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Core-periphery differences in children's health and use of general practitioner services in Finland from 1964 to 1987
Sot. Sci. Med. Vol. 33. No. 9. pp. 1023-1028, Printed in Great Britain. All tights reserved
1991 Copyright
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0277-9536191 S3.00 + 0.00 1991 Pcrgamon Press plc
CORE-PERIPHERY DIFFERENCES IN CHILDREN’S HEALTH AND USE OF GENERAL PRACTITIONER SERVICES IN FINLAND FROM 1964 TO 1987 HEIKKI S. VUORINEN,’MATTI M~KEL~~,~ HANNUTUOMIKOSKI’ and PEER FLOMAN’ ’ Department of Public Health, University of Helsinki, Haartmaninkatu 3, SF-00290, Helsinki 29, Finland. 2The Research Institute of Social Security, Social Insurance Institution, HiiyliImbtie laB, SF-00380 Helsinki, Finland and 3University Children’s Hospital, 2nd Department of Paediatrics, University of Helsinki, StenbLksg. 1I, SF-00290, Helsinki, Finland Abstract-Finland is a modem welfare state in Northern Europe especially proud of its development of programs for children’s health. The aim of this study was to investigate the development of core-periphery biff&ences in children’s health and use of health-services. The study material was obtained from the national health and social securitv interview survev carried out in 1964, 1968, 1976 and 1987. Age standardized prevalance of chronic diseases, numbe; of restricted-activity.days and physician contac% were presented for two age groups: O-6-year-olds and 7-14-year-olds. The prevalence of chronic diseases was quite similar in the core and periphery in 1976 and 1987, but the number of restricted-activity days throughout the study period (196G1987) was significantly higher in the core than in the periphery. The consistently higher frequency of physician contacts in the core in comparison with the periphery was spectacular; the welfare policy of the last decades seems to have had very little or no effect on this difference. The core-periphery division thus continues to have relevance with respect to the health of Finnish children. Key words-core,
periphery, children, health, policy
INTRODUCTION Finland is a modem Nordic welfare state. After the Second World War a universal and comprehensive child welfare system was established, and in the 1980s Finland was among those countries in the world with the lowest infant mortality rate [ 11.However, regional differences in children’s health have remained in Finland, despite its pride in its programs for children’s health. Differing social and family environment in different regions has been suggested as an important determinant of differences in children’s health [2]. After the Second World War regional differences for many different components of infant mortality tended to disappear [3,4]. For such phenomena as restricted activity, chronic diseases or the use of health care services regional differences did, however, exist during the 1960s and 1970s in Finland [5-7]. The purpose of this study was to investigate the development of regional variation in children’s health and use of health services, by applying the coreperiphery concept. There is a tendency in any hierarchy of spatial systems for polarized regional socio-economic development with constant restructuring, each region developing a central and a peripheral area [8-IO]. The concepts of core and periphery became especially meaningful in an expansive spatial organization based on dominance, such as the capitalist world economy [lo, 1I]. A core has been characterized as having besides economic also social, cultural and political dominance over the periphery [12]. It has even been argued that cores are highly dependent on peripheries for their prosperity [13]. The concept of semiperiphery has proved to be useful to describe SSM 33.9-D
those spatial entities positioned between true cores and peripheries [14]. Dominance is only one aspect of core-periphery relationships. Another aspect is the hierarchical diffusion of phenomena from core to periphery which has been observed as clearly in infectious diseases [15] as in technical innovations (see for example, Ref. [ 121).A reverse hierarchical diffusion is seen in the migration of workers and their dependents from peripheral to core areas, which is one of the most characteristic features of a core/periphery system [12, 161. Core-periphery dichotomies have implications for health. The occurrence and spread of infectious diseases has been connected to hierarchies of spatial systems [ 151.There is evidence that on different levels of spatial systems, cores are doing better than peripheries by several health and social well-being indicators (infant mortality rate, life-expectancy, mortality due to infectious diseases) [17]. People in cores and peripheries differ from each other in such characteristics as demography, family-type, educational level and health-related attitude, which have all been related to the use of health care services [18]. During the 196Os-1980s rapid socio-economic development occurred in Finland, influencing the core-periphery differences in the country. First of all there has been a rapid increase in the income level of the population leading to diminishing income differences between and within different regions of the country. Also the educational level of the population has rapidly increased in the whole country. On the other hand, unemployment has clearly polarized, with a high unemployment rate in the periphery and
HEIKKI S. VUORPEN er al.
