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Publication: Community Practitioner
Date published:
Language: English
PMID: 40570
ISSN: 14622815
Journal code: CPRA


Health visitors review and monitor every preschool child's language development, but this does not usually include bilingual or multilingual development Although perhaps 95% of the UK population speak only English, there are hundreds of thousands of speakers of other languages. These are mainly languages of Asian origin, but European languages and Caribbean languages are also widely spoken. It is worth considering what advice health visitors have for these families.

Health visitors and community practitioners can learn useful lessons from the experience m Wales. There are six officially recognised minority languages in the UK, and of these Welsh has the greatest number of speakers at around 600 000. A project named 'Twf' ('growth' in Welsh and an acronym for 'taking Welsh to families') has been developed in Wales over the past 10 years to advise, encourage and support parents to introduce Welsh as well as English to their babies. Its work and messages can be useful to health visitors across the UK.

Children who are fluent in two languages have many advantages (Baker, 2007). Speaking two languages helps the child to communicate with a wider range of people and better understand two cultures, and it can help bridge between generations within a family. Being bilingual also confers some distinct cognitive advantages, such as a greater ability to solve scientific problems (Baker, 2006). Community practitioners may wish to consider how they can advise and encourage speakers of other languages in their communities to pass on these /anguages to their children. When advising families it is helpful for practitioners to be aware of relevant research in order to provide care based on the best available evidence (NMC, 2008). The research-based approach of the Twf project makes it appropriate for health professionals to incorporate its message in their daily work where needed. It is also suggested that the project fits well with the public health role of the community practitioner.

The aim of this paper is to guide community practitioners to the main areas of research underpinning the Twf project's message and how it fits with the public health role of community practitioners and health visitors, and also to illustrate the practical support ofrered in Wales.

Background to the Twf project

The fact that parents can speak another language as well as English does not necessarily mean that they will pass this language on to their child. In 2003, the Welsh Assembly Government produced a social policy document called laith pawb (Everybody's language) , stating that: 'We see family language transfer as a key element of our language strategy. So many parents who are fluent in Welsh do not pass the language on to their children' (WAG, 2003: 39).

It was decided to give parents information about the advantages to their children of being brought up bilingually and to advise on practical ways to introduce Welsh at home.

The Twf project receives its finance from the Welsh government via the Welsh Language Board, and employs 23 community workers (11 full-time equivalents) who are located in most counties of Wales, along with four members of part-time administrative staff and a national co-ordinator.

The community workers provide health visitors, midwives and other partners in their areas with resources from the Twf project and information about relevant research, and they regularly visit antenatal and postnatal clinics to talk to parents. Where a particular need is identified, the TVf worker runs groups for new parents and parents-to-be to help them to speak Welsh to their baby through activities such as baby massage, singing and stories.

Twf project messages: research base

The Twf project sources much of its information from the ESRC Centre for Research on Bilingualism at Bangor University, North Wales. The rigorous academic approach of the centre and its criticai analysis of current research enable Twf workers and community practitioners to quote its conclusions with confidence. Other research referred to by Twf and within this paper are generally the conclusions of reviews of a body of evidence that has undergone peer review.

The Twf project in practice

The Twf project works with health visitors, midwives and community organisations to:

* Give parents information about raising children to speak two languages

* Encourage parents to introduce those languages from birth

* Offer practical activities to support parents in the choices they make.

All of this fits with the agenda of informed choice and can be compared to approaches to increase breastfeeding rates, for example.

The approach also reflects work in the field of changing behaviour. For example, Gathercole (2007) analysed strategies that community workers may adopt in order to support parents in introducing a second language in the home. These include:

* Informing parents about the advantages of bilingualism, starting from the antenatal period onward

* Offering varied and interesting activities for bilingual parents to play with their baby in Welsh, and Welsh-medium social activities for non- Welsh speaking parents

* Setting up a helpline.

Informing parents

Health visitors provide parents with information in order to make an informed choice about many health-related matters. Equally, parents need to know that it is advantageous for their child to speak more than one language hi order to decide which language or languages to speak at home.

Professor CoUn Baker, head of the survey and ethnography research group at the ESRC centre, summarises the advantages to children of being brought up to speak two or more languages under six headings:

* Communication - children are able to communicate with a wider range of people, and are able to access literature in two languages

* Cultural - language opens the door to culture and tradition

* Cognitive - bilingualism enhances fluency, flexibility and creativity of thought

* Character - language is closely linked to self-esteem and sense of identity

* Curriculum - well-developed bilinguals often achieve slightly higher success across the curriculum

* Cash - bilingualism is an additional skill in the workplace (Baker, 2007).

Baker goes on to state that even children who only have a limited exposure to one of their languages demonstrate cognitive and reading advantages. However, if a child has a low level of competence in both of their languages, then there may be some detrimental cognitive effects.

