Universal Health Visiting Pathway evaluation - phase 1: main report - primary research with health visitors and parents and case note review

3. Impact of the pathway

Early identification of strengths and concerns

A key goal of the UHVP is to promote early identification of children and families’ strengths and concerns. In the health visitors’ survey, the vast majority said that the pathway (in full or part in almost all cases) enables them to identify concerns about a child at an early stage ‘very well’ (36%) or ‘fairly well’ (57%).

Amongst the 36% of health visitors who said the pathway enabled them to identify concerns about a child ‘very well’, those working full-time were more likely than their colleagues who worked part-time to say the pathway helped them to identify concerns ‘very well’ (44% versus 29% respectively). Also, those who had been delivering the pathway for over four years (51%) were slightly more likely than those who had been delivering it for less than four years to say this.

When asked the same question in relation to identifying concerns about parents at an early stage, health visitors responded in a similar manner: 34% said the pathway enabled them to do this ‘very well’, 61% ‘fairly well’ and 4% not ‘very’ or ‘at all’ well. Full-time colleagues were again more likely than those who worked part-time to feel it did this ‘very well’ (42% versus 25% respectively).

In the qualitative interviews, many health visitors explained that the pathway facilitated frequent interaction with families and enabled early identification of strengths and any concerns.

When you’re seeing patients a lot more frequently or offering to see them a lot more frequently, it offers more opportunities for them to talk about or ask about, so therefore if there is any issues that are coming up then these will be identified earlier (Health visitor).

The frequency of visiting facilitated positive relationships between health visitors and parents [see theme 2] and allowed them to have a better understanding of the wider home environment and a family’s circumstances.

I would say that the pathway allows you to identify [a family’s strengths and concerns] and you can see how it changes. What can be a core family that you are visiting because you are following the timeline you can pick up on things that maybe you wouldn’t because you are in more often and you are getting that better relationship with families, with mums and dads and grandparents and things that you can see more so if a family is maybe reaching crisis and things like that and they do need extra help (Health visitor).

During the focus groups, health visitors agreed that the antenatal visit was particularly beneficial for identifying concerns around maternal mental health and allowed health visitors to provide support for this prior to the birth of a baby.

I’m doing a few antenatal visits and one of the things that’s come out in most of them has been mental health issues. It’s been women who share with you, because you don’t have the distraction of a baby there. I find them so valuable, and often, [mothers] will share things at an antenatal visit, that they will not share with you at a new birth visit. You then go into that new birth visit, with knowledge about that family, that then informs everything else that you do … I’m yet to find an antenatal [visit] that hasn’t been valuable, in some way or another, compared to just going in on day 11 or day 12, and meeting them for the first time (Health visitor, Focus Group).

However, a few health visitors disagreed and shared views indicating that the frequent visits embedded in the pathway had little to no influence on early identification of families’ strengths and concerns, as this was already embedded in practice.

I don’t think it’s necessarily changed. I think health visitors are doing that anyway. I think we have quite a good awareness of all of those issues, so I’m not really sure that the pathway has changed that (Health visitor).

It is difficult to explain this disparity, but it is likely that the variation in health visiting services across Health Boards that existed prior to the implementation of the UHVP may have influenced health visitors’ responses regarding early identification of families’ strengths and concerns.

The point at which strengths and concerns were recorded within case notes was also explored. The timeframe for identification of strengths and concerns is provided within Table 3.1.

Table 3.1 The time at which Assessment of Strengths and Concerns took place

	Assessment of Strengths & Concerns
Health Board	10-14 days /possible cases	6 – 8 weeks /possible cases	3 & 4 months /possible cases	6/12 record review /possible cases	8 months /possible cases	13 – 15 months /possible cases	In addition
HB1	14/15	10/15	0/15	0/15	1/15	3/15	1 x at LAAC Review (112 weeks = 2 years and 2 months)	All records provided evidence that assessment of strengths and concerns had taken place either at the first visit or at 6-8 week assessment or both
HB2	5/13	3/13	2/13	5/13	4/13	5/13
HB3	None evident	10/15	None evident	None evident	7/15	11/15	4/10 at 27 – 30 months	There is evidence that 14/15 had an assessment of strengths at some point; however for one this was not identified until 13 – 15 months.
HB4	6/15	3/15	2/15	None evident	3/15	5/15		There is evidence that 14/15 had an assessment of strengths at some point; however for 2 cases this was not identified until 8 months.
HB5	None evident	15/15	None evident	None evident	None evident	8/15		In all cases strengths were assessed at the 6-8 week assessment

The data collected indicated that strengths were identified in the records, in relation to both child and parents/carers; however, no specific strengths were named. Concerns, however, were identified and named; frequently indicating the need for health visitor action upon identification. This is an important step to ensure families receive appropriate support or help. Table 3.2 (children) and 3.3 (parents) show the identification of at least one concern during assessment. Appendices 8 and 9 show the type of concerns identified in relation to children and parents across the Health Boards.

Table 3.2 Where there is evidence of at least one Concern related to the baby/child

Health Board	Evidence of at least one concern related to the baby/child identified during assessment in each of the following number of records
	Core	Additional
HB1	5/10	4/5
HB2	3/8	3/5
HB3	3/10	5/5
HB4	4/11	3/4
HB5	4/9	4/6

Table 3.3 Concerns identified in relation to the parents'/carers' behaviour/well-being

Health Board	Evidence of at least one concern related to the parent/carer identified during assessment in each of the following number of records
	Core	Additional
HB1	2/10	4/5
HB2	4/8	3/5
HB3	2/10	4/5
HB4	1/11	4/4
HB5	4/9	6/6

Health visitors providing child wellbeing, safety and attachment advice and support

It was intended that the pathway would promote children’s wellbeing, safety and attachment. Health visitors were asked in the survey the extent to which the pathway gave them the opportunity to discuss a number of topics related to child safety and wellbeing with families. Table 3.4 represents proportions of health visitors who said ‘a great deal’/’quite a lot’ for topics relating to child safety and wellbeing.

Table 3.4 The proportions of health visitors who answered ‘a great deal’ or ’quite a lot’ to the question that the UHVP provided opportunities to discuss topics related to child safety and wellbeing

Topic related to child safety and wellbeing	A great deal (%)	Quite a lot (%)
Children’s learning and development	46	41
Child safety	41	43
Children’s general happiness and wellbeing	36	46
Parents’ mental health and wellbeing	32	48
The impact on children of parents’ smoking, drinking alcohol or using drugs	28	41

Child wellbeing, safety and attachment was also explored in the qualitative study with health visitors. There were mixed responses regarding changes in practice as a result of the introduction of the pathway, some of the health visitors did not feel that the pathway had markedly influenced their advice or discussion around wellbeing, safety and attachment as this was embedded in practice prior to the introduction of the pathway. While others felt that the pathway had enhanced practice in these areas.

I wouldn’t say they’ve changed dramatically; I think because I’ve been a health visitor for several years, I know what’s gone before and personally, I am very committed to what I do as a health visitor. I think this acts as a prompt to remind me of when I need to do things but I don’t think the pathway has changed my practice, as such because I am very committed to what I do as a health visitor, basically (Health visitor).

No. If you identify the safety issue, you would make a plan around about that. If you identified an attachment issue you would make a plan, you would adjust your visits accordingly. I don’t think the pathway has made a difference to that (Health visitor).

I don't think [the pathway] has [made any difference to wellbeing, safety and attachment discussion]; I don't feel it really has at all. I think it's the same, the same as it always was for health visiting (Health visitor).

Although it appeared these issues had always been part of health visiting practice, other health visitors felt the pathway provided the opportunity to highlight the discussion of these issues overall, and the addition of the antenatal visit meant that these issues could be discussed at an earlier point.

So I think maybe there’s been a growing awareness of the importance of attachment over the years. But I suppose because it’s embedded in the pathway, then yes, it’s something that we talk more about and raise the awareness with parents (Health visitor).

I think we have certain checklists, well we do have certain checklists that we go, antenatally and the first postnatal visit, which just looks at attachment. So I guess without the pathway, you wouldn’t have your antenatal visits, so you wouldn’t have that early opportunity to ask if the mum is bonding with her unborn baby. There’s lots of research and evidence to suggest that this is hugely important. So without the pathway, without that visit, we wouldn’t be able to do that, so that’s obviously really important and the first visit as well, if there’s any concerns that are raised from the attachment and bonding, then I guess you have your further pathway visits to help model and refer onto any further services or to do some extra work with the family, to help to improve that attachment. So I guess the pathway just sets it up, so there is an early opportunity to recognise any bonding issues that there may be (Health visitor).

Impact on parental understanding, choices and behaviour

Another main aim of the introduction of the UHVP is to improve families’ understanding and application of positive parenting, ultimately leading to improved health and developmental outcomes for children. In order to achieve these outcomes, health visitors need to have an impact on families’ understanding of a wide range of issues. The logic model for the UHVP evaluation includes: child development, wellbeing and safety; healthy lifestyle and behaviour choices (including smoke free home, breastfeeding, oral health); and attachment and its impact on children’s brain development.

The evaluation explored parents’ perceptions of (a) their own level of knowledge about a range of parenting and child development topics, and (b) the extent to which they felt their health visitors had provided them with information about these topics. The survey and qualitative research cannot definitively assess the impact of health visiting on parental understanding. This is because it is possible parents may have acquired knowledge from elsewhere and the survey questionnaire only assesses self-rated knowledge as opposed to actual knowledge, which may be higher or lower. However, the survey can provide an indication of areas where parents feel more or less well informed, and where there may need to be a greater focus as the UHVP is embedded, in order for it to meet its aims.

From the survey data, Table 3.5 shows perceived knowledge and reported receipt of information from health visitors for each of the items asked about. Across a large number of topics, almost all parents rated their level of knowledge highly. The highest levels of self-reported knowledge were for: ‘the benefits of reading to children under five’ (94% said they knew ‘a great deal’ or ‘a fair amount’ about this), ‘keeping your child safe’ (94%), ‘options for feeding your child in the first 6 months’ (92%), ‘weaning/healthy eating for children’ (91%) and ‘the benefits of playing with children under five’ (91%). Topics where fewer parents, but still a majority, felt well informed included: ‘how to manage your own mental health and wellbeing’ (77% felt they knew ‘a great deal’ or ‘a fair amount’ about this), ‘how to handle behaviour that you find difficult from your child’ (71%), and ‘where to go for help with money issues or benefits’ (55%). While it is possible that the latter issue may not affect all parents, managing one’s own mental health and handling challenging behaviour are likely to be issues that arise at some point for all parents. It may be of value to consider these reported areas as opportunities to provide more information for parents.

Table 3.5 information provided by health visitor and own knowledge on a range of topics

Item[2]	% of parents who felt they knew a great/deal a fair amount	% of parents who said they had received a great deal/a fair amount of info/advice on this from their health visitor
The benefits of reading to children under 5	94	53
Keeping your child safe	94	48
Options for feeding your child in the first 6 months	92	60
Weaning/healthy eating for children	91	61
The benefits of playing with children under five	91	55
The impact on children of parents smoking, drinking alcohol or using drugs	89	35
How to support your child’s physical health and development	89	58
How to build a secure relationship with your child	87	38
How to support your child’s learning and development	85	57
How to talk with children under 5	85	42
How to support your child’s general emotional development and wellbeing	81	50
How to manage your own mental health and wellbeing	77	41
How to handle behaviour that you find challenging from your child	71	28
Where to go for help with money issues or benefits	55	15

The proportion of parents reporting that they had received ‘a great deal’ or ‘a fair amount’ of information about each topic varied to a greater extent in comparison to self-reported knowledge. Topics where the greatest number of parents said they had received information or advice were: ‘weaning/healthy eating for children’ (61%), ‘options for feeding your child in the first six months’ (60%), ‘your child’s physical health (58%), ‘your child’s learning and development (57%), and ‘the benefits of playing with children under five’ (55%). On the other hand, only 15% of parents said they had received a great deal or a fair amount of information or advice about where to go for help with money issues or benefits and just 28% said that they had received a great deal or a fair amount of information or advice about how to handle behaviours that they found difficult. Thirty-five per cent said they had received a great deal or a fair amount of information or advice about the impact on children of parental substance misuse, and 38% said the same in relation to information or advice about how to build a secure relationship with your child.

It is to be noted that the sample for this survey includes parents of children aged 0-5 years from across Scotland. Given the different stages of UHVP roll-out across Scotland, some parents – particularly those answering for children towards the older end of the age spectrum – were unlikely to have received the full UHVP for their child. A further breakdown of responses on each topic is provided below, with subgroup differences, including by age of child. This shows a general pattern for parents answering about children at aged 4 or 5 years. These parents are less likely than average to report that their health visitor had provided them with information/advice on all topics. This is with the exception of handling challenging behaviour and money issues and benefits, both of which are presumed to be more relevant for parents to require information on as their child gets older.

As mentioned above, it is possible that responses reflect the fact that parents with children at aged 4 or 5 years may be less likely to have received the full UHVP; the passing of time and reliance on memory recall may have also impacted parent’s ability to remember any information received on particular topics. In addition, it can be assumed that some parents of pre-school children access information and support from a variety of sources including Early Learning and Childcare Staff. Nevertheless, as the UHVP is intended to impact on these areas, findings indicate where particular attention to topics and timing in relation to milestones may be needed to ensure that parents are getting the information and advice, they require to develop understanding and application of positive parenting skills and more widely meet the aims of the UHVP.

Survey responses indicate parents living in the most deprived areas of Scotland are most likely to report having received a great deal or a fair amount of information from their health visitor on specific topics. Survey responses, therefore, suggest that those living in the most deprived areas in Scotland are being offered or are accessing more support on these issues. Older parents, aged 35 years and above, were significantly less likely to say they had received information or advice on a number of issues. In part, this is likely to reflect the fact that parents in this age group are less likely to be first time parents and may be less likely to ask for or want further information or advice. There was also a correlation between the age of the respondent and the age of child they were answering about, with older parents being more likely to be answering about an older child.

Child development, wellbeing and safety

Nine in ten (89%) parents felt they knew a great deal or a fair amount about how to support their child’s physical health and development, with half of parents (49%) saying that they knew a great deal about this. Only a very small percentage of parents (3%) reported not knowing very much or nothing at all (see Appendix 10 for full responses to the parental knowledge questions).

