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

Appendix A: Discussion guides

Stage One discussion guide

Introductions (2 mins)

Note to interviewers: "support" = preventative actions but also treatment actions (e.g. specific dietary assessment and advice or eventual referral onto weight management services)

1. Overview of their role (2 mins)

Interviewer note: this section is designed to briefly cover participant's role in relation to assessment and support for healthy weight of pregnant women and children up to Primary 1 in their area. We should already have some information about them from recruitment, so this is just covered briefly as a warmup.

Thank you very much for agreeing to take part. Before we start, I'd just like to ask a bit of background about yourself:

How would you describe your role? What professional qualifications do you have? What are your main responsibilities?

• Probe: Steer specifically to early years healthy weight assessment and support if not mentioned

And how long you've been in this role?

2. Overview of assessment and support for healthy weight in pregnant women and young children (10 mins)

I'd like to start by asking…

2.1. If you could give me a broad overview of how healthy weight for pregnant women and children up to Primary 1 age is assessed and supported in your area? So, for pregnant women, babies, toddlers, pre-school and Primary 1 children.

Probe if not covered:

Prevention of overweight and obesity

What proactive steps are taken to prevent overweight and obesity among pregnant women and young children up to Primary 1 age in the local area?

• Are any specific groups of people targeted?
• How do you engage with them?
• Any challenges and how manage them?

Interviewer note: the term 'risk of obesity' can mean being at risk or becoming overweight/obese or actually being overweight/obese - depending on the Health Board approach, interventions may be initiated at early signs of risk of becoming overweight/obese as well as at having been assessed to be overweight/obese.

Identification of risk of overweight and obesity

When and how is risk of being overweight or obese assessed in your local area during pregnancy and in a child's early years?

• What data is collected? At what points? Who collects the data?
• How is it used? How are assessments on risk made?
• Are there any specific groups of people that prioritised? Are there any differences in the assessment of risks for these priority groups?

Healthy weight interventions

How is risk of or being overweight and obesity acted on in the local area?

• Are there specific points at which interventions occur?
• What would trigger these interventions? Are there specific thresholds?
• If there is more than one possible intervention/action available, how do professionals decide on which is the most appropriate?

If not already mentioned Are Primary 1 data and UHVP data used to assess and support child healthy weight? How?

If not already mentioned: How are transition points from pregnancy to post-natal support and from the health visiting pathway to Primary 1 and beyond managed where weight remains a concern?

2.2. Has any of what you described changed since the Coronavirus pandemic?

• Is this likely to influence/change your approach going forwards?

2.3. How was your Board's policy/approach around assessment and support for pregnancy and early childhood healthy weight developed? Why were these elements selected?

• How long have these elements been in place? Probe for all elements

2.4. Is there an individual responsible for the whole of pregnancy and early years healthy weight assessment and support in your Health Board?

• Who has responsibility? Are different individuals responsible for different elements? Why is that?

2.5. Which standards/policies/guidelines were used in the development of your Board's approach to pregnancy and early childhood healthy weight support and assessment?

• (If not mentioned) How did you decide which to use?
• To what extent, do you think, does your approach align with national guidelines?
• What are the key differences?
• As far as you know, is there anything unique or innovative about your approach?
• If not based on national expectations: In your view, how closely does it align?

2.6. How are relevant professionals (if necessary: those involved in implementing it) in your area made aware of the approach in your local area? Probe fully

• If necessary: What training/support/guidance/resources are available, if any? Probe fully
• If necessary: How are they kept up to date with any changes?

2.7. Has your Board's approach to assessment and support for pregnancy and early years healthy weight changed at all since the introduction of the UVHP? If yes, how? If no, why do you think that is?

3. Perspectives on the implementation of the local system (5 mins)

3.1. How consistently do you think the approach in your local area is implemented in practice? What makes you say that?

• Which elements are implemented more or less consistently? Why do you think that is?
• How coherent is the approach from one stage to the next? i.e. from pregnancy to post-natal and from UHVP to Primary 1.

3.2. What helps support consistent implementation? Probe fully

3.3. What measures, if any, are used to review implementation? Probe fully

• Do you collect any information about implementation across the health board? Why/why not?
• Are professionals in your area asked for their feedback on implementation? Why/why not?

4. Perspectives on the effectiveness of the local system (5 mins)

4.1. In your view, when it is implemented, how effective do you feel your local area approach is to assessing and supporting healthy weight in pregnancy and children's early years? Probe fully

If asked what is meant by 'effective', ask participant to explain what they feel would signify effectiveness.

• Are certain elements working better/more effective than others? Why do you think that is?
• And which elements are working less well/are less effective? Why do you think that is?

4.2. What measures, if any, are used to determine the effectiveness of your Board's approach to assessing and supporting healthy weight? Probe fully

• Do you collect any information about effectiveness? Why/why not?
• Are professionals in your area asked for their feedback on how effective they think the approach is? Why/why not?

5. Opportunities for improvement (5 mins)

5.1. What, in your view, are the key challenges/barriers faced in your area in relation to assessing and supporting pregnant women and young children up to Primary 1 age to have a healthy weight?

5.2. What improvements, if any, could be made?

• Probe: What should the priorities for improvement be?
• How could the approach in your area be implemented more consistently?

5.3. How could national support be improved?

6. Wrap up (1 min)

That's all the questions I wanted to ask you today. Before we finish off, is there anything else you would like to say or ask that we haven't covered?

Thank and close

Early Years Healthy Weight Research

Midwife manager interviews – topic guide (Stage 2)

1. Introduce self and Ipsos MORI

2. This research has been commissioned by the Scottish Government to explore how pregnancy and early years healthy weight systems work across Scotland

3. We have conducted an initial interview with an individual in most health boards in Scotland. Following this, five areas were selected as case studies and [area] is one of them.

4. Within each case study area, we are speaking to health professionals, like yourself, to get your views on pregnancy and early years healthy weight practices in your area and experiences of supporting healthy weight in your role. We'll cover your role in general, the role of you and your team in relation into the prevention and identification of overweight and obesity and the available interventions in your area. We'll then move on to talk about training and support needs before finishing with your views on the consistency and effectiveness of the system.

5. The interview will last around an hour

6. Participation is voluntary – all questions are optional, you do not have to answer anything you do not wish to, and we can finish the interview at any time

7. There are no right or wrong answers – we just want to know what you think

8. Ensure confidentiality and anonymity – no identifying information will be passed onto the Scottish Government. In the methods section of the report, we will name the health boards that participated in the case study stage. However, when we report the findings, we will not attribute any findings to individual health boards.

9. Request permission to record – will not be shared with anyone outside the research team and will be securely deleted after the research is complete

1. Background (2 mins)

Thank you very much for agreeing to take part. Before we start, I'd just like to begin by asking some questions about your role.

Can I just confirm your role?

And can you sum up what your role involves?

Do you have a caseload in addition to your management role?

And how long have you been in this role?

How many midwives are in your team?

And do you work full time or part time? (if part time: How many hours per week are you contracted to work?)

2. Perspectives on role in relation to healthy weight (5 mins)

Aim not to get into too much detail on specifics of their role at this stage. Want to get their unprompted perspectives on their role.

Thanks. I'd now like to move on to ask about healthy weight for pregnant women and children up to Primary 1 age in your area.

Firstly, how much would you say you know about how healthy weight for pregnant women and children up to Primary 1 age is assessed and supported in your health board area? So, for pregnant women, babies, toddlers, pre-school and Primary 1 children.

• And where have you got this information from?

And how would you describe your role in relation to healthy weight in pregnant women and the early years?

How do you feel about your role? Are you clear about it?

How much of a priority is healthy weight management for you and your team among the competing demands you face? If not a priority: What is more important?

3. Detailed understanding of their role in prevention, identification and intervention (30 mins)

I'd just like to go into a bit more detail now on some of the things we've just discussed.

First, what would you say are your main responsibilities in relation to the prevention of overweight and obesity in pregnancy and the early years? Prompt only if necessary: For example, do you/your team provide information or advice to pregnant women or new mothers on topics like healthy eating and physical activity and weight gain during pregnancy and feeding their baby in the first few months?

• Is this provided universally or is it targeted at specific pregnant women?
• Are there resources midwives can use or places they can signpost to?
• Are these topics covered in parent education classes?
• In your experience do pregnant women want advice on healthy diet and lifestyle during pregnancy?
  • i) How do they react to receiving it?
• And to what extent do they want advice on feeding their baby in the first few months?
  • ii) How do they react to receiving it?
• What support, if any, do you and your team request in relation to providing advice to pregnant women on healthy diets and lifestyles in pregnancy and feeding their babies in the first few months?
• Have you and members of your team received any training on this?
  • iii) Do you think there is a need for (further) midwife training on this?
  • iv) Have midwives requested training on this?

And moving on now from prevention to the identification of pregnant women who may be overweight or obese or experience excessive weight gain. What is the process for identifying women in these circumstances? Probe fully

BMI

• At what point or points during pregnancy is a women's BMI taken?
  • v) Is this always the same for all women or are there circumstances in which it differs?
• What happens to the BMI data that is collect?
• Are there specific points (BMI thresholds, or concerns about gestational diabetes) at which they would be eligible for referral to a weight management or other type of intervention (e.g. gestational diabetes)?
• And for women who have a healthy BMI at the start of their pregnancy, how is pregnancy weight gain monitored?
  • vi) Is there a threshold that would trigger intervention or concern about gestational diabetes?

Referrals

• Once it has been identified that a pregnant woman is overweight or obese, what happens?
• Would it always be raised with the women and a referral offered?
  • vii) Across your team, do you know what proportion of women who are overweight or obese will be offered a referral?
  • viii) What reasons might there be for not bringing it up or referring them?
• How do you/the midwives in your team raise the issue with women?
  • (a) And would you raise it differntly for different groups of pregnant women? In what way? Why?
• How do they tend to react when it is raised?
• Are there factors that appear to affect women's receptiveness to the referral? Probe:
  • ix) The age of the woman
  • x) The extent of overweight/obesity
  • xi) The type of service being offered
  • xii) Previous attempts to lose weight
  • xiii) Other health conditions
  • xiv) Other things going on in the woman's life e.g. poverty, work situation, language barriers
• Does weight tend to be discussed again after the initial conversation? IF NOT: why not?

Interventions

• What services or interventions are available in your area to refer pregnant women who are overweight or obese on to?
• Are there occasions where you would like to be able to refer them to a service but you are not aware of anything suitable to refer them to?
• If there is more than one possible intervention/action available, how do you decide on which is the most appropriate?
• How much do you know about how well pregnant women who agree to be referred to services engage with them?
• And how effective you think these services are for the women who do engage with them?
  • xv) Are you aware of any evaluations or audits of these services?

How has the COVID-19 pandemic affected what you and your team are able to do in relation to supporting healthy weight in pregnancy and the early years? Probe on:

• Prevention
• Taking BMI
• Referrals
• Available interventions
• Staffing/resourcing

4. Confidence, support and training

Now, moving on to talk a bit more about confidence and skills and training, both your own and the midwives you manage.

How confident do you feel about the parts of your job we have just discussed? So:

• Measuring pregnant women's BMI
• Managing sensitive conversations with pregnant women about their weight and/or their pregnancy weight gain?
• Knowing about your services/options for pregnant women in your area – where you could refer them on

Could you rank them in order from most to least confident?

Do you feel you need any further support or training? On which of the above aspects, if any, do you feel you need most support with?

And thinking now about the midwives in your team, do they come to you for support on issues relating to healthy weight?

Do you discuss healthy weight as a team?

• When do these discussions happen? e.g. team meetings, supervisions
• What kinds of issues do you discuss?

From your discussions with midwives, are there parts of the role they lack confidence in?

Prompt if necessary:

• Measuring pregnant women's BMI
• Managing sensitive conversations with pregnant women about their weight and/or their pregnancy weight gain?
• Knowing about your services/options for pregnant women in your area – where you could refer them on

What, if any, skills gaps are there?

What training, if any would your team benefit from?

• And are there any groups of midwives who would most benefit from training e.g. newly qualified midwives
• How should this training be delivered?
• What are the barriers to them receiving this type of training?

Are you aware of the SIGN guidelines?

• If yes: do you or your team use the SIGN 115 guidelines from 2010 in your work at all?

Are you aware of the minimum standards for assessing and supporting healthy weight in pregnancy and the early years?

5. Consistency and coherence

I'm going to move on now and ask some questions about the consistency of pregnancy and early years healthy weight systems across your health board.

As far as you are aware, how consistent is the approach taken by midwives, both within your team and across teams in your health board, in supporting healthy weight in pregnancy and the early years?

• To what extent to do you think midwives are consistent in the advice they provide to pregnant women?
• And to what extent do you think midwives are consistent in relation to referring eligible pregnant women to services?
  • (a) Is this something that is monitored, either within your team or across teams?

And is there coherence across the system as a whole so from pregnancy to the early years to Primary 1?

• How are transition points from pregnancy to post-natal support and from the health visiting pathway to Primary 1 and beyond managed where weight remains a concern?

Are there any systems and/or resources aimed at ensuring consistency of approach across the health board?

6. Perceived effectiveness, barriers and opportunities for improvement

Overall, how effective do you think your health board's current system to assess and support healthy weight in pregnant women and the early years is?

• Are you aware of any evaluations or audits that have been conducted?

What are the main challenges and barriers to supporting healthy weight in pregnant women and the early years in your area?

• What are the main difficulties for parents in your view?

And do you have any suggestions for how your health board's system could be improved?

• What should the priorities for improvements be?
• Are you aware of any improvements currently being carried out?

7. Wrap up

And just before we finish…

In your experience, what is the biggest challenge to health professionals supporting healthy weight in pregnancy and the early years?

Before we finish up, is there anything else you'd like to raise about what we've discussed today? Or any questions about this research?

Thank them and remind them they can contact us again if they have any questions or concerns.

Early Years Healthy Weight Research

Midwife interviews – topic guide (stage 2)

1. Introduce self and Ipsos MORI

2. This research has been commissioned by the Scottish Government to explore how pregnancy and early years healthy weight systems work across Scotland

3. We have conducted an initial interview with an individual in most health boards in Scotland. Following this, five areas were selected as case studies and [area] is one of them.

4. Within each case study area, we are speaking to health professionals, like yourself, to get your views on pregnancy and early years healthy weight practices in your area and experiences of supporting healthy weight in your role. We'll cover your role in general, your role in relation into the prevention and identification of overweight and obesity and the available interventions in your area. We'll then move on to talk about your training and support needs before finishing with your views on the consistency and effectiveness of the system.

5. The interview will last around an hour

6. Participation is voluntary – all questions are optional, you do not have to answer anything you do not wish to, and we can finish the interview at any time

7. There are no right or wrong answers – we just want to know what you think

8. Ensure confidentiality and anonymity – no identifying information will be passed onto the Scottish Government. In the methods section of the report, we will name the health boards that participated in the case study stage. However, when we report the findings, we will not attribute any findings to individual health boards.

9. Request permission to record – will not be shared with anyone outside the research team and will be securely deleted after the research is complete

1. Background (2 mins)

Thank you very much for agreeing to take part. Before we start, I'd just like to begin by asking some questions about your role.

Can I just confirm your role?

And can you sum up what your role involves?

And how long have you been in this role?

And do you work full time or part time? (if part time: How many hours per week are you contracted to work?)

2. Perspectives on role in relation to healthy weight (5 mins)

Aim not to get into too much detail on specifics of their role at this stage. Want to get their unprompted perspectives on their role.

Thanks. I'd now like to move on to ask about healthy weight for pregnant women and children up to Primary 1 age in your area.

Firstly, how much would you say you know about how healthy weight for pregnant women and children up to Primary 1 age is assessed and supported in your health board area?

• And where have you got this information from?

And how would you describe your role in relation to healthy weight in pregnant women and the early years?

How do you feel about your role? Are you clear about it?

How much of a priority is healthy weight management among the competing demands of your role? If not a priority: What is more important?

3. Detailed understanding of their role in prevention, identification and intervention (30 mins)

I'd just like to go into a bit more detail now on some of the things we've just discussed.

First, what would you say are the main things you do to in relation to the prevention of overweight and obesity in pregnancy and the early years? Prompt only if necessary: For example, do you provide any information or advice to pregnant women or new mothers on topics like healthy eating and physical activity and weight gain during pregnancy and feeding their baby in the first few months?

• Would you provide this universally or is it targeted at specific pregnant women?
• Do you have resources to give women or places to signpost them for this type of advice?
• Are these topics covered in parent education classes?
• In your experience to what extent do pregnant women want advice on healthy diet and lifestyle during pregnancy?
  • xvi) How do they react to receiving it?
• And do they want advice on feeding their baby in the first few months?
  • xvii) How do they react to receiving it?
• And, as far as you know, where else do pregnant women get their information on diet and physical activity during pregnancy?
  • xviii) To what extent does it fit with the advice you give?
• And, again, as far as you know, where else do they get their information on feeding their babies in the first few months?
  • xix) To what extent does it fit with the advice you give?
• How confident do you feel providing advice to pregnant women on healthy diets and lifestyles in pregnancy and feeding their babies in the first few months?
• Do you feel you have the support you need to carry out this part of your job effectively? Is there any other support you'd like to receive?
• Have you received any training on this?
  • xx) Would you like any further training on this?

And moving on now from prevention, how do you identify pregnant women who may be overweight or obese? Probe fully

BMI

• At what point or points during pregnancy do you measure a women's BMI?
  • xxi) Is this always the same for all women or are there circumstances in which it differs?
• What happens to the BMI data you collect?
• Are there specific points (BMI thresholds, or concerns about gestational diabetes) at which they would be eligible for referral to a weight management or other type of intervention (e.g. gestational diabetes)?
• And for women who have a healthy BMI at the start of their pregnancy, do you monitor pregnancy weight gain?
  • xxii) Is there a threshold that would trigger intervention or concern about gestational diabetes?

Referrals

• Once you have identified that a pregnant woman is overweight or obese, can you talk me through what happens?
  • xxiii) Would you always bring it up with the women and offer to refer them to a service?
  • xxiv) What reasons are there for not bringing it up? What other factors are you taking into account when making that decision?
• How would you initiate that conversation?
  • (a) And would you initiate it differntly for different groups of pregnant women? In what way? Why?
• In your experience, how do women tend to react?
• Are they generally keen to take up the referral?
• Are there factors that appear to affect women's receptiveness to the referral? Probe:
  • xxv) The age of the woman
  • xxvi) The extent of overweight/obesity
  • xxvii) The type of service being offered
  • xxviii) Previous attempts to lose weight
  • xxix) Other health conditions
  • xxx) Other things going on in the woman's life e.g. poverty, work situation, language barriers
  • xxxi) Perceived support from other family members, or their relationships with other family members in general
• Would you discuss their weight again after the initial conversation?
• Do pregnant women ever raise concerns about their weight with you and ask for your advice and/or to be referred to a service before you have raised it?

Interventions

• What services or interventions are available in your area to refer pregnant women who are overweight or obese on to?
• Are there occasions where you would like to be able to refer them to a service but you are not aware of anything suitable to refer them to?
• If there is more than one possible intervention/action available, how do you decide on which is the most appropriate?
• How much do you know about how well pregnant women who agree to be referred to services engage with them?
• And how effective do you think these services are for the women who do engage with them?
  • xxxii) Are you aware of any evaluations or audits of these services?

How has the COVID-19 pandemic affected what you are able to do in relation to supporting healthy weight in pregnancy and the early years? Probe on:

• Prevention
• Taking BMI
• Referrals
• Available interventions

4. Confidence, support and training

How confident do you feel about the parts of your job we have just discussed? So:

• Measuring pregnant women's BMI
• Managing sensitive conversations with pregnant women about their weight and/or their pregnancy weight gain?
• Knowing about your services/options for pregnant women in your area – where you could refer them on

And could you rank them in order from most to least confident?

Do you feel you have the support you need to carry out these parts of your job effectively? On which of the above aspects, if any, do you feel you need most support with? Is there any other support you'd like to receive?

And have you received training on any of these areas?

Are you aware of the SIGN guidelines?

• If yes: do you use the SIGN 115 guidelines from 2010 in your work at all?

Are you aware of the minimum standards for assessing and supporting healthy weight in pregnancy and the early years?

Is there anything you would like to receive more training on?

How do you think this training should be delivered?

