Guidance

School aged years high impact area 6: Supporting self-care and improving health literacy

Updated 19 May 2021

Applies to England

There are 11.6 million young people aged 10 to 24 in the UK, 1 in 5 of the population (Association for Young People’s Health (AYPH), 2019). More than 20% are from an ethnic minority. Young people experience huge physical, psychological and behavioural changes as they mature from children to adults. Supporting young people on their journey to adulthood is essential to ensure future good health and wellbeing.

Adolescence is a time of rapid change including:

• physical development, for example growth spurt and sexual maturation
• cognitive development, for example evidence that suggests brain development continues up to age 25
• emotional development, for example identity, self-esteem and resilience
• social development, for example peer influences, sexual identity
• behavioural development, for example risk taking and the beginning of lifelong behaviours

Although adolescence tends to be a period of good health, the effects of poor health care in adolescence can last a lifetime, such as:

• Twenty-three per cent of 11 to 15 year olds report having a long-term illness or disability
• half of all lifetime cases of psychiatric disorders start by age 14 and three-quarters by age 24
• half of 14 to 15 year olds report visiting their GP in the last 3 months
• accident and emergency attendances for those aged 15 to 19 have risen by 10% since 2010
• a quarter of 11 to 19 year olds live in households with the lowest incomes – deprivation increases likelihood of having worse physical, mental and sexual health outcomes, or being killed or seriously injured on roads

Young people living in deprivation may require additional resources and support for early identification and prevention of poor physical and mental health outcomes. As young people prepare for adulthood, they need access to information and support, and knowledge of services to help keep them healthy. They are increasing their independence and becoming less reliant on parents and carers. Building confidence in communicating with health professionals and accessing appropriate services is an important part of improving health literacy.

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

Encouraging children and young people to feel confident in accessing health services is key to engaging and involving them in decisions about their health and wellbeing and care. You’re Welcome is a set of quality criteria for young people friendly health services. It provides a systematic framework to help commissioners and service providers to improve the suitability, accessibility, quality and safety of health services for young people.

Article 12 of the United Nations Convention on the Rights of the Child (UNCRC, 1990) says that children and young people should have a say in decisions that affect their lives. School councils can provide a meaningful way in which pupils can voice their opinions and have their views considered in decisions which impact upon them, giving young people a platform to express themselves.

The move from primary to secondary school is a crucial transition stage that offers an opportunity to provide support and advice. Evidence suggests that the outcomes for both children and adults are strongly influenced by factors that operate during these years, particularly as they take more control of their own health and wellbeing, including making diagnoses and choices about their health (Public Health England (PHE), 2015). Not all young people become more independent as they get older and some, for example those with long-term conditions or particularly complex, physical or medical or life-limiting conditions, may become more dependant over time rather than less.

The role of school nurses

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 to enable them to become confident and healthy adults. It is essential that young people in secondary education or college can have access to safe, confidential and accessible services when 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 partners to deliver a comprehensive programme of evidence-based interventions.

School nurses and their teams provide a crucial interface between children, young people and families, communities and schools having 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.

Using their skills with the wider health and care system and their trusted relationships with other partners helps 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 provide opportunities for health promotion, Making Every Contact Count to support behaviour change.

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.

Healthy Child Programme

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’ to improve outcomes.

Improving health and wellbeing

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 or 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

School nurses can support young people who might struggle with the transition to adult services, suggesting additional strategies to build resilience and coping mechanisms to deal with the challenges ahead(AYPH, 2019).

During transition, school nurses deliver a universal offer to all young people, for example they can work with individual young people using strength-based approaches to:

• develop informed decisions about their health and wellbeing
• develop their knowledge of self-care, autonomy and decision making, including how to access health services (including responding safely and appropriately to unintentional injuries)
• support young people with long-term conditions, providing information and appropriate advice
• educate them on the importance of using antibiotics appropriately

School nurses help young people to be ready for adulthood by supporting vulnerable young people, including those who have gender identity issues or who are a part of the lesbian, gay, bisexual or transgender community, children and young people in care and other vulnerable groups, where life choices will impact on wider family functioning.

