Universal Health Visiting Pathway evaluation: phase 1 report - routine data analysis - baseline outcomes

Results

Outcome results are grouped according to the research question to which they contribute evidence. The first research question explores the impact that the implementation of the UHVP has had on outcomes of children aged up to 3 years relating to parental health-related behaviours.

This Phase 1 report outlines the baseline data for these outcomes up until March 2016. The parental health-related behaviours examined, in chronological order, are:

• infant feeding (both exclusive breastfeeding and any breastfeeding);
• immunisations received up to the child's second birthday;
• any attendance at a dentist by the child's second birthday; and
• parental smoking.

These outcomes will be explored in turn at Scotland level and by SIMD.

Infant feeding recorded in the 6-8 week review

(a) Scotland

Outcomes 1a and 1b: Data availability in the 6-8 week review

Coverage of the 6-8 week child health review was high, with 93.6% of children having a record of this visit (see Table 4 and Figure 1). The vast majority of these children (92.2%) also had 'meaningful' data available on infant feeding at this review: that is, in the 6-8 week review, the item 'current feeding' had a response of B (breast milk only), F (formula milk only), M (mixed breast and formula milk), O (other) or U (unknown) recorded. This figure was fairly consistent over time, although there was a very slight decrease in the percentage of children with a 6-8 review recorded from March 2015 onwards (from 93.7% to 90.5% in March 2016).

Outcome 1a: Exclusive breast milk feeding at 6-8 weeks

Of the babies who had meaningful data available on infant feeding, 26.8% were exclusively breastfed (Table 4). In Figure 2, a very slight gradual trend can be seen for babies born in the quarters ending March 2011 to March 2016, with the percentage of babies who were exclusively breastfed increasing from 25.5% for those born in the quarter ending March 2011 (i.e. 3,293 of the 12,929 children who had meaningful data on current feeding in the 6-8 week review) to 29.6% for those born in the quarter ending March 2016, although the percentage who were exclusively breast fed fluctuated over the time period.

Table 4 Number of totally unexposed infants who had exclusive breast milk feeding at 6-8 weeks (Outcome 1a), for Scotland level data

Variable	Babies born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of infants in totally unexposed cohort	293,081	13,956
Number (%) of totally unexposed infants with subsequent record of 6-8 week review	274,311	13,062	(93.6%)
Number (%) of totally unexposed infants with meaningful data for 'current feeding' (B/F/M/O/U)	270,388	12,876	(92.3%)
Outcome 1a: Number (%) of totally unexposed infants with meaningful data who were exclusively breast fed at 6-8 weeks ('current feeding' = B)	72,508	3,453	(26.8%)

Notes

B breast milk only

F formula milk only

M mixed breast and formula milk

O other

U unknown

Outcome 1b: Any breast milk feeding at 6-8 weeks

The percentage of babies receiving any breast milk feeding at 6-8 weeks (including combined bottle feeding and breastfeeding) was 37.4% on average (Table 5). A similar trend can be seen to that for exclusive breastfeeding. The percentage of infants receiving any breast milk increased very slightly from 35.7% for children born in the quarter ending March 2011 to 39.6% for those born in the quarter ending March 2016 (Figure 3).

Table 5 Number of totally unexposed infants who had any breast milk feeding at 6-8 weeks (Outcome 1b), for Scotland level data

Variable	Babies born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of infants in totally unexposed cohort	293,081	13,956
Number (%) of totally unexposed infants with subsequent record of 6-8 w review	274,311	13,062	(93.6%)
Number (%) of totally unexposed infants with meaningful data for 'current feeding' (B/F/M/O/U)	270,388	12,876	(92.2%)
Outcome 1b: Number (%) of totally unexposed infants with meaningful data with any breast milk feeding at 6-8 weeks ('current feeding' = B or M)	101,147	4,817	(37.4%)

Notes

B breast milk only

F formula milk only

M mixed breast and formula milk

O other

U unknown

(b) Scotland, stratified by SIMD quintile

Outcomes 1a and 1b: Data availability in the 6-8 week review

Patterns of outcomes were explored by level of area deprivation (SIMD quintiles). As described in the Methodology section (SIMD data subsection), to give an approximation of the number of children who have been excluded from the deprivation analysis, the total number of children with unknown SIMD has been calculated as a percentage of the total number of children in Scotland for:

• review coverage,
• data availability and
• Outcomes 1a and 1b.

As can be observed (Table 6), a negligible number of children have unknown deprivation level for this outcome.

Coverage for the 6-8 week review varies by SIMD fairly consistently over time, with babies living in the least deprived areas more likely to receive a 6-8 week review (an average of 96.0% in the least deprived areas receiving this review for children born between 1 January 2011 and 31 March 2016), and areas with higher levels of deprivation having correspondingly lower levels of coverage (an average of 92.4% from the most deprived areas having received a 6-8 week review for children born between 1 January 2011 and 31 March 2016) (see Table 7). This was seen to fluctuate a little for all quintiles over time (see Figure 4).

Table 6 Investigation of totally unexposed infants with unknown SIMD for current feeding outcomes (1a and 1b)

Description
Number of 6-8 week reviews where SIMD is unknown	202
Number of 6-8 week reviews with meaningful data where infant SIMD is unknown	194
Outcome 1a: Number of totally unexposed babies exclusively breast fed at 6-8 weeks where SIMD is unknown	50
Of totally unexposed babies who were exclusively breast fed at 6-8 weeks, percentage where SIMD is unknown	0.07%
Outcome 1b: Number of totally unexposed babies with any breast feeding at 6-8 weeks, where SIMD is unknown	73
Of totally unexposed babies with any breast feeding at 6-8 weeks, percentage where SIMD is unknown	0.07%

In line with this, the percentage of babies with meaningful data on infant feeding also varied by level of deprivation, with babies living in the least deprived areas being more likely to have these data recorded than those living in more deprived areas (an average of 94.8% of babies having infant feeding data available in the least deprived areas compared with 91.0% in the most deprived areas) (Table 7). Fluctuation in the percentage with meaningful data available could be seen in all deprivation groups, with a slight downwards trend across the quintiles between quarters ending March 2015 and March 2016 (see Figure 5).

Outcome 1a: Exclusive breast milk feeding at 6-8 weeks by SIMD

The percentage of infants who received breast milk exclusively at 6-8 weeks varies substantially by SIMD quintile. Overall, 41.8% children in the least deprived areas were receiving exclusive breast milk at this stage, compared with 14.8% in the most deprived areas (Table 7). Patterns across the years were fairly similar across SIMD quintiles, with a slight increase overall in exclusive breast milk feeding across all SIMD quintiles (Figure 6). However, the gap between the least and most deprived quintiles widened slightly over the five years, from a 26.2 percentage-point difference in exclusive breast feeding level for children born in the quarter ending March 2011 to a 28.7 percentage-point difference for children born in the quarter ending March 2016.

Table 7 Number of totally unexposed infants who had exclusive breast milk feeding at 6-8 weeks (Outcome 1a), stratified by SIMD

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed infants1	n	76,418	62,405	56,038	53,174	48,144
Number (%) of totally unexposed infants with subsequent record of 6-8 week review1	n	70,599	58,402	52,734	50,275	46,230
	%	92.4	93.6	94.1	94.5	96.0
Number (%) of totally unexposed infants with meaningful data for 'current feeding' (B/F/M/O/U)1	n	69,521	57,475	51,982	49,651	45,645
	%	91.0	92.1	92.8	93.4	94.8
Outcome 1a: Number (%) of totally unexposed infants with meaningful data who were exclusively breast fed at 6-8 weeks ('current feeding' = B) 1	n	10,274	11,832	15,087	17,403	19,094
	%	14.8	20.6	29.0	35.1	41.8

Notes

B breast milk only

F formula milk only

M mixed breast and formula milk

O other

U unknown

¹ Total number for quarters ending March 2011 to March 2016.

Outcome 1b: Any breast milk feeding at 6-8 weeks by SIMD

The percentage of babies receiving any breast milk feeding at 6-8 weeks followed similar patterns by SIMD to those with exclusive breast milk feeding. More than half of infants living in the least deprived areas were receiving any breast milk feeding at 6-8 weeks (56.8%), compared with less than a quarter (22.6%) from the most deprived areas (Table 8). There is a very slight upward trend across all SIMD quintiles over time (Figure 7). For children born in the quarter ending March 2011, the gap between the percentage of babies in SIMD 5 receiving any breast milk feeding and those in SIMD 5 was 34.4 percentage points, whereas for those born in the quarter ending March 2016 this had decreased very slightly to 33.9 percentage points.

Table 8 Number of totally unexposed infants who had any breast milk feeding at 6-8 weeks (Outcome 1b), stratified by SIMD

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed infants1	n	76,418	62,405	56,038	53,174	48,144
Number (%) of totally unexposed infants with subsequent record of 6-8 week review1	n	70,599	58,402	52,734	50,275	46,230
	%	92.4	93.6	94.1	94.5	96.0
Number (%) of totally unexposed infants with meaningful data for 'current feeding' (B/F/M/O/U)1	n	69,521	57,475	51,982	49,651	45,645
	%	91.0	92.1	92.8	93.4	94.8
Outcome 1a: Number (%) of totally unexposed infants with meaningful data who were exclusively breast fed at 6-8 weeks ('current feeding' = B) 1	n	15,677	17,078	20,630	23,391	25,914
	%	22.6	29.7	39.7	47.1	56.8

Notes

B breast milk only

F formula milk only

M mixed breast and formula milk

O other

U unknown

¹ Total number for quarters ending March 2011 to March 2016.

Immunisations

(a) Scotland

Outcome 2: Complete coverage of universal primary and end infancy immunisations by 2^nd birthday

The majority of children had received all of their universal immunisations by their second birthday (93.6%) (Table 9), with essentially no change in coverage between 2011 and 2016 (Figure 8).

Table 9 Number of totally unexposed children with complete immunisation coverage recorded on SIRS by second birthday (Outcome 2), for Scotland level data

Variable	Children born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of children in totally unexposed cohort	296,817	14,134
Outcome 2: Number (%) of totally unexposed children with complete immunisation coverage recorded on SIRS by 2nd birthday	278,023	13,239	(93.6%)

Note

Complete coverage of universal primary and end infancy immunisations by second birthday (Outcome 2) is defined as the child having received all of the following vaccines:

• 3 doses of the 5-in-1 (DOB up to 31 July 2017) or 6-in-1 (DOB from 1 August 2017) vaccine (provided at any point);
• 1 dose of pneumococcal (provided on or after 1^st birthday);
• 1 dose of HiB/MenC booster (provided on or after 1^st birthday); and
• 1 dose of MMR (provided on or after 1^st birthday).

(b) Scotland, stratified by SIMD quintile

As described above (SIMD data), a number of children have been excluded from the deprivation analysis because their postcode was missing, and as a consequence they have been categorised as SIMD unknown. Unlike the other outcomes, all of the data for Outcome 2 have been accessed from SIRS and are longitudinal. Therefore for this outcome, 294 children were excluded from the deprivation analysis: that is, <0.1% of babies born between 1 January 2011 and 31 March 2016. Of these 294 children, 258 were recorded as having complete immunisation coverage by their second birthday (i.e. 87.8%).

Outcome 2: Complete coverage of universal primary and end infancy immunisations by 2^nd birthday by SIMD

Very little difference could be seen by SIMD quintile, with children from the least deprived areas very slightly more likely to receive their full set of immunisations (94.2% in the least deprived areas), compared with children living in the most deprived areas (93.0%) (Table 10). Inequalities appeared to widen slightly over time: for children born in the quarter ending March 2011, there was a 0.39 percentage-point difference between the least and most deprived quintiles; however, this difference had increased slightly to 2.36 percentage points by the quarter ending March 2016 (Figure 9).

Table 10 Number of totally unexposed children who had complete coverage of universal primary and end infancy immunisations, by 2nd birthday (Outcome 2), stratified by SIMD

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children1	n	74,340	61,206	54,906	55,974	54,420
Outcome 2: Number (%) of totally unexposed children who had complete coverage of universal primary and end infancy immunisations by 2nd birthday1	n	69,170	57,248	51,428	52,647	51,292
	%	93.0	93.5	93.7	94.1	94.2

Note

¹Mean number for quarters ending March 2011 to March 2016.

Dental care

(a) Scotland

Outcome 3: Any attendance at dentist by 2nd birthday

For outcome 3, an average of 67.1% of children were found to have attended a dentist at least once by their second birthday (Table 11). This has risen from 63.0% for children born in the quarter ending March 2011 to 69.4% for children born in the quarter ending June 2015, before decreasing slightly to 68.0% for children born in the quarter ending March 2016 (Figure 10).

Table 11 Number of totally unexposed children for whom any dental attendance before second birthday was recorded (Outcome 3), for Scotland level data

Variable	Children born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Outcome 3: Number (%) of totally unexposed children for whom any dental attendance before second birthday was recorded	196,694	9,366	(67.1%)

(b) Scotland, stratified by SIMD quintile

Outcome 3: Any attendance at dentist by 2^nd birthday by SIMD

Relatively large differences could be seen in dental attendance by the child's second birthday when explored by SIMD quintile. Children from the least deprived areas were substantially more likely to have attended the dentist at least once by their second birthday (76.3%), compared with children from the most deprived areas (61.2% of whom had attended the dentist by their second birthday) (Table 12). Fluctuations in attendance by SIMD quintile were indicated over time, with inequalities reducing more recently, primarily due to increases in attendance by children in the most deprived group, from 56.9% to 60.2% (Figure 11).

For this outcome, the SIMD quintile for 294 children was unknown, and they are therefore excluded from the analysis. However, 258 (87.8%) of these children have been recorded as having attended a dentist before their second birthday.

Table 12 Number of totally unexposed children for whom any dental attendance before second birthday was recorded, stratified by SIMD

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children1	n	76,418	62,405	56,038	53,174	48,144
Outcome 3: Number (%) of totally unexposed children who had any attendance at dentist by 2nd birthday1	n	46,771	40,443	37,210	38,113	36,728
	%	61.2	64.8	66.4	71.7	76.3

Note

¹ Total number for quarters ending March 2011 to March 2016.

Parental smoking recorded in the 27-30 month review

The final parental health-related behaviour outcomes include smoking in the household. These have been split into two parts: first, the percentage of primary carers who are current smokers (recorded at the 27-30 month review) are examined, and then whether the child was reported as being exposed to second-hand smoke. The latter is important, as a health visitor might be able to affect behaviour change in terms of encouraging parents to smoke outside the home, thus lessening the impact on the child, even where a primary carer continues to smoke.

