Scientific Justification of Methodological and Organizational Approaches to Meeting the Medical and Social Needs of the Child Population in the Course of Medical Care

The dissertation is devoted to the scientific justification of methodological and organizational approaches to meeting the medical and social needs of the child population in the course of medical care. The research focuses on the problems of identifying and differentiating the medical and social needs of children depending on the social protection of their families, the intensity of social stress, and the socio-psychological status of mothers. A methodology for typologizing families raising children by the risk marker "Social Vulnerability of the Family" has been developed, and the principles of adapting the maternal and child health protection system to the real conditions of different categories of families have been justified.

Medical-statistical, medical-sociological, and psychosocial profiling have been applied in the work to assess the needs of different contingents of the child population, including disabled children and children with chronic pathology. A systemic approach to planning medical care, taking into account the objective and subjective needs of families, has been proposed, and a "Family Social Protection Passport" has been developed for the selection of children in need of additional support. The results of the research have been used in the preparation of methodological and programme-targeted documents in a number of Russian regions.

Relevance of the problem. The prerequisites for stabilizing domestic healthcare and forecasting the development of the sector for the period 2001–2005 are the positive trends in the transformation of the socio-economic structure of the state (Shevchenko Yu.L. 1999, Shchepin O.P., Denisov I.N., Ovcharov V.K., Starodubov V.I., Lindenbraten A.A., Filatov V.B. et al., 2000). The necessity of developing and implementing resource-saving and high-technology models of population health protection has been noted by the majority of Russian scientists in the field of public health and healthcare (Komarov Yu.M., 1996, Potapov A.N., 1997, Vyalkov A.I. 1998, Stochik A.M., 1998, Grinenko A.Ya., 1998, Lisitsyn Yu.P., 1999, Semenov V.Yu., 1999, Al'bitsky V.Yu., 2003 and many others).

Liberalization of prices, as one of the key directions of economic reforms, in the mid-1990s led to rapid inflation, a relative and absolute decline in population incomes, and low volumes of funds allocated to social programmes. The severity of economic reforms was largely reflected in a large group of the population, represented by the most socially vulnerable residents of the country, including those requiring state support (Vaganov N.N., 1996, "Standard of Living of the Population of the Russian Federation" — Goskomstat of Russia, 1995).

In 1995, the concept of "Difficult Life Situation" (DLS), in which citizens and their families may find themselves, was defined at the legislative level for the first time. The updated regulatory and legislative framework of the Russian Federation, primarily the adoption of the "Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens' Health," recognized healthcare as the leading medical and social system of society, called upon to satisfy the biological and psychosocial needs of people. The exclusive significance of the Maternal and Child Health Protection Service (MCHPS) in the system of public healthcare was declared, along with its leading role in ensuring the health of the present and future generations.

The problems of optimizing medical and social assistance to mothers and children have been reflected in numerous studies, including those of Boyarsky A.P., Chernova N.G., 1993; Veselova N.G., 1996; Al'bitsky V.Yu., Baranova A.A., 1999; Orla V.I., 1998; Voroncova I.M., 1999; Chicherina L.P., 2000, Zelinsky D.I. 2000, Kulakova V.I., Danilishina E.I., 2001 and many others. These studies are united by the following position: today, in order to optimize medical services and medical and social assistance in healthcare, comprehensive, scientifically grounded measures that are realistically implementable in practice are required. The MCHPS, despite its uniqueness in scale, volume, and structure of medical care provided, has not yet been supplied with effective recommendations for identifying typologically significant functions. The selection of priority directions, maximally effective for preserving the population's health through medical interventions under conditions of scarcity of material and human resources in healthcare, remains an urgent task for organizers at various levels.

The term "differentiated approach to primary medical and sanitary care" defines the existence of priorities that are based not on popular data on morbidity and mortality, but on conditions of epidemiological significance, for which the introduction of preventive measures may be decisive. The differentiated approach is an important element of the microeconomics of healthcare. The application of inexpensive and technically simple measures can improve the effectiveness of services, primarily maternal and child health protection.

The application of the differentiated approach is currently hindered by objective obstacles. First, information about the real scale of problems of urban families raising children is fragmentary and far from complete. To systematize constantly updated data, it is necessary to introduce a unified methodology for the assessment and analysis of information received about families and children. Second, methodological approaches to identifying socially vulnerable groups of society are somewhat outdated, since in Russia the majority of families with children are subject to the influence of various risk factors, both medical-biological and socio-hygienic and/or socio-psychological in nature. It is necessary to conduct monitoring of social processes leading to the deterioration of the health of the nation and of the child population in particular. Ultimately, only the individual and population characteristics of contemporary families determine the extent to which these families are able to satisfy needs and protect the rights of their children at various stages of their development. Third, the system of primary medical and sanitary assistance to mothers and children lacks an adequate typologization of families according to the principle of their social protection, agreed upon at all levels — legislative, directive, organizational, and practical. