HEALTH FOR ALL CHILDREN 4: GUIDANCE ON IMPLEMENTATION IN SCOTLAND 2005

3 health promotion

3.1 Improving Health in Scotland - The Challenge²⁶ provides a strategic framework to support the processes needed to deliver a more rapid rate of health improvement for Scotland and to effect a step change in the health of Scotland's people. It focuses on four key themes: early years; teenage transition; workplace; and community. The Challenge also emphasises the importance of cross-cutting and partnership working - and there was considerable agreement in the consultation on this guidance, about the role that staff across sectors and agencies can play.

3.2 There is clear evidence that health throughout life is powerfully influenced by experiences in early childhood and even from conception. Promoting the health and wellbeing of mothers and children is key to preserving and promoting the health of current and future generations. As The Challenge states, "it is only by showing individuals that realistic, achievable changes in their own actions can bring both immediate and long-term benefit to them, their families and Scotland that we will succeed in improving health".

3.3 Health promotion is the process of enabling people to increase control over and improve their health through the overlapping spheres of health education, prevention and health protection. As well as actions aimed at strengthening people's skills and capabilities, it includes actions directed towards changing social, environmental conditions to prevent or to improve their impact on individual and public health ²⁷. Health education is communication activity aimed at enhancing positive health or preventing diminishing health in individuals and groups, through influencing beliefs, attitudes, and behaviour of those with power and of the community at large ²⁸. In this guidance, health promotion, includes activity to promote both physical and mental health and wellbeing.

3.4 Hall 4 is rooted in evidence-based effective practice, and health promotion activity is no exception. Initiatives such as the Starting Well national health demonstration project ²⁹ and Sure Start Scotland, are already providing programmes of activity to promote children's healthy development through intensive home-based support for families and ensuring access to enhanced community-based resources. The Early Years National Learning Network ³⁰, based at NHS Health Scotland, was established in 2003 to facilitate the sharing of learning across Scotland by disseminating the lessons learned from Starting Well and enhancing evidence-based policy and practice in early years activity.

3.5 Implementation of Hall 4 will require NHS Boards and local authorities to work together to foster integrated approaches to health improvement through delivery of health promotion in primary care settings and in pre-school centres and schools. NHS Health Scotland produces a range of existing materials, and is planning a number of further initiatives that will support practitioners in developing and delivering these approaches.

Early years

3.6 The primary responsibility for children's health and development rests with parents. However, they need information and support to fulfil that responsibility most effectively and all pre-school children and their families should, therefore, have access to an effective health promotion programme, delivered by the network of health, social work and education professionals through their routine contacts with children and families.

3.7 Parents and prospective parents will continue to need different forms of information and advice about healthy living, and social support will be needed to help parents and prospective parents to understand their own and their children's social, emotional, psychological and physical needs. These include:

• Written information about pregnancy and birth, and healthy infant and child development - NHS Health Scotland produces extensive public information about child health and development in various publications and on the Internet ³¹. All pregnant women receive comprehensive information in preparation for parenthood in a free NHS Health Scotland publication, Ready Steady Baby³², which includes advice on health and development from conception to infancy. NHS Health Scotland is currently reviewing the format and content of Ready Steady Baby to extend coverage of information beyond infancy to the pre-school period. New mothers also receive written information on breastfeeding and on prevention of cot death ³³, to support the advice that they receive from their midwife. Patient information leaflets for use with the newborn screening programmes (hearing, cystic fibrosis, PKU and congenital hypothyroidism) are also published by NHS Health Scotland.
• Healthy living information and advice - Health visitors, school nurses and other members of the primary care team should provide advice on a range of issues in the course of their regular contact with individual parents and children at clinics, GP practices, family centres and at home. Leaflets and posters can be used to highlight key issues about diet, exercise, and effective management of behaviour, and signpost children and their families to different sources and types of information and support.
• Access to information and professional advice about specific aspects of child development and behaviour through group activities and workshops - Parenting education and support programmes should be provided in a wide range of health service and local authority settings, and many voluntary organisations offer direct access to support through helplines or self-referral.
• Support through local community networks - For example, breastfeeding peer support, smoking cessation services and other addiction services and networks.

3.8 Where written information is published, it must be clear and be available in a range of formats and languages.

3.9 The core child health programme provides valuable opportunities to assess needs and provide support and information for parents at key points in the early years, and to develop empathetic and trusting relationships, which provide the best basis for effective health promotion. Establishing such relationships requires skill, particularly for successful engagement with families who may be suspicious, unaware of or reluctant to engage with the public services that are available. NHS Boards and local authorities should collaborate to ensure that staff receive appropriate training and support to capitalise on opportunities for interaction with parents at key points in the early years. NHS Boards should also ensure that professional supervision is in place for all frontline staff, so that regular opportunities are available for them to discuss concerns.

3.10 Eighty five per cent of three year olds and 100 per cent of four year olds in Scotland are currently accessing a part-time place in a pre-school education centre ³⁴. Staff in early years settings, such as family centres, nurseries and pre-schools, are usually in daily contact with children and parents, and are therefore in a strong position to reinforce health promotion messages. Indeed, many already do so routinely.

3.11 Although pre-school centres are not required to meet the Scottish Executive target to become a health promoting school, many are already applying the principles and introducing effective approaches to improving the health of children and their families.

School years

3.12 Integrated Community Schools are founded on the twin principles of improving educational attainment and enhancing social inclusion, by bringing together professionals and services - including health, education and social work - to take a holistic approach to education and support for children and their families. They are therefore ideally placed to support children and families in adopting healthy lifestyles, through activity embedded in the school curriculum and through wider community activity. The White Paper, Towards a Healthier Scotland³⁵, identified the concept of health promoting schools as a key component of future health improvements. Integrated Community Schools are leading the way, working towards becoming Health Promoting Schools by 2007.

A health promoting school is one in which all members of the school community work together to provide children and young people with integrated and positive experiences and structures, which promote and protect their health. This includes both the formal and the informal curriculum in health, the creation of a safe and healthy school environment, the provision of appropriate health services and the involvement of the family and wider community in efforts to promote health.
World Health Organisation ( WHO), 1995

3.13 The Scottish Executive, in partnership with NHS Health Scotland, CoSLA and LT Scotland, has established the Scottish Health Promoting Schools Unit ( SHPSU) to champion, facilitate and support the implementation of the health promoting school concept throughout Scotland through strategic and practical support to local authorities, schools, NHS Boards and other stakeholders. In conjunction with national and local partners, the SHPSU has developed Being Well - Doing Well³⁶, which provides a broad statement, based on a holistic view of education and health promotion, as a foundation for planning processes. It draws upon current thinking and practice, and aims to:

• Promote discussion of the health promoting schools concept within the context of other developments.
• Identify the values, aims and key characteristics of health promoting schools.
• Establish a broad national consensus on the nature of health promoting schools.
• Inform the planning and development of health promoting schools at national and local levels.
• Promote an integrated approach through partnership working to the development and maintenance of health promoting schools.
• Provide a basis for the development of instruments and procedures for evaluating the progress made by schools towards becoming and improving as health promoting schools.

3.14 The work of the SHPSU has recently been strengthened by the appointment of three new health specialists for food, physical activity and mental wellbeing to help schools build all these strands into a single whole school approach to health.

3.15 In 2003, the Scottish Executive published A Scottish Framework for Nursing in Schools³⁷, which sets out the role of the school nursing team and standards for practice. NHS Health Scotland is currently undertaking development work on a school health profiling tool that will inform the development of school health plans and ultimately the school planning process. This will inform school-based approaches to health improvement, including the activities of the school nursing service within each school. The role of the school nursing service will move away from a focus on routine surveillance, towards a combination of school population-focused health improvement, and addressing the individual health needs of vulnerable children.

3.16 In accordance with the recommendations in both Hall 4 and A Scottish Framework for Nursing in Schools, there should be a named nurse for each school, with access to a wider team of health support such as community children's nurses, paediatricians and therapists.

Nutrition and physical activity

3.17 In common with virtually all other developed industrialised countries, obesity is increasing in Scotland. Of particular concern is the increasing incidence of obesity in children. Efforts to tackle obesity through the promotion of healthy choices must therefore be a key component of any child health programme in Scotland. The question of body weight, obesity and body image is a complex question for children and young people, and they require sophisticated support that ensures the relationship they have with food and physical activity remains as positive as possible.

3.18 Hall 4 stresses the need for a multi-agency approach to the promotion of healthy eating and physical activity. It also recommends a wide range of activity to promote healthy eating and exercise amongst all children, and not just those who are overweight or at risk of obesity. It notes that "a programme that addresses the issue of obesity in the population as a whole will also be likely to reduce the risks of cardiovascular disease, diabetes and cancer".

3.19 Health promotion activity in the early years should encourage breastfeeding for infants exclusively for 4-6 months. However, it is important that women are supported in whatever feeding choice they make for their baby. Mothers who are unable to breastfeed may need particular emotional support. The Scottish Executive is supporting implementation of the Breastfeeding (Scotland) Act 2004 ³⁸. The Executive is also working on the development of national infant feeding strategy to promote infant nutrition and increase the update and duration of breastfeeding.

3.20 It is important that parents are aware of the link between first weaning foods and early oral health. NHS Health Scotland is producing a new weaning leaflet to help parents introduce their child to healthy foods and drinks and establish good oral hygiene practice from an early age.

3.21 Pre-school centres can play a significant role through health education, discouraging consumption of high sugar and high fat foods and drinks by providing healthy alternatives, encouraging consumption of fruit and vegetables, and providing varied opportunities for physical activity. Physical development and movement is one of the five key areas in the curriculum framework for children aged three to five years. The Scottish Executive is already working with the pre-school and childcare sector to support active play, and NHS Health Scotland has produced Adventures in Foodland³⁹, a resource for pre-school centres on healthy eating and play. The Executive is also investing in the further development and rollout of the Play@Home resource ⁴⁰, a physical activity programme for children from birth to five years.

3.22 There is a great deal of activity already underway to encourage and support school age young people in making healthy choices, both in and outwith school. Hungry for Success⁴¹ introduced nutrient standards for school meals in both primary and secondary schools, and detailed guidance has been published to support implementation and the establishment of free fruit schemes. Good practice initiatives such as breakfast clubs, fruit and salad bars and healthy tuck shops, have also been established in schools across Scotland. The Scottish Executive is also developing support materials and advice for teachers about how they can best deliver nutrition education in schools, including practical food skills, shopping and making meals.

3.23 Active Schools⁴² also continues to be developed and rolled out, supported by the recruitment of more than 600 Active School Co-ordinators by 2007 to help get pupils more active. Local authorities are also working to promote physical activity outwith the pre-school and school environment by increasing the accessibility and affordability of sport and leisure facilities for children and young people. It is important that an active life for children and young people includes access to a range of options such as dance, outdoor activities, walking and cycling, so that they enjoy being active in their everyday lives.

3.24 A new education performance measure ⁴³ has been introduced which focuses on how schools and authorities might encourage pupils to take part in health related physical activity for one hour each day.

Oral health

3.25 Dental disease in childhood is a significant marker for later poor health and is associated with deprivation and disadvantage. It is also a major reason for young children being hospitalised and for the administration of general anaesthesia to young children. And it is largely preventable.

3.26 Although there has been a decline in childhood dental caries over the last 30 years, there has been little improvement over the last 10 years in the youngest children. In Scotland, around 55% of children start school with evidence of dental decay ⁴⁴.

3.27 The risk factors for early dental disease include absence of registration with, and regular attendance at a dentist (both child and parent), diet, whether the parent is enabling tooth brushing with fluoride toothpaste, socio-economic status, and underlying medical history. In preparation for teething, information and advice should be made available to parents in their child's first year about the risk factors for dental disease, and the action that they can take to reduce these, including advice about weaning. Children under seven years are usually not well-equipped to manage effective tooth brushing without adult supervision and parents should be advised to check regularly how thoroughly their child is brushing until they are confident that the child has acquired the necessary skill.

3.28 Information should be made available to parents within their child's first year in preparation for teething, including advice about risk factors for problems with milk teeth, such as sustained use of sugared and sweetened drinks in bottles. There is a need to build on existing oral health promotion work, roll this out to other staff groups, and to apply health promotion messages from infancy, in the early years and beyond.

3.29 The range of practitioners in touch with children and families are well placed to identify risk factors for dental disease and communicate messages about the importance of oral health. There are many opportunities for professionals to identify risk factors for dental disease and to promote key oral health messages, some in the course of their regular contact with children and parents, others on a more opportunistic basis. It is vital that all healthcare workers, including members of the dental team, give consistent advice.

