Public health is concerned with the local population’s health and takes into consideration the economic, social and environmental factors of both communities and individuals. Health visitors clearly have a major part to play in the role of public health, which has become a high priority over the last decade (Cowley, 2008). There has clearly been a move away from a medical model towards a social model of care which requires health visitors to have specialised skills and knowledge in order to assess a family holistically. Through a health needs assessment, the health visitor can identify the needs of a population and then focus on an intervention that would benefit the population’s unmet needs (Peterson and Alexander 2001).
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The aim of this assignment will be to identify, using the health needs assessment process, an issue that needs readdressing. The identified health need will be analysed and then a service or intervention will be created in order to reduce health inequalities and improve health (Health Development Agency 2004). The National Institute for Clinical Excellence (Cavanagh & Chadwick, 2005) provides an in depth framework to follow which will help to address the chosen health need. Using the framework, and a combination of evidence taken from epidemiology and theory, will enhance the decision making process.
The population chosen to focus on will be mothers who suffer from postnatal depression. A population can be geographical, a client group or people with particular health problems (Calman, 1999). The assessment will look at the needs of these mothers. The main aim will be to provide an intervention that reduces the intensity of the illness and the number of mothers suffering from postnatal depression.
The rationale for choosing this population is that postnatal depression can be seen as a significant public health problem (Sharp et al , 2010). It can also have a significant negative impact on the lives of the mothers, their babies and their families. Beck (2006) writes how postnatal depression is, ‘… a serious mood disorder that can cripple a woman’s first few months as a new mother.’ There appears to be a lack of services available for mothers with postnatal depression and we need to consider, ‘Is there any point in identifying women with PND if we have no services to offer them?’
Public health is defined in the Acheson report as, ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.’ (Acheson, 1988). This definition clearly reflects the essential focus of today’s public health. Ten years later Acheson completed a further report which looked at inequalities in health (Acheson 1998). Both these reports have been the development and result of many public health associated documents. Oliver and Nutheam (2003) point out that these new government policies have been developed to ‘explicitly address existing health inequalities,’ following the election of the new Labour government in 1997.
Health promotion can be seen as a comprehensive political and social method. It is not just aimed at improving an individual’s capabilities and skills , but also looking at making changes to environmental, social and economic issues in order to reduce their impact on both individual and public health (WHO, 1998). Mitcheson (2008) suggests that health promotion is about helping people to have the capabilities and resources to take control of and improve their health needs. A phrase by Milio, (1986), appropriately sums up health promotion by saying; ‘Making the healthy choice the easier choice.’ Acheson (1998) talks about the ‘upstream’ and ‘downstream’ public health strategies in which health promotion can be seen as an upstream approach, focusing on preventative measures.
As health promotion is fairly complex, there are a number of different health promotion approaches that can be used. The choice of approach can depend on the health need assessment and the aims (Ewles & Simnett, 2003). Models, which are a type of theoretical framework, can be useful for planning, implementing and evaluating interventions. The health promotion model is defined by Naidoo & Wills (2000), as ‘….a way of linking ideas and showing the relationship between theory and practice.’ There have been a variety of different authors that have produced models for health needs assessments such as Tones and Green, 2004 (health belief model) and Tones and Tilford, 2001, (health action model). Roden (2004) criticises the health belief model by saying that it focuses on a medical approach to health promotion rather than a holistic view.
