Universal Health Visiting Pathway in Scotland: pre-birth to pre-school
The Pathway sets out the minimum core home visiting programme to be offered to all families by Health Visitors.
Appendix 4 - Public Health Resources Toolkit Supporting the Universal Health Visiting Pathway
Introduction
This Public Health Resources Toolkit is designed to guide Health Visitors in the delivery of their public health role and support in the delivery of the Universal Health Visiting Pathway to children and their families. This toolkit covers 3 main aspects:
1. guidance for the delivery of the Health Visitor public health role
2. resources and assessment tools for parents, families and children
3. e-learning and evidence resources for practitioners
Section 1: Guidance for the delivery of the Health Visitor Public Health Role:
This section outlines the core public health issues that are crucial to the public health role and practice of Health Visitors within the Universal Pathway. The core issues that should be covered for each visit are shown below. They have been developed from current wider policy and public health strategy and are located in the broader context of improving health and reducing health inequalities. Poverty is one of the biggest risk factors linked to poorer health outcomes and children who come from families with multiple risk factors such as mental illness, substance misuse, debt, poor housing and domestic violence are more likely to experience a range of poor health and social outcomes. These might include developmental and behavioural problems, mental illness, substance misuse, teenage parenthood, low educational attainment and offending behaviour.
This list represents the minimum range of issues that should be considered for the parent and their child.
- Financial inclusion, including poverty and debt, income maximization, fuel poverty.
- Housing and homelessness
- Child wellbeing and protection
- Child safety, including unintentional injuries and home safety
- Preparing for parenthood and parenting support
- Maternal emotional health & wellbeing
- Gender based violence – this term includes rape and sexual assault; sexual harassment and intimidation at work and other settings; childhood sexual abuse; domestic abuse; stalking; harmful traditional practices such as early and forced marriage, so-called ‘honour’ based violence and female genital mutilation; sex trafficking; and commercial sexual exploitation.
- Immunisation
- Supporting tobacco control and reducing substance misuse
- Infant nutrition
- Oral health
- Healthy weight among pregnant women and their families : improving nutrition and physical activity
- Sexual health
- Active play
Delivery
While a wide range of public health issues need to be addressed in each review at appropriate time points as shown in Table 1, this will depend on individual child and family circumstances, needs and priorities. This does not mean that lengthy assessment/discussion of each issue will always be necessary. A wide range of resources are also available to families on these core public health issues and also to facilitate the delivery of consistent, clear, and evidence based messages to parents (see Section 2).
Table 1: Core public health issues by age review
Child’s Age |
Core issues and detail to be discussed At every contact discuss progress and general wellbeing of baby, mother, father, family. Explore what parents already know, accept it and provide relevant information[6]. |
|---|---|
Pre-Birth |
Folic acid and any other diet or lifestyle advice as required |
Pre-Birth Contact 32 – 34 weeks |
Parenting
Financial inclusion Discuss family finances/money worries and raise awareness of the advice available and offer families a direct referral to advice services. Domestic abuse If domestic abuse was disclosed previously, check with the midwife re action taken, and whether risk assessment was carried out. Broach the subject with the woman, if it is safe to do so, to find out whether the abuse is continuing and if she is accessing support. Carry out Domestic Abuse Risk Assessment Checklist (DASH RIC) and offer support and referral to Multi-Agency Risk Assessment Case Conference or other services as appropriate. Provide information on local services in all cases. If you suspect domestic abuse, and it is safe to do so, ask the woman using the guidance on routine enquiry, and refer Scottish Government’s guidelines for Health Care Workers in NHS Scotland in responding to domestic abuse, then continue as above. If there are other children in the family use the above guidance to check for their safety. Implement child protection procedures if required, Ensure appropriate documentation and recording but not in hand held notes. If women are experiencing other forms of gender based violence, refer to accompanying evidence updates. Immunisations Remind women to make an appointment to get immunised as soon as possible if they have not already for whooping cough immunisation and flu which are both completely safe and beneficial for mother and baby. Guidance around the COVID-19 Vaccination while pregnant or breastfeeding can be found here. Maternal emotional health and wellbeing Discuss maternal emotional wellbeing of mother according to antenatal and postnatal NICE guidance. Infant nutrition
Tobacco control and substance misuse
Oral health Check mothers’ dental registration and promote entitlement. Introduce the Childsmile programme and importance of registration of babies with a dentist from birth. Nutrition and physical activity
|
Child’s Age |
Core issues and detail to be discussed |
|---|---|
11-14 days |
Parenting
Immunisations Discuss childhood immunisation schedule Financial inclusion Discuss family finances/money worries and raise awareness of the advice available and offer families a direct referral to advice services. Infant nutrition
Nutrition and physical activity Information given on physical recovery from birth to help maximize physical and emotional functioning, including looking after themselves, nutrition. 
|
Child’s Age |
Core issues and detail to be discussed |
|---|---|
3-5 weeks |
Parenting support
Discuss importance of helping your baby to move and play everyday - this should be encouraged from birth, particularly through floor-based play and water activities in safe environments. Reduce/limit sitting time in buggies and car seats when possible Domestic abuse Routine enquiry of domestic abuse should be undertaken between this visit and the 3 month visit. The timing of this will depend on your professional judgement and whether it is safe to do so. Domestic abuse should never be discussed with the partner present. Refer to the Guidance on Routine Enquiry Scottish Government’s guidelines for Health Care Workers in NHS Scotland in responding to domestic abuse. If abuse is disclosed carry out Domestic Abuse Risk Assessment Checklist (DASH RIC) and offer support and referral to Multi-Agency Risk Assessment Case Conference or other services as appropriate. Provide information on local services and discuss safety planning in all cases whether or not high levels of risk are indicated. Use the above guidance to check for the safety of the children. Implement hild protection procedures if required. Ensure appropriate documentation and recording but not in hand held notes. If women are experiencing other forms of gender based violence, refer to accompanying evidence updates. Immunisations
Sexual Health
|
Child’s Age |
Core issues and detail to be discussed |
|---|---|
6 – 8 weeks |
Parenting Continued assessment of/ discussion as appropriate. Refer or direct families to local community services/parenting programmes. Discuss importance of helping your baby to move and play everyday - this should be encouraged from birth, particularly through floor-based play and water activities in safe environments. Reduce/limit sitting time in buggies and car seats when possible Domestic abuse Carry out routine enquiry of domestic abuse if not previously undertaken and follow guidance on routine enquiry and Scottish Government’s guidelines for Health Care Workers in NHS Scotland in responding to domestic abuse. If abuse is disclosed carry out Domestic Abuse Risk Assessment Checklist (DASH RIC) and offer support and referral to Multi-Agency Risk Assessment Case Conference or other services as appropriate. Provide information on local services and discuss safety planning in all cases whether or not high levels of risk are indicated. Use the above guidance to check for the safety of the children. Implement child protection procedures if required. Ensure appropriate documentation and recording but not in hand held notes. Share information with relevant agencies as required and in line with local protocols. If women are experiencing other forms of gender based violence, refer to accompanying evidence updates. Immunisations Discuss childhood immunisation schedule Maternal emotional health and wellbeing Discuss and enquire about depressive symptoms and undertake the Edinburgh Postnatal Depression Scale assessment. 
