Scand J SOCMed 5: 1-3, 1977
Child Health in Sweden Claes Sundelin and Ragnar Berfenstam From the Department of Social Medicine, University of Uppsala, Uppsala, Sweden
< review over the years will show that development )f the welfare of a country, with a rising economic tandard and educational level, with social reforms ind extension of the health services, brings an improvement in the health of its children. The significance of the individual components of this welfare is difficult to evaluate. The favourable effect may 3e the result of simultaneous influence of several lifferent factors. There are many indications that the state of ~ealthof the children in the industrialized countries s better than in years gone by. - No life-threatening epidemics occur. In general the children are in a good state of physical fitness. - Perinatal and infant mortality have both been reduced to a level that previously one hardly dared hope to attain. - Practically all children are in an adequate nutritional state. - The great majority of physical handicaps and abnormalities are discovered and treated at an early age. - The situation has been reached where in many countries practically no children die at home of curable diseases. Yet there are still several unsolved child health problems in a country such as Sweden. These are mostly of a socio-paediatric nature; certain such problems even' seem to have become more marked. Childtiood accidents cause, in absolute figures, fewer deaths than they did about a decade ago. Nevertheless they are the commonest cause of death in several age groups. In boys aged 5-10 years, accidents cause as many deaths as all other causative factors combined (3). Psychosocial problems are common in children of all ages. This has been shown in epidemiologic51
investigations. The prevalence of psychiatric health problems necessitating treatment amounts to at least 5 % ; during the school years this figure is even higher according to many investigations (7, 9). We have greater insight today into the importance of the first year of life for a child's development and the future formation of his or her personality (1). Our knowledge is still fragmentary, however, and even less is known about the basic causes of the psychosocial problems. The structural changes that have constituted the basis of the increasing prosperity may possibly have contributed to augmenting these problems. There is no doubt that the rapid industrialization, the concentration and urbanization, have led to new strains and stresses for the young family. Isolation,estrangement and elimination from the labour market often lie behind the interindividual and intra-individual problems that we have traditionally accorded a central place in connection with socio-paediatric work. The same perspective may be applied to some other promiment socio-paediatric problems of today, namely misuse of tobacco, alcohol and drugs, that tend to occur at ever lower school ages. Furthermore, the occurrence of physical and mental maltreatment of children, appears to an increasing extent to be a problem complex that is just as extensive as it is difficult to tackle. Another important field in socio-paediatric work where there is still room for improvement concerns the habilitation and rehabilitation of handicapped children and the provision of support to families with chronically ill and handicapped children. This group is of moderate size. About 3-3.5% of the children of ages up to 15 years have somskind of a long-term illness or a permanent handicap ( 6 ) . The overall problems for the children and for the families are similar, regardless of the nature of the
2
C. Siindelin and R. Berfenstam
long-term illness or the handicap. Support of a medical, social and psychological nature is needed and should be characterized by continuity and teamwork. Included in the continuity concept is the idea that the support to the family should be based upon an ideology that the team shares in common. An accepted strategy that is becoming more and more widespread is the integration idea. The chronically ill o r handicapped child shall be isolated to the least possible extent from healthy children during the therapeutic period. Some children still live in at-risk situations. The more notable groups are immigrant children, children in foster-homes and children for adoption. In many aspects these children need more service and more consideration from both a paediatric and a social point of view (2,4). No paediatrician, paediatric nurse or social worker can avoid coming into contact with these problems. The difficulty of finding satisfactory solutions in individual cases and the achieving of meaningful prevention are clear. Social paediatrics thus has important tasks today and will continue to have them in the future. How have the health services attempted to meet these demands? In Sweden, primary care, with the front-line responsibility for the health of thepopulation within a given area, will be supplied to children by paediatricians in the role of community doctors. One paediatrician will be responsible for the total health care of about 3 000 children, aged 0-15 years (5). It will take another 10-15 years to implement this plan. The socio-paediatric educational requirement for paediatricians in outpatient care has as yet not been entirely fulfilled. An important step in the right direction, however, is that all prospective paediatricians undergo an obligatory week-long course in social paediatrics during their specialist training. It is also obligatory for all prospective paediatricians to take pan in ambulatory care (child health care o r school health care) during their training. The post of senior medical officer of child health care has been created in all counties (except one). This has meant that child health care now comes under an organizational and administrative leadership that increases the prospects of stability, effectivity and further development. These new ;ippointments have also clearly increased the possibilities of evaluating the work carried out in the sphere of child health care.
