Well Child Health Care in Wales: A Change of Setting, a Shift of Power
—Jennifer Herman (Edited by Abby Noyce)
As a nursing student I know that promoting health is as vital as treating illness.
Lifelong health begins by building a healthy foundation in childhood. The well child health care system provides services to children and their families from birth through adolescence to prevent illness and promote health. To study an alternative way to deliver this care, I spent nine weeks in 2006 observing the structure of well child health care in Swansea, Wales. I wanted to understand the Welsh system through seeing the day-to-day work of health care providers and meeting the families they cared for. I returned home with many experiences to reflect on and new perspectives on health care, communities, empowerment, and myself.
Wales, part of the United Kingdom, and Swansea, its second largest city.
In the United Kingdom, the country of Wales boasts a dramatic terrain. It has miles of cliff-lined beaches, high mountains, deep valleys, enchanting castles, and eleven million sheep spotting its famous green hillsides. Swansea, as the poet Dylan Thomas once wrote, is an “ugly, lovely town” (Thomas, 1954). After central Swansea was bombed in World War II, hurried reconstruction of the downtown left a hodgepodge of rooftops and building fronts, creating Thomas’s “ugly loveliness.” Swansea’s lackluster architecture is offset by five miles of beaches along Swansea Bay, parks by the university, a covered market, a marina, and rows of tall houses lining the steep hillside above the sea.
This was the backdrop of my summer. As I settled in, I learned that like all cities, Swansea consists of more than its shores and shopping malls. Swansea also has a dynamic population spanning ages, ethnicities, and socioeconomic classes.
The Welsh Health Care System
In Wales, every person has access to health care through the National Health Service (NHS). The NHS is comparable to the Social Security system of the United States in that everyone pays into a common pool. With funds from this pool, health care is provided to all Welsh people as needed. Similar to Social Security in the United States, the NHS is having difficulty sustaining a balance between the growing health care needs of an aging population and the shrinking numbers of people paying into the system. This scarcity of resources affects well child health care because acute needs take priority over health promotion.
Although both systems have similar financial structures and problems, the Welsh system is very different in the setting where care is provided. Most American children visit a primary care provider in an office setting for a series of well child checkups that include physical and developmental assessment, immunizations, and education for the parent(s). In Wales, health care delivery occurs primarily in the community and to a lesser degree in a clinic or office as in the United States. During my nine weeks of research I went to schools, homes, community centers, neighborhood youth clinics, support groups, play groups, community development meetings, and even on a field trip to a zoo on a hillside farm. The delivery of well child health care happens in the places where children live, grow, and play. This focus on community-based care distinguishes the Welsh well child health care system from its American counterpart.
A school health lesson on healthy eating.
In Wales well child health care begins with a midwife who provides care for the mother and infant until ten days after birth. From then until school age, a health visitor (a specially trained public health nurse) cares for the family through home visits, well child checkups in the community clinic, and community groups. Once a child reaches school age, well child health care is provided through the school health nurse. Health visitors and school health nurses both specialize in community health and care for the well child population. As key members of the primary care team, both groups of nurses focus on health promotion by collaborating with general practitioners, parents, schools, and school-aged children to foster growth and development.
In the Home and Community: Health Visiting
Health visitors are on the front lines of well child health care. Each health visitor is responsible for several families living in the same neighborhood. They meet with families in their homes as well as at community health clinics. They assess child development, educate parents, and provide support, counseling, and a connection to community resources during the often stressful years of early childhood. Taking into consideration the needs of the families in their caseload, health visitors create community groups to support these children and their parents.
A Swansea neighborhood where a health visitor may visit several families in a day.
Four primary goals of health visiting are searching for health needs, increasing awareness of health needs, influencing policies that affect health, and facilitating health-enhancing activities (CETHV, 1978). These health-promoting goals guide the nursing processes of assessment and identification of needs, planning and implementation of care, and evaluation (Orr, 1985). By mobilizing care from the clinical setting into the home and community, health visitors can more fully understand the context in which each child lives.
The interactions between parents and health visitors that I observed on home visits were unlike interactions that happen in clinical health care settings. The family invited us into their home, offered us a seat on their couch, and began the conversation. We were guests in their space. The walls were decorated with family photos, not diplomas or posters of the anatomy of the ear. Sounds of barking dogs, arguing neighbors, cartoons on television, and brewing tea kettles filled the space. In clinics families do not control the environment, but in the home power is with the families. Empowerment is in itself health promoting. This shift in power strengthens the relationship between families and health visitors.
