This document summarizes a presentation on innovations in modern child and adolescent public health. It discusses how child public health began as a social innovation over 100 years ago to address high mortality and health issues. It then outlines several areas where further innovation is needed, including more tailored and preventative approaches. Specific innovations proposed include personalized monitoring tools, e-health platforms to provide health education and early detection, and predictive models to inform targeted prevention strategies. The presentation argues that continued innovation is essential to address ongoing challenges and integrate health and social care for children and adolescents.

1. IMIM Seminar (Hospital del Mar)
Barcelona, Spain
Modern infant, child and adolescent
public health:
effective and tailor- made
Professor Hein Raat, MD, PhD, MBA
h.raat@erasmusmc.nl
Erasmus MC – University Medical center Rotterdam, Dept. of Public Health
Rotterdam, The Netherlands
March 29, 2013

2. Sociale innovation
a. Measures
b. Counseling
c. Prediction
History of child
public health
Relevance of
child health
Conclusions
22
11
33
Innovations in public
health
55
44

3. New in EU policy:
SOCIAL INNOVATION
If at first the idea is not absurd,
then there is no hope for it.
Albert Einstein

4. Europese Union
Sociale innovation needed to solve current (health) problems
AESIR consortium
Social innovation for active citizens (5 EU cities)
CIAO consortium
‘Social marketing’ for healthy weight (EPODE)

5. Social m
eans for social ends
Cross sectors and target groups
New collaborations
All levels

6. Start of child public health:
also SOCIAL INNOVATION
An invasion of armies can be resisted,
but not an idea whose time has come.
Virginia Woolf

7. Prevention-clinic: ‘Consultatiebureau’
1892
‘Milk kitchen & clinic for mothers / babies
(Paris)
1901
First Consultatiebureau
(The Hague: dr. Plantenga)
1918
Also toddlers
Initiative of medical doctors, rich people,
‘for members only’; nurses & doctors

8. School health
1904
First school doctors in Zaandam
and Arnhem
Government initiative
medical, and nursing

9. Public health as social
innovation1875 – 1950
Public health after
epidemiological transition1950 – 1980
New public health1980 – 2012
Epidemy of sedentary behavior and overweight
Epidemy of unintentional injuries
Epidemy of anxiety, depression, behavioral problems
Epidemy of parenting insecurity
Epidemy of social differences in health
… … …
2012 - … …

10. Child public health, until 2 years ago
Youth Health Care (in the Netherlands)
Health protection
Health promotion
Primary prevention
Secondary prevention
Public health
Population-
oriented
Pro-active
Not primarily
cure and care

11. Youth Health Care
Health protection
Health promotion
Primary prevention
Secondary prevention
Public health
System change Youth
Youth care:
1. More prevention & early help help
2. Empowerment youth & parents
3. Less medicalisation
4. Integral approach & tailored care
Municipality (local level):decisions & financing

12. RELEVANCE OF CHILD HEALTH?
The first wealth is health.
Ralph Waldo Emerson, dichter

13. ‘Tracking’ &‘programming’
N ENGL J MED 1997; 337:869-873
Risk (OR) for obesity as a young adult
DSM-IV psychiatric disease as an adult
J. Am. Acad. Child Adolesc. Psychiatry, 2002, 41(2):182–189
Br. Med. J. 2001,322, 949–953
Barker hypothesis:
‘Early origin’ of
cardiovascular disease
‘JONG GELEERD, OUD GEDAAN’

14. 2,9
2,1
0,8
0,8
0
0,5
1
1,5
2
2,5
3
%
Lage opleiding
Middellage opleiding
Middelhoge opleiding
Hoge opleiding
3424
3506
3570 3601
3300
3350
3400
3450
3500
3550
3600
3650
%
Lage opleiding
Middellage opleiding
Middelhoge opleiding
Hoge opleiding
P<0.001;
n=3547
P<0.001;
n=3546
% Mothers with preeclampsia according to
educational level
Birth weight ~ educational level
Silva, 2009
Jansen, 2009
Generation R: source of data for
Policy and practice
De Graaf e.a. NTVG 2008; 2734-40

