9.2.2. Data Sources

 

In the year 2000 the European commission funded the public health information project Child Health Indicators of Life and Development (CHILD), which reported in 2002 (Rigby, Köhler, 2002; Rigby et al, 2003). This was charged with identifying a range of indicators which would measure this subject, and adopted the philosophy that it was much more important to focus measurement on health and the prevention of ill health, and the determinants of those. A total of thirty eight indicators were recommended, of which only two relate to mortality. However, with the exception of the already available mortality data, five years later few of these indicators have yet been built into any European routine statistical system, nor is there any apparent immediate prospect of this.

 

The most recent major European report on child public health was the WHO European Health Report 2005, subtitled “Public Health Action for Healthier Children and Populations” (WHO Regional Office for Europe, 2005). In its compilation the World Health Organisation Regional Office for Europe undertook a major effort to populate many of the recommended CHILD indicators, together with WHO Health For All data relating to children. Thus 24 indicators are published as Table 6 of the report as far as countries could supply the data, and form the basis of topics further analysed below. However, this was a one off exercise and the database remains static and undeveloped. Also salutary was the fact that this major publication itself cannot give the number of children in Europe, being restricted to the five-year age bands. Thus despite the apparent priority of child health for the European Commission and the World Health Organisation, a major information research project and a major data gathering exercise each remains shelved and not further progressed.  Prior to that, the Commission had produced in 2000 a Report on the State of Young People’s Health in the EU, using the limited available data.

 

Data about children are available from a range of sources. Each source contributes its own special dimension and characteristics; no one source is comprehensive and all-providing. To create a good understanding of children’s health and related pressures and services, it is therefore necessary to collate material from several sources. Among the most significant are:

 

EUROSTAT: The formal statistical organisation of the European Community has the advantage for having the power to require specific data from Member States, but it uses this sparingly so as not to overload national systems. It has a specific health and public health function, and coordinates the harmonisation of censuses across Europe, but specific children’s issues do not feature highly. For instance, the valuable analysis of suicide rates in Europe has 15-24 as its youngest age-group (see: http://epp.eurostat.ec.europa.eu).

 

WHO (European Regional Office): The specialist health agency of the United Nations, with a European Regional Office that covers the geographical regions of Europe, and treats equally the 50+ States. The Health For All database is comprehensive and provided a powerful on-line option. However, after the perinatal period children do not feature highly other than for immunisation. Statistical data are obtained on a voluntary basis from national systems, hence consensus of topics and definitions is important. (see:

www.euro.who.int/InformationSources/Data/20010827_1; www.euro.who.int/hfadb)

 

European Commission: The Commission has an interest in children in several Directorates-General, not least that of Health and Consumer Protection. However, other DGs such as those dealing with Education and Culture, Energy and Transport, Environment, and Justice, Freedom and Security (responsible for children’s rights), have major interests in issues relating to children and which may have health impacts. Such DGs commission and publish periodic reports on topics that include consideration of the effects of issues on children’s health. (Web link - ec.europa.eu/dgs_en.htm)

 

Eurobarometer: The Eurobarometer is a structured survey facility aimed primarily at obtaining a public opinion view of specific issues. Initiated to assess public views on Commission services, it can now be used to assess other topics; indeed, Directorates can bid for the inclusion of specific questions – perceptions of safety of hospital services is one such example. The sample size is too small for it to be considered a sound epidemiological or public health tool, but it can provide useful attitudinal studies. Most special topics are undertaken as one-off enquires. (Web link – http://ec.europa.eu/public_opinion/cf/index_en.cfm)

 

UNICEF: The United Nations Children’s Fund, UNICEF, is the United Nations’ primary agency to protect and promote the interests of children worldwide. Naturally, given its global remit, much of its effort is directed towards the developing world and to areas of conflict and natural disaster. However, some key initiatives such as The 1990 Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding apply universally including in Europe. The research unit of UNICEF, the Innocenti Research Centre, is based in Europe, and it undertakes some important European research which leads to local statistical output such as data on Child Friendly Cities. Their Baby Friendly Hospital Initiative to promote breastfeeding shows a far from perfect picture of compliance for EU Member State countries. Their Report Card in 2005 on Child Poverty in Rich Countries was data-rich regarding that child health inequalities topic in a number of EU states. (Web links – www.unicef.org; www.unicef-irc.org)

 

Organisation for Economic Co-operation and Development (OECD): This collaborative organisation formally involves only the most developed nations. Within that remit, however, it has proved particularly child-friendly, with a number of studies on issues affecting children, or parenting and families with children, such as the OECD Family Database. Topics covered include social exclusion, architectural design and children, and early education. More recently the European Commission has collaborated with the OECD in public health projects, so that data from European countries not in the OECD group can be included. (Web link – www.oecd.org)

 

UNAIDS – the Joint United Nations Programme on HIV/AIDS. This important cross-agency programme looks at many aspects of the HIV/AIDS epidemic globally, and has country-specific data on children. (Web link – www.unaids.org)

 

European School Survey Project on Alcohol and Other Drugs (ESPAD): This is an important (and rapidly growing) data gathering project that compiles data on the behaviour of young people with regard to alcohol, tobacco, and other drugs. Its web site provides considerable data. (Web link – www.espad.org)

 

Health Behaviour in School-aged Children (HBSC): This collaborative cross-national project with WHO support is conducted on a four yearly basis, reviewing health in currently 35 countries and regions, within and beyond Europe. Using a survey sample in each country, it gives a comprehensive account of factors influencing the health of adolescents aged 11, 13 and 15 years, who attend school. This means that it obtains a robust sample of children in each country, though there is some evidence that the inevitable exclusion of children not attending school means that small but significant deprived or atypical minorities are not included. The HBSC is wider than EU, and generally only produces reports at the global level, though with data for each participating country, but is widely respected for what it produces. (Web link – www.hbsc.org).

