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Early Health and Development Monitor
An effective means of assessing young children’s
health and development

Introduction

The Early Health and Development Monitor (EHDM) was created to meet the need of health and other authorities for an easily recordable format which provides basic information on the health and development of any sample of children from birth up to 3 or 4 years of age. It is completed in the home, starting soon after birth, and requires only a brief home visit by a health worker or other trained visitor at the end of each year. It is then entered on to computer for analysis./p>

Most of the information provided by the Monitor is not currently available on existing information systems; the instrument brings together at low cost a wide range of facts and estimates relevant to the information needs of primary care managers, GPs, public health departments, the acute health sector, social and educational services and the home visiting service itself.

It has been designed for use by para-professional or professional workers such as health visitors, health care assistants, nursery nurses, family social workers and others. As a proven field instrument it is intended for use by those whose work includes visiting parents of young children and monitoring aspects of the children’s progress. Only a modest amount of training is needed to score this information reliably.

The recorded information can be input directly by a data clerk on to a PC, with only a few items needing further coding. Analyses of the information can also be carried out directly on any PC, with a user-friendly programme offering a wide choice of automated graphical and tabular options.

The Monitor was developed as a field instrument for general usage in the early 1990s, with regular modification and upgrading since then to meet many of the current information needs of managers and home visitors, and to make it increasingly user-friendly.

Wide range of information covered

The data gathered throughout the first four years of a child’s life will all fit on to the two sides of a single printed Monitor card. Even if it is only possible to record Monitor data for the first two years of a child’s life, this will provide sufficient information to undertake most of the Monitor’s basic analyses of health and development for the area’s children. The kinds of data recorded include:

In those authorities which have previously taken on the Monitor programme, all health-based home visitors have been asked to participate, with a view to providing them with comprehensive information on the progress of the children in all those families who are part of the visitors’, clinic or GP caseloads.

The linked analysis program provides simple tables and illustrations (see examples of Monitor output later in this article), enabling managers and visitors to judge the level of progress across the child and family samples in the areas covered by the Monitor. While the analyses cannot be used to pinpoint single families (for ethical and statistical reasons), the average scores and score distributions for any combined group or sub-group can have great value in highlighting situations of concern within a defined sample or caseload, such as high levels of hospitalisation, low levels of breast-feeding or a serious dietary inadequacy in the group being studied.

Taking account of the socio-educational environment

An important feature of the instrument is that all analyses of Monitor information automatically take full account of and present the socio-educational and socio-economic situation of the home. This avoids the misleading impression given by tables which simply compare sample results on, for example, child hospitalisation, immunisation rates, abuse levels, breast-feeding and other indicators, looking at these outcomes purely within sectors, G.P. practices or home visitor caseloads and ignoring the socio-educational context.

Such direct comparisons tend to emphasise the superior health and development profiles of children and families living in more advantaged circumstances, without identifying the fact that these achievements are often linked primarily to the socio-economic, educational and nutritional environment of the homes. In contrast the Monitor analysis programme always routinely compares outcomes within relatively similar socio-educational groups. so that it is possible to see whether better results in one group are linked to the mean socio-educational level of that group.

The scoring of socio-educational factors is done on each family at the first Monitor visit when the infant is about one month of age. The family's score is a composite made up from seven social and educational characteristics:

The composite score for each family is based on a weighted formula combining all seven sub-scores; the individual family scores are then used to derive mean scores for whatever samples or sub-samples of families have been selected for analysis (for example, GP or clinic caseloads, postal districts, sectors or whole authorities.

As mentioned earlier, in order to ensure confidentiality the individual scores for a particular family cannot be obtained from the database once they have been entered on to the computer. Nor are any names or addresses stored on computer. The aim is to create a public health awareness of sample characteristics rather than to pinpoint characteristics of individual families. Characteristics of individual families are in any case known in confidence to the health staff who work with each family, so that appropriate action can be taken to support any family if serious problems arise.

Among the many functions performed by the Monitor, its completion on every child at approximately yearly intervals can focus the attention of managers, home visitors, GPs or social and educational services on problematical situations, either among individuals or within areas, which need urgent attention or remediation, or which point to a necessary redeployment of resources to try to achieve greater health and developmental equity.

Monitor requirements and advantages

The three main cards used for recording and analysis are

   a data entry card, providing for the wide variety of birth, socio-educational, health, nutritional, developmental and other information to be recorded on each child and its home environment;

  a coding card, which simplifies the task of the home visitor or other staff member in recording and categorising the information given to her/him during the annual Monitor visit to each home; and

   an analysis card, to highlight the nine main types and the many sub-types of analysis that can be carried out on the Monitor information gathered for the program.

For authorities that take up this programme and invest professional or para-professional visitor time (10 to 20 minutes a year recording child information in each monitored home) and data clerk time (requiring one to two minutes to enter each card’s annual additions), the use of the Monitor can lead to informed strategic decisions about the level of support needed by an area’s families.

The analyses can also show where that support could best be targeted, for example on mothers in the age bracket 14 to 18, or on families in the most disadvantaged areas, or on other target groups. Further breakdowns of the analyses can show significant health, developmental or other trends across socio-educational and mother’s age groups.

For individual families there is a particular advantage in these annual Monitor visits, as they enable most developing problems or deficits to be identified by trained visitors who can then call upon extra support for the families from health, social and educational services. Conventional reassurance or check visits seldom reveal such situations, which can get steadily worse until the child reaches nursery or school.

The computerised information from the Monitor (entered via Microsoft Access programs) can also be made available for use by health trusts’ IT departments, epidemiologists and researchers, if they wish to incorporate this data with other information that they have.

Successful usage of the Monitor

For well over a decade the Monitor was used to advantage by a number of health authorities, with some authorities eventually having well over 10,000 children’s data recorded (all data having been anonymised so that no outsider could identify particular children’s or family’s information). The planned expansion in the number of authorities using the Monitor was cut short at the turn of the century by the government’s efforts to set up a national Connecting for Health database, to record the health status and health history of the entire population. IT departments insisted that Connecting for Health and its feeder programs were the only database programs that the health authorities should recognise. /p>

The government’s goal of having a massive centralised database providing full health records of all 60 million UK inhabitants has not so far been realised, despite years of planning and experimentation; it is likely that the intended centralised national database may now be replaced by regional databases, each of which will have its own targets and recording strategies, but which will also be capable of talking to each other and sharing key information.

Since it may no longer be a formal aim to have all the country’s health information gathered into one database, it may again prove possible to run Monitor pilots in targeted areas for any interested health trust or other service authority. The advantage of this instrument is that it provides a low cost child health and development database by using computer programs which are already proven and operational. The analyses of that information offers in turn the kinds of relevant epidemiological information that managers and visitors need to determine the level of primary health care and other developmental support that may be needed within specific target areas.

This detailed information is still not available anywhere else in the UK in this structured and comprehensive format, nor is there as yet any possibility of official bodies providing the in depth analyses of health and development data that can now be offered by the Monitor for use in deciding on resource allocation.

As mentioned earlier, the Monitor also has the facility for recording outcomes in areas or samples where a particular intervention programme has been used, comparing this with outcomes in ‘control’ areas or samples where that programme is not being used.

Examples of Monitor’s graphical and tabular output

In the pages which follow are four examples of the graphical and tabular output that can be derived from the Monitor. The data used for these analyses were obtained from health authorities that collaborated with the Early Childhood Development Centre in using this instrument with many thousands of children.

