Ethical tensions associated with the promotion of public health policy in health visiting: a qualitative investigation of health visitors' views.

AIM: To explore whether and how health visitors experience ethical tensions between the public health agenda and the need to be responsive to individual clients. BACKGROUND: Current health policy in England gives health visitors a key role in implementing the government's public health agenda. Health visitors are also required by their Professional Code to respond to the health-related concerns and preferences of their individual clients. This may generate tensions. METHODS: A total of 17 semi-structured individual interviews covering participants' experiences of implementing public health interventions and perceptions of the ethical tensions involved were conducted. Interviews were audio-recorded, transcribed and analysed thematically using a Framework approach. FINDINGS: Health visitors raised a number of ethical concerns, which they attributed to organisational resource allocation and the introduction of protocols and targets relating to public health goals. They did not always regard it as appropriate to raise topics that employing organisations had identified as public health priorities with particular clients for whom they were not priorities, or who had other more pressing needs. They noted that resources that were allocated towards reaching public health targets were unavailable for clients who needed support in other areas. Organisational protocols designed to monitor performance put pressure on health visitors to prioritise achieving targets and undermined their ability to exercise professional judgement when supporting individual clients. This had implications for health visitors' sense of professionalism. Health visitors saw trusting relationships as key to effective health visiting practice, but the requirement to implement public health priorities, combined with a lack of resources in health visiting, eroded their ability to form these. Policies need to be evaluated with regard to their impact upon a broader range of processes and outcomes than public health goals. The erosion of health visitors' professional values and ability to develop relationships with clients could have numerous adverse implications.

Health visitor professional education and post-qualification clinical supervision: how well does it equip practitioners for dealing with ethical tensions associated with promoting the public health agenda to individual clients?

AIM: To explore how well professional education and post-qualification clinical supervision support equips health visitors to deal with ethical tensions associated with implementing the public health agenda while also being responsive to individual clients. BACKGROUND: Current health policy in England gives health visitors a key role in implementing the government's public health agenda. Health visitors are also required by their Professional Code to respond to the health-related concerns and preferences of their individual clients. This generates a number of public health-related ethical tensions. METHODS: Exploratory cross-sectional qualitative (interpretive) study using 29 semi-structured individual interviews with health visitors, practice teachers and university lecturers exploring how well health visitors' professional education and post-qualification clinical supervision support equips them for dealing with these ethical tensions and whether they thought further ethics education was needed. Interviews were audio-recorded, transcribed and analysed thematically using a Framework approach. FINDINGS: Health visitors' professional education did not always equip them to deal with ethical tensions, which arose from delivering public health interventions to their clients. However, the majority of participants thought that ethics could not be taught in a way that would equip health visitors for every situation and that ongoing post-qualification clinical supervision support was also needed, particularly in the first year after qualifying. The amount of post-qualification support available to practising health visitors was variable with some health visitors unable to access such support due to their working circumstances and pressures on staff time. Literature on the ethical tensions associated with evidence-based practice; public health ethics and ethics of care might be useful for health visitors in gaining greater understanding of the ethical tensions they face. This could be introduced as part of health visitors' professional education or on post-qualification study days.

'Facing the future': the government's real agenda for health visitors.

This paper draws on the ideas of Foucault to analyse the government's recent review of the role of health visitors in England, 'Facing the future'. It outlines the Foucauldian concepts of discourse, knowledge and power and examines the review document following an accepted six-step process for the analysis of discourse. The analysis considers how 'Facing the future' constructs the present and future roles of health visitors, and elucidates the 'regimes of truth' that operate in official policy. It highlights the way in which the document proposes a shift away from health visitors' traditional emphasis on building supportive relationships with clients, toward a stronger emphasis on outcome-oriented service provision by multi-skilled teams. In line with contemporary public health discourse, 'Facing the future' also reinforces the future role of health visitors as being one that supports individuals to make lifestyle changes to improve health rather than addressing wider environmental and social determinants. Although 'Facing the future' purports to reflect a consultative review and to encourage debate within the health visiting profession, its form is more akin to a promotional document to implement government proposals for social change.

Childhood obesity: bringing children's rights discourse to public health policy.

Childhood obesity is widely understood as a public health issue, but is not commonly understood from a legal perspective. Children's rights discourse can add significant empowerment to public health-based policy, which alone lacks effectiveness in the face of commercial and other counteracting influences. The United Nations Convention on the Rights of the Child has the potential to be used by advocates for children's health to facilitate child health policies pertaining to the issue of childhood obesity. This is because children's rights, as defined in the articles of the convention, establish the essential conditions required by children to achieve optimal health and wellbeing. A rights-based approach may improve children's welfare by encouraging a less fragmented approach to the issue of childhood obesity. The articles of the convention can be used as a template for interdisciplinary collaboration, with a more coherent outcome possible. By articulating childhood obesity as a children's rights issue--not just a public health issue--a more effective strategy for addressing the problem can be developed and implemented.

Performance of a population-based cardiac risk stratification tool in Asian patients with chest pain.

OBJECTIVES: Most contemporary cardiac risk stratification tools have been derived and validated in mixed-race populations. Their validity in single-race populations has not been tested. The authors sought to compare the performance of a risk stratification tool between a mixed-race U.S. patient population and an Asian patient population. METHODS: This study is an analysis of data from the Internet Tracking Registry for Acute Coronary Syndromes (i(*)trACS) registry of patients with chest pain presenting to the emergency departments of eight U.S. centers and one site in Singapore. The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) was computed for included patients, and its performance in predicting acute coronary syndrome (ACS) was compared between patients from the United States and Singapore. RESULTS: Of the 11,991 included patients, 1,120 experienced ACS. Although the ACI-TIPI demonstrated similar accuracy among groups (area under the curve, 0.729 [U.S.] vs. 0.719 [Singapore]; p = 0.5611), sensitivity and specificity were different when equal ACI-TIPI thresholds were considered. Recreating the logistic regression models used to create the ACI-TIPI showed similar results between the derived parameters and the parameters estimated for the U.S. group. In contrast, age older than 50 years (log-odds ratio [LOR], 0.107; 95% confidence interval [CI] = 0.518 to 0.713), male gender (LOR, 0.487; 95% CI = 0.149 to 1.122), and chest pain as a primary complaint (LOR, 0.237; 95% CI = 0.139 to 0.613) had little predictive power in patients from Singapore. CONCLUSIONS: Differences exist in presentation and factors associated with ACS among patients from the United States and Singapore that may affect the performance of risk stratification tools. These findings suggest that cardiac clinical decision rules need international validation.