they would also benefit from training The charity contacted young people through mental health services (CAMHS) is a topic around their mental health needs so that there Children in Care Councils, participation groups, frequently discussed by participants on train- is understanding about their behaviour rather the Secure Accommodation Network and the ing courses and concerns about waiting times than blame. However, they also stated that they Children’s Residential Network and visited have increased since recent cuts to CAMHS do not want to be singled out within schools as the groups who said that they would like to budgets. We spoke to young people about this could add to further stigma. take part. We provided young people with art their perception of mental health services and For a detailed look at the report go to: www. equipment, Lego, Play People, dolls, video and asked them whether this is where they chose youngminds.org.uk/assets/0000/1440/6544_ photography to help them explore their experi- to get their support. ART_FINAL_SPREADS.pdf

Book review: A guide to practical health promotion

Mary Gottwald and methods, and then apply them throughout the text, as a school nurse I did Jane Goodman-Brown to case scenarios and activities, notice that the school health case scenario Open University which is a practical way to was not included in the chapter ‘Working Press, 2012 learn as it enables the reader with groups and communities’ – the school £22.99 to interact with the text. The community being an important area as a ISBN-10: 0335244599 chapters follow on from an foundation for health promotion. introduction that explains why The final chapter focused on mass media n first impressions health promotion is important in and social marketing, which is ever-relevant Othis book appeared relevant theories and models. in today’s society and has a huge influence as a slim and easily I particularly liked the way on public perceptions, from my experience. digestible read. the book tries to encourage the To sum up, I found the book to be a Each chapter is clearly reader to develop practice skills very useful resource for any individual signposted with defined and self-awareness before leading working or studying in the field of health learning objectives, key points, implications into the practical application of these promotion. for practice and end-of-chapter questions. within communities. One of the most rewarding aspects of this However, while the importance of health Janet Hutchinson book is that you learn the theories and promotion within schools is mentioned School Nurse, County Durham

12 | Community Practitioner February 2013 Volume 86 Number 2 ANTENNA

Research evidence New resources Vitamin D status as a risk period for overweight/ counselled on the risk of both ‘Right to Go’ guidance obesity in both mother and cigarette and marijuana smoking. from ERIC of exclusively child because of excessive Clin Obstet Gynecol 2013 [Epub The guidance has been developed in response gestational weight gain (GWG). ahead of print] breastfed infants to the results of a survey The promotion of a healthy aged 2–3 months by ERIC and the ATL GWG is therefore of paramount In 2008 New Zealand adopted Gender (Association of Teachers importance in the context of WHO policy, which recommends and Lecturers). The the prevention of obesity in the differences when that all infants are exclusively research highlighted that current and next generations. breastfed until six months of parenting children 62% of primary school This study aimed to provide age. A number of countries with autism staff in the UK have a comprehensive overview of noticed an increase in now also recommend that all Parenting a child with autism the effect of prenatal physical the number of children breastfed infants receive daily may differentially affect mothers activity interventions, alone or wetting or soiling vitamin D supplementation of and fathers. Existing studies of in combination with nutritional themselves during the 400 IU to prevent rickets. New mother–father differences often school day over the past counselling, on GWG and to Zealand has no policy on the ignore the interdependence of five years, which increased address whether preventing vitamin D supplementation data within families. This study to 71% amongst those excessive GWG decreases the of ‘low-risk’ breastfed infants. investigated gender differences working specifically with incidence of infant high birth This study aimed to describe within-families using multilevel three to five year olds. weight and/or postpartum weight linear modeling. Mothers and www.eric.org.uk retention. Results showed that fathers of children with autism prenatal lifestyle interventions (161 couples) reported on their NSPCC helpline TV promoting healthy eating and own wellbeing and their child’s campaign ‘Don’t Wait physical activity habits appear to functioning. Mothers reported Until You’re Certain’ be the most effective approach to higher levels of distress compared Recent media coverage has heightened public prevent excessive GWG. with fathers, and child behaviour awareness of child sexual J Pregnancy 2012: doi: problems predicted psychological 10.1155/2012/470247 abuse. The NSPCC ‘Don’t distress for both mothers and Wait Until You’re Certain’ fathers. The authors found little national television Smoking and evidence of child functioning campaign urges the public marijuana use in variables affecting mothers to contact the NSPCC and fathers differently. Gender helpline and report their pregnancy differences in the impact of child concerns about a child. The obstetrical, neonatal, and autism on parents appear to be A poll by the NSPCC and childhood risk associated with serum 25-hydroxy-vitamin D robust. The study concludes that YouGov shows that less prenatal smoking are well (25(OH)D) concentrations in more family systems research than one in five (17%) known. Prenatal smoking has would report concerns as exclusively breastfed infants is required to fully understand been implicated in up to 25% soon as they arose. For aged 2–3 months. It concluded these gender differences and the of low birth weight infants more information visit: that vitamin D deficiency is implications for family support. primarily from preterm birth www.nspcc.org.uk prevalent in exclusively breastfed J Autism Dev Disord 2013 [Epub and fetal growth restriction and infants in New Zealand. The ahead of print] Coeliac UK campaign up to 10% of all infant mortality. authors recommend that vitamin Coeliac UK, the national The relationship between D supplementation should charity for coeliac prenatal marijuana smoking be considered as part of New disease launches a new and obstetrical and infant Zealand’s child health policy. campaign in May 2013 outcomes is less clear. Marijuana Arch Dis Child 2013 [Epub ahead with the Charity’s Health is the most commonly used of print] Ambassador, Dr Chris illicit drug during pregnancy. Steele MBE, to find the Preventing long- Neither exposure to cigarette nor missing half a million marijuana smoke has evidence people undiagnosed with term risk of for teratogenicity, but both have coeliac disease. The ‘Gut obesity for two been implicated in developmental Feeling’ campaign takes place from 13–19 May and hyperactivity disorders in generations 2013. Visit: www.coeliac. children. The authors recommend The period surrounding org.uk that pregnant women should be pregnancy has been identified

February 2013 Volume 86 Number 2 Community Practitioner | 13 BREASTFEEDING IS BEST FOR BABIES ADVERTORIAL FEATURE

Can infant formula innovation help digestion in formula fed infants?

The fi rst few months of an infant’s life can be a stressful time for their bodies as they adapt to digesting a range of nutrients and they At SMA we understand that the fi rst will often experience mild gastrointestinal (GI) disturbances.1 few months can be hard for babies with mild digestive troubles which in In fact, 55%of babies will suffer with symptoms such as mild turn can be diffi cult for their parents. constipation, colic, and wind in the fi rst 6 months of life.1 That’s why for bottle-fed babies we New parents need support from healthcare professionals (HCPs) and have designed our new SMA Comfort Infant Milk to be easy to digest and those using formula to feed their infants may be seeking alternative gentle on infant digestive systems. infant formula solutions. Specially formulated, it contains partially hydrolysed 100% whey Modifying standard infant formula to help digestion protein, an SN-2 enriched fat blend and lower levels of lactose compared Adaptations can be made to standard fi rst infant formula to respond to to standard fi rst infant milk. these challenges in a variety of ways. Designed to be easy to digest, SMA Comfort Infant Milk is also nutritionally complete. Partially hydrolysed whey protein Reduced lactose

Breast milk provides a very fast gastric In the immediate weeks after birth a young emptying time that reduces the risk of baby’s body is often unable to effi ciently digestive disturbances. A similar pattern digest lactose, and this can cause discomfort can be obtained using formula containing due to wind.3 The symptoms of colic - fractious partially hydrolysed whey proteins.2 behaviour, crying and wind - can be diffi cult for baby and their parents. If whey protein is partially hydrolysed it will form smaller peptides. Reducing the levels of lactose is one potential 90 years of breast milk research strategy to help reduce the amount of wind babies produce. For some colicky babies, decreasing the concentration of lactose in formula has been found to result in a reduction in crying and wind.3 big protein molecule

SN-2 enriched fat blend hydrolysis An SN-2 enriched fat blend structurally resembles that found in breast milk and is well absorbed by infants.4 Visit us: smahcp.co.uk As the fats are more easily absorbed, formula using an SN-2 enriched fat blend is proven to reduce soap formation in stools and help make stools softer.5 small, more easily digested peptides A recent study has also found that infants fed IMPORTANT NOTICE: Breastfeeding is best for babies. These smaller protein peptides are more formula with an SN-2 enriched fat blend spent Breast milk provides babies with the best source of manageable than larger protein molecules signifi cantly less time crying than babies whose nourishment. Infant formula milk and follow on milks for a baby’s immature GI system, making formula did not contain the same fat blend.6 are intended to be used when babies cannot be breast the formula easier to digest.2 fed. The decision to discontinue breast feeding may be diffi cult to reverse and the introduction of partial bottle- feeding may reduce breast milk supply. The fi nancial benefi ts of breast feeding should be considered before 1. Iacono G et al. Gastrointestinal symptoms in infancy: A population-based prospective study. Dig Liver Dis 2005; 37: 432-8. bottle feeding is initiated. Failure to follow preparation 2. Billeaud C et al. Gastric emptying in infants with or without gastro-oesophageal refl ux according to the type of milk. Eur J instructions carefully may be harmful to a babies health. Clin Nutr 1990; 44: 577-83. 3. Infante D et al. Dietary treatment of colic caused by excess gas in infants: Biochemical evidence. Infant formula and follow up milks should be used only World J Gastroenterol 2011; 17: 2104-8. 4. Carnielli VP et al. Structural position and amount of palmitic acid in infant formulas: on the advice of a healthcare professional. effects on fat, fatty acid, and mineral balance. JPGN 1996; 23: 553-60. 5. Yao M et al. High 2-palmitate and oligofructose in lower protein alpha-lactalbumin-enriched term infant formula: effects on stool characteristics and stool composition. JPGN 2010; ZCO1335/10/12 50: (Suppl 2). 6. Limanovitz I et al. The effects of infant formula beta-palmitate structural position on bone speed of sound, anthropometrics and infantile colic: a double blind, randomized control trial. ESPGHAN 2011.

12909 SMA CP advertorial.indd 1 12/11/2012 15:10 NEWS FEATURE

Northern Ireland: fit and well?

Northern Ireland has gone through considerable change over the last few decades. Once the scene of bitter political struggles, the 1990s saw the region develop and progress. However, poverty and health inequalities still remain some of its most stubborn problems

Northern Irish government launched a develop the skills and capacity to reach their Herpreet Kaur Grewal 10-year framework for consultation in full potential and to help improve the life Independent writer 2012 called Fit and Well – Changing Lives to and social wellbeing of working age adults. improve the health of the population and At the launch, Chief Medical Officer, Dr report published in 2012 by the tackle health inequalities. This followed Michael McBride, said: ‘Coronary heart social policy thinktank, Joseph the Investing for Health (IfH) programme, disease, cancer and respiratory disease A Rowntree Foundation, pointed out published in 2002, Northern Ireland’s 10- continue to be the main causes of death that persistent poverty in Northern Ireland year cross-cutting public health strategy, for both sexes. Many of these deaths occur is at 21% before housing costs; this is double which ended in 2012. before 65 years of age and are potentially that in Great Britain at 9% (MacInnes et al, The new strategy aims to build on the preventable, since smoking, unhealthy diet, 2012). The links between poverty and health previous document by continuing to raised blood pressure, diabetes and physical are undeniable. As Northern Ireland’s Public ‘ensure the best possible health status for inactivity are major contributors to many of Health Agency (PHA) states: ‘Both poverty the population of Northern Ireland’. The these conditions.’ and economic inequality are bad for health’ document’s main proposals include giving There have been some improvements in (PHA, 2012). every child the best possible start in life, the health of the Northern Irish population. It was no surprise, then, when the enabling all children and young people to Between 1981 and 2009 life expectancy

February 2013 Volume 86 Number 2 Community Practitioner | 15 NEWS FEATURE

increased for both men and women by could be transferred to NI. ‘There are almost eight and six years, respectively. programmes in Scotland that pay people to Advances in treatment and care have stop smoking, which could also be an option also meant that chronic conditions can that NI rolls out,’ he says. be managed differently with the aim of The government is unclear as to how the securing better quality of life for longer. strategy could impact health visitors and Despite this, as health minister, Edwin community and school nurses. In essence, Poots (pictured), points out: ‘Those who are it could mean a lot of extra work for disadvantaged in our society do not have an community practitioners. A spokesperson equal chance of experiencing good health for the DHSSPS said: ‘If the proposed and wellbeing.’ emphasis on giving children the best start A short bus trip from Donegall Square to in life is retained in the final strategy, then Finaghy Road South in Belfast illustrates his health visitors are likely to have a role to point. The life expectancy of people living play in this, but how that will differ from in these areas – which are only around five what they do at present, it is too early to miles from each other – differs by up to nine say.’ She adds that the document is in its years, from the start of the route to the end. draft stages and the department is ‘still The new strategy says that while the considering the consultation comments government will take ‘a population-wide and there will be changes, maybe some approach to health improvement, we Northern Ireland Health Minister substantial ones’ before it is finalised. must seek to reduce such inequalities’ Edwin Poots (DHSSPS, 2012). Over the next 10 years and there would be less demand on other More pressure it will aim to bring ‘together actions at services … But it has to be funded now to Gavin Fergie expressed concern at the government level to improve health and have the long-term benefits later and the extra pressures the strategy could present reduce health inequalities, which will guide rhetoric doesn’t really support that. for already overworked, underpaid health implementation at regional and local level’. ‘It will take more than one financial year visitors and community and school nurses. to carry this out and getting all the political ‘There will have to be an additional Funding parties in the province [on board] is hard.’ funding stream to educate more health Such ambitions require adequate funding The current government’s public service visitors and school nurses for what they – and while there seems to be a rough plan, budget cuts across the board also has to be would be required to do – there’s certainly the document remains vague as to how considered, he says. not enough to tackle what’s in this it will work in practice. A Department of Janet Taylor, Lead Public Health Nurse for document,’ he says. Health, Social Services and Public Safety Children’s Services for the South Eastern While Janet Taylor welcomes the strategy, (DHSSPS) spokeswoman in Northern Health and Social Care Trust, supports a she feels it seems ‘very academic’ because Ireland said the short-term outcomes document that is planning better health in ‘we don’t need to be told about this problem proposed in the framework are to be 10 years but she has reservations: ‘My only … it is not new. The problem is how to get achieved within the current budget period scepticism is that we have this document people to stop it’. by 2015. These include agreeing on and other documents out, and they need to She says: ‘If there’s a problem on the indicators at strategic, local and regional be suitably financially funded and staffed [to ground, policymakers should really come level for attaining outcomes. be successful]. But it’s not just about money, down to the level of the staff and see it from The government will increase the it’s about money appropriately used.’ their point of view [on how to fix it].’ amount allocated to public health by £10 How the strategy compares to other Often, health visitors and school and million between 2011/12 and 2014/15, countries in the UK is still being community nurses are well placed to carry says the DHSSPS. A spokesperson added: determined. However, Ms Taylor is not keen out follow-up work and this can lead to ‘In addition, other departments will be on selling services to private companies, an contributing from their budgets to their approach increasingly being taken outcomes to which they are committing in England. to in the framework. It is not possible to ‘Virgin Medical Care are getting too quantify the total contribution from involved with a lot of what England are The government will other departments.’ doing, there’s too much [influence] from increase the amount Gavin Fergie, Unite Professional Officer for the private sector. I would not want to go allocated to public the health sector in Northern Ireland, while down that route. Scotland is probably closer health by £10 million lauding the government’s good intentions, to our hearts … when I get together with between 2011/12 and remains dubious about how funding for the my colleagues across the way the Scottish strategy will materialise in practice. documents tend to be quite transferable to 2014/15, says the DHSSPS He said: ‘If the funding was found for this us in NI,’ she says. now it would save money in the long term Gavin Fergie says some Scottish initiatives

16 | Community Practitioner February 2013 Volume 86 Number 2 NEWS FEATURE

solid results. Taylor said this following-up a ‘broadstroke approach’. He says there approach was taken in a deprived, working also needs to be ‘a societal change and a class area in Northern Ireland, where people ownership of problems. Individuals have to were not turning up to immunisation decide to change’. clinics. He says this can be encouraged by ‘making ‘We thought, ‘how do we do this?’ A bit of small changes but good changes’ by focusing extra money was given to us and we put it on certain groups. in to facilitate staff to put in extra hours and ‘Men die earlier than women so they the clinic was taken to where people actually have to focus on Northern Irish men were. Then health visitors worked very – whether that means employing local hard at contacting people to come into the sports celebrities or other role models or clinic, making it easier for them to come – programmes has to be looked at,’ he says. sometimes even texting them to remind them ‘There is not one measure that will solve – all this work is very labour intensive but everyone’s health problems.’ eventually the clinic caught up,’ says Taylor. She says health visitors also need more References and better administrative support. She Department of Health, Social Services and Public thinks nursery nurses could be given more Safety (DHSSPS). (2012) Fit and Well. Changing Lives 2012-2022. Belfast: DHSSPS. responsibility and tasks, cutting the load for MacInnes T, Aldridge H, Parekh A, Kenway P. (2012) health visitors. She also believes there need housing, working with social services and Monitoring poverty and social exclusion in Northern to be more school nurses and they should be directly with people on the ground. Health Ireland 2012. York: Joseph Rountree Foundation. funded adequately. professionals and experts should be leading Public Health Agency Northern Ireland. (2012) The solution has to be multi-faceted, the approach.’ Poverty. Available from: www.publichealth.hscni. net/directorate-public-health/health-and-social- maintains Taylor. ‘There has to be a whole Gavin Fergie agrees that reaching the most wellbeing-improvement/poverty [Accessed approach … it is about working with disadvantaged in the community requires January 2012].

CPHVA Education and Development Trust MacQueen Award 2013 for Excellence in Practice and Excellence in Research Applications are invited for the MacQueen Awards 2013. This year we aim to award 2 prizes which will recognise ‘excellence in practice’ and ‘excellence in research’ The winners will receive £3500 (£1000 for personal spend and £2500 for professional use) in recognition of their personal achievement and to enable dissemination and publication of their work. A ticket and expenses (travel and accommodation) will also be provided to attend the Unite/CPHVA 2013 Annual Professional Conference. Applicants should: • Demonstrate innovation in practice or research (NB: The project must be either near completion or recently completed) • Show evidence of evaluation and the difference the project has made to peers, clients or service users . All CPHVA members are eligible and welcome to apply. For further information or to apply, please contact Kitty Lamb, Chair Professional Advisory Committee. Email: [email protected] The closing date for applications is 5pm, Friday 2nd August 2013. Successful applicants will be notified by Friday 16th August 2013. Interviews will be held in London on Friday 20 September 2013 (travel expenses will be recompensed).All applicants must have valid Unite/CPHVA membership, and be available to attend interview and annual conference.

