Which models of health visiting (HV) in England are most promising for mitigating the harms of ACES

Project outline


Other investigators: 

Jenny Woodman (Joint Lead Applicant) Senior Lecturer UCL Institute of Education, Department of Social Science

Dr Katie Harron (Joint Lead Applicant), Senior Lecturer, UCL Institute of Education

Dr Helen Weatherly (Co-applicant), Reader in Health Economics, Centre for Health Economics The University of York

Professor Ruth Gilbert (Co-Applicant) Professor of Clinical Epidemiology, Institute of Child Health University College London

Professor Jane Appleton (Co-Applicant) Professor of Primary and Community Care, Faculty of Health and Life Sciences, Oxford Brookes University

Dr Samantha Bennett (Co-Applicant) Consultant in Public Health, Kent Community Health NHS Foundation Trust, Kent County Council


Description of the Project:

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. 

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. 

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. 

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. 

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. 

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 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.

This research is being hosted by NIHR Children and Families Policy Research Unit, UCL (PIs: Dr Jenny Woodman, and Dr Katie Harrion)