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First Steps Postnatal Group: addressing the high-impact areas

Jayne Hollinshead and Keri Christie explore a postnatal group set up in Walsall to offer support to new parents in the emotional transition to and challenges of parenthood, and to help them form friendships and social bonds that will promote good health for all parties.

Evaluation of the specialist community public health nursing peripatetic assessment model

Jayne Hollinshead, Senior lecturer at the University of Wolverhampton

Keri Christie, health visitor at Walsall Healthcare NHS Trust

Key points:

  • After identifying a gap in provision for new parents, health visitors set up First Steps postnatal group.
  • Its main aim was to reduce social isolation for the parents, help them cope with the emotional challenges they faced and promote confident parenting.
  • The group presented a chance for health visitors to encourage parents to think about their role and the child’s development, and increase awareness of their family’s health.
  • Giving support to disadvantged families early in a child’s life is a cost-effective way to improve outcomes for families in the short and long term (Field, 2010).
  • Early intervention can promote infant development and help protect against emotional ill health. 

Abstract

Much attention is paid to the preparation for labour and birth but there is less provision for the emotional transition to parenthood. Many parents experience challenges as they adapt to their new role. Literature suggests that health visitors can support parents through this life stage, through education to improve their confidence and ability to adapt and cope with adjustments within the family. The First Steps postnatal group was developed around the six High Impact Areas, to offer an opportunity for early intervention and to promote positive parental self-efficacy, emotional responsiveness, infant development and the opportunity to develop friendships and social cohesion, which exerts a protection against emotional ill health.

Key terms: transition to parenthood, High Impact Areas, postnatal groups, social capital, community development


Introduction

The significance of positive support during the transition to parenthood is well-evidenced, and provides a pivotal opportunity for health visitors to utilise their public health role to facilitate and promote parental efficacy (Solmeyer and Feinberg, 2011). The transition to parenthood can be a stressful time for parents, and many women feel isolated and alone in their task of caring for a baby (Deave et al, 2008). Increasingly, new mothers no longer have access to extensive social systems and a growing body of research has highlighted social support as necessary in promoting maternal confidence and optimising parenting skills (Cabral, 2013).

Local women reported to health visitors that they had little opportunity to gain an understanding of what to expect in the early postnatal weeks; they were therefore often unprepared for the demands of parenthood. Sharing experiences between women undergoing similar life events provides them with an opportunity to come to terms with their own experiences; and participation in parenting groups results in greater confidence and self-esteem, more containment and more satisfying family relationships (Cabral, 2013). Field (2010) maintains that poor parenting impacts upon the welfare and justice system, reinforcing the necessity for early intervention with vulnerable families. Through the development of social networking and social capital it addresses those at risk of poor outcomes owing to vulnerability that results from poverty, ethnicity and homelessness. Fielden and Gallagher (2008) maintain that outside help from agencies can help promote social engagement. Subsequently, social cohesion improves self-esteem and self-confidence, resulting in courage to build social networks (Larkin, 2009).

Community focussed public health nursing is high priority for improving the health of the population (Poulton, 2009). Therefore, working with communities and other agencies to plan interventions based on local need and national health priorities is integral to health visiting, and synchronises with the four principles of health visiting (Smith and Horne, 2012). The new service vision specifies community work as one of the four tiers of health visiting (Department of Health, 2011). Pearson et al (2013) maintain that health visitors are seen in policy as catalysts and connectors, steering families and communities towards health and wellbeing, and using and building upon social capital that is usually built upon social relationships and networks.

The PREview resource (Department of Health, 2012), and local health information informed this six-week postnatal group. The main objective of First Steps was to increase participants’ social capital by equipping parents with knowledge and skills to parent effectively and enhance social cohesion through local networking (Mackereth and Appleton, 2008). The High Impact Areas for health visiting articulate the contribution of health visitors to the 0-5 agenda; describing areas where health visitors have potential for significant impact on health and wellbeing; and improving outcomes for children, families and communities (DH, 2014). The First Steps Postnatal Group was designed around the High Impact Areas.

High Impact Areas for Health Visiting (DH, 2014):

High Impact Areas for Health Visiting (DH, 2014)


Background to the project

Almost one third of children resident within Walsall live in poverty. The lower an individual’s social economic position, the worse their health will be (World Health Organisation (WHO), 2011). This indicates considerable disadvantage for residents of the borough. Furthermore, children resident in Walsall have poor health and wellbeing compared with the national averages; as a consequence, they are more likely to have a low birth weight, increased likelihood of developing obesity, are at greater risk of infant mortality and consistently achieve a lower level of development by the end of school reception year than the national average (Public Health England, 2016).

Supporting disadvantaged families early in a child’s life is a cost effective way to improve outcomes for families in the short and long term (Field, 2010). There was no local education available for new parents within the borough to tackle the cycle of poor outcomes. The decision to resurrect the traditional postnatal group stemmed from health visitors identifying a gap in provision as well as an opportunity to encourage parents to think about their parenting role, the child’s developmental needs and to become equipped with knowledge and skills to address health needs for themselves and their children.

The Department of Health identification of the High Impact Areas for health visiting (DH, 2015) provided an opportune and timely framework for the development of the course. Local child health data evidenced poor outcomes that could be addressed while facilitating local parent networks (Public Health England, 2016). Breastfeeding support is widely available within the borough and while breastfeeding mothers were supported throughout the sessions, a specific session was not developed as most infants were around six weeks when parents commenced the course and feeding choices typically were firmly established. Signposting to breastfeeding support groups was an integral component of parent support within the group.

The group was designed to run for six weeks, each session lasting for one and half hours. Two members of staff, usually a health visitor and a nursery nurse, would facilitate the group to ensure that if a parent should require additional support, help was available. Lesson plans were developed to ensure consistent and evidence-based delivery. Venues for holding the course had to change from a local children’s centre, owing to closure, to a local church hall that was made available free of charge.

The course was initially piloted with a small group of ten mothers. Both parents were invited by health visitors at the new birth visit. Yet, the initial group consisted solely of mothers and their babies, who attended the group together. Parents were invited to make a voluntary contribution towards hot and cold refreshments provided during the sessions.


The First Steps course

The overarching aim of the course was to reduce social isolation for local parents and promote positive confident parenting. The longer term aim was for health visitors to deliver the pre-devised six-week programme to new parents across the borough. The six weekly sessions were as follows:

 

Week 1: Transition to parenthood

The transition to parenthood is recognised as a pivotal life course transition for parents (Deave et al, 2008). For some, becoming a parent for the first time may be a profound stressor associated with negative long-term consequences; this period brings about major changes in men’s and women’s roles, responsibilities and identities. Parental wellbeing is fragile during this transition period, with many new parents finding the challenges of their new parenting role overwhelming (Solmeyer and Feinberg, 2011).

The PREview tool, Preparation for Birth and Beyond (DH, 2012), was utilised to develop this session. PREview is based on evidence identifying the factors in pregnancy and infancy associated with outcomes for children at five years. How parents adjust to the parenting role has implications for their personal wellbeing, parenting and their child’s development (Solmeyer and Feinberg, 2011).

In order to facilitate parental exploration of their own journey into parenthood, the session included a quiz that enabled parents to collectively consider true and false statements about the demands of parenthood. Members of the group were encouraged to think about what they worried about in their new parental role and what they aspired to for themselves and their new infant. This activity highlighted the fact that the concerns of new mothers were similar. Identification of the stress and anxiety around juggling new responsibilities, their parenting role, baby’s wellbeing, parenting practices, finances and overall adjustment were acknowledged. Parents were encouraged to consider resources and support networks available to them, including family and friends as well as voluntary agencies such as Homestart Children’s Centres, health visiting teams, libraries and leisure centres.

 

Week 2: Play and development

Evidence from neuroscience and social science demonstrates that the first two years of life are of fundamental importance in creating solid psychological and neurological foundations to optimise lifelong social, emotional and physical health, and educational and economic achievement (Department of Education, 2013); also the recognition that strong parent-child attachment and positive parenting has the potential to influence a child’s conduct, educational achievement, health, and physical and emotional wellbeing.

The Department for Education (DE, 2013) recommends that health visitors take the lead in infant mental health. Evidence suggests that a failure to meet a child’s early needs can affect her or his emotions, behaviour and future development (National Institute for Clinical Excellence, NICE 2012). Cabral (2013) recommends that problems need to be anticipated and prevented early to affect the part a child will play in society.

This session centred on play and communication whereby a family support worker demonstrated how to make treasure baskets. Treasure baskets have been used for decades as a means of teaching young babies how to select, touch, taste and feel. This simple and inexpensive idea enables babies to enrich their experience of objects around them and to gain confidence in making decisions. The nursery nurse led a discussion about the developmental ability of young infants, aimed at improving parental insight into the value of play and positive parent-child interaction, facilitating a good attachment between caregiver and infant, thus leading to better long-term emotional and social outcomes for the child (NICE 2012; Naughton 2013; DE 2013). The importance of warm, sensitive and responsive communication was reiterated and the parents were informed about infant states and infant cues. The link between early communication and reading and rhymes was identified as a precursor for early language development and later school readiness.