A series of documents and papers on health and well-being, have emerged from the Department of Health and other associated government departments. Several of these documents highlight the importance of the role of the health visitor for promoting mental health. Initially in 1997, The New NHS; Modern, Dependable (DoH, 1997), this focuses on the government’s vision to make the necessary changes to improve and tackle ill health and inequalities. Other documents that are relative to this assignment include: The NHS Plan: Shifting the balance of power (DoH, 2000), Making a Difference (DoH, 1999a), Our Health, Our Care, Our Say (DoH, 2006), Choosing Health (DoH, 2004), Report of the Chief Medical Officer’s Project to Strengthen the Public Health Function, (DoH, 2001), Saving Lives: Our Healthier Nation (DoH, 1999b), discusses the need to decrease the risks associated with different mental illnesses and also highlights the effects of depression on both the mother and child. Every Child Matters (DfES, 2004) and Securing Good Health for the Population (Wanless, 2004). A definition that reflects government policy has been provided by Wanless as, ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society, organisations, public and private communities and individuals,’ (Wanless 2004, p.3.). This definition appears to be more appropriate for the 21st century as it puts more emphasis on the joint efforts of individuals, the state of their own health and also their families’. The definition also has the additional concept of informed choice and responsibility for organisations to work collaboratively in order to promote public health. This can be seen as a way of empowering communities.
It can be seen that individuals, communities and all health professionals have a part to play in public health promotion, prevention of ill health and health protection. These are essential requirements for the role of the health visitor. The Standards for Proficiency for the specialist community public health nurse (NMC, 2004) and the health visiting principles defined in the, Council for the Education and Training of Health Visitors (CETHV, 1977), identify the four main domains that define the required proficiencies. These are: ‘the search for health needs, influence on policies affecting health, facilitation of health enhancing activities and the stimulation of the awareness of health needs.’ From these principles, and including the 10 occupational standards for public health (Prime R&D Ltd for Skills for Health 2003), it can be seen that overall the aim is to promote and protect the health of the population.
Health visitors have always had an important role to play in the promotion of public health in the community. Over the years, the numbers of health visitors has declined. The public health minister, Anne Milton (2010), admits the profession ‘has been eroded dramatically over the past decade.’ Since the report of the death of Victoria Climbie (Laming, 2003), and alongside this the new Children’s Act (2004) there has been recognition of the difference that health visitors can make. This has had a considerable effect on the health visitors’ role. Health visitors are seen as key collaborators in primary care for enforcing new legislation and improving outcomes for the young and vulnerable. However Thornhurst (2009), writes how the health visitors’ role has become so centred around child protection that there is now less time for them to work in the community, resolving the social issues that contribute to the child protection cases. This appears to be a continuing public health debate.
Prior to making any changes to improve health, we need to begin by finding out what the health needs are and how, within a population, they can be assessed. Health needs assessment is defined by Wright et al (2006), as ‘…. a systematic method of identifying unmet health and health care needs of a population and making changes to meet these unmet needs.’ The aim of the health needs assessment is to look at current data and information gathered from different sources. The information will then be analysed to determine any changes that may need to be made in order to meet the identified health need. It also involves a variety of professionals as well as the general public (Haughley, 2008). Decisions will be made in order to achieve good outcomes for the population; resources available will need to be considered. A needs assessment can help with making decisions. The National Institution for Clinical Excellence (NICE, 2005) provides a framework that is robust and it provides systematic cues to guide you through the health needs assessment process .The framework was produced by Cananagh and Chadwick , (2005). One of the strengths of the framework is that it’s an easy and simple process to follow (Coverdale and Lancaster, 2006). This framework should not be used alone but in conjunction with other models as this will help guide practitioners through the process. Haughey (2008) describes the health needs assessment as a way of gathering parts in order to complete a ‘jigsaw.’
The essay will now consider the chosen population within the author’s area of practice and a health needs assessment will follow.
Through observation in practice, it is clear that the health visitor is well placed to identify any early symptoms of postnatal depression (DOH, 2003). The National Service Framework for Mental Health (DOH, 1999c) recommends that health visitors need to use their routine visits for accessing postnatal depression and for treating the identified milder cases. However, recent research suggests that due to cuts in the numbers of health visitors and the lack of time available to attend extra training for assessing depression and psychological support approaches, most health visitors are unable to fully support depressed mothers (Brugha et al, 2010).
