7.1 General context
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Statistical information coming from surveys conducted as part of the Public Statistical Data Survey Programme (Program Badań Statystycznych Statystyki Publicznej) both by the Central Statistical Office and individual sectors (Ministry of Health, Ministry of Internal Affairs and Administration) is the most important source of statistical data relating to the health of the Polish population. Administrative data and collective publications obtained from institutions operating in the field of health care are an additional source. Data concerning young people’s health is drawn also from research done in school. It allows us to identify risk factors for civilisational illnesses occurring at a later age.
Lifestyle is a factor in civilisational illnesses, such as cardiovascular issues, diabetes, motile system disorders, which are occurring at a much earlier age. Research done in Poland towards the end of 2018 shows that many risk factors of civilisational illnesses can be identified already among children and school youth. About 1/3rd of second year students in elementary schools (so 8-year olds) are overweight or obese, and only a slightly lower fraction of seventh year students (so 13-year olds). It needs to be noted that the percentage of obese and overweight 8-year boys has increased in a statistically meaningful way between years 2016 and 2018. Levels of physical activity are on the decline. In the 11 to 15 years age group, “over 80% do not fulfill expert recommendation” – that is the percentage of youth declaring less than an hour of mildly strenuous activity a day. Furthermore, physical activity decreases with age. It comes as no surprise, then, that “arterial systolic blood pressure above the norm has been noted in 24.6% second year students, and in 13.7% of them, results represented values of hypertension of the 1st or 2nd degree (...). Increased systolic blood pressure could be found in 12.1% of seventh-year students.” One in five eight-years old, and a half of 13-year-olds do not eat breakfast daily in school, including 3% of younger students and 20% of older students who do not do so at all. Over half of children aged 11 to 15 drink carbonated sweet drinks too often, over two thirds of them eat sweets too often, and almost two thirds too rarely eat fruit and vegetables.
The conclusions of this research show that the “most common risk factor for future health issues, present in all researched groups, is an insufficient level of physical activity.” This problem increases in age. Among young people, obesity and overweight are also problems, affecting around 30% of the researched population. However, “insufficient attention is paid to low body mass problems in the child population. It shows up in 14% of children aged 7-9 and among early adolescent youth (12-14 years), which compared to the referential value of 3 to 5% suggests a concerning result.” Therefore, decision-makers are still facing lots of challenges to ensure that young people have the best possible conditions in which to develop their physical and mental health, and the young generation is still struggling with a number of problems in this scope.
The situation concerning vaccinations preventing infectious diseases is a good example thereof. Health and Healthcare in 2017, a report authored by the Central Statistical Office, sees it in a positive light: Free immunisation vaccines administered to Polish children and youth are still common. Infectious diseases, especially those affecting children, are no longer so dangerous and their prevalence has dropped. For example, since 2001 there have been neither diphtheria nor poliomyelitis cases caused by wild poliovirus. There have only been rare incidents of being infected by the virus contained in those vaccines (one case per year in 2009, 2010 and 2015). In the report for the year 2019, we read that “Free vaccinations among youth and children are still common. 9 out of 10 newborns with vaccination cards have been vaccinated against tuberculosis”. However, Central Statistical Office’s data indicates systematic decreases in the number of vaccinated children. For example, in 2010, 93.4% newborns have been vaccinated against tuberculosis, compared to 91.7% in 2018. The percentage of youth and children vaccinated against croup/tetanus (the full basic vaccination) in 2010 was 95.6%, compared to 89.7% in 2018, against pertussis 95.6% in 2010 and 87.4% in 2018, and against measles/mumps/rubella: 98.2% in 2010 and 92.9% in 2018.
