HEALTH INDICATORS FOR

SWEDISH CHILDREN
by Lennart Khler

A CONTRIBUTION TO A MUNICIPAL INDEX

Save the Children fights for childrens rights.

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2006 Save the Children and the author

ISBN 10: 91-7321-214-8
ISBN 13: 978-91-7321-214-4
Code no 3332
Author: Lennart Khler
Translation: Janet Vesterlund
Technical language edition: Keith Barnard
Production Manager, layout: Ulla Sthl
Cover: Annelie Rehnstrm
Printed in Sweden by: Elanders Infologistics Vst AB

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Contents
Foreword

Background
1. Measuring and evaluating the health of a population
2. Special conditions in measuring the health of children and adolescents
3. Some features of the development of childrens health and wellbeing in Sweden
4. Swedish municipalities and their role in childrens health

6
6
11
14
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Indicators of childrens health

5. Basis for constructing health indicators for children
6. Principles for municipal inficators of childrens health
7. A set of indicators for childrens health
8. From indicators to a municipal index
9. What is not available now but should be and perhaps will be soon

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33
47
54

Results, conclusions and further work

10. Situation in the municipalities
11. Conclusions

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64

References

67

Municipality table 1
Individual indicators and childrens health index for the 2000 period (6 indicators).
Municipalities in alphabetical order.

77

Municipality table 2
Individual indicators and childrens health index for the 1990 period (5 indicators).
Municipalities in alphabetical order.

84

Appendices
Appendix 1. Technical description of indicators used
Appendix 2. Technical description of indicators not used
Appendix 3. Final indicators

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Foreword
While I was given the task of constructing a health index for children on the municipal
level by Save the Children, this does not mean that I carried out this work entirely on
my own. I discussed the design and progress of the work with a reference group with a
broad range of competence (Sven Winberg and Eva Svedling, Save the Children
Sweden, Anders Hjern, Swedish National Board of Health and Welfare, Marie Berlin,
Statistics Sweden, Johanna Alfredsson, Gvleborg County Council) and was
encouraged at all times by the senior management of Save the Children, particularly by
Project Manager Kalle Elofsson.
In compiling municipal data for the different indicators, I received technical assistance
from the Swedish National Board of Health and Welfare (Claes Hedberg, Milla
Pakkonen and Anders berg), from the Swedish Institute of Infectious Disease
Control (Viktoria Romanus) and from Professor Tapio Salonen at Lund University
(poverty index).
I had long discussions about constructing indices with Professor Bo Eriksson at the
Nordic School of Public Health in Gteborg, who also helped me in processing the raw
data and producing an index based on the individual indicators.
I am very grateful for all the help and support I received during different stages of the
work.
Gteborg, January 2004
Lennart Khler
Foreword to the English translation
The original work was written in Swedish and published in 2004. In the beginning of
2006, Janet Vesterlund made the translation into English and, in addition, Keith
Barnard made a technical language edition. Allmnna Barnhuset, Stockholm, financed
this work. In the interval of two years between the Swedish and the English version,
important books were published, relevant reports written and the author may have
become wiser. Nevertheless, the decision was made to stick to the original contents,
without updating. New references and ideas will be saved for a follow-up report, which
will appear in a few years time.
Gteborg, May 2006
Lennart Khler

BACKGROUND
1. Measuring and evaluating the health of a population
Health as a component of welfare
Being able to measure and evaluate states of health is a central problem in all health
care: it is important in each and every contact with individual patients and is a necessary
part of epidemiological studies of groups, regardless of whether as a basis for allocating
care resources or assessing effects of measures taken, treatment or prevention.
But a populations state of health is not merely the result of care efforts on different
levels; it is also a part of welfare and, as such, is one of the targets of sociopolitical
interventions. Already the Romans were aware of the significance of health as a political
instrument. Cicero spoke of salus populi lex suprema, the health of the people is the
supreme law. The first useful international register of the components of a standard of
living was issued by the United Nations in 1961 (International Definition and Measurements
of Living). Since then this work has been further developed with ever greater
sophistication and impact by other international bodies such as the Organisation for
Economic Co-operation and Development (OECD), the Council of Europe and the
European Union.
Together with education, employment, income and social relations, health holds a
central position in all the registers of the different components of welfare, and thus also
in public policy goals. When judging progress in countries development, one or more
components are regularly included to reflect the health of the population, typically life
expectancy and causes of mortality. Even for the World Bank, an organisation focused
primarily on economic development, improvements in the health of the population are
important goals for aid and development programmes. As such, they must be measured
and evaluated (World Bank, Investment in Health, 1993).
Growing internationalisation has increased the need of systems for measuring health
that make it possible to compare developments between countries and regions. A
project in this vein is the European Commissions Health Monitoring Programme
(HMP), which was started in 1997 to develop the EUs new public health competence.
The programmes objective is to:
a) measure the state of health, its determinants and trends within the
European Union
b) facilitate planning, monitoring and evaluation of EU programmes
and actions
c)

supply the Member States with appropriate information on health

issues so comparisons can be made and national health policies
supported

A secondary project in this programme has been European Community Health

Indicators, which has resulted in the development of a set of health indicators for use

in each member state (ECHI 2001). These indicators constitute a matrix that covers the
most important areas of population health. The proposal is now under consideration in
the EUs Commission and Parliament and if adopted will in time be promulgated as a
Directive binding all Member States.
Individual countries have developed their own systems for monitoring the health of
their populations as a part of their living conditions, and the results are regularly
published in in the form of statistics, investigations and scientific reports. They are a
rich source of information for politicians, planners and researchers.
Sweden was one of the first countries to begin mapping its populations living
conditions. The first initiative was taken in 1965, the so called Low Income Survey
(Johansson 1973), the terms of which were: to make a measure-related survey of the living
conditions of the Swedish people, with the specific purpose of identifying persons with low incomes and
studying how they live. The theoretical projections made then came to have major
significance for the development of later studies, in Sweden and other countries. A so
called resource perspective was applied, whereby it was taken as given that it was the
responsibility of society to ensure that resources are equitably distributed, and largely
up to individuals to determine how those resources should be used. State of health was
given a prominent role as one of these resources, with the help of which the indivdiual can
control and consciously steer the conditions under which he or she lives, to paraphrase the Low
Income Survey (Johansson 1973) and the most recent Swedish Welfare Balance Sheet
(Vlfrdsbokslut SOU 2001).
Data on the living conditions of Swedens adult population have been published
regularly since 1976. Welfare and its distribution are reported in the following areas:
education, employment and working hours, work environment, health, financial
situation, housing, transport and communication, leisure time, individual and shared
activities, political resources, and security and safety. In October of 2003 Statistics
Sweden presented a new analysis of developments in Swedish welfare, Welfare and
Hardship in the 1990s (SCB 2003). This is however still based only on the adult
population.
In 1996 the Swedish Association of Local Authorities, the Federation of Swedish
County Councils and the Swedish National Institute of Public Health initiated a joint
project, Local Welfare Balance Sheets (Vlfrdsbokslut Folkhlsoinstitutet 1999). Its
purpose was to develop and test methods for guiding and monitoring municipal
activites in a local and realistic perspective, where the focus is the health and welfare of
the population. In the model that was developed and tested in some ten municipalities,
welfare was described in terms of 13 components that were in turn expressed as some
60 measurable key numbers. Good health, support for healthy lifestyles, social
relationships, safety and security, and access to medical care were some of these
components.
The annual reports of district medical officers started in the mid-nineteenth century and
became a valuable source of information about the populations state of health. They
were used by the National Board of Medicine (Medicinalstyrelsen), forerunner to
todays National Board of Health and Welfare, to compile national reports. This system
of reporting continued until the beginning of the twentieth century when the main
interest moved towards individual-based care instead of population health. It was only

much later, reflecting a growing international commitment to initiatives with a public

health perspective, and stimulated in part by the World Health Organisations
(WHO)health for all movement, that the Swedish Government gave the National
Board of Health and Welfare the task of preparing national public health reports. The
first came out in 1987 and has since been followed by a further five reports.
It was decided at the outset that the reports would include certain overall indicators to
reflect the commitment to greater equity (as) an overall objective in determining priorities in
matters related to public health (Public Health Bill 1990). Since then the Governments
instructions to the National Board of Health and Welfare have been expanded to cover
the whole of the social sector, in order to identify and analyse the ways in which social
welfare and social problems develop.
In later years, social reports were published simultaneously with the national public
health reports. The latest Public Health Bill (Bill 2002/2003:35) states that there has
been no overall national monitoring or evaluation of public health measures and their
effects on factors that affect health. The Government therefore places great importance
on monitoring and evaluating the health of the population, and proposes that the
efforts made in target areas should be carefully analysed and assessed. The intention is
to build up an extensive system for public health reporting to explain and understand
how ill health arises and to clarify the different aspects of health development in a
population-wide perspective.
Further, the National Board of Health and Welfares National Public Health Reports,
which describe the underlying basis for its information, are to be supplemented by a
public health policy report prepared by the the Swedish National Institute of Public
Health. This will describe the development of health indicators, particularly those that
determine population health, and propose and analyse the measures that should be
taken.

What do we mean by health?

The better the knowledge we have about the lifestyles and living conditions of the
population, the greater are our opportunities to plan public policy interventions, and to
evaluate the effect or impact of the actions we take. Sustainable, consistent and
systematic monitoring of the populations living conditions allows us to make reliable
analyses of developments and hence to avoid opportunistic and hasty actions. It is
important that the methods and measurements used are tried and tested, and relevant,
valid and reliable. In terms of health components, however, this is far from
straightforward. Health has many dimensions, and opinions differ as to what is
important and what should be measured.
Overall definitions of the concept of health are utopian rather than operational and,
more importantly, unmeasurable This applies very obviously to the most often cited
definition given in the preamble to the 1946 WHO Constitution: a state of complete
physical, mental and social wellbeing and not merely the absence of disease or infirmity. Of course
such definitions are not intended to be operational. The WHO definition is there in the
Constitution as a statement of its vision and a reference point for the Organizations
Objective, (Article 1), which is the highest attainable level of health for all peoples.
Even so, to be meaningful this objective requires measurement of its progress, more
specifically the outcomes of all the actions taken in pursuing the objective. Later,
moving towards a more operational definition and recognising health as a resource for

the individual and society, WHO proposed that the target should be that all peoples
enjoyed a level of health enabling them to live a socially and economically productive life i.e.
giving them the capacity to function in society. (WHA 30.43, the health for all
resolution 1977).
Later still in the same vein, a WHO Conference on health promotion concluded that
health is a resource that enables the individual to identify and to realise aspirations, to satisfy needs,
and to change or cope with the environment (Ottawa Conference, 1986).
While more specific in their understanding of the practical significance of good health
as a resource in everyday life, these definitions still present a problem of measurement,
and should therefore be seen as a point of departure, rather than a handbook for
everyday life. Crucially, and in common with the definitions in the action plans and
programmes of other organizations, such as the Council of Europe and the EU, they
make clear that functional health implies much more than the absence of disease. Any
operational definition of health must also include a positive element, encompass mental
and social as well as physical aspects, and have both objective and subjective
components.
This approach also accords with the general publics view of what health is. Social and
personal resources are as important as physical capacity. Health is a positive resource
and a part of our total life experience, and not necessarily something associated with
freedom from sickness (Fugelli & Ingstad 2001).
According to WHO reports, many though not all European countries have drawn up
health and medical care plans, or at least worked on strategies, that apply such thinking.
In Sweden, the opening paragraphs of the law on health and medical care, and more
recently the Governments Public Health Bill (2002), set out overall goals of this kind.
Of course we have a long way to go before the goals are attained, but this in no way
detracts from the importance of the work of defining objectives and strategies for
achieving them.
The problems Sweden faces in the welfare state of today are different from those of a
century ago and different also from those that poorer countries face today. In the new
panorama we see more elderly people, greater demands for medical care, static or
shrinking resources and overworked staff. These are the defining problems that
characterise modern health care. The problems of an uneven distribution of resources
and the use of them remain unresolved, ethical considerations and dilemmas are
becoming increasingly complex, and demands by patients for a real say are becoming
more strident.
The populations health problems are not only medical , nor are the solutions to them.
They require a societal response. Professionals and others working in sectors outside
medicine will often have a significant role to play, and an inter-disciplinary knowledge
base is essential for the development of effective responses to problems.
This knowledge base for addressing health problems is called public health science, defined
as the inter-disciplinary study of the importance of the structure of society, working life,
the environment, and the health care system and its effectiveness, or the science and art of
preventing disease, prolonging life and promoting health through organised efforts of society (Acheson

1988). It also includes studies of the effects of different policy measures and the effect
of public health operations on society and on different population groups. The work to
improve general standards of public health and to eliminate differences between
different groups in society is called public health practice (Modeste & Tamayose 1996).
These measures are systematic and goal-oriented, with an view to achieve good and
equitable standards of health throughout the population. The Governments latest
Public Health Bill (2002) states that the overall objective is to create social conditions for
good health on equal terms for the whole population.
At the same time that health, in the spirit of WHOs 1977 definition, is a resource for
the individual to live a satisfying and productive life, public health is identified as one of
societys welfare goals. Swedens public health policy is therefore directed toward those
social factors, common resources and environmental exposures that are difficult or,
indeed, impossible for individuals themselves to influence.
An important means to this end is health promotion, which starts with individuals
resources and attempts to reinforce protective factors rather than simply identifying
risk factors.. Theoretically, this approach is based in part on Aaron Antonovskys work
on sense of coherence (SOC), which tries to assess whether existence is experienced
as manageable, meaningful and comprehensive from childhood onwards (Antonovsky
1987).
Medical care is but one of many factors in improving the health of a population, and it
has been claimed that historically its role has been marginal in comparison with the role
played by the general improvement in welfare, thanks primarily to better nutrition,
better housing and less physical hardship (McKeown 1976). Peace, potatoes and vaccine,
were what Esaias Tegnr, an early 19th century Swedish poet, academician, bishop and
politician, claimed to be most important to the health of the population.
Today, when improved welfare in the privileged part of the world has created the
conditions for a long life, the provision of appropriate effective medical care is
nontheless essential for good population health, in treating and where possible curing
infirmities, in enhancing our ability to function, and in providing relief when cure is not
possible
The concept of health is thus enormously complex, and our understanding of what it is
we must measure is still imperfect. It should come as no surprise that we are still
uncertain about the measurement methods to use and how to make sense of the
measurements we make. This leads to the choice of measurement being determined to
a great extent by what data are available. The end result is that on both national and
international levels, we most often measure and compare ill health, that is, disease.
And then we are immediately on firmer ground: we know a great deal about disease and
death. We have well defined professional groups there, whose task it is to treat diseases
and abnormalities, who, under the cloak of science have gained strong positions in
society and who have thereby established precedence over others to interpret findings.
The WHOs International Classification of Disease (ICD) listing some 8 000 diagnoses
is regularly updated. It is now used all over the world, to the great benefit of
standardisation and comparisons of diagnoses. However, these diagnoses only provide
a picture of diseases and abnormalities, and only from a professional perspective. They

10

leave no room for the positive aspects of health and well-being, and very little for
peoples subjective experience of ill health.
Still, these non-medical dimensions of health are important to both individuals and
society. They cannot be ignored if our aim is to establish complete and relevant
measurements for comparisons between groups and areas and over time. The public
health perspective provides a natural starting point for the construction of a system of
health indicators for populations and groups within populations.

2. Special considerations in measuring the health of children

and adolescents
Health, welfare and children
Even though measuring welfare has thus long been an important task for politicians
and researchers, it is nonetheless obvious that the welfare of the population has been
considered to start earliest at the age of 16 childrens welfare has not attracted the
same interest. It is only possible to find data on children as a sort of appendage to
adults. An international project on childhood as a social phenomenon (Qvortrup 1994)
summarises the results gathered in 18 countries as regards collecting information about
children in the following way:

children are seldom units of observation

the information available about children is fragmented
the age categories reported are inconsistent
information about children is not published on an ongoing
basis

Swedens several hundred year old, unbroken series of population statistics and the
more recent introduction of personal identification numbers offer unique opportunities
to gather comprehensive, reliable data on the population and its living conditions. But
these early welfare surveys have made it easy for themselves by excluding children
(Khler & Jakobsson 1991), in spite of the fact that this group should be given high
priority. In the Welfare Balance Sheet from the 1990s, for example, children are named
as a key group for welfare policy (SOU 2001a).
There are several reasons why children are especially important as a target group for
public health efforts, in both in their own right and in their future as adults.

Children constitute a large portion of the population. In

Sweden, children 0 to 17 years make up over a fifth of the
population. In many developing countries children make up
more than half of the population.
Children constitute a vulnerable group, exposed to considerable
health risks and dependent upon others for their protection and
care.
Childrens health reflects the care that countries offer their
citizens.

11

The advances achieved in this area represent a measure of

countries general social standard and are frequently used in
international comparisons.
Children have no political power and are not represented in
formal or informal pressure groups, as is the case, for example,
with elderly or disabled persons.
The knowledge, attitudes and behaviour of adults in health
issues, and often their basic state of health as well, are founded
and established during childhood and adolescence.
With the ratification of the UN Convention on the Rights of
the Child in 1989, Sweden obligates itself to give all children
within its borders the rights of the child to the enjoyment of
the highest attainable standard of health (article 24), to a
standard of living adequate for the child's physical, mental,
spiritual, moral and social development (article 27) and to
education (article 28)

Thus arguments are not lacking for the urgency of the task of carefully monitoring and
following up childrens health and welfare in a society that wishes to call itself childfriendly.
There has been a comparatively large number of studies and reports in Sweden about
welfare, which in modern time have endeavoured also to include children. Some have
even concentrated on children and young people as the sole target group. A series of
reports were prepared at the end of the 1960s and beginning of the 1970s that surveyed
childrens environment and needs in different contexts, e.g. reports on daycare, on the
social care of children and young people, on childrens leisure time, on the school, on
child health care and school health care.
The broadest and most comprehensive of these was Bror Rexeds report on childrens
environment, whose purpose was to give a systematic report of childrens living
conditions. Nine volumes totalling over 1 300 pages reported on childrens
development, upbringing and health status, as well as on the financial status of families
with children, their physical, cultural and social environment and their working
conditions. This was thus in essence an historical study of childrens welfare up to the
1970s (Children Report of the Childrens Environment Investigation (Barnmiljutredningen) 1975).
Statistics Sweden (SCB) later published several reports on childrens living conditions,
and other reports have also contributed to satisfying relatively well the need for
knowledge about childrens living conditions (see e.g. Welfare Balance Sheets for the
1990s (SOU 2001a), Bremberg, Level of Living Surveys/Children (SOU 2001b),
Statistics Swedens Childrens Living Conditions, National Board of Health and
Welfares Childrens Health in Sweden, the Reports of the Childrens Ombudsman,
Follow-up of the UN Convention of the Rights of the Child.).
The first Public Health Report commissioned by the Parliament in 1988 gave no
information at all on children. In the second report in 1991, a section was devoted to
children, based on a specially developed investigation of basic information (Khler &

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Jakobsson 1991), and individual chapters on childrens health were included in later
public health reports.
The Childrens Ombudsman and Statistics Sweden (SCB) publish Up to 18 every
third year, a popular statistical reference book on children, and the SCB annually
reports register data on children from a welfare perspective.
In the Local Welfare Balance Sheet (Folkhlsoinstitutet 1999), a joint project of the
Swedish Association of Local Authorities, the Federation of Swedish County Councils
and the Swedish National Institute of Public Health, some of the participating
municipalities focused on childrens welfare, for example Gteborg and Haninge.
Developing this work further, the Swedish National Institute of Public Health
constructed a database of municipal facts as a basis for public health work, and this
treats a number of childrens issues (Folkhlsoinstitutet 2003, www.fhi.se). Proposals
have been made to facilitate monitoring of childrens health by using a standard form
for central registration of e.g. vaccinations, injuries and health examinations in preschool and schoolchildren (Socialstyrelsen Memorandum, March 2002).
Preparations are ongoing at Statistics Sweden for an expansion of routine statistics on
childrens health that will include about 40 group indicators. The goal is to regularly
present simple health measures in cooperation with other authorities to give an
overview of health developments among children, particularly on the municipal and
regional levels.
A three-year project has been carried out at the National Board of Health and Welfare
to survey the mental health of children and young people with the intention of offering
a complete, concrete and tested system for regular surveys of Swedish childrens mental
health (Hagquist 2004).
The Governments new public health policy statement highlighted secure and favourable
conditions for children and young people as one of the target areas, which will thus be an area
of careful study and will include the development of indicators and analyses of
measures.
Although all these ambitions are certainly praiseworthy, we have not yet come so far
that these reports, either by themselves or together, give a complete picture of
childrens state of health. In preparing these statistical reports, it is often pointed out
that a very large part of the information about health in different registers is not based
on personal identification numbers and that they lack information about social
background. The conclusion we drew after our earlier survey of childrens health in
Sweden (Khler & Jakobsson 1991) still applies today: One looks in vain for a systematic,
continuous and complete reporting of childrens health, in a child perspective and related to a social
context.
A sub-project, carried out in the EU Health Monitoring Programme mentioned above,
and its set of health indicators (ECHI) treated health indicators for children on a
national level (Child Health Indicators of Life and Development, CHILD). The project
gathered specialists from all EU member states, plus Norway and Iceland, and the final
report was submitted to the EU Commission in September of 2002 (Rigby & Khler

13

2002). The proposal will now be considered by the Commission and its technical
agencies and be incorporated, at least in part, if and when an overall health surveillance
programme is initiated.

Child Public Health

We can give thought to how the broad concepts of health, public health science and
childrens special needs of protection for their health and welfare can be combined into
a concept that could be called Child Public Health (Khler 1998). Action areas in Child
Public Health include educational programmes, research and practical activities. One of
its most important practical tasks should be to create centres of knowledge about
children, to conduct programmes in concert with politicians and other decisionmakers
in childrens health, and to work with action groups, voluntary organisations and
different occupational groups in other sectors of society.
Setting up a centre of knowledge about childrens and adolescents health and health
behaviour in municipalities, county councils or on a national level is a long term and
relevant goal that certainly requires much work but is not unrealistic. A knowledge
centre must be the natural entity to which politicians, the press and the general public
can turn for up-to-date, objective information on issues that have to do with childrens
and adolescents health and welfare. Components of these centres already exist in child
health care, school health care, paediatric care, the social services, schools, childrens
and young peoples clinics, child psychiatry and childrens ombudsmen. What is lacking
are common visions, overall goals, an established structure with clear strategies for
cooperation and inspired leaders for collective efforts in this vital area of society.
The strength of child public health work is that it is based on the concepts and values
of the WHO Health for All Strategy, adopted by the World Health Assembly, it
employs methodologies used in public health, and it places childrens and young
peoples health in their full social, economic and political context. This means that its
activities in education, research and practice will be practical and relevant and will
include insight and experience from a number of different professions and sciences.
The approaches and methods in child public health will form the basis for the review of
suitable health indicators for children that is given in this report. The proposal is also
coloured by experience from the recently completed EU project on health indicators
for children.

3. Some features of the development of childrens health

and wellbeing in Sweden
There are several ways to describe developments in childrens health. We can start from
the degree of severity or the frequency of health problems in children; we could use
diagnoses or organ systems or medical specialties or areas in which there have been
great changes; we could use investigative methods or sources of information as our
starting point, or survey childrens health and ill health according to age groups or sex.
Or we could use a combination of these methods.
As this review will be a part of a report about health indicators and a health index, I
have chosen to group health variables according to generally available concepts and

14

measures. Measures of this kind that are most often used in studies of health or ill
health in child populations are easily available via registers or other means, usually
mortality, morbidity and growth and development. More modern and complete descriptions
also include wellbeing, health behaviour and perhaps quality of life.
We are used to seeing Sweden and the other Nordic countries as leaders in terms of
welfare states and thus as populated by healthy, flourishing citizens. This may be so
now, but has not always been the case. In truth it was only during the twentieth century
that major advances were made in population health. This goes for children as well,
during the century that the Swedish author Ellen Key called the childrens century. To
take a longer historic perspective of childrens health status we have to look at
indicators that are easily available in population registers or medical officers reports,
and these deal with mortality and to some extent morbidity.

Mortality
The most frequently used variable for mortality is infant mortality, i.e. the number of
deaths under one year of age per 1 000 live births. Sweden has records dating back to
the middle of the eighteenth century that show that the numbers have steadily
decreased. Perinatal mortality is also often used (stillborns + deaths during the first
week of life). Neonatal mortality is sometimes also used, that is, deaths during the first
month per 1 000 live births.
The under five mortality rate (U5MR) is also used, especially in international
comparisons, and is considered by UNICEF (the United Nations Childrens Fund) to
be the single measure that best illustrates childrens situation in a country. Sweden and
the other Nordic countries have the lowest figures in the world, together with Japan.
Mortality statistics, especially infant mortality and U5MR, are generally used as a
measure of a countrys social and economic standard, more sensitive and appropriate
than the gross national product (GNP), for example. As a further measure of
socioeconomic conditions, WHO uses the proportion of live births with low
birthweight, that is, less than 2 500 g. These numbers are about 4 percent in Sweden
while they are 30-50 percent in many developing countries.
In general statistics it is also simple to relate mortality to specific diagnoses. In
diagnosis-related mortality, diseases in newborns, injuries and cancer take the leading
positions. In industrialised countries, injuries are now the leading cause of death among
children over one year old, and a large portion, often the majority, of these are deaths
in traffic.
In spite of the strong growth in road traffic in Sweden, the number of deaths from
traffic injuries, among both children and adults, has decreased, as have the number of
deaths due to drowning, suffocation and poisoning. There has also been a shift toward
less severe injuries. In the 1950s, 400 children died annually as a result of injuries, of
which 140 died in traffic. The corresponding figures during the 1990s were between 60
and 30 deaths. The child population was approximately the same, but the number of
cars had increased from one to four million (Sylwander 2001).
Another leading cause of death among children is malignant diseases. The number of
children with cancer has been relatively stable, but mortality has decreased and length

15

of survival has increased with effective treatment. It is estimated that about 300
children under 15 years of age in Sweden receive a diagnosis of cancer each year, of
whom over 70 percent survive (Public Health Report, Socialstyrelsen 2001).
While Sweden has traditionally had a reputation as a country with a high suicide rate,
the suicide frequency declined after an increase in the 1960s and 1970s. Sweden is now
in a middle group among countries in Europe. There was a clear decrease in suicides in
the age group 15 to 24 years between 1987 and 1996, but suicide attempts have shown
a tendency toward an increase. An explanation for the rise in suicide attempts could be
that poisonings that now occur are often related to intake of paracetamol rather than
acetylsalicylic acid. Intake of paracetamol leads more often to hospital care. However, it
is difficult to make a clear interpretation of the rise in registered suicide attempts.
Average length of life is in a way also a mortality statistic and indicates how long an
individual of a particular age can expect to live. Sweden is at the top here as well,
surpassed only by Japan. A newborn boy in Sweden has a life expectancy of 77.6 years
and a girl 82.1 years. However the number of years that a 50-year-old man has left to
live is only about six more than it was in the nineteenth century, which of course
illustrates that the greatest gains in terms of life expectancy have been achieved in
younger people.

Morbidity
Use of care
Morbidity among children can be described in many ways. Health care register data can
give a picture of how societys health care resources are used in terms of
hospitalisations, visits to primary care etc., in other words of the use of care among
children. This is a very common method in adults and is now also used in children.
Surveys of this kind are used foremost as a basis for planning resources and are a
questionable method for measuring morbidity.
Important factors that are not directly related to morbidity affect the need for care,
demand for care and use of care, e.g. knowledge, attitudes, values, belief in the system
and financial resources on the part of the patient, and organisation, treatment practice
and availability of the health care system.
Availability of care has been shown to be a particularly powerful means to control
utilisation of care. With the general restructuring of inpatient care in Sweden the
number of hospital beds decreased from above 2 000 in the 1980s to somewhat over 1
100 in 1998 (Socialstyrelsen 2001a). More and more children are instead treated in
ambulatory care. The average length of hospital stays decreased from 4.6 days in 1981
to 3.7 days in 1998. The majority of care days was used for diseases in newborns,
psychiatric disorders and injuries. Not counting neonatal care, the mean care time in
1998 was 2.8 days.
Somewhat over 11 percent of county councils collective costs for health care in 1999,
excluding dental care, went to the care of children between 0 and 19 years, who at the
same time represented 22 percent of the population. There has also been a marked
change in the disease panorama since the beginning of the twentieth century.
Treatment of diseases that previously led to rapid death, such as cancer and neonatal
diseases, has improved and survival times have increased. Undernourishment and

16

serious infections have disappeared, replaced by allergies, diabetes and other chronic
conmditions.
The most common chronic diseases in children are now allergies and asthma. It is
estimated that one third of schoolchildren in Sweden have or have had an allergic
disorder. The prevalence of asthma is now 8-10 percent among schoolchildren, which
is three times higher than the rate 25 years ago (Formgren 1998, Socialstyrelsen 2001a).
Diabetes is very much on the rise in Sweden The incidence has risen by an average of
over 2 percent each year, and is even higher in children under ten years of age. More
than 500 cases of diabetes in children are diagnosed each year and, despite systematic
and intensive treatment, there is a large risk of serious complications later in life. The
cause of this increase has not been clarified, but there is a strong corrrelation with the
increase in obesity and overweight in children (Dahlquist & Mustonen 2000).
As chronic conditions have become more important for families, they have come to
occupy a more prominent place in health and social care. Demands for treatment and
care have increased among both professionals and lay persons. Children with
disabilities and and long term conditions have received much greater attention in recent
decades. Still, information about the occurrence of disabilities in children remains
uncertain because the definitions and boundaries are diffuse and no comprehensive
surveys have been made. Existing data are based on estimations and prognoses from
local studies. According to a compilation by the Swedish Disability Institute using a
number of different sources, a total of 225 000 children between 0 and 17 years of age
have a long term condition or some mild to serious disability, that is, 13 percent of that
segment of the population (Hjlpmedelsinstitutet 2002). The material does not allow
any deeper analyses or breakdown on the municipal level.
Dental diseases in children are particularly interesting from three perspectives. First, they
are easy to diagnose, at least in their more serious forms. We can tell the general dental
health status of a child by simply looking in its mouth. Secondly, dental diseases,
primarily caries, are closely related to socioeconomic status. While there is generally a
clear relationship between the familys social class and childrens health, one of the
clearest relationships is seen for caries. Thirdly, preventive measures are most often the
best way to counteract dental disease. Good regional studies of childrens dental health
have been carried out in Sweden since the 1960s, and the National Board of Health and
Welfare has followed developments throughout the country since the 1970s, via the
National Dental Service and later also via private dentists. Annual reports are
published. Local and regional prevention programmes have been conducted
throughout the country at child health centres, in pre-schools and in schools, and
national care reforms have made dental care easily available and free of charge for
children. There have been significant improvements in dental status in all groups of
children and young people, although considerable regional and social differences still
exist. Reports to the National Board of Health and Welfare are not based on personal
identification numbers and connections are not routinely made to the childs
socioeconomic background and home municipality.
Children are large users of ambulatory care, especially in the ages one to four years, and
the most problems in pre-school ages are ear infections and upper respiratory
infections. It appears that infectious diseases have increased in younger age groups and
decreased in older groups, possibly because children come together in groups at pre-

17

school and not when they start school as was previously the case. Among older
children, the more common problems are injuries and psychosomatic symptoms. In a
study of children and families with children in the Nordic countries, parents reported
that about half of children aged two to 18 years had visited a doctor as an outpatient
during the most recent three months, while during the same time approximately 60
percent of the children had been absent from school or pre-school as a result of illness,
usually four to five days.
About 15 percent of mothers and 10 percent of fathers had been absent from work to
care for a sick child. 40 percent of the children in the Nordic countries were
completely healthy, i.e. had made no use of societys care resources, while 3 percent of
children were heavy users, i.e. had used hospital care, doctors and outpatient care
(Khler & Jakobsson 1991).
In the 1996/97 investigation of living conditions based on a representative sample of
Swedes, 23 percent of children, 0-15 years of age, had visited a doctor as an outpatient
during the most recent three months. Over a third of children aged 0-2 years old had
visited a doctor, a frequency exceeded only among retired people (Socialstyrelsen
2001a).

Health examinations
Another method for identifying sickness and health is health examinations. Sweden has
long had a well organised system of child health surveillance that is used by practically
all children. One might thus think that there would be large quantities of data on
childrens health (or ill health) derived from check-ups, screening investigations and
individual assessments.
Unfortunately, however, the data are seldom systematised or compiled. The results
presented in official reports have mostly to do with structural features (e.g. the
organisation, number of doctors and nurses, number of children per doctor) and
performance measures (e.g.number of visits, number of vaccinations), not with
outcome and effectiveness measures, i.e. how health is influenced by these activities
(Khler & Sundelin 1985; Medical Research Council (Medicinska forskningsrdet)
1999).
Data compiled from routine child health and school health services are thus relatively
sparse, and the data that exist are not reliable (Hagelin 2001). It is necessary instead to
consult special health examinations with specific questions and a built-in evaluation to
form a picture of childrens everyday health. A growing number of screening methods
have gradually been introduced in health examinations, i.e. simple, fast and cheap
methods for identifying those children who should undergo more extensive diagnostic
investigations.
Screening is used primarily in mass investigations to find hidden health problems that
have a significant effect on the individual and whose course can be helped by early
detection and treatment. Among children, systematic screening has been used most for
vision and hearing and for certain laboratory investigations of blood and urine. The
methods have been critically examined and evaluated and there is now good knowledge
about the value of these investigations. Studies that have followed groups of children
over several years have shown that certain complaints disappear spontaneously and

18

others make their debut. For certain individuals it can of course be important that
abnormalities are detected, but the effect of early detection and treatment on the health
of the group seems to be marginal, except possibly as regards impaired vision and early
hearing deficits (Hall 1996).
The value of formal screening of mental, behavioural, linguistic, social and moral
development has not yet been satisfactorily documented. The complex biological and
social dynamics that lie behind a childs development make it difficult to find simple
and unambiguous methods for early detection of disorders. Furthermore, their
treatment has not been particularly successful (Sundelin & Sonnander 2000). National
Board of Health and Welfare has proposed a computerised standard record that can be
used to create a central database with good quality (Socialstyrelsen Memorandum,
March 2002).
All modern surveys of population health include self-assessed health as an important
feature. This captures aspects of health that are not otherwise detected. Subjective
evaluations of health have also shown good agreement with objectively observed
disease and survival. Interviews, dialogues, questionnaires and diaries can help to give
an idea of how people experience their health or their diseases.
Studies of this kind can be designed and analysed using quantitative or qualitative
methods, methods that have commonly been used for adult populations but are now
also beginning to surface more and more often in investigations of older children.
An example is the Health Behaviour of School Children (HBSC), an international study
initiated by WHO of schoolchildrens health habits. It has been conducted every fourth
year for some years, and now encompasses more than 30 countries (WHO 2000c). The
proposed system for continuous surveillance of childrens mental health is also based
on information from children themselves (Hagquist 2004).
Self-assessments are sometimes combined with health examinations or studies of health
care utilisation, making it possible to relate subjective and objective measures of health.
This is often done in child and school health care but, in that case, it is generally parents
that give subjective information. The younger the children, the more difficult it is to use
them as sources of information.
In some projects children and parents have been asked to keep their own registers of
episodes of illness or health activities. Studies of this kind can show that small children
have many episodes of illness but that the episodes are largely managed by the parents,
most commonly the mother, without professional help (Uldall 1986).

Mental health
It is not difficult to argue that childrens health status has improved dramatically in the
last century and that this group is now the most healthy in our population. There are
solid data to confirm this and the knowledge of it is well rooted in our thinking. An
exception is childrens and young peoples mental health and the psychosocial
environment in which they grow up.
Many express their anxiety that children are not feeling well mentally and are not able
to achieve optimal development, and that societys increasingly crass priorities, the
demands made in working life, and the dissolution of families have led to more worry,

19

alienation, burn-out, substance abuse, criminality and marginalisation from working life
or society. The picture in the mass media is clear. The public is convinced, and many
health, social welfare and school professionals are deeply concerned about the
developments they see in their everyday work and politicians want to do something.
However, it is not a simple task to confirm these ideas in scientific studies or with
official statistics. It is difficult to make comparisons with how things were earlier, in
part because many of todays studies have never been carried out before,.and in part
because methods, definitions, populations and questions change. It has been shown for
instance that the very strong increase in reports to the police of battered children is not
based on a true increase in abuse but on a greater tendency to report cases.
Furthermore, physical punishment as a method for bringing up children has decreased
drastically since the 1980s, and the expressed attitudes of the general public to physical
punishment of children show clearly that it has become less accepted (Janson 2001b).
At the same time, there are a number of reports that give a completely different picture
of Swedish children and young people today, one that seems to be positive, especially in
an international context. Mental health, thus, is a very complex issue. It is however clear
that childrens mental health has become an important area for professional and
political initiatives, and it is an area that should continue to be carefully followed.
A Government investigation has been carried out, and a number of scientific studies
are being done.The National Institute of Public Health has become involved in this
work, and the National Board of Health and Welfare has proposed regular
measurements of childrens and young peoples mental health (see chapter 9).

Growth
There is a close connection between childrens growth, development and maturity on
the one hand and their ill health (in terms of mortality, morbidity and disability) on the
other. A sufficient and balanced diet is important for growth and resistance to disease
and normal growth and maturity profiles are thus often used as indicators of good
health status.
By analysing the detailed recorded data on childrens height, weight and sexual maturity,
we can show a general tendency toward larger physical size in all ages and a lower age
for onset of puberty, the so called secular changes. The growth pattern shows great
variation, however, not only between different times but also between different
geographical areas and social classes (Brundtland & Walle 1973; Cernerud 1991;
Elmn 1995).
The greatest threat to childrens health today is not insufficient nutrition but the rise in
overweight. In 18-year-olds registering for military service in Sweden, overweight (Body
Mass Index, BMI, in kilograms/m2 over 25) increased from 7 percent to 18 percent
between 1971 and 1998, and the proportion of obesity (a BMI over 30) increased from
1 percent to almost 4 percent (Rasmussen et al. 1999). A dramatic increase in
overweight has also been noted in schoolchildren and younger children. This is
considered to be caused primarily by changes in lifestyle, notably diet and physical
activity. However, WHOs investigations in schoolchildren have not shown any great
changes over time in the physical activity of Swedish children. And an investigation in
the Nordic countries did not show a decrease in schoolchildrens activity in sports and

20

physical activity between 1984 and 1996; to the contrary, it had increased somewhat
and was highest in Sweden and Finland (Nordhagen & Nystad 2000).
Obesity in both children and adults is considerably more common among those with
poorer socioeconomic conditions (Socialstyrelsen 2001b). Even if the effects of both
preventive and treatment efforts have thus far been limited, obesity and overweight
have such a strong negative impact on physical and psychological health that even small
gains must be seen to offer hope in efforts to limit the explosive obesity epidemic (SBU
2002).

Wellbeing and quality of life

Wellbeing is subjective satisfaction with different areas of life, such as external
conditions, relations with others and internal, individual characteristics. The concept of
quality of life is often used synonymously. Two studies of Nordic childrens health
(Lindstrm 1994) have used both objective and subjective estimations of quality of life
that include:
a) socioeconomic conditions,
b) structure and function of the childs and familys network and
c) the childs wellbeing
In the first study, in 1984, children showed a generally high level of quality of life.
Despite the decline in economic conditions during the 1990s, which had a great effect
on families with children, it was found in the 1996 study that objective quality of life,
such as income and time for children, had increased in all the Nordic countries.
However, subjective quality of life in the personal sphere, such as psychosomatic
complaints, poor self-confidence and bullying, had become worse in most countries,
including Sweden. We could say that children and their families now feel worse than
their socioeconomic status would indicate (Berntsson, Khler & Vuille). This kind of
findings open up for discussions of the importance of issues such as social capital,
reference anxiety and status syndrome.
Other studies of childrens and young peoples wellbeing have shown similar results:
satisfaction with the family, school, friends and life in general is good on an overall
level, but there is a clear tendency to greater unhappiness about certain things and in
certain groups. This is also reflected in the growing proportion of children that say they
have mental and psychosomatic problems and that seek professional help for their
complaints (Olsson 1998; Berntsson 2000; Danielsson & Marklund 2000).
Problems with substance abuse among young people in Sweden is still limited in an
international perspective, and no great changes in consumption habits have been noted
during the past decade.
Alcohol consumption is however considerable among many young people, particularly
drinking for the purpose of getting drunk. Politicians and researchers have expressed a
great deal of worry that the liberal tax and customs policies in the EU will lead to a
deterioration in population health, both in children and adults.

21

Use of tobacco among young people in Sweden is the lowest in Europe. Use of
narcotics, which was earlier on the rise, has now stabilised and is relatively moderate
seen in an international perspective (CAN 2002 a, b).

Inequity
It is an old truth that there is a close and consistent relationship between living
conditions and health, and it is still seen today, especially in developing countries and
countries with large differences between social classes. It is generally less well accepted
that this is relevant in rich welfare states as well. It has not been a central theme in the
political debate on health until recent decades. It has been even more difficult to accept
that there is a considerable social difference in the health of Swedish children.
However, in the past ten years, convincing evidence has been gathered to show that
this is the case. There are clear social differences in most health problems in the
childhood years, and in certain cases, very large differences (Bremberg 2002).
Childrens social and economic conditions have an effect on their health and wellbeing,
and on the occurrence and course of their illnesses, both in childhood and later on in
life. There is clear ebvidence that social, economic and health inequity has increased in
Sweden (Socialstyrelsen 2001b, SCB 2003). But social differences can be reduced and
parents situation strengthened, and both the environment and health of children
improved by a variety of political, economic and organisational efforts.
There are thus no conclusive reasons for not always including childrens socioeconomic
background in studies of their health, neither in scientific reports nor in official
statistics. This would offer the possibility to follow social developments in society in an
area that is of the utmost significance for the future.

Conclusions
The conclusions that can be drawn about childrens and young peoples health and
wellbeing in Sweden after this review can be summarised as follows:

Generally positive features

Children are generally healthy and feel well. Or, to cite the Childrens
Ombudsman in her report to UN on Swedens compliance with the UN
Convention of the Rights of the Child: In an international perspective, the situation
among children and young people in Sweden is generally good. The material standard is high
and childrens physical health is good. Parents care about their children and respect their
opinions, and children have rich leisure time (Barnombudsmannen 2001).

The welfare society has largely functioned well in its ambitions to provide the
population including children and families.with the conditions for a good life.

Potential threats

22

All children do not feel well. Long term illnesses, especially allergies,
overweight and diabetes, and psychosomatic complaints have increased. The
children who fare worst are those in families that are for different reasons at
risk, parents with low incomes, poor education, or unemployed, single parents
and families seeking asylum.

Economic, social and health inequity has increased in Swedish society.

Families with children are among those who are affected first and worst by
financial crises.

If a growing segregation of society is permitted, there is an imminent risk of an increase

in health problems, primarily among those who are already the weakest. Children in
these situations will be at particularly high risk.
In short, if the development that began in the twentieth century continues and children
are given greater importance and greater rights in our democratic society, not only
rhetorically, in formal speeches and manifestos, but also in realistic policy measures,
the 21st century can truly be a Childrens Century. Sweden has a heavy and binding
responsibility for leading developments in the right direction, and our starting point is
in fact exceptionally favourable.

4. Swedish municipalities and their role in childrens health

Swedish municipalities have historically been very independent of the Government.
This gives them a great responsibility for supplying services and utilities in important
areas of their inhabitants everyday lives, chiefly in environmental and health protection,
health care and other types of care, community planning, education and child care,
culture and leisure time. Much of these activities are regulated by law, e.g. the Social
Services Act, community planning and building laws, school laws, and environmental
acts. Other activities can be voluntary, often in cooperation with other authorities such
as the police, the National Road Authority, county councils or other organisations. The
different boards in municipalities often have descriptions of welfare goals that are
important to health, in e.g. environmental and building plans, programmes for
substance abuse, violence and bullying. The activities of the municipalities thus span
over large areas, each of which are important in their own way to the lives of their
inhabitants. They can be said to be the core areas of welfare policy and thus to have
great significance for population health. Municipalities can help to create the conditions
for a good living environment and possibilities for their inhabitants to live good and
healthy lives, for example by offering good housing, opportunities for physical activity
and recreation, communication, access to health care and other types of care, and good
education. Municipalities have recently come to be important actors in health
promotion and have particularly good prerequisites for taking responsibility for general,
primary preventive and inhabitant-oriented efforts. Municipalities can be said to have a
special position in terms of creating conditions for a good life (SOU 2001a).
Municipalities are not alone in their responsibility for welfare policy and provision of
services, however, and can of course not influence all the factors that help to promote
health and quality of life. The Government has the overall responsibility for welfare
issues by forming legislation, by the economic possibilities it offers, by social policies,
labour market policies etc. County councils and regions have the operative
responsibility for the greater part of health care and for transport questions and
regional planning. The municipalities capacity to carry out their tasks has recently been
questioned. Most importantly, many small municipalities are experiencing difficulties as

23

a result of their decreasing populations, which must finance services for the growing
number of elderly persons through municipal taxes.
A Government committee was established in 2003 to analyse the organisation of
Swedish society, demographically, socioeconomically and technologically. One of the
factors being studied is the municipalities future role in relation to central Government
and the county councils. We must ask ourselves whether many of our municipalities are too small
to be able to survive in the long run (Mats Svegfors, Chairof the Government committee, in
Dagens Nyheter, the Stockholm newspaper, 25 January 2003).
The municipalities most important efforts for the health of its citizens are currently in
social services.They provide individuals, chiefly elderly persons, with care and service,
usually to compensate for their inability to manage their daily lives in some area.
whether running the home , nutrition, personal hygiene or self-care.
It is difficult to draw a clear line between social services and health care. Attempts are
being made by WHO and the EU to create an overall international system to determine
the boundaries between efforts to maintain health, to care for the sick and to provide
social care in order to allow comparisons between countries and over time.
By analysing the activities of different personnel categories in the municipalities, the
Swedish National Board of Health and Welfare calculated that about 15 percent of
personnel time in care financed by the municipalities is spent on tasks within the areas
of health maintenance and care for the sick. This means that the cost of municipalities
efforts in health care during 2000 was SEK 14.6 billion, or 0.7 percent of GNP.
At the same time, the Governments and the county councils expenditure on health
care was 7.7 percent of GNP. It can be assumed, although there is no complete proof
of this, that the municipalities health care efforts grew during the 1990s because of
medical, technical and structural changes and shifts in assessments during difficult
economic times (Socialstyrelsen 2001c).
The municipalities have a special responsibility for children that is expressed most
clearly in the Social Services Act and the Education Act. These are also the areas that
cost most; the annual cost for one child in pre-school in 2002 was over SEK 90 000,
for one young person in upper secondary school SEK 80 000 and for one child in
compulsory school SEK 60 000 (Socialstyrelsen 2003). (10 000 SEK is about 1 250
USD).
Together with music school, after-school activities and support to non-profit
associations, child care and schools are the areas in which the municipalities can
generally report their costs for children as separate categories. Other municipal
activities, such as libraries and care for individuals and families, combine different age
groups, and thus costs cannot be reported separately with respect to childrens
utilisation of these resources.
In a study of all welfare activity for children in the county of Stockholm, each child was
estimated to cost society SEK 3.400 000 in 1996. The familys cost in terms of time and
money was estimated at SEK 2.100 000. The municipality was the largest public actor
with SEK 1.200 000, primarily for daycare and schooling. The county council and

24

voluntary organisations came in third and fourth, with SEK 120.000 and 90.000,
respectively.
Differences in the scope of activity were relatively large between municipalities and
could be explained only to a small degree by social conditions (Dalman & Bremberg
1999). During the economic recession in the beginning of the 1990s, municipalities
were forced to make serious cut-backs in their activities, over 7 percent during 1993
and 1994. Activities for children and adolescents were hit hardest: daycare by almost 15
percent and music school by 12 percent (Socialstyrelsen 1994). The cut-backs that most
affected children were in personnel reductions that resulted in children being cared for
and taught in larger groups .
The municipality has a great responsibility in child care and schools for making
childrens environment as supportive and stimulating as possible. As stated in the
guidelines for the municipalities social welfare board: The Social Welfare Board shall work
to give children and adolescents secure and beneficial conditions. This is of course a highly
important determinant for childrens health and wellbeing and should as such be
included in a system of indicators. However, as the Child Municipality Index of Save
the Children will include a third part relating specifically to education, which will be
presented in a later stage, education indicators will not be treated in the health context
here.
It is possible however to include in a health index an indicator that reflects deviations in
children and young peoples social behaviour. If a child or adolescent is at risk of
unfavourable development, the social welfare board can take over care and place the
child outside the home, in a family home or a group home. These placements can be
made on the basis of the Social Services Act (voluntary placements) or of LVU, the law
regulating the care of children and adolescents (where the placement is in conflict with
the desires of the children or of the guardian). The municipalities report their
interventions to the National Board of Health and Welfare, which compiles the results
on an annual basis and publishes a social report every third year that also includes
information on the structure of the municipal activities. This social report is thus a
counterpart to the public health report and is intended to give information about and
analyse how social welfare and social problems develop.
As mentioned in Chapter 2, there is a joint project Local Welfare Balance Sheets
(Folkhlsoinstitutet 1999) involving the Swedish Association of Local Authorities, the
Federation of Swedish County Councils and the Swedish National Institute of Public
Health. Some of the participating municipalities, such as Gteborg and Haninge, focus
on childrens welfare. There is now a database with basic information on the municipal
level that gives a foundation for work in public health, and attention is also given to
some child areas (www.fhi.se). It includes a number of concepts that are interesting
from a child perspective.
One is safe communities, which means that the municipality fulfils six criteria drawn
up by WHO. The municipality works in an intersectoral, structured way to prevent
injuries in all risk groups.
The other is the allergy-adapted municipality, which means that the municipality has
taken a political decision to work for the prevention of allergy, that there is an allergy

25

committee with broad representation and an action plan for the work. In October of
2002, 38 municipalities out of 289 complied with these requirements. The goal is for all
municipalities in Sweden to be allergy-adapted.
Both these indicators were included in the first version of this proposal for indicators
for children (a wish list). Another indicator was also included that reflects the
municipalities interventions among children and adolescents. The indicator was
selected that shows the total number of children with at least one intervention during
the year in question: Children and adolescents who have been the subject of one or more
interventions at some time during the year.
In total, in all of Swedens municipalities, 16 000 children and young people were the
object of some measure in 1998, and the information has already been broken down on
the municipal level and calculated per 1 000 children in the population according to age
groups 0-12 years, 13-17 years and 18-20 years (Socialstyrelsen 1999).
This indicator describes the municipalities efforts and not actually childrens health
status. It is a process indicator and, as such, is affected by the resources, ambitions and
prevailing ideologies of the local social welfare board, and of course by the composition
and needs of each municipalitys population. The purpose of placing a child outside the
home however is to improve the childs growth and development and to prevent
harmful development. The action can thus be expected to be significant for the childs
health and wellbeing. For this reason it can be justifiable to attempt to document these
measures and use them as an indicator of the municipalitys support to children and
adolescents and their families. The indicator is presently difficult to interpret but, in
relation to other indicators that give information about the municipalitys social
eonomic and ethnic structure, it should be valuable in the future. The quality of the
data is not yet satisfactory and work is being done to improve it .

26

Indicators of childrens health

5. A basis for constructing health indicators for children
The previous chapters analysed the foundations upon which a municipal child index
should be based. A picture was presented of the historical development of population
health measurement both in Sweden and internationally, together with the special
considerations that come into play when measuring the health of children and
adolescents.
As the point of departure the municipalities, the rights of their inhabitants and their
corresponding responsibilities with respect to health were described. A short review
was also given of the health status of children in Sweden at the present time. There has
been reference to the various factors pointing to the need for and the problems to be
confronted in creating a health index for children on the municipal level.
The relevance of health measurement as an aspect of welfare measurement is
increasingly recognised. Several international organisations, UN, WHO, UNICEF,
OECD and EU,. regularly publish reports in the area, Nevertheless, the availability of
reliable, comparable health data is still very limited, and the reports contain only the
simplest and crudest measurement points. However, systematic efforts are now being
made by WHO, OECD and EU to establish unified and comparable measurement
methods. The most important development in Europe at this time is EUs Health
Monitoring Project (HMP), which works on a number of different fronts to set up a
common system of health indicators for the Member States. A number of countries
have introduced regular health measurements and tried to create health indicators for
children, e.g. Australia (Waters et al 2002), Canada (The Health of Canadas children),
Italy (Tamburlini 2001), New Zealand (Our Childrens Health), UK (Health of Young
People) and the US (Americas Children).
In all these cases the chosen indicators are used to describe the general situation in the
country. The results of studies of representative samples of the national child
population are extrapolated to reflect conditions in the country as a whole. But subnationally, the smaller the population one wishes to study, the more detailed and
complete the information must be. Most national data are not detailed enough to be
broken down to the municipal level. Another feature of these national reports is that
no one has tried to combine several indicators into one index. To the contrary, it is
advised that this should not be done.
Sweden has a long tradition of official demographic statistics, and in recent decades
welfare measurements have been developed into a relatively complete system involving
different national authorities. However, most of the data collected relate to the health
and welfare of the adult population. While there has been some improvement in recent
years, information about childrens welfare remains limited. There is currently no
system that can survey and follow childrens health and wellbeing over time and
compare developments between different parts of the country or between one part and
the national population. However, there are some welfare and health projects that
include children or even focus on children (Statistics Sweden, National Board of Health

27

and Welfare, Swedish National Institute of Public Health). This is further discussed in
chapter 9.
Save the Childrens initiative, to create a child index that can be used to track or
monitor and evaluate the situation in Sweden, comes at a very opportune time. It is
important for several reasons that the Convention on the Rights of the Child has been
used as a basis.
First, it follows an international set of regulations in whose formulation Sweden has
invested resources and prestige. Secondly, it takes the Convention s broad view of
childrens health and wellbeing, i.e. it has not only to do with the right to life but also
the right to survive and develop. This means physical, mental, spiritual, moral, psychological
and social development that must be provided for so that the child is prepared for an independent life in
a free society (Childrens Ombudsman, Barnombudsmannen 2001). It is important that
central responsibility is placed on the municipalities. They have a major influence on
the environments in which children live; they have the greater part of the responsibility
for addressing the factors that promote the wellbeing of children and families.
But in terms of identifying potential indicators to reflect childrens health status, there is
a problem in going down to the municipal level. Most of the so called health indicators
in common use have to do with disease and treatment measures, and this is normally
the county councils, not the municipalities area of responsibility. However, indicators
should not focus on purely medical features. A broad multidimensional and
multisectoral concept of health must be emphasised. It is important to identify
determinants of health (both risk and protective factors) as well as manifestations of
disease. It is also important that the indicators focus on childrens conditions, that the
perspective is that of children and not of adults.
There is a strength in using local indicators because they can so easily be connected
with local activities. They can form the foundation for future work, spurring local
peoples involvement and debate.
Health problems, especiaslly those causing impairments, disabilities and handicaps, are
very important for the childs capacity to function in society .They carry a risk for
secondary psychological disorders and for a long period of time, as we have a long
life expectancy. But they also impact on the childs family. The life of the whole family
can change. Everyday care often requires much time and great effort. The childs needs
require the attention and concern of the other family members, and the familys social
activities may need to be altered. Siblings also run a higher risk of psychosocial
problems.
Society and its resources are also burdened as the problem tests the functioning of the
medical and social care system, in small matters and large. The effects of childrens
disorders can reach far into the world of adults and can even affect the next generation.
However, it is important to emphasise that children are individuals and citizens with
their own rights. Childhood is not simply a road to adulthood; it has a value of its own
and should be as healthy, constructive and happy as possible. Monitoring and
protecting children are thus central tasks for society, not least because children are not
able themselves to claim their share of welfare or express their preferences.

28

It is evident that the most vulnerable children, those who do not have the advantages
of good health or of living in families with good financial, social and cultural resources,
need to be most carefully monitored. These risk children require particular
interventions and it is important that they are identified and given support as early as
possible. On the other hand, new threats to health can arise which change the current
picture of problems and services requireed. Risks can change, new risk groups can
arise and old ones disappear. Furthermore, even if there is an over-representation of
cases within risk groups, the large volume of non-risk children makes most of the
cases still appear outside the risk groups. It is thus necessary to follow the entire
population.
Childrens health is consequently a very large and complex area, and there are many
different aspects to take into account. It can be difficult to find the exact number of
children for a special indicator, for example, both as numerators and denominators.
The fundamental requirement for any indicator is that it must relate to children who are
covered by the Convention on the Rights of the Child, i.e. between the ages of 0 and
17. The Convention ceases to apply at the age of 18, and also at that time children in
Sweden come of age. This can cause problems when using data from existing routine
registers. Most registers are kept according to demographic principles, i.e. grouped
according to age bands 1-4, 5-9, 10-14 and 14-19. There is no cut-off at 18 years.
Other registers, such as the diabetes register, include only patients receiving care at
childrens clinics, which used to be children under 16 years, meaning that we must
either abandon the limit of 18 years, or request special treatment of data where this is
possible. This must be determined case by case, but it is in childrens interests that the
data and the knowledge derived from them, are adapted to the childs needs and not the
reverse. Hopefully, in the long run, all data , whether registered on the central, regional
or local level, will be treated and presented in ways consistent with the Convention on
the Rights of the Child. It would mean that children are made the unit of focus in the
statistics in question.
Even though interest is said to be in children, it is often the adult perspective that can
be glimpsed behind. For instance, when reporting the occurrence of passive smoking
with reference to foetuses or infants, it is important to use the number of children who
are exposed to tobacco as the numerator and not the number of parents or households
that smoke.
There are further aspects of health indicators in general, and indicators for children in
particular, that must be considered before a realistic proposal can be presented. A
health indicator shall be a defined and most often quantitatively measurable dimension
of an important part of health, the health care system or related factors. An indicator
can be said to quantify and simplify phenomena and facilitate the understanding of
complex realities. It must be informative and sensitive to changes over time and
between areas. It must fit logically within a framework and there must be a general
understanding as to what is being measured and why (ISO/TS 2002). Thus the chosen
indicators must satisfy strict criteria and properly reflect the parts of the system one
wishes to measure.

29

As Wolfson writes: Data and facts are not like pebbles on a beach, waiting to be picked up and
collected. They can only be perceived and measured through an underlying theoretical and conceptual
framework, which defines relevant facts and distinguishes them from background noise (Wolfson
1994).
In formulating an indicator, both quantitative and qualitative criteria must be applied.
1. The indicator must reflect conditions which are
a)
b)
c)

significant to the populations health, in the short or long term, i.e. it shall
be widespread and/or serious,
an economic burden to the individual, the family and/or society and
treatable.

In Sweden, the most important health problems in childhood, estimated as causes of

disability-adjusted lost years of life, are diseases in infancy, congenital malformations,
mental ill health, injuries, infections, allergies and cancer. The primary determinants are
less favourable social conditions, use of tobacco, deficiencies in the immune system,
poor breastfeeding and several other factors having to do with mental ill health and
injuries (Bremberg 1999).
2. The indicator must be flexible and it must be possible to change it according to
changes in conditions, for example in the composition of the population or scientific
advances.
3. There must be access to the indicator. To be able to suggest indicators that are
meaningful, it must of course be possible to measure and collect them. In point of fact,
many indicators are constructed on the basis of available data sources, i.e. that which is
not present in existing data sources is not considered. And things that are at a particular
time impossible to measure or too expensive to measure are not included. We look for
the coin weve lost under the light of the street lamp and not where we actually lost it.
For this reason it is important not only to propose indicators but also to identify
conceivable sources of data.
There must also be a vision and preparedness for the future. But if we keep simply to
what exists, we will be unable to create anything new, however necessary it becomes to
do so.If we always do what weve always done, well always get what we always have gotten (Kevin
Dunbar).
4. Scientific requirements and qualitative criteria must be fulfilled.
a) There must be high validity, both as regards the ability to measure
that which it is intended it shall measure (face validity), the ability to
cover important aspects of that which it shall measure (content
validity) and the ability to co-variate with other indicators that
measure the same thing (construct validity).
b) Reliability must be high, i.e. repeated measurements in different
areas and over time must show as small differences as possible. This
is achieved by strict definitions and by precision in collecting and
reporting data.

30

c)

Sensitivity and specificity must be high, i.e. the risk must be as

small as possible of a measurement missing those who according
to the definitions belong to the group, and of including individuals
who do not belong in the group in question.

Thus, there must be solid, knowledge-based insights behind each and every indicator.
Together, they should build a system for surveying childrens health and wellbeing on
the municipal level, a system that will allow practical measures that improve their
health. This ismeasuring for doing, not measuring for measuring.
Although these indicators are not being constructed for use in scientific studies;
scientific surveys and analyses should be carried out. A number of such studies are
recommended at the end of this report that can contribute to expanding the scope and
improving the quality of the next generation of indicators. The criteria laid down here
for the construction of indicators must be followed up and evaluated on a continuing
basis.

6. Principles for municipal indicators of childrens health

On the basis of the goals set by Save the Children and the analyses and considerations
introduced above, we can formulate a number of principles for the construction of
health indicators to be included in a municipal child index.
1. The index shall measure and evaluate childrens health status and the factors that
determine their health status on a municipal level and follow them over time.
2. The index shall facilitate planning, monitoring and evaluation of municipal efforts to
protect and promote childrens health.
3. The index shall cover all important aspects of childrens health.
4. The index shall aim for an ideal set of indicators.
The ideal outcome would be a set of indicators that reflect the broad concepts of
health, wellbeing and development, from birth to 18 years. From this ideal (and perhaps
utopic) level, a group of realistic, available and at the same time functional indicators
have been chosen for the final report. A proposal for future work to develop the
indicators and their availability will also be made, so that the ideal outcome may in time
be reached.
The important reason for this approach is that care of the health and wellbeing of our
citizens is an overall goal for both individual countries and international organisations
such as the UN, WHO and EU. The most vulnerable group among all citizens is
children, who are most at risk and who are politically the weakest. Supervising
developments in childrens health is therefore an important task for all countries and
should be followed as energetically and effectively as possible. For several practical and
economic reasons, however, it is not possible to immediately achieve the goal of a
complete, systematic and detailed surveillance, and so we must lower our ambitions.
Instead of basing work on the indicators that are already available in general registers,

31

this analysis is based on what we want to achieve, seen in terms of what is best for
children. The final proposal for indicators will then be a compromise between goals
and possibilities, but there must not be any doubt as to what the final goal of health
indicators for children is: a comprehensive, relevant and high quality surveillance of childrens
health, development and wellbeing, placed in a social and political context.
5. The index shall be based on a public health perspective.
In order to follow developments in childrens health and protect and promote it, it is
not sufficient to use factors that reflect medical circumstances or weaknesses in
individuals. Broad, multidisciplinary and intersectoral aspects must be taken into
account, not only those that reflect morbidity and mortality. With this perspective, the
factors that determine health will also be meaningful. This is in agreement with the
modern interpretation of public health as it is referred to in national and international
policy documents, and elaborated in chapter 1.
6. The index shall be based on a general population perspective.
The indicators must cover the entire child population and not be oriented towards risk
groups only. In a population perspective, the gains to be made with risk group thinking
are small. A large proportion of high risk group children will usually remain healthy,
and a not insignficant proportion of those who become sick will come from low risk
groups. Furthermore, the definitions of risk groups are often imprecise and can vary
over time and area, which creates considerable problems in agreeing common and
sustainable definitions.
7. The index shall be characterized by a child perspective.
Children are an important investment for the future and a healthy childhood is the best
foundation for a healthy adult life. Nonetheless, children must be seen as an important
group in society in themselves, a valued group with its own needs and rights, here and
now, not merely future adults. The often used family perspective is based on the needs
of adults, which do not necessarily coincide with the needs of children. Children need
and deserve their own perspective. A system for surveying childrens health. should be at the
centre of Child Health, not at the periphery of monitoring (Rigby & Khler 2002).
8. The index shall, if possible, be based on outcome variables, and at times on process
variables, while the use of structure variables is questionable.
An indicator based on an outcome variable is more reliable and generally has a higher
validity than other types of variables. They are better suited to measurements of health
status and of the effects of health and sociopolitical interventions. However, when
measuring the effects of plans and strategies, especially in the short term, process variables
can be valuable. They can give an idea about the factors that affect outcomes, and they
are usually easy to change in the plans.
Structure variables often lie far from outcomes, and it is not always easy to find direct
causal connections between structure and outcomes. Confounders, disturbing factors,
often appear and make it difficult to interpret the situation.
9. The index shall include socioeconomic, cultural and demographic background
factors.
All health indicators must be seen in their social context in order to analyse what
factors determine health, which is usually unevenly distributed in the population, and to

32

set priorities for interventions. As far as possible, indicators must be reported according
to age group, sex, socioeconomic status and ethnicity.
10. The index shall permit systematic monitoring, quality assurance and cost
estimations.
11. The index shall be open and allow future additions and changes.
These principles are intended to guide the construction of an ideal set of indicators for
childrens health and wellbeing. It is obvious that the economic, staffing and
organisational resources needed for constructing an ideal set do not exist today and
perhaps not tomorrow either. But that is not the crucial point.
In a progressive society that values and protects children, there must be a
comprehensive system for monitoring and evaluating childrens health and wellbeing
that is set in a social and political context and. adopts the childrens own perspective.
Its construction will require perseverence and commitment from everyone involved,
from people at the grass roots to the highest political leadership, and it may take a long
time.

7. A set of indicators for childrens health

Childrens health and its determinants can be structured according to particular
domains. The following division into four domains is based on analyses adopted by the
EU project Child Health Indicators for Life and Development (CHILD). They are also
well suited for a Swedish system of municipal level indicators.
A) Demographics and socioeconomics
B) Health status and wellbeing
C) Determinants (risk and protective factors)
D) Service, support and health policy
The following set of indicators within these four domains accords with the principles
and criteria presented in the previous chapters. In full use it would present a
comrehensive picture of childrens health and welfare.However, as of today, this set
remains in the nature of a wish list As will become clear below , it is not yet possible
to employ all of them. Some will have to wait.

A. Demographics and socioeconomics

The indicators in this domain have two purposes. They give an overall picture of the
social and population structure, which varies markedly between municipalities. Most of
them will be used as background variables for other indicators on the list. As explained
under principle 9 in Chapter 6 above, the reason is that health and ill health and the
factors that determine them do not occur randomly in the population.
In all societies even in rich welfare states they are unevenly distributed in the
population, so that children from families in a good financial position and a high
education level have the best health, and children from families in a poorer financial
position and a lower education level have higher mortality and morbidity and poorer

33

wellbeing. Extreme social, economic and cultural factors make immigrant and refugee
children particularly vulnerable.
Ideally, to understand the problems and to determine appropriate priority interventions,
the indicators should be reported according to age group, sex, socioeconomic class and
ethnicity.
In this context it has been decided to use parents social group, education and ethnicity
as well as family structure. All these variables have been well tested in a welfare context
and have been shown to be strongly connected to health problems of many different
kinds (Hjern et al 1998, 2001 Socialstyrelsen 2001b, Bremberg 2002, SCB/National
Institute for Working Life 2002).

B. Health status and wellbeing

Mortality is one of the most commonly used indicators of ill health in an international
perspective as it has such a great impact on the individual and on society. It is also
definitive, easy to determine, and allows fairly exact comparisons over time and
betrween areas.
However childhood mortality is very low in Sweden; a little over 600 children under 20
years of age die each year. If these deaths are distributed over different ages and
socioeconomic groups, the numbers become too small to be usable on the municipal
level, even if several years are pooled. Thus mortality cannot be used in the municipal
index, and even less, cause specific mortality.
Instead of mortality, injuries treated in hospitals has been chosen.. They can be prevented
by different types of interventions, not least on the municipal level. Diagnoses of
injuries are available in the National Board of Health and Welfares inpatient register
and in sufficiently large numbers to be disaggregated to the municipal level.
Morbidity is a considerably more complicated measure of ill health than mortality. The
concept of ill health is not clear and may be defined differently by the general public
and professionals. The measurement methods are also more uncertain, and results
reflect more than only morbidity. Geographic, social, economic, cultural and
organisational factors affect the availability of care and are also decisive for how
questions about morbidity are asked, and the answers registered and used. Centrally
available data on local use of care resources are limited to outpatient activities in
hospitals. Data from primary care units are still lacking.
The physical diseases included as indicators are either those whose incidence is
increasing most in the Western world and have a great effect on the individual, family
and society (asthma, diabetes, overweight/obesity) or those whose prevention is simple
(caries).
One of the most common complaints in childhood is infections, which can also cause
significant disruption in the childs and the familys daily lives. Most infections are now
shortlived and mild and are treated by parents without the help of professional care
(Uldall 1986). To capture serious infections, one must have data on children treated in
hospital. But fewer and fewer children receive hospital care for their infections, an
effect of successful ambulatory treatment and the provision of fewer hospital beds.

34

In comparisons over time, it is difficult to know what causes changes in the use of care:
is it the panorama of disease that has changed or is it the care resources, care
organisation or treatment routines? To capture common and mild infections and their
consequences for the family and society, we must have information from parents, preschools and schools. Studies of this kind have been done in limited areas, but
information is not available for the majority of municipalities and not systematically.
Extensive and dynamic vaccination programmes prevent the most serious infections .
The number of children vaccinated for the most important infectious diseases has been
suggested as an indicator under the Determinants group below. The most important
risk factor for upper respiratory infections passive smoking is also included as a
further indicator among the determinants.
Mental health is much more difficult than physical health to capture with simple and
easily available indicators, and yet this is a part of childrens health that may be most
affected by the social environment in the municipality (Bremberg 1999, Hwang 2002).
The methods available (questionnaires, interviews) have been used only in particular
areas or in more or less representative samples of the national population
(Children/Swedish Level of Living Survey, Health Behavior of Swedish Schoolchildren). They cannot be used to describe the situation in individual municipalities.
This will only be possible when the proposal for regular measurements of childrens
and young peoples mental health becomes a reality (Hagquist 2004). Positive aspects of
mental health will then also be given greater attention in formulating appropriate
indicators.
The present set of indicators has included for mental health attempted suicide among
children and children in the care of the municipality, both of which have a negative
connotation.

C. Determinants (Risk and protective factors)

This domain contains a number of indicators that all have a clear and documented
effect on health status in childhood and later. It is also possible to influence them
through health promotion, not least on the municipal level. Two of them are positive
(children who are breastfed and children who are vaccinated), and five are negative (low
birthweight, passive smoking, active smoking, alcohol habits and teenage abortions).
The educational system should be able to add more indicators to this group, such as the
number of children who attend pre-school and children who complete the compulsory
school years. The national, regular measurement of childrens mental health will be able
to give further suggestions in this area (Hagquist 2004).
Certain indicators could also appear in this section as risk factors, as they are both signs
of ill health in themselves and determinants for other health problems, e.g. refugee
children and children in the care of the municipality.

D. Service, support and health policy

Three municipality-related indicators have been identified, safe communities, allergy-adapted
communities and community action programme against bullying in schools. The first two are part
of the National Institute of Public Healths municipal database. The educational system

35

and the new measurements of childrens mental health should be able to generate
further policy indicators in this domain.

A wish list
A list follows below of indicators that would reflect childrens health and wellbeing and
allow comparisons over time and between municipalities. It is not strictly an idealistic
wish list ; certain adaptations that acknowledge practical realities have been made, and
are explained in the text.

Domain A. Demographics and socioeconomics

Indicators

Definition

Childrens Proportion of children that live in households where parents

social class (primarily the father and mother or single-parent families): are
not professional workers, lower white-collar workers, middlelevel workers and above, entrepreneurs, farmers or students.
Distributed according to boys and girls and total as well as
age groups 0-4, 5-9, 10-14, 15-17.
Parents
education

Proportion of children that live in families with an educational

level (primarily the father and mother or single-parent families):
low education level (compulsory school), middlelevel education (upper secondary school or further education
less than 3 years) or high education level (3 years of school post
secondary school or longer or post-graduate education).
Distributed among boys and girls and age groups 0-4, 5-9, 10-14, 15-17.

Childrens
structure

Proportion of children who live in families with only one parent

or guardian, male, female and total, and percent of children who
live in families with co-habitating parents in age groups 0-4, 5-9,
10-14, 15-17.

Children
Proportion of children born in: the Nordic countries,
from other European countries outside the Nordic area, and others.
countries Distributed among boys and girls and total as well as age
groups 0-4, 5-9, 10-14, 15-17.
Refugee
children

36

Proportion of children seeking asylum, alone or as part of a

family, per 100 children in the municipality, distributed
according to boys and girls and total as well as age groups
0-4, 5-9, 10-14, 15-17.

B. Health status and wellbeing

Indicators

Definition

Children with
external
injuries

Proportion of children 0-17 years who have received

hospital care for external injuries, distributed according to
boys and girls and total.

Children with
diabetes

Proportion of children with a diagnosis of diabetes (type 1,

insulin-dependent), distributed according to boys and girls
and total, and age groups 1-4, 5-9, 10-14, and total.

Children
without caries

Proportion of children who at 6 years of age are caries-free

in the primary dentition, distributed according to boys and
girls and total.

Suicide attempts Incidence of suicide attempts, defined as release from

among children hospitals with a diagnosis of attempted suicide, distributed
according to boys and girls and total, and age group 10-17.
Children with
asthma

Prevalence of asthma among boys and girls and total, and in

age groups 0-4, 5-9, 10-14, 15-19, and by social group.

Overweight and Proportion of children with an age and sex standardised Body
obese children
Mass Index (BMI) of at least 25 and 30, measured at the time
they begin school and at 18-19 years (boys).
Children placed
in municipal
care

Proportion of children and young people who have been

the object of some municipal intervention one or more times
during the year. Distributed according to boys and girls and
total, and to age groups 0-12 and 13-17 years, per 1.000
children in corresponding population groups.

C. Determinants (Risk and protective factors)

Indicators

Definition

Children with
birthweight

Proportion of infants with birthweight <2 500 g,

as a percentage of the number of live births, according to
socioeconomic class and family structure.

Children that
are breastfed

Proportion of children that are breastfed solely or partially at

4 months of age as a percentage of live births and
distribution among social groups.

Foetal exposure Proportion of children exposed to tobacco in the womb

to tobacco
by mothers smoking, per social group.

37

Teenage
abortions

Proportion of abortions per 1 000 women 10-17 years,

per social group.

Tobacco
Proportion of children that report that they smoke every
smoking among week. Distributed according to boys and girls and total, and
children and
according to ages 11, 13 and 15, and social group.
young people
Alcohol
consumption
among young
people

Proportion of children in the 9th grade that report intensive

consumption of alcohol some time during a month or more
frequently. Distributed according to boys and girls and total,
and according to social group.

Vaccination

Proportion of children who have complete vaccination

protection for measles, mumps and rubella at the age of 2,
as percent of all children in the age group.

D. Service, support and health policy

Indicator

Definition

Safe
community

Municipality has been named a safe community for the current

year by the National Institute of Public Health/Rescue Services
Agnecy.

Allergyadapted
community

Municipality has been named an allergy-adapted community

or the current year by the National Institute of Public Health.

Action programme
against
bullying

Proportion of children attending a school with a

written, implemented and monitored action programme to
counteract bullying, as percent of all schoolchildren.

Excluded indicators
While keeping in mind the ideal presented in chapters 5 and 6, indicators must meet
other requirements. To have a chance of being adopted in municipal planning,
indicators must be understandable and reliable as well as readily and economically
available, and all who handle them should realise their value. They must be meaningful
to those who provide and collect the data and manageable to those who then process
the data and interpret the results.
It is not possible to use all indicators that are desirable, at least not at the present. But
the indicators that are possible are not necessarily desirable if, for example, they do not
fulfil the quality requirement.
Thus the list must be examined and shortened so that the indicators that are finally
selected are relevant, valid, reliable and available. The following indicators listed
according to domain will now be excluded from the original list.

38

Domain A. Demographics and socioeconomics

The indicators here are intended to serve two purposes: to give a general description of
the municipalities and their structure and to function as background and explanatory
variables to the other outcome indicators. The same or very similar indicators were
already used in the first report in Save the Childrens series on Municipal Child Index,
Child Poverty in Sweden (Salonen 2002). They are thererfore all excluded here.
Instead, the poverty index in the report will be used, for both the purposes given
above. Salonens definition is based on a combination of two indicators children who live
neither in economically poor households nor in households with means tested social assistance.

Domain B. Health status and wellbeing

Indicator

Reason for exclusion

Children with Diabetes is in many ways an excellent indicator: it reflects a

diabetes
serious disease with a unified diagnosis and treatment
that is on the rise in Sweden, as in the rest of the Western world.
However, the number is still too low for a meaningful
report per municipality, even if age groups are pooled.
Nonetheless it is a disease that must be followed carefully on the
national level, and this is being done in national
medical registers, as well as in several research projects.
Children
without
caries

Caries is in many ways an important disease: it can be painful

inextreme cases, it is related to other diseases, it is easy to
diagnose, it clearly reflects socioeconomic differences, it is
easily available for preventive efforts and it is used
internationally as an indicator. In other words it is an almost
ideal health indicator for children and should as such be
included in a complete health surveillance system.
Unfortunately, there is still not information on all children on
the municipal level and it has thus been excluded here. These
data may however become available within a few years.

Suicide
attempts
among
children

Suicide reflects both individual and social conditions

It is fortunately rare during childhood, and even suicide
attempts, an important predictor for later suicide, are not
sufficient in number to be broken down on the municipal
level in any meaningful way. They are however part of
indicator B 1 children injured by external causes.

Children with Asthma and allergies are now the most common long term
asthma
conditions in children and young people and there has a
been strong increase in practically every Western country.
There has been great interest in tracing, treating and
preventing them. However, there are no clear and
standardised criteria for diagnosis and the large geographical

39

variations in prevalence are partly due to variations in

diagnostic criteria. Neither is there good agreement between
the occurrence of symptoms and use of care. Inpatient care
of children 5-18 years for asthma has e.g. in Gteborg
decreased by 90 percent in the past 10 years, which might
indicate that there is effective outpatient care (Wennergren &
Strannegrd 2002), but outpatient data are not generally
available. The indicator has been excluded because the
diagnosis is uncertain and varies between different clinics and
because it is unclear what the indicator reflects.
Children with Overweight has become one of the fastest growing crucial
overweight
public health problems in the West. There are internationally
and obesity accepted definitions but complete data are not yet available,
neither in pre-school ages nor school ages. All 18-19-year-old
boys are weighed and their height measured when they enrol
for military service, presently about 90 percent of this subpopulation.
Girls do not enrol and hence are not measured. The indicator
has been excluded because data collection is incomplete.
Enrolled boys represent only half of the actual population and
moreover often fall outside the limit of 18 year.
Children
placed in
municipal
care

This indicator describes community efforts rather than childrens health

status. It is a process indicator influenced by the resources, ambitions
and ideologies of the local social welfare board, and by the composition
and needs of the population in question. The quality of the data has
been criticised for being poor because the indications for interventions
vary and because all municipalities do not report their interventions to
the National Board of Health and Welfare. Work is ongoing to improve
quality. The indicator has been excluded because the quality of the data
is questionable and their interpretation unclear.

Domain C. Determinants (Risk and protective factors)

Indicator

Reason for exclusion

Tobacco
smoking
among
children and
adolescents

The indicator is well documented and very often used in studies of

young peoples health habits. It is clearly related to a number of
serious health problems, both in adolescence and in adulthood.
All studies so far have been conducted on more or less representative
samples and are not available for all children on the municipal level.
The indicator has been excluded because data are not available on the
municipal level.

Alcohol
Alcohol consumption is clearly related important health problems , and
comsumption is very often included in surveys of young peoples health. This is done
among
in random testing among representative samples and not in complete
adolescents population groups. The indicator has been excluded because data are
not available on the municipal level.

40

Domain D. Service, support and healthy policy

Indicator

Reason for exclusion

Safe municipality

WHO and the National Institute of Public Health/Rescue

Services Agency have revised the criteria for this indicator and
now focus on 6 instead of the previous 12 criteria. However, it
is still not entirely clear how the criteria shall be interpreted and
there is no established plan for systematic monitoring of how
municipalities apply the criteria each year. The indicator has
been excluded because the concept of safe municipality is
vaguely defined and unclear in terms of its continuity and
because the evidence on any direct relation to childrens health
is weak.

Allergy-adapted
community

The indicator reflects the municipalitys efforts to work in

such a way as to prevent allergy. This includes actions that are
diffuse and difficult to capture. What actions such as a
political decision to appoint a committee to establish an
action plan actually imply for allergic diseases is difficult to
say. They may reflect the municipalities ambitions, but have
largely unproven effects on health. Furthermore, even the
best intentions can lead to actions that are later found to be
completely meaningless or even harmful, which has been the
case in many well meaning medical recommendations in the
area of allergy. The indicator has been excluded because the
criteria are not clear and the consequences for childrens
health are doubtful.

Action
programme
against bullying
in schools

This is again a process indicator that does not directly reflect

childrens health status but instead describes how seriously
the municipality views a grave and widespread health problem
and its attempts to prevent it. This indicator is included in the
proposal for a common European indicator system for
childrens health. It has been excluded here because it may
come to be treated within the framework of Save the
Childrens third part of the project concerning the
educational system.

Remaining indicators
Now that the above indicators have been removed, there remains one indicator that
reflects significant health problems in children and young people, namely hospitalised
external injuries including suicide attempts. As determinants, there are five indicators that are
significant for current or future health, of which two are positive (breastfeeding and
vaccination) and three negative (low birthweight, early exposure to tobacco and teenage abortions).

41

Domain A. Demographics and socioeconomics

No indicators remain

Domain B. Health status and wellbeing

Indicator

Rationale

Children
injured by
external
causes

External injuries treated in hospital reflect a serious

complaint that could to some extent be prevented by social
interventions, not least by municipalities. Data have long been
available.

Domain C. Determinants (Risk and protective factors)

Indicator

Rationale

Children with
low birthweight

There is a connection between low birthweight and difficult

socio- economic family conditions, but also low birthweight
in itself increases risks for later medical and developmental
complications. It can be influenced at least to some extent
by local efforts. Used world wide as a health and welfare indicator.

Children that
are breastfed

Although not intimately connected with survival, as

it is indeveloping countries, breastfeeding is a positive
factor for health and wellbeing in rich industrial
countries as well. Efforts to stimulate breastfeeding can be
initiated on the local level. It is used internationally as
a health and welfare indicator.

Foetal
exposure to
tobacco

More and more knowledge is being gathered on the harmful effects

of tobacco, especially on immature and growing organisms. Great
efforts must be made to protect newborns and small children from
this health threat, and much can be done within the municipalities.

Teenage
abortions

Teenage abortions are a sign of the effectiveness or failure of

preventive efforts, primarily those in schools and young peoples
clinics. The increasing numbers in recent years and the uneven
geographical distribution indicate that local actions are significant.

Vaccination

Vaccination is one of the most used and most cost-effective methods

of preventing disease. The percentage of children that are vaccinated
describes how good the protection against infection is in the child
population in question and how well health information given at
childrens health centres and other local actors has reached parents
and gained their trust. Local vaccination data are collected both
regionally and centrally and can be broken down on the municipal
level via the central register at the Swedish Institute for Infectious
Disease Control.

42

Domain D. Service, support and health policy

No remaining indicators
Final selection of indicators1
(1 See appendix 1 for an exact definition and technical description)
1. Children injured by external causes
2. Children exposed to tobacco in the womb
3. Children with low birthweight
4. Children that are breastfed
5. Teenage abortions
6. Children vaccinated against MPR
Sources of data
The indicators that have met the requirements for quality and availability on the
municipal level are all based on data produced within the local health care system and
then collected and processed by central authorities. The results are presented as reports
and tables to various target groups, such as Parliament, the Government, county
councils, municipalities, and to the general public. These reports are available in
printed versions and electronically on the authorities websites.
The results are most often disaggregated to county council areas. But because most
information is connected to personal identification numbers, on special request it is
very easy technically to match it to smaller units, such as municipalities.
The reliability of published reports depends primarily on how carefully and uniformly
the data have been collected on the local level. The primary collection of data is by
individual doctors nurses, secretaries and others working in the care system.. The task
requires precision and interest on the part of individuals following detailed instructions,
functioning routines and an effective control system. These prereqisites do indeed exist,
but the amount and quality of the data still vary between different areas of the country,
e.g. data on drop-out rates. However, quality is generally good and the reliability of the
data high, and there is a continuous supervision of quality.
Information on the data used in this report, the sources, background, history, drop-out
and general reliability, now follows.
The information on injuries treated in hospital, low birthweight, breastfeeding, smoking
during pregnancy and teenage abortions was taken from the National Board of Health
and Welfare and on children vaccinated from the Swedish Institute for Infectious
Disease Control.

National Board of Health and Welfare

The National Board of Health and Welfare is the central authority for public health
surveillance. For this purpose it has established the Centre for Epidemiology (EpC), whose
task is to monitor, analyse and report on health and social conditions in Sweden. The
EpC is responsible for several registers, including the cancer register, medical birth
register and patient register, as well as for classification and national reports on
population health and social conditions.

43

Patient Register
The Patient Register includes information on all patients that have been treated in
hospitals and is thus the basis for the indicator children injured by external causes. Central
compilations of citizens illnesses and treatments have been made in Sweden for over
100 years, and the present register has covered the entire country since 1987. The most
recent years include information on 1.5 1.7 million treatment episodes each year.
There is information on diagnoses, surgery, external causes of injury, sex, age,
residence, hospital, specialty and means of admission and discharge.
The Patient Register is a so called health data register and is regulated by the law on
health data registers (1998:543), the National Board of Health and Welfare regulation
on patient registers (2001:707) and the National Board of Health and Welfares
instructions for compulsory information to the patient register (2001:1). The legislation
makes it possible for the National Board of Health and Welfare to keep a register based
on personal identification numbers.
Regular quality controls of the data submitted by the health care authorities are made
by the EpC and show generally high quality for the variables of interest in this context.
The drop-out in primary diagnoses in 2001 was 0.9 percent and in personal
identification numbers 0.4 percent. Validation studies have also shown good reliability
(www.sos.se/epc).
The Medical Birth Register (Medicinska fdelseregistret, MFR) was introduced throughout the
country in 1973 and uses individual records from antenatal care, obstetrical care and
neonatal care. Copies of the records are submitted on a running basis from every
clinic/ward to the National Board of Health and Welfare, where they are compiled and
analysed. The purpose of the register is to provide a basis for analyses of risks in
women and children during pregnancy, childbirth and the neonatal period and to study
mortality, morbidity, injuries and care routines. The register has the permission of the
Swedish Data Inspection Board to base the information on personal identification numbers
and can thus be connected to other registers with data relating to children and parents.
It contains information on the age of the mother, previous pregnancies, smoking
during pregnancy, period of care, pain relief, interventions during delivery, weight and
length at birth, malformations and the parents social conditions.
Errors can occur in reporting when records are filled in, when infants are transferred to
childrens clinics, in the event of stillbirths and in registering children born outside the
country.
Repeated analyses have been made of the quality of the data and the drop-out rate is
estimated to be between 0.5 and 1.5 percent per year. In respect of records of the
Medical Birth Register (MFR) and the population register kept by Statistics Sweden (SCB)
a more detailed analysis of the quality of the MFR has been published in English
(Cnattingius et al. 1990).

Statistics on breastfeeding
Information on breastfeeding has been collected for many years at child health centres
(BVC), but there has only been complete information since the end of the 1960s.
Because of the importance of data on breastfeeding, the National Board of Health and
Welfare and the Federation of County Councils now recommend that county councils

44

compile regional breastfeeding statistics that are then forwarded to the National Board
of Health and Welfare, which compiles the information on a national basis every year.
The information is collected on a running basis during the mothers regular visits to the
child health centre and is recorded in the childs record that is kept there. This record
follows the child when they move to a different area of the country. Since computerised
information on the municipal level was not available until the end of the 1990s,
breastfeeding at the age of 4 months can not be used as an indicator for the beginning
of the 1990s.
Contrary to data from (e.g.) patient statistics, breastfeeding statistics do not count the
total number of children as a denominator but use instead the number of children registered
at the child health centre. This means a certain drop-out since some children do not use
the child health centres. This portion of children is however very small, about 0.5
percent, and does not affect reliability. Information in the records is still entered by
hand, which means that a further small number of records are illegible.

