Healthy weight - local health systems support for pregnant women and young children: research

Executive summary

Background and methods

This report presents the main findings from a research study on child healthy weight systems, conducted by Ipsos MORI Scotland on behalf of the Scottish Government. Fieldwork was conducted between March 2020 and September 2021, during the COVID-19 pandemic, the impact of which is acknowledged throughout the report.

In 2019/20, 23% of children were at risk of overweight/obesity by Primary 1. Children with higher BMIs are more likely to experience mental and physical health issues and to experience obesity as adults. The 2019/20 data also shows that 27% of Primary 1 children in the most deprived areas are at risk of overweight/obesity, compared with 17% of those in the least deprived areas^[1].

The Scottish Government's strategy for reducing overweight and obesity is contained in A Healthier Future: Scotland's Diet and Healthy Weight Delivery Plan (2018).

The overarching aim of this research was to enhance the Scottish Government's understanding of how effectively local health systems seek to support pregnant women^[2] and children up to Primary 1 to have a healthy weight. The research comprised two stages:

• Stage 1: overview of the local health systems in place within health boards across Scotland (13 of 14 territorial health boards participated, with a total of 17 interviews undertaken. Participant roles included child weight management lead, nutrition/infant feeding lead, and dietician).
• Stage 2: case study research with five selected health boards to gather more in depth information (a total of 41 participants took part, including midwives, health visitors, family nurse practitioners, school nurses, public health/dietetics professionals).

Prevention

Professionals identified challenges in undertaking prevention work in relation to a woman's weight, particularly pre-conception but also during pregnancy (with the primary focus at this stage being on identification of a high BMI, managing any associated risks and promoting healthy weight gain).

Professionals felt confident, on the whole, supporting pregnant women and new parents on infant feeding, the introduction of complementary foods and having healthy lifestyles during toddler and pre-school years. This was primarily undertaken via core midwifery and health visiting services. However, additional support for breastfeeding and weaning was provided by others, for example, third sector organisations.

School nurses felt that they were less involved in preventative work since their role had changed. There was evidence of other preventative work being delivered in schools, including links with leisure services and delivery of prevention work by teachers.

Identification and referral

Identification of a high BMI in pregnancy happened at the 8-12 weeks booking-in appointment. A BMI of 25 or 30 would generally trigger gestational diabetes monitoring. Referral thresholds to other interventions varied.

Babies and children were weighed and measured at every core Universal Health Visiting Pathway (UHVP) visit, with each one providing an opportunity for a high BMI to be picked up. A BMI in the 91st centile or above was generally used to identify a weight issue.

Identification in Primary 1 happened at the Primary 1 health review. There was variation in health board approach to the measurements (generally using an opt-out approach, with a small number asking parents to opt-in) and how (if at all) parents were contacted after a high BMI was identified.

When raising the issue with parents, health professionals stressed the importance of not appearing judgemental. Midwives, health visitors and school nurses used similar tactics to approach conversations with parents:

• using existing relationships to their advantage (particularly for health visitors who benefitted from strong relationships through the UHVP)
• using a direct, factual tone and neutral language with families
• assessing parents' motivations and understanding of the issues, following their cues, and helping them make small goals

Healthcare professionals with more experience and relevant training found it easier than others to raise the issue. It was more challenging for professionals to raise a weight issue with a family when the family's circumstances were complex or when their own workload meant they would find it difficult to support the family.

Midwives encountered varied reactions from expectant women – feelings of wanting to 'just get through' pregnancy, feelings of guilt, or feelings of motivation to make changes. Health visitors reported that families were often open to advice but did not accept referral, and that there were families that denied there was a weight issue. School nurses reported having little opportunity to build relationships with parents and so felt they experienced more resistance from parents.

Intervention

Professionals decided on referral options based on parents' preferences, the nature of the issue, past experiences, and available provision. Provision varied across health boards but examples of interventions in pregnancy and the early years are illustrated below.

Interventions in pregnancy

Clinician-led interventions

• Vitamin supplements
• Gestational diabetes tests
• Referral for extra scans
• Informal support at appointments
• Group interventions
• Leisure services referral
• Interventions for those with gestational diabetes

Midwife-led interventions

• Multidisciplinary services may involve dieticians, psychiatrists, gestational diabetes experts etc
• May replace (to some extent) midwife care, or sit alongside it

Intervention from early years – Primary 1

Health visitor-led interventions

• Monitoring and support at UHVP appointments
• Additional appointments
• Information and support to make small changes

Programmes aimed at the whole family

• Around 8-10 weeks, sometimes with follow-up afterwards
• Mix of family and parent only sessions
• May include education, cooking, exercise, mental health support

Dietician-led interventions

• Often includes food diaries, education support
• Can be more intensive, delivered in family homes

Support provided by other services and professionals

• Third sector support and family support groups/classes
• Local authority and ELC support
• Private Sector e.g. baby/toddler activity classes

Overall, health professionals were generally positive about existing interventions but recognised that their effectiveness depended on parental engagement. They also noted that it was hard for them to comment on effectiveness as they would not always be informed about the engagement or progress of those they referred.

Consistency and coherence

Consistency of support and referral was perceived by staff on the ground to be high, and higher where staff had relevant training, where referral pathways were clear, and where there were services to refer to. It was felt to be harder to achieve where health boards were very large, where they included remote areas, where they had a skills mix, and where caseloads were very high. COVID-19 had also caused inconsistency as, for example, those who were shielding may have completed all their visits by phone (or 'Near Me' if available), while others continued to visit families face-to-face.

On the whole, boards did not have coherent pathways, nor any overall leadership, for child healthy weight that ran from pregnancy through to Primary 1. Different strategic teams generally dealt with different parts of the system, meaning that health boards may have a strong offering in pregnancy (for example) but little on offer for the early years.

There did not appear to be a consistent handover protocol around child healthy weight (from midwives to health visitor, and health visitor to school nurse).

Key factors influencing current practice

At the system design level, strengths included the committed and knowledgeable workforce, and the core provision, with the UHVP, Family Nurse Partnership (FNP) and UNICEF Baby Friendly Initiative all working well. Challenges at the system design level included short-term funding cycles, perceived low levels of funding, a lack of monitoring, a lack of focus on healthy weight in pregnancy, lack of join up across the system, the need to target support at more deprived areas and the need for more holistic support.

At the system implementation level, strengths included the strong relationships built through UHVP and FNP, the relatively high levels of confidence among professionals, and broad adherence to referral thresholds. Challenges included high caseloads, continued use of centiles as opposed to the recommended use of BMI, and varying knowledge on available services among healthcare professionals.

Levels of parental engagement with services were perceived to be affected by wider societal issues including: poverty, cultural norms, complex family circumstances, and parenting skills.

Key findings and issues for consideration for policy and practice

The research has shown that there are many elements of child healthy weight systems that appear to be working well. However, considerable variations existed and boards were committed to making improvements. A number of issues for consideration for the provision of healthy weight support in pregnancy and the early years have been identified.

Local health board level

• Increased focus on prevention at the preconception stage – and on prevention among pregnant women more generally.
• Improved pathways/co-ordination of services from preconception to Primary 1 - greater strategic oversight of child healthy weight across the system as well as practical improvements e.g., handovers between professionals (midwife to health visitor, and health visitor to school nurse).
• Increased capacity for treatment services to accommodate those who are eligible.
• Increased focus on deprived areas, including greater time available for health professionals to work with families with more challenging circumstances.
• Maximising the potential of the strong existing relationships health visitors have built with families.
• Work with families to understand better what might engage them to work with health professionals and services, and to sustain this engagement.
• Better auditing and evaluation of service engagement and effectiveness.
• Greater knowledge sharing, both within and between health boards, on service engagement and effectiveness. The Public Health Scotland Healthy Weight Leads Network, which was considered a useful means of sharing learning, may offer one way of facilitating this.
• Increased join up with other parts of the system – for example, local authorities, third sector organisations.
• Facilitating healthcare professionals to refer directly to exercise facilities (rather than having to go via a weight management service).
• Further consideration of the training needs of midwifery and health visiting workforces. For example: ensure health visitors are using BMI centiles and have a means of calculating BMI while out on visits; increase the prominence of the role of sleep hygiene and screen time in childhood obesity; and ensure healthcare professionals are aware of the current guidance on healthy weight gain in pregnancy and kept informed of any subsequent changes to this.

National level

• Establish whether increased and longer term funding could be provided for child healthy weight activities.
• Explore whether factors that limit the work school nurses are able to do on child healthy weight (e.g. workload, few existing relationships with families) could be addressed to allow them to take on a greater role in this.
• Consider whether health visitor caseloads can be reduced, allowing them to spend more time on healthy weight, particularly with families who require more intensive support