Over half (58%) of parents reported that they had received a great deal or a fair amount of information from their health visitor on their child’s physical health with just under a quarter (23%) saying they had received a great deal of information on this topic. One in ten (10%) said they had not received very much information from their health visitor on this topic, while 6% said they received no information at all (see Appendix 11 for full responses to the questions on advice and information provided by health visitors).

Parents living in the most deprived areas (SIMD 1 and 2) were most likely to say they had been given a great deal or a fair amount of information about their child’s physical health (66% and 64% respectively, compared with 50% of those in the least deprived areas (SIMD 5). Parents answering about children aged 4 or 5 years were less likely to say they had been given a great deal or a fair amount of information on child’s physical health (44%, compared with 59% of parents of 3 year-olds, 69% of parents of 2 year-olds, and 74% of those responding about a child aged one or under). A large majority (81%) of parents felt they knew a great deal/a fair amount about how to support their child’s general emotional development and wellbeing, while 14% said they knew something about this and 5% that they knew not very much or nothing at all.

The proportion saying they knew a great deal or a fair amount was highest amongst parents in the least deprived areas (87% in SIMD 5, compared with 75%-81% in other deprivation quintiles).

Half (50%) of parents said they had received a great deal (19%) or a fair amount (31%) of information on their children’s general happiness and wellbeing while a fifth (22%) said they had received some information on this. A further fifth (20%) said they had not received much or anything, 6% that they had been offered but declined this information and 2% that they did not know. Reported receipt of information on this topic was lowest among parents aged 35 years and above (44% a great deal or a fair amount, compared with 58% of those under 30 years and 61% of those aged 30-44 years) and those answering about children aged 4 or 5 years (35%, compared with 64% of those answering for a child aged one or younger, 62% answering for a 2 year-old, and 53% answering for a 3 year-old).

Infant feeding

Parents were also asked about several specific child health and development topics, including options for feeding in the first six months, weaning and healthy eating.

Almost all (92%) parents felt they knew a great deal or a fair amount about options for feeding their child in the first six months (either breastfeeding or first infant formula milk or a combination of both), while just 1% said they knew not very much or nothing at all. Similarly, the vast majority (91%) of parents felt they knew a great deal or a fair amount about weaning and healthy eating for children, while just 1% reported knowing not very much about this. Six in ten (60%) parents said they felt their health visitor had given them a great deal or a fair amount of information on feeding their child in the first six months, with one third (32%) saying they had received a great deal of information on this topic. Just 15% of parents said they received not very much or nothing at all from their health visitor on this topic.

Those answering for older children were more likely to say they had not received any information about options for feeding in the first six months (12%, compared with 4% with children aged 2 years or younger). As noted above, this may reflect recall bias, since it will be longer since such information would have been offered to parents of children in this age group, or due the fact they have had less exposure to the full UHVP.

Parents in the most deprived areas (SIMD 1) were more likely than average to say they had received a great deal or a fair amount of information (69%, compared with 51% of those in SIMD 5). A similar proportion overall (61%) reported having received a great deal (28%) or a fair amount (33%) of information or advice from their health visitors on weaning and healthy eating, while 14% reported receiving not very much or nothing at all. Parents in urban areas were more likely than parents in rural areas to say they had received a great deal or a fair amount of information on this (63% compared with 53%). Parents answering about children aged 4 or 5 years were least likely to say they had received a great deal or a fair amount of information (54%) on weaning or healthy eating, with parents of two year-olds most likely to say they had been given information on this topic (71%). Parents in more deprived areas (SIMD 1/2) were also more likely than parents in other areas to report receiving a great deal of information on weaning / healthy eating (38% in SIMD 1 and 34% in SIMD 2, compared with 20%-28% in more affluent areas).

In the qualitative interviews, parents were asked to reflect on the feeding advice and support received from health visitors and state specific examples to illustrate how advice and support provided influenced their choices and behaviour, especially with regards to breastfeeding and weaning. It is to be noted that many parents from the qualitative interviews reported that they had received a great deal of information about feeding from their health visitor. In exploring how this information influenced their behaviours, many parents felt it was impactful and were appreciative of the support; this was almost universal amongst those breastfeeding and formula feeding.

Well, I don't know, from the off I kind of wanted to breastfeed, but I guess I was ready to give up because [my child] wouldn't latch on to me herself and then [my health visitor] suggested the expressing, so I guess she influenced me to keep going then with it. I wouldn't say she influenced me in a bad way, she just tried to kind of prompt me to do what I wanted to do, but I was ready to give up (Parent, first time).

I think I may have gone, oh well, it’s a day and a half so she can just have bottle milk for that day. But yeah, based on [my health visitor’s] suggestion, we’ve been definitely more active with the breastfeeding, yeah (Parent, first time).

