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Research in the maternity and child welfare centre
MATERNITY
AND
CHILD
WELFARE
CENTRE
353
to suggest that enthusiasm on the part of the centre staff does much tt~ surmount this difficulty. There is, of course, one genuine drawback in a project of this kind, but it is one which must be common to almost all forms of education other than compulsory education, viz. those who would probably receive most benefit are the least likely to be interested. The personality of a keen health visitor can do much to offset indifference in her district, and there are many ways of trying to make the project attractive: above all, there must be no suggestion that the meetings are of a "cultural" nature (and thus, by implication, the concern of the middle classes). However, even taking this disadvantage into account, the value to a district of an organised programme of health discussions in the local child welfare centre is unquestionable, because of the "snowball effect" which is produced. The parents who are interested do not subsequently tend to be reticent about what they have learned; in fact it is frequently observed that they are only too willing to communicate their enlightened attitudes to their relatives, friends and neighbours and for 'lqs reason also, it is especially valuable to have in the group one or more :rs from the local infant or nurser), school. Here, then~ is a challenge to the child welfare centre, a challenge which it can meet by extending its traditional rrle to include an organised campaign of education in its own special field of child health and welfare. Those centres which have already responded are finding a gratifying degree of parental enthusiasm. There is no doubt that the child welfare centre is ideally placed to cope with this work, serving as it does a definite district in which it is already fully accepted as a reliable source of advice and help.
RESEARCH IN THE MATERNITY AND CHILD WELFARE CENTRE By M A R Y
T. P A T E R S O N ,
M.B., B.S., D.P.H.
Deputy Divisional M.O., London County Council ALTHOUGH maternity and child welfare centres have been in existence in this country for over 50 years and supported by t h e local authorities for the past 40, very little research has been undertaken in them. Every year large numbers of normal babies and young children are examined by medical officers and their progress recorded. This should be a golden opportunity for ascertaining facts about normal development and minor deviations therefrom, b u t very little use so far has been made of the information obtained. One reason for this is that the records are not standardised and often consist largely of remarks by the medical officer about the particular aspects of child health and care in which he or she is interested. C
354
PUBLIC
HEALTH
VOL.
LXXV
NO.
6
In order to undertake research in this field the information must be collected and recorded specially for this purpose. Forms and questionnaires must be completed and the results tabulated. No single clinic or group of clinics can hope to handle sufficient cases to make a project statistically valid nor do they usually possess the technical skill and resources necessary. Surveys on a nationwide scale are undertaken from time to time in which medical officers and health visitors are asked to participate. Valuable information is obtained which provides up to date knowledge on children's weights, developmental milestones and behaviour. From the point of view of the field worker the work involved is often rather unsatisfying. They usually know little about the project as a whole and have no say in the design of the questionnaire which is sometimes unsuitable for their particular set of circumstances. Many medical officers do already undertake special investigations in their clinics. They collect groups of cases in which they are interested and experiment with different methods of management. All too often they fail to publish their results and conclusions. The Maternity and child welfare clinics offer an excellent opportunity for these small studies. Each medical officer sees large numbers of babies and will quite easily be able to collect sufficient material. He or she has the additional advantage of being able to obtain home reports through the health visitor. There are many subjects which could be studied in this way by a medical officer alone, or combining with health visitors. For example he or she might observe the behaviour of haemiangiomata by measuring them at regular intervals over the first five years. The usual reassurance to the mother that it will disappear in time would be greatly reinforced if the medical officer could s a y " I have seen 100 of these in the last year and 90 of them disappeared." The same might be done with umbilical herniae. Most of us now believe that most of them disappear without any treatment at all and advise the mother to leave it alone. But it would be much more satisfactory if observations could be made on a large series and the results recorded. In some areas many families are living under overcrowded conditions, even in one room. It would be interesting here to observe the sleep habits of babies and young children and perhaps compare them with a group of babies with a nursery to themselves. Another possible study would be to obse~'e the effects (if any) of thumb sucking, blanket sucking and the dummy on the shape of the mouth and jaw, the quality and alignment of the teeth, and mouth infection. Large numbers of babies are immunised in the clinics. Detailed records of the reactions to these procedures would be valuable. Most of them are mild and transient and only discovered by direct questioning. A day nursery where the babies are under daily supervision would be useful here. These are examples of the kind of investigations that can readily be undertaken b y a medical officer. By publishing the results he or she could add to our knowledge and indicate lines of future treatment and attitudes. By