However, specialists are seriously concerned about a growing anti-vaccination movement - data provided by the National Institute of Hygiene shows that in 2010 there were as many as 3 437 parental refusals to have their children vaccinated, 16 689 in 2015 and up to 48 609 in 2019 (between January and October 2020, 50 088 such cases have been recorded). Even at the moment the percentage of children receiving recommended vaccines (that is non-compulsory ones, for example against chickenpox) continues to be very low. The above report states that: "the prevalence of diseases not included in the compulsory vaccination programme is still high. In 2011, there were over 18,000 cases of scarlet fever and almost 163,000 cases of chickenpox (an upward trend) in the population aged between 0 and 19". Specialists say that it does not end there as lowered vaccination ratios, for example against measles, will cause a multi-fold increase in the number of cases. It is also possible that as a result of lowered immunity certain forgotten diseases might be back, such as diphtheria, tetanus, whooping cough and even polio. These concerned are confirmed by the National Institute of Public Health, according to which an increase in measles cases on Poland has been noticed since October 2018. In 2019, there have been 1492 diagnosed cases, a fourfold increase from 359 in 2018.
The condition of teeth is an important element of young people’s health. In this respect, young Poles rank very low, also in comparison with the rest of Europe. The survey conducted by Woynarowska and Oblacińska proves that tooth decay is the most prevalent chronic disease in children and youth. It can start as early as in the first year of life and its prevalence and intensity will grow with patients’ age. In 2012, only 14% of six-year-olds and 4% of eighteen-year-olds were free from tooth decay. Research done in years 2016-2019 indicates a slight improvement in the area – the analogous values among 6-year olds have reached 18.4%, and among 18-year olds 6.8% percent. The prevalence of tooth decay in Poland, when compared with many EU countries, is still high. No comprehensive solutions are being applied to this important health issue (bad teeth constitute a significant risk that the whole body will be affected by more infections). For many years now, there has been no medical care (including dental care) provided in schools. There was, however, an unsuccessful attempt to solve this problem by introducing so-called dentobuses (dental van units). The Ministry of Health bought 16 specialist vehicles (one for each province, which cost in total PLN 24,000,000). They were supposed to provide dental care to children and young people under 18 years of age, thus facilitating the youngest children’s access to that kind of service even in the most remote or deprived neighbourhoods. It turned out that the conditions offered failed to satisfy dentists and as a result, mobile dental surgeries did not significantly improve young people’s access to dental care.
The system of health care for young people with mental problems leaves a lot to be desired. Most of the facilities where young people can get help are situated in big cities. There are fewer psychiatrists and psychologists than necessary, the effectiveness of prevention is poor, and the extent of the problem still fails to be reliably recognised.
The situation has not improved in many years, and may have even deteriorated. At the end of 2019, there were - depending on the source - between 379 and 441 practicing child psychiatrists in Poland. The population of children up to age of 18 in Poland is approximately 7 million (6 949 000 by the end of 2019). Therefore, there are 5 to 6 child psychiatrists per 100 000 minors in Poland, when the WHO standard is 10. Hospital admission takes at least a few months, hospital beds are being reduced, the hospitals themselves are overburdened and it is not uncommon for minors to be admitted to the so called “add-ons” (beds in hospital corridors). The situation is described by a report by the Citizen Network Watchdog Poland: Minor Psychiatry in Poland (Psychiatria Dzieci i Młodzieży w Polsce). This state of affairs has been confirmed in the Ombudsman’s statements and interventions. A similarly negative opinion has been issued by the Supreme Audit Office. Its report has pointed towards the insufficient number of children and youth psychiatrists, advancing age among current professionals (32% are over 55 years old, and promoting child psychiatry as a priority specializations has not led to wider interest in this career among medical personnel), and uneven distribution of psychiatrists and hospitals working with youth and children across the country (with the worst results in Lubuskie, Pokarpackie, and Podlaskie voievodships, and best in Lódzkie voivevodship). As a result, psychiatric wards for youths and children are overpopulated. Even worse is the general availability of psychiatric help for youths and children in out-patient clinics, with average waiting period increasing from 44 days in 2017 to 56 days in 2019, which stems mostly from the low number of specialist staff employed (the number of patients per specialist has gone up from the average of 1091 in 2017 to 1124 in 2018).
A significant issue in psychiatric care for youth and children is the insufficiency of preventive care, which is hard to find in mental health clinics. This is justified by putting the burden of preventive care on schools (teachers or school psychologists), or on psychological-pedagogical clinics. However, as the SAO audit indicates, almost half of public schools of various types (44%) are not currently employing a psychologist or a pedagogue as a separate position, and where they are employed, preventive care is rendered difficult by the high number of students per specialist.
