Systematic reviews have shown that in high-income countries approximately 10% of pregnant women, and 13% of those who have given birth, experience some type of mental disorder, primarily depression or anxiety. Mothers who have mental illness and their families have been recognised as prime targets for early intervention strategies, to prevent the intergenerational transmission of mental illness. Research to date has suggested that health visitors are in a crucial position to support not only the mother’s mental health, but also the family. Family focused practice (FFP) is an approach that recognises the inter-related needs of family members, and the need to address and support the shared needs of the whole family. This approach to practice is thought to improve outcomes for families when mothers have mental illness. While family focused practice has been explored within the disciplines of mental health nursing and social work, there is limited evidence in the field of health visiting. Studies which have examined health visiting have often solely considered research questions from the health visitor’s perspective. There are no studies to date which have explored health visitors’ family focused practice with mothers who have mental illness or who have sought to integrate the perspectives of health visitors, mothers and their partners.
This thesis aimed to explore multiple perspectives of health visitors’ FFP with mothers who have mental illness and their families. The objectives included; a) To investigate the predictors of health visitors’ FFP; b) To measure the level of health visitors’ FFP; c) To determine the psychometric properties of the family focused mental health practice questionnaire in health visiting; d) To explore health visitors’ experiences of FFP; e) To explore mothers’ experiences of FFP within health visiting services; f) To explore partners’ experiences of FFP within health visiting services; g) To develop recommendations for the future development of health visitors’ FFP, with mothers who have mental illness and their families.
In order to critically appraise and synthesise the current literature on health visitors’ family focused practice, two systematic reviews were conducted. The first was a qualitative systematic review synthesising the experiences of health visitor’s family focused practice for mothers who have mental illness and their families. The second review explored the quantitative literature and included a meta-analysis to examine the effectiveness of family focused health visiting interventions for mothers with mental illness.
At the outset of this thesis a matrix of family focused activities was developed to categories high, medium and low rated activities. The matrix was used within the systematic reviews to determine if the study could be considered to be family focused and suitable of inclusion. In addition, the matrix was used to determine what family focused activities health visitors are engaging in based of the present findings.
Based on the findings from the reviews, a sequential mixed methods design was employed, consisting of a cross sectional survey in phase one, followed by semi-structured interviews with health visitors, mothers who have mental illness and their partners in phase two. Two hundred and thirty health visitors completed the Family Focused Mental Health Practice Questionnaire. In addition, ten health visitors with high and low scores on the Family Focused Mental Health Practice Questionnaire (FFMHPQ) completed follow up interviews. Eleven mothers who had mental illness and seven of their partners also took part in semi-structured interviews.
Data from phase one was analysed through descriptive and inferential statistics, namely, t-tests, analysis of variance and multiple regression analysis. The regression analysis tested whether workload, professional knowledge and health visitors’ professional and personal experience predicted their family focused practice. In order to test the psychometric properties of the FFMHPQ an exploratory factor analysis and tests of internal consistency were conducted. Data from phase two was initially analysed through thematic analysis of each group (i.e. health visitor, mother, partner), after which the three perspectives were synthesised. Mixed methods analysis entailed integration of quantitative and qualitative data following a triangulation protocol approach.
The qualitative systematic review found three main findings: (a) parents’ needs regarding health visitors’ family-focused practice, (b) the ambiguity of mental illness in health visiting, and (c) the challenges of family-focused practice in health visiting. However, exploration of these themes identified problematic areas for consideration; the limited views of service users, a lack of distinction between mental health and mental illness, and a lack of continuity in how family focused practice was defined. Furthermore, findings from the meta-analysis indicated that there was no effect of health visiting interventions on maternal depression and maternal stress.
The exploratory factors analysis revealed a 2-factor solution consisting of 20 items, compared with a sixteen-factor solution with 45 items, in the original scale. Internal consistency of the new scale was assessed by Cronbach's alpha and was considered as excellent α = 0.949.
The questionnaire was completed by 230 health visitors from 5 Health and Social Care Trusts across Northern Ireland. All participants were female, with a mean age of 44.31 (SD = 9.35). Three multiple regression models were developed to test whether workload, professional knowledge and health visitors’ professional and personal experience predicted their family focused practice. Model three (professional and personal experience) was significant (p < .01), while models one (workload) and two (professional knowledge) were not.
Thematic analysis of interview data suggested that health visitor’s family focused practice largely consisted of supporting the mother and child, with partners seen as secondary. In addition, underpinning health visitor’s family focused practice were feelings of stigma and fear of mental illness and traditional perceptions of the family and gender roles (i.e. father as the breadwinner). Following synthesis of the three perspectives (health visitor, mother and partner) it was evident that health visitors and mothers converged on many issues, including the influence of the health visitor’s personal qualities and personal and professional experiences on their practice and relationships with mothers. Dissonance was largely found in relation to differing perceptions of the partner, for example, mothers and health visitors had views of the partners that were not in agreement with how the partners viewed themselves. Partners did not see themselves as the primary focus of health visitors, nor did they believe that health visiting support would be beneficial. Contrary to this both health visitors and mothers believed that partners required support in relation to their own well-being.
After integration of quantitative and qualitative data, findings suggested that Family Focused Practice, is not only an approach to practice, it is also a mentality; the manifestation of ideologies (such as family, gender and mental health) through an individual’s behaviour and attitudes. Viewing family focused practice in this way, clarifies why physical attributes of the healthcare system, such as workload, and knowledge, did not predict health visitor’s family focused practice. It is also not only influenced by the health visitor’s perceptions but also the family that the health visitor works with, and their mentality towards gender roles, mental health and support. Mothers and partners that had more traditional views of gender roles within the family were less likely to believe that the partner required support, thus the partner had less engagement with the health visitor. In addition, mothers who feared the stigma of mental illness, were more reluctant to seek support from their health visitor.
The findings from this thesis suggest that health visitors engage in family focused practice that is centred on supporting the mother and child, which is considered to be at a relatively low level. While UK policy endorses a whole family approach, it does not stipulate what family focused activities health visitors are expected to engage in. Due to this lack of clarity, it is unclear whether health visitors are expected to undertake low, medium or high family focused activities. High level family focused activities may not be realistic for health visitors to achieve giving their role, remit, skills and knowledge. In addition, if health visitors do not engage with fathers they will never surpass low level FFP. If health visitors want to improve engagement with partners there needs to be more understanding of what support would be suitable. Based on the findings from this thesis, partners should be enabled to support the mother, through providing them with the skills and knowledge to do so. Furthermore, health visitors’ family focused practice needs to be viewed through an ecological lens, which considers micro, meso and macro level influences, particularly issues like stigma of mental illness, conceptualisations of the family and gender roles.
|Date of Award||Jul 2020|
- Queen's University Belfast
|Supervisor||Mark Linden (Supervisor) & Anne Grant (Supervisor)|