Despite the well known evidence to show the impact of postnatal depression on the mother and her family as well as the long term impact on the baby, less than 50% of post natal cases are indentified. A qualitative review of forty studies revealed that a women ‘s inability to reveal their real feelings proved to be a general barrier for seeking help (Dennis & Chung-Lee, 2006). Beck, (2006) writes how health practitioners fail to detect postnatal depression as they ‘don’t know what to look for. He also suggests that mothers often hide their depression. For the cases where postnatal depression is identified, there appears to be a lack of services to support them (Hewitt et al , 2009). Raising awareness of the need to identify and support mothers with postnatal depression includes the role of the SCPHN and is also highlighted in the public health definition.
Epidemiology is the study of diseases of populations and is a major science that underpins public health. Epidemiology allows us to understand diseases and the causes, identify groups that are particularly affected and understand the effectiveness of interventions for tackling identified problems (Heller et al, 2001). Epidemiology of postnatal depression appears to be poorly understood. Up to date official national figures for postnatal depression have proved difficult to gather and the data that is available gives conflicting figures. There is a certain amount of statistical evidence around the prevalence of mental illness but a limited amount of statistics that focus on postnatal depression. The data that will be used for the purpose of this paper and which has been most frequently quoted, has been sourced from the NHS (2009), which suggests that 1 in 10 women will suffer from postnatal depression and MIND (2008) which also suggests 1 in 10 women, the NICE guidelines (2006) and the NSF – MH figures (DOH, 2007c), show a prevalence of 10-15% of women with postnatal depression. In England and Wales, this is between 64,000 and 94,000 women a year.
Health visitors are unable to diagnose postnatal depression, if they detect, using a range of screening tools, or recognise signs and symptoms of post natal depression then this information can be recorded in the mother’s maternal health section. No caseload data can be collected to show the prevalence or severity of postnatal depression. A diagnosis will rely on the mother choosing to attend an appointment with her G.P.. Following a meeting with one of the local G.P.s, in the author’s area of work it was discovered that the primary care databases that G.P.s use have a variety of ‘read codes’ to distinguish diagnoses and symptoms, however the read code that highlights postnatal depression requires the G.P. to go on and complete a lengthy questionnaire with the mother. For a mother with postnatal depression this might mean that the G.P.s are choosing other read codes, for example, anxiety where no questionnaire is required. This could be seen as a potential barrier for identifying mothers with postnatal depression. Many health visitors do not have access to the G.P.s notes. If a mother has seen her GP and postnatal depression has been identified then unless there is good communication between the GP and the health visitor the mother may be left without the full help and support that she may need.
Postnatal depression will have the same characteristic symptoms as clinical depression, such as tearfulness, loss of enjoyment in life, low mood, loss of confidence, sleeping problems, feelings of guilt, self blame and sometimes suicidal thoughts. For a diagnoses to be made three or more of these symptoms (which have persisted for at least two weeks) will be identified (Davies, 2000). There does not appear to be a single cause of postnatal depression, some experts consider it is due to hormonal changes whilst others suggest a combination of psychological and social factors (Clinical knowledge summaries, 2010). Postnatal depression normally develops during the first three postnatal months (Cox et al, 1993). Research shows that for the mother, PND has considerable health implications, it can also effect her long term relationships, have an adverse effect on the fathers and possibly the rest of the family (Stein et al 2008). There is also substantial research evidence to show that the effects on the baby can include disturbed patterns of communication, display unresponsive or withdrawn behaviour and longer term impairments in cognitive and emotional development (Meredith & Noller, 2003).
Following the evidence, prevalence and the possible major health implications of postnatal depression, the emphasis sited by NICE for the need of early identification, diagnosis and treatment of postnatal treatment, during both the antenatal and postnatal period appears to be completely justifiable (NICE, 2007a).