5. Consistency and coherence

I'm going to move on now and ask some questions about the consistency of pregnancy and early years healthy weight systems across your health board.

Do you discuss healthy weight with your team leader and/or other colleagues?

• What kinds of issues do you discuss?

As far as you are aware, how consistent is the approach taken by midwives in supporting healthy weight in pregnancy and the early years across your health board?

• Do you think the advice you provide is consistent with the advice provided by other midwives?
• Do pregnant women ever indicate that they have received inconsistent/conflicting advice?
• To what extent do you think midwives are consistent in relation to referring eligible pregnant women to services?

And is there coherence across the system as a whole so from pregnancy to the early years to Primary 1?

• How are transition points from pregnancy to post-natal support and from the health visiting pathway to Primary 1 and beyond managed where weight remains a concern?

Are there any systems and/or resources aimed at ensuring consistency of approach across the health board?

6. Perceived effectiveness, barriers and opportunities for improvement

Overall, how effective do you think your health board's current system to assess and support healthy weight in pregnant women and the early years is?

• Are you aware of any evaluations or audits that have been conducted?

What are the main challenges and barriers to supporting healthy weight in pregnant women and the early years in your area?

• What are the main difficulties for parents in your view?

And do you have any suggestions for how your health board's system could be improved?

• What should the priorities for improvements be?
• Are you aware of any improvements currently being carried out?

7. Wrap up

And just before we finish…

In your experience, what is the biggest challenge to health professionals supporting healthy weight in pregnancy and the early years?

Before we finish up, is there anything else you'd like to raise about what we've discussed today? Or any questions about this research?

Thank them and remind them they can contact us again if they have any questions or concerns.

Early Years Healthy Weight Research

Health visitor manager interviews – topic guide (stage 2)

1. Introduce self and Ipsos MORI

2. This research has been commissioned by the Scottish Government to explore how pregnancy and early years healthy weight systems work across Scotland

3. We have conducted an initial interview with an individual in most health boards in Scotland. Following this, five areas were selected as case studies and [area] is one of them.

4. Within each case study area, we are speaking to health professionals, like yourself, to get your views on pregnancy and early years weight practices in your area and experiences of supporting healthy weight in your role. We'll cover your role in general, the role of you and your team in relation into the prevention and identification of overweight and obesity and the available interventions in your area. We'll then move on to talk about training and support needs before finishing with your views on the consistency and effectiveness of the system.

5. The interview will last around an hour

6. Participation is voluntary – all questions are optional, you do not have to answer anything you do not wish to, and we can finish the interview at any time

7. There are no right or wrong answers – we just want to know what you think

8. Ensure confidentiality and anonymity – no identifying information will be passed onto the Scottish Government. In the methods section of the report, we will name the health boards that participated in the case study stage. However, when we report the findings, we will not attribute any findings to individual health boards.

9. Request permission to record – will not be shared with anyone outside the research team and will be securely deleted after the research is complete

1. Background (2 mins)

Thank you very much for agreeing to take part. Before we start, I'd just like to begin by asking some questions about your role.

Can I just confirm your role?

And can you sum up what your role involves?

Do you have a caseload in addition to your management role?

And how long have you been in this role?

How many health visitors are in your team?

And do you work full time or part time? (if part time: How many hours per week are you contracted to work?)

2. Perspectives on role in relation to child healthy weight (5 mins)

Aim not to get into too much detail on specifics of their role at this stage. Want to get their unprompted perspectives on their role.

Thanks. I'd now like to move on to ask about healthy weight for pregnant women and children up to Primary 1 age in your area.

Firstly, how much would you say you know about how healthy weight for pregnant women and children up to Primary 1 age is assessed and supported in your health board area? So, for pregnant women, babies, toddlers, pre-school and Primary 1 children.

• And where have you got this information from?

And how would you describe your role in relation to healthy weight in pregnant women and the early years?

How do you feel about your role? Are you clear about it?

How much of a priority is healthy weight management among the competing demands of your role? If not a priority: What is more important?

3. Detailed understanding of their role in prevention, identification and intervention (25 mins)

I'd just like to go into a bit more detail now on some of the things we've just discussed.

First, what would you say are your main responsibilities in relation to the prevention of overweight and obesity in the early years. Prompt only if necessary: For example, do you/your team provide any information or advice to families on topics like feeding in the first few months, weaning, healthy eating, physical activity, screen time?

• And are there specific stages from infancy through to age four or five that you would provide this information?
• And would you provide this universally or is it targeted at specific families?
• Do you have resources to give families or places to signpost them for this type of advice?
• In your experience do families want advice on healthy diets and lifestyles?
  • xxxiii) How do they react to receiving it?
• How confident do you feel providing advice to families on healthy diets and lifestyles?
• What support, if any, do you and your team need to carry out this part of your job effectively? Is there any other support you'd like to receive?
• Have you received any training on this?
  • xxxiv) Would you like any further training on this?

And moving on now from prevention, how do you identify children who may be overweight or obese? Probe fully

Weighing and measuring

• At what points on the UHVP are children weighed and measured?
  • xxxv) And are there circumstances in which you would weigh and measure a child or refer them to a child healthy weight service at a time that is not a standard UHVP measurement point?
• What happens to the weight and height data collected?
• How would you assess from the measurements you take whether a child was overweight or obese?
• Are there specific points (BMI thresholds) at which they would be eligible for referral to child healthy weight interventions?

Referrals

• Once it has been identified that a child is overweight or obese, can you talk me through what happens?
  • xxxvi) Would it always be raised with the family and a referral offered?
  • xxxvii) Across your team, do you know what proportion of children who are overweight or obese will be offered a referral?
  • xxxviii) What reasons are there for not bringing it up? What other factors are you taking into account when making that decision?
• How would you/the health visitors in your team initiate that conversation?
  • (a) And would you/they initiate it differntly for different groups of parents? In what way? Why?
• In your experience, how do parents tend to react?
• Are they generally keen to take up the referral?
• Are there factors that appear to affect families' receptiveness to the referral? PROBE:
  • xxxix) Any concerns about the child's health
  • xl) The age of the child
  • xli) The extent of overweight/obesity
  • xlii) Your relationship with the family
  • xliii) The type of service being offered
  • xliv) Whether parents are overweight/obese
  • xlv) Other challenges facing the family e.g. poverty, work situation, language barriers
  • xlvi) Perceived support from other family members, or their relationships with other family members in general
• Would you discuss their child's weight again after the initial conversation? IF NOT: why not?
• Do you ever have families coming to you with a concern about their child's weight and asking for your advice and/or to be referred to a service?

Interventions

• What services or interventions are available in your area to refer children who are overweight or obese on to?
• Are there occasions where you would like to be able to refer them to a service but you are not aware of anything suitable to refer them to?
• If there is more than one possible intervention/action available, how do you decide on which is the most appropriate?
• How much do you know about how well families who agree to be referred to services engage with them?
• And how effective you think these services are for the families who do engage with them?

