Health promotion

Greater expectations
Nicola Brooke looks back on the first three years of a health promotion post which offers targeted training and multimedia resources to try to ensure that all children, wherever they live, have the opportunity to develop communication skills to their full potential.

tatistics on the prevalence of children with speech, language and communication needs vary considerably (Law et al., 1998) but anecdotal evidence and work carried out by I CAN (Hartshorne, 2006) seems to indicate the number of children experiencing delayed and / or impoverished language skills is on the increase. Whether this is due to increased awareness or an actual increase in incidence is not clear. What is clear is that the impact of such delays can be severe and long-term. Children entering school with delayed spoken language skills are unable to access the curriculum fully and consequently are at high risk of developing behavioural difficulties and low self-esteem. In the long-term they are more likely to leave school without the necessary qualifications to gain employment (Letts and Hall, 2003). To counter this, policies such as Every Child Matters and the National Service Framework (NSF) for children strive for preventative input rather than focusing on remediation of established difficulties. They call for more collaboration between services and with families. This all sounds like a good idea but - with constraints such as limited budgets and time - how can NHS speech and language therapy departments achieve this, and how can we measure the success of our input? I have been working as clinical lead speech and language therapist for health promotion for Southampton City Primary Care Trust since the post was created in 2004. Recent statistics for Southampton (DH, 2007) show significantly worse rates of GCSE attainment compared to the average in England, alongside significantly higher rates of income deprivation and children living in poverty. Consequently there is a strong need for health promotion activities within the city. I have been very fortunate to get joint funding to implement several initiatives targeting awareness of early speech and language acquisition. Each project has focused on increasing knowledge amongst practitioners and families of how to encourage normal language development and make onward referrals in a timely manner. There has been a strong emphasis on collaborative multi-agency working and inclusion of evaluation measures to assess effectiveness. 1. Training programme During the preschool years children access many professionals from health, education, social services and voluntary agencies including health visitors, nursery staff and childminders. In Southampton it is acknowledged that such 14

practitioners require support to increase their knowledge of early language development. Using funding from Sure Start local programmes and a Neighbourhood Renewal Fund, I devised a programme with colleagues for practitioners from all these services. The rationale is that if practitioners working with preschool children, especially those in deprived areas, can be skilled in supporting normal language acquisition it will help reduce the incidence and prevalence of preschool language delay. This in turn should improve academic outcomes for children. We have delivered the annual training programme three times and revised it several times based upon participant feedback. Whilst the main content has remained the same (see box 1) we now deliver it during a one day workshop rather than over 3-4 half days. We made this change to facilitate attendance, as many practitioners found it difficult to spare so many sessions from their work schedule. Alongside weekday workshops we now also offer evening workshops for childminders and others who are unable to attend during the day. Since implementing these changes attendance rates have increased from 69 to 83 per cent. Each workshop is delivered by two speech and language therapists, and lots of therapists from our department have been involved. This facilitates city wide

READ THIS IF YOU WANT TO ADDRESS THE ATTAINMENT GAP ASSOCIATED WITH DEPRIVATION SEND OUT CONSISTENT MESSAGES FROM YOUR DEPARTMENT EVALUATE OUTCOME AS WELL AS PROCESS

Over three years we have trained 164 practitioners from a range of disciplines. Participants have consistently demonstrated increased knowledge post training.
collaborative working and also ensures that all local therapists are promoting the same messages. We have evaluated the effectiveness of the workshops in three ways: I. Attendance registers allow us to monitor uptake of courses and the range of professionals trained. This is important as during early training we identified key professional groups who had not been invited and also patterns of failure to attend. These issues were then rectified for future workshops. II. Immediately prior to and following each workshop we ask participants to complete a questionnaire to assess their knowledge of areas covered. Analysis has allowed us to

quantify knowledge gained and to identify and alter teaching of particular areas where most participants failed to gain knowledge. III. Several months after completion we send participants a further functional questionnaire designed to evaluate how they have managed to implement their newly acquired knowledge into the workplace. This questionnaire also aims to identify any areas of training that could have been improved. The feedback has led us to offer refresher workshops to provide practical support to practitioners in converting theory into workplace practice. The content for example, clarifying referral criteria and procedures - is determined by requests from participants. The evaluations have shown positive outcomes in all instances. Over three years we have trained 164 practitioners from a range of disciplines (box 2). Participants have consistently demonstrated increased knowledge post training. During the most recent workshops participants showed limited baseline knowledge, with the majority achieving scores of between 0 and 25 per cent correct on the pre-workshop questionnaire. Post-workshop, 88 per cent achieved scores between 76 and 100 per cent correct (figure 1). Seventy one per cent of participants who returned a functional questionnaire rated the workshop as very good or excellent and 100 per cent reported that they could now identify children with feeding and communication difficulties. There will always be a percentage of children with specific speech and language difficulties who require specialist help from a speech and language therapist. However, empowering other professionals to facilitate communication development should help reduce the incidence of preventable speech and language delays resulting from impoverished language stimulation. 2. Literature Training professionals is just the tip of the iceberg when considering how to promote early communication development. Parental involve-

