Abstract
Objective. To examine demographic and socioeconomic characteristics of parents and children in families not participating in preventive child health examinations at the general practitioner in a society with free and easy access to healthcare. Design. Population-covering register linkage study. Setting. Denmark, 2002–2004. Subjects. Two cohorts comprising all children born in Denmark between 1 July 1998 and 30 June 1999 (n =70 891) and in 2002 (n =65 995), respectively. The demographic and socioeconomic characteristics of these children and the adults living in the same household as these were identified through register linkage. Main outcome measures. Crude and mutually adjusted odds ratios for non-participation in scheduled preventive child health examinations at the GP (age 5 weeks, 5 months, 12 months, 4 years, and 5 years) according to child characteristics (sex, number of hospitalizations, and older siblings) and parental characteristics (age, educational level, attachment to labour market, ethnicity, household income, and number of adults in the household). Results. Children of young and single parents were less likely to receive a preventive child health examination. Increased odds ratios for non-participation were found for children of parents outside the labour market, with low educational level, and especially for the combination of these. Non-participation increased with decreasing household income and with the number of older siblings. Conclusion. Despite the fact that Denmark has free and easy access to the GP, the utilization of preventive child health examinations is lower among the more deprived part of the population.
In Denmark, all children are offered free preventive child health examinations at the GP when they are 5 weeks, 5 and 12 months, and 2, 3, 4, and 5 years old Citation[1]. According to the guidelines from the Danish National Board of Health, the examinations ought to focus on the discovery of illnesses, psychosocial and behavioural problems along with prevention of accidents Citation[1]. Some studies have found that such examinations might be important to the health and well-being of children Citation[2], Citation[3] and in a small Danish qualitative study from 1979 the examinations were found to be essential in the discovery of risk factors of morbidity and in early diagnosis Citation[4]. However, the actual effect has been difficult to evaluate Citation[2], Citation[5]. Even though the examinations are without charge, not all children participate. If they are important for child health, there is a risk that children who do not participate will develop poor health compared with the children who do participate.
Even though preventive child health examinations might be important to the health of the child, not all children do participate in them.
Pronounced social inequality in the use of child health examinations exists in Denmark despite the fact that they are offered free of charge.
Important risk factors for non-participation include household income, the parent's occupational and educational level as well as the number of older biological siblings.
Studies have found that participation is associated with demographic and socioeconomic status. The Danish study from 1979 indicated that children of less privileged families had a lower participation rate than children of more privileged families Citation[4]. Studies from other countries have found associations between non-participation and number of older siblings Citation[6–8], health problems Citation[6], Citation[9], Citation[10], low parental educational status Citation[6], Citation[9–11], single parenthood Citation[8], Citation[11], Citation[12], ethnicity Citation[10], Citation[11], Citation[13] and the age of the parents Citation[8], Citation[10], Citation[11] as well as household income Citation[9], Citation[11], respectively. However, other studies found no association between non-participation and the child's health problems Citation[8], household income Citation[14], parental education Citation[8], and occupational status Citation[9] along with ethnicity Citation[8], respectively.
The Danish study is more than 25 years old and the other studies referred to were undertaken in countries other than Denmark. Because of different ways of organizing the examinations and a probability that conditions affecting use may have changed during the last 25 years, the same socioeconomic pattern might not be found today.
The purpose of this study is to examine whether children not participating in the child health examinations and the parents of these children possess socioeconomic and demographic characteristics that differentiate them from other children and parents. The 5-week, 5-month, 12-month, 4-year, and 5-year examinations are included in the present study.
Material and methods
This study was based on data from registers in Statistics Denmark that hold information on health, use of healthcare, and demographic and socioeconomic data on all individuals in the Danish population, using the Personal Identification Number.