How has the COVID-19 pandemic affected what you are able to do in relation to supporting healthy weight in the early years? Probe on:

• Prevention
• Weighing and measuring
• Referrals
• Available interventions
• Staffing/resourcing

And what impact, if any, has the UHVP had on your work in relation to healthy weight in the early years?

4. Confidence, support and training (10 mins)

Now, moving on to talk a bit more about confidence and skills and training, both your own and the health visitors you manage.

How confident do you feel about the parts of your job we have just discussed? So:

• Identifying children who are overweight or obese
• Weighing children accurately and measuring children's BMI
• Managing sensitive conversations with parents about their child's weight
• Knowing about your services/options for families in your area – where you could refer them on

And could you rank them in order from most to least confident?

Do you feel you need any further support or training? On which of the above aspects, if any, do you feel you need most support with?

And thinking now about the health visitors in your team, do they come to you for support on issues relating to healthy weight?

Do you discuss healthy weight as a team?

• When do these discussions happen? e.g. team meetings, supervisions
• What kinds of issues do you discuss?

From your discussions with health visitors, are there parts of the role they lack confidence in?

Prompt if necessary:

• Identifying children who are overweight or obese
• Weighing children accurately and measuring children's BMI
• Managing sensitive conversations with parents about their child's weight
• Knowing about your services/options for families in your area – where you could refer them on

What, if any, skills gaps are there?

What training, if any would your team benefit from?

• And are there any groups of midwives who would most benefit from training e.g. newly qualified midwives
• How should this training be delivered?
• What are the barriers to them receiving this type of training?

Are you aware of the SIGN guidelines?

• If yes: do you use the SIGN 115 guidelines from 2010 in your work at all?

Are you aware of the minimum standards for assessing and supporting healthy weight in pregnancy and the early years?

5. Consistency and coherence (10 mins)

I'm going to move on now and ask some questions about the consistency of child healthy weight systems across your health board.

Do you discuss child healthy weight with your team leader and/or other colleagues?

• What kinds of issues do you discuss?

As far as you are aware, how consistent is the approach taken by health visitors, both within your team and across teams, in your health board in supporting child healthy weight across your health board?

• To what extent do you think the advice health visitors are consistent in the advice they provide to families?
• And to what extent do you think health visitors are consistent in relation to referring eligible children to services?
• (a) Is this something that is monitored, either within your team or across teams?

And is there coherence across the system as a whole so from pregnancy to the early years to Primary 1?

• How are transition points from pregnancy to post-natal support and from the health visiting pathway to Primary 1 and beyond managed where weight remains a concern?

Are there any systems and/or resources aimed at ensuring consistency of approach across the health board?

6. Perceived effectiveness, barriers and opportunities for improvement (5 mins)

Overall, how effective do you think your health board's current system to assess and support healthy weight in pregnant women and the early years is?

• Are you aware of any evaluations or audits that have been conducted?

What are the main challenges and barriers to supporting children in your area to have healthy weight?

• What are the main difficulties for parents in your view?

And do you have any suggestions for how your health board's system could be improved?

• What should the priorities for improvements be?
• Are you aware of any improvements currently being carried out?

7. Wrap up (3 mins)

And just before we finish…

In your experience, what is the biggest challenge to health professionals supporting families with their child's weight?

Before we finish up, is there anything else you'd like to raise about what we've discussed today? Or any questions about this research?

Thank them and remind them they can contact us again if they have any questions or concerns.

Early Years Healthy Weight Research

Health visitor interviews – topic guide (stage 2)

1. Introduce self and Ipsos MORI

2. This research has been commissioned by the Scottish Government to explore how pregnancy and early years healthy weight systems work across Scotland

3. We have conducted an initial interview with an individual in most health boards in Scotland. Following this, five areas were selected as case studies and [area] is one of them.

4. Within each case study area, we are speaking to health professionals, like yourself, to get your views on pregnancy and early years weight practices in your area and experiences of supporting healthy weight in your role. We'll cover your role in general, your role in relation into the prevention and identification of overweight and obesity and the available interventions in your area. We'll then move on to talk about your training and support needs before finishing with your views on the consistency and effectiveness of the system.

5. The interview will last around an hour

6. Participation is voluntary – all questions are optional, you do not have to answer anything you do not wish to, and we can finish the interview at any time

7. There are no right or wrong answers – we just want to know what you think

8. Ensure confidentiality and anonymity – no identifying information will be passed onto the Scottish Government and we will not name the case study health boards in any reports from the study.

9. Request permission to record – will not be shared with anyone outside the research team and will be securely deleted after the research is complete

1. Background (2 mins)

Thank you very much for agreeing to take part. Before we start, I'd just like to begin by asking some questions about your role.

Can I just confirm your role?

And can you sum up what your role involves?

And how long have you been in this role?

And do you work full time or part time? (if part time: How many hours per week are you contracted to work?)

2. Perspectives on role in relation to child healthy weight (5 mins)

Aim not to get into too much detail on specifics of their role at this stage. Want to get their unprompted perspectives on their role.

Thanks. I'd now like to move on to ask about healthy weight for pregnant women and children up to Primary 1 age in your area.

Firstly, how much would you say you know about how healthy weight for pregnant women and children up to Primary 1 age is assessed and supported in your health board area? So, for pregnant women, babies, toddlers, pre-school and Primary 1 children.

• And where have you got this information from?

And how would you describe your role in relation to healthy weight in pregnant women and the early years?

How do you feel about your role? Are you clear about it?

How much of a priority is healthy weight management among the competing demands of your role? If not a priority: What is more important?

3. Detailed understanding of their role in prevention, identification and intervention (25 mins)

I'd just like to go into a bit more detail now on some of the things we've just discussed.

First, what would you say are the main things you do to in relation to the prevention of overweight and obesity in the early years. For example, do you provide any information or advice to families on topics like feeding in the first few months, weaning, healthy eating, physical activity, screen time?

• And are there specific stages from infancy through to age four or five that you would provide this information?
• And would you provide this universally or is it targeted at specific families?
• Do you have resources to give families or places to signpost them for this type of advice?
• In your experience do families want advice on healthy diets and lifestyles?
  • xlvii) How do they react to receiving it?
• And, as far as you know, where else do families get their information on healthy diets and lifestyles?
  • xlviii) To what extent does it fit with the advice you give?
• How confident do you feel providing advice to families on healthy diets and lifestyles?
• Do you feel you have the support you need to carry out this part of your job effectively? Is there any other support you'd like to receive?
• Have you received any training on this?
  • xlix) Would you like any further training on this?

And moving on now from prevention, how do you identify children who may be overweight or obese? PROBE FULLY

Weighing and measuring

• At what points on the UHVP do you weigh and measure children?
  • l) And are there circumstances in which you would weigh and measure a child or refer them to a child healthy weight service at a time that is not a standard UHVP measurement point?
• What happens to the weight and height data you collect?
• How would you assess from the measurements you take whether a child was overweight or obese?
• Are there specific points (BMI thresholds) at which they would be eligible for referral to child healthy weight interventions?
• Would anything stop you from referring a child with a BMI over this threshold?