In Wales, the Twf project has produced a short illustrated leaflet called Eight good reasons to help the health professional to inform parents of the advantages of bilingualism. In addition, the all- Wales handheld maternity notes are held within a purposedesigned folder that has the Twf logo and message on the cover, along with contact information for the project website and helpline. Twf community workers visit antenatal and postnatal clinics Un order to talk to parents and also to inform midwives and health visitors of current developments and research.

Encouraging families

Health visitors have a short time within which to work with families and many issues to address. Timing can be the key to success. If parents are informed of the advantages of bilingualism in the antenatal period, then they can be encouraged to speak the home languages to the baby as soon as possible after birth to take advantage of the windows of opportunity for language development in the infant brain.

Here the project refers to work by Robin Balbernie, consultant child psychotherapist at Gloucestershire Child and Adolescent Mental Health Service, reviewing and analysing the research into the neurobiological consequences of early relationships (including language).

The most sensitive period for brain growth - the time of optimal plasticity - is during the first two or three years of life (Balbernie, 2001). Different processes of the brain are sensitive to development at different ages, and in particular there seem to be multiple critical periods for the different aspects of language development (Newport et al, 2001).

The critical periods for development of the neural pathways for language in the baby's brain are thought to be birth to six-months old for vocabulary, and six to 12 months for language capacity and speech (Kühl, 1992). By six-months old, babies start to specialise in the sounds of then· native language(s). By the end of the first year, infants tend to be less sensitive to the sounds of languages that are not their own native language (Werker and Tees, 1984).

Knowing how important it is to start early can help motivate parents to introduce two languages from birth.

In order to help and encourage parents to start speaking Welsh as well as English with the baby from birth, the Twf project has produced a magazine-style resource, You and Twf, which aims to answer parents' most commonly asked questions and give pointers as to how to introduce two languages to the baby. Health visitors also offer new parents a Welsh nursery rhymes CD from Twf as a prompt to encourage them to speak Welsh early on. Anecdotal evidence suggests that parents like the CD and start to use phrases from it with the baby.

Twf and public health

Hall and Elliman (2003) suggest that 'in the light of growing evidence that communities, relationships and the environment are important determinants of health, investment in community development and social support is increasingly important; health professionals should contribute to and sometimes lead in these aspects of health care' (Hall and Elliman, 2003: xvii).

Indeed, over the last decade, the Department of Health has encouraged a focus on health inequalities hi the wider community and on a public health role for health practitioners: 'We are encouraging all health visitors to develop a family-centred public health role, working with individuals, families and communities to improve health and tackle inequalities. Health visitors need to work in new ways, across traditional boundaries and with other professionals and voluntary workers' (DH, 1999: 61).

The Welsh Assembly Government also refers to a public health role for maternity services in Wales in its recently published draft strategy document stating that 'Pregnancy is a powerful motivator for change... [it] presents a golden opportunity to impact on the health and wellbeing of individuals and communities' (WAG, 2011: 3). This extends the public health role into the antenatal period.

Social capital

Research by the ESRC Centre for Research on Bilingualism (Baker, 2007) and the research programme of the Office for National Statistics (Harper and Kelly, 2003) suggests that encouraging families and communities to pass on their languages to their children can bring direct social advantages to children and also improve families' and communities' social capital, leading to unproved health status, and is consequently part of the public health ro!e of community practitioners. Health visitors' investment in community development and their work with other professionals can improve social capital and therefore communities' health.

Children benefit socially from speaking two languages by being able to communicate with a wider range of people, being able to bridge between generations and communities, and in some cases also having the added advantage of being bi-literate, enabling them to participate more effectively in two cultures (Baker, 2007). These direct benefits of bilingualism are also factors that can influence social participation and networks, which are among other indicators of social capital (Harper and KeUy, 2003).

Social capital is the 'networks together with shared norms, values and understandings that facilitate co-operation within or among groups' (Harper and Kelly, 2003: 3). Increased social capital is linked with improved health in numerous studies, and the World Health Organization health glossary states: 'The stronger these networks and bonds the more likely it is that members of a community will co-operate for mutual benefit. In this way social capital creates health and may enhance the benefits of investments for health' (WHO, 1998: 29).

Factors that may result in higher levels of social capital include trust, a sense of belonging, membership of groups (identification with them as well as formal membership of them), reciprocal help and support, and even gossip (Putnam, 2004).

Many of these factors may be familiar to community practitioners when observing which families seem to thrive in a community and which families struggle.

It is important to note that although poverty has an immense impact upon health, (Cowley, 2010), it is not sufficient by itself to explain differences in health within and between communities. Focusing on improving social capital is not to ignore the impact of income inequalities, but rather to complement poverty alleviation policies with improved social participation policies.