In the School and Community: School Health Nursing
Unlike most American school nurses, the Welsh school health nurses had an office at a health center and traveled from there to their schools. The seven nurses I worked with all shared one office with two desks, only one phone, and limited storage space. This was an early clue that resources for school health were scarce.
School health nurses in their limited office space.
Each nurse was responsible for over four thousand students at more than a dozen schools. At each school the nurses are responsible for promoting health through height, weight, and vision screening; immunization programs; and education on topics from hygiene and nutrition to puberty and adolescent sexual health. Each school health nurse I spoke with told me that the high number of children in their caseload prevented them from delivering optimal well child care. The school nurses were spread too thinly to establish health-promoting relationships like those between health visitors and families.
The school health structure has the potential to effectively promote child health if more resources are allocated to it. However, the NHS does not have the extra funds to spend. This shortage manifests itself in the lack of school health nursing jobs available. Despite the identified need for school health nurses, school health nursing students from Swansea University were worried about their future employment. As is often the case, health promotion is left under funded when resources are scarce. I shared the nursing students’ frustration at the disparity between needs and funds and began thinking about the ways that resources are allocated.
Inequity and Community-Based Health Care
As I gained understanding of the well child health care system, I recognized that I needed to examine it in the context of broader systems including socioeconomic, political, and cultural ones. These systems affect the workings of the health care system as well as individual, family, and community health. Imbalances in these systems affect human growth and development, especially in the formative years of childhood
I understood this concept more fully by accompanying health visitors into homes in many areas of Swansea. These homes varied in their proximity to the road, quality of the sidewalk, amount of garden space, and state of upkeep. The environments that people live in shape their health. Lower class neighborhoods often had high levels of air pollutants, even indoors. Houses in these areas had hardly any grassy space in front and frequently needed structural repairs. Each of these aspects will negatively affect the overall health of the people who live there. Families with more money live in healthier environments because they have the economic and political power to make healthier choices, and this affects their wellness on all levels.
The NHS provides equitable access to health care but cannot compensate for the disparities in the other systems. Community-based health care professionals cannot level the entire playing field, but they can contribute to a more just society by shifting power to the people to whom they provide care. By understanding the whole picture of each child’s environment, community-based health care providers are in a prime position to advocate for systemic changes.
Coming Home
When I returned from spending the summer researching child health, many people asked, “So, do you want to be a pediatric nurse?” Despite my concern for childhood health care, I do not want to specialize in pediatrics. I am interested in the whole spectrum of human health. Childhood, the most rapid period of growth and development, is at the core of lifelong health. For this reason, well child health care is essential. However, throughout our lives we develop as individuals in the context of our family, our community, our society, and our world.
The author enjoying a Welsh afternoon at Rhossili Beach, outside Swansea.
My trip to Wales took me out of my familiar New England context. My friends and family were an ocean away, and I found myself growing and developing in my new environment. I filled two and a half journals during my summer in Wales. To write this article, I reread those pages to refresh my memory. Many pages are filled with the joy of adventurous days. I explored the Gower Peninsula, encountering sheep, cattle, and wild horses; conversed with friendly locals; sang with a Welsh choir; and created art by the ocean with community artists. Many journal pages are also filled with questions: What does it mean to be an American outside America? What was it like for the generations before me to travel over the Atlantic just as I had? How will I feel when I return home?
Months later and back home, I continue to ponder these questions. Although it was only a nine-week trip, my summer in Wales enabled me to create a space away from my comfort zone, where my sense of home was not in the destination but in the journey itself. My experiences solidified my belief in the power of human interaction and the value of striving for healthier environments in our local and global communities. As I prepare to leave the University and embark on my nursing career, I carry these ideas as a reminder that each of us has the power to shape our world simply by engaging in it.
My research experience could not have happened without the guidance, support, and encouragement of many people. I would like to thank my mentors, Dr. Gene Harkless from the UNH Nursing Department and Dr. Joy Merrell from the University of Wales in Swansea, for the countless hours they spent encouraging my intellectual curiosity. Thank you to the International Research Opportunities Program and its donors for creating this opportunity for me, particularly staff member Dr. Georgeann Murphy. Thank you to the members of the UNH community for creating an enriching context for me to grow and develop. Lastly, my sincere gratitude extends to the welcoming people of Wales for sharing their insight, humor, and knowledge with me for an incredible nine weeks.
References
An Investigation into the Principles of Health Visiting, (1977). Council for the Education and Training of Health Visitors: London.
Orr J., (1985). “Assessing Individual and Family Health Needs.” In: Luker K., Orr J. (Eds) Health Visiting. Blackwell Scientific: Oxford.
Thomas, D., (1954). “Reminiscences of Childhood”. In Quite Early One Morning. New Directions: New York.
