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The overall aim of this study is to explore how health visiting and mothering practices have been shaped by the implementation of Health for All Children (Hall). ‘Hall’ denotes a programme of work around child health surveillance and promotion published in four reports between 1989 and 2003. The fourth Hall report (Hall 4) marked a shift towards a more targeted approach to service provision, predominantly through the work of health visitors, yet aimed to meet the needs of all families with young children. The study explores how health visitors’ work practices have been shaped by this new policy context, including how it has influenced their relationships with families as well as the profession as a whole. It also examines the experiences of mothers, their relationships with health visitors, and how they negotiate and manage their children’s health and well-being. A review of Scottish policy reveals an early years agenda focused on risk and early intervention; and that community nursing has been at the centre of, and shown resistance to, a number of policy directives over the last decade. A review of the existing literature explores the relationship between evidence and Hall and identifies health visitors as the profession charged with its implementation. Literature on mothering and fathering exposes a focus on parenting in policy which belies the gendered nature of caring for children. The empirical study reported in this thesis is located theoretically in relation to the shifting emphasis in disciplinary practices shaping child health from normality to risk. The study uses a qualitative approach and took place within the Lothian region of Scotland. Initially, discussions with policy-makers and practitioners working in the early years, nationally and locally, were carried out to scope the context for the study. Semi-structured interviews with 16 health visitors and 20 mothers were then undertaken and analysed thematically, with the findings chapters shaped through an iteration between theory and grounded analysis of the accounts of the health visitors and mothers. The health visitors’ accounts reveal the changing nature and form of their knowledge and expertise and the implications of this for their practice and profession. The discussions of health visiting practice identify the important roles of observation and relationships work with families, in homes and clinics over time, and how these activities enable health visitors to construct knowledge of families. The interviews with mothers suggest a blurring between lay and professional knowledge where normality is defined by mothers themselves and through their relationships with health visitors. While the mothers work to construct themselves as morally adequate, attention to the stories mothers tell, and, in particular, the emotion in them, suggests that vulnerability can be experienced by any mother. This phenomenon sits in contrast to increasing attention by professionals placed on the monitoring and policing of ‘vulnerable’ families while opportunities for observation and relationships work diminish. The study concludes by exploring key conceptual issues. It considers shifts between normality and risk and how these are shaping how vulnerability is constituted through health visiting practice. In conjunction, it explores the implications of changing health visiting practices, for health visitors, as a profession. Finally, the scope for the health visiting profession to shape policy and practice are considered.

The term 'hard to reach' first appeared in the Health Visiting Review (Lowe 2007). This review claimed that the health visiting service was able and experienced in reaching the 'hard to reach'. Yet there was a dearth of health visiting literature on what this concept meant and how it was interpreted in practice. A wide literature review was undertaken which examined government child health policies on reducing health inequalities and how the targeting of services to meet the needs of 'vulnerable', 'disadvantaged' or 'hard to reach' families had developed. The literature review identified how the concept of risk in relation to child health promotion had been defined and redefined since the 1970s. The latest shift involved the identification of 'new social risks' and the promotion of early intervention to prevent social exclusion and health inequalities. At the time of the study's inception, health visiting was a service both in decline and under threat. In contrast, the development of new early intervention programmes such as Sure Start (National Evaluation of Sure Start 2005), On Track (Doherty et al. 2003) and intensive home visiting (Barlow et al. 2005) also led to the critical examination of the concept of 'hard to reach'. In response to the lack of information on the concept of 'hard to reach' in health visiting, I set out to examine critically how Health Visitors (HVs) working in a disadvantaged area conceptualised and operationalised the concept of 'hard to reach'. This qualitative ethnographic case study (Yin 2003), by using research methods of focus groups, participant observation of a Well-Baby Clinic and interviews, gathered perceptions and experiences of HVs and service users. Thematic analysis was guided by Gee's (2005) method of critical discourse analysis and revealed how the term was contested by HV practitioners. It was considered a broad term that in practice could be applied widely and negatively as a label for non-engaging service users; yet themes emerged which also demonstrated how HVs related to and constructed the concept in their day-to-day practices of client engagement. The findings were categorised and a typology was developed in relation to the reach of health visiting within a predominantly deficit model of health. The typology consists of four types, all of which relate to the 'reach' of the health visiting service at the interpersonal level. The first type, the 'easy to reach' client, highlights the diversity of clients: not all clients living within a disadvantaged area were 'hard to reach'. This category also identifies how some clients living within this disadvantaged area developed relationships with HVs. Including the type 'easy to reach' within the typology acknowledges the diversity of clients living within an area of disadvantage, and also the facilitators in HV/Client relationships. The second type identified was the 'emotionally hard to reach' client, and identifies characteristics of clients who had a tentative relationship with the health visiting service. Working with 'emotionally hard to reach' clients involved negotiation and the building of trust at each encounter. The third type, 'physically hard to reach', developed following the identification of a range of barriers that reduced access to vulnerable clients. The fourth type, 'hard to reach services', arose from the findings - and this type relates to barriers created by the organisation of the health visiting service in a disadvantaged area. The typology highlights the importance of both clients' and HVs' engagement in the development of working relationships. It recognises the organisational structures and discourses that act as barriers and facilitators to client engagement. It recommends that health visiting should take the opportunity offered in the Health Visitor Implementation Plan (DH 2011) to develop a health visiting service underpinned with a strengths-based model of public health.

Research emphasises the importance of the mother-infant relationship for infants’ well-being. To benefit interventions, the current research, using a critical realist lens, investigates an area that research has neglected, which is the subjective experience of the mother-infant relationship, including experiences of moments of connection. Bourdieu’s ‘thinking tools’ enables exploration of mechanisms that may affect the mother-infant relationship. How the study’s results can inform health visiting practice is considered. Six mothers were interviewed, four of whom participated in a video of their mother-infant interaction. Two focus groups, each with six health visitors, discussed their practice in the context of supporting the mother-infant relationship. Interpretative phenomenological analysis and thematic analysis were employed. This research indicated a high arousal state, referred to as Vigilantia, was experienced by mothers and infants. Vigilantia appeared to support mothers’ drive to make sense of their young infants but also seemed associated with mothers’ reliance on a discourse of the ‘traditional baby’, which stressed instrumental care and omitted the relational infant. The mothers found it difficult to make sense of the “bizarre” relational connection they felt for their infants. Health visitors described obstacles to supporting the mother-infant relationship associated with their service’s design and their role. Health visitors also seemed to identify with some mothers and in doing so could overlook the infants. Neoliberal values discount the relational and these values affect the experience of the mother-infant relationship. Ideas for improving practice are suggested, as well as acknowledgment of the need for social structural changes.