The first chart, below, shows the levels of breast-feeding among all mothers in a large health authority sample. It points to the known links with socio-educational status, but also highlights the influence of mothers’ age in determining breast-feeding rates. Note that this chart provides average feeding levels for all mothers in the sample, including those who did not attempt breast-feeding.

breast feeding rates

At the bottom of each graph such as that pictured here appears a detailed table of the average values of each factor, divided according to the groups named in the table and pictured in the graph. The tabular data (not pictured here) show a sample size of 2,068, with 30% in the low socio-educational (SES) division, 20% in the middle group and 50% in the high SES group. The mothers’ age levels showed 35% in the young age group, 55% in the middle age group and less than 10% in the higher age group. An option with this analysis program enables users to set their own SES and age divisions, so as to make each group large enough for reliable analyses.

The second chart, below, offers an interesting comparison across SES groups and mothers’ confidence levels. This chart, based on 1586 mothers, shows the expected relationship between SES and breast-feeding - the higher the SES the bigger the mean breast-feeding score across all mothers, feeders and non-feeders.

breast feeding vs confidence

What is particularly interesting here is that mothers with low self-confidence (as measured at child age six months) hardly breast-fed if they were in the low or mid SES groups, but if they had a high SES they breast-fed at the same level as other mothers, despite the formers’ low self-confidence. Another chart (not shown here) illustrated the complex relationship between 542 breast-feeding mothers’ level of education and their breast-feeding rates; only the higher education mothers (post-school education) showed a strong SES influence on breast-feeding.

The third chart, below, points to the children’s mean intake of vegetables when diet was assessed at age 2 years.

vegetable intake levels

The most noticeable feature of this chart, measured across 485 families, is that for young mothers, the higher their socio-educational status the less inclined they were to feed vegetables to their children. It may be that having higher income enabled them to feed more commercial baby feeds at that age - in which vegetables would be unlikely to play a large part.

The fourth chart, below, shows the combination of chart and tabular data that are a feature of all the Monitor output.

ospital days children

While the charts themselves offer a useful and easily assimilated view of the relationship between the child or family and various factors, the set of figures below below each chart give the full details on which each chart is based, enabling more extensive analyses to be undertaken, if needed.

Understanding the relationship between the chart and the data can help to deepen understanding of the relationships between health, development and other indicators, and this in turn can contribute to policy formulation. An interesting feature of this particular chart (based on 1287 families) is that the expected relationship between the level of the mother’s birth delivery trauma and the child’s subsequent hospitalisation in the first year, is only seen for families in the low SES group. With the large numbers in each sub-group, these relationships can be seen as quite strong and reasonably reliable.

An important feature of the Monitor is that a number of recorded items are based on estimates made by trained visitors (with the remaining items based on parents’ reports). The reliability of the visitors’ estimates of various indicators of health and development is therefore important. To aid that process, visitors are urged to explore issues with parents, as far as possible, rather than simply asking closed questions. This encourages parents to discuss particular topics openly and thereby strengthens the reliability of the instrument.

Reliability assessment

Children’s language development is thought to be a difficult variable to estimate. It was therefore chosen for a reliability assessment. The research chart (below) depicts the results of this assessment.

hospital days children

Based on over 1,000 births monitored by approximately 40 health visitors in one large authority, this black and white chart (Children’s mean language levels) shows the reliability of the health visitors’ estimates of the levels of language development of each individual child at 24 months. The expected graded difference in language ability between the least and most advantaged is very clear, and so too is the known fact that first-born children tend to have higher levels of language development than children living in homes with more than one child.

The importance of this reliability check is that the reliability of home visitors’ Monitor assessments of individual children’s levels of language and other forms of development has been questioned in the past by those who feel that such estimates can and should only be made by using time-consuming tests (and preferably involving psychologists or other research workers). In fact, for most ordinary purposes, such as judging whether a child’s language or other development is delayed, advanced or normal, compared to the average child of that age, the trained visitors who regularly call on the homes of the children in their client areas quickly acquire the ability to make reasonably reliable judgements for the Monitor records.