Healthy lifestyle advice can be offered by school nurses so that young people are able to understand the importance of good mental and physical health, emotional wellbeing and resilience, health behaviours and healthy lifestyles such as healthy eating, physical activity, sun safety and good oral health. School nurses can also refer to sexual health and contraceptive services or drug and alcohol services where appropriate.

School nurses can offer a more targeted approach to young people with additional and, or complex needs, for example:

• during transition points such as from school to college, work or university, school nurses can offer practical support to targeted young people – support is person-centred and strengths-based, focusing on solutions and developing healthy lifestyle choices and behaviours (this includes encouraging young people to be registered with a GP, dentist and optician if they are not already)
• where young people who use health or social care services, including those with long-term health conditions or disabilities, as well as children in care, can be supported by school nurses to develop skills to be able to plan, manage and make decisions about their own care and treatment
• during the transition from child to adult services, school nurses can advocate for young people with additional needs, including physical and mental health needs or learning disabilities – they work closely with parents, carers and other professionals to ensure that the young person’s voice is heard and that their needs met
• young people who are in the youth justice system are offered a health assessment and support to ensure they get the health information and care that they need

Community

School nurses are skilled to deliver public health services for school-aged children, addressing local need at times when children and young people can access the service and in locations that are convenient, in and out of school and during holidays.

They are in a unique position within community and education settings to support multidisciplinary teams, offering clinical input and effective leadership to:

• develop integrated services between health, education providers, community and third sector organisations to ensure they are responsive to national and local needs and demonstrate improved public health outcomes
• provide improved access to information and local support for children, young people and families, including digital and online services

School nursing teams can also:

• ensure that young people are aware and confident in how to access health and oral health services in their community – this includes appropriate use of Accident and Emergency, GP and community pharmacists to support self-care
• work closely with schools and children and young people (5 to 19), educating them on the importance of prevention of illness through appropriate infection prevention and control activities such as hygiene, particularly when they are ill or when family members are ill
• ensure young people are aware of, and recognise, medical emergencies – for example meningitis or sepsis that may affect themselves or their peers and how to get medical help
• support schools and colleges through the delivery of personal, social, health and economic education (PSHE) and health promotion sessions, for example, well man and well woman, being breast or testicle aware, sexual and reproductive health and drug and alcohol use

School nurses can provide universal information and advice to young people around alcohol, drug and tobacco use, targeted support to those considered most at risk of developing problems and referral to specialist substance misuse services for those requiring more intensive support through a variety of approaches including PSHE education, health promotion sessions and drop-in clinics.

They can give young people strategies to build resilience and to manage difficult situations and stress. This may include family and exam stress and transition to college, work or university.

Technology and social media can be used by school nurses to deliver health messages, promote services and offer accessible, confidential advice that is acceptable to the young people using them, for example texting health advice service or email to enable first contact to school nursing services. School nurses can publicise school nursing service to marginalised young people, such as those not in education, employment or training, so that they have timely access to health services that they need.

School nurses lead an effective and high-quality preventative service through implementation of the Healthy Child Programme (5 to 19). Some young people may be identified as requiring additional support through transitional phases. School nurses can define support and advocate for young people with additional needs, physical or learning disabilities and those with mental health problems, and can work closely with parents, carers and other professionals to ensure that the young person’s voice is heard and their needs met by:

• working collaboratively with local authorities, primary, secondary and specialist services to achieve seamless transition of care to adulthood
• forging links with local services, including voluntary and community services, and encouraging and supporting young people to link in with their local community health and wellbeing initiatives – ensuring all pupils are aware of and know how to access local services is a requirement of the statutory Relationships and sex education (RSE) and health education guidance (Department for Education (DfE), 2019)
• working with community members and groups to support them to take action to improve the mental health and wellbeing of young adults

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 transition and preparation for adulthood.

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

School nursing teams have an important role to play in increasing participation in the PHE dental epidemiology programme and evidence-based health promotion activities, and supporting health protection through immunisation programmes.