|
Oral health
1. Reduce the consumption and especially the frequency of intake of foods and drinks containing sugar 2. Keep food and drinks containing sugar to mealtimes only 3. Plain milk and tap water are the safest drinks for teeth (N.B not in advance of weaning) 4. Brush teeth and gums at least twice daily, in the morning and last thing at night. Use toothpaste containing at least 1000 ppm (parts per million) fluoride. Spit, don’t rinse – this gives fluoride time to work |
Child’s Age |
Core issues and detail to be discussed |
|---|---|
5. Children should be supervised until the age of 7 and encouraged not to swallow toothpaste while brushing 6. Visit the dentist regularly or as advised for oral examinations 7. Participate in Public Health Programmes, which improve oral health such as Childsmile Sexual Health Discuss wellbeing of mother including contraceptive choices |
|
3 months |
Parenting Continued assessment of and discuss issues around the home learning environment and importance of play, talking, reading & singing on bonding and for early language skills (including Bookbug and play@home programmes and Play Talk Read). Discuss importance of helping your baby to move and play everyday including providing plenty of floor-based tummy time and water activities in safe environments. Reduce/limit sitting time in buggies/car seats, baby walkers and bouncers. Immunisations Discuss childhood immunisation schedule Maternal emotional health and wellbeing Continued assessment of/discussion as appropriate Domestic abuse Carry out routine enquiry of domestic abuse if not previously undertaken and follow guidance on routine enquiry and Scottish Government’s guidelines for Health Care Workers in NHS Scotland in responding to domestic abuse. If abuse is disclosed carry out Domestic Abuse Risk Assessment Checklist (DASH RIC) and offer support and referral to Multi-Agency Risk Assessment Case Conference or other services as appropriate. Provide information on local services and discuss safety planning in all cases whether or not high levels of risk are indicated. Use the above guidance to check for the safety of the children. Implement Child Protection procedures if required. Ensure appropriate documentation and recording but not in hand held notes. Share information with relevant agencies as required and in line with local protocols. If women are experiencing other forms of gender based violence, refer to accompanying evidence updates. Family/Infant Nutrition Introduce the subject of weaning and highlight importance of delaying introducing solids until around 6 months. Post-natal weight management support. Oral Health Assess baby’s oral health risk and refer for additional support from a Childsmile support worker where applicable and promote key oral health messages for all children (see content 6-8 weeks). |
Child’s Age |
Core issues and detail to be discussed |
|---|---|
4 months |
Discuss importance of helping your baby to move and play every day ncluding providing plenty of floor-based tummy time and water activities in safe environments. Reduce/limit sitting time in buggies/car seats, baby walkers and bouncers. Immunisations Discuss childhood immunisation schedule Domestic abuse Continue to monitor the situation if abuse disclosed, checking whether there has been any escalation in frequency or severity. Using your professional judgement, re-assess using Domestic Abuse Risk Assessment Checklist (DASH RIC) as appropriate and follow guidance on domestic abuse as above. Infant Nutrition
Oral Health First distribution point for tooth brushing packs (toothbrush and 1000ppm fluoride toothpaste) and free flow drinking cup to all families and promote key oral health messages (see 6-8 weeks). |
Child’s Age |
Core issues and detail to be discussed |
|---|---|
8 months |
Parenting Continued assessment of/discussion as appropriate and in particular reinforce the home learning environment and advice on home safety in relation to accident prevention, minor illness and what to do when their child is unwell. Discuss importance of helping your baby to move and play everyday including providing plenty of tummy time, time outside and water play in safe environments. Reduce/limit sitting time in buggies/car seats. For walkers use physical activity guidelines for children under 5. Domestic abuse Continue to monitor the situation if abuse disclosed, checking whether there has been any escalation in frequency or severity. Using your professional judgement, re-assess using Domestic Abuse Risk Assessment Checklist (DASH RIC) as appropriate and follow guidance on domestic abuse as above. Infant nutrition
|
Child’s Age |
Core issues and detail to be discussed |
|---|---|
13-15 months |
As per the priorities for the review Parenting Continued assessment of/discussion as appropriate and in particular promote secure attachment and parenting skills using evidence based approaches; Discuss importance of physically active play both at home and outside using physical activity guidelines for children under 5. Immunisations
Domestic abuse Continue to monitor the situation if abuse disclosed, checking whether there has been any escalation in frequency or severity. Using your professional judgement, re-assess using Domestic Abuse Risk Assessment Checklist (DASH RIC) as appropriate and follow guidance on domestic abuse as above. Financial inclusion Discuss family finances/money worries and raise awareness of the advice available and offer families a direct referral to advice services. Oral Health Promote key oral health messages outlined at 6-8 weeks |