 

Week 3: Perinatal mental health

The Healthy Child Programme (DH, 2009) identifies the importance of recognition and provision of early interventions to meet the needs of children who are at risk of poor outcomes. It is widely acknowledged that mental disorders during pregnancy and the postnatal period can have serious consequences for the mother, infant and other family members (NICE, 2014). Disorders are common; many are serious and can have long-lasting effects on maternal health and child development (Maternal Mental Health Alliance, 2014). Optimal infant mental health is reliant upon the unfolding relationship between the infant and parent, therefore support for new parents during this potentially stressful period is vital in order for health visitors to address this public health issue.

The health visitor led a discussion with the group regarding the prevalence of mood disorders in the ante and postnatal period. Parents were encouraged to consider the signs and symptoms of anxiety and depression, and were made aware that their health visitors were available to support them should they be experiencing any difficulties. In addition, other support, including the GP and local talking therapy service, was also identified.

An emotional wellbeing practitioner from Walsall Healthcare NHS Trust attended the session to explore with parents ways of promoting positive emotional health, including mindfulness techniques, exercise and socialisation. A short mindfulness exercise was practised as part of the session. Participants were then asked to reflect upon what enjoyable activities they did prior to parenthood and how they might incorporate some ‘me time’ into their lives as parents.

 

Week 4: Introduction to solids (healthy weight, healthy nutrition)

Developing healthy eating and activity habits early in life is critical for optimum growth and development and for maintaining a healthy weight throughout childhood and later life (IHV, 2015). Parents completed a quiz to ascertain their knowledge and beliefs around the nutritional requirements of their infant and their readiness for solid foods. A group discussion was followed by a DVD demonstrating baby-led weaning as recommended by Department of Health guidelines (DH, 2011).

 

Week 5: Managing minor illness (reducing hospital attendance)

Attendances in emergency departments have increased by 50% over the past ten years (DH, 2012), with the majority deemed to be inappropriate attendances that could have been managed within a primary care setting (Roland and Abel, 2012).

This session consisted of educating parents on the management of common minor illnesses. The health visitor determined parental knowledge regarding the illnesses and subsequently explored the action they would take in managing the conditions.

Parents then observed an interactive presentation on the common reasons for attending the local emergency department; these included fever, diarrhoea and vomiting, common childhood rashes, coughs and colds and chicken pox. Furthermore, parents were provided with evidence-based information on how to self-manage these conditions and were advised of when to seek medical advice. Home safety information was also discussed in relation to the age and stage of a child’s development in the early years.

 

Week 6: Graduation

The last of the six sessions offered the opportunity to share contact details between the parents, to facilitate ongoing relationships to offer mutual support. These resultant relationships promote the development of social capital and enhance social cohesion by local networking beyond the confines of the First Steps group (Mackereth and Appleton, 2008). Health visitors assisted the parents in taking footprints of their baby on a printed poem, as a memory of the group and as a reminder of how the health visiting team supported their transition to parenthood experience.


Evaluation and outcomes

The aim of the evaluation was to establish the reasons for participation and the experiences of first-time parents who had attended the group. The overarching aim of First Steps was to increase social capital and improve parental self-efficacy, while impacting outcomes in relation to the High Impact Areas for health visiting (DH, 2014). The six structured sessions for the group were designed in response to national and local information relating to child health and wellbeing. Following each session, parents evaluated how useful it was and how they rated their confidence in relation to newly acquired knowledge. Of the parents, 100% reported an increase in overall knowledge on the topics covered.


The final course evaluation gave parents the opportunity to describe how attending the group had benefited them (see below):

‘Great – met lots of lovely mums and shared experiences. Good information and help too.’

‘It has been good and I have learned lots of new stuff.’ ‘It has really helped me, especially with communicating with other mums.’

‘Loads of new information about babies. Great place to meet new mums.’

‘Brilliant to have access to health visitors on a weekly basis in a more relaxed environment than the clinic. Nice to meet new mums.’

‘I have learned a lot about various things to do with babies.’

‘Making friends and knowing more groups.


All parents were positive about the group, and evaluations following each session enabled the facilitators to consider any required amendments. Internet access to enable the viewing of video clips was the biggest obstacle identified. Learning to parent was the motivating factor for attending the group; the social aspect was an advantage but receiving professional advice alongside other mothers was acknowledged, as well as the value of group learning. The opportunity to share thoughts and ideas around aspects of parenting that caused anxiety was also praised.

Mothers from the group have continued to meet up weekly at the Arboretum for a Ready Steady Mums socialise gathering. They have described to health visitors the longer term value of meaningful, supportive friendships that have materialised from the group and many of the mothers meet weekly to undertake parent and child activities and offer mutual support to one another. Subsequent group graduates have also been signposted to the social sessions, which have been successfully running for over a year.