 

National Statistics: Each EU Member State has its own statistical office and other data sources. These are invaluable at the national level, but may not be comparable between countries.

 

General surveys such as national censuses and household surveys, and health interview and health examination studies, are important sources of health data. However, though households may contain children, seldom are the data analysed to focus on those children. Much more information could be obtained from existing data if child-centric analyses were automatically prepared. However, there are currently difficulties over the comparability of nationally-originating data, as different data definitions and collection methods may be used in different countries. Although most European countries run regular health interview surveys to monitor population health, many were set up before the recent trend to harmonise information collection within the EU, and are at variance with the standard (Robine et al 2004). Organisations such as Eurostat and WHO have been working supra-nationally to bring together common frameworks, and are developing commonly agreed and tested indicators, which produce comparable data. Even so, it has proven immensely complicated to reach a consensus on common instruments for measuring health status in different languages and in different cultural settings, in order to produce results that can be compared within, and across, countries of the EU (De Smedt, 2004). Moreover, the focus is still on adults and households, and not on producing child-specific data or analyses.

 

The European Community is of course steadily expanding. Dates of sources will give an indication as to the period and EU area in which data was gathered. Areas are delineated as to whether data encompasses, for example, the former EU-15, intermediate EU-25 or present EU-27 states, Accession and other States outside.

 

9.2.2.1. Issues related to data collection on children

 

Defining and counting children: Children are defined by the United Nations Convention on the Rights of the Child, to which all European countries are signatories, as “every human being below the age of eighteen years” (United Nations General Assembly, 1989). So how many children are there in Europe, and what is their state of health? Worryingly, neither of these questions can be answered from any routine and readily available means. For most statistical purposes, population and health data are grouped into five-year age bands. This means that tabulations can be produced for those aged 0-14 years inclusive, or those aged 0-19 years inclusive. Children in their totality, namely persons aged 0-17 years inclusive, can seldom be identified. The comparatively minor inconvenience and cost of producing an additional tabulation of 0-17 years is usually not considered worthwhile or justified, and this appears a sad but possibly realistic expression of the limited value placed on considering children as a group in their own right, or of discharging national and societal responsibility to ensure “the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health” (United Nations, 1989).

 

This is not a minor or pedantic point – it is effectively a statement of the attitude of Europe and its Member States to identifying and caring for children as a group. Using a cut-off at 14 years excludes an important element of the child population at a key stage of their development, and forming one sixth of the total child population. The use of a 0-19 years category results in young adults who may be married householders with paid employment being put in the same category as preschool children: physiologically, socially, and in other respects this is clearly not logical.

 

Lost Adolescents: By forcing the consideration of children as generally being those aged 0-14 years (from birth to early secondary school age), an important and vulnerable group is overlooked. Those aged 15-17 years inclusive, who effectively may be referred to as adolescents, are in a particularly important stage of physical and behavioural development. This is not just the age of puberty and other physical maturation; it is the period when many health-related lifestyles become established, which are likely to endure into adulthood. This includes eating patterns and nutrition, physical exercise, alcohol consumption patterns, sexual health practices, and other patterns of risk taking behaviour. It is the period of onset of specific health conditions. Arguably this is also the period when social attitudes mature, linking in wider ways to their own health and wellbeing and that of family and society. Yet this is the age-group group effectively ignored in national population and health statistics.

 

Gaps in data: A major deficit in public health knowledge in Europe is how little we know about the wellbeing of children. Nor is enough known about the determinants of well being, at national or sub-national level. Research may also be failing to capture information on those at high risk, or outside of the school system i.e. truants and those involved in illegal underage employment (WHO/HSBC 2004). These groups may be living in extreme rural and urban poverty, and are therefore highly prone to medical conditions and behaviours which are exacerbated by socio-economic factors.

 

Cultural variation: Context can have as much relevance as individual behaviour when reporting on a particular health outcome. Food and alcohol consumption are examples. Food preferences will vary geographically, culturally, according to socioeconomic opportunity, and food availability. Distinct differences are seen between the Northern and Southern (Mediterranean) food cultures. Structural and social contexts such as school environment, family and peers can further reinforce or challenge these patterns. Educational opportunity can be a prime indicator: across all Member States it is the least educated who consume fewest fresh vegetables.

 

Perspective: There is a place for qualitative data to supplement the quantitative. For example, when assessing a child’s experience, it is necessary to take their living arrangements into account and not solely the parents’ marital status, as is often the norm (Andersson, 2002). Caution must be used to ensure that sources do not merely reflect the status quo. For example, in some countries in Europe, where co-habitation is high, dissolution of consensual unions, (and thereby the effect on children of the union) is not measured in the same way as marital disruption (Heuveline and Timberlake 2000). Demographic information is too often based solely on marriage and divorce rates.

 

Children are not miniature adults, their needs and their service requirements are different, yet despite comprising about one quarter of the population of Europe they appear almost invisible in studies such as this, swamped by the interests of adults, and by the major diseases of adulthood.

 

The European Commission has sponsored important work on standardising questions in Health Interview Health Examination Surveys, as well as the work through EUROSTAT in standardising and harmonising statistical definitions. However, almost the whole of this work is still focused on the adult section of the population – the main exception being infant mortality. There would appear to be a serious lack of child-orientation in European public health and statistical work.