"Knowing Me, Knowing You, Knowing Us: Anwen Naylor- Evans (Health Visitor). This innovative three phased project has used an Action Learning approach to develop an integrated community perinatal mental health service for women in Andover
“Knowing Me, Knowing You, Knowing Us: Anwen Naylor- Evans (Health Visitor) This innovative three phased project has used an Action Learning approach to develop an integrated community perinatal mental health service for women in Andover.
Phase 1: In response to service user feedback a perinatal mental health support group called “Knowing Me, Knowing You” was developed as a collaborative partnership between Andover Mind and the health visiting team, with supervision provided by Melbury Lodge in-patient perinatal mental health unit. The group programme was delivered over 7 weeks and comprised a 2 hour session for women experiencing mild to moderate perinatal mental health difficulties. Group facilitation was undertaken by a health visitor, community nursery nurse and a well-being practitioner provided by Andover MIND. The aim of the group was to enable mothers to talk about their feelings, develop new coping strategies by developing a personal wellness toolkit and mindfulness techniques, improve parental confidence by focussing on infant mental health and attunement, and to provide an environment that was conducive to the development of social support networks. Alongside the mental health component, activities for mother and baby were incorporated into each session, ranging from rhyme time to baby massage. Fathers were also invited to attend a one off “dads” session on a Saturday morning to offer information and advice on living with perinatal mental health difficulties and respond to the individual needs and requirements of these fathers.
The results from the initial pilot were very positive. Seven women were referred into the group programme and all 7 women enrolled and completed the full course. The mean group Edinburgh Postnatal Depression Scale score was 16/30 at the start of the programme, with an improved rating of 11/30 at the end. Parental confidence was measured using the Karitane Parental confidence scale and this showed an improvement over the course of the programme, with a mean pre-course KPCS score of 33.8 and post –course score of 38, demonstrating a mean increase of 4.2.
Qualitative findings were positive and are captured in the following quote: “Until the group I felt like I was the only one and very isolated which made me scared to ask for help as I didn’t really understand what was wrong… the group helped me do something about what was wrong and understand my feelings and reactions… The group sharing and my HV helped me trust and gain confidence”
The initial pilot project results have been shared with the Perinatal mental health “champion” health visitors across the Trust and the Wessex Regional Perinatal Mental Health pathway group and this project will now be replicated across Hampshire.
Phase 2: Perinatal mental health service co-design: Women with perinatal mental health problems have been highlighted as “hard to reach” with traditional group settings and children centre activities. Understanding their views and experiences of the health visiting service is central to designing a perinatal mental health service that is more responsive to mothers’ needs. The mothers who had attended this 7 week group programme were invited to a co-design forum one week after the last group session. The King’s Fund experience based co-design toolkit was used in an amended format to suit the community and mental health focus http://www.kingsfund.org.uk/projects/ebcd
Experience based co- design involves gathering experiences from patients through in depth interviewing, observation and group discussions, identifying key touch points (emotionally significant points) and assigning positive or negative feelings. A short edited film is created from the patient interviews. Findings convey in an impactful way how patients experience their illness and the service. Patients are engaged in the process to explore the findings and to identify ways to improve the service.
7 mothers engaged in the forum and were able to share their views in the group discussion which was captured on flipcharts and by completing a questionnaire based on the Experience based co-design questions. Four of these mothers also consented to participate in video recorded interviews.
The findings from all forms of data collection were presented as a timeline to represent the perinatal mental health treatment journey. The mothers were also asked to consider ways to address the identified themes, called co-design strategies, as they arose at the parent forum and a few weeks later, once the main themes had been collated. The co-design strategies included: More information in the antenatal period on the range of physical and psychological symptoms of perinatal mental health difficulties to improve early recognition; information in the antenatal period for partners and ways for them to provide improved support; greater awareness of the potential impact of a traumatic birth on emotional wellbeing, with earlier signposting to support; earlier availability/ recommendation of support available; signposting to information on managing and treating perinatal mental health difficulties and ways of coping, ideally in the form of a website; improved access to group provision for mothers experiencing perinatal mental health difficulties in the antenatal and postnatal period; and a recommendation that health professional address the needs of fathers– these mothers suggested that this simply required health practitioners to speak to fathers and ensure that they felt included at every appointment. The mothers in the co-design group are working with the health visiting service to design a more acceptable perinatal mental health leaflet which contains the “patient voice” as a means to address stigma, encourage parents to talk about how they are feeling and ensure that more parents who are experiencing perinatal mental health difficulties are able to access appropriate support. The Trust Communications team are also working with the Health Visiting Service to produce a short case study and film which captures women’s experiences of perinatal mental health difficulties and support available.