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2008

HEALTH PROMOTION

Box 1 Training course content What is communication? Pre-linguistic skills Receptive language How to recognise difficulties How to promote normal development and remediate difficulties Expressive language How to recognise difficulties How to promote normal development and remediate difficulties Developmental norms of language Creating opportunities for communication Speech development Categorising sounds Typical development and developmental processes How to promote normal development and remediate difficulties Eating and drinking Swallowing process Normal development Common difficulties and how to help Fluency Referral to the speech and language therapy service

Box 2 Range of professions trained Child minder Community health nurse Community worker Cook Crche worker Emotional literacy support assistant Family support worker Foster carer Health visitor Home play visitor Learning support assistant Figure 1 Recent workshop results 100 Percentage of participants
80 60 40 20 0

Librarian (book and toy) Nursery nurse Nursery practitioner Oral health educator Play project workers / supervisor Portage home visitor Pre-school practitioner Sessional worker Special needs practitioner Toy library van driver

Pre Post

Percentage of questions answered correctly

0 - 25%

26 - 50%

51 - 75%

76 - 100%

ment is central to success; if a parent is given the confidence they will do it for themselves rather than being done to. Yet reaching parents to promote communication development is not an easy task in a department severely affected by vacancies. In 2005, in collaboration with the local Childrens Information Service and using funding from Early Excellence in Cities, our department helped to script a magazine that could be distributed to families. This magazine contained information on how communication develops from birth to 4 years, top tips to promote development, ideas on how to manage dummies and television, the benefits of reading and singing to your child, how spoken language affects school transition and more. We circulated it to all families of preschool and reception aged children across the city and it was well received by parents and professionals alike. 3. Multimedia Following the success of the magazine the Childrens Information Service asked us to collaborate on a similar project but this time producing a DVD and CD-ROM. The use of disks rather than magazines to reach families has several benefits. The disk has been produced in the seven most used languages in Southampton so is accessible to a much wider audience. Additionally it includes video clips showing positive parent child interaction so families can learn by real life modelling rather than just reading advice. We made the videos in partnership with local families, so they are culturally appropriate to the local population. The disks cover speech and language development from birth to four. They are split into six developmental stages with each stage detailing what children should learn, how to help (using a film clip) and suitable home based items to play with. Additionally there are sections on frequently asked questions, how to seek further support and printable sheets summarising the disk content. Each disk has a section for parents / carers and a section for those who work with children.

They are due to be distributed to various locations including childrens centres, educational settings and community health teams. They will then be available to families via professionals who can support the implementation of the advice on the disk. We are also entering a number onto the city library catalogue so that parents and practitioners can always access a copy via their local library.

The disk includes video clips showing positive parent child interaction so families can learn by real life modelling.
Despite the huge success of the initiatives implemented so far, we need to address a number of ongoing challenges: a) Expectations Southampton is typical of many UK cities in that, whilst it has areas of affluence, it also has areas of extreme deprivation. Health promotion initiatives should help bridge the gap in achievement between children living in these different areas. However, one of the key factors in influencing change is altering the perception of parents and professionals that it is normal for children in deprived areas to present with delayed skills. All children entering state school have to access the same national curriculum regardless of where they live and their family circumstances. By accepting at a preschool stage that delays are normal for a particular geographical area - and consequently not providing support or referring on for specialist input - we are setting children up to fail on school entry, rather than to achieve to the best of their ability as promoted in Every Child Matters. b) Training gaps Reaching the right people for training will require ongoing analysis. So far we have accessed a large number and range of professionals but gaps

