This is the second progress report to provide findings on health conditions identified and referrals made during Child Health Checks (CHCs) that were undertaken as part of the Northern Territory Emergency Response (NTER) Child Health Check Initiative (CHCI). In addition, for the first time, results from three follow-up CHCI data collections - the Chart Review, Audiology and Dental collection - are provided.
This report provides a preliminary analysis of the data available as at 17 October 2008. The purpose of publishing these data is to describe the extent to which Aboriginal and Torres Strait Islander children who had a CHC as part of the NTER have received the follow-up services they need and to identify emerging issues that require attention. While the data presented here are of sufficient quality and completeness to provide a snapshot of the extent of follow-up as at 17 October 2008, there are caveats made throughout the document that should be noted. These stem from several factors, principally:
- The data collections are new and their validity and reliability are still being established.
- The data are being collected as a by-product of clinical and administrative processes in the health care setting rather than a research process and are not a substitute for data derived from rigorous, scientific research.
- Delays sometimes occur in data transmission to the AIHW, so more services may have been provided as at 17 October than are reported here.
Child Health Check data collection
As of 17 October 2008, an estimated total of 12,263 valid CHCs have been performed through the NTER and Medicare Benefits Scheme (MBS) Item 708 since the implementation commenced on 1 July 2007. Data to monitor and evaluate the CHCI were only collected for children who received a check that was specifically funded through the NTER. There were no MBS data analysed in this report apart from that used to calculate the overall number of checks. The 'coverage', or proportion of the estimated 16,259 children aged 15 years or less living in the prescribed area with a current CHC (NTER and MBS CHCs) for the 12 months to 31 August 2008, is 74% (11,972).
A total of 10,251 CHCs had been entered into the CHC database as at 17 October 2008. A number of these checks, however, belonged to the same child, because children are eligible to have CHCs every 9 months as long as they are aged 15 years or less at the time of the check. To enable a description of the findings from the CHC collection according to the number of children who had various health conditions and referrals, the unit of analyses for the information presented in Chapter 2 is a 'child'. For those children who had undertaken more than one CHC, only their latest CHC was used in order to provide the most up-to-date information on the health conditions and referral status of these children. The information provided in Chapter 2 of this report relates to 8,997 children who had received at least one valid CHC as at 17 October 2008, after excluding 889 children whose information was provided on non-standard CHC forms. This compares with the 7,733 children whose data were analysed in the May 2008 progress report.
Health conditions - key findings
The prevalence of 25 health conditions in children who had CHCs are summarised below.
- Three in four (75% or 6,760) children were identified as living in a household with a smoker.
- Seventy-three per cent (483) of children aged less than 1 year were at risk of sudden infant death syndrome (SIDS) due to bed sharing, while 35% (229) were at risk due to soft sleeping surfaces and loose bedding.
- Forty-three per cent (3,883) of children had at least one type of oral health condition. In particular, 40% (3,618) of children were reported to have untreated caries.
- Thirty-eight per cent (3,406) of children had a reported history of recurrent chest infection.
- One in three (30% or 2,702) children was reported to have ear disease.
- Thirty-one per cent (2,753) of children had at least one type of skin condition. In particular, 10% (895) of children were reported to have skin sores (four or more) and 8% (714) of children had scabies.
- Fifteen per cent (1,387) of children were found to have anaemia.
- Sixteen per cent (1,409) of children were due for immunisations.
In general, there has been little change between the May 2008 progress report and this report in the proportion of children identified with various conditions. This is because an additional 1,264 children are included in the present analyses.
Referrals and treatment
The proportion of children who were referred to each of 21 follow-up health service types is discussed in this report, as well as the proportion of children who received a vaccination during their CHC. Key findings are summarised below.
- Just over two in three (69% or 6,246) children were referred for at least one type of follow-up service.
- Just under two in five (39% or 3,498) children who received a health check required a Primary Health Care clinic follow-up.
- Thirty-five per cent (3,131) of children received a dental referral.
- Fourteen per cent (1,261) of children were given a tympanometry and audiology referral.