Child’s Age |
Core issues and detail to be discussed |
|---|---|
27-30 months |
As per the priorities for the review Parenting
Discuss importance of physically active play both at home and outside using physical activity guidelines for children under 5 Financial inclusion Discuss family finances/money worries and raise awareness of the advice available and offer families a direct referral to advice services. Domestic abuse Carry out routine enquiry of domestic abuse following the guidance on routine enquiry and Scottish Government’s guidelines for Health Care Workers in NHS Scotland in responding to domestic abuse. If abuse is disclosed carry out Domestic Abuse Risk Assessment Checklist (DASH RIC) and offer support and referral to a Multi-Agency Risk Assessment Case Conference or other services as appropriate. Provide information on local services and discuss safety planning in all cases whether or not high levels of risk are indicated. Use the above guidance to check for the safety of the children. Implement child protection procedures if required. Ensure appropriate documentation and recording but not in hand held notes. Share information with relevant agencies as required and in line with local protocols. If women are experiencing other forms of gender based violence, refer to accompanying evidence updates. Immunisations Discuss childhood immunisation schedule Oral Health
|
Child’s Age |
Core issues and detail to be discussed |
|---|---|
4 - 5 years |
As per the priorities for the review Parenting Discuss planning for school and the home learning environment. Discuss importance of physically active play both at home and outside using physical activity guidelines for children under 5 Financial inclusion Discuss family finances/money worries and raise awareness of the advice available and offer families a direct referral to advice services. Nutrition Promote good family nutrition using Food Standards Scotland Eatwell Plate Oral Health Continued assessment of/discussion as appropriate |
Section 2: Resources and Assessment Tools
Introduction
This section is designed to guide health professionals through the national information resources available to support the delivery of the Universal Pathway. It covers pre- birth to pre-school and details the national resources to be disseminated to parents at every visit and used to facilitate discussion in the delivery of the pathway. This pathway is underpinned by the National Practice Model for all children in Scotland. Assessment tools to support the contacts health professionals have with families are also included.
NHS Health Scotland universal resources
NHS Health Scotland provides a number of universal resources for families that health professionals should be familiar with and reinforce to parents in routine contacts to access high quality, evidence-based information. These include the following, but it is not exhaustive:
Ready Steady Baby! (RSB!) is the key resource for all expectant and new parents. It provides parents with important information that they will need before, during, and after pregnancy. It is useful for all professionals who have contact with women and their partners and they should refer to it in their ongoing interactions with parents. It has been designed to reduce the need for many different leaflets. RSB! is also available online (through this link) and as a smartphone app.
Ready Steady Toddler! (RST!) is a guide which takes a practical problem-solving approach, with sections on understanding toddler behaviour and ways for parents to tackle new challenges. RST! is also available online (through this link).
Off to a Good Start is an information booklet highlighting the benefits of, and available support for, breastfeeding. As with other resources, health professionals should refer back to it and work through to support their interaction with women at all stages.
play@home baby, toddler and pre-school books are provided to families in Scotland with a child 0–5 years old. Activities in the books are age and stage
developmentally appropriate and promote all-round development and family communications. Health professionals should refer to the activities when discussing children’s physical, social and emotional growth, and the acquisition of speech and language skills. It can also be used by professionals as a resource to discuss baby massage.
Supporting parents with learning disabilities – (Non-NHS Health Scotland Resources)
The keys to life learning disability strategy and Supported Parenting: Refreshed Scottish Good Practice Guidelines for Supporting Parents with a Learning Disability aim to improve the lives of people with learning disabilities. NHS Health Scotland is committed to providing accessible information to advance equality and reduce discrimination. NHS Health Scotland has worked with CHANGE who are a leading national human rights organisation, led by disabled people to provide three pregnancy and parenting resources: My Pregnancy My Choice, You and Your Baby and You and Your Little Child which are Easy Read resources specifically designed to support parents with learning disabilities. These are to be given by the professional providing care at the appropriate stages as an alternative to (or as well as) Ready Steady Baby! (RSB!) and Ready Steady Toddler! (RST!)