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a recurrent and worsening shortage of manpower in core areas. In this period people have moved from agriculture to industry, but above all the movement has been both from agriculture and from industry to service occupations. For hundreds of thousands of Finns during the 1960s and early 1970s this movement even meant emigration to Sweden. Inside Finland this migration lead to depopulation of the periphery and congestion in the core. The demography of Finland changed, causing fertility to diminish and families to become smaller, especially in urban areas and in southern Finland. The peripheral areas in northern and eastern Finland were characterized by a diminishing ageing population comprising fewer families with children, although the number of children in these families was higher than in southern Finland [16, 19-211. This rapid and pronounced rise in standard of living has meant a drastic change in the life-style of Finns. The rapid development of communications (both national and international) with an explosive increase in such things as cars, TV-sets, and trips abroad [22], together with a universal increase in leisure time have led to a more homogenous culture. From the late 1960s to the early 198Os, regional policy in Finland was aimed strongly toward equality. In the area of welfare politics proper, this goal of equality is apparent in the 1960s and 1970s. There were several universal and comprehensive laws: the National Sickness Insurance Act (1963) Primary Health Care Act (1972), and Child Day-Care Act (1973). The modernization and extension of elementary education, covering children from 7 to 15 years old, was implemented (from 1972 to 1977) first in the peripheral areas, as was the system of comprehensive municipal primary health care. The provision of health services has been quite centrally organized at all levels of care in Finland, and use of health care services is intimately connected with the distances involved. One of the measures of the national Sickness Insurance Act for equalizing use of the health care system was to refund travel expenses. The reimbursement level from the early 1970s onwards has been, for example, around 80% of the transportation expenses for the use of private sector health services [23]. Finnish child day-care was quite institutionally organized, although the majority of young children (under 7 years old) were cared for in their own homes through the 1970s and 1980s. The form of child care, however, varied so that in towns and in southern Finland there were more children whose day-care was arranged in municipal day care centers. In rural areas and in central and northern Finland home day-care was the more typical arrangement [24]. It can be hypothesized then, that the rapid general growth of welfare in Finland and the scope of universal welfare politics (health, social, regional) shall diminish core-periphery differences in health and health care utilization of children. MATERIAL
AND METHODS
The national health and social security interview surveys carried out in 1964, 1968, 1976 and 1987 yield comparable data on children’s health status and utilization of health care services in Finland. In these
studies, data on the children (under 15 years of age) were obtained by interviewing an adult member of the family, the mother wherever possible. The interviews were carried out in late May and early June of each study years, the data covering the time of the interview or the period between that date back to the fist day of the year of interview. The personal frequency figures describing morbidity and medical care use were related to length of recall period (on average approximately 5 months for all the studies) by their being expressed per 100 days. This was done separately for each person by dividing such figures as the number of a person’s physician visits during the recall period by the number of days in the recall period. The public health nurses of municipal health centers carried out these interviews. The children of the survey represent the entire non-institutionalized child population of Finland in the study years. The percentage of interviews that could not be carried out was 8.9% in 1964, 3.1% in 1968, 8.6% in 1976 and 15.8% in 1986. The main reports include a detailed description of data and the methodology of the study [25-281. To study the effect of the core/periphery division on children’s health and use of health services, the two most clearly contrasting groups of children were compared: (1) those children living less than 3000 m from the nearest physician’s office in urban municipalities in the national core (=core in the following text) and (2) children living more than 3000 m from the nearest physician’s office in rural municipalities in the national periphery (=periphery). By these definitions the problems of the temporal instability of core and periphery arising from the continuous restructuring of the spatial hierarchies was minimized. The more problematic concept of semiperiphery was also thus avoided. To achieve the thus defined core and periphery, the core/periphery dichotomy was determined at three levels of spatial hierarchy: (1) the whole of Finland was divided into core and periphery, (2) the national core and the national periphery were divided into urban and rural areas, and (3) at the local level, the distance to the nearest physician (more or less than 3000m), separated the core from the periphery. At the national level, the insurance areas of the Social Insurance Institution were used to divide Finland into core and periphery, with the south-western and southern insurance areas of the Social Insurance Institution defined as the core, and northern, western and eastern insurance areas of the Social Insurance Institution as the periphery (Fig. 1). The urban/rural division had as its basis the legal status (chartered or non-chartered borough, rural commune) of the municipality in the study year. The national health and social security interview surveys included two variables defining the health of a child: (1) restricted-activity days and (2) chronic conditions; another variable defined the use of medical primary health care services by number of physician contacts. Restricted-activity days were defined as days per 100 days that the child has been confined to bed, been absent from school, or has neglected customary duties because of sickness. Quite a similar variable was used in the international collaborative study of