- Twelve per cent (1,089) of children were referred to a paediatrician.
- Nine per cent (799) of children were referred to an Ear, Nose and Throat (ENT) specialist.
- Seven per cent (592) of children received a vaccination during their CHC.
The discrepancy between the number of children diagnosed with particular health conditions and the number referred to relevant follow-up services (e.g. 43% (3,883) with oral health problems compared with 35% (3,131) given a dental referral) is most likely explained by the fact that where an existing referral was already in place for the identified problem, a new referral was not made.
In general, there has been little change between the May progress report and this report in the proportion of children referred to various types of follow-up services.
Follow-up: chart review
Follow-up of CHC referrals through existing Primary Health Care (PHC) or specialist services available in the Northern Territory often commenced soon after the checks were completed. The Australian Government provided additional follow-up funding to both Aboriginal Community Controlled Health Organisations (ACCHO) and Department of Health and Families (DHF) service providers and the Chart Review data collection reflects the commencement of this specifically funded follow-up phase by the clinicians providing children with their follow-up care. These chart reviews involved assessment of the health records of children who had received a CHC to ascertain whether the children had the follow-up care that had been recommended during the CHC.
As at 17 October 2008, 4,387 (46%) children who had participated in a health check also had a chart review. The results from the analyses indicate that:
- Eighty-nine per cent (3,911) of children had one or more health conditions with a referral, while 11% did not require follow-up care.
- Of the 3,911 children with a chart review and referral, 33% (1,275) had been seen at least once for all of their health conditions and 52% (667 out of 1,275) of these children required further action at the time of their chart review. Approximately 28% (1,108 out of 3,911) of children had been seen for some of their health conditions with a referral. Of them 84% (930 out of 1,108) needed further action at chart review.
- About 39% (1,528 out of 3,911) of the children with a referral at CHC had not yet been seen for any of their health conditions.
- There were 508 children with a skin condition who had a PHC referral; 89% (450) of these children had been seen at least once at the time of their chart review. Of the 489 children with ear conditions and with a referral to PHC, 86% (421) had been seen at PHC. Over 90% (239) of the 264 children who had a PHC referral for their oral health condition had been seen at least once at the time of their chart review.
- There were 1,319 children with oral health problems who had a referral to a specialist or other service, and 21% (278) of them had been seen at least once by the relevant service at the time of chart review. Approximately 43% (285 out of 671) of children who had a specialist or other service referral for ear problems had been seen by that service, while 50% (76 out of 151) of the children with cardiac and respiratory abnormalities had been seen.
- In terms of specific referrals that children had, 77% (1,601) of the children with a referral to PHC had been seen, while 37% (166) of children with referrals to paediatrician and 21% (284) with a dental referral had been seen. Furthermore, 35% (132) of children with an ENT referral and 44% (201) with a tympanometry and audiology referral had been seen by appropriate services.
- Approximately 21% (784) of children had an initial chart review within 3 months of their CHC, while 42% (1,581) had an initial chart review 9 months or more after their CHC. The variation in elapsed time can partly be explained by the differences in timing when CHC and follow-up services were rolled out into different communities.
Audiological testing is done to assess hearing and is repeated during the course of care provided for children with ear disease to measure change in response to treatment. Audiology is not in itself a therapeutic intervention but part of a larger process of care. It is expected that the need for further action following audiological assessment will be a common occurrence.
As at 17 October 2008, 1,814 unique audiology forms for children within the applicable age range had been received; information from 1,627 of these forms had been entered into the Audiology database. The unit of analysis for the Audiology data collection used throughout this report is a 'child'. The 1,627 forms provide information on the results of audiology checks for 1,323 individual children, and show the following:
- Twenty per cent (328) of children who had been referred for follow-up audiology services during their CHC had received an audiology check.
- Fifty-one per cent (672) of all Indigenous children who had an audiology check were reported to have bilateral or unilateral hearing loss.
- Forty-seven per cent (621) of children had conductive hearing loss, 2% (32) had sensorineural hearing loss and 2% had mixed hearing loss.