Health Literacy
The provision of written resources is useful to complement effective communication between the professional and the parent, however we know that health illiteracy is a significant public health concern in Scotland. The Health Literacy Action for Scotland highlights 26.7% of the population have occasional difficulties with day-to-day reading and numeracy and 3.6% will have severe constraints. So it is therefore vitally important to ensure that information resources are not given out without full discussion of their contents. It may be more appropriate to consider other materials which may be available through local health resource libraries and/or individual support such as:
- Check directly with person how best to meet their needs
- Check understanding using ‘Teach Back’ a simple technique for confirming that people have understood what has been said
- Chunk and check: break what you need to discuss into small chunks, and check understanding using teach-back before continuing
- Use pictures: draw or show a picture to help convey a complex concept or body part
- Use simple language: avoid jargon and use language that is easy for the person in front of you to understand, both when you speak to them and in any written information you provide
- Literacy awareness: routinely ask people if they would like help in filling out forms
Translating and interpreting services
Women and families from minority ethnic groups may require assistance with communication through the provision of interpreting and translated written resources. Translation and interpreting services are arranged independently by each Health Board. Health professionals should contact their local equality and diversity officer for local arrangements within each Health Board. NHS Health Scotland can be contacted about materials for families whose vision is impaired, or for sources of information in other formats. NHS Health Scotland is committed to providing accessible and inclusive resources and will consider requests for translations and alternative languages and formats.
Age/Visit Appropriate Available Public Health/Health Promotion and Information Resources and Assessment Tools
Child’s Age |
NHS Health Scotland Resources unless specified | Assessment tools | ||
|---|---|---|---|---|
Pre-Birth |
Local antenatal letter |
Ready Steady Baby online and app: information on preconceptual health including importance of folic acid, stopping smoking & eating a healthy balanced diet. There will also be information on COVID-19 and pregnancy. |
||
Child’s Age |
NHS Health Scotland Resources unless specified | Assessment tools | |||
|---|---|---|---|---|---|
Pre-birth contact 32-34 weeks (Important: resources outlined here are provided and discussed at booking in and earlier appointments by Midwife or Family Nurse. Check whether parent has any subsequent questions/use as a tool for discussion) |
Area health visiting leaflet Bump to Breastfeeding DVD |
Fresh start: and/or Off to a Good Start- All you need to know about breastfeeding your baby |
Healthy Start information and application (DoH) Money Helper (online resource and UK wide) A guide to maternity benefits N1 17A Pregnancy and Work – what you need to know as an employee F8 Prescription exemption |
Edinburgh Postnatal Depression Scale National Risk Assessment tool Learning disability assessment tool |
|
Child’s Age |
NHS Health Scotland Resources unless specified | Assessment tools | |||
|---|---|---|---|---|---|
Pregnant? Get the flu vaccine to help protect you and your baby |
|||||
Ready Steady Baby Smartphone App |
The NHS Minor Ailment Service at your local pharmacy |
||||
Child’s Age |
NHS Health Scotland Resources unless specified |
Assessment tools |
|||
|---|---|---|---|---|---|
11 – 14 days |
Introduce and explain Red Book |
Child Health Programme |
World Health Organisation (WHO) Guidelines for Child Growth Strength based approaches to parenting National Risk Assessment tool Learning disability assessment tool |
||
Child’s Age |
NHS Health Scotland Resources unless specified | Assessment tools | |||
|---|---|---|---|---|---|
Protect your baby’s natural headshape: tummy time to play, back to sleep |
|||||
Handle with Care National Society for the Prevention of cruelty to Children (NSPCC) |
Longer-lasting contraception: Your guide to sexual health and wellbeing |
||||
Child’s Age |
NHS Health Scotland Resources unless specified |
Assessment Tools |
|||
3 – 5 weeks (All Families) |
Introduce and explain Baby Bookbug |
Introduce and explain play@home baby |
Strength based approaches to parenting Domestic Abuse Risk Assessment Checklist National Risk Assessment Tool |
||
6-8 weeks (All Families) |
