public perceptions of a health visitor

Pergamon ht. J. Nun. Stud., Vol. 33. No. 3, pp. 285-296, 1996

CopyrIght 73 1996 Elsevier Science Ltd. All rights reserved Printed in Great Bntam

002&7489/96 S.lS.OO+O.OO

0020-7489(95)0006%1

Public perceptions of a health visitor

CHRISTINEKELLY,* R.G.N., R.M., R.H.V., B.Sc.(Hons.)Comm. Hlth Hounslow and Spelthorne Community and Mental Health NHS Trust, Hounslow, Middlesex, U.K.

Abstract-This paper outlines the views of a random sample of 175 members of the public on the role and function of the health visitor. Those who had previous contact with a health visitor were more likely to know? her employer but not necessarily her qualifications. They also had a greater knowledge of the type of clients a health visitor may see and the advice she is able to give. Although many people were aware of the health visitor’s work in health promotion, very few would contact a health visitor for health advice, the vast majority choosing to see their GP. Health visitors should be aware of this and the way in which their profession is viewed by those whose health they aim to influence and may also consider a change of name and/or direction if the profession is to continue to develop and be more responsive to the needs of the 90s. Copyright 0 1996 Elsevier Science Ltd.

Introduction “Health visitors themselves, those with whom they work and society in general are confused about what they are and what they do” (Abbott and Sapsford, 1990, p. 120).

The growth of the health visiting profession can be viewed as a reflection of a health service which has become increasingly medicalised. As more areas of life have become the subject of medical jurisdiction, problems which are primarily social in nature have been redefined

*Address for correspondence: Lyndhurst, 63 Newdigate Road, Harefield, Middlesex UB9 6EL, U.K. Tin the absence of a generic term the health visitor is referred to in the female gender, although the author recognises that health visitors may be male or female.

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in medical terms, e.g. alcoholism, violence and homelessness (Math&, 1993). Childbirth, child development and family life have also become subject to scrutiny by ‘experts’ who

make judgements as to what is normal and abnormal and, in doing so, aim to shape mothers

in particular directions. Among these so-called experts are health visitors who, paradoxically, aim to be impartial

in giving advice to mothers but who, nevertheless, have had prior training with a strong medical influence (they are registered nurses and, in some cases, midwives). This training, it is argued, leads them to work with a particular view of what a family should be like and how mothers should behave, which is essentially patriarchal and middle-class (Abbott and Sapsford, op. cit.; Orr, 1980). Ironically, in the past, health visitors have tried to maintain their separate identity (they are registered, after all, with the United Kingdom Central Council for Nursing, Midwifery and Health Visiting), but at the same time may have alienated themselves from the clients they serve who identify more readily (and, it can be argued, are more receptive to) nurses and the work they do. Health visiting has, in effect, had to re-invent itself several times during the course of its historical development.

Health visiting is indeed a changing profession. It had its roots in the mid-19th century when epidemics of cholera and typhoid were prevalent and volunteers were called upon to educate people in their own homes. Originating in Salford and Manchester, Ladies Sanitary Associations were set up which comprised a lady volunteer supervising a number of mission women who lived among the people they hoped to educate by their own good example. Eventually training courses were set up with specific entry requirements, Further concern about population trends, particularly infant death rates, at the turn of the century prompted the growth of the infant welfare movement. In 1904 the Interdepartmental Committee on Physical Deterioration recommended the provision of a nationally co-ordinated health visiting service.

The voluntary element of health visiting disappeared when the welfare state was estab- lished after the Second World War, and in 1946 health visiting became a statutory service. With improvements in nutrition, child health improved and the emphasis moved towards the family unit as a whole, although, as Goodwin (1988) points out, it is still seen pre- dominantly as a child-centred service.

Community nursing itself is also changing. It has been given a new prominence in nurse education with the advent of Project 2000 and now finds itself in the new market economy of health care as a result of the NHS and Community Care Act (Report, 1990). With the advent of Trusts and GP fund-holding practices, community nurses are increasingly having to put a ‘value on the service they offer and to look at ways of marketing their services and measuring their effectiveness but it is not always an easy service to quantify in terms of results.