The most recent comprehensive review on identifying and assessing methods used to identify PND was by NICE (2007b). Following this review, clinical guidance was produced on the management of antenatal and postnatal mental health. Identification of women with postnatal depression may have already been completed during an antenatal visit. During a visit a mother can be asked about her history and if she has experienced any previous episodes of depression. However, due to the shortage of health visitors, heavy workload and because of other commitments, it may be that not all mothers are seen for antenatal appointments, (Shakespeare, 2001). Recent and up to date research continues to confirm the effectiveness of the role of health visitors in reducing postnatal depression (Brugha et al, 2010). The Edinburgh Postnatal Depression Scale is a client centred approach that helps to uncover postnatal depression in mothers that might otherwise go undetected. It uses a self reporting, 10-item questionnaire that focuses on how the mother felt the previous week. A score of 12 or over is considered ‘probable depression’, whilst a lower score of 9/10 suggests ‘possible depression,’ (Cox et al , 1987). Following a recent study to identify methods for accessing postnatal depression, the EPDS was the most frequently explored, simple, precise, safe and preferred cost-effective tool (Hewitt et al , 2009). The Community Practitioners and Health Visitors’ Association recommends that along with the EPDS, the health visitor also needs to include her own clinical assessment. A recently published qualitative study by Slade et. al. (2010), reports how ‘symptom identification’ through the use of the EPDS has helped women to see that the health visitor is ‘there for them,’ as well as the baby. However one of the observed negative issues regarding the EPDS is that women from other cultures have difficulties understanding and filling in the questionnaire, even though there are some EPDS sheets translated into other languages. ‘Depression’ is not always culturally recognised in other countries (Barclay & Kent 1998).
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Once a mother has been identified by the health visitor or diagnosed by the GP for postnatal depression, then consideration can be explored into why some mothers fare better than others in mental well being. Health determinants can be useful to consider, Dahlgren and Whitehead’s model ‘Determinants of Health,’ can be useful to help explore and build a profile of a local community. Health outcomes and inequalities can be greatly influenced both positively or negatively by individuals and communities. Health can be strongly influenced by the way people live their lives including the conditions in which they live and work, by family, friends and social networks, (Marmote & Wilkinson, 2003). For example a social determinant such as a lack of family or community support might exasperate or negatively impact on a mother with postnatal depression. However, good support could have a powerful and positive impact on an individual’s health.
Step three of the HNA will now follow. This part of the process will direct the practitioner to establish a helpful and acceptable intervention. Literature surrounding postnatal depression appears to focus on the effectiveness of support groups (Alakus et al, 2007, Dennis & Chung-Lee, 2006). The Royal College of Psychiatrists, et al (2000) write how support in the antenatal period can reduce the severity of PND. More recently, Dennis et al (2004) writes that PND can be difficult to predict antenatally and suggests that preventative methods have mainly proved ineffective. Cox in 1986 wrote how support groups during the postnatal period can be ‘one of the most successful means of treatment.’ Dennis, et al, (2009) writes how support groups are well acknowledged in literature as valuable for reducing and treating depression. For this health needs assessment, it seems that a pilot postnatal support group would be appropriate. In the area where the author works there is currently no group running to support mothers with postnatal depression.
The complexity of PND and the care required can be complex, so a whole team approach will be needed, instead of an individual one. This will ensure the care needed will be successfully provided. When considering the health needs intervention a team will be required to lead it. Ideally the team would consist of the health visitor, G.P.s, nursery nurses and a community mental health nurse. For the intervention to be successful then the team will need to have: a shared vision, an understanding of each other’s roles within the team, a respected leader to drive the intervention forward, a sound action plan, flexibility, and the ability to work collaboratively (Hill et al, 2007). Collaborative working has been greatly emphasised over the last few years in a variety of documents and is also considered an important role of the SCPHN (NMC, 2004) who works within a community, alongside multidisciplinary agencies to improve health and well being, this is also reflected in the last part of Acheson’s definition, ‘…through the organised efforts of society.’ There are often barriers that can negatively impact effective collaborative working such as, lack of communication, time restrictions, differing perspectives and values and often difficulties even obtaining a room to meet in, (Almond & Cowley, 2008). The support group will be a good example to demonstrate collaborative working between professionals and services uses.