Phase 3: The group of mothers who engaged in phase 1 and 2 have now established a peer support group called “Knowing Us” that meets weekly at the local Children centre and is an open group available for all mothers who are experiencing perinatal mental health difficulties in Andover. The group members are currently in the process of applying for formal charitable status and honorary contracts as Trust volunteers.
This project has been developed in partnership between the Andover health visiting team, Andover MIND, Melbury Lodge Perinatal Mental Health team, Spring Meadow (Action for Children) Children Centre and service users. Details of involvement are contained in the project report above.
Phase 2 of this project describes an innovative approach to service user engagement in service co-design that seeks to move beyond superficial Friends and Family Test to capture feedback. The project used the Kings Fund Experience based co-design toolkit to capture rich data across the patient journey. The findings have been used to shape health visiting perinatal mental health services within the trust and have also been shared more widely at the Wessex Region Perinatal mental health multi-agency group.
This project has used an action learning approach that relies on continual reflection, listening and adaptation to improve services. We consider that this is a “work in progress” and anticipate that we will continue to make numerous changes to our service model in the months ahead. In hindsight we would have benefitted from including the midwifery service in phase 1 of this project, however they have now become an integral part of phase 2 and wider roll out of this project. We recognise that midwives are key stakeholders to raise awareness of perinatal mental health problems in the antenatal period and increase early identification of mother who may be at risk of poor outcomes.
We identified 2 main challenges in delivery of phase 1:-Recruitment and retention of women- we addressed this by drawing on the recommendations from the Rapid review Healthy Child Programme: “Reaching the “hard to reach”: Difficulties in engaging families, including recruitment and retention, are one of the main reasons for interventions failing. Brief intensive engagement interventions that target both practical and psychological barriers, at the point of entry to treatment, can be effective in improving engagement”. The health visitor incorporated this recommendation by visiting all mothers who had been referred to the group at home to discuss the group programme, attempt to allay any fears and start to build a relationship with the mother. After the visit, the health visitor also sent a hand written card to the mother which said that she was pleased to have met them and she was looking forward to seeing them again at the group. One of the mothers acknowledged how important this had been on her evaluation saying, “when I received your card, it made me smile and I felt valued”.
Inability to provide a creche facility – this meant that the group would need to accommodate babies. We were unsure of the impact that this would have on the delivery of the programme. We managed this by limiting membership to mothers with babies less than a year old to try and minimise disruption. In hindsight this solution was very effective and the mothers said that they enjoyed being able to keep their babies with them during the sessions.
The lead Health visitor has presented her findings to the Local Authority commissioner who was keen to see this group replicated across Hampshire and published in a peer reviewed journal. A paper on the project is currently being prepared for submission to the journal Community Practitioner which is the most widely read health visiting journal. The Lead Health Visitor has also prepared a group manual and training programme for health visiting teams- training will be delivered from June- December 2016. Ongoing regular supervision of group facilitators has been agreed by Melbury Lodge Perinatal mental health team.
This pilot project has been evaluated and has shown positive outcomes as described in the project report. Evaluation of the trust wide roll out will comprise a short patient reported outcome measure, Karitane Parenting confidence scores and Edinburgh Post natal depression scale scores. These will be collated on completion of the Universal Plus health visiting care plan.
The lead Health visitor has presented her findings to the Local Authority commissioner who was keen to see this group replicated across Hampshire and published in a peer reviewed journal. A paper on the project is currently being prepared for submission to the journal Community Practitioner which is the most widely read health visiting journal. The Lead Health Visitor has also prepared a group manual and training programme for health visiting teams- training will be delivered from June- December 2016. Ongoing regular supervision of group facilitators has been agreed by Melbury Lodge Perinatal mental health team.