Core-periphery
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differences in children’s health
Table I. Children in different age groups in core and periphery by year Year Boys Boys Girls Girls Boys Boys Girls Girls Boys Boys Girls Girls Total
Fig. I. The core (C) and periphery (I’) at the national level of Finland. medical care utilization of the World Health Organisation in 1969 [ 181.This variable measures the social dysfunction, the changes in social contact and participation because of illness. Chronic diseases were defined as the prevalence of any reported chronic condition causing disablement. This variable was obtained only for the years 1976 and 1987, and measures the chronicity of the perceived morbidity of the non-institutionalized child population in quite a similar way to that of the 1969 WHO study [18]. Physician contacts were defined as the number of times per 100 days the child had been in contact with a physician because of sickness, not counting hospitalizations. Compulsory health check-ups and acquisition of medical certificates were excluded. This variable measures the overall use of primary care
O-2 yr. core O-2 yr, periphery O-2 yr, core O-2 yr. periphery 3-6 yr, core. 3-6 yr, periphery 3-6 yr, core 3-6 yr, periphery 7-14 yr, core 7-14 yr, periphery 7-14 yr, core 7-14 yr, periphery
1964
1968
1976
1987
143 160 IIS 166 152 292 146 287 353 891 348 785 3838
161 140 152 113 235 233 210 212 506 648 509 640 3759
107 57 90 56 137 78 120 82 299 404 283 344 2057
71 43 78 45 93 62 92 70 203 148 202 112 1219
physicians including private practitioners and municipal health center physicians. Age and sex are well-known factors related to children’s health and utilization of health services. The number of children in the core and periphery is presented in Table 1. The number of children in the national health and social security interview survey decreased considerably in 1976 and again in 1987. In the year 1964, 56.4% of the children of the interview were in the study groups. The proportion was 61.0%, 44.7% and 39.1% in 1968, 1976, and 1987 respectively. To avoid any possible problems of changing agestructures, direct age-standardization (1 year agegroups) was used separately for both under schoolage (< 7 year olds) and school-age children (from 7 to 14 years old). The differences between core and periphery were first analyzed for both age groups separately for boys and girls (data not shown). Because of the systematic, identical difference between core and periphery in both age groups and for both boys and girls, gender groups were pooled in the final analysis. The 95% confidence limits of agestandardized means were calculated to study the significance of differences between the core and periphery [29]. RESULTS
A natural standard of comparison for the core and periphery were the results for the whole of Finland which are included in Table 2 and Figs 2 and 3. The following observations can be made from the development of study variables in the whole of Finland: (1) The number of restricted-activity days first increased (up to 1968 or 1976), but then began to drop (2) a steady increase occurred throughout the period in the
Table 2. Age-standardized prevalance of chronic disease per 100 children, core and periphery areas in 197687, KXCScombined, 0 to 6-year-olds and 7 to 14-year-olds, mean and 95% confidence interval of mean Yeat
1976 O-6 yr, core o-6 yr, periphery M yr, whole Finland 7-14 yr, core 7-l 4 yr, periphery 7-14 M. whole Finland
6.2 6.1 7.1 13.7
(3.9-8.5) (3.0-9.1) (H-8.4) (10.6-16.7)
9.6 (7.4-l I .9) 11.1 (9.8-12.3)
1987 10.6 4.4 8.8 16.4
(7.1-14.2) (1.5-7.4) (7.3-10.3) (12.420.4)
Change % +71 -28 +24 +20
18.3 (13.1-23.6)
+91
15.0 (13.2-16.9)
+35
HEIKKI S. VUORINENet al.
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DISCUSSION AND CONCLUSIONS
(b)
Fig. 2. (a) Restricted-activity days per 100 days per child, age-standardized means in various years in Finland, core and periphery, @-6 yr. both sexes. (b) 7+ yr.
number of physician contacts, and (3) the prevalence of chronic conditions increased especially in schoolage children from 1976 to 1987. Table 2 and Fig. 2 present the results of the development of core-periphery variation in children’s health. Young girls and boys (O-6 years old) in the core had systematically significantly more restrictedactivity days than did children in the periphery from 1964 to 1987 (Fig. 2a). The core/periphery ratio was for those under 7 years old: 1.3 in 1964, 1.6 in 1968, 1.6 in 1976 and 2.4 in 1987. School-age children exhibited this same pattern, but the difference was not statistically significant for 1987 (Fig. 2b). For 7-14 year olds the core/periphery ratios were 1.3 in 1964, 1.2 in 1968, 1.2 in 1976 and 1.0 in 1987. The number of restricted-activity days per child seems to have reached a plateau (or even diminished) from 1968-76 in both core and periphery. In young boys and girls the prevalence of any chronic conditions diminished in the periphery and increased in the core (Table 2). In schoolage children, the increase in chronic conditions, although evident in the core, was more marked in the periphery. In both core and periphery, physician contacts increased considerably, both synchronously and identically during this period (Figs 3a and b). All through this period a significant difference in favor of the core was evident in the number of physician contacts. The core/periphery ratio for under 7 years old was 2.4 in 1964, 2.0 in 1968, 1.8 in 1976 and 1.6 in 1987. For 7-14 year olds the core/periphery ratios were 1.9 in 1964, 1.7 in 1968, I.5 in 1976 and 1.4 in 1987. For younger children the increase in the number of contacts seemed to accelerate towards the end of the period, but for older children there was a deceleration.