We identified two cohorts as the study population. One cohort comprised all children born between 1 July 1998 and 30 June 1999. These children were offered their 4-year and 5-year examinations between 2002 and 2004. The other cohort consisted of all children born in the year 2002. These children were offered their 5-week, 5-month, and 12-month examinations in the same period. After exclusion of children who died during the first year of life or immigrated during the period 2002–2004, the cohorts consisted of 67 191 and 63 648 children.
Approximately 5% of the children were excluded because they were lacking information on at least one variable.
Information concerning the children's participation in examinations was accessible in the Register of Health Insurance Statistics. Parents were defined as the adults living in the same household as the child. These adults were traced in the Integrated Database for Labour Market Research (IDA), where information was obtained on household income, educational and occupational status, ethnicity, and number of adults in the household. Information on the parents’ age was found in the Register of Population Statistics. Data on child's sex, birthday, and number of older biological siblings was retrieved from the Fertility Database. The Register of hospitalization contained information about the child's number of hospitalizations.
The data on socioeconomic and demographic information were registered as of 1 January each year. We extracted the information for the 12-month, 4-year, and 5-year examinations no more than 6 months from the expected date of the examination. This was the date when the examination would have taken place if the guidelines from the Danish National Board of Health were followed. Due to registry technical reasons we extracted the sociodemographic information for the 5-week and 5-month examinations on 1 January 2003. Age of the parents was determined as the age at date of birth of the child. The child's number of hospitalizations was extracted in the year prior to the expected date of the health examination, except for the earliest examinations where it was extracted in the end of the year when the child was born. The number of hospitalizations was an indication of the health status. Due to collinearity, parental educational and occupational status were combined into one variable with four categories. Occupational status was dichotomized as “in job” or “no job”. The last group comprised students, the unemployed, and individuals outside the workforce. The educational status was divided into “basic education” and “more than basic education”. The “basic education” group consisted of parents with no more than a high school exam and no vocational training.
Household income was weighted on the basis of the numbers of individuals living in the household. Ethnicity was categorized by citizenship and place of birth and the categories of immigrants were defined on the basis of a definition from the UN Citation[15].
Odds ratios for non-participation were calculated using logistic regression analyses in SAS version 9.1. We estimated the association between each of the covariates and non-participation, and then calculated mutually adjusted odds ratios for non-participation.
Results
The participation rates in the examinations were: 94% (5-week), 93% (5-month), 93% (12-month), 77% (4-year), and 83% (5-year). In the univariate analyses we found that non-participating children had been hospitalized more, lived more often with a single parent and more often had older biological siblings compared with participating children. This was also the case for children with parents who were immigrants and descendants of immigrants along with children of younger (<25 years) and older (>34 years) parents. Increased crude odds ratios were found for children of parents with basic education and those outside the workforce along with a household income below the 50% percentile. Results for the 5-month and 4-year examinations are given in , but similar results applied to the 5-week, 12-month, and 5-year examinations.
Table I. Participation rate and crude OR for preventive child health examinations at the GP according to socioeconomic and demographic characteristics, Denmark 2002–2004.
In the multivariate analyses () we found that families with a household income below the 25% percentile had an increased risk of non-participation, and that this risk increased with decreasing income. We found increased odds ratios for non-participation for children of parents outside the labour market and with basic education and especially for the combination of these. In general, the contrasts were larger for the variables concerning the mother. Compared with children of Danish mothers, children of mothers who were immigrants from the developed countries had an increased risk of non-participation in the 5-week, 4-year, and 5-year examinations. Children of immigrants from less developed countries only had an increased risk of non-participation in the 4-year examination (1.19 (1.07 to 1.32)) whereas the risk was decreased in the 12-month examination (0.80 (0.67 to 0.96)). In contrast to the univariate analyses, the multivariate analyses showed that in general the ethnicity of the father was not associated with non-participation. Overall, children of single parents had an increased risk of non-participation compared with children living with two adults. The risk of non-participation also increased with the number of older siblings. In the later examinations children of parents below the age of 25 had an increased risk of non-participation compared with children of parents aged between 25 and 34 years. The risk of non-participation also increased with the number of hospitalizations.