Statistics on mothers smoking habits

This register is also based on child health centre records. Information is collected and
treated in the same way. Smoking habits are reported by the mothers at the time of
their registration at the antenatal clinic. The same calculation bases are used and the
limitations are the same. Note that it is children who breastfeed and are exposed to
tobacco and not the mothers who breastfeed and smoke that are used as the basis for
calculation.

Teenage abortions
The new abortion law of 1975 required new routines for data collection to be able to
provide statistics that would allow a rapid follow-up of its effects. A special form was
drawn up for reporting to the National Board of Health and Welfare that is submitted
from all clinics or units at which abortions are carried out. The form has been revised a
couple of times, and information on the womans home district was added in 1985. The
information on the form is anonymised, i.e. it can not be traced to an individual, but it
can be broken down to the municipal level because it contains information on the
home district. The register is compiled on a continuous basis, and preliminary reports
are published every six months. There is a very small drop-out that has to do with
errors in filling out the form and transferring data. These errors are assumed to be
relatively constant and there is nothing to indicate that the drop-out affects the purpose
of the register, i.e. to measure changes over time.

Information on vaccination
The current reporting on vaccination from childrens health centres to central
authorities began in 1981. It is done using special forms. Each countys Head of Child
Health Services collects information from all the centres in their districts and then
transfers it electronically to Childrens Health Services in Stockholm which then passes
it to the Swedish Institute for Infectious Disease Control to be compiled and analysed.
Reporting is based on vaccination status in children who had their second birthday
during the previous calendar year and is calculated as the proportion of children of the
same age who at the start of the year were registered at a childrens health centre.
The indicator shows the combined vaccination for measles, mumps and rubella (MMR)
(Swedish morbilli, parotitis and rubella- MPR).

45

During the 1990s a measles vaccine was also given separately, but only to a small
extent, 0.2 0.3 percent. These cases have been counted in the MMR numbers.
The reporting frequency has increased over the years, but is still not complete for the
whole country. Two of 21 county councils (rebro and Uppsala) are missing for the
year 2000. These counties have chosen to keep their own registers, based on personal
identification numbers, and the statistics are thus not fully comparable with those of
other counties and do not exist on the municipal level. Thus, in the calculation of an
index and in statistical treatments, the municipalities missing in these counties have
been given values for this indicator that correspond to the mean value of the respective
municipal group (see Table 2, chapter 8).
Reporting from municipalities in other parts of the country also varies . The
explanation is in part that the boundaries of the childrens health centres catchment
areas and the municipalities are not always the same. It is calculated that in total in the
counties reporting there are reports for over 99 percent of the children for each
calendar year, or 93 percent of the total number of children in the entire country
(Smittskyddsinstitutet 2001).

Ordering data
Extensive discussions have been held with the responsible persons at the various
authorities regarding availability, suitability of format and data processing methods.
Two groups of data were finally ordered, consisting of the latest available and complete
annual compilations, and a group of corresponding data ten years back in time. There is
complete information on most indicators most recently for 2001, for one indicator up
to 2002. The most recent year when all indicators were available was 2000.
To achieve a uniform starting point, it was decided that 2000 would be used as a base
year; and, to avoid the risk of values from one single year deviating from the usual
pattern, the values were pooled to obtain a mean value for the most recent years, i.e.
usually 1998, 1999 and 2000. This group is called the 2000 group or the 2000 period. The
same calculation was made for information ten years back in time, i.e. the mean value
for three years, usually 1988, 1989 and 1990, was used to form the 1990 group or 1990
period.
The indicator breastfeeding at 4 months of age was not available so many years back and
thus comparisons between the two periods are made only for the other five indicators.

46

Table 1. Years from which data were used for statistical treatment
2000 period

1990 period

B1. Children receiving inpatient

care for external injuries

1998, 1999, 2000

1988, 1989, 1990

C1. children exposed to tobacco

in the womb

1998, 1999. 2000

1988, 1989, 1990

C2. Children with low birthweight 1998, 1999, 2000

1988, 1989, 1990

C3. Children who breastfedd

1988, 1989, 1990

1998, 1999, 2000

C4. Children vaccinated for MRP 1998, 1999., 2000 1988, 1989, 1990
C5. Teenage abortions

1998, 1999, 2000

1988, 1989, 1990

The years for the vaccination indicator are years during which data were collected and
cover children who turned two years old during the previous calendar year.
The cost for extracting these data from the registers for each of the 289 municipalities
amounted to a few hundred dollars.
Professor Tapio Salonen provided data from his poverty study, which used the years
2000 and 1991.

8. From indicators to municipal index

The review thus far should have made it plain that health measurements are a
complicated business, in part because the concept of health is so multifaceted and in
part because the methods we use are uncertain. Nonetheless it is a very important task
to measure and evaluate the health of the population and to monitor it over time.
Health is a central component of welfare and as such is used as a way to characterize a
country or a region. It is also important to measure health in parts of the population
and in parts o a country because living conditions can be so different that it is
meaningless to pool results; we get simply a porridge of numbers. This is one of the
reasons why observing childrens health in municipalities is justified in it self.
Earlier chapters have made it clear that children deserve their own health surveillance
system (chapters 2 and 3) and that municipalities are suitable units in which to work to
promote health and prevent ill health (chapter 4). The first problem is then to identify
children s health indicators that are valid, reliable and relevant on the municipal level.
This is discussed in chapter 5.

47

Few indicators fulfil all these requirements today. But intense development efforts are
being made in several areas of the country, often involving close cooperation between
different government authorities (see chapter 9). It is reasonable to believe that within
a few years there will be possibilities for a qualitatively strong and comprehensive
surveillance system for childrens health, even on the municipal level.
This system will also include the difficult task of mapping childrens mental health in
detail. It will be easier, although still complicated, to create a childrens health index that
expresses the municipalities goal achievement on a scale from 0 to 100. Until the
planned indicators work in reality, we can only do the best with the opportunities we
have.
The municipalities ultimate health goal must be to ensure that their inhabitants can
enjoy their highest possible or attainable level of health. At the least it must be to
provide the conditions for good health.
This does not mean eternal life or a life without injury or sickness. There must be
realistic goals. And room must be left for human variations, even among children. In
terms of childrens economic conditions, it may be justifiable to use the goal that no
child shall live in an impoverished household (Salonen 2002), which is an operationalisation
of article 27 of the Convention on the Rights of the Child.
Article 24 of the Convention states that children have the right to enjoyment of the highest
attainable standard of health and facilities for treatment of illness and rehabilitation of health
Right to the highest attainable standard or level of health means in this context that
consideration is given both to the individuals physical and socioeconomic
circumstances and to the municipalitys resources and possibilities. The child and its
parents themselves have a responsibility for any choice to engage in potentially
dangerous activities. And of course, they have their own set of genetic conditions for
health and disease.
Society has an obligation to facilitate, promote and provide for the right to health of its
population. Society has the responsibility to provide health services of different kinds
(disease prevention as well as care and treatment) to as great an extent as possible (UN
Declaration on Human Rights 1948).
The latest public health bill from the Swedish Government states that work in public
health, on the national, regional and local levels, shall focus on the factors that determine
health (Ml fr folkhlsan, Bill 2002/03:35). This of course has to do with how available
rresources are used, as there are no absolute answers to what is sufficient. This leads
naturally to judgements about priorities and decisions on actions to be taken, and these
are not always objective and not always agreed upon by all.
Thus, it is no simple matter for a municipalitiy to operationalise its tasks. Many tasks
are linked with responsibility for health care which is borne primarily by the county
councils and the Government. The proposed indicators have been formulated such that

48

they reflect areas in which the municipalities have at least a certain responsibility and
influence.
The municipalities should set challenging goals. It is manifestly desirable, for example,
that no child should need hospital care for injuries, or undergo an abortion ,or be
exposed to tobacco smoke. And although such ideal outcomes do not stand up as
credible operational targets, it is reasonable to make use of a zero vision as a
reference point, and then to calculate how far each municipality has come in
comparison with it .
For example, the Swedish Road Administration states as a zero vision that no child
shall die or suffer a long term loss of health or experience insecurity in moving to or from school as a
result of deficiencies in the road transport system (Vgverket, 1999, 2002).
The WHO European Region has used this approach in its HEALTH 21 policy
document, which it commended to Member States as a model for their consideration.
The targets set are more loosely formulated, and there is only an attempt at
quantification, a matter that is left to countries to determine for thermselves. In Goal 4,
Young Peoples Health, it is stated that By the year 2020 young people in the Region should be
healthier and better able to fulfill their roles in society. According to the strategy, this will
happen for instance by reducing mortality and disability from violence and accidents by at least 50
percent and by reducing teenage pregnancies by at least one third (WHO 1999b).
A collective measure of population health development has been produced by Statistics
Sweden and is used in the National Board of Health and Welfares Public Health Reports
as a Health Index. Here, the population is classified according to four morbidity groups
based on a combination of the responses in Statistics Swedens investigation of living
conditions (ULF) to questions on self-assessed health, long term illness and impaired
capacity for work Its use is limited to the ages 16-84 years, no report is made of
diagnoses or determining factors and it is based on an investigation of a sample of the
population. It is thus not suitable for several reasons as a child index on the municipal
level.
A more advanced way to present a collective measure of health development in a
country is to use the concept of Disability Adjusted Life Years (DALY). One DALY
corresponds to one year of health lost as a result of illness. It was developed by WHO
and the World Bank to measure the burden of illness in a population and make
comparisons between different parts of the world (World Bank 1993). It has also been
applied in Sweden to provide a basis for decisionmaking in health policies, as a kind of
ill health GNP (Diderichsen et al. 1998).
Although DALY has been seen as a breakthrough for making possible internationally
comparable health measurements among populations, it is not unproblematic. The
focus is on professional diagnoses of diseases according to defined codes, and there is a
lack of a holistic perspective on health (see chapter 1). Self-experienced ill health is not
included, and neither usually are risk or protective factors. Furthermore, calculations
are most often made for adults, primarily because there is less knowledge about the
incidence, prevalence and duration of illnesses among children and there are greater
difficulties in extrapolating the weights of the functions. Other consequences of illness
among children that have not been considered are that hospital stays can mean losses in

49

school time and play time. These in turn can lead to losses in education, poorer
socialisation and perhaps lower social competence (Rigby et al. 2002).
Another difficulty with the DALY is that both the intricate weighting and the
subjective evaluations the ethical values and social preferences must be carried out
having in mind the significance of different health problems for individuals and groups
of individuals. The DALY, in spite of its enticing apparent objectivity, is not free of
valuation The values are simply expressed in numbers and carried out in a consistent
manner (Diderichsen et al. 1998, SOU 2000).
More recently, WHO has used another international measurement method, DALE
(Disability Adjusted Life Expectancy), which is an even more crude calculation that
does not involve specific weights but is directly comparable with the measure of life
expectancy (WHO 2000b).
DALY and similar measurement methods are now being developed all over the world,
also in Sweden. To make them useable in a municipal index for children, however,
there needs to be much more detailed analyses of the data, including extensive
evaluations by panels of experts.
It would also be possible to use all the indicators that are included to construct a health
profile for each municipality, with the values of the indicators put into a figure with lines
or columns.
By placing the profiles on top of or next to one another, the municipalities can
compare their profiles with others ,and identify their particular strengths and
weaknesses. They can focus on what they consider to be important for their
municipality and its population without combining them into a single integer and
without needing to relate the results to a hypothetical or unrealistic goal.
More refined comparisons can be made between all or selected municipalities by
expressing the values as risk quotas and by e.g. standardising for socioeconomic class. It
is not correct to assume that all municipalities are like one another and can be
compared with each other in a simple way. The municipalities are far too different in
size and structure. To make more valid comparisons, we can use the Swedish
Association of Local Authorities division of municipalities into nine groups, which
takes into consideration population size, degree of urbanisation and economic
structure. This division is based on the 1990 population and housing census (FoB 90)
but is updated according to need.
Table 2. Swedish Association of Local Authorities division of the 289
municipalities
Urban area

Municipality with a population over 200 000 (3

municipalities).

Suburban municipality

More than 50 percent of the registered population

commutes to work in another municipality. The
most common commuting destination being an
urban area (36 municipalities).

50

Larger city
Municipalities with 50 000 to 200
.000 inhabitants and less than 40 percent of the registered population employed in the
industrial sector (26 municipalities).
Middle size city

Municipality with 20 000 to 50 000 inhabitants; over 70

percent urban area and less than 40 percent of the
population employedin the industrial sector (40 municipalities).

Industrial municipality

Municipality with more than 40 percent of the registered

population employed in the industrial sector (53 municipalities).

Semi-rural municipality

Municipality with more than 6.4 percent of the registered

population employed in the agricultural and forestry sectors,
urban area of less than 70 percent and not a rural
municipality (30 municipalities).

Rural municipality

Municipality with less than 5 inhabitants per square

kilometer and less than 20 000 inhabitants (29 municipalities).

Other larger
municipalites

Other municipalities with 15 000 to 50 000 (31

inhabitants (31 municipalities).

Other smaller
municipalities

Other municipalities with less than 15 000

inhibitants (41 municipalities).

This classification is used in the comparisons between the municipalities reported

in the following chapters. Over the years, certain changes have been made in the
municipalities. Since 1992, five new municipalities have been formed that are areas that
earlier belonged to other municipalities (Gnesta (0461), Trosa (0488), Bollebygd (1535),
Lekeberg (1814) and Nykvarn (0140). This has been taken into account in the
calculations in chapter 10 and in the tables.
By using health profiles of this kind we avoid the difficulties of weighting indicators.
But of course, having several dimensions of welfare combined into one single measure
to describe childrens health also creates difficulties, something which welfare
researchers have often warned against (see e.g. SOU 2001a; SOU2001b, WHO 2000a
and Rigby et al. 2002).

A municipal index
If nonetheless, in spite of all reasonable objections, we want to create an index (and it
was one of the tasks given by Save the Children), should it then be an index oriented
toward the ideal? Or should it perhaps be based on comparisons between actual
conditions in the municipalities, and the average or even the best values
(benchmarking) then be used as the target? Both approaches are entirely possible and
they can moreover be combined, as will be seen below.

51

In the first option it is decided that the long term goal toward which the municipality
should work shall be optimal health, which means that diseases are eradicated, injurious
determinants do not exist and the beneficial determinants are present for all inhabitants.
The maximum value for each indicator is 100, which is awarded when the goal has been
reached. The values of all the indicators are added together and divided by the number
of indicators to give a number between 0 and 100.
What is simple about this system is of course that it is not a complicated business to
add and remove indicators as new knowledge is gained or the availability of data
changes. A disadvantage is the difficulty in evaluating and weighting the different
indicators and domains, and then relating them to generally accepted and realistic goals
(see above under DALY). In truth, it is not possible, even with the help of weights, to
compare such different indicators as e.g. breastfeeding up to 4 months, teenage
abortions and serious injuries. In a changing world, any attempt to weight these
indicators would lead to ethical and practical difficulties, both immediately and in the
long term. Giving all indicators the same value is certainly not correct, but it is uniform
and less complicated.
OECD has reasoned in a similar way in constructing the so called Gini coefficient
(OECD 2000). This indicates the position on a comparative scale that a country holds
in terms of its income distribution. If income in the country is distributed such that all
people have an equal income, the index is 0; if one person has all the income, the index
is 1. This is sometimes multiplied by 100 to obtain manageable numbers, i.e. the index
varies from 0 to 100. A scale without weights is also used here, and both endpoints are
equally unrealistic.
With all these considerations in mind, the report presents the outcome of the six
indicators in all municipalities in the country in the form of a common health index.
Thus, to create a municipal health index for children, the results for each indicator are added
and the sum is divided by six, i.e. the number of indicators.
The number of children in the municipality that have not received inpatient care for external injuries is
calculated from Domain B, which consists of this single indicator. If all children from
0-17 years in the municipality (100 percent) fulfil this criterion, that is, no child received
inpatient care for external injuries, the municipality receives the value 100. If no child
fulfils the criterion, i.e. all children have received inpatient care for external injuries, the
value is 0.
The proportion of children in the municipality in each age group is calculated in the
same way for the five indicators in Domain C, breastfed up to 4 months, did not weigh less
than 2500 g at birth, did not have a teenage abortion, was not exposed to tobacco in the womb and
has complete vaccination against MPR. The goal is again that all the children in the
municipality in the respective age groups fulfil these requirements. If this is achieved,
the municipalitys value is 100.
Pooling the indicators and dividing by six gives a common municipal index between 0
and 100, where 100 is the desired goal. This index thus is an aggregated number
calculated from the municipalitys achievement in each indicator. No attempt has been
made to weight the different components each indicator has been given the same
weight, i.e. the outcome and determinant indicators are of equal worth in the final

52

judgment of how far the municipality has succeeded in creating healthy children and
good conditions for healthy children.

Pooling of data
In order to avoid distortion of the results by variations from year to year, a mean
integer has been calculated for the results of pooled years, one period around 1990,
normally 1988, 1989 and 1990, and one period around 2000, normally 1998, 1999 and
2000 (Table 1, page 47).
However, individual indicators and indices in small municipalities must be compared
with some caution. All estimations, and thus also comparisons between estimations, are
affected by random variations. The size and direction of the variations depend on the
size of the municipality and the frequency of the variable in question. Small
municipalities and rare events have a larger random distribution. The municipalities
indices can therefore vary between different measurement periods, especially among
the small municipalities.
Breastfeeding at 4 months is not available at all as an indicator in the 1990 period. This
has been taken into account in comparisons between periods; thus, the comparisons
made between the periods cover only the five indicators that exist for both periods.

Presentation
The results are presented in chapter 10 in tables that show the present situation and the
situation ten years previously as well as the change over time for each individual
municipality, for groups of municipalities, for those that rank highest and those that
rank lowest.
The results are presented both for each of the six indicators and for the combined child
health index. In this way we can form an understanding of each municipalitys current
situation and compare that with the situation one decade earlier. It is also possible to
compare one municipality with other municipalities, now and ten years earlier, and to
make statistical calculations of different relationships, e.g. between different indicators
and between the health index and the poverty index.
This ought to be interesting for both those who want to see the overall situation and
those who are interested in detailed statistics. Small municipalities and infrequent events
have a larger random distribution. The municipalities indices and ranks can thus show
a great variation between different measurement periods, especially in small
municipalities.
A number of questions remain unanswered, such as whether there is a concentration of
particularly vulnerable children and families in a municipality. It is known that it is often
the same children that are exposed to tobacco, have low birthweight and are not
breastfed. May it perhaps be that these are often the same adolescents that are injured
and who have abortions?
A deeper analysis and a detailed examination of the indicators in each municipality are
beyond the scope of this report.. It is up to each municipality to examine its own
situation and the reasons why it may have moved up or down in rank, what factors

53

have been decisive for its rank and, not least, what actions can be taken to make things
better.

9. What is not available but should be and perhaps will be

soon
The indicators presented in the final version are a compromise between what is
desirable for the surveillance and monitoring of childrens health and wellbeing in the
municipalities and what is possible on the basis of available data sources and resources.
With further research and development, other indicators could be established that
would give municipalities even better means for this task.
The greatest lack of valid, reliable and available data is in childrens mental health despite
the fact that this area is central to an individuals wellbeing and societys costs, and
despite the fact that the problems in this area show the greatest increase and cause great
concern among professionals, politicians and the general public. The reasons of course
are that mental health, particularly among children, is a difficult phenomenon to
capture, and we lack measurement methods to grasp all aspects of it at the same time.
Many studies have been made of childrens mental health and behavioural problems
and many methods have been tested. But this has not led to any systematic information
on the mental health of all Swedish children or to data that can be broken down to the
municipal level. There is broad agreement however that prevention is the most effective
way to deal with the problem and that it should preferably be in childrens closest
surroundings. It is primarily efforts made in the family, pre-school and school that can
be expected to have the greatest influence on mental health (Bremberg 1998,
Lagerberg 2002, Hwang 2002). Of particular interest is when co-ordinated efforts are
made within a municipality (Berg Kelly et al. 1993).
Another issue in this complex of problems is social capital and its significance for
childrens health and development. It has been argued in many publications during the
past decade that beyond a certain base level, it is not absolute welfare in material terms
but rather its distribution, relative welfare, which creates health and wellbeing in
populations (Wilkinson 1996). The mechanisms have not been entirely clarified, but
certain phenomena, the degree of social solidarity, the prevailing social norms and
networks between citizens that constitute social capital, are considered to play an
important role (Coleman 1988). In the investigation of Nordic childrens health
between 1984 and 1996, referred to earlier, it was found that changes in health during
this period co-varied positively with changes in social capital but negatively with
changes in economic capital (Berntsson, Khler & Vuille). There is growing interest in
how social capital can influence, and indeed improve, human relationships, which
argues for making childrens and families social networks a priority area in future
analyses of childrens wellbeing (Vimpani 2000; Bing 2003).
As mentioned in an earlier chapter, there is now intensive work in several areas of the
country to improve child health surveillance. Three initiatives in particular are expected
to improve the situation considerably within a few years.
One initiative is the collaboration between the Swedish National Institute of Public
Health, the Swedish Association of Local Authorities and the Federation of the

54

Swedish County Councils to create local welfare balance sheets, that focus on public health.
A municipal database has been developed with attention given to certain areas related
to children (Folkhlsoinstitutet 2003, www.fhi.se). A growing number of municipalities
have begun to work according to its guidelines. In February 2002, 29 municipalities had
taken the first step, a formal decision to draw up a welfare balance sheet. In 49
municipalities the process was under way, and ten municipalities had actually drawn up
a balance sheet.. When the system has been finalised and quality assessed, there will be
several more indicators that can be used for children.
The second initiative is a project, commissioned by the Government to the National
Board of Health and Welfares Centre for Epidemiology. This project will develop and
test a model for continuous surveillance of childrens and adolescents mental health
(Hagquist 2004). It will be based on regular cross-sectional investigations every third
year in schoolchildren 11-16 years of age (grades 6 and 9). The intention is to collect
data in a complete investigation of all schoolchildren, which allows the possibility to
disaggregate the results to specific municipalities. The questionnaires will be answered
anonymously in classrooms and will contain items on wellbeing and mental ill health
and on childrens conditions in the family, among friends and at school. A final
proposal was submitted to the Government in 2004. It now awaits the Governments
decision to allocate funding.
The third is a proposal for a standard form for electronic child health centre records
that has been developed to simplify the collection of data at health examinations,
growth, screening investigations, counseling and vaccination at child health centres and
in school health care (Socialstyrelsen, Memorandum, March 2002). This will allow
systematised information to be gathered on individual children, will improve the quality
of this information, and will make possible epidemiological surveillance of childrens
health on both the local and national levels.
One further source will give important information about childrens health. This deals
with childrens education, which will be Save the Childrens third component in the
creation of a municipal child index. The educational system pre-school and
compulsory school are the most important public arenas as children grow up and
have a great significance for their current and future health. For this reason it is obvious
that indicators in these areas must be considered in a complete set of indicators, chiefly
as determinants. The proposal for health indicators for children that was submitted to
the EU Commission (Rigby & Khler 2002) suggests:
proportion of children that leave school before the statutory school leaving
age,
proportion of children enrolled in pre-primary education or kindergarten
programme,
proportion of children attending schools with a written anti-bullying policy in
operation.
Gteborgs welfare balance sheet also uses proportion of children registered in preschool and proportion of children with a passing grade in core subjects in the 9th grade
(Vlfrdsbokslut 2002).
For over ten years, the Council of Europe, EU and theWHO Regional Office for
Europe have run the European Network for Health Promoting Schools. The goal is to
develop all everyday aspects of the school to support and promote the physical and

55

psychosocial environment for health and learning and to strengthen and develop health
education.
Over 40 countries are cooperating in the project. and the Swedish National Institute of
Public Health was initially the responsible authority in Sweden (Folkhlsoinstitutet
1997a). The Swedish National Agency for Education took over this responsiblity in
2002.
What is lacking and will be lacking in the immediate future is an investigation or any
large scale project in Sweden on pre-school childrens mental health, behaviour, well-being and
quality of life. These questions are extremely important, but methological problems and
costs have so far been obstacles to country-wide surveys.
A project (KIDSCREEN) is being carried out in ten European countries to develop a
screening instrument to survey the mental health and quality of life of schoolchildren
ten years and older (Ravens-Sieberer et al. 2001). The instrument was translated into
Swedish and used in an investigation among a random sample of children for validation
and standardisation.
It is said that appetite comes with eating. When a reasonable set of indicators has been
identified and tested in the municipalities and found to be operationally feasible, there
will probably be a desire to have more, better and more detailed indicators to survey
childrens health and wellbeing even more effectively. Thus we will surely want to
identify childrens injuries in more detail so that we can start countermeasures, even for
less serious injuries. While many municipalities have already started projects of this
kind, we have far to go before they cover all parts of the country.
Similarly, we will probably want to keep closer watch on the physical environment and its
impact on childrens health in the areas of air, water and noise pollution. Some
municipalities, particularly those in our large cities, make detailed measurements of air
quality. Data exist for relatively small geographical areas and their inhabitants, so called
ecological methodology, and are often used to shed light on the effect of the
environment on the population (Elliot et al. 1992).
Eating habits and nutrition are important components of the health behaviour of the
growing numbers of overweight and obese children, in the long run also at increased
risk of diabetes and cardiovascular disease. It is important to construct surveillance
systems with appropriate reliable, sensitive and available indicators as a complement to
the traditional system of weighing and measuring children at child health centres and in
schools.
The offering of cultural experiences for children and participation in cultural events, opportunities
for play, sports and other leisure activities are all areas that have not been possible to
bring into this proposal. This is not because they are not important to childrens and
young peoples health and wellbeing but because we do not have reliable methods and
routines for measuring these activities and their effects.
Particularly vulnerable are those children with disabilities or other long term disorders. These
conditions limit children in their normal function and activity and they increase
psychosomatic problems. Children in this group are also exposed more to bullying; a
Nordic study showed that these children had a twofold risk of being bullied over other

56

children (Nordhagen 2000). It is well documented and generally accepted that families
with disabled children bear a greater burden and are more vulnerable than other
families. The stresses can be physical, mental, social and economic. For these children
and their families, childhood is often a very worrisome period with frequent
hospitalisations and visits to doctors, complicated and difficult treatments, limitations
in lifestyle, financial difficulties, and uncertainty and anxiety over the childs future
(Khler & Jakobsson 1991). Even though more recent studies indicate that we have
succeeded in improving conditions for these children and their families, they still bear a
very large burden and much remains to be improved in terms of psychosocial support.
It would thus be desirable to be able to include children with long term illnesses in a
systematic health surveillance system and as a part of a health index actions that are
currently not possible. The proposal for measurements of childrens mental health,
which will be a complete investigation of two school grades, may be able to contribute
to this survey.

57

Results, conclusions and further work

10. Situation in the municipalities
As described in earlier chapters, the values of each indicator are put together to form
one single index with a maximum and optimum value of 100. For the sake of simplicity,
this means that the values can be expressed as percentages. All six indicators are
included in the 2000 period the mean value for three years around the year 2000
while the mean value for the three years around 1990 includes only five indicators since
breastfeeding data are not available for that time. The two periods are therefore not
directly comparable (see below).
Childrens health index for individual municipalities and groups of
municipalities in the 2000 and the 1990 periods
The values in the 2000 period vary in the municipalities by a maximum of 9.5
percentage points. With a maximum possible value of 100, they go from 93.0 in Eker,
a Stockholm suburban municipality, to 83.5 in Tanum, a small municipality in the
northern part of the Westcoast. The mean value for all municipalities is 88.0 and the
median is 88.8. The 20 municipalities that rank at the top and the bottom are shown in
Table 3.
Table 3. Municipalities with the lowest and the highest indices, 2000 period (6
indicators)
Municipalities with the
highest index in the 2000 period

Municipalities with the lowest index

in the 2000 period

Municipality
Eker
Tby
Vaxholm
Danderyd
Hammar
Liding
Nacka
Sollentuna
Hrjedalen
Solna
Munkfors
Berg
Jrflla
Lomma
Ydre
Karlstad
Lerum
re
Emmaboda
Heby

Municipality
Tanum
Degerfors
Ljusnarsberg
Kumla
lvkarleby
Storfors
stra Ginge
Landskrona
Mellerud
Grums
Bjuv
Sorsele
Sderhamn
Bromlla
rkelljunga
deshg
Norberg
Markaryd
Munkedal
Lilla Edet

58

Index
93
92.8
92.6
92.6
92.3
92.3
92.2
92.2
92.2
91.7
91.7
91.6
91.5
91.5
91.5
91.3
91.3
91.3
91.3
91.3

Index
83.5
84
84.6
84.8
84.8
84.8
85
85
85.2
85.6
85.7
85.8
85.8
85.8
85.9
86
86.2
86.3
86.3
86.4

Ten years earlier, in the 1990 period, the values varied between the municipalities by 7.9
percentage points, from 94.4 in sele to 86.5 in Jokkmokk. The mean value for all the
municipalities was 90.3 and the median 90.4. The 20 municipalities that rank at the top
and the bottom are shown in Table 4.
Table 4. Municipalities with the highest and lowest indices, 1990 period (5
indicators)
Municipalities with the highest
the 1990 period index

Municipalities with the lowest index in

in 1990 period

Municipality
sele
Lomma
Danderyd
Essunga
Lycksele
Habo
Trans
Strmstad
Sollentuna
Alvesta
Krokom
Uppsala
Torss
rnskldsvik
Liding
Sunne
Nssj
Lund
Falun
Karlstad

Municipality
Jokkmokk
Orsa
storp
Osby
lvkarleby
Burlv
Sdertlje
Svalv
Landskrona
Kvlinge
Norberg
Malm
Sala
Bjuv
Kramfors
Sderhamn
Kiruna
Sorsele
Grums
Norrtlje

Index
94.4
93.3
93.3
93.2
93
92.9
92.9
92.7
92.6
92.5
92.4
92.4
92.4
92.3
92.3
92.2
92.2
92.2
92.2
92.2

Index
86
86.8
87.2
87.6
87.6
87.6
87.7
87.7
87.9
88
88
88
88.1
88.1
88.2
88.2
88.3
88.3
88.4
88.4

The gap between the highest and lowest municipality increased somewhat, from 7.9
percentage points in the 1990 period to 9.5 in the 2000 period. This means that the
addition of the sixth indicator, breastfeeding status, increased the deviation between the
municipalities and also decreased the mean value. Tables 3 and 4 are not directly
comparable, as they include a different number of indicators.
The municipal tables in Appendices 1 and 2 give the health index for all municipalities
for both the 2000 and the 1990 periods. As discussed earlier, the municipalities differ a
great deal among themselves in terms of number of inhabitants, business and industry
profile etc. For this reason the municipalities are often divided into nine different
groups (see chapter 8).
The large cities ranked somewhat worse than other groups of municipalities in the 1990
period (almost 3 percentage points). The suburban municipalities ranked highest,
together with the rural municipalities. In the 2000 period, the large cities climbed in
rank as a group, while the industrial municipalities are lowest and the suburban

59

municipalities again highest. The differences between the groups of municipalities are
not great, however, neither in the 1990 period nor the 2000 period.
Table 5. Mean values of the childrens health index in the 1990 and 2000 periods
according to groups of municipalities
2000(6
indicators)
Municipality
group
Urban (3)
Suburban
(36)
Larger
cities (26)
Mid size
cities (40)
Industrial
(53)
Semi-rural
(30)
Rural (29)
Other
larger (31)
Other
smaller (41)
All municipalities
(289)

1990 (5
indicators)

2000 (5
indicators)

Difference 19902000 (5 indicator)

Mean

S.D.