I did find the breastfeeding support that she provided very helpful (Parent, first time).

In the interviews with parents, all parents who needed weaning information said they received this information. However, it appears health visitors took a cautious approach in actively engaging women in discussions around weaning at the four month visit to prevent weaning too early. Many parents also reported being provided with weaning packs in advance to prepare for this stage.

She gave us a weaning pack, she gave us leaflets, she explained it all and what the most recent advice is about it being six months, and I can’t remember if it was four months with my first daughter, I can’t actually remember to be honest. But she basically went through all what’s advised now and what to do and, yeah, that was all fine (Parent, two children).

Most parents who received the advice and information about weaning found it helpful irrespective of the age of their children and this was especially true for those who engaged in further discussions with the health visitor. The data suggests that information and advice might have increased parental understanding, although there is no evidence to demonstrate it influenced weaning behaviour.

Yeah, I found it really helpful, in particular the…one of the things that I wasn’t 100 per cent sure was weaning and stuff. I solely breastfeed my baby and I know that the old advice was to start weaning at four months and the new advice is to start weaning at six months and how to do this, to do baby-led or to do spoon fed and all that, kind of stuff (Parent, first time parent).

Yes, she just, I, kind of, even though I’ve had three others, I, sort of, needed a bit of a recap again on how to, like, what, where do we start. So, she did help me and, sort of, talked me through that, and current thinking (Parent, four children).

As mentioned previously, within the UHVP, health visitors provide weaning information to parents at the four months visit and parents are expected to begin weaning at around six months. Some parents specifically shared feelings of a lack of support during the critical period of weaning because of the time between the four and eight month visits. It appears some parents would have liked to receive weaning information and support nearer to six months rather than at the four-month stage.

She did say, you don’t wean your baby until – well, you’re recommended not to do it till they’re six months, but she did the weaning chat at like four months and I couldn’t understand it. But I did ask her why and she said, there’s quite a lot of mums do it too early, and by the time she actually goes to do the weaning chat, they’ve started weaning, so she does it early so that she can catch some parents before they actually do it, but my wee boy didn’t need weaned until he was six months, so that was a bit early (Parent, two children).

I, sort of, was, kind of like, wow, because I think they see you at five months and then the next time they see you is at eight months. So, if weaning’s supposed to be six months, they completely miss that. So, they get you ready for weaning, so they dropped off a little book and a little pack. But it, sort of, kind of, when they, sort of, leave you at five-months and then say, alright we’ll see you again at eight-months and I just feel like, wow, you’re left on your own there. And it’s really quite a, sort of, a steep, kind of, curve between five and eight months because you do introduce food and there’s lots of different things going on, and lots of…and the development in a baby between five months and eight months is huge. So, I do feel like there’s maybe an appointment that’s, sort of, missing out the middle of those two (Parent, first time).

During the semi-structured interviews and focus groups with health visitors, similar concerns about the gap between the four and eight-month pathway visits were raised in the pathway schedule section above. Health visitors felt that the time between the four to eight month pathway visits needed to be highlighted because it is during this period that weaning usually begins.

Yeah, I think the weaning at four months, when you're encouraging them to wait until six months, is kind of, it doesn’t quite align quite right with the pathway (Health visitor, Focus Group).

Sometimes it feels like maybe don’t need both of these visits and that to maybe do one and maybe do a six month contact or a contact just after weaning, because weaning is quite a big thing and it’s round about six to seven months, so we’re given all the information here and then they’re starting it around six months and then we’re going in afterwards at around eight months. So it sometimes feels like, yeah, something like that could be a bit more useful, because parents get a bit anxious about weaning, and although we say, phone us, pick up the phone, they don’t really very often do it in reality (Health visitor).

But I feel that the pathway visit at four months would be better if it was five or six months because we’re kind of missing the key weaning, you know, introducing solid foods. By the time we do four months to eight months, there’s a big gap, everybody’s stressing, mums are stressing because they haven’t moved on to the next stage of weaning and they miss a whole lot of support at that time (Health visitor).

In one of the focus groups, all participating health visitors agreed that the gap between the four to eight month pathway visits is an important concern. Some health visitors also added that they usually make contact with parents at six months via telephone and use their professional judgment to make a decision on whether a parent may benefit from a visit or not. Another health visitor described how she used the six months update as opportunity to contact parents.

You’re missing that whole, kind of, weaning period, but I always try and update the GIRFEC at six months anyway, so I always try and make a phone call at that point, at least, just touch base with a phone call, with the families, just to speak about weaning and things, and see if they’ve got any issues. And if they wanted a visit at that time, do you know, I would probably, I would do, like, a non-pathway visit, if they needed me to (Health visitor).

