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Don’t forget the basics : Health. Malmö, September 26, 2013 Stefan Kling, MD City of Malmo , Sweden s The European health report 2005 Public health action for healthier children and populations. The Scandinavian Welfare societies.

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Don t forget the basics health

Don’tforget the basics: Health

Malmö, September 26, 2013

Stefan Kling, MD

City ofMalmo, Sweden

Don t forget the basics health

  • The European health report 2005

  • Public health action for healthier children and populations

The scandinavian welfare societies
The Scandinavian Welfare societies

  • Belief in social engineering

  • Contractbetweencitizens and state: stateprovides social and economicsecurity, but has a certain right tointrudeinto the private sphere for controlofmisuse and reliable statistics as a base for health and social policy.

Personal id number pnr
Personal ID number (PNR)

  • All nordiccountrieshave a unique personal ID number for its residents

  • Makes it easytofollowindividuals over time in national registers and healthrecords

  • Makes it easytolink data from different sourcestoindividuals

I childrens health in sweden what do we know
I. Childrens Health in Sweden –What do weknow?

  • 2 million children

  • 60-70% live withbothparents

  • Majority – goodpsychosocialhealth

  • Psychosocialhealth and wellbeingamongschoolchildrenworsenacrossages

  • Students not livingwiththeirparents – mostvulnerable

Ii childrens health in sweden what do we know

II. Childrens Health in Sweden –What do weknow?

Majorityofchildren – goodpsychosocialhealth

Percievedphysicalimpairment– 14 % of students

-allergiesor asthma

- overweight

- visualand/or hearing impairments


- chronicdisease; epilepsyor diabetes

- dyslexia

(Swedish National Institute of Public Health, 2009; National Board of Health and Welfare, 2009)

The swedish s chool system
The Swedish schoolsystem

  • Preschool for all from 3yearsof age (not compulsory, butincludes >95% of resident children)

  • Optional preparatory year from age 6 (preeschoolclass)

  • A unitarycompulsoryprimaryschoolofnineyears from age 7 to16.

  • A diverse secondaryschool from age 16.

Health care system for c hildren
Health Care System for Children

  • Child Health Service, age 0-5

  • School Health Service, age 6-18

Child h ealth service
Child Health Service

  • Developmentassement visits

  • Growth checks

  • Vaccination schedule

  • Parental support

School health service
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

Don t forget the basics health

Substitute CareAny 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

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
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
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
Physicalhealth - Scandinavian studies.

  • Swedish National Board of Health and Welfare:

    2/3 of 108 children in foster carereported at leastonephysicalhealth problem (Socialstyrelsen, 2000)

  • Longitudinal Danishstudy:

    At 7 yearsof age disabilities and chronicdisorders aremuchmore common than in the general population

    At 11 yearsof age difference in health status remain (Egelund et al. 2008)

Physical health international studies i
Physicalhealth- International studies I

  • 92% havesomephysical ”abnormality”

  • 35% a chronic disorder N= 1.407

    Chernoffet al, 1994, USA

Physical health international studies ii
Physicalhealth- 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
Physicalhealth- International studies III

  • 97% ofthe samplereportedlevelsofphysicaldiscomfort

  • 45% ofthe youthhadsomemedicalcondition

    Health status ofyoungoffenders and theirfamilies(SheltonD, 2000), Maryland, USA

Physical health international studies iv
Physicalhealth- International studies IV

  • Extremelyhigh rates of co-occurringhealth risk behaviours

  • Lacking access to the healthcare system

  • Extremelyhigh rates ofphysical and sexual health problems

    The health status ofyouth in juvenile detentionfacilities (Golzari et al, 2006), California, USA

How about immunizations

  • Spanishstudy (Olivian, 2001)

    17 % ofadolescents, age 13-17, hadincompleteimmunizations on medical examination

  • Canadianstudy (Bartlett et al, 2008)

    73 % ofadolescents, age 12-17, incomplete vaccinations

And oral health
…………and oral health?

A majorityofdetainees in thisstudyhadunmet dental treatmentneeds.

(Bohlin, 2006), Texas, USA

Don t forget the basics health

  • 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
AAP Guidelines2002 – childrenshouldreceive and be assigned……..

  • a healthevaluationshortlyafter, if not before, entering foster caretoidentifyanyimmediatemedicalneeds;

  • a thoroughpediatricassessmentwithin 30 daysofentry;

  • a consistent source ofmedicalcare (referredto as a “permanent medicalhome”) toensurecontinuityofcare;

  • ongoingdevelopmental, educational, and emotional assessments.

Fosterbarns h lsa malm 2010 children i foster care a retrospective review
Fosterbarns Hälsa – Malmö 2010Children i Foster Care - a retrospectivereview

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

  • Retrospectivestudy

  • Data obtained from Health records:

    Child Health Care

    School Health Care

    (Kling et al, 2010)


Child Health Care

  • 15 % incompleteimmunizations

  • 50% missing screening test for vision, age 4

School Health Care

  • 10 % incompleteimmunizations

  • 10 % missing screening tests for hearing and vision

  • 15 % missinghealthdialogue



Highrates ofmissing screening tests for hearing and vision

Highdrop-out rates for healthdialouges


Summary i
Summary I

  • Monitoringchilddevelopment, preventive medicine, immunizationagainst preventable diseasesis a complex process.

  • Optimallyeffectivehealthcare is based on activecollaborationbetweenfamilies and healthcareprofessionals.

Summary ii
Summary II

  • National Guidelinesfor health supervision provides effectiveapproachestocaring for children and familieswhosehealth and adaption arethoughtto be in the normal range.

Summary iii
Summary III

  • The highincidenceofsomatichealth problems amongchildrenin care is welldocumented in international litterature. Differentiatingbetweenphysical symptoms oforganic cause and symptoms of a psychosocialnatureis a professionalchallenge

Summary iv
Summary IV

  • A pediatrichealth supervision visit, includingmedicalinterview, physical examination and screening procedures is an opportunitytoexploreissuesofphysical symptoms and tomanagefailureofpreviousattemptstoaddresshealth prevention and medical problems.

Summary v
Summary V

  • All children in foster careneedtoreceive initial health screenings and comprehensiveassessmentsoftheirmedical, mental, dental health and developmental status.

  • Resultsoftheseassessments must be included in the court-approved service plan.

Yours sincerely stefan kling@malmo se
Yourssincerely –