Developing the capability of the health visiting workforce to offer early relationship support: a policy briefing from the Relationships Alliance. (Click here to download the PDF file)
As a universal service, health visiting enjoys a unique position in regard to its potential to affect the life course and life chances of babies and young children.
It is natural therefore that what health visitors do should be the subject of regular debate; indeed, as recently as 2011 the Government introduced a new health visiting implementation plan which set out a revised structure and roles for the profession (Department of Health, 2011).
While the Healthy Child Programme (DCSF/DH, 2009), led by health visitors, contains a major focus on parenting support (including ‘supporting strong couple relationships and stable positive relationships within families’), there is little evidence to suggest that such an approach has become central to current health visitor practice. Indeed, a major literature review (Cowley, 2013) commissioned to support the Health Visiting Implementation Plan 2011-15 found only ‘a collection of disparate studies that vary in methodology and quality with little conclusive evidence of service outcomes’ relating to support for parents, and does not even cover the topic of parental relationship support as a core task of health visiting. This is worrying, given research showing that couples going through this transition of becoming a new parent are at risk of decreased relationship satisfaction (Mitnick et al., 2009)
The impact of poor parental relationship quality and conflict on babies and young children
The research evidence on the impact of couple conflict (Coleman, 2010) (TCCR, 2011) (Harold and Leve, 2012) tells us that conflict which is frequent, intense and poorly resolved is very harmful, and that this kind of conflict can have an effect on children of all ages. Babies as young as six months, for example, exhibit higher physiological symptoms of distress such as elevated heart rate in response to overt, hostile exchanges between their parents when compared to exchanges between non-parental adults. Infants and children up to the age of five years show signs of distress by crying, acting out, freezing, as well as withdrawing from or attempting to intervene in the actual conflict itself.
The ambition therefore to develop the practice of key frontline professions – such as health visitors and children’s centre workers – such that it better incorporates a couple dimension stems therefore from a desire by policy-makers and practitioners to respond to this evidence by identifying opportune ways to strengthen couple and family relationships, and thereby reduce the exposure to, and impact of, such couple distress and conflict (Coleman, 2010).
The earlier we can intervene to support the quality of the parental couple relationship, the better our chances of reducing babies’ and young children’s exposure to potentially harmful levels and types of couple distress and conflict, as well as of reducing the incidence of postnatal depression in one or both partners (being a factor associated with poorer children’s outcomes) (Murray, 1996). Moreover, the fact that research suggests that poor parental relationship quality, and parental
relationship conflict, are associated with the development of insecure attachment between infants and parents lends further weight to the notion that services should be aiming to intervene as early as possible to support the parental couple relationship (TCCR, 2012); improvements in relationships are more probable if these solutions are considered and implemented at an early stage (Feinberg et al., 2010; Halford et al., 2010; Schulz et al., 2006; Shapiro & Gottman, 2005).
Overview of evidence supporting the addition of a couple dimension to health visiting practice
Research investigating the impact of adding a couple dimension or focus to the practice of health visiting has been scarce (though one notable exception will be explored below); however, a number of studies have explored the effects of couple-focused work by other frontline practitioner groups on the relationship quality and functioning of couples experiencing the transition to parenthood.
For example, the Becoming a Family Project, a longitudinal study in the U.S. of partners becoming parents for the first time, followed families from late pregnancy until their child completed the first year of elementary school (Cowan & Cowan, 2000). The authors of this study found that the relationship quality of those couples expecting a first child who were randomly assigned to a couples group meeting weekly for six months led by clinically trained male-female teams was maintained over a period of 5-1/2 years, as opposed to the relationship quality of couples in the control/ no-treatment arm of the study, whose marital satisfaction declined over time.
