Cover Page

Health Visiting

Preparation for Practice

Fourth Edition


Edited by

Karen A. Luker

CBE, FMedSci, FQNI, PhD, BNurs, RN, SCPHN (HV), NDNCert
QNI Professor of Community Nursing
School of Nursing, Midwifery and Social Work
The University of Manchester
Manchester, UK


Gretl A. McHugh

FQNI, PhD, MSc (Public Health), BNurs (Hons), RN, SCPHN (HV)
Professor of Applied Health Research
School of Healthcare
The University of Leeds
Leeds, UK


Rosamund M. Bryar

FQNI, HonMFPH, PhD, MPhil, BNurs, RN, SCPHN (HV), NDNCert, CertEd (FE), SCM
Professor Emeritus Community and Primary Care Nursing
School of Health Sciences
City University London
London, UK




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List of Contributors

  1. Ms Sharin Baldwin FiHV, QN, MSc, PG Dip, BSc (Hons), RN, RM, SCPHN (HV)
  2. NIHR Clinical Doctoral Fellow and Clinical, Academic & Innovations Lead (Health Visiting)
  3. King's College London
  4. and
  5. London North West Healthcare
  6. NHS Trust Health Visiting Clinical Academic Hub
  7. London, UK


  1. Professor Rosamund M. Bryar FQNI, HonMFPH, PhD, MPhil, BNurs, RN, SCPHN (HV), NDNCert, CertEd (FE), SCM
  2. Professor Emeritus Community and Primary Care Nursing
  3. School of Health Sciences
  4. City University London
  5. London, UK


  1. Professor Karen I. Chalmers PhD, MSc (A), BScN, RN
  2. Honorary Professor
  3. School of Nursing, Midwifery and Social Work
  4. The University of Manchester
  5. Manchester, UK


  1. Ms Julianne Harlow MA, BSc (Hons), PGCE, SCPHN (HV), RN
  2. Senior Lecturer
  3. Department of Education & Childhood
  4. University of Derby
  5. Derby, UK


  1. Professor Mark R.D. Johnson PhD, MA, PG Dip (HE)
  2. Emeritus Professor of Diversity in Health & Social Care
  3. Mary Seacole Research Centre
  4. Health Policy Research Unit
  5. De Montfort University
  6. Leicester, UK


  1. Professor Karen A. Luker CBE, FMedSci, FQNI, PhD, BNurs, RN, SCPHN (HV), NDNCert
  2. QNI Professor of Community Nursing
  3. School of Nursing, Midwifery & Social Work
  4. The University of Manchester
  5. Manchester, UK


  1. Professor Gretl A. McHugh FQNI, PhD, MSc (Public Health), BNurs (Hons), RN, SCPHN (HV)
  2. Professor of Applied Health Research
  3. School of Healthcare
  4. The University of Leeds
  5. Leeds, UK


  1. Professor Kate Robinson PhD, BA, RN, SCPHN (HV)
  2. Professor Emeritus
  3. University of Bedfordshire
  4. Luton, UK


  1. Mr Martin Smith MPH, FFPH, PGCert HEd, FHEA, BA (Hons), RN, DipHV, SCPHN (HV),
  2. Consultant in Public Health
  3. Liverpool City Council
  4. Liverpool, UK


  1. Dr Karen A. Whittaker FiHV, FHEA, PhD, MSc, PGCE, BNurs (Hons), RN, SCPHN (HV)
  2. Reader in Child and Family Health
  3. School of Nursing
  4. College of Health and Wellbeing
  5. University of Central Lancashire
  6. Preston, UK


Karen A. Luker, Gretl A. McHugh and Rosamund M. Bryar

Our fourth edition of Health Visiting: Preparation for Practice is a key resource for health visitors, health visitor students, students on nursing, public health, early years, and health sciences programmes, and other health professionals working in public health, primary care, and community services. The practice of health visiting is focused on the promotion of health and the prevention of ill health. The fourth edition of Health Visiting: Preparation for Practice aims to inform, educate, and challenge you to deliver the most effective health visiting and so enable the promotion of health and prevention of ill health in the children, families, and communities with whom you work.

