Our children and
young people
are healthy
Focussing on:
Babies born with
a low birth weight
Breastfeeding
rates, either fully
or partially at 6-8
weeks
% of reception
age children who
are overweight or
obese
March 2017
Progress report
on the Outcomes
Based Accountability
Process
Improving outcomes for young children in Jersey.
‘Our children and young people are healthy’
Focussing on:
• Babies born with a low birth weight
• Breastfeeding rates, either fully or partially at 6-8
weeks
• % reception age children who are overweight or obese
Progress report on the Outcomes Based Accountability
Process
March 2017
2
Contents
Background ................................................................................................................ 3
Turning the curve reports ........................................................................................... 7
Summary of recommendations for Steering Group .................................................. 11
Appendix 1: Turning the curve workshops: summary of discussions ....................... 14
1. Turning the curve on babies born with a low birth weight ..................................... 15
2. Turning the curve on breastfeeding rates ............................................................. 20
3. Turning the curve on obesity in young children .................................................... 23
Appendix 2: Turning the curve workshop attendees................................................. 27
Appendix 3: A rapid review of the evidence and policy context ................................ 31
Appendix 4: A map of early years service provision in Jersey .................................. 48
3
Background
In 2014, Optimus (founded by UBS) commissioned Professor Philip Wilson and Dr Louise
Marryat to examine opportunities for enhancing early childhood development. The report
uncovered a range of issues (e.g. a lack of data on children's developmental stage) that may
have a negative impact on children's early childhood experiences and later outcomes. The
report made several recommendations to help improve childhood experiences including:
- Improving current service provision (availability and quality of services);
- Improving access to services;
- Improving overall ECD capacity through better data collection systems and processes;
- Putting in place robust evaluation system for new services.
In response to the recommendations made in the above report, in late 2015 Optimus
Foundation appointed NCB as the partner of choice to support the Early Childhood
Development Programme (ECDP). The programme has five strands, including:
1. Development of an Outcomes Framework for Jersey, co-produced with stakeholders;
2. Securing the support of the States of Jersey Government for the project.
3. Implementation of evidence-based approaches to improve the quality of early years
settings and service provision (including extending the Making it REAL project1);
4. Supporting improved partnership, communication and collaboration across relevant
services
5. Dissemination of up to date knowledge of ‘what works’ to support early child
development, making it accessible to practitioners and parents.
NCB has facilitated the implementation of an Outcomes Based Accountability2 approach to
support improvements in children and young people’s outcomes. The approach, set out by
Mark Friedman in his book ‘Trying hard is not good enough’3 provides a disciplined way of
thinking to move from thought to action. Key definitions in this approach include:
1 Making it REAL sets out to improve the way practitioners work with parents; to hand over knowledge and build confidence through meaningful early literacy activities to support the early home learning environment and ultimately improve literacy and wider outcomes for young children and their families. 2 For more information on Outcomes Based Accountability (also known as Results Based Accountability) see: http://resultsaccountability.com/about/what-is-results-based-accountability/ 3 Friedman, M. (2005) Trying hard is not good enough: How to produce measurable improvements for customers and communities. PARSE Publishing.
4
Outcomes: conditions of well-being that we want to achieve for the overall population e.g.
all children, families and communities in Jersey
Indicators: measures that help quantify the achievement of these outcomes.
Turning the Curve: the planning process within OBA which helps to move from talk to
action and identify potential ‘what works’ ideas which will improve the prioritised indicators.
The ECDP is informed by the 1001 critical days manifesto4 and the work of the Jersey Early
Years taskforce. The vision is for all children and young people to grow up in a safe,
supportive Island community in which they achieve their full potential and lead happy,
healthy lives. Key outcomes are for all children and young people to:
• Be healthy;
• Be safe;
• Achieve and do;
• Grow confidently;
• Be responsible and respected; and
• Have a voice and be heard.
To support the prioritisation of these outcomes, and to select indicators on which to focus
initial work of the ECDP, an audit of available data was completed by NCB5. The audit
aimed to:
• Provide an overview of all available indicators data for children aged 0-18 in Jersey to
build a picture of children’s health and well-being
• To look more closely at indicator data for children aged 0-5 to identify where support is
most needed.
Following initial training in the Outcomes Based Accountability approach for key
stakeholders, the ECDP Steering Group met on 13th September 2016 to consider the first
outcome of focus, ‘All children in Jersey are healthy’, and agree a prioritised set of
4 The 1001 Critical Days: The importance of the conception to age two period. A cross-Party Manifesto. http://www.1001criticaldays.co.uk/sites/default/files/1001%20days_Nov15%20%2800000002%29.pdf 5 Jersey Early Childhood Development Programme. Report 1: An analysis of data on children and young people’s well-being and development. NCB, February 2017.
5
indicators. The steering group reviewed the full data report and used three criteria to
determine what indicators best informed the progress of an outcome:
• Communication power: does the indicator communicate to a broad and diverse
audience?
• Proxy power: does the indicator say something of central importance about the
outcome?
• Data power: do we have quality, reliable and consistent data on a timely basis?
Turning the curve on health indicators
Outcome: ‘All children and young people in Jersey are healthy’
Given the current data available the following indicators were chosen as the best fit6:
Prioritised indicators:
• Breastfeeding rates (either fully or partially) at 6-8 weeks
• % babies born with a low birth weight
• % reception age children who are overweight or obese
OBA encourages collaboration and engagement working towards overall outcomes. The
process for building that engagement is called “Turning the Curve”, and involves asking the
following questions:
1. What are the quality of life conditions we want for the children, adults and families
who live in our community? (outcomes)
2. What would these conditions look like if we could see or experience them?
3. How can we measure these conditions? (indicators)
4. How are we doing on the most important measures?
5. Who are the partners that have a role in doing better?
6. What might work to do better?
7. What do we propose to do? (Action plan)
6 P15, Jersey Early Childhood Development Programme. Report 1: An analysis of data on children and young people’s well-being and development. NCB, February 2017
6
A wide variety of stakeholders are invited to take part in Turning the Curve workshops to
examine each of the prioritised indicators and begin to inform what should happen to
improve that indicator. Two sets of these Turning the Curve workshops have taken place to
consider actions to move ahead on prioritised indicators (December 2016 & January 2017).
Alongside the audit of available data, NCB also completed an audit of the early years
services (conception to age 4) currently delivered in Jersey (see appendix 4), and provided
reviews of current evidence and relevant policy to inform the discussions on ‘what might
work to do better’. This additional information helps to better inform discussions at the
workshops.
This report sets out the progression on the selected health indicators, and includes:
• Turning the Curve one-page reports based on discussions at the workshops
• Recommendations for further consideration by the ECDP Steering Group.