February 2013 Volume 86 Number 2 Community Practitioner | 17 PROFESSIONAL AND RESEARCH: PEER REVIEWED

Building community capacity using web-supported work-based learning

Introduction and confidence of people and community Pauline Pearson BA PhD PGDipSocRes CerT&L(HE) Health visitors are at the core of the govern- groups to take effective action and leading DipThMin RGN RHV ment’s promise to build up support to gen- roles in the development of communities’ Professor of Nursing, Northumbria University erate strong and stable families and com- (Skinner, 2006: 4).

Lesley Young-Murphy RN RM HV PhD munities. Their importance is reflected in The BCC educational programme was Interim Director of Community Care and OD, the promise (Department of Health (DH), commissioned by the DH in the closing NHS North of Tyne 2011), that 4,200 additional health visitors days of 2010 – work started in January would be recruited during the present term 2011. It needed to be potentially available Jonathan Yaseen BSc (Interactive Entertainment Systems) of government. to all 10,000 health visitors working across Learning Technologist, Northumbria University Building from the principles they have England. The team were aware that some espoused for more than three decades (CE- are situated in urban areas with high levels Gillian Shiel RNMH MEd CertEd THV, 1977; Cowley and Twinn, 1992; Cow- of health and social need, and often multi- Health Visitor, Camden PCT, Principal Lecturer, Northumbria University ley and Frost, 2006), health visitors are seen ple agencies intervening. as guiding the complex networks required Others are in suburban areas and com- Correspondence: pauline.pearson@northumbria. to support children, families and commu- muter towns, where needs may be less ob- ac.uk nities to achieve the best possible health vious but often related to patterns of em- Abstract outcomes. However, while the existing ployment, substance misuse, and stress. Yet Health visitors are a central component of policy workforce has the potential to undertake others work in rural areas, in market towns to create strong, stable families and communities. this role, many have been overwhelmed by and villages, with communities which are The programme which is described here is current workloads and few have been able more geographically bounded, but which intended to facilitate existing health visitors to gain confidence and extend or renew their to sustain the necessary skills or up-to-date can be subject to intense pressures through skills in building community capacity (BCC). knowledge to go beyond core tasks. natural disasters (foot and mouth, flood) Networking and relationships are essential to One important area for development and economic change (reducing tourism). effective community development. These are highlighted in the Health Visitor Imple- It was seen as crucial that the programme key skills for the health visitor, which along with professional principles support community mentation Plan 2011–15 (DH, 2011) is could be relevant in disparate communities capacity building. Learning in this programme is the facilitation of community engagement and to health visitors recently qualified as self-directed, supported by web-based resources in health improvement. The programme well as those with a wide range of experi- over a 24 week period. Learning mainly takes described here was initially intended to ence. The design also needed to be acces- place in practice. It involves carrying out a work based project through to completion. facilitate existing health visitors to gain sible and attractive to all these groups. For Participants register online, and follow a series confidence and extend or renew their skills employers to release staff it was important of six phases. Evaluation of the pilot took place in building community capacity (BCC). that participation would enhance employ- during 2011. Three main areas for improvement However, it was also intended that it should ability and facilitate achievement of na- were identified: reflective software; signposting access to resources; and dealing with workload have the potential to be used by student tional, regional or local strategic objectives. pressures. Community engagement for health health visitors, and be transferrable to oth- For commissioners, it would be impor- improvement remains an important element of er groups such as school nurses. tant to encourage participants to gather the vision for health visiting. The programme Skinner (2006) defined community ca- evidence of relatively short-term change in described is a core resource through which health visitors can build the skills and confidence of pacity building as: ‘Activities, resources and the health and wellbeing of children, fami- community groups and staff in other agencies to support that strengthen the skills, abilities lies or communities, as well as movement make a difference to health and wellbeing.

Key words Box 1. Project proposals Community development, health improvement, community capacity, work based, web based l A peer-led grandparent/kinship carer support group for those acting in loco parentis l Improving the health and wellbeing of asylum seeker and refugee families with children Community Practitioner, 2013; 86(2): 18–22. aged 0–5 years l No conflict of interest declared Support group for parents of teenage parents l Developing services which improve the wellbeing of families moving into the area l Increasing cooking skills to enable parents to provide healthy, home-cooked food l Increasing parental confidence in dealing appropriately with minor ailments l ‘Too much too young’: an antenatal group at a local school

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towards longer-term objectives. In a time of Box 2. Proposal – rationale transition a focus on joint strategic needs and clear evidence of outcomes would be Healthy Lifestyles Group Sessions: The health visitor proposing these says: even more important. A further feature of the process of devel- ‘The local children’s centre approached me to do a group for parents and children opment was community engagement in the that would help in reducing obesity. In 2010, in the UK almost one in three children design process. To maximise the potential are overweight or obese; this has a devastating impact on their health in later life and transferability of the BCC framework into increases the pressure on the NHS (THSCIC, 2012). One of the children’s centre key a range of communities and settings, the targets is to reduce obesity in their area. They have done a 10-week Henry course but team engaged a reference group of individ- found it difficult to continue supporting families around healthy lifestyles once this uals mirroring some of the most likely key course finished. We did not want to focus the group strictly on weight loss as this could create anxiety for parents who have relatively healthy young children. Healthy lifestyles stakeholders, who advised on and reviewed (healthy eating and exercise) will promote small lifestyle changes, while highlighting the the developing programme. Piloting took benefits and discussing the barriers. By promoting small changes to family’s lifestyle place in first wave Early Implementer Sites this hopefully will make a positive impact on improving long-term health outcomes, during May-November 2011 and roll-out such as reducing obesity.’ across England began in 2012.

Underpinning models implement programmes impacting upon possible to log online anytime of the day, in Health visitors are seen in policy as cata- the community). principle fitting with individual workloads. lysts and connectors who steer families and The programme which was developed in- As part of BCC it was envisaged that every communities towards health and wellbeing, volved two dimensions, seeking to incor- participant taking part in online learning using and building up social capital. Social porate these models and responding to the would be, or become, competent in using capital (Putnam, 2000) is usually under- original brief. To promote accessibility and online materials, and manage their learning stood as built upon networks and relation- provide resources to support use in diverse in ways that best suited them around their ships. It can be defined as ‘the goodwill that locations, a web-based portal was devel- lifestyle. This would enable them to experi- is engendered by the fabric of social rela- oped through which a series of resources ence online learning in a busy context. As tions and that can be mobilised to facilitate and links can be accessed. To facilitate re- well as increasing individuals’ IT skills, it action’ (Adler and Kwon, 2002: 17). lational and organisational engagement was envisaged that studying online would Gilchrist (2009) describes networking models for workplace support were devel- facilitate students to follow their strengths and relationships as essential to effective oped. and preferences in taking in and processing community development. These are key The overall programme was based on information. skills for the health visitor in building com- principles drawn from the work of Boud munity capacity. Gilchrist also highlights and colleagues (2006); in particular, the What does the programme involve? some of the lessons which can be drawn notion of productive reflection, which The programme is hosted on the web (cur- from work in developing countries. Eade harnesses reflection on work experience rently at www.hces-online.net/health-visi- (1997), looking at examples in developing and work practice to enhance productiv- tors), but the nature of the learning is self- countries, makes clear that building com- ity and engagement as well as learning. It directed, supported by web-based resources munity capacity is about more than deliv- drew heavily on work by Rhodes and Shiel over a 24-week period. Learning predomi- ering competences or weight of investment (2007), both of whom were members of the nantly takes place in practice. It involves – it is linked to impacting upon social and project team. bringing a work-based project through to economic (or in this case health) outcomes. The programme blends work-based and fruition, which will build personal as well Communities will be motivated to work online learning. Developing online learn- as community capacity. with professionals when their perceived ing materials requires the use of techniques Before participants begin there needs to needs are addressed. that will hold a participant’s concentration be a period of organisational preparation Florin and Wandersman (1990) discuss and understanding. According to Rossett and readiness to support the initiative. models of citizen participation and em- (2002), online learning makes many prom- There should be clear roles and responsi- powerment, and examine how these affect ises, but it takes commitment and resourc- bilities assigned to key people within the who participates, why some organisations es, and must be done right. ‘Doing it right’ host organisation (and among local com- are more successful in community devel- means that not only must online learning missioners) as well as a raised level of un- opment, and the overall effects of develop- materials be designed properly, with the derstanding about what participants are ment. learners and learning in focus, but that ad- aiming to achieve. Foster-Fishman and colleagues (2001) equate support must also be provided. Champions play an important role in suggest that collaborative capacity is built Ring and Mathieux (2002) suggest that on- ensuring the success of BCC and in doing around four levels: individual (member); line learning should have high authenticity so make a difference to one or more local relational; organisational (effective leader- (for example, through work-based learn- communities’ health and wellbeing. It is ship and management of a partnership); ing), high interactivity and high collabo- often helpful to have a Board level cham- and programme (the capacity to design and ration. With mobiles and laptops it is also pion, someone who can raise the profile

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and promote understanding of the health robust project from which participants will ally in the nature of a pilot, gathering visitor role. It also ensures that when health learn, and which will make a difference lo- evidence about any outcomes previous- visitors are involving other staff and organ- cally. In the pilot face-to-face training was ly agreed with the employer and other isations in their projects, or asking for in- offered, but a workplace adviser master- stakeholders. Understanding when and formation, the reason for this is understood class with some case study examples is now why a project didn’t work can be as im- and supported. The champion should also available on the site. portant as knowing that it did. show an active interest in projects ensuring Effective workplace advisers help partici- l In Phase 5, participants produce and that where appropriate steps are taken to pants to identify opportunities to address submit a report on their work, incorpo- roll out initiatives and consider how learn- learning outcomes, act as a link between rating evidence of change, but are also ing will be disseminated across the health participant and organisation in estab- encouraged to share their findings more economy. There will usually also be an or- lishing a realistic, appropriately focused widely. Box 3 lists some recently com- ganisational BCC lead to ensure that the project, and support reflective practice by pleted topics. Those seeking accredita- programme is delivered within an agreed individuals as well as communities of prac- tion add a reflective portfolio in a format organisational plan They may provide sup- tice, building organisational capacity to agreed with the accrediting institution. A port and guidance to the work place advis- build community capacity. list of institutions offering accreditation ers or ensure that there are people desig- Having identified a workplace adviser for work based learning is available on nated to do so. Some participants will want and begun with them to consider a possi- the site. to choose the option to have their work ac- ble project focus, aligning strategic needs l Phase 6 encourages everyone who under- credited. A process for this needs to have with issues facing their local community, takes the programme to reflect on what been agreed within the organisation and participants register and follow a series of they have learnt and what their organi- with the accrediting university. steps (see Figure 1). The first three are in- sation and especially their community Projects undertaken as part of BCC must tertwined in practice. have gained, as well as how any benefits be aligned to organisational objectives and l Phase 1 requires people to look at their might be sustained. contribute to delivery of the local Children past experience and what they need to and Young People’s Plan. This alignment learn or refresh to develop their think- Evaluation is an important feature of ensuring future ing, drawing up and submitting a learn- Evaluation of the Building Community sustainability. ing contract. Capacity Programme pilot took place dur- The organisational lead helps to ensure l In Phase 2 they can access a range of re- ing 2011 to inform the roll-out of the pro- that workplace advisers understand how sources and master classes to help them gramme during 2012. A realistic evaluation these areas fit together and where BCC address the gaps identified. framework was used (Pawson and Tilley projects are most likely to fit. The project l Phase 3 involves settling on a project, 1997), which asks what works for whom may contribute part of an existing team or which engages with community part- in what circumstances. Data were gathered multiagency project where a need for ca- ners and will deliver relevant measurable from the pilot cohort (n=56) and their or- pacity building has been identified. Work- outcomes for health and wellbeing, and ganisations through online questionnaires, place advisers (usually drawn from among is manageable in scale. During this stage telephone interviews and data on registra- community practice teachers and managers participants may need to undertake (for tion and usage, as well as user feedback within the local health economy, with some example) a period of shadowing, a rapid through the site. Since completion of the from community development or public appraisal or an appreciative inquiry. A pilot phase, modifications have continued health posts) are an essential part of the project proposal is submitted (see Box 1 to be made in response to feedback from BCC programme. Their role is to facilitate and 2). users. and support participants to engage in the l In Phase 4, the project is taken forward. Many of those participating in the pilot programme and to help them undertake a Given the overall timespan this is usu- are working in areas which they believe are poor, with many problems, poor housing Box 3. Recently completed projects and low levels of employment. This pro- file may reflect managers’ perceptions of l Postnatal healthy lifestyle group locations most likely to benefit from the l Cook and eat sessions for parents and a ‘walking bus’ with the local nursery (aimed at programme. Schools, transport and leisure reducing obesity in children) facilities are generally perceived to be sat- l Play-based community clinic (aimed at readiness for school) isfactory. l First-time mums drop-in (with local children’s centre) Identified health needs – many of these l Fun with food (to raise awareness of nutrition and healthy lifestyle for toddlers) recurring – include the need to reduce lo- l Promoting bonding and attachment with new parents cal morbidity and mortality rates associ- l Supporting children and families encountering domestic violence ated with alcohol, smoking, obesity, mental l Healthy mums, healthy babies (aimed at mums to be and partners, and reducing health issues and teenage pregnancy rates, health inequalities) addressing low breastfeeding rates, high l Targeting parental isolation in rural areas – in partnership with two children’s centres unemployment, and parental lack of con- l 5 actions for babies (aimed at improved attachment) fidence, maintaining an overall good level

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QI09

On the whole it appeared that the mas- terclasses, once accessed, functioned as in- tended:

‘Masterclasses have been excellent for gath- ering information about my community and helping me to prepare for my project’ 11/11/2011 14:50

The third important area for improve- ment which surfaced relates to workload. Some people commented on their own workload as a barrier to progress:

‘The learning contract and work-based proposal are very comprehensive with lots of detail that make them easy enough to follow. However, the amount of work seems to be phenomenal!’ 14/11/2011 18:26

Figure 1. Project steps A constructive suggestion to facilitate progress was made by one respondent: of general health, with people being mo- documents in a set format, like an electronic tivated to comply with seeking advice and portfolio’ 14/11/2011 18:09 ‘A lot of work for one person who is not fa- treatment, and dealing with inequalities This direct method (suggested by several miliar with this type of study, and within an in health. respondents) has subsequently been adopt- organisation [that] is unused to this kind of Almost two thirds of respondents felt that ed for the roll-out phase. study. Would think a team approach may be they had adequate or better support from A second area for improvement related to better- esp. as we work within geographical a workplace adviser. More than a third access to resources. Where participants had teams. This would mean I would not be made (37.5%) rated their workplace adviser sup- accessed them the master classes and the re- to feel I am skiving, and they would be more port as excellent. Comments included: source links were mainly viewed as helpful: engaged. I imagine most studies could be split into manageable sections, and this would ‘Good support from management to en- ‘The resources have been extremely valu- help build teams, and community initiatives able team to help with providing cover to able to my project. Having been out of study- in itself’ 8/11/2011 17:01 enable time to pursue this. Very good sup- ing mode for five years, I needed the resources port and enthusiasm from workplace adviser’ to get me started and focused on my project’ In some of the sites involved in the roll- 8/11/2011 7:52 14/11/2011 14:23 out, this approach was encouraged and led to some projects where a number of col- There were three main areas for improve- Some respondents pinpointed the learn- leagues each intervened with different as- ment. Participants experienced a number ing contract and workbook resources pects of one focus. of difficulties during the pilot phase with among the items helpful to them, but com- logging in, and with the software system mented on accessibility. Queries through Discussion (PebblePad) originally embedded to en- the site also asked for documents which The BCC programme has now been rolled courage reflection and collaboration. This were, in fact, available. Again, amendments out across England. There are currently 611 system is widely used in academic courses were made to the signposting on the site participants registered. The programme is in UK, but around a quarter of participants and the accessibility of freestanding edit- aimed at providing accessible and practi- found it an added layer of difficulty: able documents in response to comments cal professional development resources for such as these. Among those who had looked health visitors, which enable them to em- ‘I am not bad at IT but feel that there has at the masterclasses some were positive, bark confidently on community engage- just been too much information and dupli- even if they found them time consuming: ment in relation to health improvement, cation on the website and assumptions made and through this to build community ca- about practitioners’ ability to use Pebble Pad. ‘Have looked at master classes and links, pacity. With the refinements made follow- I would have preferred a different method of appears easy to navigate your way round, al- ing the evaluation, the web-based resources submitting information about the progress of though I find I do go off at a tangent as all appear to be viewed as largely satisfactory. the project such as emailing word processed the links appear so relevant and interesting’ However, the ongoing roll-out raises some

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Key points Coates, David Nichol, Carole Proud, Garth Rhodes, John Unsworth) for their input to l This programme aims to facilitate existing health visitors to extend or renew their skills the development of this programme, and in building community capacity to all the participants, especially those who l It combines web- and work-based learning to deliver a work-based project have shared constructive suggestions for l Evaluation identified three areas for improvement, around reflection, signposting of improvement. access to resources and dealing with workload We are also grateful to the reference group l Community engagement for health improvement is a continuing part of the DH vision members, Dr Stan Chapman, GP, Gates- for health visiting head, Janice Craig, Denton Young Peo- l This programme can build the skills and confidence of community groups and staff in ple’s Partnership, Newcastle, Community other agencies to make a difference to health and wellbeing development project, Community Police representative nominated by Northumbria Police, Parent representatives identified issues and questions for the future. relatively restricted timescale placed on the by Netmums, Joan Flood, Newcastle Com- Whilst the programme remains relevant projects, possibly because of organisational munity Safety Officer, Domestic Violence: to delivery of the Health Visitor Imple- demands, and partly perhaps because of Local authority representative, Susann mentation Plan, structural change in the pragmatism, some projects have looked at Craig, All Saints College Trust Secondary NHS during this first roll-out year has led building staff capacity – as a means to make School, Newcastle, Sue Bainbridge, Head to some confusion about who was respon- a difference. Others have looked at building Teacher, Red Rose Primary School, Chester sible for overseeing it. While in some areas organisational capacity – for example iden- Le Street, Ann Tulip, Health Co-ordinator organisational support has been driven by tifying networks with other agencies which for the Outer West area of Newcastle, nomi- regional public health leads or nominated might form the underpinning for more nated by Sure Start, for their advice in the implementation leads, other organisations specific community focused work. development of the programme. have seen significant senior team change, In reviewing project reports, the key ques- impacting on continuity in engagement tions continue to be where or for whom References and inhibiting information cascades. The is this building capacity, and what differ- Adler PS, Kwon S-W. (2002) Social capital: Prospects recruitment and support of workplace ad- ence is it making to health and wellbeing for a new concept. Academy of Management Review 27(1): 17–40. visers has also been affected by this. Where in that community? Measuring the initial Boud D, Cressey P, Docherty P. (2006) Productive there has been continuity, advisers ap- outcomes of building community capacity Reflection at Work. Oxford: Routledge. pear to be well briefed, and supported in and the outcomes of the ongoing develop- Cowley S, Twinn S. (1992) The Principles of Health working with participants to focus their ment of social capital in a meaningful way Visiting: A Re-examination. London: CPHVA. projects and navigate the demands of requires further exploration. Cowley S, Frost M. (2006) The Principles of Health their workloads. Visiting: Opening the doors to public health practice in the twenty first century. London: CPHVA. Although there was an early flurry of en- Conclusion Eade D. (1997) Capacity Building. An approach to quiries about accreditation there seems to Community engagement for health im- people-centred development. Oxford: Oxfam. have been little interest in formalising these provement remains an important part of Florin P, Wandersman A. (1990) An introduction to enquiries. On the whole, it seems that the the future for health visiting. The Building citizen participation, voluntary organizations, and cost for accreditation acts as a disincen- Community Capacity programme which community development: Insights for empowerment through research. Am J Community Psychol 18(1): tive. For higher education institutions, the we have described uses work based learning 41–54. workload involved in supporting specific in an innovative way, supported by web- Gilchrist A. (2009) The well-connected community: accreditation is not viable in the longer based resources over a 24-week period to a networking approach to community development. term, unless there are relatively large num- help participants refresh and develop their Bristol: Policy Press. bers requesting it. For most participants, own skills and to find ways of making a Pawson R, Tilley N. (1997) Realistic Evaluation. London: Sage. using the project outputs and reflective difference in particular communities. We Pearson P, Machin A. (2010) Clinical Leaders for portfolio as a basis for APEL in accessing have described some of the areas for change the Future? Evaluation of the Early Clinical Careers another specific course is more likely to which have emerged during the pilot phase. Fellowship Pilot Programme. NHS Education Scotland. be practical. The programme now forms a central part Putnam RD. (2000) Bowling Alone: the collapse and Most importantly, the roll-out has seen a of the resources available through which we revival of American Communities. New York: Simon and Schuster. very wide range of project proposals, the can build the skills and confidence of staff Rhodes G, Shiel G. (2007) Meeting the needs of majority of which have been innovative, in other agencies and community groups the workplace and the learner through work based with the potential – as demonstrated in to act and innovate to improve health learning, Journal of Workplace Learning 19(3): 173–87. the final reports in most cases – to make and wellbeing. Ring G, Mathieux G. (2002) The key components of quality learning. Proceedings of the ASTD a real impact to health and wellbeing for Techknowledge 2002 Conference, Las Vegas. particular communities or groups. Most Acknowledgements Rossett A (ed). (2002) The ASTD E-Learning also show signs of being sustainable in the The authors are grateful to the rest of the Handbook. New York: McGraw-Hill. medium term. However, because of the project team (Joanne Bennett, Maggie

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Supporting women with perinatal mental health problems: the role of the voluntary sector

Background a proactive approach to antenatal screening Chris Coe MA SCM Prevalence rates of depression in the ante- by health professionals such as midwives. It Senior Research Fellow natal period are similar to postpartum lev- also endorses an antenatal role for health els and range from 12% to 20% (Marcus et visitors in order to strengthen assessment Jane Barlow DPhil MSc al, 2003; Heron et al, 2004). The prevalence and identification of anxiety and depres- Professor of Public Health in the Early Years Director, Warwick Infant and Family Wellbeing of postnatal depression (PND) is in the sion. Unit region of 13%, ranging from 7 to 19% of Supporting the mother and the develop- women (O’Hara, 2009). ing infant through this period is recognised Warwick Medical School Anxiety and depression in pregnancy are to be a key time for intervention in order to University of Warwick strongly associated with adverse outcomes mitigate these negative outcomes. A number Correspondence: [email protected] for mothers and babies, including preterm of psychological therapies have been found delivery and low birth weight (Dunkel to improve maternal mood in both the pre Key words Schetter and Tanner, 2012; Dunkel Schet- (Vieten and Astin, 2008) and postnatal Perinatal mental health problems, postnatal ter, 2011). They are also associated with period (National Institute for Health and depression, perinatal support service, befriending alterations to the neurobiological substrate Clinical Excellence (NICE), 2006), with im- service, infant mental health of the affect regulation system of the foetus portant components of both being the use Abstract including for example, higher basal cortisol of effective listening and the provision of The prevalence of perinatal mental health levels and reduced high-frequency heart- techniques for regulating affect. problems is high with estimates suggesting that rate variability (HRV), low dopamine and Evidence suggests that current needs in around a fifth of women experience anxiety and serotonin levels (see Bergner et al, 2008). terms of women experiencing perinatal or depression during the ante- and post-natal period. Mental health problems in pregnancy and Longitudinal studies also show alterations anxiety and depression exceeds statutory the postnatal period have an adverse impact on in HPA axis (hypothalamic-pituitary-ad- sector capacity and that many women are the development of the foetal and infant nervous renal) functioning in 10-year-old children being prescribed drugs for such problems, system and the parent-infant relationship, with (Dunkel Schetter and Tanner, 2012; Dunkel particularly during the postnatal period significant long-term consequences for the child. Schetter, 2011). (4Children, 2011). The charity Family Action established a Perinatal Support Project (PSP) underpinned by the Both anxiety (Beebe et al, 2011) and de- Newpin model of working, at four sites across pression (Murray, 1996) in mothers during The Perinatal Support Project the UK. The service offered women experiencing the postnatal period have been shown to The Perinatal Support Project (PSP) was es- perinatal anxiety and depression support from have a deleterious effect on the the parent– tablished in July 2010 for a period of three volunteer befrienders. The result of a service infant relationship which, in turn, has been years and emerged from the earlier Newpin evaluation of PSP shows high levels of need, and promising results in terms of outcomes for identified as being an important predictor project, which found that women assessed parents. The stakeholder interview data found of insecure infant attachment (DeWoolf as vulnerable to perinatal depression who that front-line professionals such as midwives and and Ijzendoorn, 1997), with insecure (eg, received social support were half as likely health visitors highly valued the service being Berlin et al, 2008; Granot and Mayseless, as those in the control group to have ex- offered. The PSP appears to be filling a gap in 2001; Sroufe, 2005) and disorganised at- perienced the onset of a depression suffi- service provision with women who have mild to moderate ante and post natal depression. There tachment (Green and Goldwyn, 2002) be- ciently severe to warrant antidepressants, would appear to be scope for the PSP to work ing associated with a range of compromised or to have remained without recovery from with service users earlier in the antenatal period outcomes. depression throughout the 12-month study where the impact may be even greater. Recent evidence suggests that detection, period (Harris, 2008). It comprises a serv- referral and treatment of women with ice for mothers who are either affected by, Community Practitioner, 2013; 86(2): 23–26. perinatal depression by obstetric provid- or at risk of, postnatal depression and other Conflict of interest: this research was funded by ers is poor (Turner et al, 2008; Goodman mental health problems. Family Action and Tyer-Viola, 2010). A report by 4Chil- The service has been established in four dren, Suffering in Silence (4Children, 2011), areas of the UK: Hackney; West Mansfield; advocates a multifaceted approach, which Swaffham; and Oxford. The four areas are includes raising awareness of the issue diverse and contrast strongly, particularly through national campaigns and promotes in terms of ethnicity and geography. The

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Esteem scale (RSE) (Rosenberg, 1989). Table 1. Mean scores for the key measures pre- and post-intervention Quantitative data were collected, entered Measures N Baseline Post- Sig into a database (Excel) by project co-ordi- (standard intervention deviation (SD)) (SD) nators at Family Action, and an anonymised dataset was then transferred to the Univer- Parental mental 33 sity of Warwick for analysis. A range of de- health scriptive statistics (means and chi-squared Anxiety 11.8 (4.1) 8.4 (3.8) .000 tests) was used to depict the demographic Depression 10.1 (4.3) 6.1 (2.7) .000 characteristics of participants, and a non- parametric test (Mann-Whitney U test) Mother’s 35 was used to identify statistically significant relationship changes between baseline and post-inter- with the baby vention measures. Data were calculated for Warmth 22.9 (7.8) 29.0 (4.4) .000 the following period: July 2010 to end May Invasiveness 12.1 (6.3) 10.3 (5.3) .109 2012.

Social support 42 18.7 (6.3) 20.6 (5.2) .007 Stakeholder interviews Project co-ordinators were invited to take Self-esteem 80 30.6 (4.8) 32.2 (4.4) .000 part in the research and identified other (Volunteer participants, including volunteer befriend- befrienders) ers, service users and referring agencies. Informed consent was taken prior to con- PSP aims to: pilot phase of the PSP. ducting a semi-structured interview (face- l Improve the mental health of participants to-face or telephone) at a time and place l Improve attachment between mothers Aim convenient to the participant. Interviews and infants This research aimed to measure outcomes were conducted by the researcher and were l Reduce social isolation for service participants and volunteer be- then fully transcribed, returned to the inter- l Improve self-confidence of participants frienders engaged in the PSP and to explore viewee for comment, and then entered into and volunteers. stakeholder perceptions and experiences of the qualitative database, NVivo 8 (2008). Women with mild-to-moderate mental delivering and engaging with the PSP. Through a process of coding and analysis, health issues who are pregnant or mothers common themes were identified. A narra- with infants under one year of age are re- Method tive summary of the key themes that were cruited to the project via a range of referral Both qualitative and quantitative research identified is presented using quotations se- routes, including midwives, GPs and health methods were employed and comprised two lected on the basis of their capacity to dem- visitors. Women may also self-refer. Women components: onstrate some aspect of the theme. with severe mental illness are not offered l Service evaluation addressing the impact The research was conducted in accord- the service. of the PSP on the following key outcomes: ance with the Department of Health (DH) The PSP provides intensive community- anxiety and depression; social support; research governance procedures (DH, 2005) based support throughout the woman’s and self-esteem and ethics committee approval was granted pregnancy and during the first year of the l Interviews with a range of participants by the University of Warwick Biomedical child’s life. Support ceases on the infant’s drawn from those providing the service, Research Ethics Committee. first birthday. An initial assessment of need those receiving the service and referrers to is made by a project co-ordinator and is fol- the PSP in order to explore perceptions, Results lowed by the provision of home visits by a views and experiences the PSP. Service evaluation trained volunteer befriender and or attend- A total of 86 volunteer befrienders were ance at a targeted support group. Parents Service evaluation recruited and trained, and the service was are encouraged to attend parenting groups All families involved in the PSP were re- provided to around 189 women during the to increase understanding and knowledge quired to complete a range of standard- study period. Each of the four PSPs received of the infant’s needs and to help to develop ised measures on entry to the project (ie, a significant number of referrals over the informal support networks. at baseline) and following completion of study period ranging from 42–52 and wait- Volunteer befrienders receive an initial six service delivery (ie, post-intervention): ing lists were implemented when demand days of training, covering a range of top- Hospital Anxiety Depression scale (HADS) outstripped capacity. ics including child development, perinatal (Zigmond and Snaith, 1983); Mother Ob- The demographic data suggest that the problems and roles and responsibilities. ject Relationship scale (MORS) (Oates et PSP was serving a high-risk group of wom- Ongoing supervision and support is pro- al, 2005); Maternal Social Support Index en, with over two-thirds living in no-wage vided by the project coordinator. (MSSI) (Pascoe et al, 1988). Volunteer be- households, a third being single parent This paper describes an evaluation of the frienders completed the Rosenberg’s Self- families and between 2% and 11% having

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child protection issues in addition to the helped us with the sort of socialising. Because a bit of depression, but not serious enough to presenting problems (eg, perinatal anxiety obviously I was frightened to take her to bring in the services of sort of mental health and/or depression). Around 20% of women baby centres and stuff. Especially on my own’ or anything’ (Referrer #20) did not take up the offer of the service, with (Service user #17) some being non-contactable. Agencies referring to the project were very Pre- and post-intervention data were Some interviewees highlighted the ben- appreciative of the PSP, alongside the po- available for one-third of the women who efits of the additional support: tential support available to clients who had received the service, and Table 1 shows the ‘To have somewhere to go once a week and previously been unable to access suitable mean scores pre- and post-intervention for meet other people and sort of somewhere, if services. One health visitor referred to the the three outcomes. The results show sig- you like, to offload a few of your problems level of need in her area as follows: nificant improvements in anxiety and de- and somebody just to get you to understand pression, social support and in the moth- that it’s not you that’s a bad person that ... ‘Yeah, very high need. I’d say probably 25% er’s relationship with the baby in terms of do you know what I mean? Oh I can’t explain of my adults that I continue to visit is because warmth and invasiveness. There was also a it. It’s support. Because you’ve got your part- of emotional health problems, including post- significant improvement in the self-esteem ner, you’ve got your immediate family, but ... natal illness. So there’s a very high need in of the volunteer befrienders. my mum’s fantastic and we’re really close, I this area’ (Referrer #10) don’t know ... So I think without having the Stakeholder interviews co-ordinator and the other girls there to un- The use of joint assessments was high- Face-to-face and telephone interviews were derstand it’s not just me and there’s somebody lighted, and the feedback provided by PSP conducted with a total of 41 individuals else there, I don’t know where I’d be now to be co-ordinators was highly rated by referrers: from the following groups: co-ordinators fair’ (Service user #9) (5); volunteer befrienders (14); service us- ‘Very good feedback I have to say. So writ- ers (13); and referrers to the service (9). The acceptance and non-judgemental ap- ten updates. Letters. Emails. Verbal updates. proach of the volunteers appeared to be im- We do joint visits. Joint assessments. Initial Service users portant to many women: visits’ (Referrer #23) Service users who took part in an interview were aged between 20 and 45, the majority ‘It sounded good, yeah. Um. I was a bit The following case study (names have being in their 20s. They were all in relation- sceptical about admitting that I might have been altered) illustrates the benefits of the ships and cohabiting, except one mother needed some help because I thought people PSP for one couple. who had separated from her partner. All might judge me. But no X [project co-ordina- In answer to the question ‘What difference women classed themselves as ‘white British’. tor] made me feel at ease and everything so it has this project made to you?’ Tracy hesitat- Numbers of children ranged from 1–5. One was OK’ (Service user #9) ed and, in a voice filled with emotion, said: father took part in the research. The quantitative data highlighted the The overwhelming message from the ‘To be quite honest I think when we first high level of need in the population being interviews with the service recipients was had Tom he might have ended up in care’. served by the PSP and this was confirmed that of relief and gratitude: by the interviews, which indicated a range Both Shaun and Tracy are in their late 20s, of problems such as social isolation and re- ‘Just to thank [co-ordinator] because she both have learning difficulties and Tracy is lationship difficulties. One lone mother de- really, really changed my life. I didn’t know physically disabled and a wheelchair user. scribed the impact of her depression on her that one time I could be somewhere happy. Shaun is Tracy’s full-time carer. Both par- young daughter: That’s the only thing I can say … Really, ents report unhappy childhoods and dif- really did a good job in my life’ (Service user ficult relationships with their families and ‘Because she used to like to sit in one corner #12) for Tracy, difficulties making and sustaining and stay there. Because sometimes I thought friendships. one day she was even sick but she wasn’t. But Referrers to the PSP The couple were stable and self-sufficient I think it was the situation and the place Referrers were unanimous that the PSP until their situation changed swiftly with where we were staying it was small. And my- filled a gap left by other services. Frontline an unplanned pregnancy and the birth of self I was depressed …so I didn’t have time practitioners, such as midwives, health visi- a pre-term infant at 28 weeks. Bringing for her’ (Service user #12) tors, family workers and social workers, em- home baby Tom was daunting and both braced the project wholeheartedly and were parents reported feeling depressed and A number of women highlighted the im- pleased to have a service such as the PSP to overwhelmed. For Shaun it represented an portance of being supported and given the which to refer women: overload in terms of caring responsibilities: opportunity to socialise with other mothers and babies: ‘But I thought, that sounds really good, be- ‘I’ll put my hand up. I said to Tracy I don’t cause we deal with um lots of mums who are want him. I actually said that to her twice, ‘So we’ve been to a baby centre like she has socially isolated or culturally isolated, who didn’t I?’ suggested ... So we do do that. So she has have difficulties getting out, who suffer with

