A Research Evaluation of Health Support Workers in a Sure Start Project

By Smith, Christine Prosser, Meryl; Joomun, Lorraine

Abstract Sure Start is a government initiative aimed at reducing the effects of poverty on pre-school children and their families in deprived areas. Skill mix has been identified in recent policies as a credible way of providing high quality services in a cost effective manner. Health support workers, under the supervision of health visitors, provide support through home visiting, group work and clinics with research identifying that such interventions can have beneficial outcomes for children and their families. This research is part of a larger study that evaluated a Sure Start service in a borough in south Wales, using realistic evaluation. The aim of this aspect of the study was to ascertain the effectiveness and acceptability of the services provided by the health support workers. Qualitative methods included focus group discussions with service providers (10 health visitors and six health support workers) and semi-structured interviews with seven service users. Content analysis inductively developed categories and themes. The main findings show that health visitors and service users valued the input of the health support workers but there were important issues regarding training and supervision that needed to be addressed.

Key words

Skill mix, health visiting, Sure Start, poverty, pre-school children

Community Practitioner 2007; 80(11): 32-35

Introduction

Our study was commissioned by a service provider in a deprived urban area in south Wales and looked at three separate projects within its Sure Start service. This paper focuses on one, the use of health support workers to supplement the health visiting service by providing support to families in the Sure Start areas through home visiting and group work.

Sure Start services In the UK

The Sure Start programme subject to this evaluation was established in April 2000 and is targeted at children under five and their families in the most deprived communities. It has developed a broad range of initiatives to meet the main objectives of improving health, social and emotional development and providing greater opportunities for learning. Each project is encouraged to build upon services already in existence within the locality. An essential component of this strategy is partnership working, not only between professionals and agencies, but also with service users and communities.

Young children living in poverty suffer a number of detrimental effects and present with poor physical, intellectual, social and emotional development.1 This may lead to multiple disadvantages in later life and such children are less likely to succeed at school and to be employed as young adults. They are more likely to become involved in crime and to become teenage parents.2 However, these effects are not necessarily deterministic and it is suggested that co-ordination of services in the early years of a child’s life and ongoing, sustainable support can be beneficial.3,4 Research has cited effective interventions that can either protect children or provide support to parents. For example, home visiting support for socially disadvantaged mothers can have a significant effect on maternal and child functioning,5,6 including a reduction in levels of child abuse and neglect, maternal welfare dependence, alcohol and drug misuse problems, and child antisocial behaviour and criminality.

Skill mix

The objective of skill-mix is to ensure that appropriate skills are available so that the needs of service users are identified and met in the most cost-effective way.7 Some go further in stating that, although the evidence base on skill-mix is limited, it remains evident that determining the ideal mix of staff is not just a matter of using the cheapest options.8 It is about assessing the context of care and deploying the most cost-effective mix to deliver care to a high standard. Concerns have been raised in the literature that skill-mix is aimed at rationalising services and that highly qualified resources are wasted and the skills and potential of other staff are not fully utilised.9,10

Issues around skill mix have been examined in the context of the development of a home play scheme by health visitors in Sheffield11 and the use of support workers in mental health teams.12 The former found that support workers were able to utilise their expertise on play development, that their relationships with families were more informal and they had more time to devote to families than health visitors. The second study found that support workers were able to take on some of the more time-consuming tasks, freeing up time for community mental health nurses to focus more on their own practice, team cohesion and cost-effective care delivery.

Syson-Nibbs13 found that vulnerable families valued the services of the support worker after receiving regular weekly contacts, and could identify ways in which it had improved their lives. Ebeid14 outlines a systematic approach to the development of skill-mix in health visiting that frees up health visitors’ time to focus on complex needs assessments, antenatal and postnatal health promotion and child health surveillance. This was supported by Keys15 who examined health visitors’ reactions to skillmix and found that although they were anxious about the quality of the service that would be delivered; they were able to use the support workers in a flexible way according to their skills and experience and could see the advantages. Edwards16 also concluded that unqualified members of staff were capable of delivering good quality therapeutic care.

Storey17 suggests that it is vitally important that all support workers are trained adequately and that delegation and supervision of their work is monitored. A study by Cowan et al18 looking at the learning needs of support workers, found that 76% of the cohort had received some form of on the job training, eg manual handling, health and safety, first aid etc, but they wanted more formal training and a recognised qualification such as National Vocational Qualifications (NVQs).

The study background

In this research project, six health support workers worked under the supervision of the Sure Start health visitors and health access team manager. Five were allocated to health visitors within the target areas and one, the breast-feeding advisor, had a peripatetic role. Formal qualifications were described as ‘desirable’ but not essential for the role.

Compulsory training included child protection, cultural and social awareness, child development, speech and language development and basic play techniques. New support workers received 12 weeks’ training from the Sure Start health visitors.

Referrals were made by the health visitors covering the Sure Start areas, although families living outside the designated areas could also receive the service. The health visitor retained responsibility for the care plan and supervised its delivery by the support worker. The intervention was specific to each referral and was intended to be clear, focused and limited to a maximum of eight weeks and agreed by the support worker, the service user and the health visitor. The health support workers also ran or assisted at various Sure Start groups, including support for teenage parents, parents of children with special needs and parents of multiple births, in addition to programmes to address children’s behaviour problems and postnatal depression.

The study aims and purpose

The aim of this aspect of the study was to evaluate the effectiveness and appropriateness of the services provided by the health support workers and address issues to improve the service identified by service providers and service users. The approach used was that of ‘realistic evaluation’, as proposed by Pawson and Tilley.18 They argue that many evaluation studies have tended to focus on outcomes but that this does not take into account the complexity of issues relating to community initiatives such as Sure Start. In order to achieve this, the context of the project was first considered in order to determine those local factors that would be influential in its success or failure. secondly, the mechanisms within the project that encourage a change were examined before finally evaluating the perceivable outcomes.

Methods

Ethical considerations

The local research ethics committee granted approval for the study prior to commencement. All participants signed consent forms after the purpose of the research was explained to them. Service users were sent leaflets giving details about the research project prior to interview and were given the opportunity to ask further questions before the interview began and asked to sign a consent form. They were also asked whether they still agreed to the information being used after the interview concluded. An interview schedule was used to ensure all of the relevant topics were covered.

Participants included all six health support workers employed at the time including the breastfeeding advisor and a purposive sample of 10 health visitors working in the Sure Start catchment areas, who had all made referrals to the health support workers. The service users were identified by five of the health visitors; each composing a list of clients referred to the health support workers. The researcher requested that they contact those at a certain point on the list. This procedure was employed to ensure a degree of random selection and confidentiality. Seven service users were sampled, five having received input from the health support workers and two from the breastfeeding advisor. The service providers were invited to take part in three focus groups, one included all the health support workers and two comprised five health visitors each. Each group discussion lasted approximately 90 minutes and a schedule was used to ensure that pertinent research questions were covered.

Participants were encouraged to talk freely on these subjects and any others of their choosing. The interaction between participants was considered pertinent to the outcome of the discussions and different emphases emerged within each group. Members of the research team were present and took separate roles as discussion leader, facilitator and observer. All the discussions were tape- recorded and transcribed. The researchers contacted the selected service users. Individual semi-structured interviews using a schedule with open-ended questions were conducted in their own homes. The method used to analyse the data from the focus groups was content analysis. This produced a system of categories and themes which allowed us to organise the data.

Results

Several themes emerged regarding the evaluation of the health support workers’ service, and these will be discussed under the three main areas of service evaluation advocated by Pawson and Tilley:19 context, mechanisms and outcomes.

Context of the study

The context of the study explored the conditions in which the support workers operate. Socio-economic analysis of the Sure Start areas using census data and the Welsh Index of Multiple Deprivation20 confirmed that they covered the poorest in the borough. Health support workers and health visitors discussed their experiences of the stress involved in working with some of the families living in these areas of high deprivation and the level of cultural awareness required. They acknowledged that some of the families were reluctant to fully engage with the service, although the majority of service users were positive about the interventions they had received.

It would be great if we all had middle-class mums who were really keen, then, you know. And would…’this is what you’ve got to do’ and they do it…I will say that I have, genuinely will have, for every one result I have two or three that don’t want me there.” (health support worker 2)

Some of the health visitors had negative views of Sure Start when it was first established, an attitude that may still be prevalent among health visitors working outside of Sure Start. They also expressed concerns about the lack of information regarding the training of support workers.

I think a lot of people thought, you know, that it’s a typical government initiative. You put all the money up front and make it look pretty and you’re not actually supporting the service. What we could have done with was more help within the service so you could do that yourself, (health visitor 1)

Training of support workers

Training of support workers was identified as an area that needs to be addressed in order to improve confidence in the service, as does the issue of support and supervision and awareness of safe working practices, in particular in relation to child protection. This study broadly supports the findings of Cowan et al18 and McDonnell and Lynch21 in highlighting these as fundamental issues regarding skill mix.

The support workers expressed their appreciation of the consistent nature of their clinical group supervision despite the fact that there is little research evidence available about its effects on reducing stress.22 However, individual supervision was an issue in that it was considered inadequate and was associated with poor staffing levels within management.

The career pathways and salaries of support workers within the health service are also areas that need to be further examined. Support workers and health visitors expressed concerns that salaries and grading did not reflect the level of responsibility they carried. Without some form of formal training, as advocated in the study by Cowan et al18 some might leave the service, wasting a valuable resource.

Mechanisms within the Sure Start service

The mechanisms that operate within this service appear to be based on the belief that families need targeted, time-limited interventions by support workers to change a particular aspect of their child’s health or behaviour.

You have to be really firm because you can’t be dealing in six to eight visits with all these etcetera… all these different things, so if they specifically said, the mother said… she needed help with potty training, say, and you go in and then she says “Oh, I want such and such,” the health visitor will usually have to refer again after that, (health support worker 2)

Parents had a choice of whether or not they received the service, although in some cases, it was pointed out that parents might have agreed to the referral to avoid the involvement of other services. A resistance to address issues by some families, particularly those with older children, was identified as a problem by the health support workers.

There was also an important objective to encourage families to remain involved with the service by moving on to support groups or other services after the programme of intervention had ended. Some service users had benefited from their involvement with the groups and the social aspect of the service had helped some parents with issues of social isolation and low self-esteem.

It was not possible to quantify what impact this was having on parent-child relationships but it can be surmised that it was beneficial. It is worth noting that the home-start befriending service was another option for families and was seen as providing a significant source of support by both professionals and service users. It has not been considered within the remit of this evaluation.

Providing a seamless service

Some of the comments made by service users suggest that the Sure Start programme provided a ‘seamless service’ with individual projects working together to ensure that families received appropriate levels of support. In one case this avoided a situation where the parent could have been overwhelmed by too many services visiting at the same time. The interlinking of the health support workers’ roles in baby clinics and support groups and through individual support was documented in the discussion groups, and some service users had been able to access other services as a result of their informal contact with the support workers. This gave a higher profile to the service and it is likely that a similar service that only provided home visiting and relied on professional referrals would reach fewer families.

Analysis and implications

Given the complexity of social situations and the number of other factors involved, an evaluation of long-term outcomes is not always practicable. This is the basic premise of ‘realistic evaluation’.20 This study only provides a snapshot view of the service, but some positive outcomes were identified. There was a general belief that the health support workers had had a positive impact on the health visiting service, enabling specific programmes of work to be carried out over a few weeks. This was seen as very difficult for overstretched health visitors to carry out themselves.

