Baby Box: evaluation

5. Workforce training and role in the Baby Box scheme

Key findings

• The vast majority (88%) of health visitors, midwives and family nurses felt clear on the aims of the Baby Box Scheme.
• When asked about the main ways the scheme was intended to contribute to positive outcomes, the most common answer among professionals was that it did so by helping families financially by providing items for their new baby (44%). This was followed by ‘helping to reduce inequalities in health between children from different backgrounds’ (37%) and ‘helping to reduce inequalities in health between new mothers from different backgrounds’ (34%). Far fewer professionals singled out the idea that the scheme was intended to contribute to positive outcomes by increasing opportunities for them to engage with parents (6%).
• A majority of health professionals (61%) felt clear about their role in relation to the Baby Box scheme. Fourteen per cent said they were unclear and 22% that they were ‘neither clear nor unclear’ about their role.
• Training on the scheme most frequently took the form of informal discussions with colleagues (41%) and written information (35%) rather than more formal training (2%). 28% said they had not received any training or information about the scheme.
• Among the 72% who had received information or training, 37% felt it had been sufficent.
• There were clear differences by both profession and length of time in role, with midwives and more experienced professionals more likely to feel clear about their role, report that they had received sufficient training, and to feel confident discussing the box with parents.
• The main topics professionals were unsure about or wanted more information or training on were: the contents of the box (59%); practical elements of how the scheme operates (for example, 51% of those who felt training was not sufficient wanted more training on the registration process while 44% mentioned the delivery process); and the aims of the scheme (50%). Qualitative interviews with health professionals also identified a desire for more information about the purpose and evidence behind the scheme, and the main messages they should get across to parents about the box. The evaluation also indicates the scheme may benefit from providing further information for professionals about using the box for safe sleeping (mentioned by 40% of those who felt their training on the scheme was not sufficient).

As discussed in the previous chapter, the Baby Box scheme was intended to improve outcomes for families not only by providing them with essential items to support child health and development, but also by acting as a mechanism for parental engagement with services. The extent to which health professionals – particularly midwives and health visitors / family nurses, who have most contact with young families – are engaged with the Baby Box scheme is thus key to it being able to fully realise its intended outcomes. This chapter explores health professionals' understanding of their role in relation to the Baby Box scheme, their experiences and needs in relation to training and information, and their confidence in discussing the scheme with parents. It draws primarily on the survey and qualitative interviews with health professionals.

Outcomes

• Training needs identified for midwives and health visitors
• Fully trained and engaged workforce

Research Questions

• Do they feel able and confident to discuss the contents and purpose of the Box with parents?

Professionals' understanding of the purpose of the scheme

The survey of midwives, health visitors, and family nurses indicated that most felt they understood the purpose of the Baby Box scheme – 88% agreed that 'I have a clear understanding of what Scotland's Baby Box scheme is trying to achieve', while just 5% disagreed and 6% neither agreed nor disagreed.

When asked about the main ways in which they thought the Baby Box scheme was intended to contribute to positive outcomes for families, health visitors, midwives, and family nurses were more likely to single out the financial help the scheme offers than the ways in which it might increase opportunities for health professionals to engage with parents. The most commonly chosen responses were:

• 'helping families financially by providing items for their new babies' (44%);
• 'helping to reduce inequalities in health between children from different backgrounds' (37%);
• 'helping to reduce inequalities in health between new mothers from different backgrounds' (34%);
• 'helping to encourage positive parenting behaviours in parents' (24%);
• 'helping to increase opportunities for health professionals to engage with parents' (6%).

Just under half (48%) of professionals thought the Baby Box scheme was intended to contribute to positive outcomes in all of these ways.

Professionals interviewed for the qualitative research tended to focus primarily on the promotion of equality when asked about the purpose of the scheme. The box was described as a universal 'gift' which aims to 'give all babies the same start in life', by ensuring that all families have the items essential for the first few months of their baby's life. The scheme's potential role in supporting safe sleeping – by providing a safe sleep space and/or acting as a resource to support conversations about safe sleeping – was also identified by professionals in the qualitative interviews as part of the perceived purpose of the scheme. Indeed, one view was that promoting safe sleep was one of the central aims of the box. This view was sometimes linked with a perception that the Finnish scheme which inspired Scotland's Baby Box was focused on safe sleeping and reducing SIDS. The stated purpose of Scotland's Baby Box is to give every child the best start in life by improving the support available to new and expecting parents.

