Terveyspalvelujen arvioinnissa yksi keskeisistä kysymyksistä on ollut palvelujen suuntaaminen: Tulisiko niitä suunnata myös koko väestöön (universaalipalvelut, väestöstrategia) vai olisiko tehokkaampaa suunnata voimavarat riskitekijöiden ja tautien tunnistamiseen ja hallintaan (riski/ongelmasuuntautuneet palvelut).
Nämä kysymykset nousevat ajankohtaisiksi, kun Helsingin yliopistossa tarkastetaan 12.5.2023 väitöstutkimusta. Kirsi Nikander ROUTINE GENERAL HEALTH CHECKS BY SCHOOL PHYSICIANS IN PRIMARY SCHOOLS: NEEDS AND BENEFITS. ”The objective of this thesis was to evaluate the benefts and harms of school physician routine health checks in primary school grades one and fve (at ages seven and eleven years) and to explore whether school physician expertise could be targeted to those children that parents, teachers, or school nurses are concerned about.” ”The concerns remaining after the school nurse health check could be the basis for multidisciplinary evaluation of the most suitable professional/professionals to provide help instead of all children and families meeting a physician.” ”In my opinion, the law change should be implemented in such a way that physicians are not reduced from school health care. When targeting the amount of school physicians per region, service organisers should take into account the educational level of the guardians, the income level of the families and the immigrant background of the children of each school. The school nurses can strengthen the resources, health and well[1]being of every child and family. The school physician’s assessment should be aimed at those who need it most in all age groups.” Alussa esitetystä enemmän esimerkiksi: Susan B. Rifkin, Gill Walt: Why health improves: Defining the issues concerning ‘comprehensive primary health care’ and ‘selective primary health care’. Social Science & Medicine. Volume 23, Issue 6, 1986, Pages 559-566: ”The purpose of this paper is to explore these questions in depth. It begins by giving the background to the debate, then examines the origins of two concepts which have dominated the field, those of ‘primary health care’ and ‘selective primary health care.’ On this basis it suggests areas of differences in the two concepts and discusses the policy and practical implications of confusing the two approaches. The paper suggests that the differences are firstly who controls the outcome of technological interventions and the perceived time frame in which plans can be carried out.”Yliopiston tiedote
Yliopiston tiedotteessa väitöstutkimuksen tulosten tulkinta on tiivistetty otsikkoon ja täsmennetään näin: ”Helsingin yliopistossa valmistuneessa tuoreessa väitöstutkimuksessa selvitettiin alakouluikäisten määräaikaisten lääkärintarkastusten hyötyjä ja haittoja. Tulosten mukaan määräaikaisista koululääkärintarkastuksista on hyötyä vain osalle oppilaista. Alakouluikäisten lääkärintarkastukset kannattaisi tutkimuksen mukaan kohdentaa oppilaisiin, joista vanhemmilla tai ammattilaisilla on huolta. Näin koululääkäriresurssia vapautuisi todettujen ongelmien hoitoon.” ”Tutkimuksessa kartoitettiin vanhempien, opettajien ja kouluterveydenhoitajien kokemaa huolta lapsista kyselylomakkeilla, jotka he täyttivät kouluterveydenhoitajan tarkastuksen jälkeen. Noin puolesta lapsista oli jokin merkittävä huoli. Kolme suurinta huolta olivat joko kasvu tai fyysinen oire tai molemmat, tunne-elämä ja keskittymisen haasteet.Lääkärit tekivät tarkastuksensa kaikille oppilaille normaalin käytännön mukaisesti tietämättä lomakkeiden sisältöä. Sen jälkeen lääkärit arvioivat tarkastuksen hyötyä tai haittaa ennalta annettujen kriteereiden mukaan. Toimenpiteet, jotka kouluterveydenhoitaja olisi pystynyt hoitamaan tai joiden hoitamatta jättämisestä ei olisi seurannut merkittävää haittaa, luokiteltiin kategoriaan ei hyötyä. ”Lääkärit arvioivat vain noin 40 prosenttia lääkärintarkastuksista hyödyllisiksi, Nikander kertoo.”
