Child Health Checks, Medical Follow-up and Treatment
Child health checks
“An issue of importance is the validity of the Child Health Checks and, in particular, the extent to which the checks accurately identify disease, risk factors and health conditions present in the children who received checks, and whether these findings can be generalized…..” (Progress report p1).
Indigenous children in the Northern Territory have high rates of ear disease and skin disease and poor oral health. This has been commonly understood for some time. The health checks carried out as a result of the NT Emergency Response, while very successful in raising the profile of the issues within the general community, have done little to add to the sum of knowledge on the problems and their possible solutions.
The Progress report describes the number and type of health conditions identified and consequential referrals made as a result of the Child Health Checks. The Progress report also makes comparisons with other data sources where possible. There is adequate evidence to support the conclusion that the situation is worse than that recorded through the NT Emergency Response Child Health Checks. A few examples from the Progress report:
- The Child Health Checks identified 29% of children as having ear disease, while Morris et al found 91% of children aged 6 to 30 months had some form of middle ear disease (p13).
- The Child Health Checks identified 8% of children aged 10 to 14 years in the Arnhem region had scabies, while the East Arnhem Regional Healthy Skin Project (EARHSP) show that among indigenous children aged 0 – 14 years the prevalence rate was 13%.
- The Child Health Checks identified 6% of children in the Arnhem region aged 0 – 14 years had ringworm, while the EARHSP data indicate that among Indigenous children aged 0 – 14 years in East Arnhem the prevalence was 15%.
This underreporting leads Menzies to question the NT Emergency Response methodology and approach and training, (Child Health Check teams received only “two days of orientation when they arrived in the Northern Territory……”) (Progress report p2) and more importantly, the resulting diagnoses.
Additional evidence is available from the Audit and Best Practice for Chronic Disease (ABCD) project, led by Professor Ross Bailie.
The ABCD project is implementing a continuous quality improvement approach to chronic disease management and preventive health care in primary care services. The project commenced collecting annual data on chronic disease management and preventive services in a sample of primary health care services in remote Indigenous communities in the NT several years prior to the commencement of the emergency response and in other states over the past three years. The project was expanded to include child health services two to three years ago.
The ABCD project conducted audits of health records for 297 children who attended 11 primary health care centres in the NT (four services), Far West New South Wales (six services) and Western Australia (one service) during 2006. All the health records were for children aged between three months and 5 years. The ABCD study aimed to provide data on the Commonwealth Government-funded Indigenous health checks announced in June 2005 and implemented in mid-2006.
Professor Ross Bailie and the project team have recently published an analysis of baseline data about child health2 screening and follow-up of identified problems in the Medical Journal of Australia. The team found that:
- Documented delivery of primary medical services was relatively good, with little or no difference between the NT and other centres.
- Compared with children attending the NSW and WA centres, those attending NT centres were significantly more likely to have a record of growth faltering, underweight, chronic ear disease, anaemia or chronic respiratory disease.
- Documented follow-up of identified medical and social problems was poor for all centres.
The paper concludes that “existing systems are not providing for adequate follow-up of identified medical and social problems for children living in remote Aboriginal communities”, and that “Without effective systems follow-up, screening children for disease and adverse social circumstances will result in little or no benefit.”
A single study is, of course, not conclusive, but the very large difference between the relatively high levels of child health checks and the very low levels of follow-up and treatment certainly bring into question the emphasis on screening in the Emergency Response measures. Full details of the study are available in the published paper (because of copyright restrictions, a copy could not be attached to this submission):
The ABCD project is a source of ongoing data related to performance of child health services for an increasing number of services, with data for between 10 and 20 services dated back to before the NT intervention. The project will therefore be a source of data on before/after comparisons for some services and for ongoing/sustained impact of the intervention or other influences over time. Additional data can be provided on request.
This evidence indicates that the initial emphasis on health screening of Indigenous children resulted in data that was of questionable quality, and was misplaced. The initial emphasis should have been on follow-up and treatment for children with known but neglected health problems and on improving approaches to long term prevention strategies. The existing child health screening program needs to be improved, but this was not the most urgent issue because additional screening would be of little or no benefit without major improvement in follow-up and treatment services.
Medical follow up and treatment
The importance of medical follow up is supported by the statistics provided by the Progress report which indicate that two out three (67%) of children had been provided with one or more referrals. Menzies welcomes the Australian Government “…commit(ment) to providing all follow-up required as a result of the child health checks (and that) The NT Department of Health Community Services and Aboriginal community-controlled health services are being funded for this purpose.” Also that “Planning is also underway to expand primary health-care services to deliver long-term sustainable improvements in the Northern Territory primary health-care system that will assist in closing the gap between Indigenous and non-Indigenous health outcomes in the Territory.” (NT Emergency Response: One Year On p21) However it is to be regretted that follow-up was not part of the initial response.
This is an area of expertise for Menzies, which has a diverse team of experts with considerable experience in Indigenous health research, clinical trials, systematic reviews and evidence-based guidelines; and an established record of translating research into clinical practice and health outcomes.
Prevention
The NT Emergency Response has missed an opportunity to improve best practice with regards to prevention measures, particularly at population level. For example, it is clearly of limited public health benefit for children to be treated for infections or other health problems and then be returned to the same environments where they can be infected again or be exposed to the same initial risk factors for poor health. The approaches to treating children with ear disease and oral health problems detected by child health checks are excellent examples. Although nobody could argue with the importance of providing ear surgery and dental treatment to afflicted children, this is occurring at considerable expense, while the interventions currently planned to prevent further problems are insufficiently developed and resourced. Given the long history of past failures in this area there is an opportunity to trial innovative new approaches, including new schedules of immunisation. In particular, we think a new approach is needed to find solutions to the prevention of ear disease and pneumonia in Indigenous children. Menzies is already investigating some of these possibilities. We have a current vaccine trial investigating the role of maternal pneumococcal vaccination in the prevention of infant ear disease and carriage. We believe the new conjugate pneumococcal vaccines that are currently on the horizon could potentially offer significant benefit. They should urgently be considered, but only in the setting of rigorous monitoring and evaluation. In addition, options for maternal influenza vaccination and infant influenza vaccination could be valuable new initiatives.
Immunisation is perhaps the most effective preventive health strategy available. NT Indigenous children may benefit from a range of new vaccines and new schedules in coming years, but currently we have inadequate information on which to base decisions about which vaccines to use in which schedules, particularly given the difficulties in achieving timeliness of immunisation. We urge the Commonwealth to consider providing supportive infrastructure to the existing immunisation services within the NT to promote improved timeliness of vaccine administration, to standardise outcome assessment at key time points, and to answer critical questions about new vaccines and vaccine schedules. In our view, the evidence based approach provided by controlled clinical trials could be readily adapted to immunisation service delivery. Carefully designed and properly controlled, such an approach could enable the ongoing assessment of the right vaccine and the right vaccine schedule for Indigenous children in order to get the maximum benefit.
2. Ross S Bailie et al. (2008) Delivery of child health services in Indigenous communities: implications for the federal government’s emergency intervention in the Northern Territory. Med J Aust 188 (10): 615-618. http://www.mja.com.au/public/issues/188_10_190508/contents_190508.html.