• Full reports on detailed discussions at the Turning the Curve workshops (appendix 1)
• Full list of attendees who have been involved in the workshops (appendix 2)
• Reviews of evidence and policy to inform discussions (appendix 3)
• Service map of early years provision in Jersey (appendix 4)
7
Turning the curve reports
OUTCOME: All young children in Jersey are healthy
STORY BEHIND THE BASELINE
• Smoking during pregnancy
• Maternal health issues e.g. obesity, diabetes, mental health
• Social factors: economic downturn leading to poverty & deprivation
• Maternal age: high rate of older mums, some young mums
• High rate of IVF and therefore multiple births
• Prohibitive cost of accessing antenatal care and education
• Lack of legislation supporting access to healthcare
Suggestions for what might work:
• Improve uptake of current smoking cessation programme- e.g. opt out rather than opt-in, health needs assessment and referrals made at booking appointment, better sharing of information between healthcare professionals
• Preventative education in schools (for boys and girls)
• Engaging dads during antenatal period to educate and ensure they are equipped to support mum
• Flexible services to support working mums during pregnancy to enable them to make the most of support
Additional partners required:
• Midwives
• Wider health professionals (GPs, Paediatricians, social workers, dieticians)
• National Childbirth Trust (antenatal education providers)
• Parents
• Education & youth service reps
• Perinatal mental health/child health nurse
•
Data Development Agenda:
• Breakdown of data by maternal age
• Individual and family health history (e.g. smoking, pre-existing medical conditions, social care, prior interventions, family health trends
• Length of residency in Jersey
INDICATOR: % babies born at a low birth weight (below 2.5kg)
% babies born at a low birth weight in relation to gestational age
0
1
2
3
4
5
6
2012 2013 2014 2015
Per
cen
tage
Babies birth weight in relation to gestational age
% small for gestational age % large for gestational age
Source: Public Health Statistics Unit, States of Jersey (2017)
Source: Jersey Health Intelligence Unit (2016)
9
OUTCOME: All young children in Jersey are healthy
STORY BEHIND THE BASELINE
• Baby Friendly Initiative not currently implemented, but planned for 2017
• High Caesarean rates
• Higher maternal age in Jersey
• Current maternity legislation, high rates of working mothers
• Lack of universal antenatal education
• Cultural and generational attitudes to breastfeeding
• Lack of data sharing facilities between health professionals and inconsistency in messaging given
Suggestions for what might work:
• Implementation of the Baby Friendly Initiative (planned 2017)
• Education for healthcare practitioners (all those who have contact with an expectant mother) to ensure consistent messaging
• Roll out of a universal antenatal education programme e.g. a modified version of NSPCC Baby Steps
• Change in legislation to support longer paid maternity leave
• Focus on peer support training and provision
• Cultural/attitudinal change through public awareness campaign
• Rebranding of programmes/initiatives already in place to make more inclusive e.g. currently have breastfeeding cafes which could be renamed ‘infant feeding group’ to include support for weening etc., These should be women only (low cost)
• Education for the wider family, and in particular involving dads
Partners required:
• Wider relevant health professionals including GPs and Paediatricians,
• Education practitioners
• Parents / parents to be
• Wider family, in particular dads and grandparents
• Chamber of Commerce
• Social Security
• Social Security representative
• Education practitioners (representing all school ages as preventative role as important)
Data Development Agenda:
Information needed on drop-off point for breastfeeding and reasons behind stopping:
• Initiation rates for exclusive breastfeeding
• Breastfeeding rates at discharge and 14 weeks currently collected
• Ideally would like data at 6 months- currently pick this up retrospectively at 9 months
• How many mums gave up breastfeeding on return to work
• Reasons why mums give up breastfeeding
INDICATOR: Breastfeeding rates (either fully or partially) at 6-8 weeks
Source: Jersey Health Intelligence Unit (2016)
10
OUTCOME: All young children in Jersey are healthy
STORY BEHIND THE BASELINE
• Changes in modern living- working parents, driving rather than walking, technology, move away from compulsory PE
• Pressure on parents from media to provide treats
• The price of ‘healthy’ foods compared to ‘junk’
• Lack of skills, opportunities and facilities (in particular inadequate housing – bedsits etc.) to prepare healthy meals.
• Differences in preschool provision for hot meals- private vs state
• Family dynamics and cultural differences
• Food and nutrition strategy due shortly
Suggestions for what might work:
• Junior Parkrun
• Children’s menus in restaurants (mini portions of adult food)- Links to ‘Real food for kids’ scheme (Caring Cooks & Co-op initiative)
• Cross-departmental forum to share good practice
• Free fruit in supermarkets (Tesco already running this)
• Community mobile outreach re cooking skills, specifically targeted at minority ethnic groups and providing bilingual support to reduce inequalities (Caring Cooks** planned initiative)
Partners required:
• Nursery/primary education representative
• Jersey sports partnership
• Parent representative from target groups
• Retail Steering Group representative/ Chamber of Commerce
• Wider healthcare professionals e.g. GPs, paediatricians
• Practitioners working with Polish/Portuguese families
• Private health providers (Cleaveland Clinic, Leicester Surgery)
• Relevant Ministers
Data Development Agenda:
• Parish information on nutritional provision in pre-schools
• Data on eating behaviours of young children (e.g. fruit intake)
• Information on ethnic/cultural differences in dietary habits
• What proportion of 2 year olds are currently overweight?
• Relative food costs (e.g. Jersey vs UK)
• Physical aspects of the curriculum e.g. knowing about outdoor space
• Children’s dental health
Source: Child Health System, Public Health, Jersey (2016)
INDICATOR: % reception age children (typically age 4 or 5) who are overweight or obese
Summary of recommendations for Steering Group
1. % babies born at a low birth weight (below 2.5kg)
% babies born at a low birth weight in relation to gestational age
Suggestions for what might work:
• Improve uptake of current smoking cessation programme- e.g. opt out rather than
opt-in, health needs assessment and referrals made at booking appointment,
better sharing of information between healthcare professionals
• Preventative education in schools (for boys and girls)
• Engaging dads during antenatal period to educate and ensure they are equipped
to support mum
• Flexible services to support working mums during pregnancy to enable them to
make the most of support
Actions: A new indicator, ‘birth weight by gestational age’ has since been developed and
first data is now available. This shows that only 2% of babies born in 2015 had a low
birthweight for gestational age, suggesting less of an issue than initially considered. It is
proposed that no further work to be undertaken in relation to the low birth weight indicator,
and efforts are refocused on the other priority indicators.
2. Breastfeeding rates (either fully or partially) at 6-8 weeks
Suggestions for what might work:
• Implementation of the Baby Friendly Initiative (already planned but impact won’t be
immediate)
• Roll out of a universal antenatal education programme e.g. a modified version of
NSPCC Baby Steps
• Education for healthcare practitioners (all those who have contact with a pregnant
person) to ensure consistent messaging which is informed by service user
feedback
• Statutory support- primarily a change in legislation to support longer paid maternity
leave
• Focus on peer support training and provision
12
• Rebranding of programmes/initiatives already in place e.g. currently have
breastfeeding cafes which could be renamed ‘infant feeding group’ to include
support for weening etc., using language that is more inclusive. These should be
women only (low cost)
• Education for the wider family, and in particular involving dads
Action: Ideas of what might work to be considered by ECDP Steering Group for
discussion, priority actions agreed and action plan developed.
