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

6. Key factors influencing current practice

Earlier chapters have described current practice in relation to the different strands of child healthy weight provision (prevention, identification, referral and intervention) from pregnancy through to Primary 1, and the extent to which there is consistency and coherence in this provision. This chapter pulls together themes that cut across the different strands, to identify what appears to be working well and where the key challenges lie.

It is clear that there are a huge number of factors influencing rates of overweight and obesity in pregnancy and the early years. Within the confines of this study, on the role of health systems only, there are three key stages at which the intended processes can fall down. This chapter considers what is working well and what challenges remain at the following levels of the system:

• System design - systems not in place to support healthy weight at key stages and not being aligned with national standards/guidelines
• System implementation - local systems being aligned but not being implemented in practice
• Engagement with systems - local systems being aligned and implemented, but not being effective (e.g., because parents do not engage).

System design

Strengths and opportunities

Core provision

Although provision varied significantly, there were clear examples of best practice and innovative services which professionals felt were working well. There was also evidence of both the UNICEF Baby Friendly Initiative and the UHVP helping to improve consistency of support. As discussed further below, the design of the UHVP also seemed to be showing real benefits in terms of facilitating greater continuity of care and, in turn, stronger relationships between health visitors and families. The FNP was also considered an effective approach for engaging with, and supporting, its target population.

A committed and knowledgeable workforce

Those involved in the design of services spoke knowledgeably and passionately about their area of work. Furthermore, they were united in recognition that, regardless of how effective they perceived their board's current system to be, there was room for improvement. They demonstrated commitment and enthusiasm towards achieving this. To varying degrees, plans were already in place to implement new and improved services – indeed some had been close to implementation before being paused due to the COVID-19 pandemic – and there was evidence of the Minimum Standards being used to shape early years provision. To improve coherence, some boards also described plans to create clearer pathways across the system.

I don't think it has been great up to this point, as in we have identified gaps and we have absolutely brilliant colleagues who are on the same page as us from a dietetic team to [CHW programme], I think the relationship between professionals is amazing, we work really, really, well together, and we all want the same things. So, I think it is just about making sure that we have those opportunities to progress our work and roll that out.

Health visitor manager

In planning improvements, boards also displayed an openness to new approaches that incorporated preventative elements as well as interventions - for example the HENRY programme. At the heart of these more preventative approaches was an acknowledgement that there were no 'quick fixes' and that it would take time for improvements in obesity rates to happen. In line with the standards, professionals recognised that health systems cannot work in isolation on child healthy weight and expressed a desire to work more with other parts of the system. Similarly, boards described a need to move towards a more societal approach rather than targeting provision at an individual level.

Key challenges and opportunities for improvement

As described above, boards were clear that improvements to their systems were required. Key challenges and opportunities for improvement are discussed in turn below.

Funding cycles

Although both the Standards and participants in this research recognised that long-term resource planning is required to make real differences, funding was perceived to be too short-term to allow for this. Public health professionals described cycles of short-term funding which they felt posed a number of challenges, including:

• Difficulty designing services and programmes with a longer-term strategy.
• Ongoing concern about funding being discontinued and programmes having to stop.
• Problems recruiting high calibre staff due to contracts being temporary.
• Challenges retaining staff employed on temporary contracts as they often moved on to other, permanent, roles for greater job security.

Those in smaller health boards considered current funding practices to be particularly challenging for them as they felt the risk of employing staff on permanent contracts when funding was not guaranteed. They also discussed differences in funding distribution, compared to larger boards, in that the funding was not ring-fenced in the same way.

Participants suggested that the Scottish Government should commit funding for much longer periods, for example the lifetime of their term. Comparisons were made to FNP, which had benefited from long-term funding commitment. In boards that had received funding for the HENRY programme, there was optimism that this would go some way to remedying these funding concerns.

Resources

Linked to the above, there were also those who felt that current funding was insufficient to allow boards to deliver the required services. This included having adequate numbers of staff in public health roles to support their design and evaluation as well as frontline staff to deliver them.

It all comes down to funding, I mean the team could develop more training if we were funded adequately and we are not.

Public health professional

Area for consideration (national level):

Establish whether increased and longer term funding could be provided for child healthy weight activities

For example, one participant noted that their child healthy weight service referral threshold was the 91^st centile, but that their board would not have capacity to deliver it to all in that category while another made a similar point in relation to capacity to support pregnant women.

If we were looking at supporting all women at a BMI over 25, at booking, that's half the women... That is definitely a challenge, just the sheer number of women who are presenting at that weight.

Public health professional

Area for consideration (local health board level):

Increased capacity for treatment services to accommodate those who are eligible

It was also noted that services did not typically incorporate longer-term follow up of those who had attended, again, at least in part, due to resourcing and budgetary constraints.

Furthermore, as described below, even when capacity exists to offer programmes to those who need them, the extent to which midwives, health visitors, and school nurses had capacity to dedicate sufficient time to matters of child healthy weight was affected by the way in which their roles had been shaped. Professionals described wide ranging remits, high caseloads and competing demands on their time, with child protection matters, in particular, often taking priority.

Monitoring, evaluation and sharing of best practice

Effective monitoring and evaluation of services and the sharing of knowledge and best practice across boards is an effective way of informing future planning. However, it appeared that this was not always happening, at least not in any systematic, empirical way. Evaluations of individual programmes were reportedly often solely qualitative and focused on participants' self-reported experiences of them. This appeared to be, at least in part, due to a lack of resources to conduct more comprehensive evaluations, particularly as it was recognised that to see whether any positive results have been sustained – both at a population level (e.g., breastfeeding rates) and at an individual level – evaluation must be conducted over the medium to long-term.

Area for consideration (local health board level):

Better auditing and evaluation of service engagement and effectiveness

It was also apparent that there was limited knowledge sharing both between health boards and between different life course stages within health boards. This includes the sharing of ideas as well as findings from audits and evaluations. However, in saying this, there were very positive comments about the Public Health Scotland Healthy Weight Leads Network, suggesting there is scope to build on the impact this can have.

Area for consideration (local health board and national level):

Greater knowledge sharing, both within and between health boards, on service engagement and effectiveness. The PHS Healthy Weight Leads Network, which was considered a useful means of sharing learning, may offer one way of facilitating this.

Ensuring a focus on all parts of the system

In the discussion of both current provision and improvement plans, it appeared that there was a greater focus on the early years than on interventions aimed at pregnant women. As described in Chapter 4, much of the focus in pregnancy was on gestational diabetes and risks for the women and baby, rather than on weight itself and, indeed, there was a reported lack of guidance on what constituted acceptable weight gain in pregnancy.

The reasons for the apparent greater focus on the early years were unclear but there are a number of possible reasons:

• the Standards prompting improvements in support available to families in the early years
• midwifery being in a period of change due to the implementation of The Best Start ^[53]
• reported challenges in affecting healthy weight in women both pre and during pregnancy

Lack of clear pathways/lack of join up with other parts of the system

As evidenced in Chapter 5, it was clear that there were not, on the whole, coherent health system pathways for child healthy weight from pregnancy through to Primary 1. Indeed, at a service design level, it appeared that the roles of those working in maternal health were fairly separate from those working in child healthy weight roles in the early years/school age.

Concerning join up with other parts of the health system and services outside the health sphere, there was also scope for improvement. There was considerable variation in the extent to which boards worked in conjunction with other services such as third sector weaning support, local authority physical activity provision and mental health/counselling services.

Area for consideration (local health board level):

Increased join up with other parts of the system – for example, local authorities, third sector organisations

Provision of more holistic child healthy weight support and advice

When discussing provision for the early years, participants tended to focus on diet and physical activity. While these are, of course, key components, the Standards also recognise the importance of sleep hygiene and limited screen time. While there was some discussion of these topics, it was unclear how much they were routinely covered and how much prominence they were afforded.

Area for consideration (local health board level):

Increase prominence of the role of sleep hygiene and screen time in childhood obesity

Targeting support at those in more deprived areas

As discussed in Chapter 1, rates of obesity in Primary 1 are far higher in the most deprived areas of Scotland than in the least deprived, and this gap has widened over recent years. Healthcare professionals described significant challenges of effecting behavioural changes with families experiencing poverty and other challenging circumstances (discussed in more detail below). This is indicative of a need for more intensive intervention with these families and a greater targeting of resources in these areas. While there was some evidence of boards planning to use funding to specifically target these areas, other boards did not explicitly state intentions to do so.

System implementation

For systems to operate as intended, frontline professionals must have a clear understanding of their role in the process and be equipped with the knowledge and skills to undertake their roles effectively. Interventions must also be available and accessible to those eligible. Consistency is also a key element of implementation. However, as this has been fully explored in Chapter 5, it is not covered in detail here.

Strengths and opportunities

Relationships built up via the UHVP and the FNP

Health visitors play a key role in child healthy weight in the early years and, as intended by the design of the UHVP, they reported having developed close working relationships with families. These facilitate an increased understanding of a families' circumstances, allow issues to be raised more easily and make it easier for them to make a judgement on the best course of action for a family.

Due to the intensive nature of the programme, family nurses described particularly close relationships with their clients that enabled them to work with them on healthy lifestyles.

So, the therapeutic relationship is definitely something that works really well for us. So, if you think we have known a client from being 12 weeks pregnant and being able to see them every fortnight, every week or fortnight, I mean you really get a good (relationship)…often we can be the people that they see the most in their family.

Family nurse supervisor

Area for consideration (local health board level):

Maximise the potential of the strong existing relationships health visitors have built with families

Relatively high levels of confidence

Although there was variance, health professionals were, on the whole, confident in their knowledge and abilities in the maternal/child healthy weight realm and did not identify any particular training gaps. However, there were suggestions from those working in public health that more in-depth training may be required. This was not said as a criticism of frontline professionals but rather as an acknowledgement that having conversations around diet and healthy lifestyles is difficult, particularly when a weight issue had been identified.

Area for consideration (local health board level):

Further consideration of the training needs of midwifery and health visiting workforces

Broad adherence to referral thresholds

Overall, frontline professionals were making referrals in line with the thresholds stipulated by their boards and, as noted in Chapter 5, this happened more consistently when they had health services within their board to refer to. However, there was a degree of professional judgement involved. For example, when a health visitor identified that a child was at the 91^st centile for weight (Standards threshold for tier 2 intervention), they tended to work with the family themselves before making a referral, feeling like their existing relationship with the family would make them more likely to engage. However, there was also some discussion of waiting lists for services, which may have influenced their decision to intervene themselves.

Key challenges and opportunities for improvement

High caseloads

As described in previous chapters, frontline professionals considered their workloads to be high, with many competing priorities. This meant that they were not always able to give child healthy weight issues as much focus as they would like, including providing more intensive support to families who required it, and that planned visits were at times delayed due to more urgent issues.

Area for consideration (national level):

Consider whether health visitor caseloads can be reduced, allowing them to spend more time on healthy weight, particularly with families who would require more intensive support

Ensuring use of BMI for identification in the early years

While SIGN guidelines state that BMI centiles should be used to identify weight issues^[54], there was some evidence of health visitors using weight/weight and height centiles (Chapter 3) to do this, suggesting a need for further training on use of BMI. Providing health visitors with a way to easily calculate BMI while on visits (Chapter 3) could also help to increase use of BMI measurements, and improve consistency.

Awareness of available services

As noted in previous chapters, there was evidence of health professionals' knowledge of available services varying, suggesting that there is room for improvement in terms of keeping them up to date on what is available in their area.

Engagement with systems

While there was some discussion around giving families choices about services, for example whether they would prefer to undertake a group or individual programme, there was little evidence of health boards having done extensive work with parents to understand what might help them to engage.

Area for consideration (local health board level):

Work with families to understand better what might engage them to work with health professionals and services, and to sustain this engagement

This section therefore focuses on the perceived wider challenges that contribute to overweight and obesity in the early years and the reasons eligible families who are offered support or referral to programmes do not always take it up. In keeping with the fact that rates of obesity are highest in the most deprived areas, the challenges described below all relate more to families in these areas. There was a view that it is very hard for health systems to effect change while these wider challenges exist, supporting the need for a whole systems approach,

It feels like being a hamster in a wheel. Without changes at a higher level, putting a child or a family on an 8-10 week programme isn't really going to change anything. We need more of a whole systems approach at a higher level, not at a local level.

Public health professional

Deprivation and poverty

Poverty was deemed to be a key barrier to healthy weight. Participants spoke of high numbers of families being reliant on foodbanks, which were not always able to provide them with nutritious food. More generally, healthier foods such as fruit and vegetables were considered by families to be more expensive than less healthy options. While there was an acknowledgement of this among professionals, it was also noted that often parents lack knowledge of how they could incorporate fruit and vegetables into their diets, within their budgets.

They say things like, 'a pot noodle is 40p, do you think I'm going to go out and spend my money on broccoli and avocado?'. You get a bit of that. That's challenging but there are ways round it like talking about making a pot of soup, that's got a lot of vegetables in it and is a cheap way of having a nutritious meal.

Public health professional

Supermarket promotions on less healthy foods and the availability and affordability of fast food outlets were also seen to contribute to less healthy diets among families experiencing poverty.

As well as being able to afford healthy food options, one professional pointed out that families also need to be able to afford the electricity to cook.

Overall poverty is a big issue. You can do all you want to teach people how to cook but if they don't have enough electricity and gas to put the cooker on, they are not going to change their diet.

Public health professional

Professionals acknowledged that these families were often encountering a number of difficulties, linked to poverty, and needed extensive support in order to be able to improve their families' diets.

Area for consideration (local health board level):

Increased focus on deprived areas, including greater time available for health professionals to work with families with more challenging circumstances

Cultural norms

Professionals described a number of cultural and/or generational norms (particularly prevalent in more deprived areas) which they felt were difficult to break down. These included:

• overweight and obesity being normalised
• generations of poor eating habits, leading to a lack of awareness of what constitutes a healthy lifestyle and a lack of cooking skills
• breastfeeding not being normalised
• sedentary lifestyles

While they felt some progress was being made, they stressed the significant role that peer pressure and family influence has in relation to health and lifestyles, and why cultural change was necessary.

Personal and family circumstances

The circumstances of individual parents and families were also deemed as a significant barrier to child healthy weight intervention. Of course, these individual situations are highly interlinked with the issues of poverty and generational cycles described above. Circumstances that made it particularly challenging for families to engage included parental mental health/previous trauma (including linked to food and/or weight), members of the family being in poor health or having learning disabilities (meaning that this was the priority), alcohol and substance use.

Within families that have a lot going on, when you're talking about limited income, limited ability to be cooking healthy meals and multiple children with different demands of them, potentially children who have, developmental conditions, autistic, potentially minimal communication or minimal speech, then for those families I don't think that it becomes a high priority, because for them to just get by is the priority. So, being able to afford to provide all the meals they need to, whether they are healthy or not is the priority, being able to get the kids settled to bed at night even if that means they are having a bottle of milk to go to sleep at three years old, that is the priority, the day to day coping and living is the priority as opposed to the long-term impact of that.

Health visitor

The perceived lack of support for psychological issues more generally was considered to have a significant impact on healthy weight matters. One view was that there are those who would require intensive psychological support before being able to engage. As noted in Chapter 4, one public health professional was optimistic about their board's new child healthy weight intervention which included psychological support as they considered this to be an important component which was not commonplace due to a perceived shortage of psychologists.

Parenting skills

Again linked to other factors discussed above, parenting skills were identified as a further challenge. Professionals described families with a lack of routine and boundaries around factors affecting weight including food, screen time and sleep. They also described witnessing food being used as a sign of love or to allay feelings of guilt, for example if parents worked full-time. Relatedly, the busy lives of working parents were seen to be a barrier to cooking healthy family meals.

Sometimes it is around behaviour management, you know, they are pacifying them with three bags of crisps in a row because they don't know how to deal with their emotional outbursts, and that then is a point where we would ask the nursery nurse to be coming in and supporting. So, we are kind of going to see what is behind it to try and identify what we can actually focus on as the fundamental issue so that definitely guides who we would be then trying to support them with.

Health visitor

The COVID-19 pandemic

Health visitors reported that they had witnessed a number of the above-mentioned issues being exacerbated due to the implications of the pandemic. These included parents' mental health and wellbeing (with families being described as being 'in crisis'), increased screen time and more sedentary behaviours. Once more, these were felt to have disproportionately affected families in more deprived areas.