Health indices for the evaluation and monitoring of health in children and adolescents in prevention and health promotion: a scoping review

Health indicators are used in different settings to monitor health [1]. For example, the World Health Organization (WHO) published a global reference list of 100 core health indicators and health-related SDGs (Sustainable Development Goals) [2]. These are standard sets of core indicators prioritized by the global community to provide concise information on the health situation and trends, including responses at national and global levels. Its purpose is to serve as a normative guidance for the selection of standard indicators and their definitions that countries and partners can use for monitoring health in accordance with their respective health priorities and capacity. The Organisation for Economic Co-operation and Development (OECD) compares key indicators and reports on trends over time on population health, risk factors for health and health system performance across OECD members and partner countries [3].

Child and adolescent health is arguably one of the most important areas for the application of indices and indicators in prevention and health promotion [4]. Investment in child and adolescent health and control of adverse determinants will have a long-lasting effect on the whole population, including influencing the health of the next generation [4]. Furthermore, young people are citizens in their own right, yet largely unable to act as self-advocates, particularly at the population level [5]. Children, particularly in infancy, are unable to demand better services for themselves, and therefore information systems such as indicators act as the child’s and adolescent’s advocate [4].

The World Health Organization describes health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [6]. Understanding health as a complex and multidimensional phenomenon, indicators from a wide range of domains come into consideration to evaluate health.

Although a combination of single health indicators may help to understand the complexity of the health status of children, a selected set of indicators may be overcomplex, not least by their sheer numbers or unclear selection or priority setting algorithm [1]. One approach to overcome this complexity and to gain feasibility is to combine indicators into a composite score or index [1]. An index is argued to be more accessible for advocacy and political intervention decisions [1]. Furthermore, a well-designed index may provide a comprehensive vision of a multidimensional phenomenon, to “allow for the setting of national benchmarks and for further international comparisons and is a starting point for analysis and discussion” [1].

However, up to date there is no international consensus on the selection and use of indices despite many narrative reviews, opinions and policy briefs [1, 7]. Therefore, our objectives were to scope the existing evidence with the two specific aims: a) to identify and describe health indices that monitor and evaluate health of children and adolescents, and b) to appraise the quality and value of the identified indices that may guide the further applications of these indices in particular settings.

This scoping review was conducted according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) [8] and performed according to a preregistered protocol published in the open science framework under the following link: https://​osf.​io/​htgeu.

With this scoping review, we provided an overview of the literature that report health indices on health outcomes and risk factors as well as health behaviour in children and adolescents. We identified and described these health indices and conducted quality appraisals of these indices.

In total, we identified 36 eligible studies and 18 health indices. The majority of the identified indices covered anthropometrical or dental variables. Furthermore, there were indices for newborns as well as indices assessing lifestyle and functional ability. One identified index combines different aspects out of all.

Interestingly, the number of indices identified was very limited.

Not all existing indicators for children and adolescents have been captured by our scoping review since these did not meet study’s inclusion criteria of a composite index. However, none of the provided composite indices gives a complete picture of child and adolescent health. To function as effective tools for evaluating and monitoring health, this complex “state of complete physical, mental and social well-being” other essential indicators or sub-indices should be incorporated or added [1, 57].

Indeed, in our review, composite indices did not include many health determinants except in two indices (Healthy Lifestyle Index (HLI); Health Indicators for Swedish Children), despite of their importance for health monitoring [4, 26].

Also, the topic of injuries, a relevant area in child health [4] and leading cause of death, disability and burden in children, could only be found in one index parameter (children injured by external causes in the index Health Indicators for Swedish Children). However, several publications identified through our search reported on single indicators related to these topics (for examples cited in this review see the work by Peoples-Sheps et al. and Kohen et al. [32, 40]). However not covered by our search results, indices on child road safety have been published, such as the work by Gitelman et al. that describes the development of a composite index of child road safety in a municipality [58]. In addition, the European Child Safety Alliance developed child safety report cards as tools that were specifically designed to bring attention to child injury as a major public health issue [59]. They include single indicators and composite indices [59].

Although the scoping review focused on children and adolescents, some of the indices were not limited for use in this age group and might have therefore been excluded. It is noteworthy, that in most studies indices were calculated with primary data collection. This is an important aspect when evaluating their applicability in monitoring and evaluation of health prevention and promotion initiatives where routine data use would most desirable for feasibility reasons.