3. % reception age children (typically age 4 or 5) who are overweight or obese
Suggestions for what might work:
• Junior Parkrun
• Children’s menus in restaurants (mini portions of adult food)- Links to ‘Real food
for kids’ scheme (Caring Cooks & Co-op initiative)
• Cross-departmental forum to share good practice
• Free fruit in supermarkets (Tesco already running this)
• Community mobile outreach re cooking skills, specifically targeted at minority
ethnic groups and providing bilingual support to reduce inequalities (Caring
Cooks** planned initiative)
Action: Ideas of what might work to be considered by ECDP Steering Group for
discussion, priority actions agreed and action plan developed.
Consideration to be given to the forthcoming Food and Nutrition Strategy (pending) and
any potential overlap with this work.
Next Steps in the OBA process:
• Consider stakeholders who have been involved in the Turning the Curve process
to date and identify gaps where further stakeholder engagement would be
beneficial. Consider the option of one to one interviews with these identified
partners if required. Proposed stakeholders include:
- GPs
- Business/Chamber of Commerce rep
- NCT
- Parents- new or expectant
- Sport rep (e.g. Jersey Sports Partnership)
13
- Relevant Ministers (Louise Doublet, Tracey Vallois suggested)
- Perinatal mental health nurse (Liz Auld suggested)
• Review of existing evidence on suggestions for what might work, to inform
discussion by ECD Programme Steering Group. Decisions to be made on actions
to improve health outcomes for young children in Jersey.
• Development and implementation of action plans.
14
Appendix 1: Turning the curve workshops: summary of discussions
1. Turning the curve on babies born with a low birth weight
Population: All young children in Jersey…
Outcome: …are healthy
Indicator: % of babies born with a low birth weight (below 2.5kg)
Baseline data:
Midwives advised of a new measurement being collected: low birth weight for gestational
age (below the 10th percentile as per the WHO Child Growth Standards). First data available
Jan 2017. Without available data (Dec 2016), midwives developed the working baseline
below based on collective knowledge:
Direction of curve to turn
Direction of curve to turn
16
The story behind the baseline:
• Smoking during pregnancy is thought to be by far the biggest factor impacting
low birth weight of baby
• Other maternal health factors or conditions, such as obesity, high blood pressure,
diabetes, or anorexia, mental health issues, depression or anxiety, substance misuse
• Social factors, including the economic downturn, poverty and deprivation
• Maternal age: in particular, the increase in the number of older mums (35+) in
Jersey. Younger mums are also more likely to have a low birth weight baby,
although this isn’t as big an issue in Jersey.
• The higher rate of IVF has increased the rate of multiple births, which in turn are
more likely to be low birth weight babies.
• The cost of accessing antenatal care is currently prohibitive and therefore we are
missing a vital opportunity to educate pregnant mums and their partners.
• The lack of legislation supporting access to healthcare is seen as a barrier to
accessing appropriate support and services.
• Several services already exist which were felt to contribute positively to this indicator,
including:
- Baby Steps (NSPCC)
- MECSH
- Ante-natal care / midwifery
- Bumps and Babies (NCT)
- Preventative education in schools
- Help to Quit – referrals to service
- Brighter Futures
- Pathways (FNHC)
Data Development Agenda: To further inform the story behind the baseline, attendees felt
it would be useful to look at data broken down at the following levels:
• Gestational age
• Maternal age
• Pre-existing medical conditions of mother
• Prior interventions received
• Smoking history
• Family health and social care history
• Length of residency in Jersey - this may impact on entitlement to claim benefits.
17
• How does quality of care and subsequent outcomes for Jersey compare to other
areas e.g. UK and further.
Additional partners to be involved:
• Midwives are key- ongoing engagement needed with pregnant mums & partners
• Wider health professionals, including obstetricians, GPs, paediatricians, dieticians,
smoking cessation programme practitioners, social workers
• Charity/voluntary sector representatives e.g. Caring Cooks
• Statisticians
• Schools/education/youth service representatives
• Parents to be
• EAL representatives
• National Childbirth Trust
• Perinatal Nurse/Child mental Health Nurse (Liz Auld suggested)
Suggestions for what might work prioritised?
1. Improve uptake of smoking cessation programme currently in place – ideas include
changing how it is offered, i.e. referring all mothers identified as smoking at booking
appointment, rather than self-referral. Could also consider opt-out method rather
than ‘opt in’. (low cost)
2. Preventative education in schools. In particular, preventative education programme
on healthy lifestyle choices, and the impact of poor health choices during pregnancy
for babies, should be standardised across schools and delivered to both boys and
girls, aged 14-16. Although currently covered in the curriculum, it isn’t examined
therefore not given the focus that it should be, and lacks consistency from school to
school.
3. Completion of a health needs assessment at the booking stage to identify ‘at risk’
mothers earlier. Additionally, timely sharing of information from midwife to health
visitor when an ‘at risk’ pregnant mother is identified at booking appointment,
ensuring that early support can be offered within window of opportunity for change.
4. Engaging dads throughout the antenatal period to ensure they are informed and
educated & are equipped to support mums, particularly on health and lifestyle
factors impacting on birth weight. Recent change in legislation means fathers now
have parental responsibility and their wider involvement must be supported.
18
5. Services that are available to support working mums during pregnancy should be
flexible to maximise accessibility, e.g. appointments offered in the evening rather
than during the working day. Flexibility of employers also needed to facilitate
attendance at day time appointments.
6. Provision of vouchers for fresh fruit and vegetables for pregnant mums.
Actions taken and recommendations for consideration by the Steering Group
The audit of data completed by NCB (Dec 2016) alongside the discussions at the TTC
workshops have highlighted the need for good quality data to demonstrate effectively the
issues facing young children. Discussions around birthweight brought up the concern that
babies born early would naturally weigh less; it was felt that weight relative to gestational
age would be a more representative statistic. The Department of Health have now
confirmed that this data is available and will be reported moving forward.
New indicator ‘Baby birth weight in relation to gestational age’
The following information has been provided by the Department of Health, States of Jersey:
A baby is considered to be of healthy birthweight (a weight appropriate for its gestational
age) when it lies between the 5th and 95th centile for weight at its gestational age. Babies
whose birthweight is above the 95th centile are considered ‘large for gestational age’,
while those below the 5th centile are considered ‘small for gestational age’.
Gestational age is a way of expressing the age or development of a baby. It is typically
based on an antenatal ultrasound scan; however, it may also be estimated from the number
of weeks since the mother's last normal menstrual period.
The data used in this indicator are produced by comparing the birthweights and gestations of
births of Jersey resident babies with a set of standard tables based on
UK-WHO Child Growth Standards (UK 1990).
19
Source: Public Health Statistics Unit, States of Jersey
Coverage of indicator: 92% (2012) – 97% (2015)
The first data available on this new indicator shows only 2% of babies born in 2015 had a
low birthweight for gestational age, suggesting less of an issue than first thought.
This new data does however show that 5% of babies are born overweight for gestational
age; we suggest that this is the more pressing issue, and should be considered in
conjunction with the third indicator ‘children who are overweight or obese at reception age’.