This was supported by some of the parents that were interviewed, who mentioned that in order to compensate for lack of support around 6 months, some health visitors make provision for additional visit around 6 months.

I mean, she helped me with an issue around the six month mark. I remember she came specifically, even though I don’t think we needed to have an appointment, but she went ahead and came back because it was when I was supposed to start weaning. And so she came to offer specific advice and see if I had any questions, or needed advice regarding that. Every time she’s come, she’s offered plenty of advice and been able to answer all of my questions (Parent, first time).

Healthy lifestyle and behaviour choices

Improved family understanding of a healthy lifestyle and the impact of behaviour choices on the early years and beyond is another key outcome for the UHVP. The vast majority (89%) of parents of 0–5-year-olds who responded to the survey said they knew a great deal or a fair amount about the impact on children of parents smoking, drinking alcohol or using drugs, including two thirds (67%) who said that they knew a great deal about this.

However, parents reported receiving less information on this topic from their health visitor in comparison to other topics.

• Around a third (35%) of parents said they had received a great deal or a fair amount of information from their health visitor on the subject of the impact on children of parents smoking, drinking alcohol or using drugs.
• Almost as many parents (33%) said their health visitor had given them not very much or no information at all on it.
• A further 14% had been offered this information but felt they already knew enough about the topic.

An analysis of parents who reported being offered more information or advice on this topic reveals a number of significant differences across groups:

• Parents under 35 years were significantly more likely to say they had received at least a fair amount of information about the impact on children of parents smoking, drinking alcohol or taking drugs compared with parents aged 35 years and above (45% of under 30 years and 43% of 30-34 year-olds, compared with 29% of those aged 35 years and above).
• Parents in the most deprived areas (45% in SIMD 1) were more likely to report receiving a great deal or a fair amount of information from their health visitor on this subject than were parents in the least deprived areas (25% in SIMD 5).
• Parents answering about children aged 4 or 5 years were less likely than parents of younger children to say they had been given a great deal or a fair amount of information or advice on this topic (27%, compared with 40% of parents answering for a child aged one or under, 44% of those answering for a 2 year-old, and 34% of those answering for a 3 year-old).

Attachment

The survey also included questions on a range of issues relating to attachment, including building a secure relationship with their child and how to talk with children under 5 years. Most (87%) parents who responded to the survey said they knew a great deal or a fair amount about how to build a secure relationship with their child; just 3% said they knew not very much or nothing at all about this. However, although parents felt knowledgeable about this topic, a much smaller proportion said they had received information or advice about it from their health visitor: 15% said they had been given a great deal of information, 22% a fair amount, 17% some, 19% not very much, and 15% nothing at all.

Older parents (35 years and above) were less likely to say they had received a great deal or a fair amount of information or advice on building a secure relationship (33%, compared with 46% of those aged under 30 years and 47% of those aged 30-34 years). Those answering about children aged 4 or 5 years were least likely to say they had received information on building a secure relationship (28%), while parents answering about a 2 year-old were most likely to say this (49%).

Parents on lower incomes and living in more deprived areas were more likely to say they had received this information. For example, 68% of those earning less than £15,599 said they had received great deal or a fair amount of information or advice on this topic, compared with 29% of those earning £36,400-£51,999 and 31% of those earning £52,000 or more. Also, 52% of those in SIMD 1 and 45% of those in SIMD2 said they had received a great deal or a fair amount of information on this topic, compared with 28% of those in SIMD 5.

The majority (85%) of parents also felt they knew a great deal or a fair amount about how to talk with children under five, while 9% of parents said they knew something and just 6% felt they knew not very much or nothing at all. Knowledge grows with direct experience – parents who had no other children in the household felt less knowledgeable than others (80% versus 87% of those who had other children), suggesting that first time parents may need more advice on this topic^[3].

How to talk to their child was one of the topics on which parents were least likely to have received information or advice from their health visitor. Four in ten (42%) said they had received a great deal (18%) or a fair amount (24%) of information but 28% said they had not received very much (14%) or anything at all (14%).

• In line with other findings in this section, it was parents of children aged 4 or 5 years who were least likely to say they had received this information (35%, compared with 50% of parents answering for a child aged one or under, and 49% of those answering about a 2 year-old).
• Parents in the most deprived areas were more likely to say they had received a great deal of information on this topic (32%, compared with 17% in SIMD 2, 16% in SIMD 3 and 14% in SIMD 4 and 5).
• Parents in the West Health Board Region were more likely to say they had received this information than those in the East (49% versus 35%).

Home learning environment

Improved family home learning environments was also identified as a key aim of UHVP in the logic model produced for this evaluation. This can encompass play as well as reading with young children. The vast majority of parents (91%) felt they knew a great deal or a fair amount about the benefits of playing with children under five, with 62% saying they knew a great deal; just 3% said they knew not very much or nothing at all. Parents in the least deprived areas reported a higher overall level of knowledge than others (97% in SIMD 5 said they knew a great deal or a fair amount, compared with between 86% and 92% in relatively more deprived areas).^[4]

Over half of parents (55%) reported receiving a great deal (24%) or a fair amount (31%) of information from their health visitor on playing with their child. A further 18% had received some information while 8% said they had received not very much and 9% nothing at all.