(a) Scotland

Outcome 4a: Primary carer current smoker at 27-30 months

Data coverage for the 27-30 month child health review is high (90.5%), although a little lower than coverage of the 6-8 week review (93.6%). It should be noted that this is a little higher than the coverage reported by Public Health Scotland (90.7% for the 6-8 week review and 87.5% for the 27-30 month review), due to the differences in the demonimator used, as explained in the Methodology section. Within the data recorded at the 27-30 month review, 88.0% of children have meaningful data on primary carer smoking at this stage (i.e. a yes/no response) (Table 13). Coverage for both the 27-30 month review data and the specific data on primary carer smoking can be seen to increase for children born between the quarters ending March 2011 and March 2016 (Figure 12). Over the five-year period, the percentage of children whose primary carer smokes was 18.6%; this can be seen to decrease over time, from 21.5% in 2011 to 16.0% in 2016 (Figure 13). This is in line with general trends in the adult population, where smoking rates for over 16s fell from 23.8% in 2012 to 19.6% in 2016.⁷

Table 13 1Number of totally unexposed children whose primary carer is a current smoker at 27-30 months (Outcome 4a), for Scotland level data

Variable	Children born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Number (%) of totally unexposed children with subsequent record of 27-30 month review	265,094	12,624	(90.5%)
Number (%) of totally unexposed children with meaningful data for 'primary carer current smoker at 27-30 months' outcome	257,563	12,265	(87.9%)
Outcome 4a: Number (%) of totally unexposed children with meaningful data whose primary carer is a current smoker at 27-30 months	48,013	2,286	(18.6%)

Outcome 4b: Child exposed to second hand smoke at 27-30 months

Data availability for child exposure to second hand smoke was similar to primary carer smoking, at 87.4% (Table 14 and Figure 14); again, data availability increased over time. The percentage of children exposed to second hand smoke at 27-30 months, however, was much lower: over the five-year period, a mean of 10.5% of children with meaningful data were reported to be exposed to second hand smoke at home. The actual percentage had almost halved for children born in the quarters ending March 2011 and March 2016, from 14.4% to 7.4% (Figure 15).

Table 14 Number of totally unexposed children who are exposed to second hand smoke at 27-30 months (Outcome 4b), for Scotland level data

Variable	Children born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Number (%) of totally unexposed children with subsequent record of 27-30 month review	265,094	12,624	(90.5%)
Number (%) of totally unexposed children with meaningful data for 'child exposed to second hand smoke at 27-30 months'	255,988	12,190	(87.3%)
Outcome 4b: Number (%) of totally unexposed children with meaningful data who are exposed to second hand smoke at 27-30 months	26,864	1,279	(10.5%)

(b) Scotland, stratified by SIMD quintile

Patterns of outcomes were explored by level of deprivation (SIMD quintiles). As described in the Methodology section (SIMD data), postcodes were not available for some children, resulting in these children being categorised as 'SIMD unknown' and not included in the deprivation analyses.

To offer an approximation of the number of children who have been excluded from the deprivation analysis, the total number of children with unknown SIMD has been calculated as a percentage of the total number of children in Scotland for:

• review coverage,
• data availability and
• Outcomes 4a and 4b.

These percentages are presented in Table 15.

Table 15 Investigation of children with unknown SIMD for parental smoking Outcomes 4a and 4b

Description
Number of 27-30 month reviews where SIMD is unknown	12,167
Number of 27-30 month reviews with meaningful data where SIMD is unknown	11,674
Outcome 4a: Number of totally unexposed children whose primary carer is a current smoker at 27-30 months, where SIMD is unknown	1,488
Of totally unexposed children whose primary carer is a current smoker at 27-30 months, percentage where child SIMD is unknown	3.1%
Outcome 4b: Number of totally unexposed children exposed to second-hand smoke at 27-30 months, where child SIMD is unknown	869
Of totally unexposed children exposed to second-hand smoke at 27-30 months, percentage where child SIMD is unknown	3.2%

Outcome 4a: Primary carer current smoker at 27-30 months by SIMD

As reported above with respect to the 6-8 week review, some variation could be seen in the coverage of the 27-30 month review when explored by SIMD quintile: those in the least deprived areas were more likely to have had a 27-30 month review than those in the most deprived areas (90.2% vs 85.8%, respectively) (see Table 16 and Figure 16Figure).

For children born in the quarter ending March 2011, the difference between the quintiles with the highest coverage (SIMD 5) and the lowest coverage (SIMD 1) was 3.61 percentage points. Quintile positions fluctuated and the gap between those with highest and lowest coverage increased, so that among children born in the quarter ending December 2011 the gap between the highest (SIMD 5) and lowest coverage (SIMD 3) was 13.2 percentage points. This wide gap was maintained over the course of 2.5 years; the quintiles for children born in the quarter ending June 2014 clustered together, but interestingly, the positions had reversed, and SIMD 3 had the highest coverage (89.0%) and SIMD 5 the lowest (86.1%). The gap widened again for children born in the quarter ending June 2015, with SIMD 4 having the highest coverage (93.0%) and SIMD 5 the lowest (84.8%), but for children born in the quarter ending March 2016 the quintiles were closely clustered, with SIMD 2 having the highest coverage (89.7%) and SIMD 4 the lowest (87.9%).

There was also a similar pattern of disparity and fluctuation among SIMD quintiles in terms of data availability, with 87.3% of those from the least deprived areas having meaningful data on primary carer smoking, compared with 84.1% from the most deprived areas (Table 16 and Figure 17).

Patterns of primary carer current smoking by SIMD quintile were striking: 6.4% of children living in the least deprived areas had a parent who was a current smoker at the 27-30 month review, compared with 30.4% of those in the most deprived areas (Table 16). All quintiles demonstrated a decrease in rates over time (Figure 18); however, this was most apparent for children in the most deprived areas, where rates of primary carer smoking have fallen from 35.2% for children born in the quarter ending in March 2011 to 25.8% for children born in the quarter ending in March 2016.

Table 16 Number of totally unexposed children whose primary carer is a current smoker at 27-30 months (Outcome 4a), stratified by SIMD quintile

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children1	n	76,418	62,405	56,038	53,174	48,144
Number (%) of totally unexposed children with subsequent record of 27-30 month review1	n	65,568	53,890	47,416	46,424	43,435
	%	85.8	86.4	84.6	87.3	90.2
Number (%) of totally unexposed children with meaningful data for 'primary carer current smoker at 27-30 months' outcome1	n	64,288	52,446	46,081	44,815	42,015
	%	84.1	84.0	82.2	84.3	87.3
Outcome 4a: Number (%) of totally unexposed children with meaningful data whose primary carer is a current smoker at 27-30 months1	n	19,538	12,220	7,821	4,955	2,690
	%	30.4	23.3	17.0	11.1	6.4

Note

¹Total number for quarters ending March 2011 to March 2016.

Outcome 4b: Child exposed to second hand smoke at 27-30 months by SIMD

Patterns for child exposure to second hand smoke were similar to those for Outcome 4a described above: data availability was marginally higher in the least deprived areas (86.9%) than the most deprived areas (83.7%) (Table 17), with increases in data availability across all groups over time (Figure 19).

As with primary carer smoking, a substantial difference could be observed between SIMD quintiles in terms of child exposure to second hand smoke, with those in more deprived areas having higher levels of children exposed: overall, 3.7% children in the least deprived areas were exposed to second hand smoke, in contrast to 17.4% children in the most deprived areas (Table 17). Across all SIMD quintiles, a decrease in the percentage of children exposed to second hand smoke could be observed over time (Figure 20), and this was again particularly notable in the most deprived quintile, where levels decreased from 24.2% for children born in the quarter ending March 2011 to 12.4% for those born in the quarter ending March 2016. This compares with a decrease from 5.4% to 2.2% in the least deprived quintile.