The health visitor needs to have a clear view of her role in the community and, more importantly, to ensure that members of the community in which she hopes to have an influence on health, are also aware of her role and the parameters within which she works. In a wider context, it also raises the question of how a particular occupation is viewed by the general public and whether or not they hold any pre-conceived or stereotypical views.

The aim of this study was to question a geographically-based sample of the general public about their views on the role and function of the health visitor, including the training required, employing authority, status, clients and type of advice given, together with details of the respondents themselves, including whether or not they had any previous contact with the health visiting service.

PUBLIC PERCEPTIONS OF A HEALTH VISITOR 287

Previous studies

Several researchers have aimed to elicit the views of mothers on the health visiting service which they were offered (Clark, 1984; Field et al., 1982; Pearson, 1991).

Both Clark and Pearson agree that health visitors need to explain more clearly to clients the full range of their role, although Abbott and Sapsford (op. cit.) feel that health visiting itself has no clearly defined role.

Thompson (1986) chose to look at stereotyping in the media. She describes the typical health visitor stereotype as

“an overweight middle-aged lady in a hat, sitting down drinking tea and dishing out unsympathetic, authoritarian advice, apparently oblivious of the fact that a marriage may be falling apart around her or that a child is being abused under her nose” (1986, p.64).

Studies of other professions, whereby clients are asked about their perceptions of a professional providing a service, have usually concentrated on those clients who already had access to the service in question. Musgrove and Taylor (1965), for example, looked at both teachers’ and parents’ conception of the teacher’s role and Mayer and Timms (1970) questioned clients of the Family Welfare Association about the service they had received from social work staff.

Design

A questionnaire was designed to ascertain the views of the general public on the role of the health visitor, including the training required, employing authority, status, clients and type of advice given. Respondents were also asked about previous contact with the health visiting service together with details of their own behaviour regarding the use of health services and personal details such as age, gender and occupation. The questionnaire included a combination of both open and closed questions, using guidelines from the work of Frey (1989).

Data collection

The study took the form of a telephone questionnaire administered at varying times of the day, to maximise the response rate and to reduce the possible gender bias that may occur due to the fact that women are more likely to be home during the day. Numbers were taken using a systematic sampling method. The initial number was selected from a Table of Random Numbers and the sample interval calculated by dividing the number of people in the telephone directory by the sample size.

All the selected telephone numbers were listed and allocated a number from 1 to 250 inclusive. Each number was called up to three times, at differing times of the day to maximise the possibility of a respondent being available. In the event of a business number being called, the next residential number listed was chosen in its place. The sample interval was calculated using the original number.

A pilot study of 50 people was carried out prior to finalising the questionnaire. This allowed the author to analyse the questionnaire in terms of respondents’ comprehension and their ease of response. It also allowed the author to develop a more confident interview technique. Following the pilot study an additional question was added in order to ascertain people’s own personal views of health visitors.

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Rationale

The telephone survey

Frey (1989) recognises that the telephone survey has been accorded a place as an equal partner with other methods such as the mail survey and face-to-face interview.

While the author recognised that not all people have access to a telephone, statistics show that in 1990, 88% of all households in the United Kingdom had a telephone (Social Trends Report, 1993). No one method, however, can guarantee that everyone has an equal chance to respond. A mail survey, for example, does not reach the homeless and an intercept survey may favour a certain cohort, e.g. those who do not work, if conducted during working hours.

This method was chosen in preference to face-to-face interviews whereby interviewer bias may be a factor Salazer (1990)). Salazer also sees an advantage in retaining visual anonymity which can help relieve self-consciousness on the part of the respondent and reduce the possibility of the respondent giving socially acceptable answers which can occur in face-to- face interactions.

Ethical issues

There were no ethical issues surrounding the selection of people to be questioned. Every effort was made to emphasise the confidential nature of the study and to give clear explanation of its purpose. The only ethical dilemma encountered was a personal one regarding the author divulging that she herself was a health visitor, while eliciting from the general public their own particular views on health visitors. The possibility of this affecting the response was considered but, on reflection, the author considered that honesty was more conducive to a good response.

Analysis

The results were analysed using the computerised Statistical Programme for the Social Sciences (SPSS). Respondents views were compared to the actual role and function of the health visiting service (as defined by the CETHV (Council for the Education and Training of Health Visitors) (CETHV, 1977). A comparison was made of the respondents who had prior experience of the health visiting service and those who had not, taking into account the nature of the experience and how recently it took place.

Response rate

From a total of 250 questionnaires there was a positive response from 175, giving a response rate of 70%. Fifty-one people (29.1 Oh) refused to complete the survey, and there was no response after three attempts from 24 numbers contacted, giving a non-contact rate (NCR) of 9.6%.

Results

Previous contact

There was a fairly even split between those who had previous contact with a health visitor (48.6%) and those who did not (51.4%). Of those who had previous contact the largest


percentage (44.8%) had seen a health visitor over 5 years previously, 20% within the last 5 years and 35.3% within the past year. An open question was then included to ascertain the main reason for the contact with the health visitor.

There was quite a narrow range of reasons overall and by far the most popular reason was having young children. This accounted for 70.6% of those who had seen a health visitor for any reason and will have an influence on the way the health visitor’s role is perceived. Other reasons included illness in the family and personal contact (e.g. through work).

Knowledge of health visitors

In order to ascertain the knowledge about health visitors, respondents were asked who health visitors are employed by and the type of training required. With regard to employing authority the options given were: social services, general practitioners, Health Authority or Trust, don’t know. The results are shown in Fig. 1.

The largest group (37.1%) rightly thought that health visitors were employed by a Health Authority or Trust, although this only accounts for just over one-third of the total number of respondents. Just under one-third (30.95%) had no idea who a health visitor was employed by and a small percentage thought that she was employed by others not listed.

With regard to training, respondents were asked if a health visitor was: a trained nurse, a social worker, qualified in another way (with the option to state how), not qualified, don’t know. The results are shown in Fig. 2.

Registration as a nurse is a pre-requisite for training as a health visitor and, until recently when entry requirements were changed, registration as a midwife (or relevant obstetric experience). A further l-year training course is required leading to qualification as a registered health visitor.

Less than half of all respondents (42.9%) knew that nurse training was required. Some, 25.7%, thought that she was qualified in another way, but a very small percentage, only 3.4%, said that further training, in addition to nurse training was required. Only one respondent, who herself was a retired health visitor, said that there was a special training course for health visitors.

Health visitors’ employer

0 Social services GPs HA/trust Other Don’t know

Fig. 1. Health visitors’ employer.

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Health visitor training

0 Nurses Social workers Other N00e Additional training Don’t know

Fig. 2. Health visitor training.

The results were analysed to investigate whether those who had previous contact with a health visitor knew more about the employing authority and training required.

Using the formula chi-squared (x2) there was a statistically significant relationship between those who had previous contact with the health visitor and knowledge of her employer (P = 0.0035).

In terms of health visitor training there was no significant statistical relationship between previous contact with the health visiting service and knowledge of the health visitor’s qualifications (P = 0.17 1).

With regard to the health visitor’s clients, respondents were asked if they knew whether or not the health visitor visited: the elderly, mothers and children under 5, sick people at home, healthy people, others not mentioned (with the opportunity to state who).

Although much of the health visitor’s work is with mothers and young children she does see some elderly clients and is concerned with health promotion issues among all ages. She does not routinely see sick people at home who are more likely to receive the services of the district nurse if they need regular nursing care. She may see them, in some instances, to give general support and provide knowledge of others who the client can call on for help (such as local or national support groups and charities) and details of benefits, etc.

Overall the majority of people thought that a health visitor would visit the elderly (73.7%) and mothers and young children (82.9%). Nearly 70% thought that a health visitor would see sick people at home but only 40% considered that she might visit healthy people.

An analysis was made to see if those who had previous contact with the health visiting service had greater knowledge of the clients she visits.

Using chi-squared (op. cit.) the statistical relationship between previous contact with the health visiting service and the knowledge that she visited healthy people was highly significant (P=O.OOOl). The relationship between previous contact and the knowledge that she visited the elderly, mothers and young children, and sick people at home was not statistically significant (P= > 0.05 in all cases).

Further analysis was made using the Spearman correlation coefficient (rho) comparing


those who had previous contact with the health visiting service and knowledge about her clients and the work she does.

There was a negative correlation with regard to visiting sick people at home, indicating that those who did not have any previous contact with the health visiting service were more likely to answer positively when asked if they knew whether or not a health visitor would see sick people at home.

All other areas showed a positive correlation, i.e. visiting the elderly, mothers and young children, and healthy people. The positive correlation indicates that those who had previous contact with the health visiting service were more likely to answer positively to the question regarding the health visitor numbering these among her clients, which possibly reflects their own experience of the service.

With regard to the work of the health visitor, respondents were asked on which of the following would a health visitor be able to give advice? The options were: problems caused by unemployment, child care, health promotion issues, local groups and services, other advice (with the opportunity to state which).

A large majority (96%) thought that a health visitor could give advice on child care, health promotion issues (86.9%) and local groups and services (89.1%). Over 60% did not feel that a health visitor could give advice on unemployment, although she is increasingly counting the unemployed among her clients.

There was a statistical relationship between those who had previous contact with the health visiting service and knowledge about the advice she is able to give, with those having contact over the last 5 years having the greatest knowledge overall.

Beliefs about health visitors

In order to ascertain the feelings of the respondents about health visitors they were given examples of a number of occupations and invited to chose the one which they thought was closest in status to a health visitor. The options were: teacher, police officer, doctor, social worker, don’t know. The results are shown in Fig. 3.

Comparison with other professions

50 r

0 Teacher Police officer Social worker Don’t know Other No reply

Fig. 3. Comparison with other professions

292 C. KELLY

The largest percentage of respondents (45.7%) thought that a health visitor was closest in status to a social worker, which was double the nearest figure of 40 (22.9%) for those who thought the person closest in status was a doctor.

An open question was also included “what do you personally think of health visitors?“.

Positive comments

Eighty-seven respondents (49.7%) gave positive comments about health visitors. Many were based on previous experience of the health visiting service, e.g.

“in my experience they are excellent”

“my health visitor is invaluable. I ask all sorts of advice about myself and the children”

“I think they are excellent. My first one was called ‘Granny Greenteeth’ but even she was good”.

Others gave positive comments but did not necessarily base this on previous experience, e.g.

“valuable-1 would think”

“I’m sure if the service is there it’s very good”

“I’m sure they’re very good-so I’ve heard”.

Negative comments

Sixteen respondents (9.1 Oh) gave negative comments about health visitors. Some negative comments were based on previous experience, e.g.

“I think they can be a bit interfering”

“I’ve only ever asked for help once and they weren’t very helpful”

“not too good as yet”.

Other negative comments did not imply previous contact with the service “from what I’ve read they need a bit more authority to investigate where young children are concerned”

“I think they could do more. They don’t see me”

“I don’t think much of them. I haven’t had any help since I’ve had M.E. (myalgic ence- phalomyelitis)“.

Mixed comments

As well as positive and negative comments some respondents were non-committal in their responses (10.3%), e.g.

“I expect they do a good job when they’re needed”

“we didn’t need them in our day. I expect there is more call for them now”

“they’ve definitely got their place”.

Fifty-four respondents (30.9%) did not feel that they could comment because they had never had any contact with a health visitor.

In addition to questions about who a health visitor might visit, respondents were asked who they would normally talk to if they needed health advice (e.g. about giving up smoking


Health advice

60

0 Family GP Practice nurse Health visitor Comb’tion Other Don’t know

Fig. 4. Health advice.

or losing weight). The options were: family or friends, the GP, practice nurse, health visitor, other, don’t know. The results are shown in Fig. 4.