In the UK, findings were published in 2010 from a project designed to maximize the effectiveness of parenting support to vulnerable families (through sensitizing the workforce of a community-based adult mental health agency to take account of the parental couple in providing postnatal support groups, parenting workshops and relationship counselling). Evaluating outcomes from these services suggests that a couple orientation adds significant value to the effectiveness of parenting support with “all three of the evaluated services [being able to] claim to have reduced the risk of depression among the mothers who used them” (Clulow, 2010). As the authors of this study state: “The importance of the relationship between parents is frequently underestimated by those designing and developing services to support parents in bringing up their children”.
A recent randomised contolled trial found that a relationship support training programme (Brief encounters®) for frontline practitioners working with families had a large and positive impact on the way practitioners handled conversations with parents about their relationship difficulties, in using more appropriate techniques such as listening and summarising. Practitioners in the intervention group were also more than twice as likely as those in the control group to be confident in knowing both where and how to refer parents on for further support. The training also increased the likelihood of offering equivalent support in the future. These positive outcomes were experienced across the sample, irrespective of people’s prior years of working in the arena of children and families and their level of confidence in dealing with such matters (Coleman, 2013).
While children’s centre workers were the main recipient of the training in this study (albeit some health visitors and student health visitors also received the training), the authors suggest “there are of course other professional groups who may benefit from this training such as midwives and health visitors”. Given the “well documented barriers to more formal, more professional avenues for relationship support (not least cost), and the fact that such support is often taken at a late point in time or as a last resort”, this study, the authors argue, points to the potential for “training the relational capability of the wider family support workforce, and to the importance of providing early preventative relationship support through a means that is arguably of greater acceptability and accessibility compared to more professional sources” (Coleman, 2013).
This view is supported by findings from a study of the effects of training health visitors on the Brief Encounters course which also underpinned the approach studied by Coleman et al. (see previous paragraph) (Simons, 2003). Brief Encounters is a training programme aimed at frontline staff who are ‘turned to’ by clients regarding relationship problems and which aims to give them greater confidence to listen without becoming overwhelmed, and to offer effective support and make a referral where necessary. The Simons study also looked at the quality of the parents’ relationship during the postnatal period and the value of support provided by health visitors in cases of discord.
Evidence obtained from 450 mothers seen by health visitors based at nine clinics in an outer London borough found that attendance by the health visitors at a four-day training course for health visitors enabled them to screen for relationship problems during the postnatal period and to provide support when required in a way that was valued by mothers. Most health visitors were enthusiastic about the value of the intervention in improving their contribution to family welfare (Simons, 2003).
Developing the capability of the health visiting workforce to offer early relationship support
Evidence highlighted above indicates that a person experiencing relationship distress is most likely to turn to someone that they are already in routine contact with such as a health visitor; and that such opportunities for early intervention are often missed or ignored because health visitors don’t have the training to feel able to discuss relationship issues, or respond to meet the need, or refer appropriately to more specialist therapeutic services.
With effective training, however, it is possible to build a relationally capable workforce that is relationally minded, can identify the signs of difficulties and respond appropriately, and promote ways of protecting and strengthening relationships (Coleman et al 2013).
There are a number of ways in which the development of such a workforce could be achieved, including:
Cascade model of training
A training package to train 2 relationship champions in each employing organisation and universities offering health visitor training programmes (146 in England) who would be responsible for cascading a blended learning programme to student health visitors and the health visiting workforce, which will total 14-15000 by March 2015 as result of the HV Implementation plan (DH 2011). This offer could also be extended to Scotland, Wales and Northern Ireland.
A blended learning training programme delivered directly to the health visiting workforce consisting of an eLearning module and one day skills workshop.
Standalone e-learning package that provides the learner with knowledge, understanding and tools to offer relationship support in practice.
Evidence relating to health visiting, and allied frontline professionals, strongly supports the contention that incorporating a couple dimension into health visiting practice has the potential to help intervene effectively where there is relationship distress. Given the evidence regarding the impact of relationship distress and couple conflict on young children, the Relationships Alliance believes that the development of relational practice in health visiting should be a priority.
