School-aged years high impact area 3: Supporting healthy lifestyles

Question 1

Childhood obesity and physical activity

Accepted Answer

Childhood obesity is a significant health inequality, with higher rates amongst children in disadvantaged areas and some ethnic groups. Nearly a third of children aged 2 to 15 are overweight or obese and younger generations are becoming obese at earlier ages and staying obese for longer. Obese people are more likely to suffer from physical health conditions, for example type 2 diabetes, musculoskeletal conditions or mental health conditions such as depression. Obesity also increases the risk of dying prematurely.

Children living with obesity can find that their weight affects their prospects in life, self-esteem and underlying mental health, with poor health behaviours persisting into adulthood, leading to lifelong negative effects on health. There is a link between low self-esteem and obesity, with obese children reporting feeling less athletic, less agile and less fit than their peers who are a more ‘normal’ weight.

There is also strong evidence that regular physical activity is associated with numerous health benefits for children. The UK Chief Medical Officer recommends that all children and young people aged 5 to 18 should engage in moderate to vigorous intensity physical activity for an average of 60 minutes per day across the week.

The economic costs of obesity are great. It was estimated that the NHS in the United Kingdom spent £6.1 billion on overweight and obesity-related ill-health in 2014 to 2015. The treatment of obesity and diabetes costs more than the national spend on the police, fire service and judicial system combined .

The impact falls hardest on children from low income backgrounds, with obesity rates highest for children from the most deprived areas. Children aged 5 living in the most deprived areas are twice as likely to be obese compared to those living in the least deprived areas. By age 11, the gap is evidenced to increase even further.

In 2016, the Government launched the Childhood Obesity: A Plan for Action. This was followed in 2018 by Childhood Obesity: A Plan for Action: Chapter 2 which sets out the ambition to halve childhood obesity and significantly reduce the gap in obesity between children from the most and least deprived areas by 2030. These documents also recognise that this will require sustained collaboration across the political divide, across society and across public and private sector organisations.

The Childhood Obesity Plan recognises the role that health and social care professionals can play in supporting children with their weight and pledges to provide them with the latest tools so that they can support children, young people and families with their weight.

Oral health

Oral health is an important aspect of a child’s overall health status and of their school readiness. Poor oral health impacts not just on the individual’s health but also their wellbeing and that of their family. Children who have toothache or who need treatment may have pain, infections and difficulties with eating, speech, sleeping, low self-esteem, and difficulty socialising. Approximately 23% of 5-year-olds have tooth decay when they start school. Children who have toothache or who need treatment may have to be absent from school and parents may also have to take time off work to take their children to a dentist or hospital.

Tooth decay is largely preventable, yet it remains a serious problem. Findings from the National Dental Epidemiology programme for England: Oral health survey of 5 year old children showed that in 2017 in England almost a quarter (23.3%) of 5 year olds had experienced tooth decay, having on average 3 or 4 teeth affected. The vast majority of tooth decay was untreated with a wide variation in the prevalence of tooth decay.

Awareness of oral health messages can be improved by providing children, young people and families with key oral health evidence. Such evidence may include how breastfeeding is associated with a decreased risk of tooth decay, how brushing teeth at least twice a day using a fluoride toothpaste can reduce incidence of cavities, and how registering with a dentist and having regular reviews can help to maintain good oral health. Advice may also encompass limiting the number of sugary drinks and snacks, eating a healthy diet that reflects the Eatwell guide and reducing tobacco and alcohol use and referring to quit smoking support.

The areas with poorer dental health tend to be in the north and in the more deprived local authority areas. The most recent data for 5 year olds shows that 43% of variation can be explained by deprivation, with 34% of 5-year-olds in the most deprived quartile affected, compared with 14% in the most affluent. Vulnerable groups of children and young people, such as young carers and those in the criminal justice system, may experience additional risk of poor oral health. Consumption of free sugars is a risk factor both for dental caries and obesity. Tooth decay is caused by increased frequency of consumption of sugar.

There is a clear association between children’s BMI and the prevalence and severity of caries, even when other potential influences such as deprivation are taken into account. Children who are overweight and very overweight are more likely to have caries than those of healthy weight.

For children and young people, there are many different factors involved in staying healthy, including personal choices and behaviours (for example smoking, oral health, nutrition, physical activity, and sexual activity). A diverse range of social, economic and environmental factors have an impact on health, as do social networks and the media. The impact of these factors varies at different times in a child or young person’s life; all have the ability to influence health and wellbeing.

Health Literacy

School nurses have a role in supporting young people to become health literate, signposting them to sources of advice for improving and maintaining their physical and mental health. Health literacy plays a vital role in the lives of young people who are at a stage where they are increasing their independence and becoming less reliant on parents and carers. Helping them to build knowledge about their health and wellbeing provides them with skills for life. Health literacy also empowers them to make decisions about their own health, and helps them to access and use health services appropriately.

