Municipal indicators for childrens health in Sweden

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Municipal indicators for childrens health in
Sweden

• Lennart Köhler
• Professor
• Nordic School of Public Health
• Göteborg, Sweden
• 2007 

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Child Health Indicators for Life and
Development(CHILD)

• A project within the EU Health Monitoring
  Programme

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Rigby M, Köhler L, Blair M, Mechtler R.Child
Health Indicators for Europe a Priority for a
Caring Society.

• European Journal of Public Health 200313 (3
  Suppl) 38-42

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• One looks in vain for a systematic, continuous
  and comprehensive reporting of childrens health,
  viewed in a child perspective and related to a
  social context
• (Köhler Jakobsson 1991)

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Municipality Child IndexA project for Save the
Children, Sweden

• Operationalization in 3 steps of UNs
  Convention of the Rights of the Child on the
  municipality level
• The Childs right to standard of living (art 27)
• The Childs right to health (art 24)
• The Childs right to education (art 28)

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Requirements

• Index should measure and assess childrens health
  and its determinants in the municipalities and
  follow them over time
• Index should facilitate planning, follow-up and
  evaluation of the municipalities actions for
  childrens health 

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Principles

• Index should use a Child Public Health
  perspective
• Index should cover all important health aspects  
• Index should use a general population perspective
• Index should permeated by a child perspective
• Outcome indicators are preferred, sometimes
  process indicators are accepted. Structure
  indicators should be avoided.

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The task

• Indicators to be
• Relevant
• Valid
• Reliable
• Solid
• Available

• Apply these indicators on the municipality level
• Create a combined index out of these indicators

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The process

• A thorough and systematic review of childrens
  health, methods to measure it and availability to
  assess it, leading to a first set of 22 indicators

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CHILD Framework

• A. Demographic and Socio-economic determinants
  of Child Health
• Child Health Status and Well-being
• Determinants of Child Health Risk and
  Protective Factors
• D. Child Health Systems and Policy

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Final indicators

• Health and well-being
• Rates of children hospitalized for injuries
• Determinants
• Rates of children with birthweight under
• 2 500 g
• Rates of children breastfed at 4 months
• Rates of children exposed to tobacco by
  mothers smoking in pregnancy
• Rates of children immunized against MPR
• Rates of teenage abortions

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Examples of rejected indicators

• Children with overweight and obesity
• Data incomplete, not available in all
  municipalities
• Children with asthma
• The diagnose is doubtful and varying between
  institutions, it is unclear what the indicator
  really reflects

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Examples of rejected indicators

• Childrens alcohol use
• Data available only in samples of representative
  populations, not on all children in a
  municipality
• Safe and secure community
• Vaguely defined and unclear in its continuity
  the direct connection with childrens health is
  difficult to prove

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Child Health Index

• The aim of each municipality is optimal health,
  i.e. the indicators should be 100
• If 60 of the children are breastfed at 4 months,
  the indicator is 60
• If abortion is performed on 22 per 1000 girls
  under 18 years, the indicator is 97.8
• To create a Child Health Index, the indicators
  are added and divided by 6, i.e. all indicators
  carry the same weight

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The results

• Childens health is good
• Index is generally high, range 93.0-83.5 (mean
  88.8), and comparable national mean index has
  increased over a 10-year period
• The greatest variation is found for
  breastfeeding (44 -points) and tobacco (29
  -points)
• For the combined Index and for several individual
  indicators there is a significant correlation
  with Poverty Index (breastfeeding, tobacco,
  abortion)  

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Poverty index

• children who live neither in households with
  low income standard nor in households with means
  tested social assistance
• (Save the Children, Sweden 2002)

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Education index

• is a teacher resource index, consisting of two
  parts
• Number of full time employed teachers per 100
  pupils
• Proportion of teachers with a formal certificate
  to teach
• (Save the Children, Sweden 2006)

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Child Municipal Index

• The same municipalities are found at the top and
  at the bottom for each of the three sets of
  indicators,
• (poverty, health and education)

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The good news

• The UN Convention of the Rights of the Child
  gives a politically and ideologically firm basis
  for the work
• To relate the index to the local level is
  important, because the municipalities have a
  major responsibility for the most important
  determinants of the wellbeing of children and
  families

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The good news 2

• Both the indicators and the combined Index are
  based on existing data, collected by national
  authorities and easily available in aggregated
  form, and can be compiled for all municipalities
  at no extra cost 
• The results show the need for further research
  and development of methodologies in measurement

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The bad news

• Indicators fulfilling the basic requirements are
  few and cover only part of the child population
  and its health spectrum
•  No indicators are based on childrens own
  appreciation of their health
•  The 289 municipalities differ in many ways
  (population, infrastructure, economy), which
  makes comparisons problematic

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The bad news 2

• Great variations can be found within the
  municipalities, especially the big ones, but are
  hidden in the averages
• The combined Health Index is the sum of several
  indicators with varying mathematical weight and
  different influence on the well-being of
  individuals and populations

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Conclusions

• The study offers a thorough and systematic review
  of childrens health, seen in a broad public
  health perspective and focused on the
  municipalities
• A few, well defined and easily available child
  health indicators are presented. Additional
  indicators are suggested and further research
  proposed
• By studying the individual indicators of the
  Index the municipalities can prioritize its
  activities and follow their outcomes
•  

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A Healthy Start
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Forward 1

• How to make the municipalities prioritize actions
  in this field, in competion with more than 100
  other indicators imposed on them?
• Although the municipalities have a great
  responsibity for the health of their inhabitants,
  they are not alone, and improvements are reached
  only by collaboration with other actors (county,
  state, private)

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Forward 2

• Existing indicators should be kept and their
  quality secured, new indicators should be added.
• Children should always be the unit in focus. Age
  groups should be adapted to the needs of
  children, not to demographic routines.

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Forward 3

• This study should not be a once-only occurrence
  but should be repeated, with continuously
  improved methods. The ultimate aim should be to
  establish a surveillance of childrens health and
  well-being which is of good quality, systematic,
  continuous and covering, with children in focus
  and put in a social and political context