- Twenty-three per cent (310) of children had mild hearing loss in the better ear, 10% (134) had moderate hearing loss and less than 1% (6) had severe or profound hearing loss.
- Sixty-eight per cent (899) of children had middle ear conditions, with the most common type being otitis media with effusion (28% (376) of the children who had an audiology check had this type of middle ear condition in at least one ear).
- Sixty-nine per cent (913) of children required further action following the audiology check.
Of those children who had an audiology examination, 68% (898) had also had a CHC while 32% (415) had not had a CHC. The proportion of children with either unilateral or bilateral hearing loss was higher among those who had had a CHC (55% or 490) compared with those who had not (49% or 201).
The CHCs identified oral health problems in 43% (3883) of children and 35% (3131) of children received a dental referral. As at 17 October 2008, dental forms for 1,900 occasions of service had been received by either the AIHW (134 forms) or the NT DHF Child Oral Health Team (1,766 forms). Forms received by this date are analysed in this report.
The NT DHF holds all dental check forms for the checks it has undertaken. The NT DHF provided the AIHW with already tabulated information from 1,766 forms, as it encountered technical difficulties in electronically transferring the unit record data. The AIHW separately analysed data on the 134 dental forms provided to the AIHW by Aboriginal Community Controlled Health Organisations (ACCHOs) and combined this with the tabulated information provided by the NT DHF. As tabulated data received by AIHW could not be linked with the CHC data, it was not possible to use the dental forms received to provide an estimate of how many children who had CHC referrals received follow-up dental care. However, the following observations can be made regarding the dental services provided to children, the problems treated and the proportion of occasions of care (number of dental services received) requiring follow-up:
- A diagnostic component was involved in 74% (1,407) of occasions of care.
- A preventative component was involved in 38% (714) of occasions of care.
- A restorative component was involved in 31% (592) of occasions of care.
- A surgical component was involved in 11% (210) of occasions of care.
- Oral health education was involved in 35% (656) of occasions of care.
- Untreated caries were treated in 34% (650) of occasions of care.
- Treatment of dental hygiene issues (including plaque and calcification) was involved in 14% (264) of occasions of care.
- Further follow-up was required in 47% (898) of occasions of care.
The purpose of the follow-up data collections is to measure the extent to which children who had a CHC have received the follow-up care that they needed.
Data from the Chart Review, Audiology and Dental data collections show that by 17 October 2008, a large volume of follow-up care had been provided, including:
- 77% (1,601) of children with a referral to PHC had been seen at least once;
- There had been 1,627 audiology checks performed on 1,323 children, with 69% (913) requiring further action; and
- 1,900 occasions of dental service delivery provided to 1,529 children 1.
While these dental and audiology services have been provided with specific NTER follow-up service delivery funding, the primary care follow-up has been achieved through a combination of existing PHC services and NTER-specific funding.
The data also show the extent to which follow-up services are still required. Many children (1,528) have yet to be seen for referrals and for those that have been seen, there is a continuing need for follow-up care. In particular, there are a large number of referrals outstanding for more specialised services, such as dental care.
The fact that many of the children (1,597 out of 2,383 or 67%) who have received some follow-up care require further action is due to the chronic nature of many of the conditions being treated. More fundamentally, many ear, skin, physical growth and oral health problems are the result of poor living conditions, poverty, overcrowding and lack of adequate nutrition. While these conditions can be ameliorated through health interventions, their prevention requires change to these broader determinants of health.
Future data collection and evaluation
Child Health Check and follow-up data will continue to be collected until 30 June 2009. It is expected that the final data set on CHCs and follow-up services will be available for analysis from September 2009.
The Department of Health and Ageing will commission an independent evaluation of the CHCI. As part of this, the DoHA and its evaluation partners will be taking advice on the feasibility of conducting an evaluation of the outcomes of the program to determine whether there has been measurable change in the health status of children who received a check and whether this can be attributed to the program.
 This assumes that there is no overlap between children seen by a DHF dental clinician and those seen by a ACCHO dental clinician.