The way ahead:
No further work to be undertaken in relation to babies with a low birth weight for gestational
age, however the data from this new indicator will contribute to the story behind the baseline
for indicator 3: ‘reception age children who are overweight or obese’.
0
1
2
3
4
5
6
2012 2013 2014 2015
Per
cen
tage
Babies birth weight in relation to gestational age
% small for gestational age % large for gestational age
20
2. Turning the curve on breastfeeding rates
Population: All young children in Jersey…
Outcome: …are healthy
Indicator: Breastfeeding rates (either fully or partially) at 6-8 weeks
Baseline:
Source: Jersey Health Intelligence Unit, 2016
The story behind the baseline:
• Baby Friendly Initiative not currently implemented however this is planned (2017) and
should increase breastfeeding rates longer term (although not expected to produce
an immediate change due to implementation timeframe).
• High caesarean rates (30%) and higher maternal age (35+) in Jersey- both have
been identified in evidence as having a negative impact on breastfeeding rates.
• Current maternity legislation is not supportive of breastfeeding, in particular the return
to work policy and current short paid maternity leave. A review of legislation is
currently ongoing however no update has yet been provided.
Direction of curve to turn
21
• Linked to above, Jersey currently has the highest rates of working mothers in the
world.
• Lack of provision of universal antenatal programme across Jersey, due to staff
capacity issues; parents are not receiving the education that they need which may
impact on decision to initiate/continue breastfeeding.
• Society and attitudes to breastfeeding create a negative and unsupportive culture
which may act as a deterrent to breastfeeding. Wider family involvement and support
needed e.g. older generations, dads etc. There are also changing family structures
and lack of close family nearby to support, particularly a concern for immigrant
families.
• There appears to be inconsistent information on breastfeeding provided by different
healthcare professionals due to varying knowledge base.
• Data can’t be shared between midwives and health visitors which is an obstacle in
providing the bigger picture for individual mums to be.
Data Development Agenda:
• Need to be able to identify drop-off point for breastfeeding so need to collect/collate
data at additional points in time.
o Initiation rates for exclusive breastfeeding
o Breastfeeding rates at discharge and 14 weeks currently collected
o Ideally would like data at 6 months- this is currently picked up retrospectively
at 9 months
• How many mums gave up breastfeeding on return to work or cite this as the reason
they gave up?
• Information to be included from other sources such as breast feeding working group
(chaired by Michelle Cummings), and Chamber for Commerce (alongside States of
Jersey, this is the biggest employer)
• Length of residency & parish of residency
Additional partners to be involved
• Wider relevant health professionals including GPs and Paediatricians,
• Parents / parents to be
• Wider family, in particular dads and grandparents
• Chamber of Commerce/ business representatives
22
• Social Security representative
• Education practitioners (representing all school ages as preventative role as
important)
Suggestions for what might work prioritised?
1. Implementation of the Baby Friendly Initiative (already planned but impact won’t be
immediate)
2. Roll out of a universal antenatal education programme. Consideration should be
given to customising the NSPCC Baby Steps programme to become a universal
programme for all- this programme begins earlier in pregnancy than traditional ante-
natal education, therefore provides opportunity to get information to mothers at risk of
having a low birth weight baby. Could also consider other dissemination methods for
educational information to make it more accessible e.g. leaflets at the GP, pharmacy
etc.
3. Education for healthcare practitioners (all those who have contact with a pregnant
person) to ensure consistent messaging which is informed by service user feedback
4. Statutory support- primarily a change in legislation to support longer paid maternity
leave
5. Focus on peer support training and provision
6. Rebranding of programmes/initiatives already in place e.g. currently have
breastfeeding cafes which could be renamed ‘infant feeding group’ to include support
for weening etc., using language that is more inclusive. These should be women only
(low cost)
7. Education for the wider family, and in particular involving dads
The way ahead
Ideas for what might work to be considered by ECDP Steering Group for discussion, priority
actions agreed and action plan developed.
23
3. Turning the curve on obesity in young children
Population: All young children in Jersey…
Outcome: …are healthy
Indicator: % reception age children who are overweight or obese
Baseline:
Source: Child Health System, Public Health Jersey (2016)
The story behind the baseline:
• Inconsistency in education and information provided to parents around healthy
choices, including at the antenatal stage and in the early years. Lack of school
education too, e.g. home economics
• Changes in modern living- working parents, density of road and therefore
convenience of driving rather than walking, general lack of physical activity
opportunities, technology, compulsory PE
Direction of curve to turn
24
• Pressure on parents from media- the need to provide treats and price of ‘healthy’
foods compared to ‘junk’. Demands from children.
• Lack of skills, opportunities and facilities (in particular inadequate housing – bedsits
etc.) to prepare healthy meals for children. Particularly a problem for low income
families.
• Differences in preschool provision for hot meals- private day-care likely to provide hot
healthy meal while state preschools are less so.
• Cultural challenges, in particular availability of healthy eating information in
appropriate translations to ensure accessible for Polish and Portuguese people
• Changing family dynamics- cooking skills and knowledge previously handed down
however many families no longer have extended families living nearby to provide this
support.
• Nurseries currently provided with nutritional guidance, however no knowledge in the
system about what is done with this information.
• Lots of existing programmes in place, e.g. mile a day happens in some schools,
some nurseries have their own chefs, parent cooking classes are available, however
again consistency is an issue
• Work-life balance- Parents are ‘time poor’ which may impact their ability to prepare
healthy meals
• Convenience and processed foods perceived to be cheaper and more accessible
than healthy ones
• Draft food and nutrition strategy is due to be launched early 2017, so by 2020
positive changes in trend should begin to be evident. Healthy Start vouchers are
beginning in 2018.
• Impact of potential sugar tax
• Healthy School Programme
• Improving the Public Realms Strategy- which will support improvement in public play
and outdoor spaces
• 4 steps to a fitter future campaign
Data development Agenda
Further information to inform the story behind the baseline include:
• Information on nutritional provision in pre-schools broken down by parish
• Data on eating behaviours of young children (e.g. data on fruit and veg intake - this is
currently collected for older age groups, Year 6 etc.)
25
• Information on ethnic/cultural differences in dietary habits
• What proportion of 2 year olds are currently overweight? (based on health visitor
growth measurements), broken down by postcode/school
• Relative food costs (e.g. Jersey vs UK)
• Physical aspects included the curriculum e.g. knowing about outdoor space
• Children’s dental health
Additional partners to be involved:
• Nursery/primary education representative
• Jersey sports partnership
• Parent representative from target groups (ID’d via data)
• Retail Steering Group representative (Chamber of Commerce/Department of
Economic Development)
• Wider health practitioners e.g. GPs, paediatricians, dentists
• Practitioners working with Polish/Portuguese families
• Private health providers (Cleaveland Clinic, Leicester Surgery)
• Ministers (in particular Louise Doublet, Tracey Vallois)
Suggestions for what might work prioritised*:
1. Invest in ‘Real food for Kids’ programme, a partnership developed by Caring Cooks
in conjunction with Co-op and working with farms, shops, restaurants and
incorporating a half price scheme on adult food in restaurants for children. (Melissa
Nobrega key contact).
