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Health of children and young people
In Germany, the health of children and young people and the health care available to them can be rated good to very good. These were the findings from parent surveys and studies of children and young people carried out by the Robert Koch Institute (Robert-Koch-Institut) as part of the German Health Interview and Examination Survey for Children and Adolescents (Kinder- und Jugendgesundheitssurvey, KiGGS). However, there is a noticeable shift away from acute and towards chronic diseases and psychological disorders. The chances of enjoying a life free from disease and health problems are also spread unequally. In particular, children from socially disadvantaged families are exposed to higher health risks. These can be caused by family lifestyle and living conditions. For example, children and young people from disadvantaged families are affected more than average by traffic accidents, various diseases, being overweight and psychological disorders.
Representative studies also show that there are significant problems in Germany as a result of people being overweight and inactive on the one hand, and suffering from eating disorders and malnutrition on the other, as well as a lack of exercise. This increases the risk that children and young people in particular will also suffer from health problems.
The federal government has therefore developed and adopted a strategy for the promotion of child health (Strategie der Bundesregierung zur Förderung der Kindergesundheit). The strategy is based on the findings of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS study) carried out by the Robert Koch Institute (Robert-Koch-Institut) from 2003 to 2006. This study was the first of its kind to collect extensive and representative data on the health of children and young people in Germany, their attitudes to health, and the health care available to them. The initial findings from the first follow-up, KiGGS Wave 1 (KiGGS-Welle 1), are summarised in the booklet 'The health of children and adolescents in Germany – 2013' (Die Gesundheit von Kindern und Jugendlichen in Deutschland - 2013), available at www.kiggs-studie.de. The federal government's child health strategy pulls together the various initiatives to promote child health that extend to many areas outside of the health care system, and initiates new measures.
First results of the KiGGS Wave 2 (KiGGS-Welle 2) are published in the Journal of Health Monitoring (Ausgabe 1/2018; PDF, 892 KB).
The strategy includes initiatives in the following key action areas:
- Improving prevention and promoting health
- Promoting equity in health
- Reducing health risks
- Monitoring the current situation, carrying out basic research and identifying risk and protection factors
To meet these targets, the Federal Ministry of Health (Bundesministerium für Gesundheit) has launched a number of projects (in German). Measures to promote the mental health of children and young people have been implemented, educational programmes for children with all types of chronic diseases have been developed and tested, and reviews into the expansion of preventive services initiated.
The strategy for the promotion of child health enhances the federal government's child welfare initiatives, which include the National Action Plan for a Germany fit for children 2005–2010 (Nationaler Aktionsplan der Bundesregierung für ein kindergerechtes Deutschland 2005–2010).
As part of the state's guardian role, the government must ensure that parents take responsibility for the health and well-being of their children. The federal states (Bundesländer) and local communities have the main responsibility for ensuring child welfare and child protection. Outreach work by child and youth services (Kinder- und Jugendhilfe) and the public health care service along with targeted support for families in difficult living circumstances are important tools in the battle against child neglect and child abuse. The aim is to identify risks before birth and provide families with appropriate offers of assistance. The initiatives in the federal states and local communities support the federal government, for example, as part of the government initiative Early Prevention in Childhood (Frühe Hilfen).
Active child protection thanks to Early Prevention in Childhood (Frühe Hilfen) and reliable networks
The Early Prevention in Childhood (Frühe Hilfen) programme offers basic child and youth services to parents and parents-to-be. The federal states (Bundesländer) and local communities decide how they approach parents to give them information and advice on local support services. This could be done by the health authorities or youth offices, for example. All key agents of child protection, such as youth offices, schools, health authorities, hospitals, pregnancy advice centres, doctors and the police are brought together in one Early Prevention in Childhood (Frühe Hilfen) network to ensure the support services offered to families on the birth of a child are well coordinated.
Germany’s Federal Child Protection Act (Bundeskinderschutzgesetz ), adopted on 1 January 2012, was the first piece of legislation to enshrine the Early Prevention in Childhood programme. It incorporated a federal initiative on Early Prevention in Childhood and Family Midwifery (Bundesinitiative Netzwerke Frühe Hilfen und Familienhebammen, or Bundesinitiative Frühe Hilfen for short), which initially ran from 2012 to 2015 and was a quality development process that served to establish and strengthen early prevention in childhood services. Once this federal initiative expired, the federal foundation for early prevention in childhood (Bundesstiftung Frühe Hilfen) stepped in to continue these successful efforts and ensure that existing structures and tried-and-tested early prevention in childhood services would be supported in the long term.