Once more, parents answering about children aged 4 or 5 years were least likely to say they had received information (46% a great deal or a fair amount, compared with 57% - 64% of those answering in relation to younger children).

An even higher proportion of parents (94%) felt they knew a great deal/a fair amount about the benefits of reading to children under five with just 3% saying they knew not very much or nothing at all about this. Parents in the least deprived areas (SIMD 5) were most likely to say they knew a great deal or a fair amount about this (100%) while those in the most deprived areas (SIMD 1) were least likely to say this (88%).

As before, just over half of parents (53%) said they had received information from their health visitor on reading to their child (24% a great deal and 28% a fair amount), 19% had received some information, 9% had not received very much and 10% had received none at all. Parents answering about children aged 4 or 5 years were once again least likely to say they had received information (43%) and those answering about a 2 year-old most likely (62%). Older parents were again less likely to say they had received at least a fair amount of information on this (47% of those aged 35 years and above, compared with 62% of 30-34 year-olds and 58% of those under 30).

Similar to the survey findings, the qualitative interviews with parents found that most parents received information from health visitors about the importance of promoting a home learning environment and reading to the child. Those who said they did, mentioned that health visitors often used resources such as Bookbug to facilitate the discussion.

On reading, yes. Then she brought the Bookbug. She mentioned that it’s a good idea to start reading with the baby. I could start as young as I wanted, and it was a good habit to get into (Parent, first time).

We had a conversation one day about that, yeah, and we had – I think we got a couple of little books and we’ve got a CD, it was like another pack that we got given, and there was a little leaflet in it that suggested ways to play and basically suggestions of basically how to talk to a baby and entertain them and sort of engage with them (Parent, two children).

It appeared that those who mentioned that they didn’t receive much information or discussion about home learning and reading to their child were parents who already had older children and felt that health visitors assumed they already knew what to do.

I think she gave me some leaflets and a book about it, things like that, but again I‘m a second time mum, I kind of know what to do with my wee boy to develop his social skills and things like that, we go to classes and things, so I’ve not really needed her involvement in that (Parent, two children).

Within the case note review however there was evidence of recordings where toys/books had been observed within the home (see Table 3.6).

Table 3.6. The number of cases where toys/books had been observed and recorded at least once

Health Board	Number of case notes where Toys/books have been observed, and recorded in record at least once/possible cases	Percentage of Total cases
HB1	15/15	100%
HB2	8/13	61%
HB3	9/15	60%
HB4	13/15	87%
HB5	15/15	100%

There was also evidence of recordings where discussions about theimportance of toys, activities, and/or bedtime stories had taken place with the parent/carer at least once, as reported in Table 3.7.

Table 3.7. Numbers of Cases where the importance of toys/books/bedtime stories had been discussed with parents/carers at least once

	Numbers where discussion had taken place and been recorded /possible cases	Percentage of total possible cases where discussion achieved	Comments
HB1	8/15	53%	6 x only at First New-born Visit
HB2	7/13	54%	3 x only at First New-born Visit and 2 x at 6-8 week home visit
HB3	8/15	53%	no indication from data gathering when this was
HB4	12/15	80%	a wide range of ages including 8/12 and 13-15/12
HB5	11/15	73%	no indication from data gathering when this was achieved

Parenting and parenting techniques

The health visitors’ survey also included a question on the extent to which health visitors felt the pathway they were delivering gave them the opportunity to discuss topics relating to parenting. Overall, responses were less positive than those relating to child safety and wellbeing. Table 3.8 shows the proportions of health visitors who indicated that the pathway promoted the discussion of parenting topics.

Table 3.8. Proportion of health visitors who indicated that provide opportunity to discuss parenting issues either ‘a great deal’ or ’quite a lot’.

Topic related to parenting	A great deal (%)	Quite a lot (%)
Support families with developing parent-child relationships	34	45
Talk to families about how to handle behaviour they find challenging from their children	22	39
Talk to families affected by money issues about where to find help	22	36

A closer analysis showed that health visitors in the West Region and those who had been delivering the UHVP for more than four years were more likely than others to say that the pathway they were delivering gave them ‘a great deal’ of opportunity to:

• Support parents with developing parent-child relationships (39% in West versus 22% in East and 34% overall; 49% of those who had been delivering the UHVP for over four years, compared with 34% overall).
• Talk to families about how to handle behaviour they find challenging (28% in West versus 12% in East and 22% overall; 38% of those who had been delivering the UHVP for over four years, compared with 22% overall)
• Talk to families affected by money issues about where to find help (31% in West versus 11% in North, 10% in East and 22% overall; 32% of those who had been delivering the UHVP for over four years versus 22% overall).