Unexpected outcomes

Although one of the main objectives of the group was to promote social support, it was never anticipated that this would extend borough-wide. The perinatal mental health session offered the opportunity to explore the benefits of physical activity upon emotional wellbeing. This gave the health visitor the opportunity to discuss the Ready Steady Mums initiative, a parent-led exercise group. A volunteer from within the group has now established a Walsall Ready Steady Mums group that meets weekly at the local Arboretum for a buggy walk and the chance to share experiences of parenthood and extend social support networks. Local health visitors are encouraged to promote the group via flyers and directing parents to the Ready Steady Mums Walsall Facebook page.


Discussion

The current contest for health visitors is managing a caseload and undertaking community development initiatives, which organisational structures and commissioning contracts do not always support. This is a challenge because many social capital projects have a disputed evidence base (Cowley et al, 2013). The new service vision has a specific community tier; practitioners must influence managers and commissioners to appreciate that caseloads provide a legitimate gateway into the community, enabling health visitors to familiarise with existing networks and mediate between communities and the health service agenda. Health visitors must act as community advocates, and this requires the upskilling of the workforce. In Walsall the group continues to run and receives excellent client feedback. This package is being rolled out across the health visiting teams and will be offered across the borough by the end of this year. The course has been awarded a grant from the Burdett Nursing Fund to be developed further and is being accredited by the Institute of Health Visiting. 


Conclusion

The First Steps group differed from traditional postnatal groups in that it was specifically centred on the High Impact Areas. It supported mothers during the pivotal transition period, successfully promoting early positive parenting and achieving greater parental confidence. While delivery of the Healthy Child Programme (DH, 2009) and key performance indicators dominate practice, the outcomes from First Steps highlighted the value of community development initiatives for new parents. If health visiting is to positively impact at a community level, this must be acknowledged by service managers and commissioners and accompanied by appropriate training and support. This initiative of updating the traditional postnatal group to incorporate the High Impact Areas for health visiting has proven successful in assisting the transition to parenthood, enhancing social capital and improving parental knowledge and self-efficacy.


References

Cabral J. (2013) The value of evaluating parenting groups; a new researcher’s perspective on methods and results. Community Practitioner, 86(6):30-33.

Cowley, S., Whittaker, K., Grigulis, A., Malone, M., Donetto, S., Wood, H., Morrow, E., Maben, J. (2013) Why Health Visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. National Nursing Research Unit. London: King’s College.

Deave, T., Johnson, D., Ingram, J. (2008) Transition to Parenthood: the needs of parents in pregnancy and early parenthood. BMC Pregnancy and Childbirth, 8:30-36.

Department of Health (2014) Overview of the six early years high impact areas. London: Department of Health.

Department of Health (2012) Preparation for Birth and Beyond. London: Department of Health.

Department of Health (2009) The Healthy Child Programme: Pregnancy and the first five years of life. London: Department of Health

Department for Education (2013) Conception to age 2 - the age of opportunity. London: Wave Trust.

Field, F. (2010) The Foundation Years: Preventing poor children becoming poor adults. The report on the independent review on poverty and life chances. London: HM Government

Fielden, J. and Gallagher, L. (2008) Building social capital in first-time parents through a group-parenting program: a questionnaire survey. International Journal of Nursing Studies, 45: 406-41.

The Healthy Child Programme: Pregnancy and the first five years of life. London: Department of Health. See: gov.uk/government/publications/healthy-child-programme-pregnancy-and-the-first-5-years-of-life

Institute of Health Visiting (2015) A National Framework for Continuing Professional Development for Health Visitors - Standards for the High Impact Areas for Early Years. London: Institute of Health Visiting

Larkin, M. (2009) Vulnerable groups in health and social care. London: SAGE publications.

Mackereth, C. and Appleton, J. (2008) Social networks and health inequalities: evidence for working with disadvantaged groups. Community Practitioner, 81 (8): 21-26

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Naughton, L. (2013) Serve and return. Community Practitioner, 86:12-15

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1. Why is this topic important?

Supporting families in a preventative and supportive manner is a cost-effective intervention and aligns with the four principles of health visiting.

2. What does this study attempt to show?

The course aimed to reduce social isolation for local parents and promote positive and confident parenting strategies.

3. What are the key findings?

The study found that 100% parents who attended reported an increase in knowledge regarding the topics covered within the course.

4. How is patient care impacted?

The project aimed to develop a local provision of evidence-based parent education against the backdrop of service cuts and the closure of local children’s centres as the availability of parent support and education was reducing. At the end of the programme, parents reported increased confidence and knowledge, something that would hopefully improve health outcomes for parent and child.

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