Mean

S.D.

Mean

S.D.

Mean

S.D.

89
90.3

1.9
1.6

89.2
90.5

1.1
1.2

93.1
93.9

1.1
1

4.0
3.4

0.5
0.8

89.5

1.3

91

2.2

93.6

0.9

2.6

0.8

88.7

1.2

90.1

1.1

93.1

0.9

3.0

1.1

88.2

1.8

90.2

1.1

93.2

1.1

3.0

1.3

88.4

1.8

90.3

1.3

93

1.1

2.7

1.3

89.2
88.7

1.7
1.3

90.5
90.2

1.8
1.3

93.3
93.3

1.3
1

2.8
3.1

1.8
1.2

88.2

1.5

90.3

1.2

92.5

1.6

2.2

1.5

88.8

1.7

90.3

1.3

93.2

1.2

2.9

1.3

When the values are grouped according to geographic region, the childrens health
index is found to be highest, 90.4, in the Stockholm region and lowest, 87.0, in the
rebro region. Mean values of the childrens health index in the regions of Gtaland,
Svealand and Norrland show no differences, however. (Southern, Middle and Northern
regions of the country).

Comparison between the periods

The numbers must be corrected to be able to compare the two periods and judge
changes in the health index between them because data on breastfeeding are lacking for
the 1990 period. A correct comparison can thus only be made when breastfeeding data
are removed from the 2000 period and the five indicators remaining for both periods
are used.
In the comparison, consideration has also been given to the changes in the number of
municipalities so that the five municipalities that did not exist in the 1990 period have
been given an average value for their municipality groups.

60

It is found then that the index, after having been made comparable, has shown an
improvement during these ten years, with an increase in the mean value from 90.3 to
93.2. All municipalities except Ljusnarsberg (-3.1 percentage points) and sele (-2.3
percentage points) improved their health index between the two measurement periods.
The greatest improvement, over 5 percentage points, took place in 11 municipalities
(see table 3). The difference between the maximum and minimum was 7.9 percentage
points in the 1990 period (from 94.4 to 86.5). In the comparable 2000 period (5
indicators), the difference between the municipalities maximum and minimum values
was 9.2 (from 96.3 to 87.1), i.e. an increase of 1.3 percentage points.
Table 6. Municipalities that improved their childrens health index between the
1990 period and the 2000 period by more than 5 percentage points (5 indicators)
Municipality
Jokkmokk
Norberg
Sala
Osby
Ragunda
storp
Kvlinge
Munkfors
Kiruna
Robertsfors
Sigtuna

Improvement in percentage points

7.6
7.2
6.3
5.6
5.6
5.5
5.5
5.4
5.3
5.3
5.1

Seen together, there is a clear consistency between the periods, which means that those
who ranked high in the 1990 period did so also in the 2000 period.
In terms of municipality group, the greatest improvement took place in the three large
cities of Stockholm, Gteborg and Malm, 4 percentage points, and the smallest
change was seen among the 41 municipalities with less than 15 000 inhabitants.

Individual indicators in the index

When the health index is broken down into its components it is seen that it is more
difficult to achieve the goal in the case of some indicators than in others (see table 7).
Teenage abortions show the best average value; this is the least frequent negative health
indicator. Less than two of 100 girls <18 years underwent an abortion. Immunisation
and low birthweight also show good values. In the entire country, the low birthweight
indicator is just below 96, i.e. only four of 100 newborns weigh less than 2 500 g. The
Breastfeeding indicator can be improved most; an average of only two thirds of infants
are breastfed at four months.

61

Table 7. Highest and lowest values in individual indicators, 2000 period and
1990 period
2000-period
Indicator
Municipality
Injuries
Tobacco
Birthweight
Breastfed
Vaccination
Abortions

Municipality

Storfors
Danderyd
Orsa

High
value
96.3
97.7
99.4

Range

dershg
Ljusnarsberg
Ockelbo

Lowest
value
81.9
68.7
91.4

14.4
29.0
8.0

Mean
value
90.2
86.1
95.7

Emmaboda

85.2

Storfors

41.1

44.1

66.8

Eda

99.8

Ljusnarsberg

81.6

18.2

95.8

Lomma

99.6

Bjurholm

95.8

3.8

98.3

Municipality
Sala
Eda
Vaxholm

Lowest
value
82.0
59.3
91.8

Range

Ludvika
Lycksele
Habo

High
value
96.1
88.2
99.5

14.1
28.9
7.7

Mean
value
89.9
73.4
95.6

___

__

__

__

__

__

Kungsr

99.7

Gagnef

80.8

18.9

94.5

Olofstrm

99.6

Sundbyberg

96.3

3.3

98.3

1990-period
Indicator
Municipality
Injuries
Tobacco
Birthweight
Breastfed
Vaccination
Abortions

The greatest variation in the municipalities is found in the breastfeeding indicator,

where there is a difference of 44.1 percentage points between Storfors, 41.1, and
Emmaboda, 85.2. There are also strong differences in individual municipalities in
mothers smoking during pregnancy, from 97.7 in Danderyd to 68.7 in Ljusnarsberg (29
percentage points). The variation in teenage abortions is very small, however only 3.8
percentage points between Lomma, with 99.6, and Bjurholm, with 95.8.
Regardless of the varying weights of the indicators purely in terms of health, their
mathematical values are also significant. Even if we consistently use average values to
construct indicators and add them to an index and thus give them identical weights in
all calculations, the variations between municipalities are important: the greater the
variation an indicator shows between municipalities, the more it affects the comparison
between the municipalities. Thus teenage abortions and low birthweight, for example,
show little variation between the municipalities and therefore have little explanatory
power in terms of the differences between the municipalities. The opposite is true for
breastfeeding, with its strong variation.
The above reasoning applies in principle for both the 2000 and the 1990 periods. The
tobacco indicator is alone in showing a strong change between the two measurement

62

periods. Only five municipalities demonstrate poorer values (Markaryd, Smedjebacken,

Hallstahammar, Ljusnarsberg and Upplands Vsby). This health threat has decreased in
all the other municipalities, in certain cases by 25-30 percentage points (Munkfors,
Jokkmokk, Ragunda, Robertsfors, Hllefors, Norberg and Ydre).

Significance of the childrens health index

Are these differences between the municipalities significant and are the results
important to children and society? They are significant in the sense that there is a
systematic difference. The correlation between the municipalities rankings in the 1990
and 2000 periods is strong (p < 0.01). The differences are notable, although not
particularly large. The difference in the 2000 period was at most 9.5 percentage points
and the deviation from the maximum was at most 16.5 percentage points. This can be
compared with the difference between the municipalities in the poverty index
presented earlier by Salonen.
There is a greater variation in the municipalities with regard to the proportion of
children who live in households that are neither poor nor draw means tested social
assistance from 62.3 percent in Malm to 94.5 percent in Nykvarn, , a range of 32
percentage points. In 1999, 38 municipalities had less than 80 percent while 17
municipalities showed over 90 percent. It must be kept in mind, however, that the
index can be affected in small municipalities by temporary variations in individual
indicators (see also chapter 8).
We group municipalities according to types, but the results are still given as an average
for the municipalities included in each group. This is a considerable twisting of the
truth, especially for the large cities, since there are marked differences between different
areas within these cities, which often have sub-populations that represent both the
most healthy and the most sick, the richest and the most impoverished in the country.
However, we are not able at this time to break down the data to units smaller than the
municipality. It must be a task for the municipalities themselves to investigate their
populations in greater detail or for future special studies of the large cities.
The results are important because this kind of compilation of data on childrens health
on the municipal level has not been done before. It gives municipalities a unique basis
for further analysis of where they have succeeded and where there is room for
improvement and where thus efforts should be made.

Health index and child poverty index

The differences between the municipalities are significant because they show that health
differences coincide with other differences in society. If we relate the health index to
the poverty index, which was calculated for the same populations (Salonen 2002), we
find a consistent association. There is a statistically significant correlation over all
municipalities between the poverty index and the childrens health index on the 0.01
level in both the 1990 and the 2000 periods.
This is true even when the index is compared within each group of municipalities.
However, there is no given relationship between a low childrens health index and child
poverty in each individual municipality, just as it would not be true to say that all poor
individuals are sick or that all rich individuals are healthy.

63

Individual indicators also show a statistically significant relationship with the child
poverty index in the 2000 period. This concerns the indicators of breastfeeding (p <
0.02), tobacco use during pregnancy (p < 0.001) and teenage abortions (p < 0.001).
These relationships are so strong that they have an impact on and give statistical
significance to the index as a whole, even if the other indicators are not themselves
significantly correlated to the child poverty index (injuries, low birthweight and
vaccination). Again, the calculations are based on mean values and pooled data.

Conclusions
It can thus be confirmed that, measured in this way, childrens health in Swedish
municipalities is very good and that the differences in the health index are lower than
the differences in the poverty index. However, there is still room for improvement.
Using the goal of 100 percent, there is still a considerable number of children who do
not achieve this optimal health.
Even if we were to be satisfied with the best municipality as a target for childrens
health (benchmarking), there are many children in other muncipalities that do not reach
this level. It is not possible to determine exactly how many children this means without
more detailed analyses.
These calculations are difficult even when data are put together on the individual level
because the indicators that together comprise the index cover different periods of the
childhood years and thus different groups of children and in part also different
denominators. Furthermore, the statistics on abortions are anonymised and cannot be
connected to specific individuals.

11. Conclusions
This report must be seen in the light of the long term work of Save the Children to
create an index based on rights that provides information about different aspects of the
welfare of children and adolescents in Sweden on the municipal and national levels.
Earlier reports have shed light on the economic dimension of childrens welfare. (See
e.g. Child Poverty in Sweden a contribution to a municipal childrens index and
subsequent annual follow-up reports, all written by Professor Tapio Salonen for Save
the Children).
The purpose of this report is to shed light in a systematic way on childrens health in
Sweden and on methods that can be used to measure it. On the basis of the
Convention on the Rights of the Child, childrens right to the highest attainable
standard of health (article 24) has been placed in a Swedish perspective with a focus on
the municipal level. This is the first time an attempt has been made to construct a
municipal health index for children in a broad public health perspective. The results of
this extensive review can be presented under three headings: gaps in knowledge,
ongoing efforts and current results.

Gaps in knowledge
The report clearly shows that there is a great deal that we do not know about childrens
health. A great deal of the usefulness of the review presented in this report is that it
shows the difficulties and shortcomings in measuring childrens health. The

64

municipalities currently have too few and too incomplete indicators. We thus lack
information to systematically follow pre-school childrens mental health, behaviour,
wellbeing and quality of life.
Information about childrens physical environment and its impact on their health is also
very poor. Other areas in which there is a lack of reliable data are eating habits and
nutrition and cultural offerings and experiences.
The conclusion that was drawn after an earlier review of childrens health in Sweden
(Khler & Jakobsson 1991) is essentially still true today: 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

Ongoing efforts
As stated, there is a gaping absence of available information with which to monitor
childrens health. Several promising initiatives have however been taken to systematise
the surveillance of the health and wellbeing of the population in Sweden, although few
have a child perspective. Three initiatives particularly worthwhile mentioning are:
(i)

Local welfare balance sheets. The Swedish Association of Local

Authorities and Regions together with the Federation of Swedish County
Councils and the Swedish National Institute of Public Health are the
organisations that have taken this initiative. Not all municipalities
participate and the set of indicators used differs from municipality to
municipality. Some of the participating municipalities have focused on
childrens welfare, however. Work is now continuing to develop a national
database of municipal basic facts as a foundation for public health work.
Some of the indicators chosen also cover children.

(ii)

The National Board of Health and Welfares Centre for Epidemiology has
presented a system for continuous surveillance of childrens and
adolescents mental health. The plan is to perform repeated surveys of a
few age-groups of all children, giving the municipalities access to the
results. A decision to implement this proposal has not yet been made.

(iii)

A third initiative is a proposed nationally standardised form for

computerised health records from the Child Health Sevices and the School
Health Services, which would facilitate the collection of important
information.

Current results
As is obvious from the previous discussions, it has not been easy to construct a relevant
health index for children on the municipal level. In many cases data have been
insufficient to describe the broad and complex area that childrens health represents. Of
the 22 indicators originally proposed, six remain (children injured by external causes,
foetal exposure to tobacco, children with low birthweight, children that are breastfed,
MPR vaccination and teenage abortions. After careful examination only these six were
found to fulfil the requirements that were set for quality and availability. In spite of
shortcomings, on the basis of the analyses of the six indicators (for all of Swedens
municipalitie) we can confirm that:

65

(i)

Childrens health is good in Sweden. Between the two measurement

periods, the 1990 and 2000 periods, the pooled health index increased
from 90.3 to 93.2. During the same period, 11 municipalities improved
their health index by more than five percentage points (pp) while the index
fell in only two municipalities. There is a high national average for several
individual indicators. For example, only two of 100 girls under 18 years of
age undergo an abortion and slightly less than 4.5 percent of all newborns
weigh less than 2 500 grams.

(ii)

There are large differences between the municipalities. The difference

between the municipality with the highest index value and that with the
lowest value in the 2000 period was almost ten percentage points (pp). The
differences between the municipalities in individual indicators are also large.
The greatest variation is seen in the following indicators: breastfeeding (44
pp), foetal exposure to tobacco (29 pp), vaccination (18.2 pp) and injuries
(14.4 pp). Moreover, comparison of the two periods shows that the
deviation has increased, with the exception of the vaccination indicator.

(iii)

As is almost always the case, there is a strong correlation between childrens

health and their economic vulnerability. Obviously, this cannot always be
demonstrated for individual municipalities, but there is a statistically
significant correlation between the general poverty index and the general
health index, both the 1990 period and the 2000 period. The same is true
when the indices are compared within the different groups of
municipalities.

The report does not offer recommendations for measures that municipalities and/or
county councils should take to improve childrens health. It should be the responsibility
of the individual municipalities and county councils to analyse in detail the data
presented in municipality tables 1 and 2.

66

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national road safety plan for 199-2001). Vgverket, Borlnge
Vgverket (2002). Barn och nrsamhlle. (Children and society) Vgverket, Borlnge
Yngve A, Kylberg E & Sjstrm M (2001). Breastfeeding surveillance in the EU and
EFTA: Recommendations adopted at the Breastfeeding Surveillance Conference.
Breastfeeding Surveillance Conference, Stockholm

76

Municipality table 1
Individual indicators and childrens health index for the 2000 period (6 indicators). 100
is the highest value and 0 the lowest value. Municipalities in alphabetical order.
Municipality

Injuries

Tobacco

Birthweight

Breastfeeding

Vaccination

Abortion

Index

Ale
Alingss
Alvesta
Aneby
Arboga
Arjeplog
Arvidsjaur
Arvika
Askersund
Avesta
Bengtsfors
Berg
Bjurholm
Bjuv
Boden
Bollebygd
Bollns
Borgholm
Borlnge
Bors
Botkyrka
Boxholm
Bromlla
Brcke
Burlv
Bstad
Dals-Ed
Danderyd
Degerfors
Dorotea
Eda
Eker
Eksj
Emmaboda
Enkping

87.8
90.5
91.5
86.6
94.9
88.6
89.1
93.9
89.9
91.0
89.8
87.1
83.2
91.2
89.1
90.0
92.3
89.5
88.3
87.0
93.6
85.3
86.0
91.2
91.8
92.5
85.4
93.4
92.9
91.9
90.9
94.3
84.9
87.0
92.7

81.5
85.6
87.5
84.7
87.1
86.3
84.3
82.8
86.1
85.5
82.4
92.1
91.0
78.9
85.0
88.2
81.8
87.2
82.9
83.7
85.4
82.5
78.7
87.3
82.0
86.1
84.5
97.7
79.1
90.8
73.7
92.4
93.7
84.9
87.1

96.0
96.6
94.5
95.6
97.0
94.4
93.4
96.0
95.5
96.0
96.7
96.4
93.7
97.1
94.6
95.8
96.9
95.9
95.9
96.2
94.3
98.0
95.4
95.5
93.8
95.6
92.0
96.5
92.5
93.3
94.0
97.6
95.6
94.3
96.2

62.2
74.0
67.4
59.2
70.3
74.7
68.5
61.6
56.5
70.5
61.8
80.9
66.7
51.8
75.8
73.1
64.3
75.0
61.6
67.1
62.3
65.5
62.4
63.4
57.8
75.9
65.7
77.2
49.4
73.4
68.0
81.5
70.2
85.2
67.5

96.1
94.6
99.1
95.3
97.5
81.8
94.2
95.8
94.2
99.1
97.5
94.7
95.9
97.3
95.7
98.9
90.9
97.3
96.1
95.0
95.6
96.1
94.1
97.7
95.7
95.7
99.5
91.6
92.9
93.1
99.8
93.3
99.2
98.3
91.9

98.2
98.5
98.7
98.8
97.8
98.2
98.6
98.8
98.3
98.3
98.5
98.2
95.8
97.6
98.1
98.0
98.6
99.0
97.7
98.3
98.0
98.6
97.9
97.4
98.1
98.6
97.6
99.1
97.4
97.5
96.4
98.9
98.9
98.0
98.5

87.0
90.0
89.8
86.7
90.8
87.3
88.0
88.2
86.7
90.1
87.8
91.6
87.7
85.7
89.7
90.7
87.5
90.6
87.1
87.9
88.2
87.7
85.8
88.8
86.5
90.7
87.4
92.6
84.0
90.0
87.1
93.0
90.4
91.3
89.0

77

Municipality

Injuries

Tobacco

Birthweight

Breastfeeding

Vaccination

Abortion

Index

Eskilstuna
Eslv
Essunga
Fagersta
Falkenberg
Falkping
Falun
Filipstad
Finspng
Flen
Forshaga
Frgelanda
Gagnef
Gislaved
Gnesta
Gnosj
Gotland
Grums
Grstorp
Gullspng
Gllivare
Gvle
Gteborg
Gtene
Habo
Hagfors
Hallsberg
Hallstahammar
Halmstad
Hammar
Haninge
Haparanda
Heby
Hedemora
Helsingborg
Herrljunga
Hjo
Hofors
Huddinge
Hudiksvall
Hultsfred
Hylte
Hbo
Hllefors
Hrjedalen

86.4
91.2
89.4
94.5
89.4
88.5
88.2
90.8
90.5
90.6
92.0
91.6
87.3
91.4
89.9
89.7
86.7
91.3
88.4
90.5
90.1
89.6
85.9
91.1
93.5
92.2
89.4
95.5
89.2
91.1
92.8
91.8
95.3
89.5
90.2
89.3
87.4
88.8
92.0
87.6
89.6
90.0
93.6
92.1
88.5

83.0
83.0
87.2
82.9
87.6
87.7
89.5
82.7
89.5
85.0
82.9
82.3
87.3
87.9
79.9
89.1
85.1
81.8
89.7
84.5
85.5
85.3
88.4
85.6
88.9
83.8
87.2
84.4
85.7
94.2
82.3
80.3
81.8
84.3
85.2
87.5
90.9
81.8
87.5
86.1
87.2
83.8
86.8
88.2
90.8

94.5
93.4
96.7
95.0
95.5
95.8
96.2
97.1
96.7
97.6
95.8
94.0
96.5
96.3
96.6
96.7
94.7
97.1
93.4
94.8
95.0
94.8
95.1
95.5
94.0
97.2
96.3
94.6
94.8
95.1
94.8
95.3
95.8
96.1
94.9
95.6
95.4
94.1
95.1
94.4
95.9
97.7
95.8
94.1
97.2

64.5
61.8
68.1
60.7
66.8
62.2
71.3
67.4
64.3
66.1
73.0
58.6
67.9
65.6
66.5
66.5
72.5
58.0
72.6
59.0
68.0
67.7
66.9
64.5
66.0
60.9
59.1
63.7
66.2
76.7
66.0
57.9
79.0
63.1
68.5
61.8
62.9
58.6
70.4
68.4
71.9
65.9
72.4
64.9
80.9

97.0
96.2
97.5
98.1
96.6
97.2
97.0
98.4
99.3
97.9
97.7
97.4
89.7
95.0
92.0
99.1
95.4
88.4
90.4
97.3
97.1
97.6
95.9
97.8
95.9
99.0
94.3
98.3
98.4
98.5
96.1
96.0
97.0
93.6
95.4
91.7
99.4
98.0
95.4
96.2
98.3
98.6
93.9
93.2
97.6

98.2
98.1
98.7
96.2
98.6
98.3
98.9
97.8
99.0
98.0
97.4
98.4
98.5
98.9
98.2
99.1
98.2
97.0
97.7
98.3
98.3
97.9
98.0
98.2
98.9
98.6
98.3
98.7
99.0
98.2
97.1
97.0
98.6
98.0
98.0
98.6
98.6
98.6
97.4
98.0
99.3
97.7
98.0
97.0
98.0

87.3
87.3
89.9
87.9
89.1
88.3
90.2
89.0
89.9
89.2
89.8
87.0
87.9
89.2
87.2
90.1
88.8
85.6
88.7
87.4
89.0
88.8
88.4
88.8
89.6
88.6
87.4
89.2
88.9
92.3
88.2
86.4
91.3
87.4
88.7
87.4
89.1
86.7
89.6
88.4
90.3
88.9
90.1
88.2
92.2

78

Municipality

Injuries

Tobacco

Birthweight

Breastfeeding

Vaccination

Abortion

Index

Hrnsand
Hrryda
Hssleholm
Hgans
Hgsby
Hrby
Hr
Jokkmokk
Jrflla
Jnkping
Kalix
Kalmar
Karlsborg
Karlshamn
Karlskoga
Karlskrona
Karlstad
Katrineholm
Kil
Kinda
Kiruna
Klippan
Kramfors
Kristianstad
Kristinehamn
Krokom
Kumla
Kungsbacka
Kungsr
Kunglv
Kvlinge
Kping
Laholm
Landskrona
Lax
Lekeberg
Leksand
Lerum
Lessebo
Liding
Lidkping

91.1
85.3
88.7
91.4
89.5
90.0
90.6
89.9
93.1
91.7
90.6
87.6
87.0
92.7
94.2
95.0
90.8
92.4
91.6
88.8
91.8
90.6
87.4
87.8
95.6
87.0
89.0
89.7
95.5
90.4
91.8
94.1
89.4
91.4
91.6
89.0
89.1
89.5
89.9
93.0
92.1

86.7
92.0
85.3
86.5
85.8
83.6
77.3
89.9
88.6
89.6
84.5
86.9
84.7
87.1
88.0
87.7
88.2
85.9
84.0
86.4
88.0
81.0
85.3
86.4
84.5
89.5
86.4
91.1
85.3
90.6
85.7
82.8
83.8
76.7
86.7
87.1
89.9
89.9
84.9
95.8
90.6

95.6
95.3
97.4
94.1
97.5
94.3
94.0
95.2
96.6
95.4
94.9
95.4
97.5
94.3
94.7
95.1
96.1
94.1
96.2
97.0
94.2
92.4
95.9
97.0
93.3
98.6
95.4
95.8
97.7
96.7
95.9
95.3
92.7
94.6
95.9
92.4
95.1
96.3
96.6
97.0
96.3

69.8
75.3
64.5
70.0
60.5
61.7
66.6
58.4
76.0
68.9
61.9
73.4
61.6
62.8
57.6
68.7
76.7
65.8
64.4
68.9
60.5
59.5
56.3
62.8
67.8
76.8
42.2
70.6
67.4
70.6
66.0
70.2
59.6
53.4
63.8
66.7
70.7
78.2
57.8
77.9
65.8

96.3
97.2
95.2
93.5
98.2
96.1
95.2
97.4
96.2
99.0
93.1
98.0
96.7
98.7
98.3
98.2
97.7
97.8
97.9
97.9
95.4
96.7
98.7
98.1
99.3
96.8
98.0
91.7
98.4
93.0
96.1
98.0
97.1
96.0
93.7
92.4
94.9
96.0
97.8
91.2
99.1

98.7
98.4
98.8
98.4
98.0
98.8
98.3
98.3
98.5
98.9
98.4
98.6
98.7
98.9
98.6
98.3
98.6
98.7
99.0
98.9
98.5
98.4
98.2
98.5
97.5
98.7
98.1
98.7
97.9
98.4
98.3
97.6
99.1
98.1
99.1
98.4
98.9
98.2
97.9
98.7
98.6

89.7
90.6
88.3
89.0
88.2
87.4
87.0
88.2
91.5
90.6
87.2
90.0
87.7
89.1
88.6
90.5
91.3
89.1
88.8
89.7
88.1
86.4
87.0
88.4
89.6
91.2
84.8
89.6
90.4
89.9
89.0
89.7
86.9
85.0
88.5
87.7
89.8
91.3
87.5
92.3
90.4

79

Municipality

Injuries

Tobacco

Birthweigt

Breastfeeding

Vaccination

Abortion

Index

Lilla Edet
Lindesberg
Linkping
Ljungby
Ljusdal
Ljusnarsberg
Lomma
Ludvika
Lule
Lund
Lycksele
Lysekil
Malm
Malung
Mal
Mariestad
Mark
Markaryd
Mellerud
Mjlby
Mora
Motala
Mullsj
Munkedal
Munkfors
Mlndal
Mnsters
Mrbylnga
Nacka
Nora
Norberg
Nordanstig
Nordmaling
Norrkping
Norrtlje
Norsj
Nybro
Nykvarn
Nykping
Nynshamn
Nssj

85.3
90.6
88.9
93.8
90.0
91.4
91.8
91.5
91.0
91.4
88.3
91.8
88.5
89.4
92.6
88.5
89.8
91.4
89.2
84.0
85.3
84.3
93.8
89.1
92.6
86.5
91.0
85.7
93.4
91.3
93.8
84.3
85.9
88.6
92.4
90.0
87.4
92.1
89.4
92.4
89.4

82.9
83.3
91.3
88.5
83.6
68.7
95.3
83.0
87.3
92.2
95.2
85.5
84.8
90.1
92.5
83.9
85.5
81.4
78.8
85.2
88.0
83.3
86.4
76.2
93.9
91.2
82.1
83.5
91.1
85.2
88.7
79.8
89.1
86.2
82.8
92.1
86.1
82.7
85.4
82.6
88.1

95.3
97.0
96.1
92.8
96.8
97.3
93.7
96.7
96.6
96.0
98.0
96.9
95.3
96.4
96.5
95.6
95.0
94.6
95.8
94.3
96.2
95.5
98.6
95.8
95.0
95.3
92.7
94.6
95.7
95.6
96.5
96.2
98.5
95.6
96.6
96.1
93.7
93.4
96.1
95.8
93.8

62.6
54.1
71.2
62.8
71.1
72.2
71.4
66.5
73.5
72.8
66.8
60.2
63.3
65.5
68.7
62.9
64.1
54.7
52.9
64.4
73.2
71.4
66.1
63.3
72.0
70.2
73.0
70.3
81.2
66.8
41.7
67.5
61.1
67.4
66.7
51.6
65.2
73.2
68.2
67.7
65.5

94.2
96.1
95.2
98.1
96.8
81.6
97.2
96.6
95.0
92.5
91.6
98.3
95.7
97.4
94.9
97.8
96.7
97.3
96.5
98.9
92.7
98.0
98.1
95.5
98.5
96.8
97.3
98.5
93.9
98.4
98.6
96.1
91.7
94.2
92.9
92.3
98.0
87.5
98.5
94.5
98.1

98.0
98.7
98.8
98.4
98.4
96.6
99.6
97.8
98.6
98.5
98.8
98.9
97.7
98.7
98.5
98.8
98.3
98.6
97.8
98.3
98.4
98.5
99.0
97.7
97.9
97.9
98.3
98.1
98.2
98.4
98.2
98.4
97.6
97.8
97.6
98.3
98.3
97.6
98.2
96.8
98.9

86.4
86.6
90.2
89.1
89.5
84.6
91.5
88.7
90.3
90.6
89.8
88.6
87.5
89.6
90.6
87.9
88.2
86.3
85.2
87.5
89.0
88.5
90.3
86.3
91.7
89.6
89.1
88.4
92.2
89.3
86.2
87.1
87.3
88.3
88.1
86.7
88.1
87.7
89.3
88.3
89.0

