Public health nurses in Finland: a life-course approach to the prevention of noncommunicable diseases: good practice brief

PUBLIC HEALTH NURSES IN FINLAND: A life-course approach to the prevention of noncommunicable diseases GOOD PRACTICE BRIEF Summary Kirsi Grym1, Liesbeth Borgermans2 Motivation In Finland, registered public health nurses manage and deliver high- quality preventive health services throughout a person’s life-course. The Finnish system is exemplary, as an integrated, effective life-course approach to health through its emphasis on prevention and health promotion, interprofessional collaboration and task-shifting from doctors to nurses, while safeguarding the quality of care and achievement of good health outcomes in the Finnish population, including the satisfaction of its citizens. An integrated chain of public health services is delivered through maternal and child health, school health and student health clinics, occupational health and adult and elderly health care facilities. The services offered reflect national life-course-related health goals that are defined for different age groups. The Finnish system is an integrated, effective life-course approach to health facilitated by a large number of public health nurses. A life- course approach to health is used, as social and cognitive skills, habits, coping strategies, attitudes and values acquired in early childhood and adolescence strongly influence the remainder of the life-course, with implications for the risks for noncommunicable diseases (NCDs) and general health. Investment in a life-course approach to health has been shown to have important returns for public health and the economy by addressing the causes, not the consequences, of ill health. 1 Kirsi Grym – PHN, Research Fellow at the Barcelona Office for Health System Strengthening, WHO Regional Office for Europe, Spain 2 Liesbeth Borgermans - Consultant to the Division of Health Systems and Public Health, WHO Regional Office for Europe, Copenhagen, Denmark. Key Messages • Registered public health nurses manage and deliver services throughout the life-course and are front-line workers in health promotion and prevention. • They eff ectively address the prevention of NCDs by off ering comprehensive services, inter- professional collaboration and continuity of care. • Their services refl ect the national life-course-related health goals for diff erent age groups. • Health inequality is addressed by early, targeted support, especially for socioeconomically vulnerable groups. • Government agencies are responsible for the design and evaluation of maternal and child health, and school health services, although municipalities are in charge of the practical arrangements for these services. 1 Table 1. Examples of services provided by public health nurses over the life-course A total of 5200 public health nurses (KT Kuntatyönantajat, 2017) manage and deliver high-quality public health services in municipalities. They are employed in various sectors, including maternal and child health care clinics (neuvola) and school health care services, which are essential parts of the preventive and health promotion services in municipal primary health care. Neuvola services are located mainly in primary health care centres, while school health care is organized in schools. Municipalities are in charge of the practical arrangements of these free, mainly tax-funded services. The Ministry of Social Affairs and Health is responsible for guiding maternal and child and school health services, while the National Institution for Health and Wellfare publishes guidelines, arranges training and compiles data from monitoring. The National Public Health and Safety Authority (Valvira) and regional agencies oversee the services in a nationwide programme. Finnish parents have frequent individual health check-ups with public health nurses during pregnancy and with their child until the child starts school at the age of 7 years. After this, periodic individual health check-ups are continued by school public health nurses until the child graduates at the age of 16 years. The same public health nurse follows up the family from the beginning of the pregnancy until the child starts school. The interventions include assessments of children’s physical, mental and social health, vaccinations and supporting parents in providing secure, child-focused upbringing. These services promote healthy growing environments for children and healthy family lifestyles. Support is also provided through home visits and by parents’ groups. Health inequalities are addressed by early, targeted support, especially for socioeconomically vulnerable groups. The services offered reflect the national life-course-related health goals defined for different age groups. Services specifi c to age or condition General services Maternal care Monitoring normal pregnancies and screening for high-risk pregnancies Supporting parenthood, early interaction and breastfeeding Monitoring women with pregnancy-related diabetes Promoting a healthy lifestyle through tailored health counselling (e.g. nutrition, physical