15. Generation R
van Rossem, 2011
0
5
10
15
20
25
30
35
Low Middle High
Maternal educational level
PercentageofchildrenexceedingAAP
guidelines(<2hrs/day)
Dutch
Mediterranean
Caribbean
P<0.05;
n=3479
Wijtzes e.a., 2012
% 4-year olds> 2 hours per day TV’, Education/Ethnicity mother
PLoS ONE 6(11): e27608

16. Kruizinga Jansen Raat ea PLoSONE 2012:e38762
16% of parents of 2-year olds inRotterdam worry about behavior,emotions and relations of the child;this is reflected in BITSEA scores 23% of parents with a ‘non-Dutch’
child worry;
this is reflected in BITSEA scores

17. WRR, Uitval overbelaste jongeren, 2009
Mieloo Raat Jansen ea, PLoSONE 2012:e36805
Somewhat more parents thanteachers of Rotterdam 5-year oldsreport emotional and behavioralproblems by using the SDQ;Somewhat more aamong boys,compared to girls
%
%
%
%

18. Some reflections, “before we move on to innovation”
 100 years ago, child public health was social innovation
 Effective response to high mortality, health problemas at
schools, and social inequalities in health
 In Europe, child public health is a well-organised profession
 But, many challenges, especially with the current crisis
 Europe and the Netherlands are priviledged
 We have the tools to do good things for society
 Innovations are needed to make the next steps
 Integrated social and health care asks for innovation
 Health style and parenting
 Combat inequalities in growth, development and health

19. Where can we innovate in
child public health?
I am not afraid ... I was born to do this.
Jeanne d’Arc

20. Monitoring Intervention
Child &
parents
Screening & early detection
Growth & development
Parenting
Behavior en emotion
Life style
Vaccination
Education
Counseling
Light care
Referral
Population
Epidemiological profile
School, neighborhood, city
Trends
New threats
Effects of care and policy
Social innovation
Healthy school
Healthy city
Health policy
Youth health care

21. Child   society
Monitoring Intervention
Child &
parents
Screening & early detection
Growth & development
Parenting
Behavior en emotion
Life style
Vaccination
Education
Counseling
Light care
Referral
Population
Epidemiological profile
School, neighborhood, city
Trends
New threats
Effects of care and policy
Social innovation
Healthy school
Healthy city
Health policy
Youth health care Innovative preventive care,
protection and promotion

22. Inspiration & ‘promise for tomorrow’:
To catalyse a new paradigm for health care
Gezondheidszorg
ersonal  tailored
redictive  risk for future problems
not only current problems
reventive & pro-active  primary and secondary prevention
articipative  empowerment of individuals and communities
P
‘Personalized medicine’
P
P
P

23. Tailored child public health:
Personal Predictive Preventive Participative
1. Tailored: Measuring and monitoring of health
2. Tailored: E-health4Uth (‘Feed-back’ & information-for-you)
3. Tailored: Prediction models for risks, not current problems
BMJ 2012;344:e2161

24. Tailored 1
EU-PROMIS FOR THE
MEASUREMENT & MONITORING
to improve something,
first measure it.
UNICEF, 2007

25. NIH PROMIS  EU PROMIS:
Patient Reported Outcomes Measurement Information System
 ‘Told’ by patient
 Adults & children
 Clinic, public health, epidemiology
 Clinimetrics  Consensus  Logistics
 North America, Europa
GeneQol consortium Qual Life Res. 2010;19:1395-403
Individual characteristics
Environmental characteristics
Genetic
factors
Biological
factors
Symptoms Functioning
Health
perception
Quality of
life 

26. Example: measurement of physical functioning
Stap 1. > 100 instruments with 1860 questions (items)
Stap 2. Evaluation & editing  247 items for one domain
Stap 3. Long&short questionnaire, and … tailored questionnaire (internet)
0 50 100
Bank with ALL items of physical functioning
Item
1
Item
2
Item
3
Item
4
Item
5
Item
6
Item
7
Item
8
Item
9
Item
n
I could come out of the bed
I could stand up from the floor myself
I could bicycle
I could run 5 kilometers

27. Example: reliability of a ‘tailored questionnaire’ (CAT)
-2,5 -1,5 -0,5 0,5 1,5 2,5
NO FATIGUE SERIOUS FATIGUE
4-items SF36-Vitality
4-items PROMIS-CAT
13-items FACIT-Fatigue
13-items PROMIS-CAT
RELIABILITY
r=0.90
r=0.95
 PROMIS ‘bank’ with items on Fatigue
 ‘Computer-adaptive test’ (CAT) with 4 and 13 items
 Comparison SF36 (4 fixed items) & FACIT (13 fixed items)
 r=0.95 very high reliability; r=0.90 high reliability