80

Municipality

Injuries Tobacco Birth- Breast- Vacci- Abortion Index

weight feeding nation

Ockelbo
Olofstrm
Orsa
Orust
Osby
Oskarshamn
Ovanker
Oxelsund
Pajala
Partille
Perstorp
Pite
Ragunda
Robertsfors
Ronneby
Rttvik
Sala
Salem
Sandviken
Sigtuna
Simrishamn
Sjbo
Skara
Skellefte
Skinnskatteberg
Skurup
Skvde
Smedjebacken
Sollefte
Sollentuna
Solna
Sorsele
Sotens
Staffanstorp
Stenungsund
Stockholm
Storfors
Storuman
Strngns
Strmstad
Strmsund
Sundbyberg
Sundsvall
Sunne
Surahammar

92.9
92.8
88.4
89.2
86.8
91.5
92.8
90.2
95.4
85.6
89.5
91.6
85.6
87.6
86.1
87.0
85.6
89.1
85.0
93.6
91.8
92.0
88.3
89.1
93.9
92.4
88.1
91.5
85.5
93.5
94.0
87.8
88.7
91.3
89.2
93.7
96.3
93.0
89.0
89.1
88.9
93.7
86.8
91.7
94.4

88.5
85.6
77.0
86.1
86.0
86.3
87.7
83.8
84.9
89.9
83.4
86.3
91.9
94.8
95.1
93.8
94.9
95.2
93.9
86.7
80.6
78.3
88.3
90.4
78.8
79.5
88.2
84.0
86.7
92.7
91.4
83.3
82.7
89.0
87.9
90.8
82.4
94.5
83.1
85.5
91.1
89.0
87.4
86.4
82.0

91.4
93.9
99.4
97.4
97.2
96.2
96.9
95.8
93.7
95.4
95.3
96.3
97.6
93.1
63.7
78.2
66.1
73.1
62.2
95.4
96.2
94.9
94.5
95.9
96.0
95.1
96.2
94.0
96.5
96.2
96.3
98.9
97.0
94.6
96.8
95.7
92.0
95.5
94.9
96.3
96.6
95.5
96.4
93.4
96.3

64.2
60.4
69.0
72.3
65.0
70.8
63.4
76.0
68.0
70.7
65.1
71.0
74.5
61.3
97.8
92.3
97.6
95.7
98.6
68.1
63.6
66.6
62.4
64.7
74.6
68.8
68.2
61.7
63.0
76.1
76.1
57.0
57.7
63.9
63.3
75.4
41.1
70.9
70.3
65.6
65.3
70.8
70.0
65.8
56.2

99.1
98.8
90.1
89.1
97.2
98.1
95.4
99.3
95.9
97.7
96.6
96.4
97.3
96.1
98.8
98.6
98.2
97.2
98.2
95.8
94.2
93.3
98.8
96.1
94.3
97.4
98.3
96.8
96.3
95.7
95.1
90.3
93.9
96.5
85.5
93.5
99.4
95.8
95.4
95.3
98.2
95.3
98.5
95.7
96.9

98.5
99.1
98.5
98.7
98.9
98.6
98.5
96.9
98.7
98.0
97.7
98.5
97.8
98.9
89.4
89.7
89.7
90.4
88.3
98.4
98.6
97.8
98.4
98.9
98.0
98.0
98.2
98.1
98.3
98.9
97.7
97.6
98.6
98.8
98.1
98.1
97.4
97.7
98.5
99.0
97.8
98.0
97.9
97.7
96.7

89.1
88.4
87.1
88.8
88.5
90.2
89.1
90.3
89.4
89.6
87.9
90.0
90.8
88.6
94.9
88.3
95.9
92.1
91.9
89.7
87.5
87.1
88.5
89.2
89.3
88.5
89.5
87.7
87.7
92.2
91.7
85.8
86.4
89.0
86.8
91.2
84.8
91.2
88.5
88.5
89.7
90.4
89.5
88.4
87.1

81

Municipality

Injuries Tobacco Birth- Breast- Vacci- Abortion Index

weight feeding nation

Svalv
Svedala
Svenljunga
Sffle
Ster
Svsj
Sderhamn
Sderkping
Sdertlje
Slvesborg
Tanum
Tibro
Tidaholm
Tierp
Timr
Tingsryd
Tjrn
Tomelilla
Torsby
Torss
Tranemo
Trans
Trelleborg
Trollhttan
Trosa
Tyres
Tby
Treboda
Uddevalla
Ulricehamn
Ume
Upplands-Bro
UpplandsVsby
Uppsala
Uppvidinge
Vadstena
Vaggeryd
Valdemarsvik
Vallentuna
Vansbro
Vara
Varberg
Vaxholm
Vellinge
Vetlanda

91.1
90.0
89.2
89.9
88.6
85.7
94.0
88.3
93.3
93.6
89.3
87.0
88.6
94.2
86.1
90.2
89.9
91.6
92.1
90.5
88.4
89.0
91.1
86.0
89.1
93.5
93.5
88.5
86.7
89.5
86.4
94.4
93.4

79.9
82.2
91.8
83.2
83.0
97.4
78.5
87.0
86.8
85.2
79.3
88.1
86.9
86.1
81.4
82.7
87.3
82.3
84.8
81.7
85.8
90.4
81.7
84.2
83.6
88.7
95.9
83.9
86.9
87.0
94.3
85.5
84.8

94.9
96.6
95.9
95.0
95.5
65.7
96.5
96.0
94.6
97.5
95.7
95.6
85.2
95.0
96.3
95.2
95.7
95.0
96.8
94.9
97.2
95.8
94.9
95.0
95.6
95.2
96.2
98.8
95.5
97.3
95.5
96.2
95.3

58.0
67.3
63.2
72.8
73.0
97.5
58.2
78.9
63.2
61.8
42.1
62.5
62.7
64.4
64.4
61.8
66.3
64.3
62.3
68.6
70.4
70.7
61.3
66.8
70.0
77.1
81.4
65.2
64.2
69.3
74.3
65.6
66.9

97.3
91.9
99.8
97.5
96.0
98.8
88.4
97.4
85.8
97.2
95.7
98.9
97.7
93.9
97.8
96.5
90.4
96.6
97.6
96.7
95.7
99.0
97.7
98.3
92.0
95.8
90.8
97.7
95.4
98.0
95.0
95.3
96.1

98.2
98.8
98.0
97.3
98.5
88.9
99.0
98.5
98.4
98.9
98.6
98.3
98.1
98.9
97.9
98.9
98.4
98.7
97.6
98.9
99.1
98.9
98.5
98.2
98.6
96.8
98.9
98.6
98.0
98.9
98.6
98.1
98.2

86.6
87.8
88.0
89.3
89.1
88.6
85.8
91.0
87.0
89.0
83.5
88.4
88.2
88.7
87.3
97.6
88.0
88.2
88.5
88.5
89.4
90.6
87.5
88.1
88.2
91.2
92.8
88.8
87.8
90.0
90.7
89.2
89.1

95.1
89.2
84.7
92.4
88.8
93.4
90.4
90.5
85.3
93.5
89.3
88.4

91.9
86.2
88.0
90.7
88.0
92.0
87.3
85.3
89.3
94.5
91.6
90.6

95.6
95.1
96.8
94.4
98.0
96.6
97.1
95.7
95.1
96.0
96.2
95.0

74.1
61.3
71.6
71.1
70.1
74.1
71.5
69.1
67.8
82.7
69.7
70.2

91.1
95.6
96.3
96.1
95.6
91.0
97.3
98.6
97.0
90.6
93.3
98.4

98.8
98.1
97.8
99.3
97.9
97.9
98.7
99.2
98.9
98.3
99.1
99.0

91.1
87.6
89.2
90.6
89.7
90.8
90.4
89.7
88.9
92.6
89.9
90.3

82

Municipality

Injuries Tobacco Birth- Breast- Vacci- Abortion Index

weight feeding nation

Vilhelmina
Vimmerby
Vindeln
Vingker
Vrgrda
Vnersborg
Vnns
Vrmd
Vrnamo
Vstervik
Vsters
Vxj
Ydre
Ystad
ml
nge
re
rjng
sele
storp
tvidaberg
lmhult
lvdalen
lvkarleby
lvsbyn
ngelholm
cker
deshg
rebro
rkelljunga
rnskldsvik
stersund
sterker
sthammar
stra Ginge
verkalix
vertorne

88.0
91.4
85.2
89.3
89.7
86.1
85.3
93.6
90.9
86.9
95.1
91.0
89.9
92.2
91.4
85.5
89.1
92.0
88.6
90.8
90.9
93.3
89.0
89.4
89.0
91.7
87.6
81.9
87.7
91.1
87.9
87.5
94.5
95.2
84.5
94.5
93.1

96.2
88.8
89.6
78.5
80.5
82.9
93.7
86.9
89.5
85.6
87.0
92.2
95.1
87.6
83.6
87.3
91.3
84.1
88.4
80.7
90.0
91.3
81.2
73.5
87.0
87.2
90.9
84.5
88.1
75.6
91.9
91.1
87.9
86.1
79.3
86.7
85.5

74.4
95.1
96.5
94.0
95.0
96.1
95.7
96.1
95.7
93.9
95.1
94.9
98.2
94.5
98.3
97.0
96.9
95.3
97.9
95.0
95.0
95.4
98.0
95.0
96.5
95.6
97.4
93.3
95.4
97.8
96.5
95.1
97.6
96.2
98.1
97.8
98.7

92.8
71.7
79.7
69.8
64.7
63.2
63.8
72.0
71.6
75.3
66.8
69.9
67.4
69.2
61.4
66.3
79.2
75.8
61.9
56.3
59.3
71.5
67.2
65.0
65.9
71.9
79.5
59.2
60.2
55.3
69.7
74.9
80.2
68.1
54.3
58.0
71.9

98.7
98.2
94.0
98.8
96.8
98.5
95.3
94.0
97.2
98.8
97.0
97.2
99.4
96.0
96.9
98.9
93.4
98.2
89.2
98.4
96.4
96.9
95.5
89.5
93.9
95.1
91.4
98.7
93.4
97.2
98.1
95.5
88.7
90.8
95.4
90.3
93.7

89.7
98.7
99.0
98.8
99.2
97.9
99.2
97.1
98.7
98.2
98.4
98.0
98.9
98.7
98.7
97.2
98.1
99.1
96.3
98.6
98.3
99.0
98.5
96.6
98.3
98.7
97.4
98.4
98.1
98.5
98.8
98.4
98.3
98.3
98.7
98.6
98.1

88.1
90.6
90.7
88.2
87.7
87.5
88.8
90.0
90.6
89.8
89.9
90.6
91.5
89.7
88.4
88.7
91.3
90.7
87.1
86.6
88.3
91.2
88.2
84.8
88.4
90.0
90.7
86.0
87.2
85.9
90.5
90.4
91.2
89.1
85.0
87.6
90.2

83

Municipality table 2
Individual indicators and childrens health index for the 1990 period (5 indicators). 100
is the highest value and 0 the lowest value. Municipalities in alphabetical order.
Municipality Injuries Tobacco Birtweight

Vaccination

Abortion Index

Ale
Alingss
Alvesta
Aneby
Arboga
Arjeplog
Arvidsjaur
Arvika
Askersund
Avesta
Bengtsfors
Berg
Bjurholm
Bjuv
Boden
Bollebygd
Bollns
Borgholm
Borlnge
Bors
Botkyrka
Boxholm
Bromlla
Brcke
Burlv
Bstad
Dals-Ed
Danderyd
Degerfors
Dorotea
Eda
Eker
Eksj
Emmaboda
Enkping
Eskilstuna
Eslv
Essunga
Fagersta

95.7
94.6
96.0
93.2
94.8
90.0
86.8
89.8
94.5
92.8
94.7
97.0
96.7
96.5
95.4
---94.9
96.8
94.0
94.4
93.0
97.3
94.5
97.0
90.8
95.3
85.7
94.1
94.5
97.1
95.5
90.5
95.9
95.7
94.7
97.6
92.2
98.9
97.1

98.0
98.9
98.5
98.0
98.6
98.4
97.9
98.3
99.3
97.3
97.2
97.9
97.1
98.0
97.9
---98.7
98.7
97.8
98.1
97.7
97.7
98.7
97.4
99.1
98.9
97.7
98.9
98.2
98.3
98.4
98.2
98.9
97.7
98.8
97.8
98.6
98.1
97.8

84

88.5
87.4
92.2
86.4
90.6
92.4
91.6
98.1
94.6
93.4
89.0
89.6
86.3
87.5
88.0
---88.5
90.3
94.8
93.5
90.2
87.4
84.8
90.6
89.8
89.2
90.2
92.1
90.0
89.8
93.1
91.2
86.1
87.8
89.5
86.8
90.8
89.8
89.5

71.9
75.5
79.5
79.3
75.3
66.2
72.0
74.0
74.9
75.3
69.4
74.3
81.0
63.6
71.7
---70.2
78.3
72.7
72.8
71.7
80.1
72.6
70.1
62.9
77.7
80.7
85.2
66.4
74.8
59.3
77.6
79.7
72.6
71.5
69.9
66.6
82.7
68.8

96.3
96.0
96.4
98.5
95.0
96.7
96.2
95.4
95.2
96.3
95.5
96.9
97.9
95.0
95.5
---96.3
96.7
96.3
95.4
94.4
95.3
95.7
96.1
95.3
96.5
95.1
96.1
94.3
95.9
95.9
97.8
94.8
93.8
96.1
94.4
94.3
96.7
94.7

90.1
90.5
92.5
91.1
90.9
88.5
88.9
89.9
91.7
91.0
89.2
91.1
91.8
88.1
89.7
---89.7
92.2
91.1
90.8
89.4
91.6
89.2
90.2
87.6
91.5
89.9
93.3
88.7
91.2
88.4
91.1
91.1
89.5
90.1
89.3
88.5
93.2
89.5

Municipality

Injuries Tobacco Birth- Vacci- Abortion Index

weight nation

Falkenberg
Falkping
Falun
Filipstad
Finspng
Flen
Forshaga
Frgelanda
Gagnef
Gislaved
Gnesta
Gnosj
Gotland
Grums
Grstorp
Gullspng
Gllivare
Gvle
Gteborg
Gtene
Habo
Hagfors
Hallsberg
Hallstahammar
Halmstad
Hammar
Haninge
Haparanda
Heby
Hedemora
Helsingborg
Herrljunga
Hjo
Hofors
Huddinge
Hudiksvall
Hultsfred
Hylte
Hbo
Hllefors
Hrjedalen
Hrnsand
Hrryda
Hssleholm
Hgans
Hgsby

91.4
85.7
93.4
90.6
88.8
91.3
93.7
87.7
93.0
89.3
---88.6
87.0
89.5
87.1
90.4
87.4
88.1
85.2
87.4
89.6
90.3
94.5
94.5
92.8
91.6
90.8
91.8
83.6
94.1
87.6
91.5
88.5
91.2
90.7
82.1
90.6
92.6
91.9
93.2
90.2
88.0
90.7
87.0
89.8
90.2

73.6
74.3
78.8
71.4
73.8
67.4
75.3
74.4
78.1
73.4
---76.0
68.2
65.3
72.7
74.2
69.9
71.2
73.3
72.8
76.0
66.5
75.8
68.4
73.2
77.9
69.7
69.0
71.6
70.0
70.2
73.6
73.9
74.7
71.9
74.2
73.2
72.4
67.8
65.9
72.2
73.2
73.9
72.0
69.3
67.7

95.3
95.9
95.9
95.4
96.8
94.4
96.8
95.5
97.8
96.2
---95.6
95.6
95.9
94.0
98.1
96.0
95.3
95.4
95.2
99.5
94.7
96.4
95.9
95.3
95.6
95.9
94.9
95.5
96.9
95.1
94.8
95.5
95.9
94.7
96.6
95.6
93.0
94.6
96.2
94.5
94.8
96.1
95.5
95.4
96.9

95.3
96.1
94.8
97.9
97.9
97.0
96.4
96.6
80.8
92.3
---96.0
95.6
92.5
94.6
93.3
94.8
98.1
94.9
97.9
97.2
96.4
94.5
97.1
98.0
97.3
93.6
95.5
97.9
93.2
92.6
86.6
91.6
91.6
94.7
92.9
98.3
97.0
92.9
94.5
96.0
93.3
96.2
94.6
90.7
94.7

98.4
98.8
98.0
98.1
98.4
97.8
98.2
96.9
98.2
98.8
---97.9
98.0
98.9
98.2
98.9
96.9
97.6
97.6
99.1
99.2
98.6
98.3
98.6
98.8
97.8
97.2
98.5
99.0
98.2
97.9
99.0
97.4
98.7
97.2
97.2
99.0
99.3
98.4
97.7
98.5
98.5
98.3
99.0
98.4
98.0

90.8
90.2
92.2
90.7
91.1
89.6
92.1
90.2
89.6
90.0
---90.8
88.9
88.4
89.3
91.0
89.0
90.1
89.3
90.5
92.9
89.3
91.9
90.9
91.6
92.0
89.4
90.0
89.5
90.5
88.7
89.1
89.4
90.4
89.8
88.6
91.3
90.8
89.1
89.5
90.3
89.6
91.0
89.6
88.7
89.5

85

Municipality

Injuries Tobacco Birth- Vacci- Abortion Index

weight nation

Hrby
Hr
Jokkmokk
Jrflla
Jnkping
Kalix
Kalmar
Karlsborg
Karlshamn
Karlskoga
Karlskrona
Karlstad
Katrineholm
Kil
Kinda
Kiruna
Klippan
Kramfors
Kristianstad
Kristinehamn
Krokom
Kumla
Kungsbacka
Kungsr
Kunglv
Kvlinge
Kping
Laholm
Landskrona
Lax
Lekeberg
Leksand
Lerum
Lessebo
Liding
Lidkping
Lilla Edet
Lindesberg
Linkping
Ljungby
Ljusdal
Ljusnarsberg
Lomma
Ludvika
Lule
Lund

90.3
90.8
88.4
91.8
87.4
87.6
88.8
90.6
92.5
89.4
91.5
92.2
92.3
91.5
91.1
87.8
89.3
85.2
86.1
87.6
92.3
93.6
90.2
90.4
87.9
89.6
88.9
93.4
89.3
90.3
---92.9
88.6
88.9
91.4
86.9
86.3
91.7
89.3
90.2
88.9
92.3
92.9
96.1
90.4
91.2

86

67.4
74.7
61.6
74.6
78.7
69.5
74.3
75.5
72.7
73.6
76.1
76.8
73.9
74.5
77.8
67.0
67.1
69.4
75.6
69.5
79.9
73.3
78.1
72.6
76.2
67.5
68.8
73.0
62.4
74.3
---82.5
79.4
74.0
82.5
78.8
70.4
74.9
77.7
74.9
70.4
70.0
84.0
67.4
74.1
83.2

96.4
95.2
93.9
96.5
95.6
96.3
94.0
95.8
94.9
95.9
95.0
95.9
95.6
96.4
95.5
95.2
94.4
96.0
95.3
95.1
94.8
96.4
95.1
95.2
96.5
95.6
95.9
95.6
95.0
96.4
---96.3
95.0
96.5
94.5
95.8
95.7
95.9
94.7
95.2
95.4
95.6
96.6
96.0
95.8
95.7

92.4
95.2
91.0
96.1
97.4
94.8
97.6
96.2
93.3
94.5
96.7
97.9
97.7
96.6
97.2
93.7
95.1
92.5
96.2
98.8
96.0
94.5
95.5
99.7
93.1
89.5
98.0
96.7
95.2
94.5
---89.6
94.1
95.4
94.4
95.9
94.3
94.5
95.8
97.1
93.2
94.5
94.6
91.5
94.8
92.5

98.4
98.7
97.9
97.8
98.7
98.3
98.7
99.2
99.2
97.9
98.1
98.0
98.5
97.8
98.0
97.7
98.5
98.0
98.5
97.7
99.1
98.9
98.2
98.5
98.2
97.9
97.9
99.0
97.9
97.5
---99.1
98.7
97.9
98.7
98.9
97.4
98.5
98.5
98.8
98.3
98.8
98.4
97.9
97.4
98.3

89.2
90.9
86.5
91.4
91.6
89.3
90.7
91.5
90.5
90.3
91.5
92.2
91.6
91.4
91.9
88.3
88.9
88.2
90.1
89.7
92.4
91.3
91.4
91.3
90.5
88.0
89.9
91.5
87.9
90.6
---92.1
91.1
90.5
92.3
91.3
88.8
91.1
91.2
91.3
89.2
90.3
93.3
89.8
90.5
92.2

Municipality

Injuries Tobacco Birth- Vacci- Abortion Index

weight nation

Lycksele
Lysekil
Malm
Malung
Mal
Mariestad
Mark
Markaryd
Mellerud
Mjlby
Mora
Motala
Mullsj
Munkedal
Munkfors
Mlndal
Mnsters
Mrbylnga
Nacka
Nora
Norberg
Nordanstig
Nordmaling
Norrkping
Norrtlje
Norsj
Nybro
Nykvarn
Nykping
Nynshamn
Nssj
Ockelbo
Olofstrm
Orsa
Orust
Osby
Oskarshamn
Ovanker
Oxelsund
Pajala
Partille
Perstorp
Pite
Ragunda
Robertsfors
Ronneby

86.2
90.1
87.9
92.2
90.5
89.4
87.6
92.2
91.0
89.9
90.9
85.9
88.7
84.9
92.0
91.1
90.5
86.5
91.5
91.0
88.1
83.6
87.9
92.1
88.5
91.0
88.1
---95.4
90.8
89.9
91.2
93.4
88.3
87.7
84.9
88.1
90.0
92.3
92.6
85.3
87.1
90.2
87.5
84.7
91.2

88.2
74.1
69.1
75.1
81.8
76.6
75.9
84.2
78.0
74.3
77.1
71.8
73.1
69.5
65.2
76.6
75.1
70.5
75.3
74.7
66.5
73.1
77.4
71.9
67.7
78.7
71.2
---73.4
69.8
79.1
71.9
74.6
68.1
75.8
69.4
77.4
77.7
72.7
73.4
77.1
69.6
72.6
65.7
70.6
75.7

97.1
95.5
94.0
96.0
94.9
95.7
95.2
94.4
95.4
95.4
95.3
94.5
95.4
96.1
98.8
96.0
95.2
95.9
95.8
94.2
95.5
95.0
94.8
95.2
95.4
98.9
93.8
---95.4
95.3
96.7
95.1
95.7
94.8
96.9
95.4
93.3
96.4
96.3
93.5
94.5
93.9
95.4
94.6
94.7
95.3

94.6
97.5
91.7
95.1
95.2
98.2
94.1
88.9
91.9
97.8
88.4
98.2
94.7
93.9
98.2
96.6
97.5
97.0
92.9
94.5
92.3
93.3
94.4
94.2
92.6
92.0
95.3
---95.9
91.3
96.8
97.9
90.3
85.4
95.5
90.4
97.9
90.3
98.8
91.4
96.0
97.2
94.6
95.9
95.4
94.3

99.1
99.0
97.2
97.6
98.2
98.2
98.2
98.8
98.1
98.4
98.3
98.4
99.2
98.4
96.9
98.4
99.4
98.6
97.5
98.1
97.5
97.7
98.3
97.9
97.8
98.9
98.8
---98.2
97.7
98.4
96.8
99.6
97.6
98.4
98.1
98.3
98.6
99.4
97.9
98.1
99.3
99.3
98.5
98.9
98.0

93.0
91.2
88.0
91.2
92.1
91.6
90.2
91.7
90.9
91.2
90.0
89.7
90.2
88.6
90.2
91.7
91.5
89.7
90.6
90.5
88.0
88.5
90.6
90.3
88.4
91.9
89.4
---91.6
89.0
92.2
90.6
90.7
86.8
90.8
87.6
91.0
90.6
91.9
89.8
90.2
89.4
90.4
88.4
88.9
90.9

87

Municipality

Injuries Tobacco Birth- Vacci- Abortion Index

weight nation

Rttvik
Sala
Salem
Sandviken
Sigtuna
Simrishamn
Sjbo
Skara
Skellefte
Skinnskatteberg
Skurup
Skvde
Smedjebacken
Sollefte
Sollentuna
Solna
Sorsele
Sotens
Staffanstorp
Stenungsund
Stockholm
Storfors
Storuman
Strngns
Strmstad
Strmsund
Sundbyberg
Sundsvall
Sunne
Surahammar
Svalv
Svedala
Svenljunga
Sffle
Ster
Svsj
Sderhamn
Sderkping
Sdertlje
Slvesborg
Tanum
Tibro
Tidaholm
Tierp
Timr
Tingsryd

92.3
82.0
90.8
90.2
92.0
91.3
88.2
88.7
86.0
92.4
87.8
89.2
93.2
85.3
92.2
91.7
85.4
86.9
90.7
87.9
91.2
91.2
88.5
89.8
94.2
91.5
93.3
87.3
91.4
93.6
88.0
89.7
89.0
91.0
92.9
88.1
87.6
92.6
92.6
90.7
91.7
88.9
89.8
91.7
87.0
91.3

88

76.8
68.1
70.3
68.8
71.2
69.4
70.5
71.7
77.9
65.6
69.6
74.8
73.8
72.1
80.0
73.9
66.2
66.3
72.6
73.2
76.3
65.7
78.7
68.2
78.4
75.7
74.4
72.3
79.2
69.7
64.4
67.9
70.9
75.3
72.9
79.9
66.0
75.3
69.2
67.9
72.3
76.3
76.1
74.6
68.5
67.2

96.4
95.6
95.7
95.4
95.4
95.2
94.8
95.0
95.8
95.7
94.0
95.9
95.5
95.9
95.6
95.2
95.0
96.8
96.4
94.8
95.5
96.9
95.8
94.9
95.8
96.1
96.3
95.4
96.2
96.2
93.5
94.6
94.0
92.3
95.5
95.3
96.0
97.3
95.8
97.0
96.4
97.1
95.8
97.0
94.2
93.2

87.3
96.2
95.3
98.1
88.8
92.0
91.5
95.7
93.5
92.8
95.3
96.5
96.8
90.7
97.1
94.7
97.0
95.5
93.6
94.4
90.8
95.8
96.0
91.5
96.0
96.5
93.8
98.2
95.3
95.0
94.4
93.2
94.9
93.7
94.0
90.9
93.4
94.1
83.6
95.5
91.1
94.0
95.0
94.9
95.0
94.4

98.9
98.7
97.7
98.1
97.2
98.3
98.3
98.3
99.0
98.8
98.6
98.1
97.9
98.8
98.3
97.0
97.8
97.8
98.6
97.8
97.5
98.0
99.0
97.8
98.9
99.0
96.3
98.2
99.1
97.5
98.0
98.3
98.4
98.7
98.9
97.9
97.8
98.2
97.5
99.0
98.0
99.0
98.4
98.5
98.3
98.5

90.3
88.1
90.0
90.1
88.9
89.2
88.7
89.9
90.5
89.0
89.1
90.9
91.4
88.6
92.6
90.5
88.3
88.6
90.4
89.6
90.2
89.5
91.6
88.4
92.7
91.8
90.8
90.3
92.2
90.4
87.7
88.8
89.4
90.2
90.8
90.4
88.2
91.5
87.7
90.0
89.9
91.1
91.0
91.3
88.6
88.9

Municipality

Injuries Tobacco Birth- Vacci- Abortion Index

weight nation

Tjrn
Tomelilla
Torsby
Torss
Tranemo
Trans
Trelleborg
Trollhttan
Trosa
Tyres
Tby
Treboda
Uddevalla
Ulricehamn
Ume
Upplands-Bro
Upplands-Vsby
Uppsala
Uppvidinge
Vadstena
Vaggeryd
Valdemarsvik
Vallentuna
Vansbro
Vara
Varberg
Vaxholm
Vellinge
Vetlanda
Vilhelmina
Vimmerby
Vindeln
Vingker
Vrgrda
Vnersborg
Vnns
Vrmd
Vrnamo
Vstervik
Vsters
Vxj
Ydre
Ystad
ml
nge
re

87.8
89.9
87.1
89.2
94.0
93.0
90.0
85.9
---90.3
92.0
87.6
86.1
94.4
88.0
91.0
91.5
92.6
91.2
87.2
88.9
91.0
90.5
93.7
87.8
88.8
89.4
90.3
89.9
91.2
90.9
88.6
93.2
88.3
86.5
89.8
90.5
87.5
87.4
95.3
92.1
92.2
90.7
90.8
86.2
90.6

77.4
69.4
71.3
79.9
71.6
79.8
66.3
71.9
---73.0
81.2
75.3
76.1
76.1
80.5
69.3
71.4
80.4
73.2
71.3
78.7
70.7
74.3
70.0
73.8
73.4
79.6
75.2
75.2
73.3
74.4
78.0
71.4
75.0
73.0
74.1
71.6
77.1
75.7
75.0
78.5
74.2
73.0
77.2
72.7
76.6

95.5
96.3
95.9
95.7
96.3
96.5
94.1
96.4
---95.5
94.2
96.3
96.0
95.3
95.4
95.1
96.3
96.2
96.4
92.5
93.3
96.5
95.8
96.8
95.6
96.0
91.8
95.5
96.1
96.4
95.3
97.4
96.0
94.4
96.5
93.3
95.1
95.8
95.6
95.4
95.6
97.5
95.4
97.5
94.0
97.6

92.1
91.6
95.8
98.1
95.5
96.0
95.6
95.9
---90.5
92.9
92.9
96.9
94.8
93.1
93.8
91.9
95.0
96.9
98.0
95.1
97.1
90.0
95.2
95.5
97.8
89.2
89.7
94.1
93.5
97.3
92.7
96.2
93.9
96.7
96.1
94.7
92.2
97.8
96.7
95.8
97.0
95.0
93.0
97.5
96.9

99.1
98.4
97.5
99.0
98.1
99.0
98.6
97.4
---97.8
98.7
97.9
98.6
98.7
98.2
97.4
97.8
98.2
98.5
98.6
98.9
97.7
98.2
98.3
99.3
98.0
98.7
98.6
99.1
98.2
98.9
98.3
98.9
99.0
981
98.9
97.9
98.8
98.8
97.9
98.4
98.4
97.8
98.3
98.2
97.6

90.4
89.1
89.5
92.4
91.1
92.9
88.9
89.5
---89.4
91.8
90.0
90.7
91.9
91.0
89.3
89.8
92.4
91.2
89.5
91.0
90.6
89.7
90.8
90.4
90.8
89.7
89.9
90.9
90.5
91.4
91.0
91.1
90.1
90.1
90.4
90.0
90.3
91.1
92.1
92.1
91.9
90.4
91.4
89.7
91.8

89

Municipality

Injuries Tobacco Birth- Vacci- Abortion Index

weight nation

rjng
sele
storp
tvidaberg
lmhult
lvdalen
lvkarleby
lvsbyn
ngelholm
cker
deshg
rebro
rkelljunga
rnskldsvik
stersund
sterker
sthammar
stra Ginge
verkalix
vertorne

93.9
94.4
89.1
89.1
92.5
91.5
86.8
87.7
91.2
91.5
89.2
94.1
90.9
89.4
90.0
90.8
92.2
85.4
93.2
92.9

90

71.9
84.2
61.7
77.3
78.8
76.7
63.5
75.7
72.9
74.4
75.0
77.4
68.6
79.9
78.1
76.2
72.2
72.5
69.4
79.1

93.8
97.8
94.2
95.9
95.3
96.9
95.6
96.3
93.8
96.1
95.0
95.1
96.8
95.9
95.7
96.3
95.9
95.7
92.6
96.0

94.1
97.6
92.9
94.4
92.8
90.5
93.6
90.5
94.3
92.4
92.7
94.5
95.4
97.9
97.2
91.2
95.7
93.2
94.4
92.8

97.7
98.0
98.1
99.1
98.8
96.9
98.5
98.5
99.0
99.0
99.3
98.2
98.6
98.4
98.4
98.8
97.7
98.7
98.5
98.5

90.3
94.4
87.2
91.1
91.6
90.5
87.6
89.7
90.2
90.7
90.2
91.9
90.1
92.3
91.9
90.6
90.7
89.1
89.6
91.9

Appendices
Appendix 1. Technical description of the indicators used
Domain B. Health status and wellbeing

B 1. Indicator
Children hospitalised for injuries by external causes.