Table 17 Number of totally unexposed children who were exposed to second hand smoke at 27-30 months (Outcome 4b), stratified by SIMD quintile

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children1	n	76,418	62,405	56,038	53,174	48,144
Number (%) of totally unexposed with subsequent record of 27-30 month review1	n	65,568	53,890	47,416	46,424	43,435
	%	85.8	86.4	84.6	87.3	90.2
Number (%) of totally unexposed children with meaningful data for 'primary carer current smoker at 27-30 months' outcome1	n	63,944	52,127	45,736	44,491	41,827
	%	83.7	83.5	81.6	83.7	86.9
Outcome 4b: Number (%) of totally unexposed children with meaningful data who are exposed to second hand smoke at 27-30 months1	n	11,103	6,535	4,257	2,826	1,563
	%	17.4	12.5	9.3	6.4	3.7

Note

¹ Total number for quarters ending March 2011 to March 2016.

Developmental concerns

The second group of outcomes explored was that of developmental concerns relating to children. These data were all captured at the 27-30 month review (see Appendix 1 for more information about the various domains explored). For each domain, the health visitor should record one of the following letters:

N no concern

C concern newly suspected

P concern/disorder previously identified

X assessment incomplete.

Between April 2013, when the 27-30 month review was first introduced, and April 2019, four versions of the child health review form used to record the review have evolved. In April 2017, the number of developmental domains changed: the social domain of 2013 became personal/social in 2017; the previously separate emotional, behavioural and attention domains (three) merged into a single emotional/behavioural domain; and a new problem solving domain was created.

It should also be noted that when the 27-20 month review was introduced, several validated questionnaires (for example, Ages and Stages Questionnaire 3 (ASQ 3), Schedule of Growing Skills II (SOGS II), Strengths and Difficulties Questionnaire (SDQ)) were recommended. However, when the UHVP was published in 2015, it was recommended that the ASQ 3 be used for all children undergoing 13-15 month, 27-30 month and 4-5 year reviews. Since the UHVP was adopted at different times by different health boards, some health boards took longer to begin to use ASQ 3.

(a) Scotland

Outcome 5a: Any developmental concern at 27-30 months

There is a clear upward trend in coverage of the 27-30 month review over the time period. However, the percentage of children with complete developmental data is somewhat lower than for some other outcomes: 73.5% of children had complete data for development (Table 18). Data completeness changed substantially for children born from October 2014 onwards; this relates to when the new developmental domains and assessments (primarily ASQ) were introduced on a revised version of the form. For children born in the quarter ending December 2014, there was a 20.5 percentage point decrease in the fully completed data recorded and a similar increase in partially completed data (Figure 21). This is in part related to NHS Greater Glasgow and Clyde using a different assessment tool, and therefore not being included in the complete developmental data, but a decrease in complete data for development can be seen in other health boards among children born in the two quarters ending December 2014 and March 2015, and it is likely to be related to changes in the forms, as described above.

Table 18 Number of totally unexposed children with any developmental concern at 27-30 months (Outcome 5a), for Scotland level data

Variable	Children born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Number (%) of totally unexposed children with subsequent record of 27-30 month review	265,094	12,624	(90.5%)
Number (%) of totally unexposed children with complete data for 'development' (N/C/P for each domain) at 27-30 months'	215,270	10,251	(73.5%)
Number (%) of totally unexposed children without a concern, but some domains incomplete/missing	39,892	1,900	(13.6%)
Outcome 5a: Number (%) of totally unexposed children with a 27-30 month review who have C or P recorded against any domain at 27-30 months	47,438	2,259	(17.9%)

Overall, 17.9% of children had any developmental concern noted at 27-30 months. The percentage of children with a developmental concern recorded in any domain has remained fairly static over time, with the exception of a slight rise following the change in data recording (Figure 22).

The results for the individual domains are now explored.

Notes

A Percentage of children in this birth cohort with subsequent record of 27-30 month review

B Percentage of children in this birth cohort with complete data for 'development' (N/C/P for each domain) recorded in 27-30 month review

C Percentage of children in this birth cohort without a concern recorded, but with some domains of 27-30 month review incomplete/missing

Outcome 5b: Any concern about speech, language and communication development at 27-30 months

The speech, language and communication domain was particularly well recorded, with 86.3% children having meaningful data at 27-30 months, increasing over time in line with increases in the percentage of children having their 27-30 month review (Table 19 and Figure 23).

The percentage of children with concerns noted in the speech, language and communication domain was 12.5%. This was seen to gradually fall from 12.8% to 10.3% for children born in the quarters ending between March 2011 and March 2016 (see Figure 24).

Table 19 Number of totally unexposed children with any concern about Speech, language and communication development at 27-30 months (Outcome 5b), for Scotland level data

Variable	Children born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Number (%) of totally unexposed children with subsequent record of 27-30 month review	265,094	12,624	(90.5%)
Number (%) of totally unexposed children with meaningful data for 'Speech, language & communication development' (N/C/P) at 27-30 months'	252,922	12,044	(86.3%)
Number (%) of totally unexposed children without a concern, but some domains incomplete/missing	39,892	1,900	(13.6%)
Outcome 5b: Number (%) of totally unexposed children with meaningful data who have C or P recorded against Speech, language & communication domain at 27-30 months	33,161	1,579	(12.5%)

Outcome 5c: Any concern about social and emotional development

Similarly to the speech and language domain, 85.9% children had meaningful data recorded on the social and emotional development domain (Table 20). Again, the percentage with data recorded in this domain increased as the coverage for the overall review increased (Figure 25).

The percentage of children with a concern noted on the social and emotional domain was 8.2%, with a slight decrease seen over time, from 9.9% for children born in the quarter ending in March 2011 to 7.3% for children born in the quarter ending March 2016 (Figure 26).

Table 20 Number of totally unexposed children with any concern about Social and emotional development at 27-30 months (Outcome 5c), for Scotland level data

Variable	Children born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Number (%) of totally unexposed with subsequent record of 27-30 month review	265,094	12,624	(90.5%)
Number (%) of totally unexposed children with meaningful data for 'Social and emotional development' (N/C/P) (each relevant domain) at 27-30 months'	251,646	11,983	(85.9%)
Number (%) of totally unexposed children without a concern, but some domains incomplete/missing	39,892	1,900	(13.6%)
Outcome 5c: Number of totally unexposed children (% with meaningful data) with C or P recorded against any Social & emotional domain at 27-30 months	21,745	1,035	(8.2%)

(b) Scotland, stratified by SIMD quintile

As previously, the three developmental-concern outcomes were explored by level of area deprivation (SIMD quintiles). As described in the Methodology section above (SIMD data), postcodes were not available for some children, resulting in these children being categorised as 'SIMD unknown' and not included in the deprivation-level analyses. Unfortunately it is not possible to give a precise estimate of the number of children affected, since the data on live births have been accessed from a different source (NRS) to the data relating to the 27-30 month child health review (CHSP-PS).

To offer an approximation of the number of children who have been excluded from the deprivation analysis the total number of children with unknown SIMD has been calculated as a percentage of the total number of children in Scotland for:

• review coverage,
• data availability, and
• Outcomes 5a, 5b and 5c.

These percentages are presented in Table 21, where it can be seen that the percentage whose SIMD quintile was unknown was in the region of 4.5%.

Outcome 5a: Any developmental concern at 27-30 months by SIMD

As outlined for Outcome 4a: Primary Carer current smoker at 27-30 months by SIMD, above, the pattern of coverage of the 27-30 month review varies by SIMD quintile, with those in the most deprived groups slightly less likely to receive their review than those in the least deprived group, although this fluctuates considerably over time (Figure 27), as has been described for Figure 16.