Currently, the Ministry of Health, in partnership with Warsaw’s Cardinal Stefan Wyszyński’s University) is working on a health system reform in the area of children and youth mental health. The project is to be enacted by June 2023 and is being financed under the Operational Programme for Knowledge, Education, and Development 2014-2020, with support by the European Social Fund. The reform assumes the need for urgent changes in protecting the mental health of youths and children. Its goal is to create a national, complex system that will provide support to young patients experiencing mental health disorders, as well as to their families. A side goal is to lower the regional inequalities and prevent overstressing psychiatric wards through developing support systems for patients on all levels of health systems. In 2019, the Ministry of Health has created the position of the Plenipotentiary for the reform of children and youth psychiatry. The most important duties include initiating and coordinating actions working towards the reform, and the development of the psychiatric care system for youths and children.
A new model of minor psychiatric health protection, introduces a three-tier care system. Its basic assumption is to attempt to diagnose minors in sites located as close to the patient as possible: in Local Psychological and Psychiatric Care Centers (which are to be established in every district, which do not have doctors on staff, only psychologists, psychotherapists, and environmental therapists, which do not require a doctor’s referral, in December 2021 Level I services for child psychiatry were being given in 212 sites), and only afterwards in Local Psychic Care Centers (with a psychiatric doctor on staff, and including the possibility of providing day care) and Urgent Psychiatric Care Centers (hospital units).
The National Mental Health Protection Programme for 2017-2022 (Narodowy Program Ochrony Zdrowia Psychicznego na lata 2017-2022) includes a diagnosis which contains data referring to the 18-29 age group. The diagnosis shows that 2.1% of people from this age group (1.7% of males and 2.6% of females) have had a depression episode at some point in their life, and a total of 0.4% have been affected by persistent depressive disorder called dysthymia. However, it is quite likely that the data quoted is significantly underestimated, because police data shows that the highest percentage of suicidal attempts is in the group of 20-24-year-olds. In the same way, data referring to the percentage of people receiving treatment ought to be treated very cautiously. It was confirmed by the diagnosis which was contained in the Programme of Preventing Depression in Poland for 2016-2020 (Program zapobiegania depresji w Polsce na lata 2016-2020) which indicates that depression in young people may affect from 4-8% to 20% of their population. Depression in children and young people is still less clear than adult depression. In addition to that, a high Charlson Comorbidity Index is an additional characteristic of childhood and puberty – from 30 to 75% of children with depression meet the diagnostic criteria for anxiety disorders. Therefore, it is not surprising that Polish school children quite frequently go for psychotropic substances not prescribed by doctors (for example sleeping pills or calming tablets). It refers to about 15% of 15- and 16-year-olds and about 18% of 17- and 18-year-olds. Girls are likely to use such substances twice as often as boys. The characteristics of youth depression are worth noticing. "It is inextricably linked to the difficulties of adolescence and development tasks of that phase (...) the clinical picture of the disease is often masked by tantrums, boredom and tiredness, as well as disruptive behaviour such as escaping from home, truancy as well as self-destructive and antisocial behaviour. The symptoms of depression are frequently accompanied by difficulties at school, cutting ties with peers, worse relationships with the loved ones and withdrawal. Growing depression symptoms in adolescents require special attention as they may lead to suicidal attempts or to suicide." In Poland, the rate of suicidal attempts among children and young people significantly increased over the last few years. 2015 marked its highest level in many years - 481 attempts, including 12 by children under 12. In 2016 this rate was slightly lower - 475 attempts. The number of suicide attempts among minors was 772 for 2018 (including 26 for children age 7-12) and in 2019 there were 951 such attempts (including 46 by children age 7-12).
Currently, promoting mental health is one of the operational goals of the National Health Programme for years 2021-2025, but youth and children are not singled out as a special group of concern within that programme, and the term “depression” is not mentioned in the entire document. The aforementioned Depression Prevention Programme does not have a continuation as a separate action. Its parts have been picked up by the National Health Programme, but are not clearly designated within it. In the entire Programme, the word “children” is used three times, and “youth” appears twice.
Young people’s health is significantly influenced by how they take care of themselves. Education, upbringing and information campaigns able to instil a kind of behaviour resulting in fewer health problems in young people may be of key importance in this respect. The Health and Lifestyle of Polish Students report (Zdrowie i styl życia polskich uczniów) reveals that the awareness of health-improving steps among young people is poor. For example only 61% of teenagers ages 11 to 15 declares getting breakfast on all school days. More data concerning improper health-improving behaviour (coming from the 2019 report prepared by the Centre for Public Opinion Research and entitled Young People 2018 (Młodzież 2018) indicates that the percentage of youth age 18-19 that does not smoke tobacco is, as of many years now, stable and holds at around 60%. 18% of youth of that age smokes regularly. Alcohol is far more popular as a psychoactive substance than tobacco and narcotics. In the month preceding the research date, 74% of youth age 18-19 had drunk beer at least once, 62% vodka and other high proof spirits, 43% wine. In comparison to 2016 the percentage of youth drinking beer and wine increased (the last one is the only kinds of alcohol where a long-term increase trend in consumption since 2008 is visible), while the percentage of youth drinking high-proof spirits remained the same. A concern is the number of youth who in the month preceding the research had gotten drunk at least once - 44% (13% had gotten drunk at least three times in that period. ESPAD research done among schoolchildren in 2019 indicates very similar patterns of behaviour and levels of alcohol and tobacco use.
The report does not confirm young people’s using drugs on an allegedly large scale - 83% said that within the year preceding the survey they had not experimented with drugs - on the other hand, it should be stressed that 38% of young people admitted to having ever used some kind of a drug. The most common ones are marijuana and hashish, as well as amphetamine and tranquilisers used without prescriptions from a physician. The number of young people experimenting with designer drugs decreased. The research shows that in 2018, 2.6% of youth declared having contact with those substances, indicating a rate similar to 2008, when they first appeared on Polish market.
The situation of young people being overweight or obese is not good, although better than in the rest of Europe. However, in 2018, up to 22% children of school age were overweight, and Polish children are among "the most quickly becoming overweight in Europe”. Among other things, this situation is caused by bad eating habits. As the newest National Public Health Institute’s research from 2019 shows, close to half of youths of ages 10 to 17 eat 4 meals a day, while most of the rest eat 3 or 5 (or more), but only less than 20% eat all meals at regular hours. As a result, over 60% of youths snack between meals. Young people often consume baked goods, usually white wheat bread. Vegetables are eaten daily only by less than 20% of young people, and so are fruits. Meat (especially poultry and ham) is commonly consumed, and fish is less common. Two fifths of young people sweeten their drinks and food with sugar (and over half of them do it at least once a day). Almost everyone eats sweets (and a third of them do so many times a week). Most young people drink sweetened carbonated drinks (one third a few times a week, and almost 10% daily), while almost two fifths eats “junk food” (mostly crisps and other salty snacks) several times a week.
Low level of young people’s physical activity is another factor influencing the risk of obesity and the prevalence of other conditions: Even though recent study from 2018 shows that some 31% (fewer than two years ago) of surveyed young people declared to spend their free time practicing sport, still 25% prefers to play video games and 25% surfing the internet. "Doing nothing" was a favourite passtime for 29% of the surveyed youth and it is an activity chosen by increasingly large percentage of young people (a growing trend from 2013). On the other hand, 72% of boys and 55% declare physical activity (beside PE classes) at least once a week (mainly biking and individual exercise at home).
Polish youth shows insufficient levels of physical activity. Furthermore, the COVID-19 pandemic has exacerbated the issue. Research done in the summer of 2021 shows that the level of physical activity among young people has decreased. Currently, only 41% of youths of ages 10 to 18 declare an hour of physical activity at least 4 days a week, compared to 51% in 2019. Furthermore, the percentage of youth which limits its physical activity to 1 or 2 days a week has increased (29%), as well as the percentage of young people who are not physically active at all (9%). The intensity of physical activity has also decreased (the most common form being talking walks). Actions are being taken to reverse those negative trends, such as the educational campaign Returning to Shape! (Wracamy do formy!) and the Ministry of Sports School Sport Club programme that it is promoting.