One problem in the interpretation of these results is in there being only four points of observation (cross-sections), and the difference in time between the third and fourth observation being 11 years. This gives ample room for different processes to occur in both core and periphery, involving differences in direction and timing. These different processes might cause a misleading similarity in the core and periphery in a cross-sectional observation. A cross-sectional study with shorter intervals would have been preferable. The following facts increase the credibility of the results: (1) in every study year sample and interview methods were identical and well-documented, and (2) the trends were rectilinear without irregularities. The findings of two other studies support the plausibility of this study: (1) the prevalence of chronic diseases in 2 to 18 year olds in 1984 (10%) in Finland [30] is at the same level as in this study, and (2) the development of core-periphery differences in children’s primary-care physician-contacts in the province of Uusimaa in the 1970s [6] is identical to that of this study. Interviewing parents to gather data might have had some influence on the results: we can only speculate as to how different the parents in the periphery and in core areas were, and how this might have influenced the way the parents observed their children’s problems and utilization of health services. The use of survey data on construction of temporal development of regional differences also is problematic, since all questionnaire surveys are, to some extent, culturebound [31,32]. Every one of the three variables in this study manifested different aspects of the social expression of disease. There being no simple answer to the
06 r
(b)
cmc
Fig. 3. (a) Physician-contacts per 100 days per child in core and periphery in various years in Finland, 04yr, both sexes, age-standardized means. (b) 7+ yr.
Core-periphery
differences in children’s health
question of the relationship between morbidity and physician contacts in children [33] a detailed study and discussion of relationships between restricted activity days, chronic diseases and physician contacts was beyond the scope of this study. In this study the contacts with primary care physicians occurred because of sickness, and thus there was by definition a relationship between morbidity and physician contacts. The higher number of physicians contacts in the core was more systematically seen among those children without chronic disease. How can we then interpret the results of this study to reflect core-periphery dynamics? There is a need for an integrated model of how the different mediators influence children’s health and use of health care in a core-periphery setting, perhaps something resembling the model of psychosocial mediators of pregnancy outcome by Rutter and Quine [34]. On the ground of core-periphery dynamics we may conclude that some mediators have relevance to children’s health and use of health care: (1) The number of life events and contacts with other people or infective agents is greater in the core, (2) Innovations (knowledge, attitudes, cultural traits in general) spread from core to periphery and (3) Health and social policy try to influence the core-periphery differences. Considering these premises we may hypothesize that the widening gap between the core and periphery in the number of restricted-activity days of young children was the result of the different number of contacts with other children, connected with different day-care arrangements in the core and periphery, especially after the implementation of the Child DayCare Act in 1973. From the statistics we know that a greater proportion of women are employed in the core provinces than in the periphery [35]; thus more children are in day-care centers in the core [24]. The latter difference was also seen in our study. From the literature we know that the number of illness episodes, especially respiratory infections, increase with the number of children in day-care [36]. In our study number of restricted-activity days was greater for children in day-care centers than in homecare. This might be interpreted to mean that the most crucial health-problems in early childhood are nowadays in the core, and children in the periphery escape at least some of the infections. However, the higher number of restricted-activity days in the core was observed in every type of day-care arrangement in our study. Thus the difference in day-care practices does not fully explain the core-periphery difference in restricted activity days. The scattered settlements increasingly typical for the periphery of Finland from the 1960s onwards may have spared the young children from infections. At school-age children’s situation, however, changed. An ever more typical feature from the 1960s onwards in the periphery was discontinuation of small schools and an increasingly centralized school system with transportation of pupils from a widening area of scattered settlements. Therefore, the conditions (lifestyle, contacts with other people and with infective organisms) for school-age children in the core and periphery later became more equal than for younger children. As a result we find close to an equal number
1027
of restricted-activity days and prevalence of chronic conditions in 1987. Cultural determination may explain the differences between the core and periphery especially for physician contacts and young children’s chronic conditions and need for activity-restriction. The idea that the health culture differs according to geographical context and that its determinants are quite deep rooted [371 seems quite plausible. Those conditions which in the core need to be defined as chronic diseases in the periphery may need no such definition (parents who are farmers work at home, and the child gets the help needed without outside aid). The constancy of the difference in physician contacts between the core and periphery throughout the study period was startling. An identical finding was made in the province of Uusimaa in the 1970s [6]. This may indicate some basic invariable difference, but what this difference is we can only speculatefurther studies are needed. This non-varying difference suggests, however, that the probability of different public health measures’ equalizing children’s use of primary care physicians in the core and periphery is very small. Do health and social policies in Finland have any relevance to these results? First, the steady increase in physician contacts in both the core and periphery may be seen as a result of a health policy aimed at a universal increase in availability of health services. The day-care act may be partly responsible for the widening gap between core and periphery in restricted-activity days in small children, with smaller and more isolated day-care groups in the periphery, but with day-care centers (more in the core) health problems lead more often to restriction of activity (the child is identified more easily as sick). Finally, schools have successfully equalized the living conditions of school-age children, for better or for worse. In conclusion, children’s health in general seemed no worse in the periphery than in the core in the late 1980s. This is a rather remarkable finding supported by data on lack of variation in infant mortality [4]. Even so, the division of regions onto a core and a periphery continues to have relevance with respect to children’s health. The different morbidity indicators, with their different trends, seem to reflect different aspects of the development of a regional pattern of health. Welfare policy, on the other hand, seems to have had very little or no effect on the difference between the core and periphery in use of primary health-care services.
