Title: Which health visiting models in England are most promising for mitigating the harms of maternal related Adverse Child Experiences?
Funder: Department of Health and Social Care

Abstract: As many as 1 in 10 children in England currently live with parents who are violent or abusive to each other, who misuse alcohol or drugs, or who have mental health problems. In our study we focus on children who live with these types of experiences, which have been called 'adverse childhood experiences' or 'ACEs' for short. There are lots of different types of ACEs, for example parents splitting up or a family member going into prison. All ACEs are events or situations which are probably traumatic or extremely stressful for a child. We are only looking at families where we can tell whether the mother has experienced serious violence, used drugs or alcohol at a serious level or has had serious mental health problems. Although fathers are a very important part of the family picture, we cannot 'find' fathers in the data we use so our focus is on mothers. _x000D_ _x000D_ Children who have lived with ACEs tend to have worse health and wellbeing than other children and this often carries on as they become teenagers and grow into adults. Children who grow up with ACEs whilst also living in poor households tend to have particularly worse health and wellbeing. The first years of life are key for health and development and helping children with ACEs before school can stop problems getting worse for these children and improve their health and wellbeing in the short and long term. _x000D_ _x000D_ Health visitors are qualified public health nurses whose job it is to support all families with their young children's health, including families where there are ACEs. Health visitors work in a 'health visiting team' with others, including nurses with less specialist qualifications or nursery nurses who have child care and education diplomas. The health visiting team gives advice, support and guidance to parents of young children about a broad range of child health issues. They work with other professionals such as social workers and doctors and often put families in touch with other services which can help them, such as parenting groups, charities or professionals who can help with a child's speech and communication. The government says that every family in England should see a health visitor five times before a child is three years old and that those living with ACEs should get a lot more support from the health visiting team (and also social workers and other professionals). Seeing a family often is the way that the health visiting team can build a trusting relationship with parents, support parents to tackle their problems, help change things in the family that are not helpful for the child and encourage a strong bond between the parents and the baby or young child. _x000D_ _x000D_ We do not know the best ways of balancing health visiting for all families with health visiting that targets support to families most likely to be living with ACEs (e.g. those in the poorest neighbourhoods in England). Health visiting is organised differently across England and many families, including those with ACEs, do not see their health visitor as often as the government says they should. Our research will help us understand which ways of organising health visiting are most promising for helping families with ACEs, and whether they are only likely to work in specific contexts, such in areas with a children's centre or where there are enough health visitors for the number of families in an area. This research could be used by the government as it is making changes to health visiting and by local leaders in each council in England who are designing services for babies and very young children in their area. _x000D_ _x000D_ We will use national information from health visiting services and hospitals as well as information on what types of families live in local areas to describe how often health visitors see families and whether they visit some families more than others. As the national information only contains basic (and sometimes incomplete) details of health visiting and families, we will also carry out a survey and interviews with professionals and mothers to understand the full picture, including what services are used, how often, how the services might help families with ACEs, and how much the services cost the government. We will also talk to three different groups of mothers, for example women who have experienced domestic violence. WE will also speak to one group of young men who are fathers and have experience of some of the ACEs we are looking at. We will put all this information together to describe what is currently being done in England, for whom, at what cost, and why. We anticipate that we will find between 3 and 5 different 'ways' (models) of providing health visiting in England. _x000D_ _x000D_ We will then use the national information to see if particular ways (models) of heath visiting appear better than others for helping children with ACEs, for example by improving child development, or reducing the number of times children or their mothers have a hospital stay because of alcohol or drugs , domestic violence, or mental health problems (mother) or accidents or illnesses (child). In the final year of the study (year 4) we will interpret check our results still make sense, given that COVID-19 has changed the way that families live and that health professionals work. We will check if the government is collecting the most useful information to monitor health visiting and will produce evidence briefings to support people making decisions about how to organise health visiting at national and local levels.

Lay abstract: Background: _x000D_ _x000D_ Parental alcohol and substance misuse, mental health problems and domestic violence and abuse are common adverse childhood experiences (ACEs) which are associated with worse health and development outcomes for children. As the data we are using captures children whose mothers (not fathers) had a hospital admission for one of these ACEs, we call them 'maternal ACEs'. Health visiting is designed to assess, monitor and support children affected by ACEs, including maternal ACEs, as well as deliver universal care to every child in England. However, we know little about the coverage, intensity, type and costs of health visiting in practice, to what extent health visitors support families living with maternal ACEs and how this is balanced with providing care to all families in their local area. _x000D_ Aims and objectives: To determine 1) which factors determine the coverage, intensity, type, resource-use and cost of health visiting services received by families with and without maternal ACEs; 2) which health visiting models are most promising for mitigating the impact of maternal ACEs; and 3) what these results mean for local and national decision-makers and families. _x000D_ _x000D_ Methods: _x000D_ _x000D_ The study is based on a subset of all births in England 2015-2019. We have to use a subset of all births because only about 25% of local authorities in England have sufficiently complete health visiting data to analyse. We will identify families exposed to maternal ACEs in longitudinal hospital admissions data on mother-baby pairs (HES) linked with health visiting data (Community Services Dataset; CSDS). We will combine this with information on local area need (e.g. deprivation) and surrounding services (e.g. the Family Nurse Partnership). We will use a national survey of practice in all 152 local authorities to collect extra information not available in CSDS and to extend our data beyond the subset of local areas with complete data in CSDS to all local authorities in England. We will conduct in-depth qualitative case studies in up to 6 local authorities , including interviews with Directors of Public Health, health visiting commissioners and managers, health visitors and mothers, plus analysis of locally held administrative data._x000D_ _x000D_ Work package (WP)1: Months 1-24. We will produce a taxonomy of 3-5 ‘models’ of HV, grouping all 152 local authorities in England according to similarities in coverage (universal / targeted), intensity (e.g. patterns of repeat contact) and type (face-to-face, phone, group) of services delivered to families with/without maternal ACEs. We will i) describe indicative resource use and cost for each model; ii) generate detailed descriptions of factors associated with differences between local authorities using qualitative case study methods in up to 6 areas of England s (e.g. local area need/surrounding services) and iii) use key stakeholder input, including with groups of parents who have relevant lived experience to create robust hypotheses about how each model works for families exposed to maternal ACEs._x000D_ _x000D_ WP2: Months 25-42. We will use the taxonomy to evaluate associations between different HV models and select child and maternal outcomes, for families with/without maternal ACEs. Outcomes captured in HES-CSDS will include child development (Ages and Stages Questionnaire), child safety/harm from adverse caring environments (child injury or maltreatment-related admissions), and post-birth maternal ACEs (adversity-related hospital admissions in mothers). We will explore differences the associations through qualitative work and engagement with key stakeholders. In year 4, we will use updated data and stakeholder engagement to assess the meaning, validity and generalisability of our results, including for a post COVID-19 context. _x000D_ _x000D_ WP3: Months 42-48. We will review existing HV quality metrics, based on integration of findings from WP1 and 2, and provide evidence summaries in order to inform local and national implementation of services._x000D_ _x000D_ Impact/dissemination: _x000D_ _x000D_ We will work collaboratively to disseminate our findings to key stakeholders and families. The evidence will inform the modernisation of the Healthy Child Programme, and be used by local leaders when planning and revising their Start for Life Offer for all babies and very young children in their areas.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE