Swedish Child Health Services Register: a quality register for child health services and children's well-being

BACKGROUND

Swedish child health services (CHS) is a free-of-charge healthcare system that reaches almost all children under the age of 6. The aim for the CHS is to improve children's physical, psychological and social health by promoting health and development, preventing illness and detecting emerging problems early in the child's life. The services are defined in a national programme divided into three parts: universal interventions, targeted interventions and indicated interventions.The Swedish Child Health Services Register (BHVQ) is a national Quality Register developed in 2013. The register extracts data from the child's health record and automatically presents current data in real time. At present, the register includes 21 variables.

AIM

We aim to describe data available in the BHVQ and the completeness of data in BHVQ across variables.

METHODS

Child-specific data were exported from the register, and data for children born in the regions were retrieved from Statistics Sweden to calculate coverage.

RESULTS

The register includes over 110 000 children born between 2011 and 2022 from 221 child healthcare centres in eight of Sweden's 21 regions. In seven of the eight regions, 100% of centres report data.The completeness of data differs between participating regions and birth cohorts. The average coverage for children born in 2021 is 71%.

CONCLUSIONS

The BHVQ is a valuable resource for evaluating Child Health Services nationally, with high coverage for the youngest children. As a result of continuous improvement of the services, the possibility to follow the development of children's health in Sweden is possible through the register. When fully expanded, the register will be a natural and essential part of developing preventive services, improving healthcare for children below 6 years of age and a tool for developing evidence-based child health interventions.

Breastfeeding practice, breastfeeding policy and hospitalisations for infectious diseases in early and later childhood: a register-based study in Uppsala County, Sweden

OBJECTIVE

To examine the association between breastfeeding practice and hospitalisations for infectious diseases in early and later childhood, in particular, to compare exclusive breast feeding 4-5 months with exclusive breastfeeding 6 months or more. Thereby, provide evidence to inform breastfeeding policy.

DESIGN

A register-based cohort study.

SETTING

A cohort was created by combining the Swedish Medical Birth Register, the National Inpatient Register, the Cause of Death Register, the Total Population Register, the Longitudinal integration database for health insurance and labour market studies, with the Uppsala Preventive Child Health Care database.

PATIENTS

37 825 term and post-term singletons born to women who resided in Uppsala County (Sweden) between 1998 and 2010.

MAIN OUTCOME MEASURES

Number of hospitalisations for infectious diseases in early (<2 years) and later childhood (2-4 years).

RESULTS

The risk of hospitalisations for infectious diseases decreased with duration of exclusive breastfeeding until 4 months of age. In early childhood, breast feeding was associated with a decreased risk of enteric and respiratory infections. In comparison with exclusive breast feeding 6 months or more, the strongest association was found between no breastfeeding and enteric infections (adjusted incidence rate ratios, aIRR 3.32 (95% CI 2.14 to 5.14)). In later childhood, breast feeding was associated with a lower risk of respiratory infections. In comparison with children exclusively breastfed 6 months or more, the highest risk was found in children who were not breastfed (aIRR 2.53 (95% CI 1.51 to 4.24)). The risk of hospitalisations for infectious diseases was comparable in children exclusively breastfed 4-5 months and children exclusively breastfed 6 months or more.

CONCLUSIONS

Our results support breastfeeding guidelines that recommend exclusive breastfeeding for at least 4 months.

Child Health Nurses' experiences of addressing psychosocial risk factors with the families they meet

Aim

To examine how child health nurses perceive the routine assessment of psychosocial risk factors in the family environment as well as their self‐reported competence and the present organisational conditions in this context.

Method

A mixed‐methods design was used, including three focus group interviews and a web‐based survey. Qualitative data were analysed using systematic text condensation. Quantitative data were analysed at the descriptive level.

Results

Nurses expressed that identifying psychosocial risk factors was both important and relevant to their work. They had little formal training and education on most psychosocial risk factors, and they lacked structured methods to address them. In areas where nurses reported more formal education and a structured methodology (depression, parental stress), they rated to a higher degree that they possessed sufficient skills and sense of security. The nurses perceived that they seldom came into contact with families with financial problems, hazardous alcohol use or intimate partner violence.

Conclusions

There is a gap between the nurses’ attitudes regarding the importance of helping families in need and their ability to do so with the current level of training and methodological support. The results suggest that, in many cases, psychosocial problems remain undetected.

Differences in breastfeeding rate between mothers delivering by caesarean section and those delivering vaginally

Aim: The aim of the study was to analyse the impact of delivery on breastfeeding at 6 months, with special focus on caesarean section combined with established breastfeeding at 2 months. Methods: Delivery mode and breastfeeding at 2 and 6 months were studied in a database of 130,993 infants from two Swedish counties between 1990-2011. Results: The difference in breastfeeding rates at 6 months between children delivered by caesarean section and children delivered vaginally was smaller in a subpopulation of children with established breastfeeding at 2 months compared to all children. The impact of delivery method on breastfeeding at 6 months was independent of child gender, mother's first child, maternal smoking and maternal education. Conclusions: Breastfeeding in mothers giving birth by caesarean section is more likely to continue until (at least) 6 months if established early (at 2 months). It may be worthwhile to promote breastfeeding for mothers who deliver by caesarean section.

Organisation of preventive child health services: Key to socio-economic equity in vaccine uptake?

Background: Measles has made a comeback in Western Europe, with more cases being reported each year. One factor behind this development is low vaccination coverage in socially disadvantaged segments of the population in many countries. This study investigates whether socioeconomic patterns of uptake of the measles, mumps and rubella (MMR) vaccine in the Nordic countries differ by national organisation of preventive health services for children. Methods: MMR vaccine uptake before the age of two years was analysed in register data from Denmark, Finland, Iceland and Sweden, linked to family indicators of socio-economic status (SES) from national registers. Results: Denmark, a country where child vaccinations are administered by general practitioners, presented the lowest overall coverage of MMR at 83%. It also had the greatest difference between subpopulations of low and high SES at 14 percentage points. Finland, Iceland and Sweden, countries where preschool children are vaccinated in 'well-baby' clinics, had a higher overall coverage at 91-94%, with a more equal distribution between SES groups at 1-4 percentage points. Conclusions: This study suggests that the organisation of preventive health care in special units, 'well-baby' clinics, facilitates vaccine uptake among children with low SES in a Nordic welfare context.

Agreement between mothers', fathers', and teachers' ratings of behavioural and emotional problems in 3-5-year-old children

BACKGROUND

The Strengths and Difficulties Questionnaire (SDQ), a valid and reliable instrument for measuring children's mental health, is available in parent- and teacher versions, making it an ideal tool for assessing behavioural and emotional problems in young children. However, few studies have evaluated inter-parent agreement on the SDQ, and in most studies on SDQ agreement, parent scores are either provided by only one parent or have been combined into one parent score. Furthermore, studies on SDQ inter-rater agreement usually only reflect degree of correlation, leaving the agreement between measurements unknown. The aim of the present study was therefore to examine both degree of correlation and agreement between parent and teacher SDQ reports, in a community sample of preschool-aged children in Sweden.

METHODS

Data were obtained from the Children and Parents in Focus trial. The sample comprised 4,469 children 3-5-years-old. Mothers, fathers and preschool teachers completed the SDQ as part of the routine health check-ups at Child Health Centres. Inter-rater agreement was measured using Pearson correlation coefficient and intraclass correlation (ICC).

RESULTS

Results revealed poor/fair agreement between parent and teacher ratings (ICC 0.25-0.54) and good/excellent agreement between mother and father ratings (ICC 0.66-0.76). The highest level of agreement between parents and teachers was found for the hyperactivity and peer problem subscales, whereas the strongest agreement between parents was found for the hyperactivity and conduct subscales.

CONCLUSIONS

Low inter-rater agreement between parent and teacher ratings suggests that information from both teachers and parents is important when using the SDQ as a method to identify mental health problems in preschool children. Although mothers and fathers each provide unique information about their child's behaviour, good inter-parent agreement indicates that a single parent informant may be sufficient and simplify data collection.

Relationship Between Breastfeeding and Early Childhood Obesity: Results of a Prospective Longitudinal Study from Birth to 4 Years

AIM

To study a potential link between breastfeeding in infancy and obesity at age 4.

MATERIALS AND METHODS

A total of 30,508 infants born during 2002-2007 from the databases of the Preventive Child Health Services in two Swedish counties and from national registers were studied. The outcome variable was obesity at age 4. Analyses were conducted by logistic regression models using the methodology of generalized estimating equations. Analyses were adjusted for child sex and maternal anthropometric and sociodemographic variables.

RESULTS

In unadjusted analyses, any breastfeeding up to 9 months was linked to successively decreasing odds ratios (ORs) for obesity at age 4 (ORs 0.78-0.33), however, not significantly for 1 week and 2 months of breastfeeding. In adjusted analyses, the same pattern remained statistically significant for breastfeeding for 4 (OR 0.51), 6 (OR 0.55), and 9 (OR 0.47) months. Child sex, maternal education, maternal body mass index, and maternal smoking additionally influenced child obesity.

CONCLUSION

Breastfeeding duration for at least 4 months may contribute independently to a reduced risk for childhood obesity at 4 years.

No widening socioeconomic gap within a general decline in Swedish breastfeeding

AIM

To study potential socioeconomic differences within the general decline in breastfeeding over time.

METHODS

Data was collected for 51 415 infants born 2004-2010 from the databases of statistics of the Preventive Child Health Care Services in Uppsala and Orebro counties in Sweden and socioeconomic indicators from Swedish national registers. Breastfeeding data (breastfed/not breastfed) from 1 week, 4 months and 6 months of age were used as the main outcome variables. Educational level of the mother was defined as the highest level on a three-grade scale, low, medium and high. Family type was defined as whether the mother was single or married/cohabiting. Family disposable income was divided into quartiles where quartile 1 included the 25% children in families with the lowest incomes. Analyses were conducted by logistic regression models using the methodology of generalized estimating equations (GEE). An exchangeable correlation structure was used to control for the dependence among infants with the same mother.

RESULTS

Breastfeeding rate in Sweden has declined gradually since the late 1990s. The results indicated that overall breastfeeding rates over the study period were influenced by socioeconomic status in a gradient manner but no widening socioeconomic gap was detected. Rather the interaction analyses showed a narrowing socioeconomic gap over the study period between high and low educational level and single versus cohabiting mothers at 4 months. The narrowing socioeconomic gap between the educational level categories was also detectable at 6 months.

CONCLUSION

No increase in socioeconomic gap was detected within the general decline in Swedish breastfeeding. However, there are reasons to maintain and strengthen the overall breastfeeding supportive measures including extended support for vulnerable groups.

Child healthcare nurses believe that bilingual children show slower language development, simplify screening procedures and delay referrals

AIM

A significant number of children living in Sweden are bilingual, but how language screening is performed in this group is unknown. We investigated child healthcare nurses' perceptions of the language screening of bilingual children aged 30-36 months, together with their clinical practices.

METHODS

An online questionnaire was completed by 863 nurses who performed language screening of bilingual children in Sweden at least once a month, corresponding to 89% of the target population. Cox regression identified predictors of the nurses' tendency to simplify the screening of bilingual children.

RESULTS

The nurses reported a greater lack of confidence and more difficulties in interpreting screening outcomes for bilingual than monolingual children (p < 0.001). Half of the nurses simplified the screening processes for bilingual children and 74% postponed referrals to speech and language services, basing these adaptations on their perceptions of the children's Swedish language skills (p < 0.001). Most nurses (82%) believed that language development was slower in bilingual children, and this was the strongest predictor of simplified screening practices (RR=2.00, 95% CI 1.44-2.77).

CONCLUSION

Child healthcare nurses need easily accessible information and clear guidelines on the language development of bilingual children to ensure that bilingual and monolingual children receive equitable language screening services.

Mental health in Swedish children living in joint physical custody and their parents' life satisfaction: a cross-sectional study

This study compared the psychological symptoms of 129 children in joint physical custody with children in single care and nuclear families, using a nationally representative 2011 survey of 1,297 Swedish children aged between four and 18 years. The outcome measure was the Strengths and Difficulties Questionnaire (SDQ) and its association with three dimensions of parental life satisfaction was investigated. Linear regression analyses showed higher SDQ-scores for children in joint physical custody (B = 1.4, p < 0.001) and single care (B = 2.2, p < 0.001) than in nuclear families, after adjustment for socio-demographic variables. The estimates decreased to 1.1 and 1.3, respectively, after being adjusted for parental life satisfaction ( p < 0.01). Our findings confirm previous research that showed lower symptom scores for children in nuclear families than children in single care and joint physical custody. Parental life satisfaction should be investigated further as a possible explanation of differences in symptom load between children in different living arrangements.

Socioeconomic and early-life factors and risk of being overweight or obese in children of Swedish- and foreign-born parents

BACKGROUND

Ethnic minorities/immigrants have differential health as compared with natives. The epidemic in child overweight/obesity (OW/OB) in Sweden is leveling off, but lower socioeconomic groups and immigrants/ethnic minorities may not have benefited equally from this trend. We investigated whether nonethnic Swedish children are at increased risk for being OW/OB and whether these associations are mediated by parental socioeconomic position (SEP) and/or early-life factors such as birth weight, maternal smoking, BMI, and breastfeeding.

METHODS

Data on 10,628 singleton children (51% boys, mean age: 4.8 y, born during the period 2000-2004) residing in Uppsala were analyzed. OW/OB was computed using the International Obesity Task Force's sex- and age-specific cutoffs. The mother's nativity was used as proxy for ethnicity. Logistic regression was used to analyze ethnicity-OW/OB associations.

RESULTS

Children of North African, Iranian, South American, and Turkish ethnicity had increased odds for being overweight/obese as compared with children of Swedish ethnicity (adjusted odds ratio (OR): 2.60 (95% confidence interval (CI): 1.57-4.27), 1.67 (1.03-2.72), 3.00 (1.86-4.80), and 2.90 (1.73-4.88), respectively). Finnish children had decreased odds for being overweight/obese (adjusted OR: 0.53 (0.32-0.90)).