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Klaukka T., Tuomikoski H. and Savolainen E.), pp. 301-336. Publications of the Social Insurance Institution, A:18, Helsinki, 1982. (Finnish with an English summary.) 6. Vuorinen H. S., Floman P. A. and VHiinanen I. S. Children and core-periphery differences. Sot. Sci. Med. 27, 1263-1268, 1988. 7. Vuorinen H. S. Family resources and children’s use of primary health care services in Finland in 1979. Stand. J. Sot. Med. IS, 241-247,
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1991 Copyright
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0277-9536191 S3.00 + 0.00 1991 Pcrgamon Press plc
CORE-PERIPHERY DIFFERENCES IN CHILDREN’S HEALTH AND USE OF GENERAL PRACTITIONER SERVICES IN FINLAND FROM 1964 TO 1987 HEIKKI S. VUORINEN,’MATTI M~KEL~~,~ HANNUTUOMIKOSKI’ and PEER FLOMAN’ ’ Department of Public Health, University of Helsinki, Haartmaninkatu 3, SF-00290, Helsinki 29, Finland. 2The Research Institute of Social Security, Social Insurance Institution, HiiyliImbtie laB, SF-00380 Helsinki, Finland and 3University Children’s Hospital, 2nd Department of Paediatrics, University of Helsinki, StenbLksg. 1I, SF-00290, Helsinki, Finland Abstract-Finland is a modem welfare state in Northern Europe especially proud of its development of programs for children’s health. The aim of this study was to investigate the development of core-periphery biff&ences in children’s health and use of health-services. The study material was obtained from the national health and social securitv interview survev carried out in 1964, 1968, 1976 and 1987. Age standardized prevalance of chronic diseases, numbe; of restricted-activity.days and physician contac% were presented for two age groups: O-6-year-olds and 7-14-year-olds. The prevalence of chronic diseases was quite similar in the core and periphery in 1976 and 1987, but the number of restricted-activity days throughout the study period (196G1987) was significantly higher in the core than in the periphery. The consistently higher frequency of physician contacts in the core in comparison with the periphery was spectacular; the welfare policy of the last decades seems to have had very little or no effect on this difference. The core-periphery division thus continues to have relevance with respect to the health of Finnish children. Key words-core,
periphery, children, health, policy
INTRODUCTION Finland is a modem Nordic welfare state. After the Second World War a universal and comprehensive child welfare system was established, and in the 1980s Finland was among those countries in the world with the lowest infant mortality rate [ 11.However, regional differences in children’s health have remained in Finland, despite its pride in its programs for children’s health. Differing social and family environment in different regions has been suggested as an important determinant of differences in children’s health [2]. After the Second World War regional differences for many different components of infant mortality tended to disappear [3,4]. For such phenomena as restricted activity, chronic diseases or the use of health care services regional differences did, however, exist during the 1960s and 1970s in Finland [5-7]. The purpose of this study was to investigate the development of regional variation in children’s health and use of health services, by applying the coreperiphery concept. There is a tendency in any hierarchy of spatial systems for polarized regional socio-economic development with constant restructuring, each region developing a central and a peripheral area [8-IO]. The concepts of core and periphery became especially meaningful in an expansive spatial organization based on dominance, such as the capitalist world economy [lo, 1I]. A core has been characterized as having besides economic also social, cultural and political dominance over the periphery [12]. It has even been argued that cores are highly dependent on peripheries for their prosperity [13]. The concept of semiperiphery has proved to be useful to describe SSM 33.9-D
those spatial entities positioned between true cores and peripheries [14]. Dominance is only one aspect of core-periphery relationships. Another aspect is the hierarchical diffusion of phenomena from core to periphery which has been observed as clearly in infectious diseases [15] as in technical innovations (see for example, Ref. [ 121).A reverse hierarchical diffusion is seen in the migration of workers and their dependents from peripheral to core areas, which is one of the most characteristic features of a core/periphery system [12, 161. Core-periphery dichotomies have implications for health. The occurrence and spread of infectious diseases has been connected to hierarchies of spatial systems [ 151.There is evidence that on different levels of spatial systems, cores are doing better than peripheries by several health and social well-being indicators (infant mortality rate, life-expectancy, mortality due to infectious diseases) [17]. People in cores and peripheries differ from each other in such characteristics as demography, family-type, educational level and health-related attitude, which have all been related to the use of health care services [18]. During the 196Os-1980s rapid socio-economic development occurred in Finland, influencing the core-periphery differences in the country. First of all there has been a rapid increase in the income level of the population leading to diminishing income differences between and within different regions of the country. Also the educational level of the population has rapidly increased in the whole country. On the other hand, unemployment has clearly polarized, with a high unemployment rate in the periphery and
HEIKKI S. VUORPEN er al.