3.30 The key oral health promotion messages are to:

• Encourage registration with a dentist from birth and regular attendance for dental check-ups.
• Provide advice about the impact of sugary food and drink consumption, aimed at reducing the level, and especially the frequency, of such consumption.
• Encourage twice daily supervised tooth brushing with a 1000 ppm fluoride toothpaste.

3.31 Oral health should be included in advice and support from health and other child care professionals about weaning, diet and nutrition. This should be prominent in health promotion advice linked to the core child health programme set out in Annex 1. Staff
in family and pre-school centres should have access to health promotion material on oral health.

3.32 School health services are also in a strong position to offer oral health advice consistent with the dental and oral health statement outlined in A Scottish Framework for Nursing in Schools, contributing to positive oral health by:

• Working with schools to develop suitable policies on nutrition and health promotion.
• Developing awareness of oral health with children, young people and parents.
• Working with pre-school centres and schools to facilitate the development of regular tooth brushing programmes through structured interventions such as breakfast clubs and post-snack brushing.

3.33 In response to the consultation on Towards Better Oral Health in Children⁴⁵, the Scottish Executive is currently considering a range of new measures to support children and young people's oral health.

Unintentional injury

3.34 Unintentional injuries (including poisonings) are the most common cause of death and a cause of considerable morbidity in children between the ages of 1 and 14 years. Reducing incidence, and the social class gradient, are highlighted by Hall 4 as an important objective, requiring multi-agency collaboration and investment at national and local levels. Health and child care professionals are well-placed to promote positive messages about safety and to encourage a safe environment for children in the course of their regular contact with children and families.

3.35 As well as primary prevention, Hall 4 suggests that a home visit by a health visitor or other community worker following an unintentional injury to a child, may help to prevent further incidents. At a community level, local accident and emergency admission data, as well as other sources of health and social data, should be used to inform the development of multi-agency strategies, linked to children's services and community planning, for a reduction in the number of unintentional injuries.

Mental health and wellbeing

3.36 Interventions in the early years are likely to be the most effective in preventing a child developing mental health problems. These include interventions to improve and enhance the wellbeing of the mother and the baby, which promote good early parent-child attachment and interaction, and which support parents' problem-solving skills and recognise and support the role of fathers.

3.37 Implementation of Hall 4 also links strongly with implementation of the Framework ⁴⁶ for children and young people's mental health, a draft of which has been published by the Scottish Executive for consultation. The Framework has been developed to support integrated approaches to children and young people's mental health, across mental health promotion, prevention of mental illness, and care and treatment for those with mental health problems. It highlights mental health promotion and stresses the importance of considering the child's global environment, recognising elements which support mental health and wellbeing as well as those factors which may increase the risk of mental health problems, including the potential impact of a parent's ill health on their child.

3.38 The Framework promotes a "mainstream" approach to mental health and wellbeing, which equips a range of health and other children's services professionals with the basic skills to be able to support parents in developing a basic understanding of risk and protective factors that may affect their child's mental health and wellbeing. To support this, NHS Education for Scotland has published a mental health competency framework ⁴⁷ for all those involved in supporting children, young people and their families.

3.39 Education policy and practice already has a strong focus on promoting and supporting emotional wellbeing, and the Health Promoting Schools concept broadens this focus beyond the curriculum to a "whole school approach".

3.40 Children and Young People's Mental Health: A Framework for Promotion, Prevention and Care sets out the range of activities and approaches that we would expect to see in place to support children and young people's mental health and wellbeing.

Sexual health

3.41 Implementation of Hall 4 can link with and contribute to action to implement the national sexual health strategy ⁴⁸. This highlights the various influences that can determine sexual wellbeing, and the consequent need for an integrated approach.

3.42 The Strategy recognises the role of parents in influencing their children's attitudes to sex and relationships, and recommends that NHS Boards, in conjunction with other statutory and voluntary sector interests, should provide programmes for parents and carers to enhance communication skills around relationships and sexual health. It also recognises that some vulnerable children and young people may not have access to comprehensive school-based sex and relationships education ( SRE), and seeks to address this through ongoing implementation of the McCabe report ⁴⁹. The Scottish Executive is working with NHS Health Scotland, Directors of Education and Social Work and other key stakeholders to ensure that vulnerable children and young people, including those who are disaffected or excluded from school, receive SRE that is consistent with national guidance on the provision of SRE in schools.