These topics were also explored in the survey with parents. The survey asked parents about handling behaviour from their child that they find challenging, their own mental health and wellbeing, and support around money issues and benefits - all areas where the UHVP envisions health visitors offering support.

Just over two thirds of parents (71%) felt they knew a great deal or a fair amount about how to handle behaviour that they find challenging from their child, while 20% said they knew something about this and 8% said they did not know very much or anything at all. Handling challenging behaviour was one of the topics which parents were least likely to say they had received information or advice from their health visitor. Just over a quarter (28%) said they had received a great deal or a fair amount of information on this while 17% reported they had received some, 18% said they had not received very much and 26% reported they had received nothing at all. Parents in the least deprived areas (SIMD 5) were less likely to say they had received information on this (16% said a great deal or a fair amount, compared with 27% to 36% of those in relatively more deprived areas).

Around three quarters (77%) of parents felt they knew a great deal or a fair amount about how to manage their own mental health and wellbeing, while 16% felt they knew something about this and 6% felt they knew not very much/nothing at all.

Around one in five (21%) said they had received a great deal of information or advice from their health visitor on this while similar proportions said they had received a fair amount (20%) or some information (20%) on this topic. A third had not received much (16%) or any (17%) information.

Younger parents were more likely to say they had received information about how to manage their own mental health and wellbeing 58% of parents under 30 said they had received a great deal or a fair amount, compared with 43% of those aged 30-34 years and 36% of those aged 35 years and above. Parents answering for children aged 4 or 5 years were also less likely to report having received information or advice about managing their own mental health and wellbeing (29%, compared with 40% of parents answering about a 3 year-old, 52% of those answering about a 2 year-old, and 54% answering for a child aged one or younger. Those in the least deprived areas were also less likely to say they had been given information or advice on this (29% in SIMD 5, compared with 51% in SIMD 1).

Parents’ knowledge was lowest in relation to where to go for help with money issues or benefits. In part, this may reflect the fact that not all parents may need this information or support. Just over half (55%) of parents said they knew a great deal/a fair amount about this, while 21% said they knew something and 22% said they knew not very much/nothing at all. This was also the topic on which fewest parents reported receiving information or advice from their health visitor – just 15% had received a great deal/a fair amount of information on this while 57% had not received much/anything at all.

Parents on lower incomes and those living in the most deprived areas were most likely to have received this information:

• 35% of those earning less than £15,599 had received a great deal or a fair amount of information or advice on help with money issues or benefits, compared with 7% of those earning £36,400 - £51,999 and 8% of those earning £52,000+.
• 21% of those living in SIMD 1, had received a great deal or a fair amount of information or advice, compared with 6% in SIMD 5.

Impact on parental confidence

Another key aim of UHVP is to improve family confidence in positive parenting techniques.

Almost two thirds (62%) of the health visitors surveyed felt that the pathway they were delivering enabled them to support parents to become more confident (20% ‘a great deal’, 43% ’quite a lot’). Amongst those who said ‘a great deal’ or ‘quite a lot’ those who had been delivering the pathway for over four years were more likely to say this (68%).

When parents were asked a similar question, 59% of parents surveyed agreed that ‘my health visitor has helped me feel more confident about making the right decisions for my child’ (34% strongly agreed and 25% tended to agree). However, a fifth (21%) neither agreed nor disagreed and 17% disagreed (7% strongly). In line with other findings, parents answering about children aged one or under were most likely to agree their health visitor had helped them feel more confident (69%), and those answering about children aged 4 or 5 years were least likely (53%).

Perceived impact on health inequalities

Surveyed health visitors were invited to share their views on the extent to which the UHVP being delivered was contributing to a reduction in health inequalities between children of different backgrounds. Opinion was divided: 11% felt it was contributing ‘a great deal’, 23% ‘quite a lot’, 38% ‘some’, 19% ‘not very much’ 4% ‘none at all’ and 6% ‘don’t know/prefer not to say’. In line with other findings, those who had been delivering the UHVP for longest were more likely to feel it was contributing towards reducing inequalities (46% of those who had been delivering it for over four years said it was contributing ‘a great deal’/’quite a lot’, compared with 34% overall).

The 97% of participants who were currently delivering the UHVP, in part or in full, were asked how much impact it has had on opportunities for them to engage with families who may be less likely to engage with services. Two thirds (65%) felt it had had a positive impact (20% a major positive impact and 45% a small positive impact), a further 28% felt if had no impact one way or another while 3% felt it had had a negative impact.

Those who were working full-time were more likely than their part-time colleagues to feel it had had a major positive impact (28% versus 11%), while those who had been delivering it for more than four years were more likely than average to say this (33%, compared with 20% overall).