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a recurrent and worsening shortage of manpower in core areas. In this period people have moved from agriculture to industry, but above all the movement has been both from agriculture and from industry to service occupations. For hundreds of thousands of Finns during the 1960s and early 1970s this movement even meant emigration to Sweden. Inside Finland this migration lead to depopulation of the periphery and congestion in the core. The demography of Finland changed, causing fertility to diminish and families to become smaller, especially in urban areas and in southern Finland. The peripheral areas in northern and eastern Finland were characterized by a diminishing ageing population comprising fewer families with children, although the number of children in these families was higher than in southern Finland [16, 19-211. This rapid and pronounced rise in standard of living has meant a drastic change in the life-style of Finns. The rapid development of communications (both national and international) with an explosive increase in such things as cars, TV-sets, and trips abroad [22], together with a universal increase in leisure time have led to a more homogenous culture. From the late 1960s to the early 198Os, regional policy in Finland was aimed strongly toward equality. In the area of welfare politics proper, this goal of equality is apparent in the 1960s and 1970s. There were several universal and comprehensive laws: the National Sickness Insurance Act (1963) Primary Health Care Act (1972), and Child Day-Care Act (1973). The modernization and extension of elementary education, covering children from 7 to 15 years old, was implemented (from 1972 to 1977) first in the peripheral areas, as was the system of comprehensive municipal primary health care. The provision of health services has been quite centrally organized at all levels of care in Finland, and use of health care services is intimately connected with the distances involved. One of the measures of the national Sickness Insurance Act for equalizing use of the health care system was to refund travel expenses. The reimbursement level from the early 1970s onwards has been, for example, around 80% of the transportation expenses for the use of private sector health services [23]. Finnish child day-care was quite institutionally organized, although the majority of young children (under 7 years old) were cared for in their own homes through the 1970s and 1980s. The form of child care, however, varied so that in towns and in southern Finland there were more children whose day-care was arranged in municipal day care centers. In rural areas and in central and northern Finland home day-care was the more typical arrangement [24]. It can be hypothesized then, that the rapid general growth of welfare in Finland and the scope of universal welfare politics (health, social, regional) shall diminish core-periphery differences in health and health care utilization of children. MATERIAL
AND METHODS
The national health and social security interview surveys carried out in 1964, 1968, 1976 and 1987 yield comparable data on children’s health status and utilization of health care services in Finland. In these
studies, data on the children (under 15 years of age) were obtained by interviewing an adult member of the family, the mother wherever possible. The interviews were carried out in late May and early June of each study years, the data covering the time of the interview or the period between that date back to the fist day of the year of interview. The personal frequency figures describing morbidity and medical care use were related to length of recall period (on average approximately 5 months for all the studies) by their being expressed per 100 days. This was done separately for each person by dividing such figures as the number of a person’s physician visits during the recall period by the number of days in the recall period. The public health nurses of municipal health centers carried out these interviews. The children of the survey represent the entire non-institutionalized child population of Finland in the study years. The percentage of interviews that could not be carried out was 8.9% in 1964, 3.1% in 1968, 8.6% in 1976 and 15.8% in 1986. The main reports include a detailed description of data and the methodology of the study [25-281. To study the effect of the core/periphery division on children’s health and use of health services, the two most clearly contrasting groups of children were compared: (1) those children living less than 3000 m from the nearest physician’s office in urban municipalities in the national core (=core in the following text) and (2) children living more than 3000 m from the nearest physician’s office in rural municipalities in the national periphery (=periphery). By these definitions the problems of the temporal instability of core and periphery arising from the continuous restructuring of the spatial hierarchies was minimized. The more problematic concept of semiperiphery was also thus avoided. To achieve the thus defined core and periphery, the core/periphery dichotomy was determined at three levels of spatial hierarchy: (1) the whole of Finland was divided into core and periphery, (2) the national core and the national periphery were divided into urban and rural areas, and (3) at the local level, the distance to the nearest physician (more or less than 3000m), separated the core from the periphery. At the national level, the insurance areas of the Social Insurance Institution were used to divide Finland into core and periphery, with the south-western and southern insurance areas of the Social Insurance Institution defined as the core, and northern, western and eastern insurance areas of the Social Insurance Institution as the periphery (Fig. 1). The urban/rural division had as its basis the legal status (chartered or non-chartered borough, rural commune) of the municipality in the study year. The national health and social security interview surveys included two variables defining the health of a child: (1) restricted-activity days and (2) chronic conditions; another variable defined the use of medical primary health care services by number of physician contacts. Restricted-activity days were defined as days per 100 days that the child has been confined to bed, been absent from school, or has neglected customary duties because of sickness. Quite a similar variable was used in the international collaborative study of