Edinburgh Postnatal Depression Screening Form Childsmile Manual: 6-8 week assessment (pg 76-80) Domestic Abuse Risk Assessment Checklist (DASH RIC) National Risk Assessment Tool Strength based approaches to parenting World Health Organisation Guidelines (WHO) Guidance for child growth |
||||
Child’s Age |
NHS Health Scotland Resources unless specified |
Assessment Tools |
|||
|---|---|---|---|---|---|
3 Months (12 weeks) |
Red Book |
How to protect your children’s teeth (DVD) |
Toothbrush/Cup/Dental Pack |
Edinburgh Post National Practice Model World Health Organisation (WHO) Guidelines for Child Growth Growth Chart In Baby Pack Strength based approaches Domestic Abuse Risk Assessment Checklist (DASH RIC) National Risk Assessment Tool |
|
Child’s Age |
NHS Health Scotland Resources unless specified |
Assessment tools | |||
|---|---|---|---|---|---|
4 Months |
Toothbrush/cup/Dental Pack |
Strength based parenting approaches Domestic Abuse Risk Assessment Checklist National Risk Assessment Tool |
|||
8 Months (32 weeks) |
Strength based parenting approaches Ages and Stages Questionnaires: Social- Emotional 2nd edition National Risk Assessment Tool |
||||
Child’s Age |
NHS Health Scotland Resources unless specified |
Assessment tools | |||
|---|---|---|---|---|---|
13 – 15 Months |
Pack |
Play@home toddler |
Ages & Stages Questionnaire (ASQ) Strength based parenting approaches |
||
13-15 review form |
|||||
Encouraging better behaviour: a practical guide to positive parenting |
|||||
Child’s Age |
NHS Health Scotland Resources unless specified |
Assessment tools | |||
|---|---|---|---|---|---|
27-30 Months |
Red Book |
Protect your child against flu: Information for parents of children aged 2-5 years old |
Healthy, happy kids... Simple steps for a healthy weight at home |
Ages & Stages Questionnaire (ASQ) World Health Organisation WHO Guidelines for Child Growth Strength based approaches to parenting |
|
Drinks for babies and young children Only to be given to clients receiving enhanced care |
Keeping your cool: advice for parents on managing stress and anger | NSPCC |
Only to be given to clients receiving enhanced care |
|||
Child’s Age |
NHS Health Scotland Resources unless specified |
Assessment tools | |||
|---|---|---|---|---|---|
4 – 5 years |
What to expect after immunisation: babies and young children |
Play@home preschool book N.B Given out via education |
Toothbrush/Dental Pack |
Ages & Stages Questionnaire (ASQ) Strength based approaches to parenting |
|
Rory (Alcohol Focus Scotland) |
Oh Lila! (Alcohol Focus Scotland) |
4-5 years review form |
|||
Section 3: E-Learning and Evidence Resources for Practitioners
E-learning
To support the NHS workforce, wider public sector, private and third sector across Scotland with learning and development NHS Health Scotland hosts the Virtual Learning Environment (VLE) which is the learner management system used to deliver online learning. These e-learning modules cover a range of topics relevant to reviews with children, parents and families and take 1-2 hrs to complete each one. Staff can register for the VLE to access these resources, including forums, and can be worked through at their own pace.
Health Behaviour change eLearning suite
For instructions on how to register and enrol on our suite of Health Behaviour change eLearning modules and to access the e-learning modules http://elearning.healthscotland.com/course/index.php?categoryid=108
The suite includes the following modules
- Health Behaviour Change Level 1
- Health Behaviour Change Level 2
- Raising the issue of Alcohol
- Raising the issue of Child Healthy Weight
- Raising the issue of Physical Activity
- Raising the issue of Maternal and Infant Nutrition
- Raising the issue of Smoking
- Equalities and Human Rights
- Awareness raising on health inequalities (forthcoming)
- Tackling health inequalities (forthcoming)
Other relevant training includes:
- Building Compassionate Connections e-learning http://elearning.healthscotland.com/course/view.php?id=368
- Play@home Training for Trainers - contact nhs.HealthScotland-LWDTeam@nhs.net
For a summary of the best available evidence for a number of health improvement subject areas see Course: Resources for Specialist Community Health Nursing (Health Visiting) staff and students to support delivery of the Universal Health Visiting Pathway in Scotland, Pre-Birth to Pre-School | PHS Learning and for evidence summaries on areas including play, parenting, peer support for breastfeeding, Looked After Children see Children, Families and Maternity e-bulletin - Publications - GOV.UK
The Royal College of Paediatrics and Child Health (RCPH) e-learning on the healthy child programme – http://www.rcpch.ac.uk/hcp
Contact
Email: Liam.cahill@gov.scot