…it frees me up to do something else and frees my mind up, perhaps not worrying about that particular family because I know at least someone is going into that house and helping with a particular problem, whatever, you know. I find it invaluabk in that way. (health visitor 1)

There was also a widely held view among some health visitors and health support workers that the service had had an impact on social services referrals in that the use of Sure Start as an alternative to social services was becoming accepted practice. However this also gave rise to concerns about the appropriateness of certain referrals to the Sure Start programme and there was a view that the service could be seen as a ‘last resort’ for some families. However it was seen as important to give families an opportunity to receive a service that might prevent a referral to social services.

…I referred to social services as a family in need and they didn’t accept the referral and they were pushing for me to make a referral to Sure Start. They felt that Sure Start was more appropriate but I felt that social services was more appropriate. That caused a bit of conflict initially, (health visitor 2)

The existing internal system of evaluation of the health support worker service was regarded as inadequate. Health visitors were required to complete a simple evaluation form in consultation with the parent, giving an indication only of satisfaction with the service. In one discussion group there was evidently confusion about the process. It was clear from the interviews that the service users had been very happy with their contact with the health support workers.

Addressing children’s behaviour problems was seen as a more difficult area of work in terms of providing a successful outcome and perhaps this area requires more time and expertise than simply offering advice on methods that some parents claimed they had already tried. Although there was a general view that targeted and time-limited intervention is appropriate for most families, there will be situations where a longer-term approach may be useful.

… it could be that a health visitor’s said it’s behaviour management but it’s always something else isn’t it? Always. You come up with loads of things like, he may not be sleeping and he’s not toilet trained and they’re asking more while you’re on those visits and you’re not going to just say “Well, I’m not going to focus on that because I’m just in for this” do you know what I mean? (health support worker 3) Motivation of families

The motivation of families to work with the health support workers and follow the advice given was seen as crucial to the success or failure of an intervention. However it was also seen as unrealistic to expect a significant level of improvement in family circumstances in the majority of referrals in the short time available. The service needs to consider what it regards as a realistic target for successful outcomes. It is important to focus on the positive benefits for those families the service has helped. Where the advice has been successful it has an immeasurable impact on parent-child relationships and hopefully achieves the overarching aim of Sure Start, that those children are able to thrive when they start school.

Conclusion

The limitations of this study mean that there can be no firm conclusions regarding the possible long-term beneficial outcomes for children and their families by supportive interventions as suggested in the literature. However, this study confirms previous research in identifying the valuable contribution of health support workers in complementing the health visiting service, relieving the pressure on professionals’ workloads and providing support through home visiting, group work and clinics. Health visitors and service users positively acknowledged their contribution. Working in partnership with parents was seen as important and could be a basis for further research studies.

The study highlighted the issue of training and supervision of support workers, as well as concerns regarding their financial rewards and career pathways. These aspects have been articulated elsewhere in the literature and will need to be addressed if problems with staff retention are to be avoided. Within Sure Start, the stress involved in working with the most deprived sections of society is evident. This study indicates that skill mix can be successful in these circumstances and has pointed out areas for future consideration. This is of relevance not only to the health service in the UK, where the concept is currently being incorporated into government policy, but also to other service providers internationally, to ensure the provision of high quality and cost effective care.

An essential component of this strategy is partnership working, not only between professionals and agencies, but also with service users and communities

…health support workers had had a positive impact on the health visiting service, enabling specific programmes of work to be carried out over a few weeks

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Christine SmKh RGN PhD MN RNT RCNT

Director of Primary Care/Community Nursing

Cardiff University

Meryl Presser RGN RHV BSc PGCE

Lecturer – Primary Care/Community Nursing

Cardiff University

Lorraine Joomun RGN MSc RHV (CHS Dip) PGCE

Lecturer – Primary Care/Community Nursing

Cardiff University

Copyright TG Scott & Son Ltd. Nov 2007

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