Health professionals' understanding of their roles in the Baby Box scheme

A majority (61%) of health professionals surveyed for this evaluation said they felt clear about their role in relation to the Baby Box scheme. However, more than a third said they were either unclear (14%) or 'neither clear nor unclear' about their role (22%). Midwives (88%) were much more likely to report feeling clear about their role than were health visitors and family nurses (48%). Health visitors / family nurses accounted for the vast majority of those who said they felt 'unclear' (123 of the 131 respondents who said they were unclear were health visitors / family nurses). This perhaps reflects midwives more defined role in registering parents for the scheme. Indeed, half (50%) of health visitors / family nurses who felt unclear about their role said they felt that the baby box was discussed by midwives rather than themselves, or that they did not see themselves as having any role in the scheme.

This was supported by findings from qualitative interviews with midwives and health visitors. Midwives generally had a clear view that their role was to promote take up of the scheme and help parents register for a box. In contrast, health visitors generally indicated that they felt they had defined their own roles with respect to the Baby Box scheme, as they had not received any specific training or information about their expected role.

"We don't play a huge part in it, it's just more checking that people have got it and generally I might ask them a couple of questions, like how they got on with it and stuff"

Health Visitor

Both groups of professionals varied in the extent to which they felt they also had any role in discussing the box and its contents with parents, beyond discussions about registration.

The difference in views between midwives and health visitors may, in part, reflect the fact that midwives were the main focus of information provision to professionals at the start of the baby box roll out. It is also worth noting that at the time the qualitative interviews with health professionals took place, antenatal contacts between health visitors and expectant parents – a point at which they may be particularly likely to discuss the baby box, having just received it – had come to a temporary stop in many areas as a result of the pandemic. This may also have had an impact on health visitor awareness and views of baby boxes and of their role in the scheme. There may be an opportunity to improve or reinvigorate health visitors' use of the box, as these antenatal visits restart.

Question for consideration: Is there a need to clarify or communicate the expected role of health professionals, particularly health visitors, in delivering the Baby Box scheme?

The survey found that more experienced professionals were more likely to report feeling clear about their role in relation to the scheme: 68% of those who had been practising for over ten years said they felt 'very' or 'quite' clear about their role, compared with 38% of those who had been practising for less than a year. A number of factors may help explain this difference, including the least experienced professionals not having been in post when the scheme was launched in August 2017, and more experienced professionals being able to apply their wider experience to the context of the Baby Box scheme. The findings may also be partly explained by the relationship between profession and experience - overall, the midwife population is more experienced than the health visiting population due to the increase in health visitor numbers over recent years^[34]. However, regression analysis shows that both profession and length of experience are significant in their own right (this applies to a number of findings in this chapter where there are significant differences by both profession and length of time in role).

Other reasons given by those who felt unclear about their role included: not having received training or information on the box (26%) (discussed further below); being unclear about the contents of the box (14%); being unsure what it was about the box that they should be discussing with parents (12%); how to ask parents about their use of the box (8%); how parents apply for the box (7%); and when parents receive the box (3%).

Training on the scheme

The finding that a significant minority of health professionals, predominantly health visitors and family nurses, are not clear about their role in relation to the Baby Box scheme indicates a potential need for further information or training. This section looks at the information and training received by professionals to date and provides more detail on the topics they suggest for further information and training.

The survey of health professionals indicates that the majority of information they recall receiving on the scheme was informal verbal information (for example, a chat with colleagues) (41%) or written information (35%), rather than formal training (2%). Nine per cent said they had received a demonstration of the box, while 28% said they had not received any information or training about the scheme. Health visitors / family nurses were more likely than midwives to say they had not received any information or training about the scheme (36%, compared with 11% of midwives). They were also less likely to recall having received written information, such as leaflets or factsheets (26% of health visitors / family nurses, compared with 55% of midwives).

Among the 72% of respondents who had received any information or training on the Baby Box scheme, only around a third (37%) felt they had received sufficient training, while 40% felt they had not, and 23% were unsure or preferred not to say. A higher proportion (50%) of this group felt they had received enough information about the scheme. In line with previous findings in this section, midwives and more experienced professionals were more likely to report that they had received sufficient training and information on the scheme (Table 6.1). As discussed in the previous chapter, health professionals (particularly health visitors) were divided in their views on whether the baby box was helping to support their conversations with parents. Further training or information about the scheme could potentially address this and enhance the usefulness of the scheme in supporting parent-professional interactions.

The midwives and health visitors who participated in qualitative interviews generally reported having received no formal training and little or no formal information about the Baby Box scheme, although midwives did, on occasion, recall having received some information when the scheme was first introduced in 2017. Instead, professionals described having educated themselves through informal discussions with colleagues, learning about the contents via the website, and asking mothers to show them the box and its contents. One health visiting team had also arranged training themselves from a physiotherapist on how to use the sling correctly, as they had observed parents struggling to use it and wanted to be able to support them with this.