Core-periphery
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differences in children’s health
Table I. Children in different age groups in core and periphery by year Year Boys Boys Girls Girls Boys Boys Girls Girls Boys Boys Girls Girls Total
Fig. I. The core (C) and periphery (I’) at the national level of Finland. medical care utilization of the World Health Organisation in 1969 [ 181.This variable measures the social dysfunction, the changes in social contact and participation because of illness. Chronic diseases were defined as the prevalence of any reported chronic condition causing disablement. This variable was obtained only for the years 1976 and 1987, and measures the chronicity of the perceived morbidity of the non-institutionalized child population in quite a similar way to that of the 1969 WHO study [18]. Physician contacts were defined as the number of times per 100 days the child had been in contact with a physician because of sickness, not counting hospitalizations. Compulsory health check-ups and acquisition of medical certificates were excluded. This variable measures the overall use of primary care
O-2 yr. core O-2 yr, periphery O-2 yr, core O-2 yr. periphery 3-6 yr, core. 3-6 yr, periphery 3-6 yr, core 3-6 yr, periphery 7-14 yr, core 7-14 yr, periphery 7-14 yr, core 7-14 yr, periphery
1964
1968
1976
1987
143 160 IIS 166 152 292 146 287 353 891 348 785 3838
161 140 152 113 235 233 210 212 506 648 509 640 3759
107 57 90 56 137 78 120 82 299 404 283 344 2057
71 43 78 45 93 62 92 70 203 148 202 112 1219
physicians including private practitioners and municipal health center physicians. Age and sex are well-known factors related to children’s health and utilization of health services. The number of children in the core and periphery is presented in Table 1. The number of children in the national health and social security interview survey decreased considerably in 1976 and again in 1987. In the year 1964, 56.4% of the children of the interview were in the study groups. The proportion was 61.0%, 44.7% and 39.1% in 1968, 1976, and 1987 respectively. To avoid any possible problems of changing agestructures, direct age-standardization (1 year agegroups) was used separately for both under schoolage (< 7 year olds) and school-age children (from 7 to 14 years old). The differences between core and periphery were first analyzed for both age groups separately for boys and girls (data not shown). Because of the systematic, identical difference between core and periphery in both age groups and for both boys and girls, gender groups were pooled in the final analysis. The 95% confidence limits of agestandardized means were calculated to study the significance of differences between the core and periphery [29]. RESULTS
A natural standard of comparison for the core and periphery were the results for the whole of Finland which are included in Table 2 and Figs 2 and 3. The following observations can be made from the development of study variables in the whole of Finland: (1) The number of restricted-activity days first increased (up to 1968 or 1976), but then began to drop (2) a steady increase occurred throughout the period in the
Table 2. Age-standardized prevalance of chronic disease per 100 children, core and periphery areas in 197687, KXCScombined, 0 to 6-year-olds and 7 to 14-year-olds, mean and 95% confidence interval of mean Yeat
1976 O-6 yr, core o-6 yr, periphery M yr, whole Finland 7-14 yr, core 7-l 4 yr, periphery 7-14 M. whole Finland
6.2 6.1 7.1 13.7
(3.9-8.5) (3.0-9.1) (H-8.4) (10.6-16.7)
9.6 (7.4-l I .9) 11.1 (9.8-12.3)
1987 10.6 4.4 8.8 16.4
(7.1-14.2) (1.5-7.4) (7.3-10.3) (12.420.4)
Change % +71 -28 +24 +20
18.3 (13.1-23.6)
+91
15.0 (13.2-16.9)
+35
HEIKKI S. VUORINENet al.
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DISCUSSION AND CONCLUSIONS
(b)
Fig. 2. (a) Restricted-activity days per 100 days per child, age-standardized means in various years in Finland, core and periphery, @-6 yr. both sexes. (b) 7+ yr.
number of physician contacts, and (3) the prevalence of chronic conditions increased especially in schoolage children from 1976 to 1987. Table 2 and Fig. 2 present the results of the development of core-periphery variation in children’s health. Young girls and boys (O-6 years old) in the core had systematically significantly more restrictedactivity days than did children in the periphery from 1964 to 1987 (Fig. 2a). The core/periphery ratio was for those under 7 years old: 1.3 in 1964, 1.6 in 1968, 1.6 in 1976 and 2.4 in 1987. School-age children exhibited this same pattern, but the difference was not statistically significant for 1987 (Fig. 2b). For 7-14 year olds the core/periphery ratios were 1.3 in 1964, 1.2 in 1968, 1.2 in 1976 and 1.0 in 1987. The number of restricted-activity days per child seems to have reached a plateau (or even diminished) from 1968-76 in both core and periphery. In young boys and girls the prevalence of any chronic conditions diminished in the periphery and increased in the core (Table 2). In schoolage children, the increase in chronic conditions, although evident in the core, was more marked in the periphery. In both core and periphery, physician contacts increased considerably, both synchronously and identically during this period (Figs 3a and b). All through this period a significant difference in favor of the core was evident in the number of physician contacts. The core/periphery ratio for under 7 years old was 2.4 in 1964, 2.0 in 1968, 1.8 in 1976 and 1.6 in 1987. For 7-14 year olds the core/periphery ratios were 1.9 in 1964, 1.7 in 1968, I.5 in 1976 and 1.4 in 1987. For younger children the increase in the number of contacts seemed to accelerate towards the end of the period, but for older children there was a deceleration.