The percentage of children with complete developmental data recorded at the 27-30 month review follows a similar pattern: 65.5% children in the most deprived quintile had a complete set of developmental data, compared with 74.1% in the least deprived quintile (Table 22). A substantial decrease in the percentage of children with complete developmental data occurs in the quarters for children born after September 2014, relating to when the data collection changed, and levels across all quintiles are lower following this change (Figure 28).

For data relating to children born after September 2014, inequalities in complete developmental data coverage are widened, with those in the most deprived quintile substantially less likely to have a complete set of data (52.4% for children born in the quarter ending in March 2016) compared with those in the four other quintiles (ranging from 62.4% in the least deprived quintile to 69.7% in SIMD 3 in the same quarter) (Figure 28). As noted above, this is in part related to NHS Greater Glasgow and Clyde not using the ASQ as a measure following the change of assessment, and these areas accounting for large proportions of children in the lower SIMD quintiles.

Table 21 Investigation of children with unknown SIMD for developmental-concern Outcomes 5a, 5b and 5c

Description
Number of 27-30 month reviews, where child SIMD is unknown	12,167
Number of totally unexposed children with complete data for developmental domains, where child SIMD is unknown	9,478
Number of totally unexposed children without a concern, but some domains incomplete or missing, where child SIMD is unknown	2,192
Outcome 5a: Number of totally unexposed children with any developmental concern at 27-30 months, where child SIMD is unknown	2,148
Of totally unexposed children with any developmental concern at 27-30 months, percentage where child SIMD is unknown	4.5%
Number of totally unexposed children with meaningful data for Speech, language & communication development, where child SIMD is unknown	11,389
Outcome 5b: Number of totally unexposed children with any concern about Speech, language & communication development at 27-30 months, where child SIMD is unknown	1,565
Of totally unexposed children with any developmental concern about Speech, language & communication development at 27-30 months, percentage where child SIMD is unknown	4.7%
Number of totally unexposed children with meaningful data for Social & emotional development, where SIMD is unknown	11,333
Outcome 5c: Number of totally unexposed children with any concern about Social & emotional development at 27-30 months, where child SIMD is unknown	979
Of totally unexposed children with any concern about Social & emotional development at 27-30 months, percentage where child SIMD is unknown	4.4%

Over the five-year period, a quarter of children (25.1%) in the most deprived quintile had a concern noted in at least one developmental domain, compared with 10.5% in the least deprived quintile (Table 22); a linear pattern by SIMD was apparent. These differences between SIMD quintiles were maintained over time, although a slight narrowing of inequalities could be observed among children born in the quarter ending in March 2016: there was a difference of 15.8 percentage points between the most and least deprived quintiles born in the quarter ending in March 2011 compared with a difference of 13.5 percentage points among the two quintiles born in the quarter ending in March 2016. The percentage of children for whom a concern in any developmental domain was recorded was 21.9% in the most deprived quintile, born in the quarter ending in March 2016, in contrast to 8.4% in the least deprived quintile at the same time point (Figure 29).

Table 22 Number of totally unexposed children with any developmental concern at 27-30 months (Outcome 5a), stratified by SIMD quintile

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children 1	n	76,418	62,405	56,038	53,174	48,144
Number (%) of totally unexposed with subsequent record of 27-30 month review1	n	65,568	53,890	47,416	46,424	43,435
	%	85.8	86.4	84.6	87.3	90.2
Number (%) of totally unexposed with complete data for 'development at 27-30 months' outcome (N/C/P for each domain)1	n	50,049	44,502	40,045	39,163	35,653
	%	65.5	71.3	71.5	73.7	74.1
Number (%) of totally unexposed children without a concern, but some domains incomplete/missing1	n	11,336	7,363	6,069	6,185	6,911
	%	14.8	11.8	10.8	11.6	14.4
Outcome 5a: Number (%) of totally unexposed children with 27-30 month review, for whom a C or P was recorded against any domain at 27-30 months1	n	16,454	10,761	7,859	6,220	4,545
	%	25.1	20.0	16.6	13.4	10.5

Note

¹ Total number for quarters ending March 2011 to March 2016.

Figure 29 Percentage of totally unexposed birth cohort for which any developmental concern has been recorded at 27-30 months (Outcome 5a), stratified by SIMD

Outcome 5b: Any concern about speech, language and communication development at 27-30 months by SIMD

In terms of individual domain recording by SIMD, data for the speech, language and communication domain was recorded for 82.7% of children in the most deprived SIMD quintile, compared with 86.0% in the least deprived quintile (Table 23). The pattern is similar to the one described for Figure 16, in the section above entitled Outcome 4a: Primary carer current smoker at 27-30 months by SIMD. Despite fluctuations, especially in SIMD 3 and 5 quintiles, a slight increase in data availability in the domain could be discerned across all SIMD groups for children born in the quarters ending March 2011 and March 2016 (Figure 30).

More than twice the percentage of children in the most deprived quintile (17.0%) had a concern noted with speech, language and communication, compared with 7.2% in the least deprived quintile (Table 23). This pattern was consistent across time, with all SIMD quintiles seeing a slight decrease in the percentage of children with a speech, language and communication concern noted: for example, children in the most deprived quintile saw a decrease in levels of concerns in this field from 16.8% for children born in the quarter ending March 2011 to 15.2% for those born in the quarter ending March 2016 (Figure 31).

Table 23 Number of totally unexposed children with any concern about Speech, language and communication development at 27-30 months (Outcome 5b), stratified by SIMD quintile

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children 1	n	76,418	62,405	56,038	53,174	48,144
Number (%) of totally unexposed with subsequent record of 27-30 month review1	n	65,568	53,890	47,416	46,424	43,435
	%	85.8	86.4	84.6	87.3	90.2
Number (%) of totally unexposed with complete data for 'development at 27-30 months' outcome (N/C/P for each domain)1	n	50,049	44,502	40,045	39,163	35,653
	%	65.5	71.3	71.5	73.7	74.1
Number (%) of totally unexposed without a concern, but some domains incomplete/missing1	n	11,336	7,363	6,069	6,185	6,911
	%	14.8	11.8	10.8	11.6	14.4
Number (%) of totally unexposed with meaningful data recorded in Speech, language & communication domain at 27-30 months (N/C/P)1	n	63,204	51,527	45,093	44,026	41,383
	%	82.7	82.6	80.5	82.8	86.0
Outcome 5b: Number (%) of totally unexposed children with 27-30 month review, for whom a C or P was recorded against Speech, language & communication domain at 27-30 months1	n	11,134	7,707	5,643	4,382	3,113
	%	17.0	14.3	11.9	9.4	7.2

Note

¹ Total number for quarters ending March 2011 to March 2016.

Outcome 5c: Any concern about social and emotional development at 27-30 months by SIMD

The percentages of children with data available for the social and emotional domain(s) varied very slightly by SIMD quintile at the beginning and end of the time period: for children born in the quarter ending in March 2011 percentages ranged from 76.2% (SIMD 4) to 78.9% (SIMD 5), and for children born in the quarter ending in March 2016 from 82.8% (SIMD 4) to 85.0% (SIMD 2). For children born in the quarters ending from September 2012 to March 2014, those living in the least deprived areas (SIMD 5) had considerably more data available for this domain (around 90%); however, children born in the quarter ending June 2014 living in least deprived areas (Figure 32) had the lowest percentage of meaningful data available. This pattern was similar to that for data availability for speech, language and communication domain (see Figure 30 above).

Children in the most deprived quintile (SIMD 1) were more likely to have a concern noted in a social or emotional development domain, compared with children from other groups (13.2% children in the most deprived quintile compared with 3.9% children in the least deprived quintile) (Table 24). This pattern was consistent across time (Figure 33); however, all groups saw a decrease in levels of concerns in the social or emotional sphere, with children in the most deprived group showing the largest reduction, from 16.4% for children born in the quarter ending March 2011 to 11.9% in the quarter ending March 2016, thus reducing inequalities.