3.43 The Strategy recommends that an executive director within each NHS Board should be responsible for sexual health and wellbeing, and that a lead clinician should be appointed to drive forward the Strategy's practical plan for action. A National Sexual Health Advisory Committee ( NSHAC), with a wide ranging membership and chaired by the Minister for Health and Community Care, will be established to advise on policy, monitor and support implementation of the Strategy.

Smoking

3.44 Smoking is the greatest single, preventable cause of ill health and premature death in Scotland, and parental smoking, has serious affects on children's health, both in the short and longer term. Hall 4 highlights that smoking in pregnancy is associated with low birth-weight babies, and after birth, for the babies of mothers who smoke, the risks of sudden infant death, middle ear disease, meningitis and respiratory diseases are significantly increased. It also indicates that two thirds of women who succeed in stopping smoking whilst pregnant, restart after the baby is born.

3.45 The universal core child health surveillance programme offers an opportunity to provide ongoing support to mothers who were successful in stopping smoking during pregnancy. It is also an opportunity to provide advice to parents about impact of their smoking on their child's health (both in the short and longer term), and to provide information about local smoking cessation services. However, as Hall 4 emphasises, this must be done sensitively and within the context of providing wider support and health promotion advice, recognising that for many parents, smoking is a response to pressures and stresses of one sort or another.

3.46 Though trends have been moving in the right direction, the decline in smoking rates over the past 30 years have mainly been amongst more affluent groups. We know that some of the highest rates of smoking are to be found amongst our most disadvantaged communities. The approach advocated in Hall 4 relates well to the need for targeted smoking cessation approaches. To assist professionals, NHS Health Scotland and ASH Scotland have developed Smoking Cessation Guidelines for Scotland: 2004 Update⁵⁰ and the companion desktop guide, Encouraging Smokers to Stop: What You Can Do. These provide up to date evidence on effective smoking cessation interventions and practical guidance on the delivery of smoking cessation services.

3.47 In January 2004, the Scottish Executive published the Tobacco Control Action Plan⁵¹ which sets out a programme for action spanning prevention and education, protection and controls, and the expansion of smoking cessation services. This recognises that achieving any reduction in smoking levels requires action to minimise the number of 'new recruits' to the smoking habit, and emphasises that in particular, "discouraging young people from starting to smoke needs to be given the utmost priority". 96 per cent of schools now provide education on tobacco. School nurses have a key role in this, as well as providing advice and support for young people who wish to stop smoking.

Drugs and alcohol

3.48 Implementation of Hall 4 also links with, and can support action to, support children and young people in developing healthy attitudes to drugs and alcohol, and to support parents in talking to their children about these issues. Local Drug and Alcohol Action Teams ( DAATs), the Scottish Executive and NHS Health Scotland have developed information and communications materials to support this. The core child health programme can also provide opportunities to identify parents and young people at risk of developing drug or alcohol problems, and to facilitate access to appropriate support services.

3.49 Young people are one of the four pillars of the national Tackling Drugs in Scotland strategy, with a key aim "to help young people resist drug misuse in order to achieve their full potential in society". To achieve this, 99% of schools are now providing drug education for school pupils, within a wider framework to encourage young people to make responsible and healthy lifestyle choices. The strategy also recognises the need for action to ensure that particularly vulnerable children and young people, including those who may not be attending school regularly, are able to access drugs and alcohol information and services. Local DAATs will be leading the development of prevention and treatment services for under 16s.

3.50 Children and young people are similarly highlighted as a key priority within the Plan for Action on Alcohol, which was published in 2002. An update is due to be published shortly.

3.51 The Scottish Framework for Nursing in Schools⁵² highlights the role of school nurses in supporting the multi-agency effort required to promote healthy attitudes to drugs and alcohol, through the provision of advice and support to teachers, children and young people, and their families. School nurses also provide an important link between NHS primary care services, schools, local DAATs and specialist addiction services.

3.52 Action to address drugs, alcohol and substance misuse is already an identified key priority for use of the Changing Children's Services Fund.