Prevention and public health have been the focus of health visiting since the early days of the sanitary visitors – the forerunners of health visitors – appointed by the Manchester and Salford Ladies Sanitary Reform Association in 1862. Since 1862, the living conditions, life expectancy, and health of the population have evolved, and alongside this there have been changes in the health challenges faced by the population. Over these more than 150 years, health visiting has responded to these changes by contributing to addressing public health issues from prevention of infectious diseases to prevention of long-term conditions; from addressing poverty and under-nutrition to working to reduce obesity in children and their parents. The aim of this edition of Health Visiting: Preparation for Practice is to provide you with the most up-to-date evidence to support your work on the front line of public health.

The fourth edition of this book is the latest in the line of works entitled Health Visiting which have aimed to support the delivery of health visiting. The first of these, Health Visiting: A Textbook for Health Visitor Students by Margaret McEwan, was first published in 1951. This was followed by three further editions, and, in 1977, by Health Visiting, edited by Grace M. Owen and written by Grace M. Owen and health visiting colleagues drawn from the health visiting programme at the Polytechnic of the South Bank (now London South Bank University). These books remind us of the changes in the preparation of health visitors during the past 60-plus years, but the statement by McEwan (1961: 17) of the purpose of health visiting is still the centre of today's practice: ‘The health visitor is primarily a teacher and her aim is to teach the value of healthy living and to interpret the principles of health.’ In addition, her observation that health visiting is: ‘…concerned with the little things of everyday life’ (McEwan, 1961: 17) is also very pertinent. However, the evidence and knowledge base underpinning some of these ‘little things of everyday life’, such as weaning, play, and parenting, has grown enormously, as shown in the four editions of the present book. The first edition, by Karen Luker and Jean Orr, was published in 1985 and also entitled Health Visiting. The second edition followed in 1992 and was entitled Health Visiting: Towards Community Health Nursing, reflecting changes in the education of nurses and health visitors in the early 1990s. The third edition, edited by Karen Luker, Jean Orr, and Gretl McHugh, did not appear until 20 years later, in 2012, but the title, Health Visiting: A Rediscovery, shows the new confidence in health visiting and the role of health visitors in supporting families based on evidence concerning the importance of support for early child development and the need to reduce inequalities in health (Field, 2010; Marmot et al., 2010; Allen, 2011; Dartington Social Research Unit et al., 2015). The fourth edition, entitled Health Visiting: Preparation for Practice, builds on the third. It includes a new chapter on working with diverse communities, reflecting their multicultural make-up, and, critically, provides additional guidance on evaluation, enabling you to demonstrate the outcomes of your practice. What these books all illustrate are the ways that health visiting, over the past decades, has responded to and applied new and emerging evidence to support children, families, and communities to better promote their health.

Prevention, public health, and health visiting

Over the past 5 years, there has been investment into the education and employment of health visitors, with a subsequent increase in the number of health visitors, particularly in England and Scotland. Alongside this investment has been clarification of the health visiting service, with greater emphasis being placed on the public health role of health visitors working with children, their families, and communities. Health visitors have a long-standing role in helping communities to improve their health and well being; for example, in increasing immunisation uptake, preventing obesity, and tackling health inequalities. The Marmot Report, Fair Society, Healthy Lives (Marmot et al., 2010), sets out a framework for tackling the wider social determinants of health, stating that health inequalities will require action on:

Health visitors are the lead professionals for delivery of the Healthy Child Programme (DH, 2009; Public Health England, 2015), and therefore have a critical role in helping to improve the life chances of current and future generations by reducing the impact of inequalities on the immediate and long-term health of the population. Recognition of the important role that prevention has to play in improving health, and also in reducing health care costs, was identified in reports undertaken by Sir Derek Wanless in England and in Wales (Wanless, 2002; Project Team and Wanless, 2003) and reiterated for England in the NHS Five Year Forward View (DH, 2014a). In NHS Five Year Forward View: Time to Deliver (DH, 2015: 7), three gaps were identified: ‘…the health and wellbeing gap, the care and quality gap, and the funding and efficiency gap.’ Health visitors have a key role in their work with children and their families in contributing to public health outcomes that address early on the health and well being gap. The six high-impact areas show where health visitors can have the greatest influence:[

(DH, 2014b)

Over the coming years, these areas for prevention will be the focus of health visiting services. From October 2015, local authorities took over from NHS England in the commissioning of public health services for children under 5 years (DH, 2014c). Currently, health visitors continue to be employed initially by the same employer, but service commissioning processes in coming years may see a range of new models of employment. The continued contribution of health visitors to the 0–5 years will remain key, but the greater integration of health and social care services (e.g. the Greater Manchester Health and Social Care Devolution (previously referred to as Devo Manc) project developments (Ham, 2015)) may present new opportunities, including wider integration of 0–19 services and the involvement of health visitors in population-based initiatives. In Northern Ireland, an integrated service for all children up to the age of 19 years is provided by health visitors and school nurses. There is an emphasis on working together, with a focus on delivery of child health promotion programmes and increased intensive home visiting for the 0–19 years (DHSSPS, 2010). In Wales, the recent nursing and midwifery strategy by Public Health Wales places nurses and midwives at the forefront of its public health strategy (Public Health Wales, 2014). In Scotland, in 2014, the government pledged to increase the number of health visitors by 500 over the next 4 years (The Scottish Government, 2014). Greater collaboration between services and practitioners (e.g. midwives and health visitors working with women in the antenatal period, social workers and health visitors working with families experiencing domestic violence or child safeguarding issues, school nurses and health visitors working to address obesity in 0–19 services) will be central to health visiting over the coming years. These additional resources and initiatives will assist with improving health visiting services. However, there remains a need to focus on measurable outcomes in order to evaluate these initiatives, which could lead to further changes and improvements in the methods of delivering health visiting services.

Health visiting: preparation for practice

The first and second editions of this book were pioneering in the quest for evidence to support practiceand in emphasising the need for evaluation of practice. Evidence-based practice and evaluation of impact now seem to be a given, and this acknowledgement by the professional colleges, the governments of the four countries of the UK, and health visiting organisations means that our chapter on evaluating practice will be a must read and makes this an exciting time to launch the fourth edition of the book. The structure of the book is similar to that of the other editions: the content has been updated from the last edition and a new chapter has been included which focuses on the health visitor working with diverse communities. These changes have been necessary to keep pace with the developments in health policy, public health priorities, and health visiting practice. There are some new authors for this edition – some who are teaching public health and health visiting, and others who are practising as health visitors and public health specialists – ensuring that this fourth edition is relevant to meet the needs of those undergoing preparation to become health visitors and those who are practitioners working with and in the community.

Chapter 1: ‘Managing Knowledge in Health Visiting’ discusses the demands on the health visitor to understand the different forms and sources of knowledge in order ensure the delivery of evidence-based practice, with reference to case studies. It highlights the issues surrounding the use of guidelines and protocols in practice and looks at the concept of communities of practice (CoPs), with regard to how they can assist practitioners in working to improve their own practice. In addition, it discusses the generation and management of knowledge in practice using reflective practice and examines the perspective of the client in terms of what they know and how they know it, drawing attention to the use of social networking sites.

Chapter 2: ‘Health Visiting: Context and Public Health Practice’ explores the specialist and public health role of the health visitor in working with families. It examines the tensions between the public health role and the health visiting role with children and families. The public health role needs to become more clearly defined, with a focus on reducing health inequalities and giving every child in the community the best start in life (Marmot et al., 2010); this is explored in a section specifically about ‘Health Inequalities’. This chapter also examines the evidence for health inequities and the contribution health visitors can bring in addressing the wider determinants of health. In addition, it highlights the importance of good leadership in public health and the challenges for health visitors in engaging in a public health role.