The federal government thus covers more than half of the additional costs incurred by federal states and local communities in connection with the Federal Child Protection Act (Bundeskinderschutzgesetz).
The child protection guidelines (Kinderschutzleitlinie) published in February 2019 by the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V., AWMF) are the first evidence-based guidelines of this kind to be developed jointly by a number of relevant professional bodies and organisations.
The gesundheitsziele.de health targets forum involves the cooperation of more than 140 German health care organisations and aims to push forward the national health target process. It has existed for 17 years. Its members include policymakers at federal, state and community level, self-governing organisations, industry associations, patient and self-help organisations and scientific institutes.
The health target for children and young people 'Grow up healthy: life competence, physical activity, nutrition' (Gesund aufwachsen: Lebenskompetenz, Bewegung, Ernährung) was published in 2003 and updated in 2010. The setting-based approach to 'promoting health in child day care' (Gesundheitsfördernde Kindertagesstätte) is currently being evaluated.
The stated aims are:
- To improve children and young people's life skills
- To reduce stress/negative influences on children, young people and families
- To promote physical activity among children and young people
- To reduce malnutrition and promote healthy eating in families
- To improve the conditions and structures in place for promoting health in child day care centres, schools, families/environment
Initial recommended measures:
- Raise awareness among agents of child and youth services with the aim of establishing the promotion of health as a professional standard in child and youth services
- Ban food advertisements directed at children and product placement in and around children's television programmes
- Integrate life skills as a topic into training for all educators and teachers and develop on an ongoing basis to keep up with developments and quality standards
- Child day care centres implement measures in the workplace to promote health
- Child day care centres provide children with at least two free meals per day
- Encourage children and young people to enjoy exercise as part of physical education
- Include practical and theoretical education on nutrition in existing school subjects
- Remove drink vending machines and replace with drinking water dispensers
- Develop setting-based and subject-specific quality assurance tools
Improving medical care
In 2006, the commission for paediatric medicinal products (Expertenkommission Arzneimittel für Kinder und Jugendliche) was created at the Federal Institute for Drugs and Medical Services (Bundesinstitut für Arzneimittel und Medizinprodukte) to improve medical care for children and young people. The commission is consulted on national licensing decisions on paediatric medicinal products. It also assesses the licensing requirements for adult medicinal products that are also used for children and young people (Medikamente für Erwachsene, zulässig auch für Kinder).
Latest health surveys and studies
The Federal Statistics Office (Statistisches Bundesamt) regularly collects health data in Germany. The following surveys are of interest with respect to children and young people: A European comparison of accidents, violence and suicide among children and young people (Unfälle, Gewalt und Selbstverletzungen bei Kindern und Jugendlichen im europäischen Vergleich). Verdict: Between 2001 and 2016, the number of children (1 to 14 years) who died from fatal injuries fell significantly: by 43% (from 4.7 to 3.0 per 100.000) in Germany and across Europe, between 2001 and 2010 the proportion already declined by 44% (from 6.6 to 3.7 per 100.000); these are the most recent available figures. However, fatal injuries sustained by children aged one and above have been the most frequent cause of death among children and young people in Germany and Europe for many years (Unfälle, Gewalt, Selbstverletzung bei Kindern und Jugendlichen 2014. Ergebnisse der amtlichen Statistik zum Verletzungsgeschehen 2012. Fachbericht).
The large majority of young people aged 16 to 25 rate their health as very good to good (Selbsteinschätzung des Gesundheitszustandes nach Altersgruppen und Geschlecht).
German Health Interview and Examination Survey for Children and Adolescents (Kinder- und Jugendgesundheitssurvey, KiGGS)
In 1998, the Robert Koch Institute (Robert-Koch-Institut) began devising and testing a German Health Interview and Examination Survey for Children and Adolescents (Kinder- und Jugendgesundheitssurvey, KiGGS) with the support of national and international experts.
The first phase of the survey (KiGGS-Basiserhebung) ran from 2003 to 2006 and involved questionnaires and analyses. The interviewees were later contacted again for questioning in later survey phases, following a longitudinal approach. The first follow-up survey, known as KiGGS Wave 1 (KiGGS Welle 1), commenced in 2009 and ended in 2012. During this phase, most information was gathered in telephone interviews.
The second follow-up, KiGGS Wave 2 (KiGGS Welle 2), started in September 2014 and, like the first basic phase, involved questionnaires, analyses and tests. A variety of survey instruments as well as the process itself were verified for their effectiveness in a pre-test. KiGGS Welle 2 ended in August 2017.
Funding for this study, which remains one of a kind in both in Germany and abroad, was provided by the Federal Ministry of Health (Bundesministerium für Gesundheit, BMG), the Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF) and the Robert Koch Institute (Robert Koch-Institut, RKI). In-depth sub-studies were financed by the Federal Ministry of Food and Agriculture (Bundesministerium für Ernährung und Landwirtschaft, BMEL), the Federal Ministry for the Environment (Bundesministerium für Umwelt, Naturschutz und nukleare Sicherheit, BMU) and the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (Bundesministerium für Familie, Senioren, Frauen und Jugend, BMFSFJ).
The KiGGS findings were incorporated virtually directly into public health programmes and strategies. For example, the National Action Plan IN FORM (Nationaler Aktionsplan IN FORM) used the KiGGS findings to help prevent malnutrition, lack of exercise, overweight and associated diseases, as did the Life Carries Weight initiative (Leben hat Gewicht) and the federal government's strategy for the promotion of child health (Strategie der Bundesregierung zur Förderung der Kindergesundheit). Analyses of the KiGGS data are found in the federal government's Third Report on Poverty and Wealth (3. Armuts- und Reichtumsbericht), the Third Report on Child and Youth Sport (3. Deutscher Kinder- und Jugendsportbericht), the Eighth Family Report (8. Familienbericht) and a report for the Advisory Council for the Assessment of Developments in the Health Care System (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen).
Relatively recent cross-cutting data and trends (2018) exist concerning a variety of health-related topics that came out of Wave 2 of KiGGS:
- General health of children and adolescents in Germany
- Youth overweight and obesity in Germany
- Physical activity of children and adolescents in Germany
- consumption of sugary soft drinks among children and adolescents in Germany
- Smoking among children and adolescents in Germany
KiGGS has three special aspects:
- KiGGS regularly makes representative data available nationwide that can be used to describe the current state of health among children and young people under 18 years old as well as identifying trends over time
- KiGGS collects health data using surveys, medical screening, tests and lab analyses to improve the validity of measurements and obtain better estimates of disease rates
- KiGGS also contains a cohort, which means that children and young people from the baseline survey are invited to participate on a regular basis into adulthood to allow the analysis of causes and circumstances that contribute to changes in health during their lifetime.
Key data on the current KiGGS Wave 2 (KiGGS Welle 2) survey:
Project term: September 2014 to February 2017 Participants: about 23000 (planned) Age: 0 to 29 years old Locations: 167 towns and cities across Germany
The 15th child and youth report (Kinder- und Jugendbericht), entitled “Between freedom, family, all-day school and virtual worlds – Personality development and education for young people” (Zwischen Freiräumen, Familie, Ganztagsschule und virtuellen Welten – Persönlichkeitsentwicklung und Bildungsanspruch im Jugendalter), provides a current picture of the realities and lives of adolescents and young adults. It examines the circumstances under which young people are growing up, how they are influenced by digitalisation, demographic development and globalisation, and analyses the issues typically faced by this target group. It also covers the issue of young people’s health. The report was published in 2017.
PISA 2018 study
The PISA 2018 study contains a lot of data on the well-being of school pupils in Germany. For example, it found that 73% of school pupils are satisfied or very satisfied with life (OECD comparison: 71%). The study also says that only 3% of school pupils do not engage in any physical activity outside of school (OECD comparison: 7%).