Question 2

The role of school nurses

Accepted Answer

School nurses and their teams are in a unique position to build trusting and enduring professional relationships with children and young people throughout their time in education, enabling them to become confident and healthy adults. It is essential that young people in secondary education or college can have access to safe and confidential services whenever they need health support and advice.

Working with parents and families and partner agencies, school nurses identify the most appropriate level of support and intervention for individual and population needs. Although school nurses provide leadership, they will need to work with a range of partners to deliver a comprehensive programme of evidence-based interventions.

School nurses and their teams provide a crucial interface between children, young people, families, communities and schools. They have defined skills to support holistic assessment of the health and wellbeing needs of children and young people. They provide health promotion, prevention and early intervention approaches to support individual, community and population health needs.

By using their skills within the wider health and care system, and drawing on trusted relationships with other partners, school nurses can help to support and enable place-based and whole-school action to address health inequalities. Their involvement in delivering evidence-based interventions including HPV and other immunisation programmes in the teenage years, also provides opportunities for further health promotion.

School nurses deliver care in the most appropriate setting for the local community, using the principles of the You’re Welcome Quality Criteria. This includes using technology to improve access and support for children, young people and families.

Question 3

Healthy Child Programme

Accepted Answer

The Healthy Child Programme offers every family a programme of screening tests, immunisations, developmental reviews, information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.

Universal

The Healthy Child Programme is universal in reach. It sets out a range of public health support in local places to build healthy communities and to reduce inequalities. It also includes a schedule of interventions, which range from services for all through extra help to intensive support.

Personalised

The Healthy Child Programme is personalised in response. All services and interventions need to be personalised to respond to families’ needs across time. For many families this will be met by the universal offer. More targeted, intensive or specialised support and evidence-based interventions should be provided early to meet ‘predicted, assessed and expressed need’ and improve outcomes.

Question 4

Improving health and wellbeing

Accepted Answer

The high impact areas will focus on interventions at the following levels and will use a place-based approach:

individual and family
community
population

The place-based approach offers opportunities to help meet the challenges public health and the health and social care system face. This impacts on the whole community and aims to address issues that exist at the community level, such as poor housing, social isolation, poor/fragmented services, or duplication or gaps in service provision. School nurses, as leaders in public health and the Healthy Child Programme (5 to 19), are well placed to support families and communities to engage in this approach. They are essential to the leadership and delivery of integrated services for individuals, communities and population to provide RightCare that maximises place-based systems of care.

Individual and family

Healthy lifestyle advice is offered by school nurses so that children, young people and families can understand the importance of good health behaviours and healthy lifestyles such as healthy eating, physical activity and good oral health. School nurses undertake individual assessment of need, care planning as a joint process with the individual and completing onward referral or signposting to weight management and oral health services where appropriate.

School nurses can work closely with children and young people aged 5 to 19, to enable them to develop informed decision-making skills about their health and wellbeing. They can use opportunities for health promotion, Making Every Contact Count to support behaviour change and use strengths-based, motivational approaches to empower individuals to make healthier lifestyle choices.

School nurses can support children in learning about healthy eating and physical activity by following the Our Healthy Year resource. These resources help school staff create a healthy school culture. They explain measuring day to pupils, ensuring children learn about healthy lifestyles after they have been weighed and measured, as part of the National Child Measurement Programme (NCMP).

School nurses have an important role in enabling children, young people and families to make positive choices about their health. They can utilise opportunistic moments to discuss healthy weight, signposting to local services or referring to weight management programmes where required.

School nurses and their teams provide opportunities for parents, children and young people to discuss issues or concerns. They also provide advice on behaviours, attitudes and family practices around food, physical activity and oral health, for example controlling food portion size, limiting snacking on foods that are high in fat and sugar, and encouraging an active lifestyle.

School nurses can support the delivery of local weight management services and offer a consistent approach to the management of lifestyle concerns related to NCMP results. They can offer individual support to parents and families to manage lifestyle concerns and change behaviours. School nursing teams are in a unique position to help increase parental recognition of their child’s weight status. Improving parental acceptance of the result may encourage access to, and uptake of, services.

In addition, school nurses can support schools to meet statutory duties to promote children’s health and well-being, helping children to understand how to keep themselves healthy. They can promote the use of the Change4Life Food Scanner App, an interactive resource to encourage children and parents to make healthy food choices by reducing the amount of sugar, fat and salt in the foods they buy. Healthy weight maintenance can also be achieved through encouraging healthy eating and healthy nutrition in line with guidelines, and promoting the recommended levels of physical activity.