Table 6.1 Professionals' views on whether they have received sufficient training and information

Do you feel you have received sufficient training about the baby box?	Yes	No	Don't know /prefer not to say	Sample size
All	37%	40%	23%	616
Midwives	56%	21%	24%	245
Health visitors/family nurses	24%	53%	22%	371
Practicing for under 6 years	22%	60%	18%	211
Practicing for 6-10 years	37%	41%	22%	96
Practicing for 10+ years	45%	30%	25%	308
Do you feel you have received sufficient information about the baby box?	Yes	No	Don't know /prefer not to say	Sample size
All	50%	33%	17%	616
Midwives	69%	14%	18%	245
Health visitors/family nurses	37%	46%	17%	371
Practicing for under 6 years	37%	47%	21%	211
Practicing for 6-10 years	49%	29%	12%	96
Practicing for 10+ years	56%	25%	19%	308

Base: All professionals who have received any training or information

Those who felt they had not received enough training or information highlighted several aspects of the box they would like further training/information on. As shown in Table 6.2, the most common responses were 'the contents of the box' (59% more training and 68% more information), 'the registration process' (51% more training, 50% more information) and 'the aims of the Baby Box scheme' (50% more training, 51% more information). Health visitors/family nurses were more likely than midwives to want more training or information on the contents of the box, the registration process and the delivery process^[35]. These differences are likely to reflect the fact that health visitors/family nurses are not generally involved in the registration and delivery processes and are also less likely to discuss the contents of the box with parents in advance of them receiving the box.

Table 6.2 Aspects of the scheme professionals would like further training/information on

	More training	More information
The contents of the box	59%	68%
The registration process	51%	50%
The aims of the Baby Box scheme	50%	51%
The contents of leaflets included in the box	49%	58%
The delivery process	44%	46%
How to use the box for sleeping	40%	43%

Base: All professionals who have received some training or information but do not feel the training is sufficient (250) or the information is sufficient (209).

The in-depth interviews also identified the purpose of the scheme and the contents as key topics. In addition, there was a desire to be better informed about:

• The purpose of the scheme
• The history and evidence behind the scheme, particularly in relation to the safety of the box as a safe sleeping space, in order to reassure parents
• The main messages the scheme is meant to be getting across to parents ("so everyone is saying the same thing")
• How to use specific contents correctly (e.g. the sling), and
• Updates when contents change.

An additional area where the qualitative interviews with health professionals suggest further information and training may be beneficial relates to the use of the box as a safe sleep space. The Scottish Government states that Scotland's Baby Box and its bedding provide a safe sleeping place when used in accordance with other safe sleeping practices. However, concerns were expressed by a small number of professionals in the qualitative interviews about whether a baby box is definitively a safe sleep space. For example, one Health Visitor expressed confusion on conflicting advice from sources outwith the Scottish Government on the use of boxes as sleep spaces, while another questioned whether the sides of the box needed to be open/breathable (the Scottish Government guidance is that this is not required since the top is open). This suggests a need to provide health professionals with further information on the safety of the baby box for sleeping.

It was suggested that it might be helpful for all new trainees to receive brief training on the scheme – its purpose, contents, and how to register for and cancel a box. There was also a desire among some to have an opportunity to physically look through a box, to help them get to know the items included before talking to parents. There was a general consensus that any training could be delivered online, as this was more cost effective, easier to fit in, and easier to update with any changes to the scheme.

Confidence in discussing the contents and purpose of the box

In spite of these perceived gaps around training and information on the Baby Box scheme, most professionals (82%) who responded to the survey said they felt confident discussing the Baby Box scheme with parents. Midwives and more experienced professionals were more likely to feel confident (91% compared with 77% of health visitors or family nurses). Confidence was also related to experience with those with the least time practicing (under a year) less likely than those with over a year's experience to feel confident discussing the scheme with parents (61% versus 85%). These findings again reinforce the potential need to target training and information around the scheme on health visitors / family nurses and those who are newer in post.

Questions for consideration: Could the areas professionals identified as reasons for feeling unsure about their role and the areas they identified as training / information gaps be considered when designing any future information or training provision? These suggest that training / information needs to cover:

• practical elements of how the scheme operates (how parents register and when the box is delivered).
• the contents of the box (including how to use them and any changes made to the contents)
• information about using the box for safe sleeping.
• the purpose and evidence behind the scheme, and
• the main messages they should get across to parents about the box.

Could training and information also incorporate examples of how midwives and health visitors have used the box to support or reinforce key health messages, to encourage greater use of the box to support engagement with parents?

Could training and information provision also consider the different needs and roles of midwives and health visitors/family nurses and how best to reach less experienced practitioners?