Schools-based immunisation programmes often achieve high vaccine uptake which makes a significant contribution to population health. School nurses can help to support such programmes through collaboration with individual schools and immunisation providers, to help support the delivery of influenza vaccination in primary schools and in secondary schools, the delivery of vaccines against meningococcal disease, human papilloma virus (HPV) and booster doses against tetanus, diphtheria and polio. In addition, some children and young people may have missed doses of vaccines such as measles, mumps and rubella (MMR), school nurses can play an important role in checking immunisation histories and signposting to relevant services to ensure individuals are up to date with their immunisations.

School nurses promote health promotion messages, both in and out of school settings, seeing children and young people as community-based assets who can support population health and wellbeing. The United Nations Convention on the Rights of the Child Article 12 states that children have the right to participate, engage and have a voice in decisions that relate to them. School nurses can ensure that the young person is central to all decision making that impacts and relates to them personally, via shared decision-making approaches. This also includes immunisation status and transition from Child and Adolescent Mental Health Services to adult mental health services. Health literacy will support young people to understand different health services and appropriate use.

Using evidence to support delivery

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, and 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 which tend to be delivered on an individual basis, however health visitors and school nurses focus on individuals, families and communities’ 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, promote wellbeing and reduce 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, taking greater control of their own health.

Measures of success or outcome

High quality data, analysis tools and resources are available for all public health professionals to identify the health of the local population. This contributes to the decision-making process for the commissioning of services and 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 evidence of improved outcomes.

Access

Measures include:

• vaccine uptake
• You’re Welcome quality criteria
• evidence of local multi-agency policies and pathways to support transition
• evidence of young people’s attendance in adult services

Effective delivery

Measures include:

• reduced social isolation and targeted support to meet local needs
• understanding of health needs
• evidence of implementation of You’re Welcome quality criteria
• evidence of meeting young people to discuss transition planning

Measuring impact

Measures include:

• registration with GP and dentist
• persistent absentees in primary schools and in secondary schools, available in the school-age children section of Child Health Profiles 16 to 17 year olds not in education, employment or training (NEET) or whose activity is not known, available in the Public Health Outcomes Framework and Child Health Profiles
• total difficulties scores for all children in care aged between 5 and 16 at the date of their latest assessment, who have been in care for at least 12 months on 31 March, available in Public Health Outcomes Framework
• number of persons aged 15 who are regular smokers (at least one cigarette per week) – statistics on smoking from NHS Digital available in Public Health Outcomes Framework
• number of persons aged 15 who are occasional smokers – statistics on smoking from NHS Digital available in Public Health Outcomes Framework
• under 18 and under 16 conception rates
• self-reported proportion of population meeting the recommended ‘5 a day’ at age 15, collected and published in What About Youth survey
• chlamydia detection rate per 100,000 aged 15 to 24, available in the Public Health Outcomes Framework

User experience

• feedback from children, young people and families via the NHS Friends and Family Test, You’re Welcome quality criteria and local service surveys
• engagement exercises with children and young people carried out by the local authority and school

Other measures can be developed locally and could include local pathways and partnership approaches to supporting vulnerable children and young people, for example referrals to young carers groups, engagement of previously disengaged vulnerable children and young people with services, for example school nursing led sexual health services

Connection with other areas

The high-impact area documents have been developed to support delivery of the Healthy Child Programme and 5 to 19 agenda, and to highlight the link with a number of other interconnecting policy areas, for example:

• childhood obesity
• troubled families
• mental health
• drug strategy
• immunisation
• social mobility programmes

The importance of effective outcomes relies on strong partnership working between all partners in health (primary and secondary), local authority 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. The Best Start initiative 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 Strategyand 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:

• Public Health Outcomes Framework indicator reported and benchmarked by PHE and local authority
• high-impact areas and delivery of the Healthy Child Programme (5 to 19)
• information sharing agreements in place across all agencies
• integrated commissioning of services to improve health and wellbeing outcomes
• partnerships working with schools and colleges to support integrated planning, delivery, monitoring and review
• information sharing from Joint Strategic Needs Assessment (including health data and information about families and communities) to identify and respond to joint priorities
• demonstrate value for money and return on investment