Tutkimuksessa tarkasteltiin aikuisten kyselylomakkeisiin kirjaamia huolia ja arvioitiin lääkärintarkastuksen tarvetta niiden perusteella. Kyselylomakkeiden avulla määritelty lääkärintarkastuksen tarve ennusti hyvin koululääkärin arvioimaa hyötyä tarkastukselle. ”Vanhempien ja ammattilaisten täyttämää ennakkokyselyä voisi käyttää tunnistamaan ne lapset, jotka voivat hyötyä lääkärintarkastuksesta ja siten vapauttaa koululääkäriresurssia lääkärin ammattitaitoa vaativien ongelmien selvittelyyn ja hoitoon, Nikander summaa.”
Keskeisistä käsitteistä
Aloittaessani uuden tutkimuksen lukemisen yritän ensiksi löytää otsikosta ja tiivistelmästä sen keskeisimmät käsitteet. Näin etsittynä tässä tutkimuksessa ensimmäiseksi tulee ”routine general health check”. Hakuterminä se tuotti tutkimusraportista kaksi tekstiosumaa: Ensimmäinen metodipohdinnassa sivulla 65: ”The data were collected before the COVID-pandemic with a high participation rate in a normal setting of children’s routine general health checks.” Ja toinen päätelmien yhteydessä sivulla 69:”Parent, teacher, and nurse concerns are valuable predictors of school physician actions in routine general health checks. ”
Google Scholarista sama hakutermi tuotti ilman aikarajausta 61 osumaa. Vuosilta 2019–2023 löytyi 12 osumaa, joista neljä oli väittelijän tutkijaryhmän julkaisuja. Seuraavaksi hain tutkimusraportista osumia ’routine health check” hakutermillä. Tekstiosumia tuli yhdeksän. Huomioni kiinnittyi kolmanteen ja viidenteen tutkimuskysymykseen: ”What actions do school physicians undertake in routine health checks? (Study III)” ” How are parent, teacher, and nurse concerns associated with schoolphysician actions? (Study IV). Nämä tutkimuskysymykset palauttivat mieleen johdannon ensimmäisen kappaleen sivulla 12: ”School health services provide an excellent opportunity to prevent, detect, and treat precursors to future disorders in close collaboration with the educational sector. This may improve both health and education outcomes and be cost benefcial (7–14). Actions that infuence the home, communities and schools are required (15). In 2016, the Lancet commission on adolescent health and wellbeing highlighted that the most effective actions for adolescent health and wellbeing are intersectoral and multicomponent (16)” ”Actions” tuli keskeisten käsitteiden joukkoon. Yksinään se tuotti raportista 66 osumaa useissa eri yhteyksissä. Muutama poiminta: Sivu 14: ”The professionals recommended scientifc research on the effectiveness of school health care actions on children’s health and estimating the unintended efects of school health care actions.”Sivu 20: ”However, the border between secondary and tertiary prevention and treatment of diseases may be difcult to distinguish and cause diferences between municipalities in providing actions related to health checks.”
Sivut 36–37: ”An electronic report for physicians to report all their actions during the health check and their evaluation of the beneft or harm of the health check was developed (Tables 3-5). Patient-reported experience measures (PREMs) for the parent and child to evaluate the beneft or harm of the physician’s health check without previously defned criteria were developed (Table 6)”
Sivu 39: ” The trainings included description of the background and aim of the study, material and methods, and of the specifc actions required from each professional. The main topics of school physician training included reporting school physician actions and the criteria of beneft.”
Sivu 41: ”After each health check the physicians had 5-minutes of extra time to report electronically the details of the actions they undertook during the health check and to evaluate the beneft or harm of the health check according to given criteria.
Sivu 43: ”We categorised the school physician actions into six groups: instructions and/or signifcant discussions, prescriptions, laboratory tests and/or medical imaging, scheduling of follow-up appointments in school health services, referrals to other professionals and referrals to specialised care.”
Sivu 48: ”The physicians conducted actions for 78% of the 1013 children.”
Sivu 54: Physicians considered 52% of the health checks with any action benefcial (quite a lot of beneft or a great deal of beneft) and none of the health checks with no actions benefcial.”
Sivu 54: ”Physicians conducted actions in four fifths of the health checks. Most actions focused on physical health.”