Referrals

• Once you have identified that a child is overweight or obese, can you talk me through what happens?
  • li) Would you always bring it up with the family and offer to refer them to a service?
  • lii) What reasons are there for not bringing it up? What other factors are you taking into account when making that decision?
• How would you initiate that conversation?
  • (a) And would you initiate it differntly for different groups of parents? In what way? Why?
• In your experience, how do parents tend to react?
• Are they generally keen to take up the referral?
• Are there factors that appear to affect families' receptiveness to the referral? PROBE:
  • liii) Any concerns about the child's health
  • liv) The age of the child
  • lv) The extent of overweight/obesity
  • lvi) Your relationship with the family
  • lvii) The type of service being offered
  • lviii) Whether parents are overweight/obese
  • lix) Other challenges facing the family e.g. poverty, work situation, language barriers
  • lx) Perceived support from other family members, or their relationships with other family members in general
• Would you discuss their child's weight again after the initial conversation? IF NOT: why not?
• Do you ever have families coming to you with a concern about their child's weight and asking for your advice and/or to be referred to a service?

Interventions

• What services or interventions are available in your area to refer children who are overweight or obese on to?
• Are there occasions where you would like to be able to refer them to a service but you are not aware of anything suitable to refer them to?
• If there is more than one possible intervention/action available, how do you decide on which is the most appropriate?
• How much do you know about how well families who agree to be referred to services engage with them?
• And how effective you think these services are for the families who do engage with them?

How has the COVID-19 pandemic affected what you are able to do in relation to supporting healthy weight in the early years? Probe on:

• Prevention
• Weighing and measuring
• Referrals
• Available interventions

And what impact, if any, has the UHVP had on your work in relation to healthy weight in the early years?

4. Confidence, support and training (10 mins)

How confident do you feel about the parts of your job we have just discussed? So:

• Identifying children who are overweight or obese
• Weighing children accurately and measuring children's BMI
• Managing sensitive conversations with parents about their child's weight
• Knowing about your services/options for families in your area – where you could refer them on

Could you rank them in order from most to least confident?

Do you feel you have the support you need to carry out these parts of your job effectively? On which of the above aspects, if any, do you feel you need most support with? Is there any other support you'd like to receive?

And have you received training on any of these areas?

Are you aware of the SIGN guidelines?

• If yes: do you use the SIGN 115 guidelines from 2010 in your work at all?

Are you aware of the minimum standards for assessing and supporting healthy weight in pregnancy and the early years?

Is there anything you would like to receive more training on?

How do you think this training should be delivered?

5. Consistency and coherence (10 mins)

I'm going to move on now and ask some questions about the consistency of child healthy weight systems across your health board.

Do you discuss child healthy weight with your team leader and/or other colleagues?

• What kinds of issues do you discuss?

As far as you are aware, how consistent is the approach taken by health visitors in supporting child healthy weight across your health board?

• Do you think the advice you provide is consistent with the advice provided by other health visitors?
• Do parents ever indicate that they have received inconsistent/conflicting advice?
• To what extent do you think health visitors are consistent in relation to referring eligible children to services?

And is there coherence across the system as a whole so from pregnancy to the early years to Primary 1?

• How are transition points from pregnancy to post-natal support and from the health visiting pathway to Primary 1 and beyond managed where weight remains a concern?

Are there any systems and/or resources aimed at ensuring consistency of approach across the health board?

6. Perceived effectiveness, barriers and opportunities for improvement (5 mins)

Overall, how effective do you think your health board's current system to assess and support healthy weight in pregnant women and the early years is?

• Are you aware of any evaluations or audits that have been conducted?

What are the main challenges and barriers to supporting children in your area to have healthy weight?

• What are the main difficulties for parents in your view?

And do you have any suggestions for how your health board's system could be improved?

• What should the priorities for improvements be?
• Are you aware of any improvements currently being carried out?

7. Wrap up (3 mins)

And just before we finish…

In your experience, what is the biggest challenge to health professionals supporting families with their child's weight?

Before we finish up, is there anything else you'd like to raise about what we've discussed today? Or any questions about this research?

Thank them and remind them they can contact us again if they have any questions or concerns.

Early Years Healthy Weight Research

School Nurse interviews – topic guide (stage 2)

1. Introduce self and Ipsos MORI

2. This research has been commissioned by the Scottish Government to explore how pregnancy and early years healthy weight systems work across Scotland

3. We have conducted an initial interview with an individual in most health boards in Scotland. Following this, five areas were selected as case studies and [area] is one of them.

4. Within each case study area, we are speaking to health professionals, like yourself, to get your views on pregnancy and early years weight practices in your area and experiences of supporting healthy weight in your role. We'll cover your role in general, your role in relation into the prevention and identification of overweight and obesity and the available interventions in your area. We'll then move on to talk about your training and support needs before finishing with your views on the consistency and effectiveness of the system.

5. The interview will last around an hour

6. Participation is voluntary – all questions are optional, you do not have to answer anything you do not wish to, and we can finish the interview at any time

7. There are no right or wrong answers – we just want to know what you think

8. Ensure confidentiality and anonymity – no identifying information will be passed onto the Scottish Government. In the methods section of the report, we will name the health boards that participated in the case study stage. However, when we report the findings, we will not attribute any findings to individual health boards.

9. Request permission to record – will not be shared with anyone outside the research team and will be securely deleted after the research is complete

1. Background (2 mins)

Thank you very much for agreeing to take part. Before we start, I'd just like to begin by asking some questions about your role.

Can I just confirm your role?

And can you sum up what your role involves?

How many schools do you cover?

And how long have you been in this role?

And do you work full time or part time? (if part time: How many hours per week are you contracted to work?)

2. Perspectives on role in relation to child healthy weight (5 mins)

Aim to not get into too much detail on specifics of their role at this stage. Want to get their unprompted perspectives on their role.

Thanks. I'd now like to move on to ask about your role in relation to healthy weight for children in Primary 1 age in your area.

Firstly, how much would you say you know about how healthy weight for children in Primary 1 is assessed and supported in your health board area?

• And where have you got this information from?

And how would you describe your role in relation to healthy weight in Primary 1 children?

How do you feel about your role? Are you clear about it?

How much of a priority is healthy weight management among the competing demands of your role? If not a priority: What is more important?

3. Detailed understanding of their role in prevention, identification and intervention (25 mins)

I'd like to go into a bit more detail now on some of the things we've just discussed.

First, can I check do you carry out BMI assessments of Primary 1 children?