It seems likely that being part of a bilingual community strengthens social networks and therefore leads to unproved public health. As an example of how this may work, Nyqvist et al (2008) looked at the observed health advantage of the Swedish -speaking community in Finland, noting that they have a higher level of social participation than the general Finnish population. Controlling for other factors, this higher social capital explains to some extent the group's observed health advantage.

Community development

Health visitors often encourage parents to take part in support groups in order that they may benefit from and contribute to social networks. In many cases the local community can offer this support, but for some families and in some communities the specific need identified by the health visitor cannot be met by existing provision.

Health professionals may then be involved in health promotion activities, such as by establishing specific support groups.

Developing child language skills is an area in which parents can benefit from support. Reviews of die research into communitybased services were carried out by separate groups and edited by Hall and Elliman (2003). They state that 'there is growing evidence that language acquisition, preHteracy skills, and behaviour patterns are all amenable to change by appropriate patterns of child management. These insights can be incorporated into programmes like Sure Start but can equally well be provided in non-Sure Start areas' (Hall and Elliman, 2003: xviii).

Bilingual language needs could be included in an audit of health needs of the community, and existing local support identified or facilitated in order that parents are able to pass on their languages to the baby.

Bonding and bridging social capital

Social networks that help improve bonds within a particular social group can be described as 'bonding social capital* whereas links between dissimilar groups may be seen as 'bridging social capital' (Gibson, 2007). In the language context, an example of bonding would be a Welsh-medium parent and baby group in which Welsh speakers are encouraged to use the language with their child and other adults. This improves Welsh-speakers' networks, which is important for speakers of a lesser-spoken language, but may simultaneously reduce non-Welsh speakers' social capital by excluding them. An example of bridging social capital would be a Welshmedium parent and baby group with activities that aim to include non- Welsh speakers and help them to access the Welsh language for their children too.

In Wales, die health visitor or Twf worker can signpost parents to community groups that will offer the Welsh language support they require, for example bilingual story time at the local library or Welsh medium parent and baby play groups, where these exist already. Where more tailored support is required or an audit of language needs in a local community identifies a lack of community support, the Twf worker initiates and runs support groups for as long as is needed. In these 'Amser Twf' (Twf time) groups, parents are introduced to simple, interesting activities with a focus on increasing parents' skills and motivation to speak Welsh with their babies. These activities can also form the basis of a regular visit by the Twf worker to the more general health support group.

Twf support groups can be seen as influencing bonding social capital by encouraging Welsh speakers to come together for activities in Welsh aimed at passing the language on to their babies, and improving bridging social capital by offering activities in Welsh, such as baby massage, diat are accessible to nonWelsh speakers as well, and also by creating links between Welsh medium groups and English groups.


The Twf project and community practitioners in Wales have developed effective ways of informing, encouraging and supporting parents to introduce Welsh as well as English to their children.

Twf resources reflect current research in the field of bilingualism and the methods chosen by the project to inform and support parents are supported by research in the area of changing behaviour.

A large body of research indicates that children raised bilingually have certain advantages over children raised to speak only one language. Health visitors can inform parents of these advantages in order to help them choose which languages to use at home.

The best time to introduce languages to the baby is from birth in order to take advantage of the optimal plasticity of the baby's brain. From the parents' point of view it is also often easier to 'start as you mean to go on' by using both languages from the beginning.

Bilingualism increases social capital through increasing the child's social participation and improving the parents' social networks. Higher social capital is associated with improved health status.

An audit of the public health needs of a community could include its languages and the support available to parents to pass these languages on to their children. Encouraging the provision of language support groups can be part of the public health role of the community practitioner.

Areas of good practice

Pointers to good practice may be useful for health visitors and other professionals in Wales and within communities where there are ethnic minority languages across the UK:

* Include language and bilingualism in an audit of the public health needs of the local community

* Raise awareness of the advantages of bilingualism among all parents and the general public

* Identify existing community support and signpost parents to it

* Contribute to and sometimes lead community development, ie language support groups hi which speakers of other languages and English -speakers can be introduced to local community languages.

Future research

Twf support groups and activities can potentially improve bonding social capital between Welsh speakers and bridging social capital between non-Welsh speakers and fluent \VeJsh speakers. It would be useful to study to what extent these activities improve families' social capital. This would have interesting implications for the influence that the health visitor can have on social capital generally through their public health role.

Further information

Parents and health professionals can access the TWf website and helpline for information and advice, see: or Tel: 08456051551.


The author thanks Gwerfyl Roberts of Bangor University for her help in clarifying the link between public health and bilingual communities and Helen Owen, Gwynedd health visitor team leader, for her advice from the health visitor's point of view.


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Author affiliation:

Elizabeth Woodcock BSc

Twf officer, IAITH


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