The Relationships Alliance believes that such a development can best be achieved by key partners – e.g. the Institute of Health Visiting, Department of Health, Department for Work and Pensions (as department with responsibility for relationship support) – working together; the Relationships Alliance has expertise in this area and would be keen to contribute to and facilitate such a programme of work.
Clulow, C., Donaghy, M. (2010) Developing the couple perspective in parenting support: evaluation of a service initiative for vulnerable families. Journal of Family Therapy,32: 142–168
Coleman, C., Glenn, F. (2010) The Varied Impact of Couple Relationship Breakdown on Children: Implications for Practice and Policy. Children & Society, Volume 24, Issue 3, pages 238–249, May 2010
Coleman, L., Houlston, C., Casey, P., Bryson-Purdon (2013) A Randomised Control Trial of a Relationship Support Training Programme for Frontline Practitioners Working with Families. One Plus One
Cowan, C. P., & Cowan, P. A. (2000). When partners become parents : the big life change for couples. Mahwah, NJ: Lawrence Erlbaum Associates.
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. Department of Health Policy Research Programme, ref. 016 0058. National Nursing Research Unit, King’s College London
Department of Health, (2011). Health Visitor Implementation Plan 2011–15. A Call to Action
Department of Children, Schools and Families & Department of H ealth (2009). Healthy Child Programme – Pregnancy and the first five years of life
Feinberg, M. E., Jones, D. E., Kan, M. L., & Goslin, M. C. (2010). Effects of family foundations on parents and children: 3.5 years after baseline. Journal of Family Psychology, 24(5), 532–542. doi:10.1037/a0020837
Halford, W. K., Petch, J., & Creedy, D. K. (2010). Promoting a Positive Transition to Parenthood: A Randomized Clinical Trial of Couple Relationship Education. Prevention Science, 11(1), 89–100.
Harold, G., Leve, L. (2012) Parents and Partners: How the Parental Relationship affects Children’s Psychological Development in Balfour, A., Morgan, M., Vincent, C. (eds.) (2012) How Couple Relationships Shape Our World: Clinical Practice, Research and Policy Perspectives, Karnac, London
Mitnick, D.M., Heyman, R.E., Smith Slep, A.M., 2009. Changes in Relationship Satisfaction Across the Transition to Parenthood: A Meta-Analysis. J. Fam. Psychol. 43 23, 848–852
urray, L., Fiori-Cowley, A., Hooper, R., Cooper, P. (1996) The Impact of Postnatal Depression and Associated Adversity on Early Mother-Infant Interactions and Later Infant Outcome. Child Development, 67, 5, p2512–2526,
Shapiro, A. F., & Gottman, J. M. (2005). Effects on Marriage of a Psycho-Communicative-Educational Intervention With Couples Undergoing the Transition to Parenthood, Evaluation at 1-Year Post Intervention. Journal of Family Communication, 5(1), 1–24. doi:10.1207/s15327698jfc0501_1
Schulz, M. S., Cowan, C. P., & Cowan, P. A. (2006). Promoting healthy beginnings: A randomized controlled trial of a preventive intervention to preserve marital quality during the transition to parenthood. Journal of Consulting and Clinical Psychology, 74(1), 20–31. doi:10.1037/0022-006X.74.1.20
Simons, S., Reynolds, J., Mannion, J., Morison, L. (2003) How the health visitor can help when problems between parents add to postnatal stress. Journal of Advanced Nursing, Volume 44, Issue 4, pages 400–411, November 2003
TCCR, (2011). The Impact of Couple Conflict on Children. A policy briefing paper from TCCR. Tavistock Centre for Couple Relationships, London
TCCR, (2012). What do couple relationships have to do with infant mental health and secure attachment? A policy briefing paper from TCCR. Tavistock Centre for Couple Relationships, London
The Relationships Alliance, a corsortium comprising Relate, Marriage Care, One Plus One and the Tavistock Centre for Couple Relationships, exists to ensure that good quality personal and social relationships are more widely acknowledged as central to our health and wellbeing.