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because it provided time for themselves but felt the support that they provided had ben- also an opportunity for Tom to mix with efited the families: other infants, something they felt unable The results of the to provide for him themselves. Tracy was ‘But I remember this particular girl the first quantitative data also referred for counselling, which she has time I met her she just … I could tell by her from around a third found very helpful. Shaun describes the eyes what pain she was in. She just had … she of participants were project as follows: sort of glared at me. And now she does actu- suggestive of significant ally look happy again and there is that spar- improvements in anxiety ‘Basically, in one word, supportive. That’s kle in her eyes’ (Volunteer befriender #11) how we found it. I mean, they’ve been bril- liant. I mean, we come here ... all the staff Volunteer befrienders also described a are brilliant. Can’t fault one of them. I mean, range of personal benefits for themselves counsellor’s helping Tracy. Co-ordinator ... and for their families, noting increasing Tracy’s depression stemmed, in part, from without her getting everyone together and confidence. One volunteer referred to an her knowledge about Shaun’s feelings and everything ... getting Tracy that befriender ... increased sense of acceptance: her own feelings about being unprepared. I would say they’ve really helped. But in one The hospital care appeared to do little to word, supportive I would say’. ‘It’s just really … I just found it really re- prepare her for the practicalities of caring warding. I wanted to give something back to for Tom at home: A planned withdrawal of support was in the community really and I feel that I have progress, as their independence and sup- done that. Um. It’s kind of made me feel ac- ‘So we was in severe-shock [laugh] stage. port from other services has increased. cepted in a way’ (Volunteer befriender #11) And then, when he was born it was even worse because he wasn’t supposed to be born Service providers Discussion until March. So then when he did come home Characteristics of the volunteers in this The findings of this research suggest that Shaun’s sort of like ... because I’m ... because sample were as follows: the PSP was serving a population of women of my disability I’m not allowed to pick Tom l Ages ranged from 20–60 years, with over with complex needs (ie, no-wage house- up or walk around with him. Because with half in their 40s holds, single parents and child protection is- Tom being premature, um we ... I didn’t re- l All but one had children and most were sues, in addition to the presenting problems ally get a hands-on with him in the hospital either married or in stable relationships of perinatal anxiety and/or depression). either. And they didn’t know how to treat me l The majority described themselves as In addition, it is filling a significant gap in because I was in a wheelchair at the time be- ‘white British’ existing provision for women experiencing cause of my C-section. So the thing ... it was l Motivation to volunteer stemmed from perinatal mental health problems. sort of like kid gloves for Tom and for me, and either having suffered from PND (half A wide range of practitioners referred they didn’t quite know how to treat us’. the sample claimed to have had PND) and women to the PSP, including social work- others who wanted to get involved with ers, midwives, health visitors and a perina- The midwife working with the family re- the community. tal mental health service seeking input for ferred them to the PSP soon after Tom was The training and guidance they received, women discharged from the service but still born and while he was still in hospital. At coupled with ongoing support from the in need of further, less intensive support. this point there were a number of services project co-ordinator, was valued and Referrers to the service identified high levels involved in the family’s care but it soon praised by the volunteer befrienders. They of unmet need in their local populations and became apparent that the PSP was the key acknowledged the need for the PSP and re- were appreciative of the opportunity to refer resource. Through the PSP both Shaun and ferred to the way in which they felt the visits women to a service such as the PSP. Evidence Tracy were offered a volunteer befriender. increased women’s self-esteem and empow- of effective partnership working between This offer was immediately accepted by ered them. the voluntary and statutory sectors emerged, Tracy but declined by Shaun who felt They described various ways in which they including effective information sharing and that as long as Tracy was being helped, he could cope: Key points

l The impact of perinatal mental health problems are well documented in terms of the ‘Because when Tracy’s on a “downer” it af- long-term consequences for the infant fects me and it affects Tom. So of course when l The Family Action Perinatal Support Project (PSP) provides a volunteer befriending it’s helping Tracy it helps me, it helps Tom’. service which shows promising results in improving outcomes for infants and their parents l The PSP appears to fill a gap in service provision for women with mild to moderate ante A number of other services were put in and post natal depression place via the PSP co-ordinator, including l The PSP was welcomed by health visitors, midwives and other referrers to the service baby massage and respite care for the par- l Service users, referrers and providers rated the PSP highly and identified a range of ents when Tom was six months old. The benefits for service recipients and for volunteer befrienders latter was highly valued by both parents

26 | Community Practitioner February 2013 Volume 86 Number 2 the conduct of joint assessments. no control group and we cannot be sure and emerging research issues. Annual Review of The results of the quantitative data from that the changes that were identified would Psychology 62: 531–58. Dunkel Schetter C, Tanner L. (2012) Anxiety, around a third of participating women were have occurred without the benefit of the in- depression and stress in pregnancy: implications for suggestive of significant improvements in tervention (ie, regression to the mean). mothers, children, research and practice. Curr Opin anxiety and depression, self-esteem and In addition, it was only possible to col- Psychiatr 25(2): 141–8. warm feelings towards the baby. These re- lect data from one-third of the women who 4Children. (2011) Suffering in Silence. London: sults were reflected in the users’ reports received the service. This occurred because 4Children. Granot D, Mayseless O. (2001) Attachment security of the service, which were unreservedly many volunteers only managed to collect and adjustment to school in middle childhood. unanimous in their praise of the PSP, de- data at one time-point (ie, baseline or post- International Journal of Behavioral Development 25: scribed by some as being ‘life-changing’. intervention). However, we cannot be con- 530–41. The holistic and flexible nature of the sup- fident that the women for whom there was Green J, Goldwyn R. (2002) Attachment port on offer was highly valued and the data disorganisation and psychopathology: new findings in no data available at both time-points were attachment research and their potential implications suggest that following involvement with the not in some way still anxious or depressed. for developmental psychopathology in childhood. J PSP, service users were able to access a vari- Consequently, these findings should be Child Psychol Psychiatry 43: 835–46. ety of services, including opportunities for treated with caution. Goodman JH, Tyer-Viola L. (2010) Detection, socialising with other mothers and infants treatment, and referral of perinatal depression and anxiety by obstetrical providers. J Womens Health (parent support), in addition to opportu- Conclusion 19(3): 477–90. nities for learning ways of promoting their The qualitative data suggest that the women Harris T. (2008) Putting Newpin to the test. In: Mony infants wellbeing (parenting support). accessing this service had complex needs, L, Mondy S (eds) Helping families achieve generational All stakeholders who were interviewed in addition to the presenting problems of change. North Parramatta, NSW: UnitingCare rated the PSP very highly and identified a Burnside. anxiety and depression. Outcome data for a Heron J, O’Connor TG, Evans J, Golding J, Glover V. range of benefits for both service recipients third of the women who received the service (2004) The course of anxiety and depression through and volunteer providers. However, few mid- showed promising results, with improve- pregnancy and the postpartum in a community wives referred women during the antenatal ments across all measures. There would ap- sample. J Affect Disord 80(1): 65–73. Marcus SM, Flynn HA, Blow FC, Barry KL. (2003) period and, given the evidence about the pear to be further scope for the PSP to work impact of chronic anxiety and depression Depressive symptoms among pregnant women with service users in the antenatal period screened in obstetrics settings. J Womens Health 12: during pregnancy, there would appear to where the impact may be even greater. This 373–80. be scope for greater use of such services by would involve a shift in emphasis in terms Murray L, Cooper PJ. (1996) The impact of midwives who identify women in need of of referring agencies, particularly midwives postpartum depression on child development. additional support during pregnancy. International Review of Psychiatry 8: 55–63. and health visitors. NVivo qualitative data analysis software QSR The PSP was intended to support women International Pty Ltd Version 8, 2008. during the perinatal period but most refer- Acknowledgments National Institute for Clinical Excellence (NICE). rals were of women experiencing postnatal We are grateful to Family Action staff, vol- (2006) Routine postnatal care of women and their babies. London: NICE. problems. Research shows that antenatal unteers and service users who gave freely anxiety and depression are common and Oates J, Gervai J, Danis I, Tsaroucha A. (2005) and willingly of their time during the course Validation studies of the Mothers Object Relations have a significant deleterious impact on the of this research. We would also like to thank Scales Short Form (MORS-SF) (poster presentation). infant (see background for further detail), Family Action for funding the research. La Laguna, Tenerife: 12th European Conference on and there would, as such, appear to be fur- Developmental Psychology. O’Hara MW. (2009) Postpartum depression: what we ther scope for the PSP to engage in more References preventive work by offering support to know. J Clin Psychol 65(12): 1258–69. Beebe B, Steele M, Jaffe J et al. (2011) Maternal anxiety Pascoe JM, Ialongo NS, Horn WF, Reinhart MA, symptoms and mother–infant self- and interactive more women during the antenatal period. Perradatto D. (1988) The reliability and validity of the contingency. Infant Mental Health Journal 32(2): This would require the PSP to target maternal social support index. Fam Med 20(4): 271–6. 174–206. midwives and health visitors who are now Rosenberg M. (1989) Society and the Adolescent Self- Bergner S, Monk C, Werner E. (2008) Dyadic Image. Revised edition. Middletown, CT: Wesleyan conducting the antenatal promotional in- intervention during pregnancy? Treating pregnant University Press. terview at 28 weeks of pregnancy as part of women and possibly reaching the future baby. Infant Sroufe LA, Egeland B, Carlson E, Collins WA. (2005) Mental Health Journal 29(5): 399–419. the Healthy Child Programme. Intervention The Development of the Person: The Minnesota Study Berlin LJ, Cassidy J, Appleyard K. (2008) The influence during this period would enable the PSP to of early attachments on other relationships. In: of Risk and Adaptation from Birth to Adulthood. New offer opportunities for more sustained sup- Cassidy J, Shaver PR (eds). Handbook of Attachment: York: Guilford Publications. port (ie, over a longer period) that would Theory, Research and Clinical Applications, 2nd edn. Turner K, Sharp D, Folkes L, Chew-Graham CA. (2008) Women’s views and experiences of not only be aimed at addressing the wom- New York: Guilford Publications. antidepressants as a treatment for postnatal en’s mental state, but could also focus on DeWolf MS, Van IJzendoorn MH. (1997)Sensitivity and attachment: a metaanalysis on parental depression: a qualitative study. Family Pract 25(6): promoting the relationship with the baby. antecedents of infant attachment. Child Development 450–5. 68(40): 571–91. Vieten C, Astin J. (2008) Effects of a mindfulness- Limitations Department of Health (DH). Research governance based intervention during pregnancy on prenatal stress and mood: results of a pilot study. Archives of The PSP was piloted in a number of areas framework for health and social care, 2nd edition. London: DH. Womens Health 11: 67–74. and this service evaluation was the first step Dunkel Schetter, C. (2011). Psychological science on Zigmond AS, Snaith RP. (1983) The Hospital Anxiety in the evaluation process. As such, there was pregnancy: Stress processes, biopsychosocial models, and Depression Scale. Acta Psychiatr Scand 67: 361–70.

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Older women living and coping with domestic violence

Introduction however, been four recent small-scale Anne Lazenbatt BSc PhD Worldwide, 20–50% of women suffer studies in the UK: three specifically on Reader in Childhood Studies physical, psychological or sexual abuse at domestic violence against older women Institute of Child Care Research some point during their lifetime (Krug (Blood, 2004; Scott, 2008; Lazenbatt et al,

John Devaney BA(Hons) MSc PhD et al, 2002). For older women it is a more 2010); and one more generally on abuse of Lecturer in Social Work common experience; approximately 15% of older women (Pritchard, 2000). women aged over 50 years have experienced These studies highlight that women Aideen Gildea BSc RGN RMN RHV some form of domestic violence defined as aged over 50 who are victims of domestic Research Health Visitor any violence between current and former violence are suffering silently because the Institute of Child Care Research partners in an intimate relationship, problem is often ignored by many health School of Sociology, Social Policy and Social wherever violence occurs. The violence may professionals (Zink et al, 2004). Evidence Work include physical, sexual, emotional, and suggests that older women face serious Queen’s University Belfast financial abuse (Home Office, 2009) and barriers to accessing support and are offered can occur well into later life (World Health few appropriate services when they manage Correspondence: [email protected] Organisation (WHO), 2002). to enter the service system (Beaulaurier et Abstract Although women are the majority of the al, 2007). Although domestic violence is seen as a serious older population in virtually all nations The negative mental health consequences public health issue for women worldwide, of the world, little research globally has of domestic violence have been well international evidence suggests that women been given to the needs of older women documented in younger women and show aged over 50 who are victims are suffering in silence because the problem is often ignored in this respect (Zink et al, 2004). In fact, that symptoms of post-traumatic stress by health professionals. More UK research is their voices are virtually absent from the disorder (PTSD) and other psychological needed to identify the extent of the problem, research literature as service providers stress reactions are long-term mental health and services to meet the needs of older women. and policy makers often assume that DV consequences. Abused women are three This study aims to bridge this gap by gaining stops at around age 50 (Scott, 2008). A times more likely to be diagnosed with a deeper understanding of how ‘older women’ cope with domestic violence and how it affects recent UK report entitled Taskforce on the mental illness and to report depression their wellbeing. Eighteen older women who were health aspects of violence against women (Calvete et al, 2007); five times more likely currently, or had been in an abusive relationship and children (Department of Health (DH), to attempt suicide (Pico-Alfonso et al, were recruited. Semi-structured interview 2010) highlights that the NHS has not taken 2005); nine times more likely to misuse schedules were used to discuss the personal violence against women seriously enough drugs; and 15 times more likely to misuse nature of DV and its effects on wellbeing, ways of coping and sources of support. Findings and that it must now do better. alcohol (Dutton et al, 2006). suggest that living in a domestically violent It also states that the NHS spends more Depression and PTSD, which has context has extremely negative effects on older time dealing with the impact of violence substantial co-morbidity, are the most women’s wellbeing leading to severe anxiety against women and children than almost prevalent mental health sequelae of and depression. Three-quarters of the women any other agency. Although the report shows domestic violence (Sormanti and defined themselves as in ‘very poor’ mental and physical health and were using pathogenic coping that one in four UK women (28%) aged Shibusawa, 2008), with low self-esteem and mechanisms, such as excessive and long-term use between 15 and 59 have experienced DV, feelings of inferiority heightening the risk of alcohol, prescription and non-prescription drugs it excludes a considerable number of older of re-victimisation (Simmons and Scotes- and cigarettes. This negative coping increased the women who may be experiencing the effects Baxter, 2010). likelihood of these women experiencing addiction of lifelong abuse. This perception of older Long-term effects for older women who to drugs and alcohol dependence and endangered their health in the longer term. Our findings women not experiencing abuse has resulted may have experienced trauma for 30–40 suggest that health professionals must receive in serious gaps within research and service years include: permanent physical damage, appropriate education to gain knowledge and delivery as historically both have focused on disability, self-harm, self-neglect, loss of skills in order to deal effectively and support older the needs of younger women of childbearing confidence, mental health problems and women experiencing domestic violence. age (WHO, 2002). a significant link to suicide risk (Zink et Key words International research on the issue of older al, 2006b). Recent evidence suggests that Domestic violence, abuse, older women, women and domestic violence is relatively psychological violence is the most common wellbeing, coping, education recent, and much of the literature from the form of abuse for older women (Sormanti USA and Australia is not always applicable and Shibusawa, 2008). In addition to the Community Practitioner, 2013; 86(2): 28–32. in the UK context (Straka and Montminy, direct psychological effects abuse may No conflict of interest declared 2006; McGarry et al, 2010). There have, negatively affect the factors that improve

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mental health and wellbeing (Calvete et al, interviews. All women were provided with or separated, and 6% widowed. In all 89% 2007). information on services that could respond had children (range 1–5 children); 17% had To date the extensive literature on coping to their situations. Pseudonyms were given grown up in an abusive home with domestic and domestic violence has focused almost to protect anonymity and data was secured violence, child abuse and sexual abuse. exclusively on younger women and little in a locked room within the university. The All subjectively classified their ‘physical is known about how older women cope research protocol and informed consent and mental health’ as very poor; 56% with longer-term domestic violence. This forms were approved by Belfast Women’s were over drinking or alcohol dependent; Northern Ireland (NI) study aims to bridge Aid and the Ethics Committee of the School 22% addicted to painkillers and all taking this research gap. To our knowledge this is of Social Work, Queen’s University Belfast. drugs a combination of antidepressants, the first study to gain a deeper understanding tranquillisers and sleeping tablets. of how ‘older women’ living with an abusive Procedure partner for more than 30 years cope with Women were invited to talk about their Health and wellbeing lifelong domestic violence and how it relationships using semi-structured All women understood the long-term effects affects their health and wellbeing. As this interviews built on previous research that domestic violence had upon their study sought to understand women’s own findings (eg, Sormanti and Shibusawa, 2008; wellbeing, by self-reporting their current experiences a qualitative approach was best Scott, 2008; Simmons and Scotes-Baxter, health status as ‘very poor’ (eg, chronic suited to meet the research aims. 2010; McGarry et al, 2010). This provided pain and fatigue, arthritis, irritable bowel a broad evidence-based topic guide to syndrome, asthma, hypertension). Physical Methods provide focus and consistency. It included: abuse was more prominent in the early years Sampling and recruitment effects of abuse on life experiences and of marriage when children were smaller, Through Northern Ireland Women’s Aid family relationships; current demographics; with 10 women experiencing severe physical (NIWA) programmes a purposive sample of type and length of abuse; coping resources trauma such as gun-shot and knife wounds, 18 older women who are currently, or had and support networks; barriers to seeking broken jaws, teeth and limbs. been in a long-term abusive relationship help; physical and psychological effects; Twelve women felt that the most violent were recruited. NIWA groups co-ordinate current self-reported health and mental attacks were during times when their outreach and refuge (shelter) services and a health status; and use of drugs, smoking and husbands were drinking heavily. For half 24-hour helpline and maintain a strong and alcohol. The interview schedule was piloted the women the birth of their children and independent presence in helping to support on two older women for face validity and postnatal depression (PND) had an impact women of all ages experiencing domestic suitability. on the violence, a condition not understood violence. by their husbands, or by their GP, and often Snowball sampling through key informants Data analysis led to bouts of severe physical and verbal was used to provide the names of others The transcripts were checked for accuracy abuse. who were then approached and interviewed and thematic analysis of the data was thus building up a sample among this hard- examined for key themes and categories. ‘I suffered from PND but he often hit me if to-reach group. The operational definition A framework developed by Denzin and I cried. I think I was very severely depressed of ‘older’ included women aged 50 years Lincoln (2000) was taken to ensure the for years and had to hide these feelings. He and over which corresponds to research methodological rigour and trustworthiness would of course hit me anyway if he was or studies in the area. This age cut-off was of the findings through formal member drunk’ (MJ) chosen because it focuses on women largely checking of the transcribed data, and neglected in the literature (Beaulaurier et al, peer debriefing within the research team ‘He was always a heavy drinker and most 2007). ensured the credibility of the findings; violent when he had been drinking. The irony and a compilation of a reflexive journal is that I only started drinking because I was Ethical and safety recommendations promoted dependability and confirmability. frightened of the physical abuse’ (DK) Two female researchers (health visitor and Three inter-related themes emerged namely: psychologist) undertook the data collection health and wellbeing; psychological effects; Almost all talked about their childhood and were experienced in interviewing on and barriers to support which highlight the abusive experiences before marriage; sensitive topics with vulnerable respondents needs of older women dealing with domestic four women had been sexually abused as and in referring women requesting violence and the coping mechanisms used. teenagers, 10 reported physically abusive assistance to available sources of support. relationships and lived with family violence. Semi-structured interviews were conducted Results Eight women had recently (in the past five at a convenient time and in complete privacy Demographics years) attended A&E departments in large and lasted between one and three hours. The mean age of the sample (n=18) was hospitals and none had been asked questions Every effort was made to ensure safety and 61 years (age range 53–72 years). The about abuse by nurses or doctors. confidentiality, as well as flexibility when average length of the abusive relationship arranging and conducting interviews. All was 39 years, (range 32–51 years); 71% ‘He assaulted me quite badly with a hammer women gave verbal and written consent and still had an ongoing relationship with the and the wooden end of a hatchet several permission was granted to audio-tape the abusive partner, while 23% were divorced times. I went to hospital A&E and attended

