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Developing a Family Health Assessment Tool

Asst. Professional Development Officer
Foundation of Nursing Studies (Reg. Charity)
32 Buckingham Palace Road
London SW1W 0RE

Tel: 0207 233 5750

A practice development project aimed at standardising the process currently being used by health visitors within the Winchester and Eastleigh Healthcare Trust to identify families who have the greatest physical, psychological and/or social health needs.

Initial piloting of the Family Health Assessment Tool indicates that the tool provides a valid process for assessing the holistic health needs of families.

A second stage of testing is currently in progress. A training pack for health visitors and a final report on the project is planned for early 2001.

Background to practice development project

Health Visitors work with families to promote health. Many health visitors spend a lot of time working with families who have the greatest health needs, supporting and working with parents to help them cope with the stresses of parenting and other life events. (Appleton, 1996). Searching out health needs and stimulating clients’ awareness of health needs are two key principles of health visiting practice. (Chalmers, 1993). Such practice is supportive of the health visitors’ role as defined by the government in the 1999 publications, Saving Lives: Our Healthier Nation and Making a Difference.

Currently there is no standardized approach by which health visitors identify those families who are at greatest risk of developing poor physical, psychological and/or social health. A survey by Appleton (1997) found a wide variety of clinical guidelines in use nationwide to assist health visitors in identifying vulnerable families requiring extra support. However, there is no evidence to support their validity and reliability.

In 1996 a small group of health visitors within the Winchester and Eastleigh Healthcare Trust created a checklist tool based on a small literature search and discussion around professional judgement, to be used to identify those families with the greatest health needs. A date to review the use of the tool was identified and it was at this stage that it was realised that the validity and reliability of the tool had not been tested. It could be suggested that at present current practice is based largely on subjective, anecdotal data and as Gibbons (1995) comments, this is inadequate and falls short of providing an evidence base for practice. As a result, the Health Visiting Services and Primary Care Nursing managers, supported by the Trust’s Research and Development Committee created a project outline. The project aims were to redevelop the current tool by extending the literature search, collecting evidence of best practice and using health visitors’ current experience of assessing the health of families and then test the new tool for reliability and validity. A successful application for funding was made to the Foundation of Nursing Studies to support the project. A health visitor from within the trust was seconded as a project worker.

Design of Family Health Assessment Tool

Seven health visitors from across the trust (including the project worker) have designed the Family Health Assessment Tool (FHAT). Evidence from a variety of sources has been used to inform the process. This includes an extensive literature search, feedback from the other health visitors in the Trust about the current assessment process via a postal questionnaire, support and information from personnel within both academic and research institutions and contact with other researchers in the field.

The FHAT aims to provide the client with an opportunity to identify and discuss with a health visitor, areas of their lives that may be affecting their health. Information about the variety of support that is available locally can be discussed and a plan of intervention from health visiting and other services can be developed with the client and a review date set.

The FHAT is based on a list of category areas that were identified in the literature and from other supporting evidence, as contributing to the health of the family in a positive or negative way. Housing, support of family and friends, the use of tobacco, alcohol and other drugs are examples of these areas. The assessment involves the health visitor asking the client to rate how much concern e.g. housing or their family’s’ physical or mental health causes them using a Likert scale from 1 to 5. Depending on their response, the health visitor can explore the clients’ concerns about this area using follow-up questions. These questions are informed by the literature, but also the skills that health visitors use when searching out health needs and gaining access to clients. (Chalmers 1993; Luker and Chalmers 1990). These issues, along with the available evidence on professional judgment and intuition will be explored in the training package that will accompany this tool.

To summarize the assessment with the client a zoning tool has been created. This has 2 axes that cross at right angles. One axis represents how much "stress" the client feels they have and the second, how much "support" they feel they have. The result is 4 quadrants with varying combinations of high/low "stress" and "support". The client is asked to rate themselves on a scale of 0 – 10 for "stress" and "support". The resulting zone is used to discuss the family situation overall and thereby determine an appropriate plan of care/ intervention and a date for reassessment. Where the family place themselves on the zoning tool can be used to assess their situation over a period of time and in response to input from health visiting and/or other services


Determining if a tool is valid is a difficult job and especially so in this case when there are no other tools against which it can be compared. A number of approaches and checks have been applied throughout the developmental process and are still ongoing.

Content validity has been approached through a concept analysis of the term ‘vulnerability’. Having considered evidence from many sources, a consensus of opinion was reached as to what should be included in the assessment tool and will also be considered carefully when the training package is designed.

The tool was piloted in June to August 2000 with a total of 20 families for which ethical approval was gained. Whilst only a small scale pilot, a variety of methods were employed to test the validity of the tool. A theoretical sampling approach was used whereby families from the caseloads of the health visitors involved in the designing of the tool were approached. The health visitors used their current knowledge of the families and their professional judgment to allocate the family to one of the four zones on the zoning tool. In this way, it could be ensured that the sample would include families with a variety of "stresses" and levels of "support".

Having gained consent, the project worker visited the family and completed the Family Health Assessment Tool with the main caregiver. Two other validated tools, which focus on aspects of life covered by the FHAT, were also completed. (Warwick Child Health and Morbidity Profile; MOS Social Support Scale.) The clients were asked for their feedback on the tool and the process.

Criterion-related validity was measured by comparing the findings from the FHAT with those of the other validated tools, and also comparing the Likert scores on the trigger questions with the validated tools and the client’s position on the zoning tool.

As the sample size is small, statistical testing would not be appropriate. However, the pilot study found that there was a high level of agreement between the Likert scores given in the trigger questions, the scores on the zoning tool and the comments and scores from the two validated tools. There was a high degree of acceptability for the tool and the process amongst the sample group. No negative comments were recorded. A few constructive additions have been made to the tool.

The tool is currently undergoing a second stage of testing. It is being used by seven health visitors in normal practice for a period of 8 weeks and will be reviewed at the beginning of December 2000. It is hoped that by the end of this period, the tool will have been shared with in excess of 100 clients. The experiences of the health visitors using it in practice, and feedback from clients will be used to make final judgments on the validity of the tool.

Future plans

Final revisions to the tool will be made according to the findings of the second stage of testing.

A training package for health visitors will then be developed with a view to training the remaining health visitors within the trust in the use of the tool in Spring 2001.

A full report of the project will be available in early 2001.


Appleton J.V.(1996) Working with vulnerable families: a health visiting perspective. Journal of Advanced Nursing 23, 912-918

Appleton J.V.(1997) Establishing the validity and reliability of clinical practice guidelines used to identify families requiring increased health visitor support. Public Health 111, 107-113

Chalmers K. (1993) Searching for health needs: the work of health visiting. Journal of Advanced Nursing 18, 900-911

Department of Health (1999) Saving Lives: Our Healthier Nation. HMSO

Department of Health (1999) Making a Difference: Strengthening the nursing, midwifery and health visiting contribution to health and healthcare. HMSO

Gibbons B. (1995) Validity and reliability of assessment tools. Nurse Researcher Vol.2, No.4 48-55

Luker K. and Chalmers K. (1990) Gaining access to clients: the case of health visiting. Journal of Advanced Nursing 15, 74-82

Sherbourne C.D. and Stewart A.L. (1991) The MOS Social Support Survey. Soc.Sci.Med.Vol.32, No.6: 705-714