remain for differing reasons. Staff turnover is a major factor and its vital that new staff entering settings can access support. Staff shortages are also a difficulty; in Southampton midwifery shortages mean that we have been unable to provide training to this cohort of professionals, despite them being key to the right from the start approach to health promotion. c) Level of training Educating such eclectic groups of professionals certainly has its benefits such as sharing of knowledge from different perspectives and networking opportunities. However, one difficulty is pitching training at the right level to meet everyones needs. Most participants have been satisfied but some have expressed dissatisfaction at the level either being too low or too high. This is a difficulty experienced by other speech and language therapists providing training (Jack, 2004) and consideration is needed as to how to overcome this. d) Needs assessment Health promotion projects are only successful if a needs assessment has ascertained what requires promoting. One challenge to this is the evolving roles of early years professionals. In Southampton health visitors previously assessed childrens needs at 18 months and three years but are implementing a new strategy whereby assessments occur at two years and close liaison is implemented with childcare settings for children over three years. This change in service delivery will allow more time for domiciliary visiting for hard to reach families and those not attending pre-school but may result in new needs for example, will early education staff now need further training on informal assessment? Do health visitors require support regarding assessment of two year olds? Other needs may be culturally driven. Southampton is a culturally diverse city where a large number of languages are used so support is required with identifying language impairment versus delay in English as a result of bilingualism. There is also a need to train bilingual workers on how to assess bilingual children in their first language. 15

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2008

health promotion e) Outcome assessment Evaluation of the effectiveness of projects so far has shown positive results. However, most evaluation has focused on the process of the projects or how did it go? rather than the outcome or what has changed? In the climate of Every Child Matters and the NSF, we have to find more rigorous ways to measure the effectiveness of health promotion projects, both to ensure high quality input and to secure funding for further work. In Southampton we are considering several options including video studies of practitioners interaction with children pre and post training to analyse behaviour change and a longitudinal study of referrals to the speech and language therapy service. If health promotion work is successful in reducing preventable delays this study would expect to see an overall drop in referrals. Those received would be predominantly specific language impairment or language impairment related to a secondary diagnosis rather than straightforward delay. The projects in Southampton so far have resulted in an increased awareness of the importance of speech and language development in young children and how to facilitate age appropriate skills. They are being supported by other initiatives such as Sure Start and Portage groups which target early communication and feeding. However, a continued focus is required to maintain strategies that are being implemented and to establish new ideas to complement these. There are lots of challenges to overcome and, as with remediation work, we must continue to implement outcome measures to demonstrate evidence based practice. I am very aware that in Southampton we have a long way to go and that things wont change overnight. But through continued training, research and collaborative working we will be able to challenge perceptions and to educate professionals and families that all children need to develop early communication skills in order to succeed to the best of their ability and develop to their full potential. Nicola Brooke is Speech and Language Therapist, Clinical Lead for Health Promotion with Southampton City Primary Care Trust, tel. 02380 SLTP 716680.

REFLECTIONS

References

APHO and Department of Health (2007) Southampton Health Profile. Available at: http://www.communityhealthprofiles.info/profiles/hp2007/lo_res/00MS-HP2007.pdf (Accessed: 24 January 2008). Department for Education and Skills (2003) Every Child Matters summary (2003). DfES Publications. Available at: http://www.everychildmatters.gov.uk/_files/B889EFF62F56A9E4C69778A869B3DA44.pdf (Accessed: 24 January 2008). Department of Health (2004) National Service Framework for children, young people and maternity services: Executive summary. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_4089100 (Accessed: 24 January 2008). Hartshorne, M. (2006) The Cost to the Nation of Childrens Poor Communication. London: I CAN. Jack, A. (2004) How I am making a Sure Start Turning the future around, Speech and Language Therapy in Practice Summer, pp.24-25. Law, J., Boyle, J., Harris, F., Harkness, A. & Nye C. (1998) Screening for speech and language delay a systematic review of the literature, Health Technology Assessment 2 (9), pp.1-184. Letts, C. and Hall, E. (2003) Exploring early years professionals knowledge about speech and language and development and impairment, Child Language Teaching and Therapy 19 (2), pp.211-229.

1. DO I GIVE CLIENTS THE OPPORTUNITY TO BE PART OF PROJECTS SUCH AS MAKING MULTIMEDIA AND MULTICULTURAL EDUCATIONAL MATERIAL? 2. DO I EVALUATE WHO ATTENDS MY TRAINING, WHAT THEY LEARN, THE IMPACT ON PRACTICE AND THE OUTCOME FOR CLIENTS? 3. DO I OFFER A FAIR SERVICE TO ALL CLIENTS, OR ARE MY EXPECTATIONS SUBCONSCIOUSLY INFLUENCED BY CONTEXT? How has this article been helpful to you? What health promotion initiatives are working in your area? Let us know via the Spring 08 forum at www.speechmag. com/Members/

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SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2008