2. Children’s menus in restaurants as small portions of healthier adult choices rather
than burgers/sausages/chips etc.
3. Community mobile outreach on cooking skills, specifically targeted at minority ethnic
groups and providing bilingual support to reduce inequalities (Caring Cooks**
planned initiative – contact as above).
4. Cross-departmental/ cross-sectoral steering group with an interest in children’s
nutrition (led by education) to be formed to provide a forum for sharing good practice
and ensuring consistency of messaging throughout the life course.
5. Implementing Junior Parkrun (for young children)- Parkrun already in place
6. Free fruit on entering supermarket (this is already in place in Tesco)
7. Vouchers for fruit and vegetables
26
*Draft Food & Nutrition Strategy is due to be launched in early 2017 by department of
Health, this could provide a policy vehicle by which to move forward with these
actions and inform content of existing broad actions; important to make links. (Martin
Knight key contact)
**Steering Group noted that the focus must be on 0-5 year olds- Caring Cooks focus
is school age upwards.
The way ahead:
Ideas for what might work to be further distilled and presented to ECDP Steering Group for
discussion, agreement of priority actions and development of an action plan.
27
Appendix 2: Turning the curve workshop attendees
28
TTC Attendees: Monday 5th December 2016
Indicator
Name Organisation Low Birth
Weight
Breastfeeding
Rates
Obesity
Melissa
Nobrega
Caring Cooks of Jersey x
Martin Knight Head of Health
Improvement, States of
Jersey
x
Fiona Vacher JCCT x
Julie Mycroft Head of Midwifery x x x
Kerrie Touzel Little Oaks Nursery x
Jessica May Public Health x x x
Julie
Luscombe
Public Health x
Marie Raleigh Family Nursing & Home
Care
x x
Racheal
Stewart
Early Help Coordinator x x x
Kathy Palmer Community Midwifery
Manager
x x x
Sarah Wright Family Nursing & Home
Care
x x x
Jane Bravery Early Years Inclusion Team x x x
Mandy Le
Tensorer
Child Accident Prevention x x x
Kirsten Park Brighter Futures x
Urszela Sliwka Research Student x x x
Rhonda Hales Ante-natal Clinic Manager x x
Penny Byrne JCCT Trustee x x
Michelle
Cummings
Family Nursing & Home
Care
x
12 13 12
29
TTC attendees: Monday 23rd January 2017
Indicator
Name Organisation Low Birth
Weight
Breastfeeding
Rates
Obesity
Monica
Fernandes Westmount Day Nursery
x
Urszula Sliwka Health/Research Student x x
Jill Birbeck Head of Health Intelligence x x
Anna Hamon
Policy Officer, Social
Policy
x x x
Gill Speed Manager, Pathways x x x
Lisa Nash Midwife x x
Nicky Hay Nursery Teacher x x x
Julie
McCallister
Early Years Advisory
Teacher
x
Emma Eden Nursery Manager x x
Cathy Hamer Chair, EYCP x
6 6 8
The following gaps in terms of contributing stakeholders were identified during TTC
workshops:
Low Birth Weight Breastfeeding Rates Obesity
• Midwives are key-
ongoing engagement
needed with pregnant
mums & partners
• Wider health
professionals, including
obstetricians, GPs,
Paediatricians,
dieticians, smoking
cessation programme
• Wider relevant health
professionals including
GPs and Paediatricians,
• Education practitioners
• Parents / parents to be
• Wider family, in
particular dads and
grandparents
• Chamber of Commerce
• Social Security
representative
• Nursery/primary
education representative
• Jersey sports
partnership
• Parent representative
from target groups (ID’d
via data)
• Retail Steering Group
representative (Chamber
of
Commerce/Department
30
practitioners, social
workers
• Charity/voluntary sector
representatives e.g.
Caring Cooks
• Statisticians
• Schools/education/youth
service representatives
• Parents to be
• EAL Service
• Representative from
NCT
• Perinatal Nurse/Mental
Health Nurse – (e.g. Liz
Auld)
• Education practitioners
(representing all school
ages as preventative
role as important)
of Economic
Development)
• Diverse representation
for cultural input
• Wider health
practitioners e.g. GPs,
paediatricians
• Practitioners working
with Polish/Portuguese
families
• Private health providers
(Cleaveland Clinic,
Leicester Surgery)
• Ministers (Louise
Doublet, Tracey Vallois)
31
Appendix 3: A rapid review of the evidence and policy context
to inform turning the curve on low birth weight, breastfeeding
rates and childhood obesity
32
Introduction
To inform the ‘Turning the Curve’ discussions, NCB has compiled a brief overview of local
policies, services and highlights from contemporary published evidence on influential factors
and what might work to:
1 Reduce the number of babies born with a low birth weight
2 Increase breastfeeding rates (either full or partially) at 6-8 weeks
3 Reduce the % of reception age children who are overweight or obese
Which Jersey strategy/policy documents are relevant to these issues?
Children and young people specific documents
Children and Young People: A strategic framework for Jersey7 (Nov 2011): Which sets
out what is to be achieved for children and young people under six outcomes (be healthy, be
safe, achieve and do, grow confidently, be responsible and respected, have a voice and be
heard) and aims to facilitate better collective decision making about the services and
facilities needed. The document makes specific reference to concerns about pre-term births,
low birth weights, breast-feeding rates and obesity in young children and alludes to several
activities that were being developed to bring about improvements in these areas.
1001 Critical Days manifesto (January 2015): lays the foundation to give every child in
Jersey the Best start in life. Supported by the 1001 Days and Early Years Taskforce. 1001
Days commits to the wider implementation of the UNICEF Baby Friendly Initiative.
Wider policies/strategies
States of Jersey, Strategic Plan 2015-20188: which lists improving health and well-being
as one of the Council’s priorities and specifically refers to the development of a new ‘Health
7 https://www.gov.je/SiteCollectionDocuments/Government%20and%20administration/R%20StrategicFrameworkFullVersion%2020111121%20CPG%20v1.pdf 8 http://www.gov.je/SiteCollectionDocuments/Government%20and%20administration/R%20States%20of%20Jersey%20Strategic%20Plan%202015-18%2020150430%20VP.pdf
33
and Wellbeing Framework’ including a strategy on food and nutrition and a new strategy for
Children’s Services.
Health and Social Services: A new way forward (20129): outlines proposed changes to
health and social care for the next 10 years in Jersey and covers three planning phases
2013 – 15, 2016 – 18 and 2019 – 2021. In the first phase, early intervention services for
children aged 0-5 was identified as a priority area and included improving skills & knowledge
about parenting, with particular focus on the antenatal period, increased community
midwifery to offer choice of service and location for antenatal care and specific early
intervention services for families with additional needs during the antenatal period.
Mental health strategy for Jersey 2016-202010: includes a commitment to prevention
services for ante- and post-natal care.