Table 24 Number of totally unexposed children with any concern about Social and emotional development at 27-30 months (Outcome 5c), stratified by SIMD quintile

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children 1	n	76,418	62,405	56,038	53,174	48,144
Number (%) of totally unexposed children with subsequent record of 27-30 month review1	n	65,568	53,890	47,416	46,424	43,435
	%	85.8	86.4	84.6	87.3	90.2
Number (%) of totally unexposed children with complete data for 'development at 27-30 months' outcome (N/C/P for each domain)1	n	50,049	44,502	40,045	39,163	35,653
	%	65.5	71.3	71.5	73.7	74.1
Number (%) of totally unexposed children without a concern, but some domains incomplete/missing1	n	11,336	7,363	6,069	6,185	6,911
	%	14.8	11.8	10.8	11.6	14.4
Number (%) of totally unexposed children with meaningful data recorded in Social & emotional domain at 27-30 months (N/C/P)1	n	62,994	51,318	44,848	43,805	41,021
	%	82.4	82.2	80.0	82.4	85.2
Outcome 5b: Number (%) of totally unexposed children with 27-30 month review, for whom a C or P was recorded against Social & emotional domain at 27-30 months1	n	8,652	4,920	3,270	2,506	1,684
	%	13.2	9.1	6.9	5.4	3.9

Note

¹ Total number for quarters ending March 2011 to March 2016.

The third group of outcomes to be explored in the Phase 1 outcome evaluation report contribute baseline evidence to the research question: What impact has the implementation of the UHVP had on outcomes relating to child physical health for children aged up to three years? Child BMI and hospital admission for serious unintentional injuries are investigated in turn below.

Child BMI

(a) Scotland

Outcome 6a: Child at risk of overweight or obesity (BMI ≥85^th centile) at 27-30 months

Less than two-thirds (63.2%) of children had valid height and weight data that could be used to calculate their BMI recorded at the 27-30 month review (Table 25). This has increased over time, from 58.5% for children born in the quarter ending in March 2011 to 64.3% for children born in the quarter ending in March 2016, following a similar pattern to overall 27-30 month coverage (Figure 34).

Of those with valid data, 40.3% of children were at risk of overweight or obesity at 27-30 months (Table 25). Despite some fluctuation, this percentage remained reasonably constant for children born in the quarters ending between March 2011 and March 2016 (Figure 35). This proportion appears to be very high compared to levels of overweight and obesity in the P1 Scottish data, where 23% children in P1 (aged 4-5 years) were overweight or obese.⁸ This may reflect both use of the WHO growth standard (rather than the UK90 growth reference)⁹ for this age group, which is based on 'healthy breast-fed children in optimal conditions', and has a tendency to have higher levels of children falling into the overweight and obese categories,¹⁰ and possibly selective weighing of heavier children by health visitors.

Table 25 Number of totally unexposed children who were at risk of overweight or obesity ( BMI ≥ 85 ^th centile) at 27-30 months (Outcome 6a), for Scotland level data

Variable	Children born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Number (%) of totally unexposed children with subsequent record of 27-30 month review	265,094	12,624	(90.5%)
Number (%) of totally unexposed children with valid height and weight data recorded	185,135	8,816	(63.2%)
Outcome 6a: Number (%) of totally unexposed children with valid data who are at risk of overweight or obesity (BMI ≥ 85th centile) at 27-30 months	74,644	3,554	(40.3%)

Outcome 6b: Child clinically obese (BMI ≥98^th centile) at 27-30 months

In terms of the percentage of children who are clinically obese (BMI ≥ 98th centile) at 27-30 months, 11.9% children fell into this category overall (Table 26). Over the five-year period, the percentage of children who were clinically obese remained between 11.1% and 13.0% (Figure 36).

Table 26 Number of totally unexposed children who were clinically obese ( BMI ≥ 98 ^th centile) at 27-30 months (Outcome 6b), for Scotland level data

Variable	Children born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Number (%) of totally unexposed children with subsequent record of 27-30 month review	265,094	12,624	(90.5%)
Number (%) of totally unexposed children with valid height and weight data recorded	185,135	8,816	(63.2%)
Outcome 6b: Number (%) of totally unexposed children with valid data who are clinically obese (BMI ≥ 98th centile) at 27-30 months	22,095	1,052	(11.9%)

(b) Scotland, stratified by SIMD

As with Outcomes 1, 4 and 5, a number of children were categorised as SIMD unknown because their postcode was missing. Again, the total number of children with a review whose SIMD is not known has been calculated as a percentage of the total number of children in Scotland. Similar percentages have been calculated for the numbers of children whose SIMD is not known with valid data, and with each outcome. The percentages are presented in Table 27 below. Once more, about 4% of the unexposed cohort were unable to contribute data to the SIMD analyses.

Table 27 Investigation of children with unknown SIMD for outcomes 6a and 6b

Description	Percentage with SIMD unknown
Number of 27-30 month reviews, where child SIMD is unknown	12,167
Number of children with valid height & weight data, where child SIMD is unknown	8,212
Outcome 6a: Number of totally unexposed children at risk of overweight or obesity (BMI ≥ 85th centile) at 27-30 months, where child SIMD is unknown	2,947
Of totally unexposed children at risk of overweight or obesity (BMI ≥ 85th centile) at 27-30 months, percentage where child SIMD is unknown	3.9%
Outcome 6b: Number of totally unexposed children clinically obese (BMI ≥ 98th centile) at 27-30 months, where child SIMD is unknown	841
Of totally unexposed children clinically obese (BMI ≥ 98th centile) at 27-30 months, percentage where child SIMD is unknown	3.8%

Outcome 6a: Child at risk of overweight or obesity (BMI ≥85^th centile) at 27-30 months by SIMD

Coverage of the 27-30 month review varies slightly by SIMD quintile, with those in the most deprived groups slightly less likely to receive their review than those in the least deprived group, although this fluctuates considerably over time (Figure 37). For a fuller description, see Outcome 4a: Primary carer current smoker at 27-30 months by SIMD above.

Children in the highest deprivation quintile were less likely to have valid height and weight data available (54.0% in the most deprived quintile, compared with 68.5% in the lowest deprivation quintile) (Table 28). Availability of BMI data by SIMD quintile was seen to fluctuate over time; however, an increase in levels of available data could be seen for all quintiles (Figure 38).

Interestingly, and varying from most other measures, there were no differences in the percentage of children at risk of overweight or obesity (BMI ≥ 85th centile) at 27-30 months by SIMD quintile (Figure 39Figure 39).

Table 28 Number of totally unexposed children who were at risk of overweight or obesity ( BMI ≥ 85th centile) at 27-30 months in the fully unexposed cohort (Outcome 6a), stratified by SIMD

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children1	n	76,418	62,405	56,038	53,174	48,144
Number (%) of totally unexposed children with subsequent record of 27-30 month review1	n	65,568	53,890	47,416	46,424	43,435
	%	85.8	86.4	84.6	87.3	90.2
Number (%) of totally unexposed children with valid height and weight, and hence BMI, recorded in 27-30 month review1	n	41,302	36,952	34,230	34,482	32,957
	%	54.0	59.2	61.1	64.8	68.5
Outcome 6a: Number (%) of totally unexposed children with valid data who are at risk of overweight or obesity (BMI ≥ 85th centile) at 27-30 months1	n	16,626	15,130	14,029	13,897	13,303
	%	40.3	40.9	41.0	40.3	40.4

Note

¹ Total number for quarters ending March 2011 to March 2016.