Once a team had been brought together, a venue would be decided for the support group. The local sure start children’s centre would be an ideal venue. Sure start centres are a government initiative which aim is to give children the best possible start in life, (DOH, 2007). The area the author works in is a rural location with limited public transport. Many of the mothers with PND live in isolated parts, so for these mothers, free transport will be provided. However, if funding at the local children’s centre is cut this may have a negative impact on this service being offered for the group or any future groups. Allowing the mothers with PND, who live in isolated areas, the chance to attend the support group can have a significant, positive effect on their depressive symptoms (Hunker, et al, 2009). It will be important to use a venue with childcare facilities. The sure start centre has been used for a variety of groups in the past and offers a non-stigmatising venue; a warm and friendly environment.
Mothers identified with postnatal depression will be referred to the group and during a home visit, information will be provided so the mothers can decide whether they want to come. A telephone call prior to the group will also be made. Empowering people, allowing them to make informed choices and improving their life skills, which are needed for making changes, are all part of the health promotion process (Naidoo & Wills, 2000). Many mothers with PND will be in the contemplation stage described in Prochaska and DiClemente’s Stages of Change Model (1983), where they are aware that there is a problem but may not be sure or motivated to make the changes needed. This model involves the person going through a series of stages when addressing problematic behaviour. People will pass through different stages at their own pace. Prochaska and DiClimente (1982) write how identifying where a person is within the model will enable the practitioner to adapt their interventions to meet their individual needs. This might mean that the health visitor offers the mother listening visits at home (HCP, 2009) until she feels ready to attend the support group.
The support group would run over eight weeks for one and a half hours and a crèche will be provided run by the nursery nurses. The health visitor and community mental health nurse will jointly run the group and will be trained appropriately. The intention of the group will be for mothers to gain support from other mothers in similar situations and with similar experiences (Alakus et al, 2007). The aim will be for the mothers to feel less depressed, improve their self-esteem, self-worth, gain confidence, make friendships and develop coping strategies. To help the mothers achieve this, the weekly support group will offer both education and also a variety of taster sessions. For example, cognitive behavioural therapy, exercise, baby massage and holistic therapies. The beginning of the group will allow mothers to share any events of the past week.
Exercise can be an effective treatment for postnatal depression as well as increasing the mother’s sense of well being and can be a offered in the group as a combination of both exercise and relaxation techniques. Two recent clinical trials found that many women are reluctant to use medication for treatment of PND. The study also revealed that exercise can alleviate depression as effectively as medications, (Daley, et al, 2007).
Research has shown that infant massage in group work can reduce stress hormones, significantly lessen depression symptoms and also help mothers to improve relationships with their babies (Heh, et al 2008).
For women experiencing PND cognitive behavioural therapy is the treatment of choice (NICE, 2007). The sessions will help mothers to challenge negative thoughts and modify beliefs specifically relating to motherhood. CBT helps people to engage in activities and has been shown to reduce symptoms, improve a person’s quality of life and improve function (NICE, 2009).
Evaluation is an important part of a health needs assessment and evaluation of any intervention needs to be considered, as highlighted in the clinical governance principles (Adams & Forester, 2002). There are a variety of assessment methods. To measure the effectiveness of the group the mother’s original EPDS scores would be recorded and then they would be asked to fill in another one at the end of the 8 weeks to see if their scores had improved. Improved EPDS scores and a reduction in PND could mean that the group could continue to run. Long term effectiveness of the group, if it continues, will be seen in the prevention or delay of ‘morbidity or mortality,’ (Mitcheson, 2008) This may eventually lead to the reduction of cost for treating people with PND. An effective way of assessing the intervention could be through a SWOT assessment, a technique credited to Humphrey (1960-1970s). SWOT is a structured method used to identify strengths, weaknesses, opportunities and threats.
To conclude, it can be seen that by working through the stages of a health needs assessment that the need for an intervention in the author’s area was clearly identified. The literature reviews provided information to assist with the understanding of PND and the effects it can have on the mother, family and baby. There is clearly a need for a more accurate and consistent way of identifying PND and then recording and using the data. For the group to be effective, it was identified that good collaborative working was essential. As the role of the health visitor has changed over the years, it is important to demonstrate how they can improve health and reduce inequalities through successful, quality interventions.
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