Sustainable Primary Care Strategy for Jersey 2015-202011: this strategy sets out the
future plans for the delivery of primary care services which include Family Nursing & Home
Care and the childhood immunisation programme.
Sports Strategy: In 2013, the Fit for Future Strategy was launched covering the period
2014-2018 and set out to promote sports and physical fitness activities. Its aims to promote
uptake of sports activities from a very early age both within school and outside of school. As
well as providing general support to schools and to those who work with children and young
people, the strategy contained specific commitments to invest in particular sports such as
swimming.12
9 http://www.statesassembly.gov.je/AssemblyPropositions/2012/P.082-2012.pdf 10 https://www.gov.je/SiteCollectionDocuments/Health%20and%20wellbeing/R%20Mental%20Health%20Strategy%2020151105%20LJ.pdf 11 https://www.gov.je/SiteCollectionDocuments/Health%20and%20wellbeing/R%20Sustainable%20Primary%20Care%20Strategy%2020151204%20LJ.pdf 12https://www.gov.je/SiteCollectionDocuments/Government%20and%20administration/C%20Sports%20Strategy%20%20Phase%202%2020131014%20TM.pdf
34
1. Increasing breastfeeding rates (either full or partially) at 6-8 weeks
What relevant service provision currently exists in Jersey?
Local services which will have a role to play in increasing breastfeeding rates include:
• Breastfeeding Buddies
• Midwives
• NCT Antenatal courses
• Community Nursery Nurse
• GP
• Well Baby & Child Health Clinics
• Health Visiting
• MESCH/MESCH Playgroup
• Baby Steps
• Little Gems
What does the evidence tell us about influential factors and what might work?
As breastfeeding has been shown to have a positive impact across a wide range of infant
and parent outcomes, including physical health, social and emotional development and
attachment, interventions to encourage and increase breastfeeding rates are widely
evidenced worldwide.
Influencing factors:
The following key factors have been identified as having a potential impact on breastfeeding:
• Father and wider family support
• Post Natal Depression
• Low birth weight
• Age of mother
• Socio-economic background of mother
• Employer support
• Deprivation
• Caesarean
35
• Ethnic background
• Restrictions on marketing strategies for formula
Some of the key reasons identified reasons for stopping breastfeeding include:
• Physical difficulties (for mother or infant, e.g. mastitis, tongue-tie (evidence still
uncertain as to extent that this is a problem)
• Concerns about the infant’s growth, i.e. they aren’t getting enough nutrition
• Negative public perceptions of breastfeeding, making it more difficult to continue
Main factors influencing a woman’s choice to breastfeed13:
• Bonding/attachment and the positive impact that breastfeeding has.
• Body image, insecurity and dislike of the physical act of breastfeeding- mostly a
negative impact
• Self-esteem/confidence- new mothers not breastfeeding often felt guilt that it was
part of their role as a ‘good mother’ and they were failing.
• Female role models: exposure to breastfeeding mothers throughout pregnancy has a
positive impact on their own decision to breastfeed. ‘Horror stories’ of bad
experiences can have a negative impact. Support from those immediately
surrounding the new mother (including partner and close family). Peer support
networks are also important.
• Lifestyle: including work or educational commitments and how breastfeeding can be
fitted in. Also, perceived impact on social life, including lack of facilities for
breastfeeding in public which limits the options for some breastfeeding mums.
• Social attitudes to breastfeeding in public.
• Knowledge and source of education: information from health professionals can have
both positive and negative impact. Some new mums felt professionals could be
pushy and judgemental, with information given out biased towards breastfeeding.
The ecological model is important here, as these factors don’t all work in isolation, rather it is
the combination of several which will impact breastfeeding.
13 C.L. Roll, F. Cheater. A rapid review of factors affecting a new mother’s attitude to breastfeeding. International Journal of Nursing Studies 60 (2016) 145–155
36
What works to support breastfeeding?
The WHO & UNICEF Baby Friendly Initiative14 (which Jersey signed up to as part of the
1001 critical days manifesto) is an accreditation scheme developed in 1994 and aiming to
educate and equip practitioners to promote and support breastfeeding. The approach is
evidence based and identifies the following10 steps to successful breastfeeding:
• Have a written breastfeeding policy that is routinely communicated to all healthcare
staff
• Train all healthcare staff in skills necessary to implement this policy
• Inform all pregnant women about the benefits and management of breast feeding
• Help mothers initiate breast feeding soon after childbirth
• Show mothers how to breast feed and maintain lactation, even if they should be
separated from their infants
• Give new-born infants no food or drink other than breast milk, unless medically
indicated
• Practice rooming in—allow mothers and infants to remain together 24 h a day
• Encourage breast feeding on demand
• Give no artificial teats or pacifiers (dummies or soothers) to breastfeeding infants
• Foster the establishment of breastfeeding support groups and refer mothers to them
on discharge from the hospital or clinic
Various reviews of the impact of the BFI15 have been carried out and show a range of
positive impacts, including the increased initiation of and continuation of breastfeeding.
Interventions and approaches to support breastfeeding are generally targeted at the
following key areas:
• Antenatal education
• Peer support:
• Education and support for the partner and wider family
• Midwives role in supporting breastfeeding
14 https://www.unicef.org.uk/babyfriendly/what-is-baby-friendly/ 15 Being baby friendly: evidence-based Breastfeeding support J Cleminson, S Oddie, M J Renfrew and W McGuire (2014) Archives of Disease in Childhood. Fetal and Neonatal Edition Volume: 100 Issue 2 (2015)
37
• Maternity leave and employer support
Antenatal education
In the period building up to the birth, antenatal education provides an opportunity to improve
knowledge and understanding of both parents on the benefits of breastfeeding. Education
has been shown to increase openness to breastfeeding, however alone it doesn’t
necessarily increase uptake. Antenatal education must also focus on develop a mother’s
confidence and self-esteem, which has been shown to increase likelihood of initiation of
breastfeeding16. Discussions on antenatal education include:
• Timing of education: antenatal education combined with practical support
immediately after birth is most effective.
• Natural process vs a skill to be learned: a combination approach is considered the
best approach to be taken in antenatal education. This removes the burden of
‘failure’ from women who have difficulty in initiating breastfeeding, while recognising
the mother’s initiative and experience. 17
• First time mothers were shown to particularly benefit from antenatal education on
breastfeeding, however practical guidance must be combined with knowledge on the
benefits of breastfeeding to the baby, and a strengths based model is recommended
to build self-confidence and self-esteem in the mother.
Peer support18
• A Cochrane review19 of 56,000 mother-infant pairs globally showed that those
receiving additional peer of professional support were more likely to breast feed
(exclusively or not) for a longer duration.
• Peer support has been shown to have a beneficial impact on breastfeeding initiation
and continuation, particularly when provided both pre and post-natally, and when
combined with a wider primary care package.