Under the auspices of the National Board of Health and Welfare, a commission is analysing the role of child health care within the primary care organization. The purpose is to devise ways of widening the social and developmental approach in child health care and to work out plans with the aim of reducing psycho-social health problems, childhood accidents, health problems caused by an unsuitable diet, and health problems caused by smoking. The education of parents and information on health matters are considered the most important in this respect. Socio-pediatric problems cannot be solved or even markedly lessened by improvements in the field of child health services alone. Collaboration with adjacent activity areas such as child and youth psychiatry, child welfare service, nursery school, and school are necessary to produce results. In many places in Sweden fairly extensive collaborative projects between these organizations are in operation (8, 10). The problem of cooperation is often difficult to solve, however. It is seldom that anything is gained by organizational chequer moves alone. Differences in human attitudes, in frames of reference, language and methods, form barriers between different personnel groups. The growth of collaboration must therefore be regarded as a process that cannot be forced but can be facilitated by educating together and by common training components such as discussions. research activity and continuous analysis of the reasons for difficulties in collaboration. Families kith children have a manifest need for socio-paediatric activity on the local level. The content of this activity is largely dependent on the actual creation of resources. But its effectiveness also depends to a large extent on the capacity of the field workers to localize the problems of the community and the children and on their ability to collaborate.
I.
2.
3. 4.
REFERENCES Anthony, E. J. & Koupernik, C.: The .child in his family. John Wiley & Sons. New York. 1970. Aurelius. G.: -1nvandrarbarn-erfarenheter frAn en 'Ã barnavardscentral (Immigrant children~experiences from a child welfare centre). Sociiilmedicinsk tidskrift 46: 1969,458463. Berfenstam, R. &William Olsson. 1.: Early child care in Sweden. Gordon & Breach. London. 1973. Bohman. hf.: Adopted children and their families. A
Child health in Sweden
5.
6.
7. 8.
follow-up study of adopted children, their background, environment and adjustment. Stockholm, 1970. Den oppna vArdens organisation (The organization of primary care). Spri, Stockholm, 1972. With a summary in English. Lindbergh, T., Klackenberg, G., Pehrsson, G., Rundquist, A. & Gamstorp, I.: Det IAngvarigt sjuka bamet och dess familj-fysiska, psykiska och sociala behov (The chronically ill child and its family-physical, psychological and social needs). Lakartidningen, 73: 2989, 1976. With a summary in English. Lurie, 0.: The emotional health of children in the family setting. Community hlent Health J 6:229, 1970. hljolkuddenprojektet (The hljolkudden project). Socialmedicinska forskningsenheten i LuleA, Lulea, 1976.
3
9. Nilsson, C., Sundelin, C. & Vuille, J.-C.: General health screening of four-year-olds in a Swedish county. IV. An analysis of the effectiveness of the psychological examination program. Acta Paediatr Scand 65: 663, 1976. 10. The Tierp Project. A developing program for health and medical care, social welfare and student care within a local area. Tierp Municipality. The National Board of Health and Welfare, PB 2 Division, Stockholm, 1975.
Address for reprints: Prof. Ragnar Berfenstam Department of Social Medicine Akademiska sjukhuset S-750 14 Uppsala Sweden
Child Health in Sweden Claes Sundelin and Ragnar Berfenstam From the Department of Social Medicine, University of Uppsala, Uppsala, Sweden
< review over the years will show that development )f the welfare of a country, with a rising economic tandard and educational level, with social reforms ind extension of the health services, brings an improvement in the health of its children. The significance of the individual components of this welfare is difficult to evaluate. The favourable effect may 3e the result of simultaneous influence of several lifferent factors. There are many indications that the state of ~ealthof the children in the industrialized countries s better than in years gone by. - No life-threatening epidemics occur. In general the children are in a good state of physical fitness. - Perinatal and infant mortality have both been reduced to a level that previously one hardly dared hope to attain. - Practically all children are in an adequate nutritional state. - The great majority of physical handicaps and abnormalities are discovered and treated at an early age. - The situation has been reached where in many countries practically no children die at home of curable diseases. Yet there are still several unsolved child health problems in a country such as Sweden. These are mostly of a socio-paediatric nature; certain such problems even' seem to have become more marked. Childtiood accidents cause, in absolute figures, fewer deaths than they did about a decade ago. Nevertheless they are the commonest cause of death in several age groups. In boys aged 5-10 years, accidents cause as many deaths as all other causative factors combined (3). Psychosocial problems are common in children of all ages. This has been shown in epidemiologic51
investigations. The prevalence of psychiatric health problems necessitating treatment amounts to at least 5 % ; during the school years this figure is even higher according to many investigations (7, 9). We have greater insight today into the importance of the first year of life for a child's development and the future formation of his or her personality (1). Our knowledge is still fragmentary, however, and even less is known about the basic causes of the psychosocial problems. The structural changes that have constituted the basis of the increasing prosperity may possibly have contributed to augmenting these problems. There is no doubt that the rapid industrialization, the concentration and urbanization, have led to new strains and stresses for the young family. Isolation,estrangement and elimination from the labour market often lie behind the interindividual and intra-individual problems that we have traditionally accorded a central place in connection with socio-paediatric work. The same perspective may be applied to some other promiment socio-paediatric problems of today, namely misuse of tobacco, alcohol and drugs, that tend to occur at ever lower school ages. Furthermore, the occurrence of physical and mental maltreatment of children, appears to an increasing extent to be a problem complex that is just as extensive as it is difficult to tackle. Another important field in socio-paediatric work where there is still room for improvement concerns the habilitation and rehabilitation of handicapped children and the provision of support to families with chronically ill and handicapped children. This group is of moderate size. About 3-3.5% of the children of ages up to 15 years have somskind of a long-term illness or a permanent handicap ( 6 ) . The overall problems for the children and for the families are similar, regardless of the nature of the