Table II. Adjusted OR* for non-participation in five preventive child health examinations at the GP according to demographic and socioeconomic characteristics, Denmark 2002–2004.
Discussion
In Denmark, preventive child health examinations are free of charge. Despite this, socioeconomic and demographic characteristics, such as parents being young, outside the labour market, having a low educational level, and a household income below the 25% percentile along with children having older siblings increased the risk of non-participation.
This study is the largest population-covering study undertaken of non-participants in preventive child health examinations, and it includes information on both the mother and the father. The data from the registers of Statistics Denmark are considered complete and valid. In addition, the study is based on recent data about all children born in Denmark during a period of two years.
A sensitivity analysis showed that children excluded according to the criteria mentioned earlier possessed the characteristics that were associated with non-participation in the multivariate analyses. This indicates that the estimates for the entire cohort are greater than those reported in our study.
This and other studies have found that the risk of non-participation decreased with the length of the mother's education Citation[6], Citation[9–11]. An American study has found that education was not associated with non-participation Citation[8]; however, the study population mainly consisted of well-educated parents.
In contrast to our study, a Spanish study showed that the employment status of the mother was not associated with non-participation Citation[9]. A reason for the conflicting results might be that in the Spanish study the category “no job” mostly consisted of housewives, whereas it mainly consisted of unemployed persons in our study.
In line with our study an American and a Spanish study showed that low-income families participated less in the examinations Citation[9–11]. An American study found that household income was not associated with non-participation Citation[14]. A dropout rate of 40% might, however, have resulted in a non-representative study population.
The univariate analysis showed that children of immigrants from less developed countries participated less than children of Danes. However, in the multivariate analysis, children of these immigrants had the same participation rate as children of Danes. It must therefore be the socioeconomic characteristics rather than the immigration status that cause this difference in participation rate.
In line with our study American studies have found that non-participation increased with the number of older biological siblings Citation[6–8]. Our finding that participation decreased with increasing numbers of hospitalizations contrasts with other studies Citation[6], Citation[8], Citation[9]. This might be due to different ways of assessing the health status of the child or a consequence of differences in the healthcare system.
Possible explanations of the association between socioeconomic status and participation could be that parents with an education and a high income might have more flexible jobs that make it easier for them to take their child to the examinations. They might have more knowledge of the offers in the healthcare systems or a more positive attitude towards the use of preventive services. Moreover, it is possible that parents with high socioeconomic status profit more from these examinations. An American study found that compared with high-income families, low-income families more often felt that the GP did not listen to them Citation[14] and another study found that parents with a short education might understand the doctor's explanation less than highly educated families Citation[16]. However, it is also possible that parents of high socioeconomic status are more conscious about their utilisation of the healthcare system than parents with low socioeconomic status and only accept offers they regard as useful. Even though it is difficult to evaluate the effect of the examinations, this may indicate that they are considered useful by parents of high socioeconomic status. If so, it is even more important to ensure that the examinations are useful to less privileged families and that all children gain the benefits from them.
The participation rate was lower in the 4-year and 5-year examinations than in the examinations offered in infancy, and the association between non-participation and socioeconomic and demographic factors was stronger in the 4-year and 5-year examinations than in the other examinations. Hence, the social inequality increases with the age of the child.
Some characteristics were associated with non-participation in all examinations: occupational and educational status, household income, number of older biological siblings, and number of hospitalizations. They are therefore important risk factors for children who are less prone to participate.
Because of the potential beneficial effect of the examinations, it is valuable to raise the participation rate amongst the low socioeconomic families. In order to do this, it is important to investigate the barriers that make these families participate less. Therefore, an evaluation of both GPs’ and participating as well as non-participating families’ attitudes to and experiences with the examinations could be useful.
Ethical approval
According to Danish legislation ethical approval was not required for this study.
Funding
The Danish National Board of Health funded this study. The funding source had no involvement.
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