16 Avery A., Zimmermann K., Underwood P.W. & Magnus J.H. (2009) Confident commitment is a key factor for sustained breastfeeding. Birth 36 (2), 141–148 17 Locke, A. (2009) Natural versus taught: competing discourses in antenatal breastfeeding workshops. Journal of Health Psychology, 2016, vol 14 (3), pp 435-446 18 Ingram, J. (2013) A mixed methods evaluation of peer support in Bristol, UK: mothers’, midwives’ and peer supporters’ views and the effects on breastfeeding. BMC Pregnancy and Childbirth (2013) vol 13, p192 19 Renfrew MJ, McCormick FM, Wade A, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Systematic Review 2012;(5):CD001141
38
• Universal antenatal peer support doesn’t necessarily increase breastfeeding initiation
rates alone; however targeted peer support has been shown to be beneficial for
some. Peer support has been shown to be particularly beneficial in areas of
deprivation or more rural areas.
• Peer support has been found to increase self-confidence and self-esteem, improve
knowledge and change attitudes to breastfeeding, which may in turn support
continued breastfeeding.
Education and support for the wider family
Wider support for new mothers has a significant impact on their likelihood of sustained
breastfeeding. While to a lesser extent than previous generations, new mothers still gain
much of their knowledge on breastfeeding from their own mothers and close female
relatives. Education and support must therefore focus on these key influences in a new
mother’s life. Partners are also critical, with mothers more likely to initiate and sustain
breastfeeding if they have a supportive partner. One study20 on dad’s thoughts on
breastfeeding showed that:
• Fathers were generally positive about their partners breastfeeding and had some
knowledge of the benefits
• Most fathers felt it was the mother’s choice as to whether she breastfed or not.
• Fathers would like to receive more information, directed specifically at them, showing
how they can practically support their partner in breastfeeding.
• They want to know more about the health benefits for the baby
• Fathers feel excluded by healthcare professionals during the breastfeeding education
and initiation process and must be recognised as a key partner in the process.
Midwives role in supporting breastfeeding
A systematic review21 of midwives’ experience of supporting breastfeeding mums identified
the following key issues:
20 Brown, A. & Davies, R. (2014) Fathers’ experiences of supporting breastfeeding: challenges for breastfeeding promotion and education. Maternal and Child Nutrition (2014), 10, pp. 510–526 21 Swerts, M., Westhof, E., Bogaerts, A., Lemiengre, J. Supporting breast-feeding women from the perspective of the midwife: A systematic review of the literature. Midwifery, 37 (2016), pp32-40
39
Midwifery care is considered either:
• Breast-centred, where the technical process of delivering food to the baby is the
central goal, and the midwife is a ‘technical expert’ and the woman a novice who
needs taught what to do. Often very hands on and impersonal, the woman is treated
as a ‘milk-producing machine’ and language used is often patronising e.g. sweetie,
ladies, girls.
• Person centred, where the focus is on the attachment relationship and the role that
breastfeeding can play- here, the midwife is seen as a ‘skilled companion’. The
woman is recognised as having the ability to breastfeed autonomously and the
midwife is a companion who supports as and when needed.
Barriers to providing effective support include:
• Time restraints
• Staffing capacity in hospitals, leading to high caseloads
• Frustrations at conflicting advice from other health professionals e.g. paediatricians.
GPs
• Personal experience of the midwife of breastfeeding may influence their own
approach- some without children were seen as not fully understanding the
complexities.
• Midwives have been seen to ignore hospital or policy guidelines and give baby a
bottle when the mother has intended to breastfeed exclusively- this may be down to
capacity issues.
Factors contributing to more effective support by midwives include:
• Commitment to evidence based practice and guidelines, e.g. WHO
• Job satisfaction.
Maternity leave and employer support
A sufficient period of maternity leave is essential to enable mothers to establish and continue
breastfeeding their babies. Indeed, evidence suggests that mothers who intend to return to
work full time are less likely to initiate breastfeeding22. Jersey currently has the highest
population of working mothers in the world. Statutory maternity leave in Jersey is currently
22 https://www.cdc.gov/breastfeeding/pdf/BF_guide_2.pdf
40
up to 18 weeks, however the 1001 Days taskforce recognises the need to increase this to 26
weeks (in line with rest of UK), and preferably 52 weeks to give mothers the opportunity to
sustain breastfeeding longer term. Given the current low maternity leave in Jersey, employer
support for breastfeeding is particularly important.
Employer strategies recommended by the NHS23 include:
• Support for flexible working hours to be arranged around breastfeeding. Mother may
arrange for day care facilities near to the workplace so that they can pop out to
breastfeed on breaks.
• Private, comfortable provision in the workplace to allow for expressing of milk during
working hours
• Storage provision in the workplace for expressed milk
The ACAS24 (Advisory, Conciliation and Arbitration Service) recommends the following
similar steps for employers:
• Appropriate policy should be in place and made accessible to ensure new mothers
wishing to breastfeed are aware of provision in place, as well as the procedures for
accessing.
• Provision of appropriate facilities, including a private space to express milk, and
fridge and storage facilities
• Consideration of requests for flexible working hours and/or additional breaks to
facilitate breastfeeding.
Fathers’ experiences of supporting breastfeeding:
challenges for breastfeeding promotion and education
23 https://www.nhs.uk/Planners/breastfeeding/Documents/breastfeedingandwork[1].pdf 24 http://www.acas.org.uk/media/pdf/j/k/Acas_guide_on_accommodating_breastfeeding_in_the_workplace_(JANUARY2014).pdf
41
2. Reducing the number of babies born with a low birth weight
What relevant service provision currently exists in Jersey?
Local services which may contribute to the reduction of babies born with a low birth weight
include:
• Midwives
• NCT Antenatal courses
• Bumps & Babies
• GP
• Community Nursery Nurse
• MESCH
• Little Gems
• Baby Steps
What does the evidence tell us about influential factors and what might work?
Influential factors:
It is important to note that babies born with a low birth weight may be premature or carried to
full term. Factors increasing the risk of a baby being born with a low birth weight (either full
term or prematurely) include:
Socio-demographic factors, such as:
• Maternal age (younger and older mothers have an increased risk of a baby born with
a low birth weight)
• Environmental factors such as deprivation
• Ethnicity (members of minority ethnic groups more likely to have a low birth weight
baby)
• Marital Status (single mothers are more likely to have a low birth weight baby; this
may be connected to age of mother)
A range of maternal illnesses and conditions can impact on birth weight, including:
• Chronic hypertension
• Gestational diabetes
• Mother’s own weight during pregnancy
42
• Perinatal depression
• Anorexia during pregnancy
Lifestyle choices, such as:
• Drug and/or alcohol use (foetal alcohol syndrome
• Smoking during pregnancy- there is a strong evidence base to support the impact of
smoking on birth weight, and priority interventions centre on smoking reduction.
What might work to reduce the likelihood of a low birth weight baby?
Interventions and approaches to prevent low birth weight babies are generally targeted at
the following key areas:
• Education & awareness raising of the impact that lifestyle choices can have on birth
weight
• Smoking cessation programmes during pregnancy
• Drug/alcohol cessation programmes
• Health monitoring and interventions during the antenatal period
Common interventions are either aimed at reducing risk of preterm births, or reducing risk of
low birth weight baby carried to full term. Approaches include:
Education and awareness raising:
• Antenatal education: this has a particular role to play in helping expectant parents to
understand the impact of drug/alcohol use and smoking on the birth weight, and
subsequent life outcomes, for babies. Universal antenatal education is therefore
critical to ensure all parents receive the same information and support.