activity) Supporting and empowering people to maintain and promote their own health and well-being with a proactive, holistic work approach Screening for risky behaviour (e.g. use of alcohol, tobacco and drugs) Screening for mental health problems (e.g. depression, eating disorders) Vaccinations Promoting sexual health Planning, organizing and guiding health   and peer groups (e.g. parenting classes, weight management groups) Working on health equity and reducing social inequalities Recognizing the need for special support and arranging help and support when needed Working in multiprofessional intersectoral collaboration to support the health and well- being of individuals Nursing services, e.g. sickness assessments, chronic wound care, minor accidents, medication Child health Assessing, monitoring and promoting the growth and development of children (including neurocognitive development and psychosocial health and development) Supporting parenthood and early interaction Preventing accidents School health Assessing, monitoring and promoting the growth and development of children (incuding psychosocial health and development) Assessing the environment of children (including relationships with family and friends) Supporting parenthood Student health Assessing, monitoring and promoting students’ health and ability to study Planning monitoring and care of chronic illnesses during studies Assessing students’ health from the point of view of possible health and safety risks in their future occupation Occupational health Assessing, monitoring and supporting people’s health and ability to work Assessing and promoting the safety of work environments and workplaces Preventing work-related illness and accidents Adult health Preventing and managing chronic illnesses (e.g. type 2 diabetes, asthma, hypertension) Providing preventive primary care health check-ups to people outside occupational health services (including for unemployed people) Supporting people with multimorbidity in living a full life Elderly health Supporting and promoting people’s functional ability and ability to take care of themselves Supporting safe living at home Providing preventive primary care health check-ups (including memory screening) An integrated chain of public health services 2 Fig. 1. Public health nurse resources as compared with national recommendations (%) Fig. 2. Adolescent risk behaviour (%) Impact Neuvola and school health services cover the beginning of the life-course for virtually the entire Finnish population. Overall, the number of public health nurses working in these sectors nearly reaches the national recommendation target, and an increase has been seen in the past few years (Fig. 1). Because of the high-quality health care services, the rates of infant mortality and low birth weight are generally lower in Finland than in other countries (Organisation for Economic Co-operation and Development, 2017a,b). In 2016, the newborn mortality rate was 1.1 per 1000 live births, and the rate of preterm births was 5.2% (Heino, Vuori & Gissler, 2017). The relational continuity of care provided by Finnish public health nurses also infl uences maternal subjective well-being (Yokoama et al., 2017), and a large decrease has been seen in adolescent risk behaviour (Fig. 2). In a public survey in 2012, neuvola services were chosen as the best Finnish innovation of all time (Yle, 2012). Source: TEAviisari (2018) Source: Sotkanet.fi (2018) Daily smokers, as % of all pupils in the 8th and 9th year of comprehensive school (15 and 16 years old) Maternal and child health clinic Heavy drinking at least once a month, as % of all pupils in the 8th and 9th year of comprehensive school School health care Student health care The following examples show how public health nurses contribute to scaling-up core interventions and services: • Childhood obesity: The public health nurse is in the front line for detecting obesity in children, as individual weight and height are monitored closely during health check-ups and communicated to the family. Family-centred care includes behavioural change through coaching and positive feedback. If the body-mass index is alarming, a doctor’s appointment is made, and other health care professionals are involved, including nutritionists and psychologists. • Adolescent smoking: Every adolescent is evaluated for smoking habits during health check-ups, starting at the age of 10 years. Smoking is also assessed in cases of respiratory infection and among girls seeking birth control. Smoking cessation programmes are offered, and nicotine replacement therapy can be initiated. Other examples of services for different target groups over the life-course are listed in Table 1. Both maternal and child health care clinics and school health care services are part of an integrated life-course chain of services for age-dependent factors. Within this chain, public health nurses work with health professionals in primary, secondary and tertiary care. The main collaborating partners are medical specialists, social workers, nutritionists, psychologists, physiotherapists, speech therapists, occupational therapists and dentists. Identifi cation of patient data and integration of services are facilitated by a unique social security number attributed to every Finnish citizen and used in all encounters. An integrated view of a patient’s life-course is ensured, which allows the detection and follow-up of risk factors for NCDs and other health conditions (Kanta, 2017). 