Epidemiological study of child and youth medical care in Germany
An epidemiological study of paediatric care in Germany by the German Academy of Paediatrics and Adolescent Medicine (Deutsche Akademie für Kinder- und Jugendmedizin e.V., DAKJ) looks at which regions can expect problems in the future especially when it comes to ensuring outpatient paediatrics and adolescent medicine, what the problems might be, the roles of other doctor groups, health care professions or hospitals in safeguarding paediatric and adolescent medicine, and what form needs-based planning for paediatric and adolescent medicine might take. The findings stem mainly from analysing data from the statistical offices in the federal states (Bundesländer) and at a national level, analysing morbidity data and literature, and semi-statistical interviews. Project term: 1 October 2015 to 31 May 2016.
Every four years, the German Nutrition Society (Deutsche Gesellschaft für Ernährung, DGE) publishes a nutrition report on behalf of the Federal Ministry of Food and Agriculture (Bundesministerium für Ernährung und Landwirtschaft, BMEL). The report investigates what and how much is eaten in Germany, how people's eating habits and health care have changed, whether nutritional recommendations are being implemented and what measures are needed to promote public health. Summaries of the nutrition reports (Kurzfassungen der Ernährungsberichte)
The analysis of the National Nutrition Survey (Nationale Verzehrstudie, NVS II) confirms that increasing numbers of the German public suffer from weight problems: two thirds of men and more than half of women are overweight. One in five is obese and at risk of cardiovascular disease or diabetes.
A long-term study of eating habits in Germany is carried out as part of the German National Nutrition Monitoring programme (Nationales Ernährungsmonitoring, NEMONIT). Once a year, the Max-Rubner-Institut surveys a panel of almost 2000 people aged between 18 and 80 years old who have already taken part in the National Nutrition Survey (Nationale Verzehrstudie II).
Drug affinity study
Once a year, the Federal Centre for Health Education (Bundeszentrale für gesundheitliche Aufklärung, BzgA) carries out a 'drug affinity study' (Drogen- und Suchtbericht) on behalf of the Federal Ministry of Health (Bundesgesundheitsministerium). The results of the last study were published in the second half of 2018. According to the study, the federal government's drug and addiction prevention measures are successful. It says that young people are smoking less, drinking less alcohol and taking fewer drugs, but binge drinking and cannabis consumption are still a problem.
In 2008, the National Action Plan IN FORM (Nationaler Aktionsplan IN FORM) was adopted with the aim of reducing malnutrition, increasing activity levels and reducing the number of overweight people to minimise the associated diseases. The IN FORM – German national initiative to promote healthy diets and physical activity (IN FORM – Deutschlands Initiative für gesunde Ernährung und mehr Bewegung) brought a lot of momentum to the promotion of physical activity. The push by the Federal Ministry of Health (Bundesministerium für Gesundheit, BMG) resulted in physical activity and the promotion of physical activity being integrated into prevention and health promotion work, rehabilitation, care and therapy even after project funding ended.
Following this, the Faculty of Health Sciences at Bielefeld University (Fakultät für Gesundheitswissenschaften der Universität Bielefeld), in cooperation with the German Sport University Cologne (Deutsche Sporthochschule Köln, DSHS), was tasked by BMG to evaluate the development of structures to promote physical activity and to identify possible courses of action. The Ministry wanted to know how well the promotion of physical activity has been structurally integrated in various fields in Germany and where gaps remain or repetition has arisen. The focus was on health prevention/promotion work, rehabilitation, care and therapy.
The National Action Plan was evaluated between April 2017 and October 2018 and the final report was published in October 2019. The results are available for consultation on the IN FORM website.
Other representative studies
Since the 1970s, the Federal Centre for Health Education (Bundeszentrale für gesundheitliche Aufklärung, BZgA) has been carrying out regular representative studies on the knowledge, attitudes and habits of young people and young adults regarding alcohol, tobacco and illicit drugs. It has also put together a prevention-related information base on the topics of sex education and AIDS (Datengrundlagen zu den Themen Sexualaufklärung und AIDS).
Surveys on the health situation of children and adolescents in the federal states (Länder) A recent publication exists on the health and health opportunities of children in the state of Brandenburg (Gesundheit und Gesundheitschancen für Kinder im Land Brandenburg).