• Wider public awareness raising on the impact of substance misuse, including early
education strategies such as inclusion on school curriculum.
43
Smoking or drug/alcohol use cessation programmes:
• Timing is critical25: mothers who stop smoking before the third month of pregnancy
have been shown to have babies on average the same weight as non-smokers.
Those who stop smoking in the fourth month or onwards are at an increased risk of
delivering a low birth weight baby.
Screening programmes for maternal health conditions:
• A Healthy Start Programme in America26, which screens pregnant women for
depression and links them with appropriate services has been shown to reduce the
likelihood of the baby being born preterm (and therefore low birth weight).
• Medical interventions, such as screening for infections during pregnancy. Evidence
shows that these are not generally effective at a population level, rather are more
effective when targeted at those identified at increased risk.
• Preconception care for those at increased risk of medical conditions.
25 Yan, J. & Groothuis, P.A. (2015) Timing of Prenatal Smoking Cessation or Reduction and Infant Birth Weight: Evidence from the United Kingdom Millennium Cohort Study. Maternal Child Health Journal, 2015, vol 19, pp 447-458 26 Smith, M.V. et al (2011) Perinatal Depression and Birth Outcomes in a Healthy Start Project. Maternal Child Health Journal, 2011, vol 15, pp 401-409
44
3. Reducing the % of reception age children who are overweight or obese
What relevant service provision currently exists in Jersey?
Local relevant service provision includes:
• Breastfeeding Buddies
• Midwives
• NCT Antenatal courses
• Community Nursery Nurse
• Well Baby & Child Health Clinics
• Health Visiting
• GP
• MESCH
• Weaning Support Programme
• Physibods
• Activity Clubs/Day care facilities
• Caring Cooks Meal Service
What does the evidence tell us about influencing factors and what might work?
Influencing factors:
Many factors — usually working in combination — increase a child's risk of becoming
overweight or obese27 including:
• Diet. Regularly eating high-calorie foods, such as fast foods, baked goods and vending
machine snacks, can easily cause a child to gain weight. Sweets and desserts also can
cause weight gain, and more and more evidence points to sugary drinks, including fruit
juices, as culprits in obesity in some people.
• Lack of exercise. Children who don't exercise much are more likely to gain weight
because they don't burn as many calories. Too much time spent in sedentary activities,
such as watching television or playing video games, also contributes to the problem.
27 http://www.mayoclinic.org/diseases-conditions/childhood-obesity/symptoms-causes/dxc-20268891
45
• Family factors. If a child comes from a family of overweight people, they may be more
likely to put on weight. This is especially true in an environment where high-calorie foods
are always available and physical activity isn't encouraged.
• Psychological factors. Personal, parental and family stress can increase a child's risk of
obesity. Some children overeat to cope with problems or to deal with emotions, such as
stress, or to fight boredom. Their parents may have similar tendencies.
• Socioeconomic factors. People in some communities have limited resources and limited
access to supermarkets. As a result, they may opt for convenience foods that are
unhealthy. In addition, people who live in more deprived communities might not have
access to a safe place to exercise.
Looking specifically at very young children (aged 0-3), a study undertaken in the UK with a
large sample size of over 8,000 children found that there were eight key risk factors that
contributed to obesity including, amongst others: whether both parents were obese; very
early development of high body mass index; more than eight hours spent watching television
per week at age 3 years; weight gain in first year; high birth weight, and short (< 10.5 hours)
sleep duration at age 3 years.28
What might work to reduce levels of childhood obesity?
• Policy initiatives may help to support reductions in levels of childhood obesity29. Key
areas that Government could focus action include:
o Regulating the marketing of unhealthy foods and beverages to children
o Better nutrition labelling
o Imposition of Food taxes (to reduce consumption of unhealthy food) and
introduction of subsidies to promote consumption of healthy options
o Introduction of fruit and vegetable initiatives
o Promoting the development of physical activity policies
o Implementation of social marketing campaigns
28 http://www.bmj.com/content/330/7504/1357 29 http://www.who.int/dietphysicalactivity/childhood/WHO_new_childhoodobesity_PREVENTION_27nov_HR_PRINT_OK.pdf
46
• Programmes/initiatives implemented in specific settings (e.g. at school)30. The following
summarise a large-scale synthesis study in relation to a range of interventions to prevent
obesity:
o School based interventions: The strength of evidence is moderate that school-
based diet or physical activity interventions prevent obesity or overweight in
children. The strength of evidence is low that school-based combination diet and
physical activity interventions prevent obesity or overweight in children.
o School and home based interventions: The strength of the evidence is
insufficient that diet interventions within school-based studies with a home
component prevent obesity or overweight in children. However, the strength of
evidence is high that physical activity interventions within school-based studies
with a home component prevent obesity or overweight in children. The strength of
evidence is moderate that combined diet and physical activity interventions within
school-based studies with a home component prevent obesity or overweight in
children.
o School Based with a Home and Community Component: The strength of
evidence is insufficient that school-based physical activity interventions with a
home and community component prevent obesity or overweight, as there was
only one study and it had a moderate risk of bias. The strength of evidence is
high that combined diet and physical activity interventions prevent obesity or
overweight, as one study with a low risk of bias and most of the studies with a
moderate risk of bias showed a favourable effect. Studies on a combination of
diet and physical activity interventions generally showed significant improvements
in weight outcomes. Most interventions focused on education as well as structural
changes to promote a healthful diet and increased physical activity. Many of the
interventions did not specifically target obesity prevention.
o School Based with a Community Component: The strength of evidence is
insufficient that a diet approach or an approach combining physical activity with
self-management can impact weight outcomes in a community and school
setting, as only one study was included for each approach. The strength of
evidence is moderate that diet with physical activity impacts BMI or BMI z-score
30 http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=1523
47
in a community and school setting, as two of the four studies with moderate risk
of bias showed a favourable effect.
o School Based with a Consumer Health Informatics Component (i.e. an
online learning component): The strength of evidence is insufficient that
school-based physical activity interventions with a CHI component prevent
obesity or overweight in children. We graded the body of evidence as insufficient
because it lacked precision and both studies had a moderate risk of bias. The
strength of evidence is insufficient that a combination of diet and physical activity
interventions prevent obesity or overweight in children. We graded the body of
evidence as insufficient because it lacked precision and included studies with
moderate risk of bias.
o School Based with a Consumer Health Informatics Component: The strength
of evidence is insufficient that school-based physical activity interventions with a
CHI component prevent obesity or overweight in children. We graded the body of
evidence as insufficient because it lacked precision and both studies had a
moderate risk of bias. The strength of evidence is insufficient that a combination
of diet and physical activity interventions prevent obesity or overweight in
children. We graded the body of evidence as insufficient because it lacked
precision and included studies with moderate risk of bias
48
Appendix 4: A map of early years service provision in Jersey
from conception to age five
49