Which health visiting models in England are most promising for mitigating the harms of maternal related Adverse Child Experiences?

Background: Parental alcohol and substance misuse, mental health problems and domestic violence and abuse are common adverse childhood experiences (ACEs) which are associated with worse health and development outcomes for children. As the data we are using captures children whose mothers (not fathers) had a hospital admission for one of these ACEs, we call them 'maternal ACEs'. Health visiting is designed to assess, monitor and support children affected by ACEs, including maternal ACEs, as well as deliver universal care to every child in England. However, we know little about the coverage, intensity, type and costs of health visiting in practice, to what extent health visitors support families living with maternal ACEs and how this is balanced with providing care to all families in their local area. Aims and objectives: To determine 1) which factors determine the coverage, intensity, type, resource-use and cost of health visiting services received by families with and without maternal ACEs; 2) which health visiting models are most promising for mitigating the impact of maternal ACEs; and 3) what these results mean for local and national decision-makers and families. Methods: The study is based on a subset of all births in England 2015-2019. We have to use a subset of all births because only about 25% of local authorities in England have sufficiently complete health visiting data to analyse. We will identify families exposed to maternal ACEs in longitudinal hospital admissions data on mother-baby pairs (HES) linked with health visiting data (Community Services Dataset; CSDS). We will combine this with information on local area need (e.g. deprivation) and surrounding services (e.g. the Family Nurse Partnership). We will use a national survey of practice in all 152 local authorities to collect extra information not available in CSDS and to extend our data beyond the subset of local areas with complete data in CSDS to all local authorities in England. We will conduct in-depth qualitative case studies in up to 6 local authorities , including interviews with Directors of Public Health, health visiting commissioners and managers, health visitors and mothers, plus analysis of locally held administrative data. Work package (WP)1: Months 1-24. We will produce a taxonomy of 3-5 'Äòmodels'Äô of HV, grouping all 152 local authorities in England according to similarities in coverage (universal / targeted), intensity (e.g. patterns of repeat contact) and type (face-to-face, phone, group) of services delivered to families with/without maternal ACEs. We will i) describe indicative resource use and cost for each model; ii) generate detailed descriptions of factors associated with differences between local authorities using qualitative case study methods in up to 6 areas of England s (e.g. local area need/surrounding services) and iii) use key stakeholder input, including with groups of parents who have relevant lived experience to create robust hypotheses about how each model works for families exposed to maternal ACEs. WP2: Months 25-42. We will use the taxonomy to evaluate associations between different HV models and select child and maternal outcomes, for families with/without maternal ACEs. Outcomes captured in HES-CSDS will include child development (Ages and Stages Questionnaire), child safety/harm from adverse caring environments (child injury or maltreatment-related admissions), and post-birth maternal ACEs (adversity-related hospital admissions in mothers). We will explore differences the associations through qualitative work and engagement with key stakeholders. In year 4, we will use updated data and stakeholder engagement to assess the meaning, validity and generalisability of our results, including for a post COVID-19 context. WP3: Months 42-48. We will review existing HV quality metrics, based on integration of findings from WP1 and 2, and provide evidence summaries in order to inform local and national implementation of services. Impact/dissemination: We will work collaboratively to disseminate our findings to key stakeholders and families. The evidence will inform the modernisation of the Healthy Child Programme, and be used by local leaders when planning and revising their Start for Life Offer for all babies and very young children in their areas.