Community

School nurses are well placed to advocate for community centred approaches to improving health and wellbeing. Working with local authorities, parks and leisure services, school nursing teams can offer insight into community health and wellbeing needs to influence future planning and developments of leisure activities. School nursing teams can have an impact on the community by being aware of local services and by being involved in place-based activities, making communities healthier for children and families.

School nursing teams can work directly with schools to train staff on weight management concerns and to support them in developing a whole school approach to health and wellbeing.

School nurses have valuable knowledge of local services. They develop partnerships with other disciplines and agencies to support approaches and interventions that can help individuals to make healthier choices about their lifestyle. This includes supporting delivery of the new relationships, sex and health education (RSHE) curriculum which became statutory for all schools in September 2020. RSHE includes key aspects of healthy lifestyles for example, healthy eating, physical activity and oral health. Ensuring all pupils are aware of and know how to access local services is a requirement of the new guidance.

School nurses can work with partners to deliver targeted drop-ins in schools, colleges and community settings to make sure children and young people have access to confidential health information and support from someone they trust. Access for young people is enabled through the use of technology and social media to deliver health messages, promote services and offer accessible, confidential advice that is acceptable to the young people using them. This might be, for example, texting a health advice service, or using email as a way of first contacting school nursing services.

School nurses can build community capacity to enable local families to promote healthy eating and physical activity through community-led initiatives. Examples include: working with communities to facilitate active lifestyles via methods such as StreetPlay and outdoor activities, or promoting healthy food and improving cooking methods for families on low income (for example, via a fruit and vegetable co-operative).

The school nursing team are also well-placed to encourage whole school approaches to promoting healthy eating and physical activity amongst school aged children by:

offering evidence-based advice to increase activity such as What works in schools and colleges to promote physical activity, as well as ideas for using the PE and sport premium for primary schools
encouraging schools to register with the Change4Life School Zone
supporting schools to adopt healthy eating policies, including hydration, which cover what food and drink is brought into the school as well as what the school provides
supporting schools to deliver supervised tooth brushing programmes and fluoride varnish programmes

School nurses have an important role in developing health literacy in children, young people and families by supporting them to develop their knowledge of self-care, encouraging healthy lifestyles and reducing sedentary behaviours. This includes how to obtain appropriate information and support for health concerns and developing understanding and confidence to access the most appropriate health services.

Population

School nurses lead the Healthy Child Programme (5 to 19) and provide leadership at a strategic level to contribute to development and improvement of policies, pathways and strategies to support delivery of high quality, evidence-based, consistent care for children, young people and families for improving lifestyles.

School nurses can undertake population health needs assessments and understand the strengths and challenges to health and wellbeing of the population, including the identification of the additional needs of vulnerable groups such as homeless families, children in care, travellers, refugees and asylum seekers. School nurses raise awareness of needs identified and support the development of universal or targeted work in partnership with other professional disciplines and agencies, in order to improve lifestyles and support individuals to adopt healthier behaviours.

School nurses and their teams work with children, young people and families to identify approaches to improving health and wellbeing that are relevant to them in their daily lives. School nurses recognise that it is a joint responsibility to support communities to improve their health and wellbeing; as such, they work closely with other professionals to address local issues.

Tackling obesity is complex and requires co-ordinated action and integration across multiple sectors, including health, social care, planning, housing, transport and businesses. School nurse teams form part of the whole system approach, tackling obesity by supporting children and their families to make healthier choices and therefore reduce the risk of preventable ill-health.

School nurses can support the Public Health England (PHE) national dental epidemiology programme dental survey of 5 year olds. They can help parents and families to understand the purpose and importance of the information and how it can be used to develop preventative services and to improve lifestyle behaviours.

School nurses can nurture positive relationships between health providers, education providers, community and voluntary organisations to ensure all are responsive to national and local needs. They can also demonstrate improved public health outcomes.

Question 5

Using evidence to support delivery

Accepted Answer

A place-based or community-centred approach aims to develop local solutions that draw on all the assets and resources of an area, integrating services and building resilience in communities so that people can take control of their health and wellbeing. Such an approach can have more influence on the factors that underpin good health.

The All Our Health framework brings together resources and evidence that will help to support evidence-based practice and service delivery, Making Every Contact Count and building on the specialist public health skills of school nurses.

Most health and care professionals focus on interventions that tend to be delivered on an individual basis, however health visitors and school nurses focus on individuals, families and community-oriented approaches. It is critical that all professionals consider the importance of population health as an approach that aims to improve physical and mental health outcomes, while promoting wellbeing and reducing health inequalities across an entire population.