2
C. Siindelin and R. Berfenstam
long-term illness or the handicap. Support of a medical, social and psychological nature is needed and should be characterized by continuity and teamwork. Included in the continuity concept is the idea that the support to the family should be based upon an ideology that the team shares in common. An accepted strategy that is becoming more and more widespread is the integration idea. The chronically ill o r handicapped child shall be isolated to the least possible extent from healthy children during the therapeutic period. Some children still live in at-risk situations. The more notable groups are immigrant children, children in foster-homes and children for adoption. In many aspects these children need more service and more consideration from both a paediatric and a social point of view (2,4). No paediatrician, paediatric nurse or social worker can avoid coming into contact with these problems. The difficulty of finding satisfactory solutions in individual cases and the achieving of meaningful prevention are clear. Social paediatrics thus has important tasks today and will continue to have them in the future. How have the health services attempted to meet these demands? In Sweden, primary care, with the front-line responsibility for the health of thepopulation within a given area, will be supplied to children by paediatricians in the role of community doctors. One paediatrician will be responsible for the total health care of about 3 000 children, aged 0-15 years (5). It will take another 10-15 years to implement this plan. The socio-paediatric educational requirement for paediatricians in outpatient care has as yet not been entirely fulfilled. An important step in the right direction, however, is that all prospective paediatricians undergo an obligatory week-long course in social paediatrics during their specialist training. It is also obligatory for all prospective paediatricians to take pan in ambulatory care (child health care o r school health care) during their training. The post of senior medical officer of child health care has been created in all counties (except one). This has meant that child health care now comes under an organizational and administrative leadership that increases the prospects of stability, effectivity and further development. These new ;ippointments have also clearly increased the possibilities of evaluating the work carried out in the sphere of child health care.
Under the auspices of the National Board of Health and Welfare, a commission is analysing the role of child health care within the primary care organization. The purpose is to devise ways of widening the social and developmental approach in child health care and to work out plans with the aim of reducing psycho-social health problems, childhood accidents, health problems caused by an unsuitable diet, and health problems caused by smoking. The education of parents and information on health matters are considered the most important in this respect. Socio-pediatric problems cannot be solved or even markedly lessened by improvements in the field of child health services alone. Collaboration with adjacent activity areas such as child and youth psychiatry, child welfare service, nursery school, and school are necessary to produce results. In many places in Sweden fairly extensive collaborative projects between these organizations are in operation (8, 10). The problem of cooperation is often difficult to solve, however. It is seldom that anything is gained by organizational chequer moves alone. Differences in human attitudes, in frames of reference, language and methods, form barriers between different personnel groups. The growth of collaboration must therefore be regarded as a process that cannot be forced but can be facilitated by educating together and by common training components such as discussions. research activity and continuous analysis of the reasons for difficulties in collaboration. Families kith children have a manifest need for socio-paediatric activity on the local level. The content of this activity is largely dependent on the actual creation of resources. But its effectiveness also depends to a large extent on the capacity of the field workers to localize the problems of the community and the children and on their ability to collaborate.
I.
2.
3. 4.
REFERENCES Anthony, E. J. & Koupernik, C.: The .child in his family. John Wiley & Sons. New York. 1970. Aurelius. G.: -1nvandrarbarn-erfarenheter frAn en 'Ã barnavardscentral (Immigrant children~experiences from a child welfare centre). Sociiilmedicinsk tidskrift 46: 1969,458463. Berfenstam, R. &William Olsson. 1.: Early child care in Sweden. Gordon & Breach. London. 1973. Bohman. hf.: Adopted children and their families. A
Child health in Sweden
5.
6.
7. 8.
follow-up study of adopted children, their background, environment and adjustment. Stockholm, 1970. Den oppna vArdens organisation (The organization of primary care). Spri, Stockholm, 1972. With a summary in English. Lindbergh, T., Klackenberg, G., Pehrsson, G., Rundquist, A. & Gamstorp, I.: Det IAngvarigt sjuka bamet och dess familj-fysiska, psykiska och sociala behov (The chronically ill child and its family-physical, psychological and social needs). Lakartidningen, 73: 2989, 1976. With a summary in English. Lurie, 0.: The emotional health of children in the family setting. Community hlent Health J 6:229, 1970. hljolkuddenprojektet (The hljolkudden project). Socialmedicinska forskningsenheten i LuleA, Lulea, 1976.
3
9. Nilsson, C., Sundelin, C. & Vuille, J.-C.: General health screening of four-year-olds in a Swedish county. IV. An analysis of the effectiveness of the psychological examination program. Acta Paediatr Scand 65: 663, 1976. 10. The Tierp Project. A developing program for health and medical care, social welfare and student care within a local area. Tierp Municipality. The National Board of Health and Welfare, PB 2 Division, Stockholm, 1975.
Address for reprints: Prof. Ragnar Berfenstam Department of Social Medicine Akademiska sjukhuset S-750 14 Uppsala Sweden