Although nearly 90% of respondents had stated that they thought a health visitor could give advise on health promotion issues, only 2.3% would consult a health visitor for health advice. Nearly 60% would see the GP which has great implications for the overworked GP and the health visitors who are keen to get involved in health promotion issues.

Characteristics of respondents

The greatest number of respondents was in the 466.5 age group (34.3%). The smallest cohort (2.9%) was in the under- 18 group.

The majority of respondents (over 70%) were female. Every effort had been made to vary the time of day the calls were made but, even for those made in the evening, a large number of women answered the telephone.

The results were analysed to see if there was a connection between a person’s age and gender and whether or not they had any previous contact with a health visitor.

Using the formula chi-squared (op. cit.), the statistical relationship between gender and previous contact with the health visiting service was highly significant (P=O.O0004). This could be a reflection of the fact that the greatest proportion of a health visitor’s work is with mothers and young children.

The age and gender of the respondents was also compared with their knowledge about the work of the health visitor. Using the Spearman correlation coefficient (rho), taking into account the ages of the respondents, there was a positive correlation with regard to visiting mothers and young children, healthy people, giving advice on problems caused by unemployment, child care, health promotion issues and local groups and services. This confirms that the younger age groups were more likely to answer positively when asked if the health visitor counted these groups among her clients and was able to give advice on those subjects.

There was a negative correlation with reference to visiting the elderly and sick people at home. This shows that the elderly were more likely to answer positively to the question regarding the health visitor seeing these particular clients. In terms of gender there was a negative correlation in all questions related to the clients visited and all questions related

294 C. KELLY

to the advice a health visitor is able to give, showing that women were more likely to answer positively when asked if they knew about the clients a health visitor would see and the advice she is able to give. This is probably a reflection of the fact that women are more likely to have contact with the health visiting service and, consequently, greater knowledge of their work. It is interesting to note that none of the respondents in the under-18 age group had previous contact with a health visitor.

Occupation

In response to the question “what is your occupation?” replies were categorised into professional, managerial, manual and unclassified.

The largest group (40.6%) were in the managerial cohort and the smallest (7.4%) classed as professional. There was no statistical relationship between occupation and previous contact with a health visitor.

The information regarding home town was used merely to assess geographical spread. In further studies it may be useful to obtain the respondents’ postcode to identify the neighbourhoods as used in the ACORN classification which has been used in the past as a deprivation indicator and would allow for further comparisons regarding the knowledge of the role and function of health visitors (Speller and Hale, 1985).

Conclusion

The aim of this study was to ascertain the views of a geographically-based sample of the general public on the role and function of the health visitor. The method chosen was a telephone survey which has, in recent years, been recognised as a means of data collection which is of equal value to other methods such as the mail survey or face-to-face interview. The response rate of 70% was encouraging allowing for comparisons to be made between those who had previous contact with the health visiting service and those who did not; the number of respondents in each category being fairly evenly split.

In terms of knowledge about health visitors themselves, under half knew her employer and the fact that she was a trained nurse but very few people knew that further training was required. While this would seem disheartening on the part of the health visitor, the question should perhaps be raised as to whether members of the public acknowledge further training very much at all, e.g. would they know if a Macmillan Nurse was oncology trained or a paediatric nurse had undertaken a further course of study?

The majority of respondents thought that a health visitor would see the elderly, mothers and children under 5, and sick people at home, however 44% did not think that a health visitor would visit healthy people. Health visitors who are keen to cling on to their title at all costs might be advised to take note that it does not necessarily equate (in the public’s eye at least) to visiting healthy people.

As may have been expected, a large majority of people (96%) thought that a health visitor would be able to give advice on child care. Over 60% did not feel, however, that she could advise on problems caused by unemployment but did feel that she could talk about health promotion issues and local groups and services. In terms of status, 45.7% felt that she was closest in status to a social worker.