The Monitor computer programs

Data input program.     This program enables all the information on the monitor cards - apart from names and addresses which are excluded for data protection purposes - to be input into an Access database template, from where it can be analysed by any health or other authorities which have gathered this information. Alternatively the information can be downloaded into Excel for other analyses, or merged with existing authority databases to enable more comprehensive studies of the child data.

Analysis program.    Considerable work has been done on the development of this program. Currently it offers:

a.   Analysis of the following variables:

       Breast-feeding, with six sub-categories of analysis

       Child diet quality, with 7 sub-categories and a composite dietary quality category,
          all assessed at the end of each of the first three years of life

       Child hospitalisation in each year (up to age 3), each with 5 sub-categories

       A comparison of programme and non-programme children, in situations where
          part of the sample is involved in one or other authority intervention,
         while the other (control) part of the sample is not involved

b.   Analysis of the data according to a range of sample categories:

      These include visitor or clinic caseloads, GP caseloads, postal code districts, whole authority caseloads, or areas     amalgamated by grouping of any of these categories. (cont.p9) These divisions can be done automatically,       eliminating manual handling or manipulation of the individual records.

c.  Analysis of further indicators in the next program upgrade:

      The new analyses will include charts on other Monitor data such as:

        Children’s levels of language, social and cognitive development

        Parental smoking, and level of success of cessation programmes

        Environmental support, security, and children’s play space

        Home educational environment

        Various child functioning skills

d.   Protected availability of other information for analysis within authority:

As noted earlier, professionals, managers or others approved by the authority will be free to utilise certain variables from the database for further analysis for research or report purposes, such as the number/proportion of children placed on the Child Protection Register, parents’ library membership, child anthropometric measures, state of the children’s teeth and much else which is recorded on the current Monitor card. For data protection reasons the identify of the parents will not be known to anyone other than the GP and home visitor for that family. There will be added precautions to ensure that subsidiary databases released for analysis will have to be a certain minimum size so that it would not be possible to identify families by paring down a database to a handful of cases, from which personal data could be extracted.

Wider rationale for investing time and effort in the Monitor

There are three powerful reasons for investing a modest amount of time and effort into introducing and using the Monitor:

1. It provides home visitors with the only quantified measure of their effectiveness. There is nothing else available which focuses on home visitor effectiveness or outcomes, apart from expensive short-term research studies.

2. It can provide management, field staff and the medical, social and educational professions with basic information on the development and health of all the children within their areas. The information gathered is of central importance and its analysis can show where more resources may need to be channelled to improve various indicators of well-being or to reduce problems.

3. At a time when regular visiting of all families with young children is being sharply reduced in almost every health trust or board, the Monitor offers a structured method for ensuring that each child within an authority is seen at least once a year up to the age of three or four (with a suggested minimum monitoring up to the age of two years).

No one who is aware of the existing widespread problems of poor nutrition, abuse, hearing loss, language deficits, delayed development, unre¬solved ill health and the many other difficulties faced by young children, can think it is likely that stressed parents will voluntarily bring their children in to a health clinic or G.P. for observa¬tion. There are only two alternatives: to call on the home annually to see the parents and children, or to try to compel the parents to bring their children to the clinic at regular intervals. The latter solution of enforcement would be counter-productive and probably ineffective.

Current practice, for health visitors who are overloaded by crisis work, is to ignore (apart from the birth visit and one or two subsequent visits) most of those young families who do not call at the clinic, provided the families do not become known to social services or the police. While understandable, this fire-brigade approach to community health may fail to keep contact with many children who should be seen regularly in their natural (home) environment. Even families who regularly call at the clinic may be facing problem situations in the home environment, situations of which no one would be aware without a trained visitor calling at the home.

Further information    A variety of information and guidance documents are available on the completion and coding of the Monitor, on its computerisation and on the clerical and IT needs for administration and data input. These can be requested from the Early Childhood Development Centre, using the e-mail address given on the Contact page in this website.

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