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my doctor on several occasions saying that I and wellbeing, which they insisted was that I allowed him to do this. A lonely life into had banged my head on cupboards and doors. worse than physical trauma. All felt that old age leaves me with dread.’ (EK) My doctor or the hospital doctors and nurses non-physical emotional abuse was ‘totally never questioned me and I am sure they knew invisible’ even though it was the prominent The impact of this behaviour on the I was lying’ (IR) form of abuse in older age. women’s mental health Psychological effects of domestic violence ‘My health practice nurse never made any The coercive and controlling behaviour produced severe depression and a sense enquiries about my injuries, even though I of the partner of loss, self, family life, income and sexual needed 10 stitches in my head on one occasion’ Abusers used a variety of manipulating partnership, and most of all a loss of a loving (AW) and controlling behaviours, which led to relationship. Mental health issues were feelings of loss, terror, hopelessness and prominent effects of domestic violence, ‘I frequently had deep cuts and all over body powerlessness and a sense that they had with most women stating that they had been bruising, bite marks and cigarette burns on nowhere to go or anyone to talk to. Subtle seriously affected by depression and anxiety, my skin as well as broken limbs. I wanted to non-physical abuse, like constant ridiculing, and had been treated by their doctor with talk and needed emotional support but the verbal insults, threats, intimidation, tranquillisers, antidepressants and sedatives doctors and nurses just fixed me physically humiliation and long silences were for decades. Six women were being treated and didn’t seem to have the time to see me as more effective in controlling a woman for addiction to tranquilisers. a person’ (SF) than physical violence; concealed abuse alternated with loving behaviour seemed ‘My husband (a GP) got his medical partner All women felt that nurses and doctors to increase the woman’s uncertainty about to prescribe Valium for me in the 1970s and were unwilling to become involved in what herself and her ability to cope. Most women I am still taking it. I know I am addicted to they thought was a family situation. They felt that there was no help available for it’ (WL) also felt that these health professionals women of their age, particularly for those appeared to know very little about support who experienced psychological abuse: Mental health was further compromised networks and mechanisms to help women by substance misuse by more than half, deal with the issue of violence in the family. ‘Bruises heal in time but words last forever. who were using non-prescription drugs When you are told over and over how stupid, along with alcohol to help them cope better ‘The health staff at my medical centre ugly, and insane you are, you really believe it. with their lives, or make them drowsy and knew I was being beaten by my husband. I am not financially or physically capable of sleep better. Twelve women had pressurized I have been attending frequently over the going anywhere’ (FK) friends and family to give them their years and we have discussed my fears and prescription drugs such as tranquilisers distress. However, I have never been given any ‘Violence in my early marriage was extremely (Valium) or stronger painkillers to help information about Women’s Aid or where to physical and he battered me; but violence in them cope, but soon found themselves go for help and support – on one occasion my my later years has been more controlling and addicted to these drugs. GP suggested relaxation classes’ (EK) threatening. I think I can cope easier with physical beatings than with the emotional ‘I drank heavily at one stage to help me sleep Most nurses and doctors did not take the distress and loneliness of psychological abuse. as it dulls your senses. I also took up to 30 women seriously and in several cases the I know that life will never be any different codeine tablets each day’ (SF) women felt that they did not believe their unless I win the lottery!! I would like to do situation or their distress. This led further more and be able to feel alive again but this Alcohol was used by most to calm their to a sense of isolation, hopelessness and fear can only be done if others realise that violence nerves or lift their spirits. Twelve were for the women. throughout a long marriage can be like a drinking far in excess of normal limits and cancer eating away at you and never being four women who had been diagnosed as ‘My husband has physically and mentally cured. Living with lung cancer has been easier ‘alcohol dependent’ and attended Alcoholics abused me for over 50 years. He now suffers for me than living with constant fear and Anonymous. from various illnesses and I am his carer. abuse’ (BL) My medical practice has been more helpful ‘My children see me as an “old drunk”. I and supportive to my husband and his ‘He is still very moody and bad tempered feel ashamed as my children think that I am illnesses and is not interested in helping me or even after 40 years. We live and sleep in inadequate and can’t cope with life in general’ referring me to talk to someone even though separate rooms. My life is miserable and I (DK) they are fully aware of how I have to live with only have an existence. He sometimes won’t distressing violence’ (LD) acknowledge me for a week at a time’ (CA) Barriers to support All women expressed a number of barriers Psychological effects ‘My life is not happy or full of family and to support. Support from family and friends Over time a more cruel, intense and friends. I feel totally alone. My husband hated was limited, with 15 women receiving damaging psychological abuse developed my family and friends and systematically little or no support from their children, as that eroded these women’s lives, self-esteem removed them from my life. I am now angry relationships had broken down over the

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years, mostly due to their depression and Key points alcohol misuse. Likewise, the response from professionals was poor. General l Although 15% of older women aged over 50 have experienced some form of domestic practice was seen as the logical resource violence their voices are virtually absent from the research literature as service providers for obtaining short-term help. Seventeen and policy makers often assume that this abuse stops at around age 50 l women had talked to their practice nurse This small study aims to bridge this research gap by gaining a deeper understanding of how ‘older women’ living with an abusive partner for more than 30 years cope with or GP about the abuse but on no occasion domestic violence and how it affects their health and wellbeing had professionals brought up the topic, l Three inter-related themes emerged from the data namely: health and wellbeing; even though 10 women had been attending psychological effects; and barriers to support which highlight the needs of older women the health centre and A&E with severe dealing with domestic violence and the coping mechanisms used cuts, bruises, panic attacks and evidence l Findings suggest that health professionals must receive appropriate knowledge and skills of physical and psychological trauma for training to deal effectively with older women experiencing abuse many years. l Further research is needed to ascertain the use of multi-agency interventions with older women and the development of better collaboration between the aged, mental health, ‘I recently attended my practice nurse for substance misuse, and domestic and family violence sectors blood pressure readings caused by my stressful home life and she was well aware that I was getting a beating at home, but she never said Besides the inherent negative implications professionals are consequently unlikely to the words ‘can I help or get someone to help of increased rates of psychopathology, it identify signs accurately (Gutmanis et al, you? She was busy and uninterested’ (MW) has been theorised that psychopathology 2007) but should be encouraged to ‘begin in and of itself may be a risk factor for to see’ and ‘begin to ask’ so that they can ‘My doctor knew that I was living with continued long-term violence between provide adequate support (Zink et al, a violent partner but he never really got partners, thus perpetuating the cycle 2005). Stress conditions such as depression, involved – he would get all the letters from of violence and also interfering with irritable bowel and chronic pain could serve the hospital with my injuries itemised and effective use of available support (Zink et as ‘red flags’ for nurses to inquire about prescribed drugs but never provided any al, 2006a; Robinson and Spilsbury, 2008). domestic violence (Mears and Sargent, help or support. He never took the situation More research is needed to show how the 2003; Lazenbatt et al, 2010). seriously or talked about my safety or my experiences of child abuse and untreated Since health professionals are in a unique children’s safety’ (FK) depression in early married life (eg, PND) position to identify abuse, asking a question may play some role in increasing the about domestic violence would allow them Discussion chances of becoming a victim of domestic to address the root of a patient’s problem The narratives provide a powerful picture violence and increasing susceptibility to rather than solely treating the presenting of domestic violence experienced by older mental illness. symptoms which could lead to more women, its effect on wellbeing and use of Support networks were missing for all efficient and effective mental health care coping mechanisms. Psychological abuse the women, both in the past and present. services and improvement in the lives of had the strongest impact on women’s Although nurses and GPs are in a unique victims (Morgan Disney, 2000). ‘wellbeing’, destroying self-confidence, self- position to contribute towards the Practitioners must enable safe disclosure by efficacy and coping abilities. Under extreme assessment and identification of domestic seeing clients alone, and undertake training stress, all women defined themselves as violence in older women and to provide in recognising, screening, and supporting being in ‘very poor’ physical and mental access to appropriate support, they often domestic violence in older women (Mears health and were using pathogenic coping lack training and skills, and even lack and Sargent, 2003). By dealing with the resources, such as excessive and long-term awareness of the existence of domestic issue sensitively and directly nurses may use of alcohol, prescription and non- violence in older women (Gutmanis et al, help older women to disclose their abuse prescription drugs and cigarettes, leading 2007; Feder et al, 2009). Even though this and seek appropriate support. to increased addiction to drugs and alcohol is a small study all participants felt that US research has shown that family nurses dependence which endangered their long- most nurses and doctors did not take them and doctors who have been trained in term health and wellbeing. seriously or did not believe their situation, DV are more likely to ask patients about Our findings are consistent with research or distress. violence, and as such are more likely to have that describes the pervasive nature of Indeed, research highlights that 60% of patients who disclose abuse (Rodriguez psychological abuse in younger women, nurses and doctors have reported not having et al, 2009). With this in mind the British which affects all areas of a woman’s life and specific education in domestic violence- Medical Association (2007) has proposed has been associated with PTSD (Zink et related issues (Gutmanis et al, 2007). Our that all professionals should practice al, 2005; Band-Winterstein and Eisikovits, findings correspond to Morgan Disney selective enquiry and routine enquiry with 2009), depression and drug addiction (2000) who found that nurses and doctors patients, and must recognize that strategies (Pritchard, 2000; Mears and Sargent, were the professional groups most likely to tackle substance misuse must also be 2003; hegarty et al, 2004; Straka and to be accessed by older women, yet they mindful of the strong association with Montminy, 2006). appeared the most unhelpful. These health domestic violence.

February 2013 Volume 86 Number 2 Community Practitioner | 31 PROFESSIONAL AND RESEARCH: PEER REVIEWED

Recommendations and children (DH, 2010) excludes older Lazenbatt A, Devaney J, Gildea A. (2010) Older Women Coping with Lifelong Domestic Violence, Although this is a small study our findings women potentially experiencing the effects Cap Funding, Institute Governance. Belfast: Queen’s suggest that health professionals must of lifelong abuse. Therefore, if research and University. Available from: www.womensaidni. receive appropriate knowledge and skills service provision to this point focus only org/themainevent/wp-content/uploads/2012/04/ older-women-and-domestic-violence-in-northern- training to deal effectively with older women on women up to age 59, virtually the entire ireland-executive-summary.pdf [Accessed January experiencing domestic violence. Education older half of the female population at risk of 2013]. and awareness training must form part domestic violence, those aged over 60 years, McGarry J, Simpson C, Hincliff-Smith K. (2010) of undergraduate, postgraduate and The impact of domestic violence for older women: a will be ignored (Scott, 2008). review of the literature. Health Soc Care Community continuing professional practice (CDP) and 19(1): 3–14. highlight clear definitions, simple screening References Mears J, Sargent M. (2003) Older Women Speak Up: Survival is not enough, Project Report Two: for protocols, specific communication skills, Abrahams H. (2010) Rebuilding Lives after Domestic Professionals. Sydney: Older Women’s Network. efficient referral systems, and appropriate Violence: Understanding Long Term Outcomes. Available from: www.austdvclearinghouse.unsw.edu. inter-agency referral. London: Jessica Kingsley Publishers. au/RR_docs/MearsSargent_Survivalisnotenough.pdf Also education based on a multidisciplinary Band-Winterstein T, Eisikovits Z. (2009) ‘Aging Out’ [Accessed January 2013]. of violence: the multiple faces of intimate violence approach, where different groups of Morgan Disney & Associates. (2000) Two Lives – Two over the life span. Qual Health Res 19(2): 164–80. Worlds: Older People and Domestic Violence. Canberra: healthcare professionals have opportunities Beaulaurier RL, Seff LR, Newman FL, Dunlop BD. Partnerships Against Domestic Violence, Vol 1. to share experiences and learn together, is (2007) External barriers to help seeking for older Pico-Alfonso MA, Garcia-Linares MI, Celda-Navarro likely to increase inter-agency collaboration women who experience intimate partner violence. N, Blasco-Ros C, Echeburua E, Martinez M. (2005) Journal of Family Violence 22(8): 747–55. and health service effectiveness (BMA, 2007; The impact of physical, psychological, and sexual Blood I. (2004) Older women and domestic violence: intimate male partner violence on women’s mental Gutmanis et al, 2007; Abrahams, 2010). A report for Help the Aged and hact. London: Help health: depressive symptoms, posttraumatic stress Further research is needed to ascertain the Aged. disorder, state anxiety, and suicide. J Womens Health 15(5): 599–611. the use of multi-agency intervention with British Medical Association (2007) Written Evidence Pritchard J. (2000) The needs of older women: Services older women and the development of better to the Home Affairs Select Committee Inquiry into Domestic Violence. London: BMA. for victims of elder abuse and other abuse. Bristol: The collaboration between the aged, mental Policy Press. Calvete E, Estιvez A, Corral S. (2007) Intimate health, substance misuse, and domestic partner violence and depressive symptoms in Robinson L, Spilsbury K. (2008) Systematic review of and family violence sectors to allow them women: Cognitive schemas as moderators and the perceptions and experiences of accessing health services by adult victims of domestic violence. Health mediators. Behaviour Research and Therapy 45: to respond proportionately and with Soc Care Community 16(1): 16–30. 791–804. appropriate interventions (Abrahams, Rodriguez MA, Quiroga SS, Bauer HM. (1996) Department of Health (DH). (2010) Responding to Breaking the silence. Battered women’s perspectives 2010; Lazenbatt et al, 2010). Therefore, if Violence Against Women and Children – the role of on medical care. Arch Fam Med 5(3): 153–8. domestic violence contributes to factors the NHS. The report of the Taskforce on the Health such as increased mental illness, and alcohol Aspects of Violence Against Women and Children. Scott M. (2008) Updating older women and domestic London: DH. Available from: www.health.org.uk/ violence in Scotland. Edinburgh: Centre for Research and drug abuse, then interventions aimed media_manager/public/75/external-publications/ on Families and Relationships and Health. at these problems will not succeed without Responding-to-violence-against-women-and- Simmons B, Baxter JS. (2010) Intimate partner children–the-role-of-the-NHS.pdf [Accessed addressing domestic violence in older violence in older women: what home healthcare January 2013]. physicians should know. Home Healthc Nurse 28(2): women. In particular, reducing negative Denzin N, Lincoln Y. (2000) The discipline and 82–9. coping strategies such as avoidance, abuse practice of qualitative research. In: Denzin N, Lincoln Sormanti M, Shibusawa T. (2008) Intimate partner of alcohol and drugs could ameliorate Y (eds). (2000) Handbook of Qualitative Research, 2nd violence among midlife and older women: a edn. California: Sage Publications: 1–29. the negative impact of violence on older descriptive analysis of women seeking medical services. Health Soc Work 33(1): 33–41. women’s mental health and wellbeing. Dutton MA, Green BL, Kaltman SI. (2006) Intimate partner violence, PTSD, and adverse health outcomes. Straka SM, Montminy L. (2006) Responding to Journal of Interpersonal Violence 21: 955–68. the needs of older women experiencing domestic Conclusion Feder G, Ramsay J, Dunne D. (2009) How Far Does violence. Violence Against Women 12(3): 251–67. The study had limitations as the data were Screening Women for Domestic (Partner) Violence World Health Organization (WHO). (2002) Missing retrospective and self-reported. The sample in Different Healthcare Settings Meet Criteria for a voices: views of older persons on elder abuse. Geneva: Screening Programme? Systematic Reviews of Nine UK WHO. Available from: www.who.int/ageing/projects/ was a small group of women in middle age National Screening Committee Criteria. University elder_abuse/missing_voices/en/ [Accessed January whose abuse experiences occurred over of Bristol: Bristol. Available from: www.hta.ac.uk/ 2013]. fullmono/mon1316.pdf [Accessed January 2013]. several decades. Zink T, Jacobson CJ Jr, Regan S, Pabst S. (2004) Gutmanis I, Beynon C, Tutty L, Wathen CN, Hidden victims: the healthcare needs and the These findings may not correspond to MacMillan HL. (2007) Factors influencing experiences of older women in abusive relationships. women whose experiences of abuse are identification of and response to intimate partner J Womens Health 13(8): 898–908. violence: a survey of physicians and nurses. BMC more recent, or to women at other life Zink T, Fisher BS, Regan S, Pabst S. (2005) The Public Health 24(7): 12. stages, however, they go some way towards prevalence and incidence of intimate partner Hegarty K, Gunn J, Chondros P, Small R. (2004) violence in older women in primary care practices. J our understanding of how older victims of Association between depression and abuse by Gen Intern Med 20(10): 884–8. domestic violence have coped and currently partners of women attending general practice: Zink T, Jacobson C, Regan S, Fisher B, Pabst S. (2006a) cope with domestic violence and may give descriptive, cross-sectional survey. BMJ 328: 621–4. Older women’s descriptions and understandings of insight into how to assist other women who Home Office. (2009) What is Domestic Violence? their abusers. Violence Against Women 12(9): 851–65. London: Home Office. remain in long-term abusive relationships. Zink T, Jacobsen CJ Jr, Pabst S, Regan S, Fisher BS. Krug EG, Mercy JA, Dahlberg LL, Zwi AB. (2002) (2006b) A lifetime of intimate partner violence: As stated earlier the report Taskforce on the The world report on violence and health. Lancet 5: coping strategies of older women. Journal of health aspects of violence against women 1083–88. Interpersonal Violence 21(5): 634–51.

32 | Community Practitioner February 2013 Volume 86 Number 2 Feature

Ending the placement of children under three in institutions

Obi Amadi, Lead Professional Officer, Unite

n November 2012 I was given the opportunity to attend a ministerial conference in Bulgaria, Ihosted by UNICEF. The theme of the conference was ending the institutionalisation of children under three years of age. The conference was opened by the Bulgarian president, Rosen Plevneliev, who restated the commitment of the government and the state to gradually close childcare institutions in the country over the next 15 years, replacing them with a network of formal community based services in a family-type environment.

Call to action Figure 1. Increased family-like care hiding an increase in total number of children placed in all forms of care Jean-Claude Legrand, UNICEF’s senior regional advisor on child protection, Central and Eastern Cash benefits for families of children with were real heartsink moments. Parents often Europe and the Commonwealth of independent disabilities have been put into place in most encourage young marriage to ensure virginity states, presented a ‘call to action’. He shared countries to support the change in culture of in girls and do not value education for girls so statistics with the conference, which demonstrated putting children into institutions for economic do not send them to school. It was reported also that the increase in family-like care is masking the reasons. It is hoped that along with education that women do not often access antenatal care, overall rise in the numbers of children in other and direct support to families this will help to but will turn up at the hospital for the first time forms of care (see Figure 1). There are some 1.3 improve the picture in Bulgaria. They are also already in labour. million children in formal care across Eastern looking at the role of the health visitor in the UK This situation may seem a shocking prospect Europe and central Asia, illustrating a high level and what can be usefully transferred in terms of to many of you – but I remember after my of separation of children below the age of 18 from training and role change. careers advice interview at school being sent to their biological families. Following on from this, Pauline Watts from our local hospital to do voluntary work, observe The region has one of the highest rates of the UK Department of Health delivered a professionals and get a taste of what ‘nursing’ children in residential care in the world. Numbers presentation entitled Lessons Learned from was all about. I arrived and was allocated some have declined in recent times, but have been Health Visiting Services in the UK in which she children with special needs to give breakfast to – compensated for by demographic decline. Some discussed the Healthy Child Programme and the this became my task three mornings each week. 600,000 children grow up in residential care, Implementation Plan, contrasting services in the This could never happen now but it was the and at least 225,000 of these are children with UK with those available in Bulgaria. norm then. disabilities. Around 31,000 children below the Kevin Brown, Professor of Forensic Psychology That was 30 years ago … but we should not age of three still grow up in institutional care; and Child Health at the University of forget how far we have come since then and I only 2–5% of these are orphans. The changes the Nottingham, gave a presentation on the Daphne remember what a difficult process for society government hopes to make build on international Study in 10 European countries. He outlined the it was. and European Human Rights Standards. Mr effects of institutionalised care and described The Bulgarian government clearly recognises Legrand identified that one of the main challenges some of the solutions. This made me wonder – the importance of the early years in terms of was the capacity to identify the most vulnerable what preventive interactions are there? Where the impact it can have on health and disease, families, to reach them and provide them with are the midwives? What role do school nurses educational attainment, economic activity, appropriate support. In addition, policies needed play? What about working with young people, perception of ‘self’ and relationships with others. to be adopted that would prevent the need for starting early to change the attitudes of future The challenge they face now is to implement family separation. generations? The responses to these questions change in a meaningful and lasting way.

February 2013 Volume 86 Number 2 Community Practitioner | 33 Feature

A practical approach to tackling parental alcohol abuse

Parental alcohol use is worrying for both professionals and parents. It is often surrounded by secrecy and denial, which makes it a hard issue for a professional to address and for parents to access the right support

Children are impacted in a number of they have an alcohol problem, it does not Thomas Cornwallis QSW different ways: parental alcoholism affects them necessarily mean the problem is not there. Hidden Harm Co-ordinator financially; it affects their home environment; In practice, most standard policies and London Borough of Lewisham Drug they may be exposed to unsuitable care and procedures are reactive to the parent admitting and Alcohol Action Team carers or inadequate supervision, poor role they have a problem. Consequently, workers models and inappropriate behaviour; and their from universal services often focus on gaining physical/emotional development and school evidence and then initiating procedures, he significant and detrimental impact attendance can suffer. Many children whose which is a difficult balance to strike as workers on family life and child development parents drink at a significant level can often often have to make social services referrals Tcaused by parental alcohol use find themselves having to take on the role of when disclosures are made. cannot be underestimated, often putting carer, both for siblings and their parents. ‘If you do not know what the problem is you children in danger. It rarely exists in isolation It is important to understand the feelings a cannot fix it’ is a good place to start. In fact, it as a problem and is commonly twinned parent will be experiencing in relation to their is difficult to meaningfully help a parent before with mental health, bereavement, family alcohol use and to recognise that just because they have accepted there is a problem; you breakdown or domestic violence. a parent may or may not have disclosed that cannot force change or engagement.

34 | Community Practitioner February 2013 Volume 86 Number 2 Feature

From both sides, this can be difficult and have hope. If this is handled badly their on Tuesdays. This is useful as it enables the to manage as the positivity of a parent’s defences usually go up and they disengage. parent to have some basic structure to their disclosure can be overshadowed by a reaction Ideally, parents should be listened to and time. They can also tick things off as they to the referral to children’s social care. reassured that they have done the right thing in are completed, which will increase their Understandably, this can cause a dilemma for acknowledging they have a problem and that confidence and make day-to-day life seem the professional and a great deal of anxiety they will be given the right support. Stay with more manageable. It is also not reliant on the for the parent. Hopefully, the sections below them until they have finished saying everything problem behaviour changing immediately. will help professionals deal with some of they want to – they will usually indicate why these dilemmas. drinking became a problem. End by reassuring What to expect them and explain what you are going to do to Things often get worse before they get Common challenges try to help them. This might involve referral to better – be prepared initially for the parent Immediate safety your local alcohol service, providing them with to deteriorate before they improve. It is a Professionals often worry about immediate printed information or calling someone else to process and parents need to learn new coping safety when a parent has a drinking problem. look after the children. It is a good idea at this mechanisms; support networks can help. The following questions may be useful stage to give them a diary sheet to keep track of to consider: what they are drinking, when and why. Proactive planning l Has anything changed recently? (Is this a new You can now also draw up a safety plan or Think about things that can be changed and problem?) contingency plan with the parent. This is what can be put in place to support parents l How old is the child? (If they are younger important as it empowers the parent to take and their children through the period of there is a more immediate risk) control of the situation, even while the problem change. Accepting and anticipating a realistic l Who is providing the care? Is there another drinking continues, and it is something they timetable is crucial. For example, when a carer? (If there are other carers, there is less can immediately succeed at. It should prioritise child has had little or no supervision and a cause for concern) the child’s needs and safety, which will also help parent then starts to put boundaries in place l Can the child call for help? (If so, there is less the parent deal with feelings of guilt. the child will react negatively, especially if the cause for concern) parent is still drinking. Putting this part of l Is the child of school age? (If not then there The elephant in the room the programme in place will increase parents’ is cause for more concern as the child is not We have all been in a room or meeting with a stress levels and could result in further drinking being regularly seen) parent where we have suspicions of parental and disengagement with services. Therefore, l Is it the school holidays? (If yes then there alcohol use. It is really important not to ignore think about support plans you might need is cause for more concern as the child is not this, but ‘say what you see’ and offer help. Don’t for both parent and child. If the parent is still being regularly seen) add a judgement, an assumption or interpret; drinking they will find it difficult to maintain l Is there adequate food etc? (If no, then there simply say to the parent what you see. Examples the changes. The situation could be handled by is more cause for concern) of this could be: ‘I smell alcohol on your addressing the drinking first and ensuring the l Does the child have any autonomy/ breath – if you need support with that we can parent is engaged with an alcohol service that independence? (If yes, then there is less cause help’ or ‘You seem unsteady on your feet, your can provide relapse prevention support. Next, for concerned providing they have other speech seems slurred’. This is an important introduce intensive parenting support so the support and attend school) process for the parent even if it does not lead family has the maximum chance of benefiting l Is there violence in the home or inappropriate to a disclosure as it forces them to face some of from the intervention and maintaining the visitors (If the answer is yes to either of these their own denial. If this is not done they may changes by using this support network to then there is more cause for concern). convince themselves everything is fine. protect the family against wobbles.

Do the answers to the above ensure the child’s Working with parents A holistic view immediate safety? If not, think about how you Fundamental to working with parents is Think about the family as a system and look could encourage any of the above to change to accepting that it takes time to change. Goals at what works well within it and ways other make the situation safer. need to be pragmatic, realistic and timely, areas can be improved. This needs reviewing with a focus on finding solutions rather than constantly, as if one factor changes the family Handling a disclosure obstacles. dynamics will change. For example, if a parent’s Handling disclosure is key to being able to Sometimes you have to accept that it may alcohol use changes, the family system will start to support a parent and get them the help only be possible to put a simple routine in change and these periods of adjustment are they need. Listen to what the parent is saying place and that the parent will need support stressful for all involved. and recognise that by starting to talk about with anything that needs longer-term the alcohol problem they are acknowledging planning. A useful tool is a basic wall chart, Be patient it exists. This is the first step and can be a very which does actually need to go on the wall so Sometimes you have to accept that the parent’s vulnerable time; parents can become distressed it can be checked. The chart should outline alcohol abuse might not improve immediately. at this stage. The parent is usually in a very tasks to be completed each day. Allocate a However, the situation may change and, negative space and it is important that this is a specific day for household tasks; for example, importantly, things may improve for the child positive interaction where they feel supported laundry on Mondays and food shopping over time – don’t give up.

February 2013 Volume 86 Number 2 Community Practitioner | 35 Feature

T aking action against poverty: Unite Community Unite’s new category of membership brings together those outside the workplace to campaign for a better, more caring society

36 | Community Practitioner February 2013 Volume 86 Number 2 Feature

receive sums a third higher than the reality. Community will be able to use its relationships Ellie O’Hagan The TUC’s general secretary, Frances O’Grady, with reliable credit unions to support her Unite the Union lays the blame on ministers, accusing them of clients. They will be able to access trustworthy ‘deliberately misleading people about the value financial advice and become part of a local n 3 January 2013, Chris Stewart, of benefits and who gets them.’ financial structure that is of benefit to the Conservative councillor for York, In a climate where the public is consenting to local community. Karen and her fellow Unite Ocommented upon the rise in visits to ever-decreasing living standards because they members hope these connections will help food banks. According to the York Press, Stewart are being misled about the facts, health visitors clients break the cycle of poverty they have declared that ‘living standards had surged, like Karen must resort to watching their clients become trapped in. that there was no need for food banks, that sink further into poverty without help. Austerity With the help of Unite Community, they were an insult to starving people around measures and changes to the benefits system members of Karen’s branch will be trained up the world, and that donating to them allowed make it almost impossible for community in signposting so they can help clients find a recipients to spend more money on alcohol practitioners to perform their duties properly. service that will benefit them. If health visitors and cigarettes.’ After all, how can one possibly improve know their clients are suffering from financial On the day that Chris Stewart made his breastfeeding rates in one’s clients if those worries, they will be able to recommend a statement, I spoke to a health visitor called clients can’t afford to eat? People cannot be local service or Citizens Advice Bureau. Unite Karen, working in the East Midlands. Karen healthy unless they are feeling happy and secure: also offers its community members valuable spends her working life visiting those Stewart that’s an integral part of health and wellbeing. benefits, such as legal advice, debt counselling deems an ‘insult to starving people around the Despite this, the situation is not hopeless. and help with reducing utility bills. Perhaps world,’ so I asked her about her experiences. ‘I Karen is a member of Unite the Union, so most impressively, Unite Community is also have a huge number of clients who can’t afford instead of petitioning the government to change looking at ways Karen’s union branch will be clothes,’ she says, bluntly. ‘I have clients who its policies, her branch members have decided able to train up clients to support each other, have pawned their children’s Christmas presents to take on the poverty they witness through through informal buddy systems and other so that they could put food on the table.’ organising and collective action – the union means, so that problems resulting from poverty In fact, I could fill up an entire feature solely way. ‘Things haven’t been this bad in the become experienced and tackled collectively. with Karen’s stories of her interaction with twelve years I’ve been working,’ she explains. This initiative is derived from the chief clients, so shocking are they in their content. ‘I ‘We’ve got no choice but to take action.’ principle of community organising: don’t do went to visit one client for an hour, and in that Karen has met with Luke Primarolo, Unite’s for others what they can do for themselves. time four people from payday loan companies Community Co-ordinator for the East came over demanding money. They’re just Midlands, to discuss Unite’s new category of Providing support relentless,’ she adds. These stories, Karen was membership: community. This year, government cuts are expected to keen to emphasise, are not anomalies, but bite more than ever – bringing with them representative of those living in poverty in Collective approach misery and hardship. Austerity will mean Britain today. Her argument would seem to Unite’s community membership is a new more and more health workers like Karen will be borne out in the statistics: in December category for anyone who is not in paid work. find themselves going above and beyond their 2012, the Family Food Survey showed many It is the first initiative of its kind, and – the remit simply to meet minimum professional families in poverty are struggling to meet their union says – was set up in direct response targets. Public services cannot and should not basic nutritional needs. Karen rejects the idea to ‘devastating attacks on working-class be replaced by volunteering, but there are ways that poverty is something people bring on communities.’ Steve Turner, Unite’s Executive that people can come together to confront themselves. ‘All my clients who can work are Director of Policy, says the aim of Unite issues that affect entire communities. When trying to,’ she says. ‘Many of them are doing Community is to encourage people to ‘organise people are linked up and organised, they can back-to-work schemes or going on college together around really important issues’ like find positivity in ostensibly hopeless situations; courses. The work just isn’t out there.’ debt, public services, living standards and they can be resourceful when resources seem If it seems as though Karen is responding to housing. scarce. And with the right support, motivation an existing attitude about welfare claimants, it’s With that in mind, Karen’s branch has and skills, people do not simply have to tolerate because she is. used Unite Community to make connections poverty being inflicted upon them. They can ‘There seems to be this belief that people have with organisations that can help her clients fight back. chosen to be in this situation,’ she says. And she’s cope with their finances. Unite is already right: a recent poll showed that nearly half of the forming relationships with credit unions: For more information about community UK thinks our benefits system is ‘too generous,’ their co-operative nature allows them to membership, and to watch a three-minute and that those who have the least accurate put the interest of their members first, and film on the initiative produced by Unite, picture of welfare tend to be most critical of it – discourages practices such as risky lending and visit the website: www.unitetheunion.org/ on average people believe that welfare claimants poor financial advice. Karen hopes that Unite community

February 2013 Volume 86 Number 2 Community Practitioner | 37 SCHOOL NURSE CAMPAIGN

CPHVA 121 Campaign for School Nursing 2013 Calling all public health nurses who work with school-aged children ...

Qualified school nurses (male and female) l First, it will be important that you attend Rosalind Godson should be seen as essential professionals the local Unite in Health or CPHVA branch Professional Officer, Unite within the state school system, available and meetings, so that there is a professional visible in the same way as teachers. There advocate for school nursing in every area. needs to be one full-time year-round qualified Then you will be able to attend the regional he first trained school nurses started school nurse per secondary school. Organising Professional Forum (OPC) to work in Britain in 1892, with a remit School nurses are unique as they work at discuss and promote relevant issues Tto reduce infections and ensure better the interface between education and health, l Your local director of public health may nutrition for children. This public health understanding the culture of both, so well need to be updated about modern role has varied over the years, but qualified that they are effective in partnership working. school nursing, particularly about the Specialist Community Public Health Nurses They also work on a one-to-one basis wider public health role are recognised as the lead public health nurses with individual children in school and the l In your neighbourhood many people will for children and young people. community. have only a hazy idea of what the school Now, 121 years later, the health service nurse does in practice – so now is the time in England is being dismantled and What Unite/CPHVA will do to enlighten them. We would like you to commissioning for public health of 5–19 year l We will campaign nationally for school talk to school governors, local councillors olds is going to be the responsibility of local nurse numbers to be increased alongside the and church groups, for example, to authorities. increase in health visitors convince them of the benefits of school In Scotland and Northern Ireland there are l We will monitor numbers of school nurses. extremely few public health nurses for schools nurses throughout the UK and ensure that l You could write to the local paper and be or young people. Wales is the only success governments are aware of problems prepared to talk on local radio about school story, as the previous government there l We will use our social and written media to children’s health issues committed to one school nurse per secondary promote school nursing l The local elections in England in May school. However, financial constraints are l We will influence our wider Unite 2013 will be an excellent opportunity to looming in all four countries of the UK membership approach candidates and ask the question: and we must raise our game to make sure l We will build up the Organising Professional ‘If elected, would you ensure that there is a that children’s health does not lose out Committees in each region so that we have school nurse for every school?’ owing to the struggle for resources and the excellent communication from school l Your local MP will also be keen to hear fragmentation of services. nurses around the UK to the National OPC from you There is no doubt that school nurses can l We will publicise all good practice in l We hope that as many of you as possible make a tremendous difference to the health Community Practitioner will be able to attend the CPHVA Annual outcomes of young people from all socio- l We will let you have up-to-date information Professional Conference in October, and economic backgrounds, and especially to to influence local commissioners other events throughout the year. those from vulnerable families. However, that and stakeholders. is dependent upon them being employed in The CPHVA is one of the oldest women’s the first place. What each of you need to do trade unions. Are you aware that the CPHVA Much of the decision making around service colours are those of the suffragettes? Purple Aim of the campaign provision has been devolved to local decision symbolised dignity, white purity, and green Our aim is the same as it has been for several makers and there is a limit to what can be hope. Green appears to be the appropriate years – to campaign for one school nurse to one achieved nationally. School nurses must be colour for now. For more information please secondary school. prepared to become more active locally. email: [email protected]

38 | Community Practitioner February 2013 Volume 86 Number 2 Feature

Reflection: the student learning curve

would, in time, equip me with enhanced skills behaviour has meant that I have been faced Natasha Morris-Day in this area (DH, 2009). with a caseload heavily focused on child Student Health Visitor Semester one provided me with a false sense protection. This has enabled me to gain a of security, with its long stretch at university, wealth of experience in policies, procedures he Health Visitor Implementation Plan followed by a short placement of only six and practice in this area. I was overwhelmed (Department of Health (DH), 2011) weeks and most of the academic assessments by this during semester one, but through Thas seen a huge increase in recruitment completed before placement began. However, observation, reflection and working with of student health visitors at universities across I soon realised in semester two that I needed multi-agency professionals, I have increased the country over the last 12 months. I feel very to use my skills in time management and my knowledge and proficiency in ensuring privileged to be a part of this process and as I organisation to their maximum potential as the that appropriate actions are taken to safeguard reach qualification, am excited about becoming assignments and other academic assessments children in our care. a lead practitioner for the Healthy Child ran concurrent with my second placement. Programme (DH, 2009). However, this year has Despite the heavy academic workload of T he challenge ahead not been easy and as I reflect on my training semester two I felt my confidence in practice I am aware that successfully completing my I can truly see the wealth of experience I have was growing. My understanding of the health degree is only the start of my learning journey. gained as I move towards preceptorship. visiting role was developing fast and I felt As I embark on my career as a qualified Starting the course filled me with a sense able to contribute to the team rather than practitioner, I aim to take responsibility for of anticipation. I had left my comfort zone simply observing and asking questions. As my own continuing professional development as a community staff nurse and was about the semester drew to a close my practice- through accessing appropriate support and to embark on an entirely different spectrum based assessments showed I was progressing supervision. With increasing staff numbers of nursing. However, I have always been from Identification towards Internalisation, replenishing the health visiting workforce (DH, truly passionate about public health and its as required by the university (Steinaker and 2011) I hope that resources will be available importance to society and I felt a great sense of Bell, 1979). Knowing that I had developed in for me to complete a robust programme of pride in being accepted onto a programme that practice further improved my confidence, ready clinical supervision and that my knowledge will for Consolidation. increase through independent practice, coupled with a further year of formal preceptorship. Professional growth Reflection on an individual and team basis As semester three has continued at a fast pace, will allow me to improve my practice and I have spent much time reflecting on personal harness the skills of my experienced colleagues. and professional growth, and what this has There is much for me to achieve, but as the end meant for me as I move towards becoming a of my training draws near I feel ready for the qualified practitioner. I feel that the steepest challenges ahead. learning curve I have encountered has been with regards to safeguarding children within R eferences health visiting. It is an area of practice that Department for Children, Schools and Families (DCSF). before this year I had very little to do with, (2010) Working Together to Safeguard Children A Guide to Inter-Agency Working to Safeguard and Promote the as my background was adult nursing. The Welfare of Children. London: DH. Department for Children, Schools and Families Department of Health (DH). (2009) Healthy Child (DCSF) (2010) states that safeguarding children Programme: Birth and The First Five Years of Life. London: is everyone’s business and that professional DH. practice should remain child centred through DH. (2011) The Health Visitor Implementation Plan 2011-2015: A Call to Action. London: DH. effective multi-agency working. Steinaker M, Bell R. (1979) The Experiential Taxonomy: Completing my placement year in an area A New Approach to Teaching and Learning. London: of high social deprivation and anti-social Academic Press.