With regard to the personal characteristics of the respondents, the majority were female (over 70%) and the greatest number of respondents were in the 4665 age group. There


was a significant statistical relationship between gender and previous contact with the health visiting service which is reflected in the fact that a large proportion of the health visitor’s work is with mothers and young children. No one under 18 had any previous contact with the health visiting service.

The Royal College of Nursing Health Visitors Forum (RCN, 1994) feel it is important to clarify the position of health visiting in a changed NHS and recognises that the relationship between the health visitor and those with whom she works is a key component in all areas of work. This relationship will be jeopardised if her clients (and potential clients) are unsure about the work she does. The RCN recognises that

“ although parents value contact with their health visitors, they do not fully understand the premise of health visiting” (1994, p. 8).

Although nearly 90% of respondents thought that a health visitor could give advice on health promotion issues, only 2.3% would consult a health visitor on health promotion matters, nearly 60% choosing to see the GP. If they had greater knowledge about the work of a health visitor, more people may feel able to consult the health visitor instead, thus alleviating the heavy work load of the GPs and giving the health visitor greater scope for exploring health promotion issues. She may, indeed, take on a role more aligned to that of the public health nurse, looking at wider issues such as epidemiology and social policy and, in doing so, re-discover her roots in assessing and educating about influences on health in the community within which she works. She could take on the role of specialist community nursing practitioner as envisaged in the UKCC document regarding post registration education and practice (UKCC, 1994).

A new role may mean a new identity-the title of health visitor may eventually be lost, but, before it goes the way of ‘Ladies’ Sanitary Associations’, health visitors should have a clear understanding of where they are going and ensure that those whose health they hope to influence are aware of, and are sympathetic to, that role too.

Acknowledgements-This study was undertaken as part of a B.Sc. (Hons.) in Community Health at the West London Institute for Higher Education in Isleworth, Middlesex. I would like to thank Prof. David Marsland for his advice and assistance in supervising the research project.

References

Abbott, P. and Sapsford, R. (1990). Health visiting: policing the family? In The Sociology ofthe Caring Pro@sions (Abbott, P. and Wallace, C., Eds). Falmer Press, London.

CETHV (1977). An Investigation into the Principles of Health Visiting. CETHV, London. Clark, J. (1984). Mothers’ perceptions of health visiting. Health Visitor 57(September), 265-268. Field, S., Draper, J. and Kerr, M., Hare, M. (1982). A consumer view of the health visiting service. Health Vi&or

55(June), 2999301. Frey, J. (1989). Survey Research by Telephone. Sage Publications, London. Goodwin, S. (1988). Whither health visiting? Health Visitor 61(December), 3799383. Math&, A. (1993). The medicalization of homelessness and the theater of repression. Med. Anthropol. Q. 7(2),

17c-184. Mayer, J. and Timms, N. (1970). The Client Speaks. Routledge & Kegan Paul, London, Musgrove, F. and Taylor, P. (1965). Teachers’ and parents’ conceptions of the teacher’s role. Br. J. Educ. Psychol.

35, 171-178. Orr, J. (1980). Health Visiting in Focus: A Consumer’s View of Health Visiting in Northern Ireland. RCN, London. Pearson, P. (1991). Clients’ perceptions: the use of case studies in developing theory. J. Adv. Nurs. 16, 521-528.

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RCN (1994). into the 90s. Health Visitors’ Forum-A Discussion Document on the Future of Health Visiting Practice. RCN, London.

Report (DOH) (1990). NHS and Community Care Act. HMSO, London. Report (1993). Social Trends. HMSO, London. Salazer, M. K. (1990). Interviewer bias: how it affects survey research. AAOHN J. 12(December), 567-572. Speller, V. and Hale, D. (1985). Making the most of your postcode. Health Sociul Serv. J. (February), 252-253. Thompson, J. (1986). Views on health visitors. Nurs. Times November 5,64. UKCC (1994). The Future of Professional Practice. The council’s standards for education and practice following

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(Received 18 May 1995; in revised,form 19 October 1995; acceptedfor publication 6 November 1995)

public perceptions of a health visitor

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