One problem in the interpretation of these results is in there being only four points of observation (cross-sections), and the difference in time between the third and fourth observation being 11 years. This gives ample room for different processes to occur in both core and periphery, involving differences in direction and timing. These different processes might cause a misleading similarity in the core and periphery in a cross-sectional observation. A cross-sectional study with shorter intervals would have been preferable. The following facts increase the credibility of the results: (1) in every study year sample and interview methods were identical and well-documented, and (2) the trends were rectilinear without irregularities. The findings of two other studies support the plausibility of this study: (1) the prevalence of chronic diseases in 2 to 18 year olds in 1984 (10%) in Finland [30] is at the same level as in this study, and (2) the development of core-periphery differences in children’s primary-care physician-contacts in the province of Uusimaa in the 1970s [6] is identical to that of this study. Interviewing parents to gather data might have had some influence on the results: we can only speculate as to how different the parents in the periphery and in core areas were, and how this might have influenced the way the parents observed their children’s problems and utilization of health services. The use of survey data on construction of temporal development of regional differences also is problematic, since all questionnaire surveys are, to some extent, culturebound [31,32]. Every one of the three variables in this study manifested different aspects of the social expression of disease. There being no simple answer to the
06 r
(b)
cmc
Fig. 3. (a) Physician-contacts per 100 days per child in core and periphery in various years in Finland, 04yr, both sexes, age-standardized means. (b) 7+ yr.
Core-periphery
differences in children’s health
question of the relationship between morbidity and physician contacts in children [33] a detailed study and discussion of relationships between restricted activity days, chronic diseases and physician contacts was beyond the scope of this study. In this study the contacts with primary care physicians occurred because of sickness, and thus there was by definition a relationship between morbidity and physician contacts. The higher number of physicians contacts in the core was more systematically seen among those children without chronic disease. How can we then interpret the results of this study to reflect core-periphery dynamics? There is a need for an integrated model of how the different mediators influence children’s health and use of health care in a core-periphery setting, perhaps something resembling the model of psychosocial mediators of pregnancy outcome by Rutter and Quine [34]. On the ground of core-periphery dynamics we may conclude that some mediators have relevance to children’s health and use of health care: (1) The number of life events and contacts with other people or infective agents is greater in the core, (2) Innovations (knowledge, attitudes, cultural traits in general) spread from core to periphery and (3) Health and social policy try to influence the core-periphery differences. Considering these premises we may hypothesize that the widening gap between the core and periphery in the number of restricted-activity days of young children was the result of the different number of contacts with other children, connected with different day-care arrangements in the core and periphery, especially after the implementation of the Child DayCare Act in 1973. From the statistics we know that a greater proportion of women are employed in the core provinces than in the periphery [35]; thus more children are in day-care centers in the core [24]. The latter difference was also seen in our study. From the literature we know that the number of illness episodes, especially respiratory infections, increase with the number of children in day-care [36]. In our study number of restricted-activity days was greater for children in day-care centers than in homecare. This might be interpreted to mean that the most crucial health-problems in early childhood are nowadays in the core, and children in the periphery escape at least some of the infections. However, the higher number of restricted-activity days in the core was observed in every type of day-care arrangement in our study. Thus the difference in day-care practices does not fully explain the core-periphery difference in restricted activity days. The scattered settlements increasingly typical for the periphery of Finland from the 1960s onwards may have spared the young children from infections. At school-age children’s situation, however, changed. An ever more typical feature from the 1960s onwards in the periphery was discontinuation of small schools and an increasingly centralized school system with transportation of pupils from a widening area of scattered settlements. Therefore, the conditions (lifestyle, contacts with other people and with infective organisms) for school-age children in the core and periphery later became more equal than for younger children. As a result we find close to an equal number
1027
of restricted-activity days and prevalence of chronic conditions in 1987. Cultural determination may explain the differences between the core and periphery especially for physician contacts and young children’s chronic conditions and need for activity-restriction. The idea that the health culture differs according to geographical context and that its determinants are quite deep rooted [371 seems quite plausible. Those conditions which in the core need to be defined as chronic diseases in the periphery may need no such definition (parents who are farmers work at home, and the child gets the help needed without outside aid). The constancy of the difference in physician contacts between the core and periphery throughout the study period was startling. An identical finding was made in the province of Uusimaa in the 1970s [6]. This may indicate some basic invariable difference, but what this difference is we can only speculatefurther studies are needed. This non-varying difference suggests, however, that the probability of different public health measures’ equalizing children’s use of primary care physicians in the core and periphery is very small. Do health and social policies in Finland have any relevance to these results? First, the steady increase in physician contacts in both the core and periphery may be seen as a result of a health policy aimed at a universal increase in availability of health services. The day-care act may be partly responsible for the widening gap between core and periphery in restricted-activity days in small children, with smaller and more isolated day-care groups in the periphery, but with day-care centers (more in the core) health problems lead more often to restriction of activity (the child is identified more easily as sick). Finally, schools have successfully equalized the living conditions of school-age children, for better or for worse. In conclusion, children’s health in general seemed no worse in the periphery than in the core in the late 1980s. This is a rather remarkable finding supported by data on lack of variation in infant mortality [4]. Even so, the division of regions onto a core and a periphery continues to have relevance with respect to children’s health. The different morbidity indicators, with their different trends, seem to reflect different aspects of the development of a regional pattern of health. Welfare policy, on the other hand, seems to have had very little or no effect on the difference between the core and periphery in use of primary health-care services.
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