Most of the indices identified in this review consist of anthropometrical variables and were used to identify obesity in the studied population. Both generalized and abdominal obesity are associated with increased risk of morbidity and mortality [52]. The main cause of obesity-related deaths is cardiovascular disease, for which abdominal obesity is a predisposing factor [52]. BMI is the predominantly chosen indicator to measure body size and composition, and to diagnose underweight and overweight [52] as easy to measure and calculate tool [48]. However, alternative measures that reflect abdominal adiposity, such as waist circumference, waist-to-hip ratio and waist-to-height ratio, have been suggested as being superior to BMI in predicting cardiovascular disease risk [52]. This is based largely on the rationale that increased visceral adipose tissue is associated with a range of metabolic abnormalities that are risk factors for type 2 diabetes and cardiovascular diseases [52]. Since the waist circumference depends on the percentage of body fat in the abdomen and in children and adolescents growth influences this value, the waist-to-height ratio is often formed in this age group to increase the significance [52].

For assessing newborns´ health, the Apgar score was reported. It remains a widely accepted method of assessment and is endorsed by both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics [54]. Apgar scores may vary with gestational age, birth weight, maternal medications, drug use or anaesthesia, and congenital anomalies [54]. Several components of the score are also subjective and prone to inter-rater variability [54]. Thus, the Apgar score is limited in that it provides somewhat subjective information about an infant’s physiology at a point in time [54]. The perinatal health index predicted childhood health correctly for 79% [27] of the studied children. However the value of perinatal health data in predicting subsequent morbidity was questioned by Gissler et al. [27] and the index turned out to be more precise for predicting health [27].

We included indices with dental variables in this scoping review as an important aspect of health, since “oral health affects people physically and psychologically and influences how they grow, enjoy life, look, speak, chew, taste food and socialize, as well as their feelings of social well-being” [41].

There are difficulties and shortcomings in measuring children’s and adolescents´ health with indices when there are too few and too incomplete indicators [33]. In many cases, data are insufficient to describe the broad and complex area that children’s and adolescents´ health represents [33]. There is a lack in the availability of routine data [33] which can also be seen in this scoping review, since most of the studies identified reports on primary data collection. Besides, the list of composite indices that emerged from this review reflects the lack of availability of appropriate indicators and indices in some essential dimensions of child health and well-being in general. Even though we searched the database PsycINFO, we were unable to identify indices on mental health. In another study from Sweden as well as in other publications [4, 5, 33, 57, 60], a lack of data on children’s mental health is described as well. Furthermore, it is reported that information about children’s physical environment and its impact on their health is stated and reliable data on cultural offerings and experiences are also very poor or lacking [4, 5, 33, 61]. Other missing indicators and topics have been stressed in numerous indicators projects in the past, such as intentional injuries & child abuse [4, 5, 57, 61], children’s social development [5], social capital and its influence on child health and development [33, 61], educational development & school social environment [4, 5, 62], biological determinants of child obesity [63] or the consideration of health promotion resources [64], amongst others. Thus, data availability is a central aspect to be considered when developing indicators and indices to monitor child’s health [33, 61] and must be taken into account, as has been done in other indicators’ selection processes [4, 29, 63]. Furthermore, the most valuable insights are provided by repeatedly measured indicators rather than single surveys [1, 61] . Routinely conducted, continuous monitoring can inform about changes over time, allowing to identify some emerging issues or to monitor the effect of interventions [5, 61]. Thus, the long-term availability of data remains an important prerequisite to the use of indicators and indices [65].

In some countries, health monitoring systems can rely on solid, widely available, and accessible health data [61]. In Germany, though, the problem of data availability in the field of health promotion monitoring and reporting still challenges researchers [66], especially on a local level, where more attention is needed [67, 68]. Promising developments to address this issue are underway [65, 67].

In conclusion, this scoping review shows that indices may be pragmatic tools for monitoring and evaluating the health of children and adolescents, as well as to evaluate interventions in prevention and health promotion settings over time or between different groups [33]. Most indices identified were valid, consistent and sensitive. However, most indices would require primary data acquisition as prerequisite. Therefore, sets of single indicators of routine data will still have their role in monitoring children’s and adolescents´ health for the evaluation of preventive interventions. Easily available routine data of solid quality are necessary, both for single indicators and composite indices, to be able to provide relevant and effective tools to evaluate and monitor children’s and adolescents’ health in a society. A sensible selection of appropriate index and individual indicators adapted to given settings should be therefore made in any project through further reduction procedures (such as expert consensus).