Equity in health
The call for equity in health – including for children and young people – is an important subject and features heavily in discussions on health policy in Germany, especially for socially disadvantaged children and adolescents. Since early 2000, growing numbers of studies have researched the causes of social and health-related inequalities in influences on early childhood. These new studies offer an integrated view of the interplay between the environment, the human mind and inherited traits. It has been shown that experiences of poverty and neglect, particularly in the first few months of life, affect long-term behavioural development. These are permanent hormonal patterns that are set during 'sensitive periods', not just simple learning processes, and are thus very hard to change. Children exposed to these kinds of influences have concentration and memory problems and difficulty planning and seeing negotiations through to the end. By contrast, a stimulating, low-stress environment nurtures abilities that lead to success in school and professional life. This affects opportunities to resolve problems and successfully overcome challenges. The result: Opportunities in life are created or restricted, and susceptibility to disease is established at a young age. For more information, visit gesundheitliche-chancengleichheit.de
After Germany‘s Prevention Act (Präventionsgesetz) came into force in 2015, Coordination Centres for Equity in Health (Koordinierungsstellen Gesundheitliche Chancengleichheit) were rolled out across the country in order to strengthen health services at the municipal level.
Since January 2016 the Federal Centre for Health Education (BZgA) partnered up with an EU project on Intersectoral Health and Environment Research for Innovation (INHERIT), which receives funding under Horizon 2020, the EU Framework Programme for Research. The project aims to identify strategies and interventions that relate to people’s physical and social environments, encourages them to make healthy and sustainable choices, and serves to ensure that healthy lifestyles are recognised by all people as simple and attractive options.
Early Prevention (Frühe Hilfen)
Parents in Germany have access to a number of support services and facilities. Systematically linking these up in a way that provides tailored help to parents and children is the task of Early Prevention (Frühe Hilfen). This requires relevant burdens on parents to be identified systematically on the basis of the broadest possible access. Early Prevention services range from practical everyday help such as household organisation through to teaching relationship and parenting skills to mothers and fathers (to-be). The services are available to all parents, but with a focus on families in problematic areas (selective prevention).
In 2007, on behalf of the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (Bundesministerium für Familie, Senioren, Frauen und Jugend, BMFSFJ) and in cooperation with the German Youth Institute (Deutsches Jugendinstitut, DJI), the Federal Centre for Health Education (Bundeszentrale für gesundheitliche Aufklärung, BZgA) set up the National Centre on Early Prevention (Nationale Zentrum Frühe Hilfen, NZFH). The NZFH is tasked with strengthening the provision of early prevention services in Germany.
In the mid-2000s, certain criteria and processes were introduced to develop and safeguard the quality of health promotion activities. This came in response to calls from the field and financial backers for the need to be able to better identify and promote effective concepts. The Equity in Health Cooperation Network (Kooperationsverbund Gesundheitliche Chancengleichheit) lists participation as one of its 12 good practices. However, no specific concept is in place on how children and young people can contribute to promoting health.
Health promotion activities in childhood should be gender and age group-oriented and take social circumstances into account. They incorporate the ideas that young girls and boys have about their own health, as well as their cultural backgrounds. The setting-based approach aligns health promotion services with specific groups of people and their 'lifeworlds' as well as quality criteria that allow broad participation. A setting is a social context in which people spend their day-to-day life and which influences their health.
An overview of guiding concepts for health promotion activities in Germany can be found on the Federal Centre for Health Education's website (Bundeszentrale für gesundheitliche Aufklärung, BzgA).
Understanding of sport
In Germany, sport is divided into two main areas: public sports administration (by the federal government, the federal states [Länder] and local communities) and self-governed sport (in clubs and associations). Clubs are the backbone of the gymnastics and sport movement. They provide the framework for practicing exercise under the best possible conditions. Germany has about 91000 gymnastic and sports clubs with about 24 million members. Each branch of sport has its own umbrella association (federal associations, or Bundesfachverbände).
On its understanding of sport (Sportdefinition), the German Olympic Sports Confederation (Deutscher Olympischer Sportbund, DOSB) says: "Sports clubs and associations are committed to humanist values and to fair play. Their sporting activities provide people an opportunity for holistic physical and body-oriented development of their personality and strive for good physical, mental and social health. Health-oriented sport is a firm part of the member organisations' services. For children and young people in particular, clubs provide a third, important pillar – alongside family and school – for learning social skills. In parallel, clubs and associations are dedicated to the extensive inclusion of physical activity, play and sport in education."