28. National public health office
Themes + Items
Public health care
Youth monitor
Ideal:
Tailored questionnaire
More data, less burden
EU-NIH PROMIS
International library
Clinic and prevention
Child and adult

29. Tailor 2
E-HEALTH4UTH
Complement to personal counseling
A man in a well tailored suit
will always shine brighter.
Michael Kors, designer

30. Morepersonalized
Level of complexity
Massa media campagne
Folder voor doelgroep
E-health4Uth
Consult bij arts/verpleegkundige
E-health4Uth
Online platform for measurement, decision
and advice in child public health
Tailoredhealtheducation
Earlydetection
&Triage
Comparison
Knowledge
Practical tailored advice

31. E-health4Uth ‘BeSAFE’ trial in child public health
Baseline measurement (T0)
Informed consent of 1409 parents; child age 7,5 months
Randomisation
E-health4Uth Safety; cc public
health nurse
Child age 10 months
Intervention group
N = 696 parents
Control group
N = 687 parents
Personal counseling with nurse
Child age 11 months
Usual care (safety information
leaflet, discussed with nurse)
Child age 11 months
Final measurement questionnaire (T1)
N = 643+648 = 1291 parents; child age 17 months

32. E-health4Uth
Significant impact on safety measures regarding the toddler (parent report)
E-health4Uth compared to safety information leaflet
Unsafe no staregate at stairs OR 0,64 95% CI 0.49;0.84
Unsafe household cleaning OR 0,62 95% CI 0.49;0.80
Unsafe unattended in bath, ever OR 0,62 95% CI 0.48;0.83
Unsafe hot fluids near child OR 0,65 95% CI 0.51;0.83
Unsafe cooking OR 0,57 95% CI 0.41;0.78

33. Tailored 3
PREDICTION MODELS
for targeted preventive care
Prediction is very difficult,
especially if it’s about the future.
Niels Bohr, natuurkundige

34. Triage: saves lives and is efficiënt
START:
Geen hulp mogelijk
Transport en hulp met spoed
Transport en hulp kan wachten
Geen hulp nodig
Disasters
Military
medicine
Elke triage
spaart levens
‘Manchester Triage System’
Waiting time coded with
colours for urgency
Bij (telefonische)
aanmelding
Child public health
Triage by assistant
bij PGO 5 jaar
Nieuw: Consultatiebureau
triage baby 6-11 maanden

35. Triage is a decision
Prediction models may support decisions
Use the longitudinal data of patients,
parents, children
a. Develop a model
b. Validate the model
c. Implement the model, improve the model
Janssen, Vergouwe e.a. JCE 2008,76-86
CHEST 2009;135:1557-1563
Heart 2012;98:872-877

36. More than triage:
Prediction models to advice parents, and to plan care
Generation R voor het ontwikkelen en valideren van predictiemodellen:
 Jeugdgezondheidszorg, Kindergeneeskunde, Epidemiologie, Besliskunde
 Valideren, verbeteren, aanpassen voor jeugdgezondheidszorg
 Implementeren in praktijk
Caudri, Wijga e.a. Allergy Clin Immunol. 2009;124:903
PIAMA studie:
Astma predictie score
8 voorspellende factoren
Consultatiebureau:
Kind met piepende ademhaling.
Kans op later astma?

37. So …………..
 ‘Personalized medicine’ applications for child public health
 Tailored monitoring
 E-health support for monitoring, triage and tailored health education
 Prediction models to inform, and to plan tailored prevention pathways
 Investing in tailored public health:
 Creativity, also with budgets
 Cross borders
 Organise the possibilities
This is also social
innovation

38. Conclusion
Child public health started as innovation
2013:
Innovation is still needed for child growth, development and health; and to
handle social inequalities in health
Innovation is also needed to integrate medical and social care for youth
Effectiveness and efficiency of public health care:
a. For population health
b. In the Netherlands to support the current policy goals
What we need is education, research, and especially creativity and absence of
fear, in order to cross borders