THE
SCHOOL
OPHTHALMIC
SERVICE
355
undertaking an investigation the medical officer makes the work more interesting and can arouse the enthusiasm of the staff and of the mothers. Another way in which research may be carried out in the centres is in the actual organisation of the clinics. The old pattern of weighing babies, advice by health visitor, and routine examination and advice by the doctor does not entirely meet the needs of the mothers today. There is room for experiment. In some clinics the mothers attend very frequently, partly for social reasons. It is not necessary to undress, weigh and examine the baby every time. It should be possible to set aside certain sessions or part sessions for group discussion. The doctor might take two or three mothers with babies of similar age together and discuss their questions. This should not of course replace the private interview but it would cut down some of the unnecessary and repetitive work and it would also be stimulating to the mothers. Routine examinations in the clinic deserve some further consideration. One of the purposes of the examination is to relieve the mother's anxiety and she will be perfectly satisfied if the doctor " sounds" the chest and pronounces the baby to be healthy. But the doctor wants to take the opportunity of excluding certain defects. Particularly at three months and at six months a careful examination should be made with the baby lying on a couch or table to exclude congenital dislocation of the hip, signs of cerebral palsy, and cardiac lesions. Examination of hearing should also be made. If these examinations were properly carried out it might be possible to reduce the number of routine examinations later on. The time is ripe for changes in the conduct of infant welfare sessions and for experiments. It should as far as possible be left to the individual medical officer after discussion with the health visitors to design and try out new patterns. Evcn if these are not successful, full reports should be made so that others may profit from their experience.
THE SCHOOL OPHTHALMIC SERVICE By F. B. S H E V L I N , M.B., CH.B. Senior Assistant School M.O., York DEFECTIVE Vision is the commonest defect among schoolchildren apart from dental caries. The incidence of visual defects found at school medical inspections during 1959 in England and Wales was 114.37 per 1,000, and if squints are included the figure is increased to 134 per 1,000. Corresponding figures for County Boroughs were 119-38 and 144.54 per 1,000 children inspected. In some authorities the incidence is as high as 190 or more per 1,000. The varying incidence may be due to differing frequencies of testing. These figures
AND
CHILD
WELFARE
CENTRE
353
to suggest that enthusiasm on the part of the centre staff does much tt~ surmount this difficulty. There is, of course, one genuine drawback in a project of this kind, but it is one which must be common to almost all forms of education other than compulsory education, viz. those who would probably receive most benefit are the least likely to be interested. The personality of a keen health visitor can do much to offset indifference in her district, and there are many ways of trying to make the project attractive: above all, there must be no suggestion that the meetings are of a "cultural" nature (and thus, by implication, the concern of the middle classes). However, even taking this disadvantage into account, the value to a district of an organised programme of health discussions in the local child welfare centre is unquestionable, because of the "snowball effect" which is produced. The parents who are interested do not subsequently tend to be reticent about what they have learned; in fact it is frequently observed that they are only too willing to communicate their enlightened attitudes to their relatives, friends and neighbours and for 'lqs reason also, it is especially valuable to have in the group one or more :rs from the local infant or nurser), school. Here, then~ is a challenge to the child welfare centre, a challenge which it can meet by extending its traditional rrle to include an organised campaign of education in its own special field of child health and welfare. Those centres which have already responded are finding a gratifying degree of parental enthusiasm. There is no doubt that the child welfare centre is ideally placed to cope with this work, serving as it does a definite district in which it is already fully accepted as a reliable source of advice and help.
RESEARCH IN THE MATERNITY AND CHILD WELFARE CENTRE By M A R Y
T. P A T E R S O N ,
M.B., B.S., D.P.H.
Deputy Divisional M.O., London County Council ALTHOUGH maternity and child welfare centres have been in existence in this country for over 50 years and supported by t h e local authorities for the past 40, very little research has been undertaken in them. Every year large numbers of normal babies and young children are examined by medical officers and their progress recorded. This should be a golden opportunity for ascertaining facts about normal development and minor deviations therefrom, b u t very little use so far has been made of the information obtained. One reason for this is that the records are not standardised and often consist largely of remarks by the medical officer about the particular aspects of child health and care in which he or she is interested. C
354
PUBLIC
HEALTH
VOL.
LXXV
NO.