Operational definition
Proportion of children 0 17 years receiving inpatient care for external injuries, per
1 000 children.

Background
Sweden has long been a leading country in efforts to prevent accidents among children.
Fatal injuries have decreased dramatically since the 1950s, from 30 per 100 000 children
to 5 per 100 000, despite that the number of children is approximately the same and
that the number of automobiles has risen from 1 million to 4 million (Sylwander 2001).
Nonetheless, external injuries cause the largest proportion, approximately one third, of
mortalities in children and adolescents, primarily in traffic. It is also one of the causes
of mortality that varies most between socioeconomic groups and between boys and
girls (Hjern et al. 2001; SOU 2002; Bremberg 2002).
Injuries can be further reduced by protective and preventive measures, many of them
on the local level. Despite its relative importance, the number of deaths caused by
injuries in the childhood years is low; a total of 94 children and young people under 18
years of age died in 2000 (according to the register for causes of mortality of the
National Board of Health and Welfare). Even when results for several years are pooled,
there is a very small number to be broken down to the municipal level such a small
number that it can hardly be seen as meaningful. However, as external injuries are still
such an important and preventable cause of ill health, injuries caused by external factors
that are treated in hospital can be used instead. These injuries are in principle serious
and they are listed in the patient register of the National Board of Health and Welfare.
In 2000, approximately 20 000 children between 0 and 17 years received hospital care
for accidents and premeditated injuries, i.e. a sufficiently large number of cases to be
able to distribute them on the municipal level.
Data from outpatient care will be available for the entire country in a few years if there
should be a wish in the future to extend the indicator to include less serious injuries as
well. The National Board of Health and Welfare has recently been given the task by the
Government to investigate conditions for a national information system to follow
developments in personal injuries. The Government has also (October 2001) appointed
a delegation to examine and work with questions concerning safety and prevention of
injuries in childrens and adolescents environment (SOU 2000).

91

Technical criteria

Useability The advantage of including all injuries is of course that the number of
cases would then be large enough to make it meaningful to break them down
to the municipal level each year without needing to pool cases into periods of
several years. For use on the national level within the EU, it is suggested to
concentrate on fractures of long bones as an injury indicator as these injuries
are considered to always require hospital care and can hardly be sensitive to
changing treatment policies between countries (Rigby & Khler 2002). By
including all children treated as inpatients for injury diagnoses, we can not of
course exclude the possibility that varying resources and care policies in
different parts of the country will affect the number of cases. However, routine
annual statistics kept by the National Board of Health and Welfare show that
the distribution between county councils is relatively uniform.
Robustness The indicator is well documentated as being sensitive to health
outcome, socioeconomic distribution and preventive efforts.
Understandability The indicator is widely used and is easy to understand.

Data sources
Patient register of the National Board of Health and Welfare.
(includes personal identification number)

Data availability to the municipalities

As the register contains information about the patients home municipality, data can be
reported on the municipal level.

Key references
Bremberg, S. (2002). Social inequities in health in Swedish children and adolescents a review).
National Institute of Public Health, Stockholm
Hjern, A., Ringbck-Weitoft, G. & Andersson R (2001). Sociodemographic risk factors
for home-type injuries in Swedish infants and toddlers. Acta Paediatrica, 90, 61-68
Rigby, M., Khler, L. (2002). Child Health Indicators of Life and Development (CHILD).
European Commission, Luxembourg
Socialstyrelsen (2001b). Folkhlsorapport 2001.(Public Health Report 2001). Socialstyrelsen,
Stockholm
SOU (2002). Sociala skillnader i skador hos barn och ungdom. Rapport frn Barnskerhetsdelegationen. (Social differences in childhood injuries. Report from the Child Safety
Delegation.) Fritzes, Stockholm
Sylwander, L. (2001). Child Accident Prevention. A Swedish success story. In: Protection
Prevention Promotion. Development and future of Child Health Services (ed. G. Norvenius,L.
Khler, G. Wennergren, & J. Johansson). Nordic School of Public Health, Gteborg

92

Domain C. Determinants (Risk and protective factors)

C 1. Indicator
Children with low birthweight

Operational definition
Proportion of newborns with a birthweight below 2 500 g, per 100 newborns

Background
Low birthweight was previously an important cause of high mortality in infancy and
still is in developing countries. Improvements in nutritional status and generally high
living standards have drastically reduced the occurrence of low birthweight in Sweden
and decreased risks among survivors. Somewhat over 4 percent of children born today
have a birthweight below 2 500 g and less than 1 percent a birthweight below 1 500 g.
With modern neonatal care, even the smallest infants survive but as a group run greater
risks for neurological damage, difficulties in school and behavioural disorders. While
these risks have also markedly decreased, a certain elevated risk still remains.
The causes of low birthweight are complex, but there is a clear relation to poorer
socioeconomic conditions in the parents, maternal smoking and stress during
pregnancy (Elmn 1994, Bremberg 2002). These factors can be influenced at least to
some extent on the local level.

Technical criteria

Useability The definition is widely used internationally. Information is collected

from the entire country and is compiled annually by the National Board of
Health and Welfare. Information is available from 1973 and onward. The
quality is high and drop-out low.
Robustness Despite the fact that the consequences of low birthweight have
decreased, it still indicates an elevated risk for different health problems in
childhood and possibly later in life.
Understandability The indicator is easy to understand and use.

Data sources
Medical birth register, the National Board of Health and Welfare

Data availability to the municipalities

The information is based on personal identification numbers and can be broken down
to the municipal level (approximately 4 000 children with a birthweight lower than
2 500 g are born each year).
Children with birthweights under 2 500 g are included in the Swedish National Institute
of Public Healths database on municipal facts for public health planning as three-year
mean values.

Key references
Bremberg, S. (2002). Social inequities in health in Swedish children and adolescents a review).
National Institute of Public Health, Stockholm

93

Elmn, H. (1995). Child health in a Swedish city. Mortality and birthweight as indicators of health
and social inequality. Thesis. Nordic School of Public Health, Gteborg
Socialstyrelsen (2002a). Fakta om mammor, frlossningar och nyfdda barn. Medicinska
fdelseregistret 1973 till 2000. (Facts about mothers, deliveries and newborn infants. Medical
Birth Register 1973-2000). Epidemiologiskt centrum, Stockholm

C 2. Indicator
Children that are breastfed

Operational definition
Proportion of children who are breastfed at 4 months of age, per 100
Children registered at a child health centre

Background
Breastfeeding is the most natural and most often simplest way to give infants food.
Breastmilk has an ideal nutritional content and protects the child against infectious
diseases and possibly also allergies and in the longer run against overweight and type 1
diabetes and guarantees close physical contact between mother and child. Breastfeeding
prevalence is used internationally as an important health indicator. It also reflects
national, regional and local success in efforts to disperse information and promote
health. The most important factors behind a high breastfeeding frequency are
considered to be motivation, social stability and possibility for support in the event of
difficulties with breastfeeding (National Board of Health and Welfare 2002).

Technical criteria

Useability Current Swedish criteria differ from those of WHO used

internationally. For instance exclusively breastfed in Sweden allows small
amounts of other food (tasting portions), while the international definition
allows only supplementary vitamins. Breastfeeding is followed internationally
up to 12 months; in Sweden it has been followed up until now for 6 months.
The international definition is used in the new proposal for EU indicators,
which will probably be introduced in Sweden as well. To limit the amount of
data, the age of 4 months is used here, which is a reasonable compromise
between the necessary (2 months) and the desirable (6 months).
Robustness The indicator is generally known as a base indicator for optimal
development of the child.
Understandability It is somewhat difficult to understand why the Swedish
definitions should differ from those used internationally.

Data sources
Information on breastfeeding is gathered from mothers on a running basis at regular
visits to the child health centre. Via the records at the centres, the data are then
compiled by the head of the Child Health Sevices of the county and submitted to the
National Board of Health and Welfare, which presents annual reports. Results in areas
within the counties are available after special data processing at the Centre for
Epidemiology.

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Data availability to the municipalities

At this time, annual data are regularly presented by the National Board of Health and
Welfare according to health care areas, i.e. county councils, and can be broken down to
the municipal level.

Key references
Socialstyrelsen (2002b). Amning av barn fdda 2000. (Breastfeeding of children born in
2000). Stockholm
Hanson L (2002). Breastfeeding, a complex support system for the offspring. Pediatr
Int, 44, (4), 357-352
WHO (2001). Infant and young child nutrition. Resolution of the World Health Assembly
WHA 54.2. WHO, Geneva
Yngve A, Kylberg E & Sjstrm M (2001). Breastfeeding surveillance in the EU and
EFTA: Recommendations adopted at the Breastfeeding Surveillance Conference.
Breastfeeding Surveillance Conference, Stockholm

C 3. Indicator
Foetal exposure to tobacco

Operational definition
Proportion of children exposed to tobacco in the womb because of mothers smoking
habits, per 100 infants
Registered at a child health centre

Background
ETS (Environmental Tobacco Smoke) or passive smoking is the single most significant
form of air pollution in the indoor environment. It is related to a series of acute and
chronic health effects. In the foetus, it increases the risks for mortality and low
birthweight. In the infant, it increases the risks for breathing difficulties, infections and
allergies (EEA 2002). Information can considerably reduce the occurrence of ETS. In
Sweden, smoking among pregnant women has dropped by 50 percent during the past
10-year period and is now at an average of 12 percent. Pregnant teenage girls smoke
most, nearly one third of this group. Nine percent of mothers of infants smoke and 14
percent of fathers of infants smoke. When children reach the age of 8 months, 11
percent of the mothers and still 14 percent of the fathers smoke (National Board of
Health and Welfare 2002). These levels are low in international comparisons but are
still too high for childrens best. Parents in lower social groups smoke more than
others.

Technical criteria

Useability The definition used internationally is exposure to non-temporary

tobacco smoke i.e. at least each week. Data are collected by specific
questionnaires or routine questions at antenatal clinics/child health centres.
Many different definitions have been used, which make international
comparisons difficult. Smoking habits among pregnant women in Sweden are

95

identified at the first visit to the antenatal clinic and are documented in the
records there.
Robustness The indicator has clearly been shown to be related to health
problems in small children.
Understandability The indicator is easily understood.

Data sources
Medical birth register, National Board of Health and Welfare

Data availability to the municipalities

Information about smoking habits in pregnant women in Sweden is collected at the
antenatal clinics and is documented in the records there, which then follow the child to
the child health centres. The information is collected regularly by the National Board of
Health and Welfare and is presented per health care area but can be broken down to
the municipal level. The register is constructed such that the proportion of children
who are exposed to tobacco smoke is presented, and not the proportion of women
who smoke. Pregnant women who smoke are included in the Swedish National
Institute of Public Healths data base for municipal facts.

Key references
European Environmental Agency & WHO regional Office for Europe (2002).
Children's environmental health: review of the evidence. WHO, Copenhagen
Socialstyrelsen (2002a). Fakta om mammor, frlossningar och nyfdda barn. Medicinska
fdelseregistret 1973 till 2000. (Facts about mothers, deliveries and newborn infants. Medical
Birth Register 1973-2000). Epidemiologiskt centrum, Stockholm
Socialstyrelsen (2002c). Rkvanor bland gravida och smbarnsfrldrar (Smoking among pregnant
women and families with small children). Socialstyrelsen. Epidemiologiskt centrum,
Stockholm

C 4. Indicator
Teenage abortions

Operational definition
Proportion of abortions carried out per 1 000 women under 18 years of age

Background
An overall goal in society is that children shall be wanted and for society to take
responsibility for providing information and the means for people to freely and
responsibly plan the births of their children. Both unwanted pregnancies and abortions
imply a form of life crisis for many people. Thus a goal in general work to promote
health among young people is to prevent unwanted pregnancies (Action Plan for the
Prevention of Unwanted Pregnancies, 2001). On the other hand, it is not certain that a
pregnancy that is initially experienced as unwanted actually results in an unwanted child.
Up to 15 percent of women who early in their pregnancies wanted to abort changed
their minds and gave birth (Trost, 1984). In practice, it is difficult to differentiate
between wanted and unwanted pregnancies, and to document the effects of preventive

96

measures it is necessary to rely on factors that are related to unwanted pregnancies, e.g.
abortions. Swedish abortion policy has as its goal in part to decrease the number of
unwanted pregnancies and in part to ensure womens right to medically safe abortions
and good psychosocial care (Action Plan for the Prevention of Unwanted Pregnancies,
2001).
Childbirth among teenagers has decreased considerably during the latest decades and
now represents less than 5 percent of all women who give birth. Until 1995, the
number of abortions also decreased but has since increased for seven straight years,
altogether by 50 percent, of which the increase was 12 percent in the most recent years
(Abortions in Sweden, 2002). An especially large increase has been noted among 14
year olds. This indicates that preventive efforts have not had the impact they did in
previous years. The earlier successful decrease in teenage abortions has been ascribed to
the broad efforts in instruction in sex and cohabitation in schools and at adolescent
clinics (WHO 1985). There is an uneven distribution of abortions among young women
regionally and socioeconomically (Bremberg, 2002).

Technical criteria

Useability The number of teenage abortions is now over 6 000 per year or
approximately 20 per 1 000 teenage women.
Robustness The indicator shows changes in adolescents values and in their
sexual behaviour, at the same time that it is closely connected to social and
economic conditions in society. Preventive and health-promoting efforts,
especially on the municipal level, have been judged to be successful.
Understandability The indicator is easy to understand and to manage.

Data sources
National Board of Health and Welfare, Centre for Epidemiology

Data availability to the municipalities

The data are included in the Swedish National Institute of Public Healths municipal
base facts for public health planning as five-year mean values in the municipalities.

Key references
Socialstyrelsen (2002d). Aborter i Sverige 2002, januari - juni. (Abortions in Sweden 2002,
January-June). Epidemiologiskt centrum, Stockholm
Trost, A.-C. (1984). Abort och psykiska besvr. (Abortion and mental problems) International
Library, Vsters

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C 5. Indicator
Proportion of vaccinated children

Operational definition
Proportion of children who at the age of 2 years have completed the vaccination
programme for measles, mumps and rubella (MPR), per 100 children in that age group

Background
The significance of focal or mass immunity to prevent and limit epidemics of childhood
diseases is well known and has recently been demonstrated by breakouts of measles in
areas with children who have not been vaccinated in Great Britain and Holland
(Hanratty et al. 2000; van den Hof et al. 2000). Concern has grown in Sweden that the
decreasing tendency among parents to vaccinate their children will lead to poorer focal
immunity and epidemic breakouts (Norrby 1999; Vaccination of children,
Smittsskyddsinstitutet 2001; Olin 2002, Mass immunity is lacking in half our
municipalities 2002). This is considered to be able to take place when fewer than 90
percent of the population in question is vaccinated.
Vaccination is one of the most powerful and cost effective forms of primary prevention
(Vaccination of children 2001). The responsibility for vaccinations rests with the health
care organisations, primarily the child health centres, and information efforts on the
municipal level can be successful.

Technical criteria

Useabillity The MPR vaccination is the most important vaccine in early

childhood and gives a good picture of the level of protection against serious
infectious diseases and at the same time a picture of parents trust in societys
care for its citizens.
Robustness A level of vaccination of less than 90 percent of the population in
question is considered to pose risks for epidemics or endemics.

Data sources
Information on individual vaccinations is registered at local child health centres.
Aggregated data that can be broken down to the municipal level exist at the county
councils child health care units and at the Swedish Institute for Infectious Disease
Control.

Data availability to the municipalities

Data are normally reported per health care area but are also available for each
municipality.

Key references
Hanratty B, Holt T, Duffell E, Patterson W, Ramsay M, White JM, Jin L & P., L.
(2000). UK measles outbreak in non-immune anthroposophic communities: the
implications for the elimination of measles from Europe. Epidemiol Infect, 124, (2), 377383

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Olin, P. (2001). Svenska barns vaccinationsskydd. (Immunisation of Swedish children)

Lkartidningen, 98, 3654-3657
van den Hof S, van den Kerkhof JH, ten Ham PB, van Binnendijk, R., ConynvanSpaendonk, M. & JE, v.S. (2001). Measles epidemic in the Netherlands 1999-2000.
Ned Tijdschr Geneeskd, 145, (25), 29-33

Appendix 2. Technical description of the indicators not used

Domain A. Demographics and socioeconomics

Indicator
Childrens social class

Operational definition
Percent of children who live in households in which the parents belong to social group
(highest among the father and the mother or single parent): 1. Non-professional;
2. Professional; 3. Lower level white-collar; 4. Middle level and higher white-collar; 5.
Self-employed; 6. Farmer; 7. Student.
Distributed according to sex and age groups: 0-4, 5-9, 10-14, 15-17.

Background
Childrens social background is decisive in most areas for their later lives. The familys
social position has been estimated to explain 20-40 percent of childrens ill health in
Sweden (Bremberg 2002). Social groups determine families place in the social hierarchy
as they combine occupation, education and income with prestige, privileges and power.
This indicator shall describe the child population in each municipality and constitutes a
background variable for later health variables. It is in this report replaced by the poverty
index, used in the first Save the Children report, Child Poverty in Sweden (Salonen
2002).

Technical criteria

Useability The indicator is generally used in this form in national public health
reports, and in similar forms in other national and international reports on
health. However, unemployed persons should be included as a special
category.
The occupational categories are intimately associated with the economic and
social structure. Shifts in the relative size and significance of occupational
groups can thus make comparisons over time difficult.
Robustness The indicator is well documented to be strongly discriminatory for
health outcome.
Understandability The indicator is widely used and easy to understand.

Data sources
Statistics Sweden

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Data availability to the municipalities

The indicator is a part of standard statistics, even on the municipal level.

Key references
Bremberg, S. (1999). Bttre hlsa fr barn och ungdom. (Improved health for children and
adolescents). Folkhlsoinstitutet, Stockholm
Bremberg, S. (2002). Social inequities in health in Swedish children and adolescents a
review). National Institute of Public Health, Stockholm
Socialstyrelsen (2001b). Folkhlsorapport 2001. (Public Health Report 2001). Socialstyrelsen,
Stockholm

Indicator
Parents education

Operational definition
Percent of children who live in families with education levels (highest of the father and
the mother or single parent): low education (maximum of compulsory school); medium
level education (upper secondary school or less than 3 years of education past upper
secondary school); high education (3 years or more education past upper secondary
school or post-graduate education).
Distributed according to sex and age groups: 0-4, 5-9, 10-14, 15-17.

Background
Parents education, particularly mothers education, has been shown to be a reliable
predictor of childrens health and is frequently used both nationally and internationally.
The education level affects not only childrens health status of a physical, mental and
social nature but also the utilisation of care. It is applicable also for parents not
participating in the labour market. The indicator is especially robust for marginalised
children. It is in this report replaced by the poverty index, used in the first Save the
Children report Child Poverty in Sweden (Salonen 2002).

Technical criteria

Useability The indicator is generally used, in this form in national public health
reports, and in similar forms in other national and international reports on
health.
Robustness The indicator is well documented as a strongly discriminating factor
for health outcome.
Understandability The indicator is widely used and easy to understand.

Data sources
Statistics Sweden

Data availability to the municipalities

The indicator is included in standard statistics, even on the municipal level.

100

Key reference
Socialstyrelsen (2001b). Folkhlsorapport 2001. (Public Health Report 2001). Socialstyrelsen,
Stockholm

Indicator
Childrens family structure

Operational definition
Percentage of children who live families with only one parent or guardian, male and
female and total, and percentage of children who live in families with co-existing
parents, in age groups: 0-4, 5-9, 10-14, 15-17

Background
Although there seem to be considerably smaller differences between children in
families with one or two parents in Sweden than are reported in other parts of the
world, there is still sufficient evidence that children who live in families with only one
parent are more vulnerable than other children, both economically, socially and
culturally. Many studies show a greater burden among these children, resulting in
mental disorders and psychosomatic complaints.
This indicator shall describe the child population in each municipality and constitute a
background variable for later health variables. It is in this report replaced by the poverty
index, used in the first Save the Children report Child Poverty in Sweden (Salonen
2002).

Technical criteria

Useability The indicator is generally used, in this form in national public health
reports, and in similar forms in other national and international reports on
health.
Robustness The indicator is well documented to be strongly discriminatory for
health outcome.
Understandability The indicator is widely used and easy to understand.

Data sources
Statistics Sweden

Data availability to the municipalities

The indicator is included in standard statistics, even on the municipal level.

Key references
Berntsson, L. (2000). Health and well-being of children in the five Nordic countries in 1984 and
1996. Thesis. Nordic School of Public Health, Gteborg
Meltzer, H., Gatward, R., Goodman, R. & Ford, T. (2000). Mental health of children and
adolescents in Great Britain. Office for National Statistics, London
Ringbck Weitoft, G., Hjern, A., Haglund, B. & Rosn, M. (2002). Mortality, severe
morbidity and injury among children of lone parents in Sweden. Lancet, 361, 289-285.

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Socialstyrelsen (2001b). Folkhlsorapport 2001. (Public Health Report 2001). Socialstyrelsen,

Stockholm

Indicator
Children of foreign origin

Operational definition
Proportion of children born outside the country according to area: 1. the Nordic
countries; 2. Europe, outside the Nordic countries; 3. other. Girls and boys and total,
per 100 children in the municipality, distributed according to age groups: 0-4, 5-9, 1014, 15-17

Background
In Sweden at this time approximately 6 percent of children were born outside the
country and a further 18 percent have at least one immigrant parent. Thus, together,
one fourth of children in the country have a foreign background, although there are
large regional differences. A large number of scientific studies and other surveys have
shown that these children overall have poorer health, poorer social roots and poorer
resources. Children seeking asylum and children who reside illegally in the country are
particularly at risk (Hjern et al. 1997, 1998). The indicator is in this report replaced by
the poverty index, used in the first Save the Children report Child Poverty in Sweden
(Salonen 2002).

Technical criteria

Useability The indicator is generally used, in this form in the 2001 Public Health
Report, and in similar forms in other national and international reports and
scientific studies of health.
Robustness The indicator is well documented to be a strongly discriminatory
factor for general health outcome.
Understandability The indicator is widely used and is easy to understand.

Data sources
Statistics Sweden

Data availability to the municipalities

The indicator is included in standard statistics, even on the municipal level.

Key references
Hjern, A., Allebeck, P. (1997). Health examinations and health services for asylum
seekers in Sweden. Scandinavian Journal of Social Medicine, 25, 207-209.
Hjern, A., Angel, B. & Jeppson, O. (1998). Political violence, family stress and mental
health of refugee children in exile. Scandinavian Journal of Social Medicine, 26, 18-25.
SOU (2001b). Barns och ungdomars vlfrd. Antologi. Kommittn Vlfrdsbokslut. (Welfare of
children and young people. An antology). The National Committee of Welfare Balance Sheet
Fritzes, Stockholm.

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Indicator
Children seeking asylum

Operational definition
Proportion of children who have sought asylum, alone or as part of a family, per 100
children in the municipality, boys and girls and total, distributed according to age
groups: 0-4, 5-9, 10-14, 15-17

Background
One of the most important goals of the UN Convention on the Rights of the Child is
to improve treatment and living conditions for children who are at extreme risk for
their health and development. Children in exile have been forced to leave their home
countries, many also owing to military and political violence, and they run a great risk
for physical and mental problems. Up to 40-50 percent of refugee children with nonEuropean backgrounds have been shown to have mental problems (Hjern et al. 1998).
The majority of refugee families have left their social network in their home countries.
Very often, the adults who should support these children have psychological difficulties
themselves. There is great reason for refugee children to be given immediate help when
they come to the new country (Hjern et al. 1998). The indicator is in this report
replaced by the poverty index, used in the first Save the Children report Child Poverty
in Sweden (Salonen 2002).
Refugee children are also a risk population for serious infections, such as tuberculosis,
hepatitis and intestinal parasites. Children without permanent residence permits were
previously excluded from preventive and curative medical care, with the exception of
emergency treatment. This was changed in 2000 and all these children now have full
access to the same care as other children.
Over 400 children from about 50 different countries come to Sweden alone, without
their families. Of all those who sought asylum in 2001 (23 000 individuals), 32 percent
or over 7 000 individuals were under 20 years of age. The largest group among these
were 0-4 years old. Added to this is an unknown number of illegal immigrants and
refugees.
The Swedish Migration Board is responsible for people seeking asylum, even in the case
of children who come to the country alone. However, according to the Social Services
Act, the municipalities are responsible for all people living there, and have a particular
responsibility for children and young people. It is unclear how these different
responsibilities should be interpreted in individual cases. The Government has thus
given several different authorities the task of generally improving the reception of
children seeking asylum and of clarifying the division of responsibility between them
(2002).

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Technical criteria

Useability Information on the number of persons seeking asylum is not

completely reliable, especially in the case of illegal immigrants. While the
number of persons seeking asylum thus does not give a completely correct
picture of the scope of the problem, the indicator reflects at least one of the
most high risk and vulnerable groups in our society. The responsibility of the
municipalities for these children is not clear but work commissioned by the
Government is ongoing to clarify this.
Robustness The indicator focuses on one of the most vulnerable groups in
society, a group that has especially been identified in the Convention on the
Rights of the Child.
Understandability Easy to understand but difficult to document without
provoking objections.

Data sources
National Board of Health and Welfare
Statistics Sweden

Data availability to the municipalities

Personal identification numbers exist and data can in principle be broken down to the
municipal level. The municipalities responsibility is not clear.

Key references
Hjern, A., Angel, B. & Jeppson, O. (1998). Political violence, family stress and mental
health of refugee children in exile. Scandinavian Journal of Social Medicine, 26, 18-25
Hjern, A., Ringbck-Weitoft, G. & Andersson R (2001). Sociodemographic risk factors
for home-type injuries in Swedish infants and toddlers. Acta Paediatrica, 90, 61-68
Socialstyrelsen (2001b). Folkhlsorapport 2001. (Public Health Report 2001). Socialstyrelsen,
Stockholm

Domain B Health status and wellbeing

Indicator
Children with diabetes

Operational definition
Proportion of children with a new diagnosis of diabetes (type 1, insulin dependent).
Distributed among boys and girls and total, and in age groups: 0-4, 5-9 and 10-14 and
total, and according to socioeconomic group

Background
Diabetes has increased strongly in Sweden and more than in most other countries
(although the numbers are highest in Finland and Sardinia).
The frequency has increased an average of over 2 percent per year and even more in
children under 10 years of age. Approximately 600 children are diagnosed in Sweden

104

each year and, despite systematic and intensive treatment, the risks for serious
complications in the long term are greater, particularly for kidney, eye, heart and
nervous system complications. The cause of the increase has not been clarified, but
there is a strong association with the equally large increase in welfare diseases such as
obesity and overweight among children (Dahlquist & Mustonen 2000).
The strong increase, the complex causality and the serious consequences of the disease
make it very important to keep developments under close surveillance.
The indicator is defined in the same way as in the proposal for health indicators for
EUs member states.