Chapter 3: ‘The Community Dimension’ explores the importance of the communities within which people live to their health and considers the range of factors impacting on people's health. It looks at the role of health visitors working with communities and the renewed focus on this area, for example as part of the health visiting service model in England. It discusses tools that health visitors can use to gain an understanding of communities through an exploration of their social history and identification and assessment of their current health needs. It looks at the development of the skills required to work with communities, making use of health promotion theory and building on the skills that health visitors have in working with individuals and collaborating with other services, with reference to national and international learning resources and tools. Working with communities to achieve better health is a long-term process, but health visitors, with their access to all families with children under 5 years of age, are in a unique position to support the building of healthier communities.

Chapter 4: ‘Approaches to Supporting Families’ explores different approaches to supporting families and evaluates several child health programmes that are currently in existence. It discusses the evidence for successful interventions to support families, including the findings from evaluations of these programmes, and considers the influence of policies on health visitors' work in supporting families. Finally, it examines the competing challenges faced by health visitors in trying to work with families, including the public health agenda, the level of evidence, and the availability of resources.

Chapter 5: ‘Safeguarding Children: Debates and Dilemmas for Health Visitors’ focuses on safeguarding and the enhanced child protection role of the health visitor. It defines the key concepts, such as ‘child abuse’ and ‘significant harm’, and highlights the incidence and prevalence of child abuse. It discusses the policy and legislation relevant to safeguarding practice, as well as the assessment of vulnerable children using the Common Assessment Framework (CAF) and the Graded Care Profile (GCP) for neglect. It looks at the issues and dilemmas around safeguarding children that students will encounter in their practice and discusses how the utilisation of supervision to support critical reflection and thinking can provide a supportive mechanism. It also highlights examples of published inquires into child deaths and serious case reviews. Overall, this chapter will assist with the development of leadership in practitioners working in the safeguarding arena.

Chapter 6: ‘Working with Diverse Communities’ is a welcome addition to the fourth edition. It outlines the changes in the ethnic makeup of the UK population and discusses their implications for health care in general, with a specific consideration of religious issues. It introduces the concepts of ‘cultural competence’ and ‘institutional discrimination’, and considers what we mean by ‘diverse’. It discusses cultural practices relevant to health visitor practice, including matters around pregnancy, diet, customs relating to birth and naming, and mental health, and provides some examples. Finally, it considers safeguarding in a multicultural setting, with a special focus on genital cutting or female genital mutilation (FGM). Throughout the chapter, communication is addressed, and the case is made that increasing cultural competency will help in developing communication skills to support work with diverse communities.

In the previous editions, Chapter 7: ‘Evaluating Practice’ was always ahead of its time, insofar as everyday health visitors seldom formally evaluated the impact of their work. This chapter has been updated and explores the importance of evaluation in health visiting practice, which is a necessity in today's economy, to ensure that what health visitors are doing is effective and of value. It discusses key sources of evidence available to health visitors in the evaluation of their practice. It examines the different types of evaluation and suggests ways to approach them. It is important to ensure that health visitors and other practitioners have the skills and knowledge to identify and critique the available evidence and information in their role in supporting families and communities. Health visitors need knowledge about where to get the best information and the skills to be able to access up-to-date resources for the delivery of evidence-based practice; this chapter helps to provide this.

As in previous editions, the reader is encouraged to engage in learning activities at various points throughout the text; these can be found at the end of each chapter. It is anticipated that these activities will help students, health visitors, and others to reflect upon and develop their practice.

Health visitors will face many challenges over the coming years, but the vision for high-quality care and improved service provision makes it an exciting time for the profession. We hope that this new edition will assist with ‘preparation for practice’ and improve the contribution health visitors can make to the health and well being of children, their families, and communities, which will ultimately lead to better health outcomes for the whole population.


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