6
In order to undertake research in this field the information must be collected and recorded specially for this purpose. Forms and questionnaires must be completed and the results tabulated. No single clinic or group of clinics can hope to handle sufficient cases to make a project statistically valid nor do they usually possess the technical skill and resources necessary. Surveys on a nationwide scale are undertaken from time to time in which medical officers and health visitors are asked to participate. Valuable information is obtained which provides up to date knowledge on children's weights, developmental milestones and behaviour. From the point of view of the field worker the work involved is often rather unsatisfying. They usually know little about the project as a whole and have no say in the design of the questionnaire which is sometimes unsuitable for their particular set of circumstances. Many medical officers do already undertake special investigations in their clinics. They collect groups of cases in which they are interested and experiment with different methods of management. All too often they fail to publish their results and conclusions. The Maternity and child welfare clinics offer an excellent opportunity for these small studies. Each medical officer sees large numbers of babies and will quite easily be able to collect sufficient material. He or she has the additional advantage of being able to obtain home reports through the health visitor. There are many subjects which could be studied in this way by a medical officer alone, or combining with health visitors. For example he or she might observe the behaviour of haemiangiomata by measuring them at regular intervals over the first five years. The usual reassurance to the mother that it will disappear in time would be greatly reinforced if the medical officer could s a y " I have seen 100 of these in the last year and 90 of them disappeared." The same might be done with umbilical herniae. Most of us now believe that most of them disappear without any treatment at all and advise the mother to leave it alone. But it would be much more satisfactory if observations could be made on a large series and the results recorded. In some areas many families are living under overcrowded conditions, even in one room. It would be interesting here to observe the sleep habits of babies and young children and perhaps compare them with a group of babies with a nursery to themselves. Another possible study would be to obse~'e the effects (if any) of thumb sucking, blanket sucking and the dummy on the shape of the mouth and jaw, the quality and alignment of the teeth, and mouth infection. Large numbers of babies are immunised in the clinics. Detailed records of the reactions to these procedures would be valuable. Most of them are mild and transient and only discovered by direct questioning. A day nursery where the babies are under daily supervision would be useful here. These are examples of the kind of investigations that can readily be undertaken b y a medical officer. By publishing the results he or she could add to our knowledge and indicate lines of future treatment and attitudes. By
THE
SCHOOL
OPHTHALMIC
SERVICE
355
undertaking an investigation the medical officer makes the work more interesting and can arouse the enthusiasm of the staff and of the mothers. Another way in which research may be carried out in the centres is in the actual organisation of the clinics. The old pattern of weighing babies, advice by health visitor, and routine examination and advice by the doctor does not entirely meet the needs of the mothers today. There is room for experiment. In some clinics the mothers attend very frequently, partly for social reasons. It is not necessary to undress, weigh and examine the baby every time. It should be possible to set aside certain sessions or part sessions for group discussion. The doctor might take two or three mothers with babies of similar age together and discuss their questions. This should not of course replace the private interview but it would cut down some of the unnecessary and repetitive work and it would also be stimulating to the mothers. Routine examinations in the clinic deserve some further consideration. One of the purposes of the examination is to relieve the mother's anxiety and she will be perfectly satisfied if the doctor " sounds" the chest and pronounces the baby to be healthy. But the doctor wants to take the opportunity of excluding certain defects. Particularly at three months and at six months a careful examination should be made with the baby lying on a couch or table to exclude congenital dislocation of the hip, signs of cerebral palsy, and cardiac lesions. Examination of hearing should also be made. If these examinations were properly carried out it might be possible to reduce the number of routine examinations later on. The time is ripe for changes in the conduct of infant welfare sessions and for experiments. It should as far as possible be left to the individual medical officer after discussion with the health visitors to design and try out new patterns. Evcn if these are not successful, full reports should be made so that others may profit from their experience.
THE SCHOOL OPHTHALMIC SERVICE By F. B. S H E V L I N , M.B., CH.B. Senior Assistant School M.O., York DEFECTIVE Vision is the commonest defect among schoolchildren apart from dental caries. The incidence of visual defects found at school medical inspections during 1959 in England and Wales was 114.37 per 1,000, and if squints are included the figure is increased to 134 per 1,000. Corresponding figures for County Boroughs were 119-38 and 144.54 per 1,000 children inspected. In some authorities the incidence is as high as 190 or more per 1,000. The varying incidence may be due to differing frequencies of testing. These figures