Outcome 6b: Child clinically obese (BMI ≥98^th centile) at 27-30 months by SIMD

A slightly different picture emerged in relation to children who were clinically obese (BMI ≥ 98th centile) at 27-30 months, with children living in the most deprived quintiles being slightly more likely to be clinically obese (13.3%) than children in the least deprived quintiles (10.7%) (Table 29), a pattern also seen to a greater extent within the P1 obesity report.⁸ As Figure 40 demonstrates, despite some minor fluctuations, there was little difference seen in this outcome between children born in the quarters ending March 2011 and March 2016; the SIMD quintiles were generally intertwined, with a minimum value of 9.1% and a maximum of 14.5% across the quintiles.

Table 29 Number of totally unexposed children who were clinically obese ( BMI ≥ 98 ^th centile) at 27-30 months in the fully unexposed cohort (Outcome 6b), stratified by SIMD

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children	n	76,418	62,405	56,038	53,174	48,144
Number (%) of totally unexposed children with subsequent record of 27-30 month review	n	65,568	53,890	47,416	46,424	43,435
	%	85.8	86.4	84.6	87.3	90.2
Number (%) of totally unexposed with valid height and weight, and hence BMI, recorded in 27-30 month review	n	41,302	36,952	34,230	34,482	32,957
	%	54.0	59.2	61.1	64.8	68.5
Outcome 6b: Number (%) of totally unexposed children with valid data who are clinically obese (BMI ≥ 98th centile) at 27-30 months	n	5,502	4,590	4,108	3,919	3,533
	%	13.3	12.4	12.0	11.4	10.7

Note

¹ Total number for quarters ending March 2011 to March 2016.

Unintentional injuries

(a) Scotland

Outcome 7a: Any hospital admission for unintentional injury by 3^rd birthday

Hospital admissions were explored using routinely collected hospital admissions data. Overall, 3.4% children had a hospital admission for any unintentional injury recorded by their third birthday (Table 30). There has been no change in this percentage for children born in the quarters ending March 2011 and March 2016 (Figure 41).

Table 30 Number of totally unexposed children who had any hospital admission for unintentional injury by third birthday (Outcome 7a), for Scotland level data

Variable	Babies born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Outcome 7a: Number (%) of totally unexposed children with any hospital admission for unintentional injury by 3rd birthday	10,056	479	3.4%

Outcome 7b: Any hospital admission for unintentional poisoning, burn or scald by 3^rd birthday

When looking explicitly at the percentage of children admitted to hospital for unintentional poisoning, burn or scald by their 3rd birthday, data indicate that 1.0% of children experience this (Table 31). Again, there was no change demonstrated over time (Figure 42).

Table 31 Number of totally unexposed children who had any hospital admission for unintentional poisoning, burn or scald by third birthday (Outcome 7b), for Scotland level data

Variable	Babies born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Outcome 7b: Number (%) of totally unexposed children with any hospital admission for unintentional poisoning, burn or scald by 3rd birthday	2,964	141	(1.0%)

Outcome 7c: Any hospital admission for unintentional long bone fracture or head injury by 3^rd birthday

Overall, 1.8% of children had a hospital admission recorded for unintentional long bone fracture or head injury by their third birthday (Table 32). There was no change to this figure for children born between 1 January 2011 and 31 March 2016 (Figure 43).

Table 32 Number of totally unexposed children who had any hospital admission for unintentional long bone fracture or head injury by third birthday (Outcome 7c), for Scotland level data

Table 32 Number of totally unexposed children who had any hospital admission for unintentional long bone fracture or head injury by third birthday (Outcome 7c), for Scotland level data

Variable	Babies born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	293,081	13,956
Outcome 7c: Number (%) of totally unexposed children with any hospital admission for unintentional long bone fracture or head injury by 3rd birthday	5,302	252	(1.8%)

(b) Scotland, stratified by SIMD quintile

For unintentional injury outcomes, children for whom SIMD could not be identified have been excluded. However, as presented in Table 33 below, for Outcome 7a, only 1.4% of children who were admitted to hospital for any unintentional injury by their third birthday had unknown SIMD; the percentages for Outcomes 7b and 7c were 1.6% and 1.8% respectively.

Table 33 Investigation of children with unknown SIMD for serious unintentional injury: Outcomes 7a, 7b and 7c

Description	Percentage with SIMD unknown
Outcome 7a: Number of totally unexposed children with any hospital admission for unintentional injury by 3rd birthday, where child SIMD is unknown	145
Of totally unexposed children with any hospital admission for unintentional injury by 3rd birthday, percentage where child SIMD is unknown	1.4%
Outcome 7b: Number of totally unexposed children with any hospital admission for any unintentional poisoning, burn or scald by 3rd birthday, where child SIMD is unknown	49
Of totally unexposed children with any hospital admission for any unintentional poisoning, burn or scald by 3rd birthday, percentage where child SIMD is unknown	1.6%
Outcome 7c: Number of totally unexposed children with any hospital admission for any unintentional long bone fracture or head injury by 3rd birthday, where child SIMD is unknown	96
Of totally unexposed children with any hospital admission for any unintentional long bone fracture or head injury by 3rd birthday, percentage where child SIMD is unknown	1.8%

Outcome 7a: Any hospital admission for unintentional injury by 3^rd birthday by SIMD

When explored by SIMD, there was little variation between SIMD groups in the percentage of children who had been admitted to hospital for any unintentional injury by their third birthday: over the five years, mean percentages ranged from 3.1% (SIMD 4 and 5, less deprived quintiles) to 3.9% (SIMD 1, most deprived quintile) (Table 34). Although these differences are very small, this largely reflects that these are relatively rare outcomes, and the gradient seen by SIMD is in line with the literature which demonstrated that more disadvantaged children aged 0-5 years were at greater risk of any hospital admission for unintentional injury compared with less disadvantaged children.¹¹ Furthermore, as can be observed in Figure 44, for all SIMD quintiles the percentage of children who had been admitted to hospital for any unintentional injury by their third birthday was constant over the time period.

Table 34 Number of totally unexposed children with any hospital admission for unintentional injury by third birthday (Outcome 7a), stratified by SIMD

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children1	n	76,418	62,405	56,038	53,174	48,144
Outcome 7a: Number (%) of totally unexposed children with any hospital admission for unintentional injury by 3rd birthday1	n	3,006	2,066	1,804	1,638	1,509
	%	3.9	3.3	3.2	3.1	3.1

Note

1 Total number for children born in quarters ending March 2011 to March 2016.

Outcome 7b: Any hospital admission for unintentional poisoning, burn or scald by 3^rd birthday by SIMD

Again, there was very little variation between quintiles, when exploring the percentage of children with any hospital admission for unintentional poisoning, burn or scald by the third birthday: mean percentage of admissions over the five-year period varied from 0.8% (SIMD 5, least deprived quintile) to 1.3% (SIMD 1, most deprived) (Table 35). For children born in the quarter ending March 2011, the percentage with admissions for unintentional poisoning, burn or scald was 1.1% in the most deprived quintile and 0.7% in the least deprived quintile; similarly, for those born in the quarter ending March 2016, the respective percentages were 1.2% (SIMD 1) and 0.7% (SIMD 5). This was also constant across the time period (Figure 45).

Table 35 Number of totally unexposed children with any hospital admission for any unintentional poisoning, burn or scald by third birthday (Outcome 7b), stratified by SIMD

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of children in totally unexposed cohort1	n	76,418	62,405	56,038	53,174	48,144
Outcome 7b: Number (%) of totally unexposed children with any hospital admission for unintentional poisoning, burn or scald by 3rd birthday1	n	959	640	516	467	366
	%	1.3	1.0	0.9	0.9	0.8

Note

¹ Total number for children born in quarters ending March 2011 to March 2016.

