Don’t forget the basics: Health

Malmö, September 26, 2013

Stefan Kling, MDCity of Malmo, Swedenstefan.kling@malmo.se

• The European health report 2005

• Public health action for healthier children and populations

The Scandinavian Welfare societies

• Belief in social engineering• Contract between citizens and state: state

provides social and economic security, but has a certain right to intrude into the private sphere for control of misuse and reliable statistics as a base for health and social policy.

Personal ID number (PNR)

• All nordic countries have a unique personal ID number for its residents

• Makes it easy to follow individuals over time in national registers and health records

• Makes it easy to link data from different sources to individuals

I. Childrens Health in Sweden –What do we know?

• 2 million children• 60-70% live with both parents• Majority – good psychosocial health• Psychosocial health and wellbeing among

schoolchildren worsen across ages• Students not living with their parents – most

vulnerable

II. Childrens Health in Sweden –What do we know?

• Majority of children – good psychosocial health

• Percieved physical impairment – 14 % of students

- allergies or asthma- overweight- visual and/or hearing impairments- ADHD- chronic disease; epilepsy or diabetes - dyslexia(Swedish National Institute of Public Health, 2009; National Board of Health and Welfare,

2009)

The Swedish school system

• Preschool for all from 3 years of age (not compulsory, but includes >95% of resident children)

• Optional preparatory year from age 6 (preeschool class)

• A unitary compulsory primary school of nine years from age 7 to 16.

• A diverse secondary school from age 16.

Health Care System for Children

• Child Health Service, age 0-5• School Health Service, age 6-18

Child Health Service

• Development assement visits• Growth checks• Vaccination schedule• Parental support

School Health Service

• Health profiles (preschool, grade 2-4-8, upper secondary school)

• Growth checks (incl. BMI)• Vision• Hearing• Back checks • Vaccination schedule • Individual health talks

Substitute Care

Any kind of custodial or residential care for a child that is ordered or otherwise sanctioned by the court, and in which a child does not continue to live with either of the birth parents.

How many are they?

• 4% of all Swedish children are taken into care during their childhood

• 1% spend at least 5 years in the care system• 2/3 are teenagers when they first enter care

Care for younger children

• Usually foster care • Foster homes are more and more often mini-

institutions (HVB-hem), with one family caring for 3-5 children. Many are integrated into companies with many homes, run by the municipalities or private entrepeneurs

Care for older children

• A mix of foster homes and institutions• Many institutions mix children with diverse

problems, and include both genders• Foster homes are more and more often mini-

institutions (HVB-hem), with one family caring for 3-5 children. Many are integrated into companies with many homes, run by the municipalities or private entrepeneurs

Physical health - Scandinavian studies.

• Swedish National Board of Health and Welfare:

2/3 of 108 children in foster care reported at least one physical health problem (Socialstyrelsen, 2000)

• Longitudinal Danish study:

At 7 years of age disabilities and chronic disorders are much more common than in the general populationAt 11 years of age difference in health status remain (Egelund et al. 2008)

Physical health - International studies I

• 92% have some physical ”abnormality”

• 35% a chronic disorder N= 1.407

Chernoff et al, 1994, USA

Physical health - International studies II

• High prevalence of untreated acute conditions, chronic illnesses, poor nutritional status, and inadequate immunization coverage (Hochstadt, Jaudes, Zimo, & Schachter, 1987; Simms & Halfon, 1994;).

• Very few children in foster care are noted to have normal physical examinations (Silver et al., 1999)

Physical health - International studies III

• 97% of the sample reported levels of physical discomfort

• 45% of the youth had some medical condition

Health status of young offenders and their families (Shelton D, 2000), Maryland, USA

Physical health - International studies IV

• Extremely high rates of co-occurring health risk behaviours

• Lacking access to the health care system• Extremely high rates of physical and sexual

health problems

The health status of youth in juvenile detention facilities (Golzari et al, 2006), California, USA

How about immunizations?

• Spanish study (Olivian, 2001)17 % of adolescents, age 13-17, had

incomplete immunizations on medical examination

• Canadian study (Bartlett et al, 2008)73 % of adolescents, age 12-17,

incomplete vaccinations

…………and oral health?

A majority of detainees in this study had unmet dental treatment needs.

(Bohlin, 2006), Texas, USA

• What happens if society takes responsibility and steps in to protect the child?

• When society takes the role of the parent?

• What is the role of health care then?

AAP Guidelines 2002 – children should receive and be assigned……..

• a health evaluation shortly after, if not before, entering foster care to identify any immediate medical needs;

• a thorough pediatric assessment within 30 days of entry;

• a consistent source of medical care (referred to as a “permanent medical home”) to ensure continuity of care;

• ongoing developmental, educational, and emotional assessments.

Fosterbarns Hälsa – Malmö 2010Children i Foster Care - a retrospective review

• Children, age <16, n= 121 (121/223, 54 %)

• Retrospective study

• Data obtained from Health records:

Child Health CareSchool Health Care

(Kling et al, 2010)

Results

Child Health Care

• 15 % incomplete immunizations

• 50% missing screening test for vision, age 4

School Health Care

• 10 % incomplete immunizations

• 10 % missing screening tests for hearing and vision

• 15 % missing health dialogue

Conclusions

• High rates of missing screening tests for hearing and vision

• High drop-out rates for health dialouges

• High percentage of incomplete immunizations.

Summary I

• Monitoring child development, preventive medicine, immunization against preventable diseases is a complex process.

• Optimally effective health care is based on active collaboration between families and health care professionals.

Summary II

• National Guidelines for health supervision provides effective approaches to caring for children and families whose health and adaption are thought to be in the normal range.

Summary III

• The high incidence of somatic health problems among children in care is well documented in international litterature. Differentiating between physical symptoms of organic cause and symptoms of a psychosocial nature is a professional challenge

Summary IV

• A pediatric health supervision visit, including medical interview, physical examination and screening procedures is an opportunity to explore issues of physical symptoms and to manage failure of previous attempts to address health prevention and medical problems.

Summary V

• All children in foster care need to receive initial health screenings and comprehensive assessments of their medical, mental, dental health and developmental status.

• Results of these assessments must be included in the court-approved service plan.

Yours sincerely –stefan.kling@malmo.se