Sivu 55: ”Physicians reported half and parents almost 90% of the health checks with actions benefcial. Both physicians and parents more often estimated the appointments with actions benefcial than the appointments without actions.
Sivu 63: ”The appointments with actions that usually require medical training (prescriptions, laboratory tests and/or medical imaging, and referrals to specialised care) were most strongly associated with physician-evaluated beneft. The physicians estimated none of the health checks without actions benefcial.”
Sivu 65: ”Criteria for physician evaluated beneft of the health check were based on actions that require physician’s expertise.”’
Sivu 68: ”Physicians particularly valued the health checks where actions required their medical competence.”
Sivu 66: Further studies on the long-term efectivenessand cost-efectiveness of school nurse and physician actions are needed
”Benefit” ja ”need” olivat myös keskeisiä käsitteitä. Edellinen tuotti 150 osumaa ja jälkimmäinen 95. Vain muutama poimintaa molemmista:
”Benefit” Sivu 34: ”In Finland, scientifc evidence regarding the benefts of school physicians assessing the health of all children in addition to health checks by school nurses is lacking. Evidence on whether school physician assessments could be ofered as targeted actions in response to the concerns of parents, teachers, and school nurses is needed.”
Sivu 45: ”What is the beneft or harm of the school physician health check according to predetermined criteria used by school physicians and the patient-reported experience measures of parents and children? How is study-questionnaire-assessed need associated with school physician-evaluated beneft of routine health checks? (Study II) 7) How are school physician actions associated with the beneft of the health check assessed by school physicians and parents?
Sivu 43: ”The beneft/harm of the appointment was estimated by the physicians on a seven[1]point Likert scale according to the predetermined criteria shown in Table 2 of Study I. The physicians estimated quite a lot or a great deal of beneft if they considered the physician’s role irreplaceable by nurse.”
Sivu 61: ”Parents evaluated most health checks as benefcial.”
Sivu 62: ”Physicians estimated half of the health checks where they undertook actions benefcial. The physicians may have considered that the school nurse or another professional could have conducted the action as well. ”
Sivu 63: ” The appointments with actions that usually require medical training (prescriptions, laboratory tests and/or medical imaging, and referrals to specialised care) were most strongly associated with physician-evaluated beneft.”
”Need” Sivu 6: ”We assessed the need for a health check by the physician based on the respondents’ concerns using predetermined criteria.”
Sivu 10: ”What is the need for school physician health check? Altogether, 20-25% of the children had no need for a school physician health check.”
Sivu 11: ”How is study-questionnaire-assessed need associated with school physician-evaluated beneft of routine health checks? The need for a health check was associated with physician-evaluated beneft of the health check.”
Sivu 18: ” The health checks aim for 1) strengthening the resources, health and well-being of the child and the whole family, 2) early identifcation of needs for support, 3) ensuring timely provision and organisation of support, and 4) preventing marginalisation and enhancing health equity .”
Sivu 35: ”What is the need for school physician health check based on study questionnaires that assess the concerns of parents, teachers, and school nurses? (Study II)” ”How is study-questionnaire-assessed need associated with school physician-evaluated beneft of routine health checks? (Study II)” Sivut 41–42: We estimated the need for a health check based on the categorisation of study questionnaire responses of parents, teachers, and nurses” ”We also performed an exploratory analysis of the need for a health check by a school physician according to the final wish-question of the study questionnaires. For parents, the question read: “Do you wish to speak with the school doctor about these concerns or some other concern related to the child’s well-being?” For teachers and nurses, the question was: “Do you wish the school doctor to address these concerns or some other concern related to the well-being of the pupil?”
Sivu 47: ”Taking into account all questionnaire responses, 212 children (20.9%) had no need for a health check by a school physician.”
Mitä vielä?
Tämän vaiheen jälkeen tarkistin vielä pari käsitettä, jotka tuntuivat minusta mielenkiintoisilta tämän tutkimuksen yhteydessä:
”Quality of school health” -> kolme tekstiosumaa
”Quality of health check” -> nolla osumaa
”Quality of action” – > nolla osumaa
”Health education” -> viisi tesktiosumaa
”Family” -> 43 osumaa