February 2013 Volume 86 Number 2 Community Practitioner | 39 Feature

Look after yourself in 2013! The start of a new year is a time we often feel the need to reflect on the previous year and make a fresh start. Did you make any new year’s resolutions? What are you going to do differently in 2013?

Ruth Oshikanlu Health Visitor and Queen’s Nurse Island Health, London

Make one resolution Evidence suggests that new year’s resolutions don’t work. This is often because we try to change too many things at once. Rather than starting the year with a long list of resolutions you are more likely to succeed in achieving your goal when you focus on the one thing that will make the greatest impact in most areas of your life.

Put yourself first Our role as health visitors can be very challenging. Caseload sizes are growing due to growth in populations. Cuts in other services – statutory and voluntary – mean that we have to provide more support for children and their families. How, then, can you prevent burnout? The key is to look after yourself first! This may sound selfish, but when flight attendants perform their safety demonstration they advise that you fit your When you are tired and hungry it takes than you can document before the close of oxygen mask first before that of your child. you longer to complete tasks and you the day and record your visits before you go As nurses and health visitors the tendency is may become irritable and stressed. Keep home. This will enable you to leave work at to care for our patients at our own expense. hydrated throughout the day. Sometimes, as work and promote work–life balance. Engage However, there is only one of you and you community practitioners, we feel pressured in the activities that you advocate to your really matter! If you run yourself into the to come to work when we are sick. Perhaps clients: get plenty of rest, eat a healthy diet ground your clients won’t benefit from the we may feel guilty about neglecting the needs and exercise regularly. If the workload is too care you would have given. Further, whenever of our clients or leaving our colleagues to do much for you to deliver care safely, inform you are off sick, your colleagues will have our work. However, coming to work while your manager in writing supporting this with more work to do. Therefore, look after we are unwell can lengthen the period of evidence and proposing potential solutions. yourself first. recovery, which may lead to taking a longer All the above may sound like common period of absence. sense. However, it is not always common in T ake regular breaks After undertaking visits that may drain you practice. Therefore, if you resolve to change Look after your physical and emotional emotionally, ensure you debrief with your just one thing in 2013, make sure it is to health. Your employer provides you with colleagues. It prevents overwhelm and gives look after yourself as it will benefit not lunch breaks because they know you need you a more objective view of the situation. just you, but your clients, colleagues and it. So make time to take your lunch break. Endeavour not to undertake more visits employer, too.

40 | Community Practitioner February 2013 Volume 86 Number 2 PRACTICE: PEER REVIEWED

Common surgical problems in children

Introduction conditions, within the remit of community Meera Thayalan Foundation Trainee Year 2 in Paediatrics Surgical problems are relatively uncommon practitioners, with a view to aiding prompt in children and presentation may differ to that diagnosis and intervention. Siba Prosad Paul seen in adult practice. If managed appropriately, Specialty Trainee Year 5 in Paediatrics surgical conditions encountered in children Challenges Andrew Michael Fernando are often easily treated with a good outcome. There are a few reasons why recognising and Consultant Paediatrician Community practitioners, such as health diagnosing surgical conditions can pose a visitors, community midwives and school challenge to health professionals at every level. Yeovil District Hospital NHS Foundation Trust, nurses, are often the first health professionals to Some of these challenges are as follows: Yeovil, Somerset come across children with a suspected surgical l The history is generally provided by another Abstract problem. Therefore, it is vital to remain aware of individual (usually a parent) who may This article aims to take the reader through the early signs and symptoms and refer early to themselves be very worried the common presentations and assessment of improve the impact of surgical care. l Vomiting is a common presentation in surgical children presenting with a surgical condition. Although relatively uncommon, most of these Variations in symptoms caused by age-related problems; however, it is much more common conditions need urgent identification and idiosyncratic or non-specific presentations can in children without a surgical pathology (eg, management. After reading this article and pose a diagnostic challenge and whenever a gastro-oesophageal reflux) completing the questions that follow the suspicion arises this should be discussed with l Younger infants are more likely to present with reader should be able to: identify the signs and symptoms of a surgical problem; recognise and referred to medical professionals. Early congenital anomalies the importance of supporting families with a involvement of the surgical team is paramount l Bilious vomiting may mean different things surgical condition, both pre and post diagnosis; in some cases, where the situation can progress to the public and medical professionals (bile initiate appropriate referral for different surgical and rapidly deteriorate (such as intussusception is green; however, yellow vomiting is often conditions. or appendicitis). This review aims to consolidate reported by the public as ‘bilious’) Community Practitioner, 2013; 86(2): 41–45. information with regard to presentation and l Examination and diagnostic procedures management of common paediatric surgical may be difficult from technical, physical and No conflict of interest declared Table 1. Surgical conditions tend to be age specific (adapted from Davenport, 1996) To complete the questions and add to your CPD portfolio visit the journal’s website at: Infants up to one week old www.communitypractitioner.com/CPD l Gastrointestinal atresias (eg, duodenal atresia) l Malrotation of the gut l Meconium ileus (delay in passage of meconium >48 hours after birth) l Hirschsprung’s disease (delay in passage of meconium >48 hours after birth) l Hypospadias l Undescended testis l Hydrocele

Infants up to two months old l Gastro-oesophageal reflux disease (most cases need medical management) l Pyloric stenosis l Inguinal hernia l Umbilical hernia

Infants up to one year old l Intussusception l Inguinal hernia

Older children l Appendicitis l Torsion of testis l Mastoiditis l Intussusception (usually have an identifiable cause eg, Henoch-Schonlein purpura)

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Box 1. Risk factors for surgical problems in children It disappears with gentle pressure or when l Prematurity (for inguinal hernias) lying down and becomes larger when crying or l Previous abdominal surgery straining. Inguinal hernias are also associated l Early weaning on to solids (intussusception) with hydroceles (Smith and Kenny, 2008). l Henoch-Schonlein purpura (testicular torsion, intussusception) Complications arise if the hernia becomes l Viral diseases eg, influenza (appendicitis) incarcerated/obstructed (hernia cannot l Recurrent ear infections (mastoiditis) be reduced and the child will be in severe l Family history (pyloric stenosis, inguinal hernias) pain), impairing blood supply causing bowel l Genetic syndromes (eg, duodenal atresia in Down’s syndrome) ischaemia. A history of vomiting, colicky l Absence of breastfeeding (pyloric stenosis) abdominal pain, poor feeding or constipation l Male sex (inguinal hernias, pyloric stenosis, hydrocele, hypospadias) may suggest bowel obstruction (Zamakhshary et al, 2008; Spence et al, 1998). Treatment requires Box 2. Presence of red flag symptoms should raise early suspicion surgery; if an obstructed hernia is suspected an urgent surgical referral is required. If a reducible l Lethargy and listlessness (intussusception, obstructed inguinal hernia) hernia is present this is usually treated as an l Inconsolability (obstructed inguinal hernia, torsion of testis) elective case so an outpatient appointment can l Severe abdominal pain or distension (malrotation, intussusception) l Persistent vomiting (pyloric stenosis) be arranged. l Bile-stained vomit (green) (malrotation, intussusception) l Projectile vomiting (pyloric stenosis) Intussusception l High fever (appendicitis, mastoiditis) Intussusception is caused by telescoping of a l Blood in the vomit proximal segment of bowel loop distally into l Abnormal discolouration of skin over lumps and bumps (obstructed inguinal an adjacent segment, causing obstruction and hernia, mastoiditis) possibly necrosis (Rogers and Robb, 2010). l Blood in stool (intussusception) A minority of cases develop three classic symptoms: intermittent colicky abdominal emotional aspects. Some investigations are yellow (as sometimes described by parents). Bile pain with pulling up legs and screaming; only available in specialist centres. can be associated with life-threatening surgical bilious vomit; and the passage of blood per conditions, such as intestinal malrotation and rectum, described as ‘redcurrant jelly’ stool. Common surgical presentations in intussusception. Children with bile-stained In the majority of cases only one or two of children vomit should always be referred immediately these symptoms are present (Paul et al, 2010). Specific surgical problems in children may to hospital as these conditions require rapid Redcurrant jelly stool is a late sign, associated present more commonly at certain ages (Table further assessment and surgical treatment may with a late presentation, which can be associated 1). A detailed discussion about conditions be required. with a poor outcome (Yamamoto et al, 1997). community practitioners are likely to come Other important non-classical symptoms to across in their practice are described later. Red flag symptoms remain aware of include lethargy, listlessness Most of these conditions are likely to present Although identifying surgical conditions can and poor feeding (Paul et al, 2010). with ‘lumps or bumps’ or ‘vomiting’, for which be challenging (especially in young children), Intussusception is more common in boys; parents may seek advice from community identification of any (or a combination of) only one in four infants presenting with practitioners. red flag symptoms should raise the suspicion intussusception are females (Nelson and of a surgical condition in children. Some of Hosteler, 2002). The typical age group is between Risk factors for surgical problems these are highlighted in Box 2; these will enable the ages of four months and two years and the in children community practitioners to consider the aetiology is usually idiopathic (Paul et al, 2010). It is important to consider surgical problems possibility of a surgical diagnosis early. Upper respiratory tract or gastrointestinal in certain groups of children with risk factors infections have also been shown to precede that may increase their likelihood of suffering Inguinal hernia the onset of intussusceptions. Children older from such conditions. Box 1 highlights some Inguinal hernia results from the failure of the than two years of age are more likely to have risk factors community practitioners need to processus vaginalis to close, allowing protrusion an associated cause for intussusception eg, consider when presented with a child with a of abdominal contents (intestine, omentum, Henoch-Schonlein purpura. suspicion of a surgical problem. ovaries) into the groin via the inguinal canal. Once clinical suspicion is raised an urgent Hernias are more common in infants below one surgical referral is necessary. Although in a ‘Bile is bad’ year of age (more common in premature infants majority of cases the diagnosis is made clinically Green vomit is a serious sign, suggestive of an with an incidence of up to 30%) (Zamakhshary from history, ultrasound of the abdomen obstruction in the gut, until proven otherwise. et al, 2008; Spence et al, 1998). Males have a will confirm the diagnosis (doughnut sign). Parents will often describe yellow vomit as predisposition for inguinal hernias with a ratio Intussusception is the most common surgical containing ‘bile’ and it is important to elicit the of 5:1 (Smith and Kenny, 2008). emergency in younger children and is treated actual colour of the vomit, as for medical/surgical Infants will present with a groin or scrotal mostly by air enema reduction under ultrasound purposes, bilious vomiting is green, rather than lump that is usually non-tender and reducible. guidance, although open surgery is needed in

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some cases (Spence et al, 1998). Community It is characterised by sudden onset of bilious Ultrasound is currently the investigation of practitioners need to remain aware that a small vomit, abdominal pain, poor feeding or refusal choice. The definite treatment for infantile proportion (10%) of children treated with air to feed. Distension of the abdomen may also be pyloric stenosis is corrective surgical intervention enema gets a recurrence of intussusception and evident but is generally not remarkable (Kimura with a Ramstedt pyloromyotomy (Aspelund and should be referred again early if suspected (Paul and Loening-Baucke, 2000). Langer, 2007). The infant generally starts to feed et al, 2010). Malrotation is most commonly seen in within 24 hours of the operation. There appears neonates (birth to first 28 days of life) and is to be a higher incidence of gastro-oesophageal Appendicitis another surgical emergency, as the mortality reflux described after surgery so families will Appendicitis is an inflammation of the from midgut volvulus has been shown to be as need support and patients may need referral for vermiform appendix. Acute appendicitis is the high as up to 28%. Male predominance is noted treatment. most common abdominal surgical emergency in this condition with a 2:1 ratio over females occurring in older children (Alder et al, 2010). (Kouwenberg et al, 2008). Neonates presenting Mastoiditis The classical triad of symptoms include fever, late with bowel necrosis significantly increases Mastoiditis is a serious inflammatory condition vomiting and right iliac fossa pain (abdominal the risk of mortality (Kouwenberg et al, 2008). of the mastoid bone and air cells in the mastoid pain can start as central or epigastric region). A suspicion is raised from the history and portion of the temporal bone, located behind Other non-specific symptoms include loss diagnosis is made by an upper gastrointestinal the ear. Although this condition is uncommon, of appetite, non-specific back pain and contrast study, which can identify the it is a recognised complication of acute otitis lethargy. Toddlers and young children may obstruction. Rapid surgical intervention is of media, a common middle ear infection in not present with classical symptoms and may paramount importance for survival. These infants and children (Glynn et al, 2008). present with distended abdomen, difficulty in children may remain in the hospital for a length Mastoiditis is identified by evidence of fever, walking, withholding faeces and discomfort of time and post discharge will need support earache (tugging on ears in pre-verbal infants), during nappy changes as these activities cause both from community (for feeding support, discharge from the ear, post-auricular swelling, exacerbation of pain. However, appendicitis arranging missed vaccinations) and hospital redness or tenderness and the pinna being is uncommon in children less than three years health professionals. pushed forward and outward (see Figure 1) of age and accounts for only 2% of all cases (Thorne et al, 2010; Abdel-Aziz and El-Hoshy, (Spence et al, 1998). Pyloric stenosis 2010; Paul and Wilkinson, 2012). The exact cause remains unknown; however, Pyloric stenosis is caused by the thickening of Streptococcus pneumonia and Haemophilus studies have suggested a relationship between the smooth circular muscle layer of the pyloric influenzae are the most common causative viral diseases (eg, influenza) and appendicitis muscle (junction between stomach and first organisms (Kaplan et al, 2000). Resurgence (Alder et al, 2010). Community practitioners part of the small intestine) preventing adequate of mastoiditis has been seen in recent years, should be vigilant about appendicitis as it can gastric emptying and leading to projectile possibly due to stringent antibiotic prescribing quickly progress to peritonitis (as a result of vomiting. The vomit is non-bilious, usually in primary care over the last decade (Antonelli perforation and spillage of faecal matter into containing milk the infant has recently fed on. the abdominal cavity) or can lead to abscess Since the child is unable to maintain adequate formation. nutritional status, symptoms such as persistent Early referral to the paediatric/surgical hunger, dehydration, failure to thrive, lethargy team followed by examination establishes and poor urine output should also alert the diagnosis in most cases. Raised infection community practitioners to this condition. markers eg, C-reactive protein may indicate On examination, the affected infant may also a complicated case of appendicitis (Paul and present with a firm, non-tender mass in the Linney, 2011). Radiological investigations in the right upper abdominal quadrant, described as form of an ultrasound scan may help in some an olive-shaped mass (Spicer, 1982). cases. Laparoscopic removal of the inflamed Pyloric stenosis commonly presents appendix is the current treatment of choice. between the ages of two and 12 weeks, and Community practitioners may need to support is more common in males. The incidence is these children post appendicectomy. These approximately 2–4 per 1,000 live births with children may continue to have non-specific males being predisposed at 13:4. There has abdominal pain during the recovery period and been a suggestion for a genetic susceptibility school attendance may remain unsatisfactory. (increased incidence in first-born children) but the actual aetiology remains unknown (Schecter Malrotation and volvulus et al, 1997). Pyloric stenosis also appears to Malrotation is an anatomical abnormality, be more common in bottle-fed infants but Figure 1. Mastoiditis caused by incomplete rotation of the midgut a definite association remains to be proven during fetal development around the superior (Krogh et al, 2012). et al, 1999). Mastoiditis is most commonly mesenteric vessels. If left untreated it can Immediate management involves referral to noted in children under the age of four years eventually result in twisting of the gut (volvulus) hospital paediatricians for correction of salt (Abdel-Aziz and El-Hoshy, 2010) possibly as a causing obstruction and/or bowel ischaemia. and water imbalance and to recoup fluid loss. result of immature immunity.