3 This brief is part of our work programme on strengthening the health system response to noncommunicable diseases. For other good practice briefs, visit our website at http://www.euro.who.int/en/health-topics/Health-systems/health-systems-response-to-ncds. Heino A, Vuori E, Gissler M (2017) Perinataalitilasto – synnyttäjät, synnytykset ja vastasyntyneet 2016 [Perinatal statistics – parturients, deliveries and newborns]. Helsinki: Terveyden ja hyvinvoinnin laitos (National Institute for Health and Wellfare) (http://www.julkari.fi/bitstream/handle/10024/135445/ Tr_37_17.pdf?sequence=1, accessed 1 March 2018). Kanta (2017) Patient data repository. (http://www.kanta.fi/en/earkisto-esittely, accessed 18 March 2018). KT Kuntatyönantajat (2017) Local government employers. (https://www.kt.fi/tilastot-ja-julkaisut/ henkilostotilastot/ammatit, accessed 22 March 2018). Organisation for Economic Co-operation and Development (2017a) Family database. CO1.1: Infant mortality. Paris (http://www.oecd.org/els/family/CO_1_1_Infant_mortality.pdf, accessed 15 March 2018). Organisation for Economic Co-operation and Development (2017b) Family database. CO1.3: Low birth weight. Paris (http://www.oecd.org/els/family/CO_1_3_Low_birth_weight.pdf, accessed 15 March 2018). Sotkanet.fi (2018) Statistical information on welfare and health in Finland. Helsinki ( h t t p s : / / w w w . s o t k a n e t . f i / s o t k a n e t / e n / t a u l u k k o ? i n d i c a t o r = s z a p s N Y 1 B A A = & r e g i o n =s07MBAA=&year=sy6rsDbX0zUEAA==&gender=t, accessed 21 March 2018) TEAviisari (National Institute for Health and Welfare) (2018) Public health nurse resources compared to national recommendations: Whole country 2016. Helsinki (https://www.teaviisari.fi/teaviisari/en/ tulokset?view=PTHVoiA&y=2016&y=2014&y=2012&y=2010&y=2008&r=KOKOMAA&chartType=pointer &cmp=y, accessed 21 March 2018). Yle (2012) Neuvola-järjestelmä on kaikkien aikojen paras suomalainen keksintö. [Neuvola-system is the best Finnish innovation of all time]. Helsinki (https://yle.fi/aihe/artikkeli/2012/04/27/neuvola-jarjestelma -kaikkien-aikojen-paras-suomalainen-keksinto, accessed 15 March 2018). Yokoyama Y, Hakulinen T, Sugimoto M, Silventoinen K, Kalland M (2017) Maternal subjective well-being and preventive health care system in Japan and Finland. Eur Public Health. DOI: 10.1093/eurpub/ckx211. References Contact us • Registered public health nurses manage and deliver services throughout the life-course and are front-line workers in health promotion and prevention. They work in an integrated life-course chain of services that refl ect the national life-course-related health goals for diff erent age groups. • They eff ectively address the prevention of NCDs by off ering comprehensive services, inter- professional collaboration and continuity of care. Close inter-professional collaboration with other professionals in health and social care enables public health nurses to empower individuals and the population more effi ciently. • The availability of comprehensive services and the increasing health literacy of people and communities are important in the work of public health nurses. • Holistic approaches to people-centred care require continuous training, which is a statutory obligation in Finland for health care professionals so that they can maintain and develop their skills. • Health inequality is addressed by early, targeted support, especially for socioeconomically vulnerable groups. Support and help should be off ered without delay. The special needs of families that do not use the neuvola or school health services must be identifi ed and tailored support off ered to those in needs, these families are known to be in increased risk of social exclusion than the families that attend the services. • The free neuvola services complement a wide range of allowances, benefi ts and grants that are designed to strengthen the resources of individuals and families so that they can take responsibility for their own health and well-being. Parental support and health counselling are off ered at frequent periodic health check-ups and parenting classes. Continuous, confi dential relationships and interaction between public health nurses and families enhance the eff ectiveness of health counselling. • Government agencies are responsible for the design and evaluation of neuvola and school health services, although municipalities are in charge of the practical arrangements for these services. Government involvement in monitoring these preventive primary care services guarantees, for example, access to the well-resourced services. Lessons learned © World Health Organization 2018 All rights reserved. 4 Document number: WHO/EURO:2018-3387-43146-60410