In Northern Ireland, height and weight measurement is carried out during school health appraisals which are undertaken with all Year 1 and Year 8 pupils as a requirement of the regional Healthy Child, Healthy Future universal child health promotion programme (DHSSPS, 2010).
School nurses are, therefore, uniquely placed to address childhood obesity given their skill in clinical overview and the scope for individually tailored family based interventions.
What initiative or project are you involved in?
The Healthy Weight Pathway for School Nursing was developed in the Northern Health and Social Care Trust (NHSCT) as a service improvement initiative targeting childhood obesity and overweight. It is a school nurse-led care pathway which represents the route through the school nursing service which is offered following identification of overweight and obesity at school health appraisals in Year 8.
What prompted the work?
Levels of clinical obesity in Year 8 pupils in NHSCT had almost doubled from 7.5% to 14% in three years (2012/13-2015/16). It was unclear whether consistent procedures were in place for informing families of the outcome of growth measurement following school health appraisal in Northern Ireland. There was a need to improve how that information was communicated and contextualised, how misperception of weight and related issues was addressed, and how practitioners could be supported to improve family support for healthier lifestyle behaviours. School nurses wanted to formalise a guided conversation and pathway to ensure consistency and quality of practice.
How did you initiate the work?
The pathway makes provision for feedback with parents/carers and guided discussion by telephone for those assessed as ‘very overweight’ (clinically obese) and ‘overweight’ within the BMI centile range (RCPCH, 2013). Practice based learning sessions were provided to support teams to introduce the pathway and increase knowledge, skills and confidence.
School nurses complete telephone contact to inform parents of the outcome of their child’s school health appraisal and initiate discussion to increase knowledge and skills. Families are supported to make lifestyle changes to maintain healthy weight and improve BMI over time. Parents indicate how they would like to proceed with the information provided, whether self-care, or a school nurse-led health plan, with review at 3-6 months. Motivational tools, resources and local activities are provided or signposted. This is in line with 2013 NICE guidelines on lifestyle weight management services for overweight and obesity among children and young people (NICE, 2013).
Measures of success
- Universal access to school-nurse led intervention for all young people identified as overweight and obese following school health appraisal in Year 8
- Number of telephone contacts and number accepted/declined discussion
- % agreed self-care at home with school nurse support as required
- % agreed school nurse-led health plan with follow-up/review
- % self-reported healthier eating and meal patterns , new or increased physical activity, decreased weight/waist size and/or reduction in BMI centile range following clinical assessment
In 2016/17, school nursing teams completed 893 telephone contacts with families. 99% of parents accepted the telephone discussion and received feedback on the outcome of their child’s health appraisal. One third of families agreed to ‘self-care’ using information and advice provided and a third of families agreed a school nurse-led health plan with structured follow-up/review at 3-6 months. Nearly half of follow-up/reviews were achieved at 3-6 months.79% of parents reported healthier eating and meal patterns and exclusion/reduction of sugary drinks. 67% of parents reported that their child had taken up a new form of physical activity, or increased activity levels. 46.5 % of parents either self-reported that their child had decreased weight/waist size, and/or the school nurse recorded maintenance/reduction in BMI centile range at clinic follow-up.
What difference has the project or initiative made?
The Healthy Weight Pathway is an effective universal model for school nursing that supports families to make lifestyle changes, to maintain healthy weight and improve BMI over time. This is in line with 2013 NICE guidance on lifestyle weight management services for overweight and obesity among children and young people (NICE, 2013).
The Healthy Weight Pathway is integrated and quality assured into school nursing service provision. Use of the pathway’s guided conversation has been pivotal in increasing the acceptability, awareness and engagement with families. School Nurses said that ‘There were no angry, defensive, or abusive phone calls this year’; ‘staff felt better able to guide discussion’; and ‘there was less hostility, better engagement’.
The majority of parents had a positive attitude to the information and advice provided about their child’s weight status. This is notable given that there is a widely held perception that parents may have a hostile reaction to raising the sensitive issue of weight. Year on year, we demonstrate lifestyle behaviour change and re-engage parents with the role of the school nurse.
What are the long-term objectives?
This information will be used to inform concurrent health profiling work in individual schools and localities. It is also be used in the planning and development of a model of school nursing in the NHSCT Public Health Nursing Service. School localities where childhood obesity and overweight exceeds the regional average have been identified for additional support and intervention. We will continue to explore the extent to which the guided discussion, and school nurse support, changed lifestyle behaviours at home and in school. As well as contributing to regional obesity targets set out in Northern Ireland’s Obesity Strategy (DHSSPS, 2012), we record an annual profile of overweight and obesity in Y8 young people. This contributes to the work of the strategic planning group, the Northern Obesity Partnership.
1. Department of Health, Social Services and Public Safety (2010) Healthy Child, Healthy Future: A Framework for the Universal Child Health Promotion Programme in Northern Ireland
3. Department of Health, Social Services and Public Safety (2012) A Fitter Future for All: A Framework for Preventing and Addressing Overweight and Obesity in Northern Ireland 2012-2022