Outcome 7c: Any hospital admission for unintentional long bone fracture or head injury by 3^rd birthday by SIMD

In relation to unintentional long bone fracture or head injury admissions by the third birthday, there was almost no difference between SIMD quintiles (1.92% in the most deprived quintile vs 1.79% in the least deprived quintile) (Table 36), again possibly reflecting more how rare these events are. There was little variation in any quintile for children born between between 1 January 2011 and 31 March 2016 (Figure 46).

Table 36 Number of totally unexposed children with any hospital admission for any unintentional long bone fracture or head injury, by third birthday (Outcome 7c), stratified by SIMD

Description	n or %	SIMD 1 (most deprived)	SIMD 2	SIMD 3	SIMD 4	SIMD 5 (least deprived)
Number of totally unexposed children1	n	76,418	62,405	56,038	53,174	48,144
Outcome 7c: Number (%) of totally unexposed children with any hospital admission for unintentional long bone fracture or head injury by 3rd birthday1	n	1,469	1,073	977	887	859
	%	1.9	1.7	1.7	1.7	1.8

Note

¹ Total number for children born in quarters ending March 2011 to March 2016.

Child protection interventions

The final group of outcomes to be explored in this element of the evaluation focuses on child safety measures. These comprise Child Protection registrations, and Looked After Child (LAC) status, and were supplied by the Scottish Government Child Protection data, 2012-13 to 2018-19, and Children Looked After Statistics, 2008-09 to 2018-19. We will explore each of these in turn.

(a) Scotland

Outcome 8a: Placed on child protection register at any point between birth and 3^rd birthday

The percentage of children placed on the child protection register (CPR) at any point between birth and their third birthday was explored. Overall, 2.7% of children were placed on the CPR during this time (Table 37). An increase could be seen, from 1.2% of children born in the quarter ending March 2011, rising to 3.5% of children born in the quarter ending March 2016. However, it should be borne in mind that individual-level child protection data records began on 1 August 2012; therefore for children in the first seven birth cohorts (i.e. born between 1 January 2011 and 30 September 2012), the percentages that were reported as having been placed on the CPR in their first three years are almost certainly underestimated, as some children will have been placed on the CPR before the individual level data recording began (see Appendix 1 for further detail) (Figure 47).

Table 37 Number of totally unexposed children placed on child protection register at any point between birth and third birthday (Outcome 8a), for Scotland level data

Variable	Babies born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	297,337	14,159
Outcome 8a: Number (%) of totally unexposed children placed on child protection register at any point between birth and 3rd birthday	8,082	385	(2.7%)

Note

The total and mean number of children is slightly larger in the child safety outcomes because it was not possible to remove data for children who might have been partially exposed to the UHVP in Shetland and Tayside in the final four quarters and in Orkney in the final two quarters.

Outcome 8b: Placed on child protection register for ≥6 months between birth and 3rd birthday

To aid the interpretation of data about child protection registrations, data on the length of time spent on the register were additionally explored. For example, in Phase 2, following the implementation of the UHVP, and increases in home visits, one might anticipate greater detection of child protection cases, and this is not necessarily a negative outcome. However, it may be useful to analyse the data to look at whether, in intervening earlier, children might be less likely to stay on the Child Protection Register (or have Looked After Child status) for a longer period of time, hence the need to explore both the proportion of children on the register and the length of time spent on the register (i.e. whether this exceeds 182 days (6 months)).

It should be borne in mind that some children are placed on the CPR more than once between birth and their third birthday: for these multiple episodes, if the cumulative number of days on the CPR is greater than 182, then the child is considered to have spent at least six months on the CPR.

Overall, 1.3% children were placed on the child protection register for at least 6 months between birth and their third birthday (Table 38). This proportion also rose for children born in the quarters ending between March 2011 and March 2016, from 0.6% to 1.7% (Figure 48); however, again this may due to changes in recording. As explained in Outcome 8a, it should be noted that individual-level child protection data records began on 1 August 2012; therefore for children in the first seven birth cohorts (i.e. born between 1 January 2011 and 30 September 2012), the percentages that were reported as having been placed on the CPR in their first three years are almost certainly underestimated, as some children will have been placed on the CPR before the data recording began (see Appendix 1 for further detail).

Table 38 Number of totally unexposed children placed on child protection register for ≥ 6 months between birth and third birthday (Outcome 8b), for Scotland level data

Variable	Babies born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	297,337	14,159
Outcome 8b: Number (%) of totally unexposed children placed on child protection register for ≥ 6 months between birth and 3rd birthday	3,764	179	(1.3%)

Note

The total and mean number of children is slightly larger in the child safety outcomes because it was not possible to remove data for children who might have been partially exposed to the UHVP in Shetland and Tayside in the final four quarters and in Orkney in the final two quarters.

Looked After Child status

(a) Scotland

Outcome 9a: Registered as having Looked After Child status at any point between birth and 3^rd birthday

Overall, 2.1% children had Looked After Child (LAC) status at some point between birth and their third birthday (Table 39Table ). This was constant over time (see Figure 49).

Table 39 Number of totally unexposed children registered as having Looked After Child status at any point between birth and third birthday (Outcome 9a), for Scotland level data

Variable	Babies born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	297,337	14,159
Outcome 9a: Number (%) of totally unexposed children registered as having Looked After Child status at any point between birth and 3rd birthday	6,127	292	(2.1%)

Note

The total and mean number of children is slightly larger in the child safety outcomes because it was not possible to remove data for children who might have been partially exposed to the UHVP in Shetland and Tayside in the final four quarters and in Orkney in the final two quarters.

Outcome 9b: Registered as having Looked After Child status for ≥6 months between birth and 3^rd birthday

As described for the child protection registrations outcome above, some children have multiple episodes (i.e. some children are recorded as LAC or placed on the child protection register more than once between birth and third birthday). For LAC status; these episodes are summed, and if this exceeds 182 days they are considered to have been registered as LAC for six or more months between birth and 3rd birthday. The percentage of children with 'Looked After Child' status for six months or longer between birth and their third birth was 1.8% (Table 40). This showed very little change between 2011 and 2016 (Figure 50).

For a small percentage of looked after children, records show them being in care at 31 July (academic year end), but they do not appear in the following data collection; for example, there is a record for them being looked after at 31 July 2015 (i.e. the end of the 2014/15 academic year), but no record of them being looked after exists in the 2015/16 data return. This probably happens when there is a time-lag between the child's records being updated and the data being submitted to the Scottish Government Child Looked After Statistics, and they actually ceased to be looked after at some point before 31 July. For calculating the time with looked after status for Outcome 9b, it has been assumed that such children were looked after until 31 July of the last extract in which they appeared; therefore the length of time that they have looked after child status may be slightly overestimated for a very small percentage of children.

Table 40 Number of totally unexposed children registered as having Looked After Child status for ≥ 6 months between birth and third birthday (Outcome 9b), for Scotland level data

Variable	Babies born January 2011 to March 2016
	Total	Mean for quarters ending March 2011 to March 2016
Number of totally unexposed children	297,337	14,159
Outcome 9b: Number (%) of totally unexposed children registered as having Looked After Child status for ≥ 6 months between birth and 3rd birthday	5,374	256	(1.8%)

Note

The total and mean number of children is slightly larger in the child safety outcomes because it was not possible to remove data for children who might have been partially exposed to the UHVP in Shetland and Tayside in the final four quarters and in Orkney in the final two quarters.