Improvements

These include:

• improved accessibility for vulnerable groups
• integrated IT systems and information sharing across agencies
• development and use of integrated pathways
• systematic collection of user experience, for example, NHS Friends and Family Test and You’re Welcome accreditation to inform action and delivery, engagement and consultation exercises with children and young people, carried out by local authority and co-production with children and young people to design young people friendly services
• increased use of evidence-based interventions and links to other school-aged and young people performance indicators
• improved partnership working, for example, schools, GPs, oral health services, children and young people’s services, children’s and adult’s social care services, Child and Adolescent Mental Health Services
• consistent information for children, young people, parents and carers
• ensuring individual care plans are providing effective early interventions
• improved engagement of previously non-compliant children and young people

Professional and partnership mobilisation

These include:

• multi-agency training and supervision to identify risk factors and early signs of health and wellbeing issues
• multi-agency training in approach for discussion with children and young people to obtain information
• multi-agency training in evidence-based early intervention and safeguarding practices
• 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
• integrated working of school nursing services with existing local authority arrangements to provide a holistic and joined up and improved service for children, young people, parents and families; this includes effective joint working with specialist substance misuse services
• identification of skills and competence of school nursing teams to inform integrated working and skill mix
• increased integration and working with schools to offer range of services and activities to promote health and wellbeing

Associated tools and guidance

Policy

Children and Families Act 2014

Improving social mobility through education, DfE, 2017

Working Together to Safeguard Children, 2018

Research

Child and Maternal Health, PHE

Issues arising following a referral and subsequent wait for extraction under general anaesthetic: impact on children, Goodwin and others, 2015

Place-based systems of care: A way forward for the NHS in England, Ham and Alderwick, NHS England, 2015

Key Data on Young People, Association of Young People’s Health, 2019

Subjective wellbeing in adolescence and teacher connectedness: a health asset analysis, Garcia-Moye and others, Health Education Journal, 2014

Structural magnetic resonance imaging of the adolescent brain Giedd, Annals of the New York, 2004

Guidance

Complete routine immunisation schedule: Immunisation for health professionals and immunisation practioners, PHE, 2019

Delivering better oral health: An evidence-based toolkit for protection, PHE, 2014

e-bug, the free educational resource for classroom and home use

Getting it right for children, young people and families: Maximising the contribution of the school nursing team: Vision and call to action, Department of Health and Social Care (DHSC), 2012

Helping school nurses to tackle child sexual exploitation, DHSC, 2015

Improving oral health: An evidence-informed toolkit for local authorities, PHE, 2014

Improving support for young carers: Family-focussed approaches, DfE, 2011

Maximising the school nursing team contribution to the public health of school aged children: Guidance to support the commissioning of public health provision to school aged children 5 to 19, DHSC, 2014

NHS Digital, NHS Digital, 2019

Quality criteria for young people friendly health services: ‘You’re Welcome’, DHSC, NHS England, 2020

Relationships education, relationships and sex education and health education, DfE, 2019

Rise Above

Smoke free and smiling: Helping dental patients to quit tobacco, PHE, 2014

Supporting children, young people, families and communities to be safer, healthier and free of crime, DHSC, 2012

Supporting the health and wellbeing of military families, PHE, 2015

Supporting the health and wellbeing of young carers, DHSC, 2014

The role of school nurses in supporting young carers, Carers Trust

Teenage Pregnancy Prevention Framework, PHE and Local Government Association (LGA), 2018, updated 2019

A Framework to support teenage mothers and young fathers, PHE and LGA, 2016, updated 2019

NICE guidance

Behaviour change: individual approaches, NICE guidance [PH49], 2014

Behaviour change: the principles for effective interventions, NICE guidance [PH6], 2007

Looked After Children and Young People, NICE guidance [PH28], 2010

Obesity in children and young people: Prevention and lifestyle weight management programmes, [QS94]

Oral health, Local authorities and partner , NICE guidelines [PH55], 2014

Oral health promotion, general dental practice, NICE guidelines [NG30], 2015