Weighing and measuring

• Can you explain how Primary 1 assessments work in the school(s) that you cover?
  • lxi) Are all Primary 1 children weighed? Do parents need to opt on or out of the assessment? What information are they given about the purpose of the assessment and what it involves?
  • lxii) What proportion of parents opt in?
  • lxiii) Is the BMI measurement a standalone exercise or is it done as part of a wider exercise?
  • lxiv) How is this activity explained to the children?
  • lxv) Are there differences between schools with regards to how this is carried out?
  • lxvi) How do children respond to being weighed and measured? Do some children seem concerned or self conscious about their weight? and how does the assessment impact this? [probe for details on whether they take measures to address this]
  • lxvii) And are there circumstances in which you would weigh and measure a child or refer them to a child healthy weight service at a time that is not a standard measurement point?
• What happens to the weight and height data you collect?
• How would you assess from the measurements you take whether a child was overweight or obese? Are there standard procedures to follow? Would you take other factors into account?
• Are there specific points (BMI thresholds) at which they would be eligible for referral to child healthy weight interventions? Would you do anything about a child who is just below the threshold?
• Do you receive any information from health visitors on the children before they start Primary 1 or any information from the school ? For example, if a child and their family are already receiving support on healthy weight, would you be informed of that?

Referrals

• If you have identified that a child is overweight or obese, can you talk me through what happens?
  • lxviii) Would you bring it up with the family and offer to refer them to a service?
  • lxix) Would you speak to their health visitor to see if they have already been referred etc.?
  • lxx) Can you think of any scenario/ example of a time where you identified a child, but the family was not contacted (or not referred)?

If they do not follow up:

• What reasons are there for not bringing it up? What other factors are you taking into account when making that decision?
  • lxxi) Do you think that, even if they are obese at this age, they might grow out of it without intervention?

If they do speak to parents:

• How do you contact parents? Letter? Phone conversation?
• If conversation: How would you initiate that conversation?
  • lxxii) Would you adapt this to the family based on any prior knowledge of the family circumstances?
• In your experience, how do parents tend to react to referrals?
• Are they generally keen to take up the referral?
• Are there factors that appear to affect families' receptiveness to the referral? PROBE:
  • lxxiii) Any concerns about the child's health
  • lxxiv) The age of the child
  • lxxv) The extent of overweight/obesity
  • lxxvi) The type of service being offered
  • lxxvii) Whether parents are overweight/obese
  • lxxviii) Other challenges facing the family e.g. poverty, work situation, language barriers?
  • lxxix) Perceived support from other family members, or their relationships with other family members in general
• Would you discuss their child's weight again after the initial conversation? IF NOT: why not?
• Do you ever have families or schools coming to you with a concern about a child's weight and asking for your advice and/or to be referred to a service?
  • lxxx) Would you offer information or advice or an intervention? What type? E.g. physical activity, screen time, diet.

Interventions

• What services or interventions are available in your area to refer Primary 1 children who are overweight or obese on to?
• Are there occasions where you would like to be able to refer them to a service, but you are not aware of anything suitable to refer them to?
• If there is more than one possible intervention/action available, how do you decide on which is the most appropriate?
• How much do you know about how well families who agree to be referred to services engage with them?
• And how effective you think these services are for the families who do engage with them?

Do you also have a role in relation to the prevention of overweight and obesity in Primary 1 children? For example, providing information or advice to families on topics like healthy eating, physical activity, screen time?

Ask this section only if they provide info / other support

• And are there specific times that you would provide information supporting healthy weight to Primary 1 children and their families?
• And would you provide this universally or is it targeted at specific families?
• Do you have resources to give families or places to signpost them for this type of advice?
• In your experience do families want advice on healthy diets and lifestyles?
  • lxxxi) What type of advice? E.g. physical activity, screen time, diet.
  • lxxxii) How do they react to receiving it?

How has the COVID-19 pandemic affected what you are able to do in relation to supporting healthy weight in Primary 1 children? Probe on:

• Taking BMI
• Referrals
• Available interventions

4. Confidence, support and training (10 mins)

How confident do you feel about the parts of your job we have just discussed? So:

• Weighing children accurately and measuring children's BMI
• Managing sensitive conversations with parents about their child's weight
• Knowing about your services/options for families in your area – where you could refer them on
• Providing advice to families on healthy diets and lifestyles [if applicable]
• (a) Any difference in confidence on diet vs physical activity?

And could you rank them in order from most to least confident?

Do you feel you have the support you need to carry out these parts of your job effectively? On which of the above aspects, if any, do you feel you need most support with? Is there any other support you'd like to receive?

And have you received training on any of these areas?

Are you aware of the SIGN guidelines?

• If yes: do you use the SIGN 115 guidelines from 2010 in your work at all?

Are you aware of the minimum standards for assessing and supporting healthy weight in the early years?

Is there anything you would like to receive more training on?

How do you think this training should be delivered?

5. Consistency and coherence (10 mins)

I'm going to move on now and ask some questions about the consistency of child healthy weight systems across your health board.

Do you discuss child healthy weight with your team leader and/or other colleagues?

• What kinds of issues do you discuss?

As far as you are aware, are Primary 1 BMI measurements undertaken consistently across the health board?

• Are they undertaken in all schools?
• (b) If no: why not?
• (c) Are some schools easier to work with than others?
• Do you think the work you do around healthy weight is consistent with the advice provided by other school nurses in your area?
• To what extent do you think school nurses are consistent in relation to referring eligible children to services?
• Do parents ever indicate that they have received inconsistent/conflicting advice?
• Are parents ever unhappy about the advice they have received?

Do you think there is coherence across the system as a whole so from pregnancy to the early years to Primary 1?

• How is the transition from the health visiting pathway to Primary 1 and beyond managed where weight remains a concern?
• Has this changed since the introduction of the Universal Health Visiting Pathway (UHVP)? [4-5 years old may now be assessed by Health Visitors] Is it working well or not? Why?

Are there any systems and/or resources aimed at ensuring consistency of approach across the health board?

6. Perceived effectiveness, barriers and opportunities for improvement (5 mins)

Overall, how effective do you think your health board's current system to assess and support healthy weight in the early years and Primary 1 is?

• Are you aware of any evaluations or audits that have been conducted?

What are the main challenges and barriers to supporting children in your area to have healthy weight? What are the main difficulties for parents in your view?

And do you have any suggestions for how your health board's system could be improved?

• What should the priorities for improvements be?
• Are you aware of any improvements currently being carried out?

7. Wrap up (3 mins)

And just before we finish…

In your experience, what is the biggest challenge to health professionals supporting families with their child's weight?

Before we finish up, is there anything else you'd like to raise about what we've discussed today? Or any questions about this research?

Thank them and remind them they can contact us again if they have any questions or concerns.

Early Years Healthy Weight Research

Public health professional interviews – topic guide (stage 2)

1. Introduce self and Ipsos MORI

2. This research has been commissioned by the Scottish Government to explore how pregnancy and early years healthy weight systems work across Scotland

3. We have conducted an initial interview with an individual in most health boards in Scotland. Following this, five areas were selected as case studies and [area] is one of them.