CONCLUSION

Ethnic differences in a child's risk for OW/OB exist in Sweden that cannot be explained by SEP or maternal or birth factors. As OW/OB often tracks into adulthood, more effective public health policies that intervene at an early age are needed.

Child health care utilisation in families with young or single mothers in a Swedish county

Young age and lone parenthood are risk factors for impaired health among mothers and their children. Due to the higher risks of negative influences on physical and mental health, young and single mothers should be of special concern to the Child Health Services (CHS). In the present study, we investigated consumption patterns of child health care services among young and single mothers in Uppsala County, Sweden to study whether they are reached by the universal CHS program and if selective or indicative measures were administered in daily CHS practice. Register data on CHS contacts and socio-demographic indicators were collected for 10692 infants, born in 1998-2006. Results show small differences in contact pattern and immunization status, between children of young versus older, and single versus cohabiting mothers. However, both young (RR 0.64) and single (RR 0.80) mothers had significantly lower rates of participation in parental group. The CHS were consequently successful in implementing the universal preventive child health programme for all families, including families with young or single mothers. There was no indication, however, of an established selective preventive strategy aimed at these high risk families. Programs for strengthening the support provided to vulnerable families by the CHS are needed.

Child health care uptake among low-income and immigrant families in a Swedish county

AIM

To study the uptake of child health care among low-income and immigrant families in the county of Uppsala, Sweden, to investigate whether these families received extra attention as proposed in the Swedish Child Health Services (CHS) state-of-the-art consensus document from the year 2000.

METHODS

Data were collected for 25,024 infants born 1998-2006 from the database of statistics of the Child Health Care Unit in Uppsala and socio-demographic indicators from Swedish national registers. Disposable income was divided into quartiles. Country of birth of the mother was categorized into four regions with two subgroups each, mothers with or without a Swedish-born partner. Analysis was conducted by Cox regression and linear regression models.

RESULTS

Small differences between Swedish vs. immigrant and high vs. low-income families were detected. Low-income mothers (RR 0.78) as well as mothers born in all country of birth regions with an immigrant partner (RR 0.28-0.95) had lower rates of participation in parental groups.

CONCLUSION

The CHS provided basic child health care to almost all infants including children in immigrant and low-income Swedish families. However, the results did not indicate that disadvantaged families received the extra attention proposed in the consensus document.

Region of birth, income and breastfeeding in a Swedish county

AIM

To study the relationship between maternal region of birth, disposable income and breastfeeding initiation and duration.

METHODS

The study population consisted of 12,197 term born, singleton infants, born 1997-2001 in the county of Uppsala. Data on breastfeeding at 1 week, 6 months and 12 months were collected from the register of statistics of the Child Health Care Unit in Uppsala and socioeconomic indicators from Swedish national registers. Multivariate analysis was conducted using Cox regression.

RESULTS

No influence of disposable income or region of birth on breastfeeding initiation was observed. Breastfeeding rates at 6 months were lower for mothers with disposable incomes in quartile 1-3 compared with mothers with the highest incomes in quartile 4 (hazard ratios (HRs) 0.88-0.90, adjusted HRs 0.92). The breastfeeding rates at 12 months were higher for mothers born in all regions compared with mothers born in Sweden (HRs 1.25-2.45, adjusted HRs 1.20-2.14).

CONCLUSIONS

The findings in the present study show that disposable income is a strong predictor for breastfeeding at 6 months in the Swedish context. Region of birth of the mother predicted long term breastfeeding, > or =12 months. This calls for professionals in the maternity and child health care to pay extra attention to breastfeeding in low-income mothers in all ethnic groups.

Parental region of birth, socio-economic status and infants' exposure to second-hand smoke

AIM

To investigate the impact of parental region of birth on the risk of exposure to second-hand smoke for infants.

METHODS

The smoking habits, according to child health records, of parents of 14 431 infants in Uppsala county, Sweden, born during 1997-2001, were investigated with logistic regression in the presence of socio-economic and demographic confounders from national registers.

RESULTS

Fathers born outside of Sweden smoked more often than Swedish-born fathers irrespective of region of birth (adjusted odds ratios [ORs] 1.77-3.02). Mothers born in Africa (adjusted OR 0.29, 95% CI 0.15-0.58) and Asia (adjusted OR 0.53, 95% CI 0.40-0.70) smoked less often than Swedish-born mothers. Single parenthood, low income and mother's age <or=24 years increased the risk for parental smoking.

CONCLUSION

The present study indicates that the risk of smoking in immigrant parents of infants is influenced by the smoking patterns in the region of birth. Smoke cessation interventions targeting fathers are particularly important in immigrant-dense neighbourhoods in Sweden.