Technical criteria

Useability A uniform definition of the diagnosis is used throughout the country

and all children newly diagnosed receive treatment at childrens clinics. Sweden
has had a national diabetes register for children up to 15 years of age since
1977, and the register is based on reports from all paediatric clinics in the
country (this is the reason for the limit of 15 years of age). Professor Gisela
Dahlquist at Ume University is responsible for the register. The quality of the
register has been judged to be good in several evaluations (Dahlquist, personal
communication 2002).
Robustness The indicator is well documented as being significant for childrens
current and future health status.
Understandability The indicator is widely used and easy to understand.

Data sources
Childrens Diabetes Register, Ume University

Data availability to the municipalities

Personal identification numbers exist but the reports from the register are based on
anonymised information and are presented according to region. Detailed studies have
been made of parts of the material down to the parish level and even down to the
individual house level. The entire material is not available on the municipal level, and
the number of new diagnoses is small.
The indicator is most suitable for surveillance on the national level owing to the
relatively limited number of cases. It is excluded here since data are available only for a
limited number of municipalities.

Key references
EURODIAB ACE Study Group (2000). Variation and trends in incidence of childhood
diabetes in Europe. Lancet, 355, 873-876.
Dahlquist, G. & Mustonen, L. (2000). Analysis of 20 years of prospective registration of
childhood onset diabetes - time trends and birth cohort effects. Acta Paediatrica, 89,
1231-1237.
Socialstyrelsen (2001b). Folkhlsorapport 2001. (Public Health Report 2001). Socialstyrelsen,
Stockholm.

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Rigby, M., Khler, L. (2002). Child Health Indicators of Life and Development (CHILD).
European Commission, Luxembourg

Indicator
Children without caries

Operational definition
Proportion of children who are caries free in temporary dentition at the age of 6, per
100 boys and girls and total, and according to socioeconomic group

Background
Childrens dental health has radically improved during the latest decades by systematic
preventive efforts. In 1967 only 17 percent of Swedish 4-year-olds were caries free
(Wendt et al. 1999). Follow-ups done by the National Board of Health and Welfare
show that 83 percent of 3-year-olds were caries free in 1985 and that 94 percent were
caries free in 1999. During the same time, the proportion of caries free 6-year-olds
increased from 45 to 72 percent and the proportion of caries free 12-year-olds from 22
percent to 61 percent (Public Health Report 2001).
Viewed internationally, there are large differences in preventive efforts and diet patterns
(Bolin 1997).
Dental diseases in children are a health problem in themselves, but they are also related
to other health problems, in childhood and later in adulthood.
Dental health status varies between different areas and shows an easily accessible and
clear relationship with socioeconomic conditions.
The good results achieved in childrens dental health are the result of great efforts of a
primarily preventive character. These results are not automatically permanent, however,
but must be maintained and improved with continued preventive measures, particularly
among groups most at risk.

Technical criteria

106

Useability The indicator of freedom from caries, often combined in national and
international studies and reports with DFS-a, is widely used and relatively easy
to apply, even on a base level. (DFS-a means decayed and filled surface in
the approximal surface (contact surface in the dental arch) of permanent teeth.)
To limit the amount of data and simplify calculations, information has been
concentrated to caries free 6-year-olds who have had temporary dentition for a
number of years. Information is collected on a national level by the National
Board of Health and Welfare via the National Dental Service and private
dentists, although not together with personal identification numbers.
Approximately 65 percent of all 6-year-olds are currently reported.
Robustness The indicator is well documented to be discriminatory for dental
health and is strongly associated with socioeconomic status.
Understandability The indicator is widely used and easy to understand.

Data sources
The National Board of Health and Welfare

Data availability to the municipalities

The National Dental Service and certain private dentists have data that in certain cases
are available on the municipal level. In the register of the National Board of Health and
Welfare, information can be presented for groups of municipalities. However, in a few
years time information will be available for individual municipalities (Hans Sundberg
and Agenta Ekman, National Board of Health and Welfare, personal communication).
It is excluded here since data are not now available for all municipalities.

Key references
Bolin A-K (1997). Children's dental health in Europe. An epidemiological investigation
of 5- and 12 year-old children form eight EU countries. Thesis. Swedish Dental Journal,
Suppl, 1-88
Socialstyrelsen (2001b). Folkhlsorapport 2001. (Public Health Report 2001). Socialstyrelsen,
Stockholm
Wendt, L.-K., Hallonsten, A.-L. & Koch, G. (1999). Oral health in pre-school children
living in Sweden. Swedish Dental Journal, 23, 17-25

Indicator
Suicide attempts in children

Operational definition
Incidence of suicide attempts, defined as discharge from hospital with the diagnosis of
suicide attempt, per 100 boys and girls and total, and according to age group 10-17
years and to social group

Background
Sweden has traditionally had a reputation as a country with a high frequency of suicides,
but, after an increase during the 1960s and 1970s, the number of suicides decreased.
Sweden now belongs to a middle group among European countries. However, suicide
is still the most common cause of death among 15-44-year-olds and the second most
common among 15-24-year-olds.
The incidence has been almost unchanged during the past 20 years (NASP 2002).
During the period 1980-1998, 40-50 adolescents in ages up to 19 years took their lives
each year. In the youngest age group, boys and girls under 15 years of age, there was an
average of six suicides per year between 1980 and 1999. Even if the numbers are
pooled in five-year periods, they are too small to be able to be broken down to the
municipal level. Registered suicide attempts are however an important predictor for
later suicide and can thus be used as an indicator. The numbers continue to increase
among young people and are estimated now to be 3 percent among boys and 8 percent
among girls 16-17 years old.

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Several investigations show that 5 percent of teenagers carry out one or more serious
attempts to take their lives during their adolescence (NASP 2002).

Technical criteria

Useability Defined by ICD 10 codes X60 X84, Y87.0. The diagnosis suffers
from some uncertainty; roughly 20 percent are usually counted as uncertain
suicide.Very few cases are treated in hospital for suicide attempts. For the year
2000, for example, 714 children/adolescents were treated for this diagnosis,
and only 192 municipalities had one or more cases; the other municipalities
had no cases. Suicide attempts, or more correctly intentionally self-destructive
actions, have therefore been included in the injury indicator, B1.
Robustness The indicator is considered to reflect the general psychic instability
present during the teenage years and is an important predictor of later
successful suicide.
Understandability The indicator is easy to understand.

Data sources
National Board of Health and Welfares Patient Register
NASP, The National Centre for Suicide Research and Prevention of Mental Ill Health

Data availability to the municipalities

Personal identification numbers exist but the number of cases is too small to be used
alone on the municipal level. Suicide attempts are however included in the indicator
External injuries.

Key references
NASP (2002). Nyhetsbrev. NASP Nationellt centrum fr suicidforskning och prevention
av psykisk ohlsa, (Newsletter. National centre for suicide research). Stockholm
Schmidtke, A. (1996). Attempted suicides in Europe: rates, trends and
sociodemographic characteristics of suicide attempters during the period 1989-1992.
Results of the WHO/Euro Multicentre Study on Parasuicide. Acta Psychiatrica
Scandinavica, 93, (5), 327-338

Indicator
Children with asthma

Operational definition
Prevalence of asthma per 100 boys and girls and total, and in age groups: 0-4, 5-9, 1014, 15-17, and according to socioeconomic group

Background
Asthma and allergies are now the most common chronic illnesses among children and
adolescents. There has been a strong increase in nearly all countries in the West
(Formgren 1998). In Sweden, about 40 percent of schoolchildren have some form of
allergy, and children with asthma account for half of all the patients of physicians in
outpatient care (Public Health Report 2001). The causes of the illness and its increase
are not completely known, but both hereditary and environmental factors are
responsible, probably in a complex interplay.

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Conditions during childhood and the local environment probably play an important
role for the occurrence of the disease. Modern treatment can most often keep the
illness in check, but asthma is still a serious illness with a certain mortality and not
infrequently functional impairments. Occurrence decreases in adulthood but the illness
has begun in many cases in childhood.

Technical criteria

Useability There is no standard definition of the disease and comparisons

between areas and over time are difficult. International attempts at
standardisation have been made but are still not useable (ISAAC 1998). The
National Board of Health and Welfares inpatient register may perhaps be able
to be used, but the reliability of the diagnosis is uncertain. It is thought that
there is considerable underdiagnosis in the register, both in inpatient and
outpatient care (Hasselgren et al. 2001). Several studies are currently being
carried out on the regional level.
Robustness Owing to problems having to do with the definition, it is not certain
what the indicator reflects.
Understandability There are inclarities in definitions.

Data sources
The National Board of Health and Welfares inpatient register
Data availability to the municipalities
The inpatient register of the National Board of Health and Welfare is based on
personal identification numbers and can theoretically be broken down to the municipal
level.The indicator is excluded here because the diagnosis is uncertain and varies
between different clinics and because it is unclear what the indicator reflects.

Key references
Formgren, H. (1998). Allergisjukdomar hos barn och unga. I. Omfattning av allergi och annan
verknslighet. Vetenskaplig sammanstllning. (Allergies in children and youth)
Folkhlsoinstitutet, Stockholm
Hasselgren M, Arne M, Lindahl A, Janson S & Lundbck B (2001). Estimated
prevalence of respiratory symptoms, asthma and chronic obstructive pulmonary disease
realted to detection rate in primary health care. Scandinavian Journal of Primary Health
Care, 19, 54-57.
ISAAC (1998). The International Study of Asthma and Allergies in Childhood.
Worldwide variations in the prevalence of of asthma symptoms. European Respiratory
Journal, 12, 315-335.
Socialstyrelsen (2001b). Folkhlsorapport 2001.(Public Health Report 2001) Socialstyrelsen,
Stockholm.

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Indicator
Obese and overweight children

Operational definition
Proportion of children who have an age and sex standardised Body Mass Index (BMI)
of at least 25 and 30, respectively, measured at the start of school and at 18-19 years of
age (among boys), per 100 children and according to sex and socioeconomic group

Background
Overweight and obesity are associated with a number of health problems of a physical
and mental nature, both in childhood and later in adulthood, e.g. diabetes,
cardiovascular diseases, joint diseases and poorer quality of life (SBU 2002). The
occurrence is rising rapidly all over the world and has become an important public
health problem that requires preventive and treatment efforts. In Sweden, the
proportion of overweight (BMI kg/m2 > 25) boys registering for military duty increased
from 7 to 18 percent between 1971 and 1998 and the proportion of obese boys (BMI >
30) from 1 to 4 percent (National Public Health Report 2001). The increase is greatest
in families with low socioeconomic status.

Technical criteria

Useability Internally used definition with fixed limits. The method shows some
weaknesses among children, however, as it underestimates the degree of
overweight in short children and overestimates the degree of overweight in tall
children (SBU 2002).
Robustness The indicator is well documented to be discriminatory for health
outcome.
Understandability The indicator is widely used, nationally and internationally, and
is easy to understand.

Data sources
National Service Administration
Childrens Health Care
School Health Care

Data availability to the municipalities

Growth data collected regularly from the child health centres and school health services
are not yet available throughout the country. Military registration data exist only for 1819-year-old boys, who furthermore per definition are no longer children.
Several studies on smaller populations are ongoing. The indicator is excluded here
because data collection is incomplete.

Key references
Socialstyrelsen (2001b). Folkhlsorapport 2001. (Public Health Report 2001). Socialstyrelsen,
Stockholm
Rasmussen, F., Johansson, M. & Hansen, H.-O. (1999). Trends in overweight and
obesity among 18 years old males i Sweden between 1971 and 1995. Acta Paediatrica, 88,
431-437

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WHO (1998). Obesity - preventing and managing the global epidemic. Report of a
WHO consultation. WHO, Geneva

Indicator
Children in the care of the municipality

Operational definition
Proportion of children and adolescents for whom interventions have been made by the
municipality one or more times during the year, boys, girls and total, in the age groups
0-12 and 13-17 years, per 1 000 children in corresponding population groups

Background
The social welfare board of the municipality shall act such that children and adolescents
are able to grow up in secure and favourable conditions. If children and adolescents
risk developing in an unfavourable way, the municipality can provide care and
upbringing outside the home, in family homes or homes for care or residence. These
placements can be made with the support of the Social Services Act (voluntary
placement) or with the support of LVU (the law that gives the municipality the right to
place children and adolescents in care outside the home against the childs or guardians
wishes). The municipalities report their interventions to the National Board of Health
and Welfare, which compiles the results on an annual basis. In all of Swedens
municipalities, a total of 16 000 children and adolescents were the object of
interventions in 1998, and the information is already broken down to the municipal
level and calculated per 1 000 children in the population, distributed among the ages 012, 13-17 and 18-20 (Insatser fr barn och unga (Interventions among children and
adolescents) 1999).

Technical criteria

Useability This indicator describes the municipalities interventions and actually

not the health status of the children. It is a process indicator and, as such, is
affected by resources, ambitions and ideologies in the local social welfare
board, and of course by the composition and needs of the population in
question. Placement outside the home is however intended to improve the
childrens upbringing and to prevent harmful development. It can thus be
expected to be significant to the childs health and wellbeing, and it can
therefore be justifiable to include these efforts as an indicator of the
municipalitys support measures for children and adolescents and their families.
Social group is not included in the reporting, but the great majority of
measures have to do with children from families with social and economic
problems.
Robustness Alone, the indicator is probably difficult to interpret but, when put in
relation to other indicators that give information on the municipalitys social,
economic and ethnic structure, it can be valuable. The quality of the data is not
yet completely satisfactory and work is going on to improve it (Insatser fr
barn och unga 1999).
Understandability It is easy to understand but not always easy to interpret.

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Data sources
National Board of Health and Welfare, Social statistics

Data availability to the municipalities

All municipalities report to the National Board of Health and Welfare, which compiles
the results by municipality and age group. The indicator has been excluded because the
quality of the data is questionable and their interpretation unclear.

Key references
Socialstyrelsen (1999). Insatser fr barn och unga. (Contribution towards children and adolescents).
Stockholm
Socialstyrelsen (1999). Socialtjnsten i Sverige 1999. Behov - Insatser - Utveckling. (Social
services in Sweden. Needs Actions Development). Stockholm

Domain C. Determinants (Risk and wellness factors)

Indicator
Childrens and adolescents tobacco smoking

Operational definition
Proportion of children who report that they smoke each week, per 100 boys, girls and
total, at ages 11, 13 and 15 and according to socioeconomic group

Background
Tobacco smoking is a well documented risk factor for many diseases, including lung
cancer and cardiovascular diseases. The earlier an individual starts to smoke, the greater
the risks. Smoking habits are more common among adolescents from lower social
classes and are associated with other unhealthy behaviour such as use of alcohol and
narcotics (SOU 2001b, Bremberg 2002). Young people tend to continue their smoking
habits in adulthood, which makes them a primary target group for marketing
campaigns. These factors also make them an important group in terms of preventive
measures and projects to stop smoking.
Swedish adolescents smoke very little in an international perspective. In fact, Swedish
boys smoke least in Europe (Public Health Report 2001).

Technical criteria

112

Useability The indicator is based on self-reports and is used in different health

questionnaires. It is not included in routine reports in whole populations but is
directed toward representative selections of adolescents, e.g. selected schools
and at registration for military service.
Robustness The indicator has been used nationally and internationally for many
years. It has been evaluated and is judged to give a good picture of actual
conditions (WHO 2000).
Understandability The indicator is easy to understand and to delimit.

Data sources
Swedish Council for Information on Alcohol and other Drugs, CAN
Danielsson M, Marklund U. Skolungdomars hlsovanor (Adolescent schoolchildrens
health habits) 1997/1998. National Institute of Public Health, Stockholm 2001

Data availability to the municipalities

National data are not currently available on the municipal level, but many municipalities
make their own surveys. As of 2000, information on smoking habits has been available
from compulsory military service examinations (90 percent of the countrys 18-19-yearold boys). It is possible to localise these data to the region and the size of the places
where the boys have grown up and to the boys employment and foreign background.
The indicator has been excluded because data are not available on the municipal level.

Key references
Bremberg, S. (2002). Social inequities in health in Swedish children and adolescents a review).
National Institute of Public Health, Stockholm
CAN (2002 a). Drogutvecklingen i Sverige. (Development of drug abuse in Sweden)
Centralfrbundet fr alkohol- och narkotikauppplysning, Stockholm
CAN (2002 b). Skolelevers drogvanor 2002. (Drug abuse among schoolchildren 2002).
Centralfrbundet fr alkohol- och narkotikaupplysning, Stockholm
Rigby, M., Khler, L. (2002). Child Health Indicators of Life and Development (CHILD).
European Commission, Luxembourg
Socialstyrelsen (2001b). Folkhlsorapport 2001. (Public Health Report 2001). Socialstyrelsen,
Stockholm
SOU (2001b). Barns och ungdomars vlfrd. Antologi. Kommittn Vlfrdsbokslut. (Welfare of
children and young people. An antology). The National Committee of Welfare Balance Sheet
Fritzes, Stockholm
WHO (2000c). Health and Health Behaviour among Young People, Copenhagen

Indicator
Childrens and adolescents alcohol habits

Operational definition
Proportion of children in the 9th grade who report intensive consumption of alcohol
some time during a month or more frequently, per 100 boys and girls and total, and
according to socioeconomic group

Background
Alcohol is a risk factor for many health problems of a physical, mental and and social
nature. Consumption is also closely associated with injuries and violent behaviour.
Intensive consumption (intoxicated once a month or more often) is a considerably
larger risk factor than moderate drinking.

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Swedish young people generally consume less alcohol than young people on the
Continent, but they drink great quantities on each occasion (binge drinking),
particularly boys.
Consumption has also increased in recent years (CAN 2002). It is of particular concern
that the number of adolescents treated in hospital for alcohol poisoning increased
dramatically during the 1990s (National Board of Health and Welfare 2003).
Consumption habits that have been laid in adolescent years have a tendency to
continue in adulthood (Pape 1996, Public Health Report 2001).
Frequent use of alcohol is more common among adolescents of lower social class and
is associated with other unhealthy behaviour such as use of tobacco and narcotics
(Childrens and Adolescents Welfare 2001, Bremberg 2002, CAN 2002).
Preventive measures have a better effect if they are started early and in a local context.

Technical criteria

Useability The indicator is based on self-reports and is used in different health

questionnaires. It is not included in routine reports in the entire population but
is oriented toward a selection of adolescents in selected schools and toward
boys registering for military duty.
Robustness The indicator has been used nationally and internationally for many
years. It has been evaluated and judged and is considered to give a good picture
of actual conditions (WHO 2000).
Understandability The indicator is easy to understand and delimit.

Data sources
Swedish National Institute of Public Health
Swedish Council for Information on Alcohol and other Drugs, CAN

Data availability to the municipalities

Information on use of alcohol among schoolchildren and military servicemen is based
on anonymous questionnaires and is not available on the municipal level, although
many municipalities carry out their own surveys. Data from investigations of boys
registering for military service (90 percent of the countrys 18-19-year-olds) can be
localised to the region of residence and place where they have grown up and to boys
employment and immigrant background. The indicator has been excluded because data
are not available on the municipal level.

Key references
Bremberg, S. (2002). Social inequities in health in Swedish children and adolescents a review).
National Institute of Public Health, Stockholm.
CAN (2002 a). Drogutvecklingen i Sverige. (Development of drug abuse in Sweden)
Centralfrbundet fr alkohol- och narkotikauppplysning, Stockholm
CAN (2002 b). Skolelevers drogvanor 2002. (Drug abuse among schoolchildren 2002).
Centralfrbundet fr alkohol- och narkotikaupplysning, Stockholm

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Pape, H. & Hammer, T. (1996). How does young people's alcohol consumption change
during the transition to early adulthood? A longitudinal study of changes at aggregate
and individual level. Addiction, 91, 1345-1357.
Rigby, M., Khler, L. (2002). Child Health Indicators of Life and Development (CHILD).
European Commission, Luxembourg
Socialstyrelsen (2001b). Folkhlsorapport 2001. (Public Health Report 2001). Socialstyrelsen,
Stockholm.
Socialstyrelsen (2003). Folkhlsa och sociala frhllanden 2002. (Public health and social
conditions 2002). Socialstyrelsen, Stockholm.
SOU (2001b). Barns och ungdomars vlfrd. Antologi. Kommittn Vlfrdsbokslut. (Welfare of
children and young people. An antology). The National Committee of Welfare Balance Sheet
Fritzes, Stockholm.
WHO (2000c). Health and Health Behaviour among Young People. Copenhagen

Domain D. Service, support and health policies

Indicator
Safe community

Operational definition
The municipality has been named by the Swedish National Institute of Public Health/
The Rescue Services Agency as a safe community for the year in question.

Background
A number of municipalities have focused on childrens welfare in a common project,
Local Balance Sheet for Welfare (Balance Sheet for Welfare 1999), run by the Swedish
Association of Local Authorities, the Federation of Swedish County Councils and the
Swedish National Institute of Public Health. Work is now going on to develop a
database of municipal base facts as a foundation for public health work, where
attention is given to some areas dealing with children (National Institute of Public
Health, PM May 2002). This base register includes safe community, where the
municipality fulfils six criteria set up by WHO meaning that the municipality works in a
structured way across sectors to prevent injuries in all risk groups. The criteria are now
fulfilled by 14 of the countrys municipalities. The long term goal is that all
municipalities will become safe and secure.
The indicator is based on policy and only indirectly reflects childrens health. Long
term, systematic and coordinated preventive efforts have however been shown to be a
future recipe for reducing injuries in the population, for children and others (Sylwander
2001).

Technical criteria

Useability The indicator has already been developed and is used in a register that
is being constructed for all municipalities. It covers all age groups, thus not

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specifically children, but gives a good picture of the municipalitys efforts to

prevent injuries, which also benefits children, an often high priority group.
Administration, evaluation and follow-up of the register are now being done at
the Rescue Services Agency in cooperation with the Child Safety Delegation.
Robustness A large number of studies have shown that conscious and structured
preventive efforts in the municipality lead to a decreasing number of injuries in
the population. Coordinated, inter-sectoral preventive efforts are a factor
behind Swedens prominent position in injury prevention. The criteria for
achieving the title of safe community are relatively vague and not entirely
easy to define unambiguously, but work is being done to clarify them.
Understandability The criteria for the indicator need to be clarified and specified
to make them easy to understand and be used in the municipalities.

Data sources
Swedish National Institute of Public Healths database
(www.fhi.se/fakta/personskad6.asp)
Rescue Services Agency.

Data availability to the municipalities

Construction of the database is ongoing and the register is managed by the Rescue
Services Agency. At this time (November 2002), 14 municipalities fulfil the criteria. The
indicator has been excluded because the concept is vaguely defined and unclear in
terms of its continuity and because the evidence for a direct relation to childrens health
is weak.

Key references
Folkhlsoinstitutet (1999). Institute of Public Health (1999) Vlfrdsbokslut, (Balance sheet
of welfare). National Institute of Public Health, Stockholm
Karolinska institutet (2002). Safe Communities, Stockholm (www.phs.ki.se/csp)
Sylwander, L. (2001). Child Accident Prevention. A Swedish success story. In: Protection
Prevention Promotion. Development and future of Child Health Services (ed. G. Norvenius, L.
Khler, G. Wennergren, & J. Johansson). Nordic School of Public Health, Gteborg.
Indicators for international Safe Communities, according to WHO - A safe
communicty shall have:
1. An infrastructure based on participation and cooperation, led by an inter-sectoral
group that is responsible for promoting safety in its municipality;
2. A long term, permanent programme covering both sexes and all ages, environments
and situations;
3. A programme directed at high risk groups and environments and a programme to
promote safety in vulnerable groups;
4. A programme that documents the frequency and causes of injuries;
5. A method of evaluation that allows a judgement of its programmes and process and
the effect of changes;
6. Running participation in national and international Safe Community networks)

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Indicator
Allergy-adapted municipality

Operational definition
The municipality has been named an allergy-adapted municipality for the year by the
Swedish National Institute of Public Health.

Background
Allergies are the fastest growing health problem in Sweden and in many other Western
countries. They are currently the most common cause of chronic disease among
children and adolescents. The exact cause of the illness and its increase is not known,
but conditions during childhood and the local environment are probably important.
Work is going on in Local Balance Sheets for Welfare (Balance Sheet for Welfare 1999),
a cooperative project by the Swedish Association of Local Authorities, the Federation
of County Councils and the Swedish National Institute of Public Health, to develop a
database of municipal base facts as a foundation for public health work, where a few
areas are also important for children (Swedish National Institute of Public Health, PM
May 2002) (www.fhi.se/fakta/allergi10.asp). This base register includes allergy-adapted
municipality, which means that the municipality has taken a political decision to work
to prevent allergies, that there is an allergy committee with broad representation and an
action plan for the work. At this time, 38 municipalities fulfil these criteria (www.fhi.se
October 2002). The goal is that all the municipalities in the country will be allergy
adapted.
The indicator is based on policy and reflects childrens health only in an indirect way.
Long term, systematic, coordinated efforts for prevention and protection have however
been judged to be important for the population, for children and others. (Nationella
folkhlsokommitten 2000).

Technical criteria

Useability The indicator has already been defined and is used in a register that is
being constructed for all municipalities. It covers all age groups, that is, not
specifically children, but gives an overview of the municipalitys efforts to
prevent allergies, which will also benefit children.
Robustness Systematic and structured work in the municipality leads to a greater
awareness of allergies and their treatment and is intended to give greater
opportunities for prevention. The criteria are formulated in a vague way,
however, and are open to broad interpretations. There is no evidence as to the
extent to which the work has in fact reduced allergies or their consequences.
Understandability The criteria in the indicator must be clarified and specified in
order to become easy to understand and use in the municipalities.

Data sources
Swedish National Institute of Public Healths database (www.fhi.se/fakta/allergi10.asp)

117

Data availability to the municipalities

Work is ongoing to construct the database. At this time (October2002) 38
municipalities fulfil the criteria. The indicator has been excluded because the criteria are
not clear and the consequences for childrens health are doubtful.

Key references
Folkhlsoinstitutet (1999). Institute of Public Health (1999) Vlfrdsbokslut, (Balance sheet
of welfare) National Institute of Public Health, Stockholm
Nationella folkhlsokommittn (2000). Hlsa p lika villkor- nationella ml fr folkhlsan.
Slutbetnkande. (Health and equity. National goals for the citizens health). Ministry of Health,
Stockholm.

Indicator
Action programme against bullying in schools

Operational definition
Proportion of schoolchildren who attend schools with a written, defined, established
action programme, with follow up, to work against bullying, per 100 of all
schoolchildren

Background
Bullying in schools is a well known risk factor for problems with wellbeing. Children
who are bullied more often consider suicide, have physical and mental disorders and
perform poorly in school. According to a few studies, the frequency of bullying has
remained largely unchanged; 18 percent of boys 11-15 years report that they have been
bullied at least one time and 2-3 percent report that they have been bullied every week.
The frequency among girls is 12 percent and 0-2 percent, respectively. The figures were
the same four years earlier (Public Health Report 2001). Other studies show an
increase. For example, bullying in all the Nordic countries increased between 1984 and
1996, most among children between 7 and 12 years of age, but even among children 26 years of age (Nordhagen 2000). Interestingly enough, it is found that children who
bully other children run a greater risk of being bullied themselves as compared with
children who do not bully. All studies have shown that children who are bullied come
to a greater extent from socially, economically and culturally vulnerable families. Several
studies indicate that children with functional disorders and handicapped children are at
greater risk (Nordhagen 2000; Janson 2001).
The Swedish National Agency for Education, as the national authority is responsible
for this area, has followed developments and identified bullying and other offensive
treatment in schools as a high priority area for countermeasures (Swedish National
Agency for Education 1999, 2000). Well tested and effective measures are available,
both in Sweden and in other countries. A written action programme against bullying is
a first step toward solving the problem and should exist in all schools, according to the
Swedish National Agency for Education.

118

Technical criteria

Useability The indicator has been proposed to be included with the same
definition in the European system for health surveillance of children on the
national level.
Robustness Established, written and evaluated action programmes in a school are
no guarantee that bullying does not take place, but they facilitate the
management of the problem, both for prevention and for intervention. They
also show children and parents that the school takes the problem seriously.
Understandability The indicator is a policy indicator that is easy to understand
and collect.

Data sources
Swedish National Agency for Education

Data availability to the municipalities

The Swedish National Agency for Education follows the development in the
municipalities but comparative data are not yet available in all municipalities.

Key references
Janson, S. (2001). En rapport om kroppslig bestraffning och annan misshandel i Sverige i slutet av
1900-talet.(Physical punishment and other abuse in Sweden at the end of the 1990s). Fritzes,
Stockholm
Nordhagen, R. (2000). Mobbning och mobbare. (Bullying and being bullied)In: Det r
bra men kan bli nnu bttre. En studie av barns hlsa och vlfrd i de fem nordiska lnderna frn
1984 till 1996 (It is well, but could be better. A study of childrens health and weellbeing in the five
Nordic countries from 1984 to 1996) (ed. L. Khler). Nordic School of Public Health,
Gteborg
Skolverket (1999). Nationella kvalitetsgranskningar 1999. (National quality assessments 1999)
Skolverket, Stockholm
Socialstyrelsen (2001a). (Yearbook of health services 2001). Socialstyrelsen, Stockholm

Appendix 3 Final indicators

Domain B Health status and well-being
B1. Proportion of children 0-17 years hospitalised for external injuries
Domain C. Health determinants (Risk- and protective factors)
C1. Proportion of children exposed to tobacco while foetuses
C2. Proportion of children with birthweight under 2 500 g
C3. Proportion of children breastfed at 4 months
C4. Proportion of children vaccinated against morbilli, mumps and rubella (MPR)
C5. Proportion of teenage girls with abortion

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