4. Within each case study area, we are speaking to health professionals, like yourself, to get your views on pregnancy and early years weight practices in your area and experiences of supporting healthy weight in your role. This research focuses only on healthy weight management from pregnancy to Primary 1 age – so we will not be asking about how healthy weight is supported for older children and adults. We'll cover your role in general, your role in relation into CHW prevention and improvement. We'll then move on to talk about your training and support needs before finishing with your views on the consistency and effectiveness of the system.

5. The interview will last around an hour.

6. Participation is voluntary – all questions are optional, you do not have to answer anything you do not wish to, and we can finish the interview at any time

7. There are no right or wrong answers – we just want to know what you think

8. Ensure confidentiality and anonymity – no identifying information will be passed onto the Scottish Government. In the methods section of the report, we will name the health boards that participated in the case study stage. However, when we report the findings, we will not attribute any findings to individual health boards.

9. Request permission to record – will not be shared with anyone outside the research team and will be securely deleted after the research is complete

1. Background

Thank you very much for agreeing to take part. Before we start, I'd just like to begin by asking some questions about your role.

Can I just confirm your role?

And can you sum up what your role involves?

And how long have you been in this role?

And do you work full time or part time? (if part time: How many hours per week are you contracted to work?)

2. Perspectives on role in relation to child healthy weight

Thanks. I'd now like to move on to ask about healthy weight for pregnant women and children up to Primary 1 age in your area.

Firstly, how much would you say you know about how healthy weight for pregnant women and children up to Primary 1 age is assessed and supported in your health board area?

• And where have you got this information from?

And how would you describe your role in relation to healthy weight in pregnant women and the early years?

How do you feel about this role? Are you clear about it?

How much of a priority is child healthy weight management among the competing demands of your role?

3. Detailed understanding of their role in prevention and CHW health improvement

I'd just like to go into a bit more detail now on some of the things we've just discussed.

First, what would you say are the main things your public health team does to in relation to the prevention of overweight and obesity in the early years? Prompt if necessary:

• During pregnancy
• In infancy/infant feeding
• Weaning
• Toddlerhood/early childhood
• (transition to) Primary 1
• Does your work in these areas have a universal focus or are there specific population groups you target?

How much communication do you have with those working in clinical roles with pregnant women and families with young children?

• Do you provide advice and support to them?
• What kind of advice or support might you provide?

Would you say your work is primarily focused on reducing overweight and obesity overall versus reducing the inequality between more and less deprived areas?

I'd now like to mention a few different ways that public health professionals might support healthy weight in pregnancy, some of which we might have touched on already. It would be great if you could tell me whether you've been involved in each one or know of them happening in your health board.

Have you ever been involved in developing resources to inform health professionals about child healthy weight issues?

• What was the focus of these resources? Which topics did they cover?
• What was their purpose – what did you hope they might achieve?
• Did you consult with anyone else (other public health professionals, health visitors, midwives etc.) while developing them? Have you sought feedback from the people the resources are aimed at? Or have any metrics about the impact of the resources?
• Were they developed in line with any particular national standards or guidelines? Or in line with your health board's specific standards?
• Are they still in use? Do you feel they have met their intended goal?
• Do you plan to improve them or develop new resources in the near future?

Have you ever been involved in developing and/or delivering training to health professionals about healthy weight in pregnancy and the early years?

• What was the focus of this training? Which topics did it cover?
• How regularly do you provide training on healthy weight?
• What was the purpose of the training?
• Did you consult with anyone else (other public health professionals, health visitors, midwives, managers etc.) while developing the training?
• Was the training developed in line with any particular national standards or guidelines? Or in line with your health board's specific standards?
• How effective do you feel the training was?
• Do you plan to improve or develop training in the near future?

Have you been involved in developing resources for pregnant women or parents about healthy weight in pregnancy/the early years?

• What was the focus of these resources? Which topics did they cover?
• Did they target any groups of pregnant women/parents (e.g. the more deprived – were they adapted/tailored to these groups in any way?) or different ages of child, or were they more universal?
• Did you consult with anyone else (pregnant women, parents, other public health professionals, health visitors, midwives, managers etc.) while developing these resources?
• Were they developed in line with any particular national standards or guidelines?
• How effective do you feel the resources for parents were? Did they have the effect you hoped?
• Have you sought feedback from parents? If so, what did they think of the materials?
• Do you plan to improve them or develop new resources for parents in the near future?
• What are the limits of these kinds of resources / are there situations where these do not work/ are not appropriate?

And have you been involved in any other work aimed at promoting healthy weight in pregnancy and the early years in your area? Probe for details

• As far as you know, where else do families get their information on healthy diets and lifestyles? To what extent is this helpful/problematic?

What impact (if any) has COVID-19 had on your role in relation heathy weight in pregnancy and the early years?

4. Confidence, support and training

I'm going to move on now and ask a bit about your confidence in this area and any training and support you might have received.

How confident do you feel about the Child Healthy Weight aspect of your role?

• Understanding the latest healthy weight standards, guidelines and models (e.g. SIGN guidelines, minimum standards)
• Communicating healthy messaging to families effectively
• Working with other health professionals (those with a clinical caseload) to improve healthy weight systems
• Knowing about services/options for families in your area
• The relative importance of diet, physical activity, screen time in healthy weight

And have you received training on any of these areas?

Is there anything you would like to receive more training on?

How do you think this training should be delivered?

Do you feel you have the support you need to carry out these parts of your job effectively? Is there any other support you'd like to receive?

5. Consistency and coherence

I'm going to move on now and ask some questions about the consistency of child healthy weight systems across your health board.

Do you discuss child healthy weight with your team leader and/or other colleagues?

• What kinds of issues do you discuss?

As far as you are aware, how consistent is the approach taken in supporting child healthy weight across your health board?

• Is there a coherent message?
• Do different groups of health professionals provide the same advice?
• Do different areas with the health board provide the same advice?

And is there coherence across the system as a whole so from pregnancy to the early years to Primary 1?

• Are there particular stages e.g. pregnancy, infancy, weaning, toddlerhood, early childhood, transition to Primary 1 which you feel are more effective in terms of intervening to prevent obesity?
• Where are the gaps and strengths within your board?

Are there any systems and/or resources aimed at ensuring consistency of approach across the health board?

6. Perceived effectiveness, barriers and opportunities for improvement

Overall, how effective do you think your health board's current system to assess and support healthy weight in pregnant women and the early years is?

• Have any of the child healthy weight services been audited or evaluated?

What are the main challenges and barriers to supporting healthy weight in pregnant women and the early years in your area?

• What are the main difficulties for parents in your view?

And do you have any suggestions for how your health board's system could be improved?

• What should the priorities for improvements be?
• Are you aware of any improvements currently being carried out?

How do you think national support could be improved?

7. Wrap up

And just before we finish…

In your experience, what is the biggest challenge to health professionals supporting healthy weight in pregnancy and the early years?

Before we finish up, is there anything else you'd like to raise about what we've discussed today? Or any questions about this research?

Thank them and remind them they can contact us again if they have any questions or concerns.