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Table 2. Other non-urgent surgical conditions Aetiology Presentation Complications if left Management untreated

Hydrocele Caused by a patent l Seen either in Inguinal hernia l USS to confirm the (Smith and Kenny 2008, processus vaginalis neonates or early diagnosis if suspicion Tiemstra and Kapoor allowing fluid to collect infancy of hernia arises 2008) around the testes l Non-tender fluid filled l Surgical referral if scrotal swelling problem persists l Transilluminates when beyond first year of a torch is shone under life or there is a risk of the scrotum inguinal hernia

Undescended testes Incidence 33% in Picked up during routine l Testicular neoplasm l Surgical referral for (Sinha et al, 2008; pre-terms, 3-5% in full baby checks: unable to l Subfertility orchidopexy Docimo et al, 2000) term neonates and palpate testes at the l Testicular torsion l Favourable outcome 0.8 -1% by 1 year of age base of the scrotum l Inguinal hernia when fixed before 2 years of age

Hypospadias Congenital abnormality. l Backward stream of l Psychological l Surgical referral (Kraft et al, 2011; Baskin Defined by the abortive urine sequelae needed and Ebbers, 2006) development of the l Urethral opening l Poor sexual function l Parents should be urethral spongiosum. (meatus) located on l If meatus is near the advised not to get Usually associated with the ventral aspect of base of the penis their child circumcised missing foreskin at the the penis, proximal to or testes are not as foreskin may be bottom of penis the glans palpable, ambiguous necessary for repair l In older children genitalia need to be ventral curvature of ruled out penis may be noted

Umbilical hernia l Congenital anomaly. Non-tender swelling Does not get obstructed l Usually resolves within l Caused by a weak around the umbilicus first 2-3 years spot in abdominal l If the hernia is large muscles or has not resolved l Common in babies by the age of 4 years of Afro-Caribbean arrange a surgical descent referral

Immediate hospital referral is necessary under the age of 25 years is 1 in 400 (Pillai and Role of the community practitioner if mastoiditis is suspected. CT scanning is Bresner, 1998). The community practitioner plays a vital role diagnostic and management involves broad- A child with testicular torsion will often present in detecting surgical pathologies, referring spectrum intravenous antibiotics and/or ENT with unilateral redness and swelling of the early and supporting families and children surgery (Quesnel et al, 2010). Prompt hospital scrotum and acute testicular pain. Vomiting may post surgical correction. The following referral can prevent irreversible hearing loss and be a cardinal sign in pre-verbal infants. Boys in strategies may be used by practitioners: other complications, such as intracranial abscess, early puberty may not volunteer information l Early recognition of surgical conditions facial nerve paresis (partial paralysis) and sigmoid about ‘testes being sore’ and it is important to elicit l Always look for the red flag signs in sinus thrombosis. Community practitioners may that information. On examination the presence vomiting infants be required to follow up patients and make sure a of a hard scrotal mass and/or absent testes may be l Consider surgical causes of vomiting hearing test has been done (Paul and Wilkinson, evident. The testes may also be high riding due to especially if blood or bile is present 2012). the absence of the cremasteric reflex (Davenport, l Encourage uptake of newborn screening 1996; Kadish and Bolte, 1998). Testicular torsion and vaccination Testicular torsion is a common surgical emergency which can result l Advise and provide reassurance regarding Torsion of the testes results from a sudden in testicular loss if left untreated; any suspicion less serious surgical causes such as rotation of testicle about its axis leading to should lead to an immediate referral. hydrocele and umbilical hernia twisting of the spermatic cord (Gunther and Doppler ultrasound can be diagnostic and l Advise regarding the benefits of Rubben, 2012). This can compromise blood should lead to explorative surgery (Gunther and breastfeeding flow to the testicle resulting in ischemic injury Rubben, 2012). Torsion of the testes can only be l Advise about weaning around six months and infarction. Testicular torsion is usually an resolved with surgery and is a reversible problem, of age acute presentation with a double peak incidence it is necessary for community practitioners l Remain aware that a surgical problem is in children namely during the neonatal period to remain aware of the early signs to enable a more likely in a child who has undergone and early puberty. The annual incidence in males prompt referral. previous surgery.

44 | Community Practitioner February 2013 Volume 86 Number 2 PRACTICE: PEER REVIEWED

Baskin LS, Ebbers MB. (2006) Hypospadias: anatomy, mastoiditis in children. Nurs Times 108: 3. etiology, and technique. J Pediatr Surg 41(3): 463–72. Conclusion Pillai S, Bresner G. (1998) Pediatric testicular problems. Surgical problems are rare in children but can Davenport M. (1996) ABC of general surgery in children: Paediatr Clin North Am 45(4): 813–30. Acute problems of the scrotum. BMJ 312(7028): 435–7. be challenging to diagnose due to non-specific Quesnel S, Nguyen M, Pierrot S, Contencin P, Manach signs and symptoms. Many parents may consult Docimo SG, Silver RI, Cromie W (2000) The undescended Y, Couloigner V. (2010) Acute mastoiditis in children: testicle: Diagnosis and management. Am Fam Physcian 62 a retrospective study of 188 patients. Int J Pediatr community practitioners when they detect a (9): 2037–44. Otorhinolaryngol 74(12): 1388–92. lump or bump in their child. Early suspicion Glynn F, Osman L, Colreavy M, Rowley H, Dwyer TP, Blayney Rogers TN, Robb A. (2010) Intussusception in infants and A. (2008). Acute mastoiditis in children: presentation and young children. Surgery 28(8): 402–5. about a surgical condition should be followed long term consequences. J Laryngol Otol 122(3): 233–7. by a referral to specialist services. Input from Schecter R, Torfs CP, Bateson TF. (1997) The epidemiology Gunther P, Rubben I. (2012) The acute scrotum in childhood of infantile hypertrophic pyloric stenosis. Paediatr Perinat school nurses is essential in managing older and adolescence. Dtsch Arztebl Int 109(25): 449–57. Epidemiol 11(4): 407–27. children as they may continue to experience Kadish HA, Bolte RG. (1998) A retrospective review of Sinha CK, Vinay S, Kulkarni R, Nour S (2008) Delayed pain and fatigue post-operatively. They may also pediatric patients with epididymitis, testicular torsion and torsion of the testicular appendages. Pediatrics 102(1): 73–6. diagnosis for undescended testes. Indian Paediatrics 45: be able to support families where an infant has 503–4. Kaplan SL, Mason EO, Wald ER et al. (2000) Pneumococcal suffered significant morbidity early in life due mastoiditis in children. Pediatrics 106(4):695–9. Smith NP, Kenny SE. (2008) Inguinal hernia and hydrocele. Surgery 26: 307–9. to a surgical condition (eg, malrotation) and by Kimura K, Loening-Baucke V. (2000) Bilious vomiting in the Spence RK, Wait RB, Gilchrist BF, Scriven RJ, Lessin MS. ensuring immunisations are not missed due to newborn: rapid diagnosis of intestinal obstruction. Am Fam Physician 61(9): 2791–8. (1998) Frequently encountered problems in pediatric ongoing health issues. surgery II: Older infants and children. Hospital Physician Kouwenberg M, Severijnen RS, Kapusta L. (2008) 4(2): 1–9. Congenital cardiovascular defects in children with intestinal References malrotation. Pediatr Surg Int 24(3): 257–63. Spicer RD. (1982) Infantile hypertrophic pyloric stenosis: A review. Br J Surg 69(3): 128–35. Abdel-Aziz M, El-Hoshy H. (2010) Acute mastoiditis: A one Kraft KH, Shukla AR, Canning DA. (2011) Proximal year study in the paediatric hospital of Cairo university. BMC hypospadias. Scientific World Journal 19(11): 894–906. Tiemstra JD, Kapoor S. (2008) Evaluation of scrotal masses. Ear Nose Throat Disord 10: 1. Krogh C, Biggar RJ, Fischer TK, Lindholm M, Wolfarht J, Am Fam Phys 78(10): 1165–70. Alder AC, Fomby TB, Woodward WA, Haley RW, Sarosi G, Melbye M. (2012) Bottle-feeding and the risk of pyloric Thorne MC, Chewaproug L, Elden LM (2009) Suppurative Livingstone EH. (2010) Association of viral infection and stenosis. Pediatrics 130(4): e943–9. complications of acute otitis media: changes in frequency appendicitis. Arch Surg 145(1): 63–71. Paul SP, Candy DCA, Pandya N. (2010) A case series on over time. Arch Otolaryngol Head Neck Surg 135(7): 638–41. intussusceptions in infants presenting with listlessness. Antonelli PJ, Dhanani N, Giannoni CM, Kubilis PS. (1999) Yamamoto LG, Morita SY, Boychuk RB et al. (1997) Stool Infant 6(5): 1741–7. Impact of resistant pneumococcus on rates of acute appearance in intussusception: assessing the value of the mastoiditis. Otolaryngol Head Neck Surg 121(3): 190–4. Paul SP, Linney MJ. (2011). Significance of very high term ‘red currant jelly.’ Am J Emerg Med 15: 293–8. C-reactive protein (CRP) values in the paediatric practice: A Aspelund G, Langer JC. (2007) Current management of Zamakhshary M, To T, Guan J, Langer JC. (2008) Risk of retrospective study. Clin Biochem 44(7): 540–1. hypertrophic pyloric stenosis. Semin Pediatr Surg 16(1): incarceration of inguinal hernia among infants and young 27–33. Paul SP, Wilkinson R. (2012) The importance of recognising children awaiting elective surgery. CMAJ 179(10): 1001–5.

CPD questions

(i) Presentation of surgical problems in children can be challenging. (vi) Which of the following statements are true about inguinal hernia in These are...... children? 1) Common and serious 1) More commonly seen in premature babies 2) Uncommon but serious 2) When there is a suspicion of obstruction, an immediate referral 3) Presentation is same as in adults to secondary care should be made (paediatricians/surgeons) 4) All of the above 3) Discolouration of skin over hernia site, poor feeding, vomiting, looking listless, crying a lot may be all signs of an obstructed (ii) Bile is a commonly reported symptom when children vomit. What inguinal hernia is the colour of bile? 4) All of the above 1) Yellow 2) Green (vii) Which of the following statements about intussusceptions are true? 3) White and frothy 1) More commonly seen in children above 2 years of age 4) None of the above 2) Weaning on to solid food at 3 months of age is not a risk factor 3) A routine referral to GP is adequate as surgery is never (iii) An infant is suspected to have pyloric stenosis. What would be the required usual colour of the vomit? 4) None of the above are true 1) Yellow 2) Green (viii) Which of the following statements about torsion of testis are true? 3) Both of the above are true 1) It is a surgical emergency 4) None of the above are true 2) Older boys may not volunteer information about it and may look unwell, in pain, etc. (iv) Umbilical hernia is common in infants. Which of the following 3) Can be rarely associated with Henloch-Schonlein purpura statements are true? 4) All of the above are true 1) Usually resolves on its own 2) More commonly seen in the Afro-Caribbean race (ix) Hydrocele in boys: which of the following are true? 3) It is important to make sure that the newborn heel prick test 1) Never resolves on its own results were normal as hypothyroidism can be associated with 2) Always requires surgery in neonatal period umbilical hernia 3) Does not transilluminate 4) All of the above are true 4) None of the above are true

(v) ‘Redcurrant’ jelly stool is a sign of intussusceptions. It is...... (x) Which of the following are true about appendicitis in children? 1) Always present in a child with intussusceptions 1) More commonly seen in school age children 2) A late sign and occurs due to bowel necrosis 2) Fever may not always be present 3) An early sign of intussusceptions 3) Pain over the right lower abdomen should raise suspicion of 4) All of the above appendicitis 4) All of the above are true

February 2013 Volume 86 Number 2 Community Practitioner | 45 CLASSIFIED

Torbay Health Visiting Service: Family Nursing and Home Care, is the principal Proud to deliver a new way forward provider of Community Nursing and Home Care on the Island of Jersey. As one of the country’s most popular holiday destinations Torbay has much to offer as a place to live and work, with outstanding local We are currently seeking applications for the following:- coastline, steeped in heritage and history with close proximity to Exeter, Plymouth and Dartmoor. Health Visitor In Torbay our Health Visiting teams are dedicated to delivering the Permanent Contract, 37.5 hours per week highest quality support at the start of life. Working together with the Salary Scale : £40,555 - £43,189 per annum community, for the community, we offer a service to all families to support and improve children’s life chances. R.N.H.V Cert. Essential Current Driving Licence Essential Due to the Government’s commitment and recognition of the importance FAMILY NURSING AND HOME CARE IS A REGISTERED CHARITY of health visiting Torbay Health Visiting Service has a number of vacancies AND IS THE MAIN PROVIDER OF COMMUNITY NURSING IN including: JERSEY (POPULATION 90,000). WE SEEK TO EMPLOY A HEALTH VISITOR TO JOIN OUR BUSY TEAM. Specialist Intensive SCPHN Health Visitors are part of Child and Family Services who provide comprehensive and integrated community nursing (Health Visitor) services for families with children who are under 5 years old . Ref: 545-1956-RB We are planning to implement an early sustained home Band 7 - £30,460 to £40,157 pa pro rata visiting program which will provide an exciting opportunity 30 Hours Per Week for a creative and innovative practitioner in this field. An exciting opportunity has arisen within Torbay’s Family Health As a member of our health visiting team you will be flexible, Partnership (FHP). We are currently looking to recruit a highly skilled, enthusiastic, have an ability to manage and to sustain enthusiastic and resourceful practitioner to complement our team. change and be motivated to work as part of a team. The post holder will be expected to engage and recruit some of the Car owner/driver or suitable alternative transport to enable most hard to reach pregnant young women and their partners into the you to undertake the job is essential. The vehicle will need to FHP programme. Your work will start early in pregnancy and provide be insured for business use. therapeutic interventions and support through to the child’s second We offer yearly appraisal, clinical supervision, relocation birthday. The Parent Advisor Model of client work is fundamental to assistance, in house training opportunities for professional this role and comprehensive training will be offered to enable the development, 38 days paid leave (inclusive of Bank Holidays). achievement of the FHP’s goals of improving pregnancy, child health If you are ready for an exciting new challenge and would and sufficiency, by breaking through the barriers of deprivation and like to live and work on a beautiful Island please contact entrenched behaviours. Michelle Cumming, Child and Family Services Team Leader Tel. 01534 443625 for an informal discussion.For an application pack, please contact HR Department, Family Specialist Community Public Nursing and Home Care (Jersey) Inc., Le Bas Centre, Health Nurse (Health Visitor) St Saviour’s Road, St Helier, Jersey JE2 4RP, Ref: 545-185-RB Tel.01534 443604/443626, or e-mail [email protected] Closing Date for Applications: 01 March 2013 SCPHN Health Visitor’s Band 6 - £25,528 to £34,189 pa pro rata Interviews: Week commencing 08 April 2013 Practice Teachers Band 7 - £30,460 to £40,157 pa pro rata Permanent Full and Part time hours available We have a number of full and part-time vacancies across Torbay working For more information within a locality team delivering the full range of services to local families in the community and clinical settings. This is an exciting time to join or to advertise our team and your opportunity to be involved in developing innovative in Community Practitioner’s practice supported by the building community capacity agenda. If you are enthusiastic about improving health visiting to ensure positive recruitment section, call our outcomes for children and families we look forward to hearing from you. advertising team: 020 7878 2319 For further information about any of our exciting and progressive roles please contact: Jo Harper, Service Manager on Alternatively email: 07831 421505 or email; [email protected] or Christine Timmon, [email protected] Professional Lead on 07825 027629 or [email protected] To apply go to the website www.jobs.nhs.uk and search using the job reference number. Closing date: 1st March 2013 CLASSIFIED You can now follow both

DEPARTMENT OF HEALTH the Unite/ Rheynn Slaynt CPHVA and Health Services journal on Community Nursing School Nurse (SCPHN) Twitter – join (37.5 hours perk week - Term Time Only) Band: 6 us and join in! (£27,228 - £36,885 pro rata per annum) Ref: DH-161-1213 Is your quality of life as important to you as it is to us? follow We are looking for a proactive, innovative Specialist Practitioner in School Nursing to join our School Nursing @Unite_ Team. Excellent interpersonal skills and an ability to work both CPHVA within a team and on your own initiative are essential. and Car driver/owner essential. @CommPrac Please note a police check will be required for this post and a charge of £44.00 for this may be payable. For further information please contact: Sue Porter, Service Lead, Children and Families Team on (01624) 642678. Visit Please note all applications must be accompanied by an Equal Opportunities Form. www.communitypractitioner.com Closing date for applications: 5pm CLOSING DATE Full application pack and job description can be for more obtained from: www.gov.im/jobs or [email protected] alternatively, the Office ofHuman Resources, 2nd Floor, St Andrews House, Finch Road, Douglas, Isle of Man, IM1 2PX. Telephone (01624) 686300. jobs Please quote the above reference no. Applications will only be considered on receipt of a fully completed application form. Please note: If you have not heard from the Department within 6 weeks of the closing date you may assume that your application has been unsuccessful.

Rheynn Slaynt DEPARTMENT OF HEALTH Rheynn Slaynt

JOB NO 23933 Order No xxxxx

COMMUNITY PRACTITIONER JANUARY 2013 ISSUE - £2,602.00 Diary

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48 | Community Practitioner February 2013 Volume 86 Number 2

Protected skin. Joining in.

Put the fun back into playtime with Diprobase. Free from common sensitisers and irritants, Diprobase soothes, hydrates and helps to restore eczematous skin, leaving toddlers like Ellie free to create their next masterpiece.

Diprobase Prescribing Information Uses: Diprobase Cream and Ointment are emollients, with moisturising and protective Contra-indications: Hypersensitivity to any of the ingredients. Side-effects: Skin properties, indicated for follow-up treatment with topical steroids or in spacing such reactions including pruritus, rash, erythema, skin exfoliation, burning sensation, treatments. They may also be used as diluents for topical steroids. Diprobase products hypersensitivity, pain, dry skin and bullous dermatitis have been reported with are recommended for the symptomatic relief of red, inflamed, damaged, dry or product use. Package Quantities: Cream: 50g tubes, 500g pump dispensers; chapped skin, the protection of raw skin areas and as a pre-bathing emollient for Ointment: 50g tubes, 500g jar. Basic NHS Costs: Cream: £1.28 (50g), £6.32 dry/eczematous skin to alleviate drying effects. Dosage: The cream or ointment (500g); Ointment: £1.28 (50g), £5.99 (500g). Legal Category: GSL. Marketing should be thinly applied to cover the affected area completely, massaging gently Authorisation Numbers: Cream: PL 00025/0575; Ointment: PL 00025/0574. and thoroughly into the skin. Frequency of application should be established by the Marketing Authorisation Holder: Merck Sharp & Dohme Limited, Hertford Road, physician. Generally, Diprobase Cream and Ointment can be used as often as required. Hoddesdon, Hertfordshire, EN11 9BU, UK. Date of Revision: February 2012.

Please refer to the full SPC text before prescribing this product. Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to MSD Pharmacovigilance UK on +44 (0)1992 467272. Code: 08/14 DERM-1032320-0006 Date of preparation: August 2012 © Merck Sharp & Dohme Limited, 2012. All rights reserved.

20122 MSD DIP HCP Painting_Comm Prac Aug 12.indd 1 29/08/2012 11:32