Social prescribing complements such approaches, enabling public health nurses and other health and care professionals to refer people to a range of local, non-clinical services. School nurses recognise that children and young people’s health is determined primarily by a range of social, economic and environmental factors. Social prescribing seeks to address individuals needs in a holistic way, allowing individuals to take greater control of their own health.

Question 6

Measures of success or outcome

Accepted Answer

High quality data, analysis tools and resources are available for all public health professionals to identify the health needs of the local population. This contributes to the decision-making process for the commissioning of services and future plans to improve people’s health and reduce inequalities in their area. Outcome measures could include Public Health Outcomes Framework and NHS Outcomes Framework, child and maternal health profile indicators , measures of access, and service experience.

School nurses and wider stakeholders need to demonstrate impact and provide evidence of improved outcomes. This can be achieved by using the local measures.

Access

Measures include:

evidence of the use of up-to-date, evidence-based approaches to dental health promotion, healthy weight maintenance and physical activity
evidence of local multi-agency pathways setting out good practice on assessment, identification and support for children and young people aged 5 to 19 and their families
promotion of the NCMP to all schools and families
promotion of healthy weight for example, Change4Life, Let’s talk about weight tool for children and families
promotion of PHE’s online resources for families and dental health on NHS choices and Change4Life
access to dentistry and regular check-ups
access to toothbrushes and fluoride toothpaste

Effective delivery

Measures include:

evidence of implementation, including adherence to school policies in places that promote healthy food and drinks, to support dental health, healthy eating and physical activity
increased numbers of children and families who opt in to the national dental epidemiology survey at age 5 years and to NCMP at age 4 to 5 years and age 10 to 11 years
Everyday Interactions Impact Pathway for child oral health shows how public health professionals, including school nurses, can demonstrate the impact of their actions on oral health
the Royal Society of Public Health Everyday Interactions Impact Pathway for childhood obesity shows how public health professionals, including school nurses, can demonstrate the impact of their actions on childhood obesity

Measuring impact

Measures include:

User experience

Measures include:

feedback from school nursing service. Questionnaire on satisfaction with healthy weight, healthy eating information and information on NCMP via local commissioner and provider data
feedback from the NHS Friends and Family Test and You’re Welcome Quality Criteria

Other measures can be developed locally and could include local initiatives and support for dental health promotion and reducing obesity, or partnership approaches to tackling obesity and increasing physical activity.

Question 7

Connection with other areas

Accepted Answer

The high impact area documents have been developed to support delivery of the Healthy Child Programme and 5 to 19 agenda. They highlight the link with a number of other interconnecting policy areas, for example childhood obesity, troubled families, mental health, drugs, immunisation, and social mobility.

The importance of effective outcomes relies on strong working relationships between all partners in health (primary and secondary), local authorities including education services, and voluntary sector services.

Best Start in Life has been identified as a priority as part of PHE’s 5-year Strategy which runs from 2020 to 2025. Best start is a priority for government and as such is included in the Prevention Green Paper (Advancing our Health: prevention in the 2020s).

Improving services for children and young people is part of the NHS Long Term Plan. The Child Digital Strategy and Maternity Programme is currently developing and implementing infrastructure to improve access and timeliness of data with the aim to know where every child is and how well they are. This includes the development and implementation of a Digital Parent Child Health Record. This programme supports the ambitions and modernisation of the Healthy Child Programme.

Collaborative working

Approaches to improving outcomes through collaborative working include:

Improvements

These include:

improved accessibility for vulnerable groups
integrated IT systems and information sharing across agencies
development and use of integrated pathways to include prevention and early intervention
systematic collection of user experience for example, NHS Friends and Family Test and engagement with children and young people to design services that are young people friendly and can inform action
identification of risk factors and indicators for obesity and oral health
increased use of evidence-based interventions to improve healthy eating and physical activity
increased use of evidence-based intervention to improve dental health, for example school-based tooth brushing and fluoride varnish programmes
improved partnerships, for example between schools, health visitors, GPs, and dental services, plus children, young people and families
consistent information for parents and carers on dental health promotion, obesity, nutrition and activity
ensure local processes are in place to enable smooth transfer of records and continuity of programmes during transition to school
increased dental health provision in all regions

Professional or partnership mobilisation

These include:

multi-agency training on risk factors and root causes of obesity, poor dental health and dental decay
multi-agency training for healthy weight, including guidance on nutrition and activity
effective delivery of universal prevention and early intervention programmes
improved understanding of data within the Joint Strategic Needs Assessment and at the local Health and Wellbeing Board to better support integrated working of 0 to 19 health visiting and school nursing services, with existing local authority arrangements, to provide a holistic and improved services for children, young people, parents and families
identification of skills and competencies to inform integrated working and skill mix
familiarity with the NCMP and the National Dental Epidemiology Programme
closer links with early years settings, schools, dental teams, health visitors and GPs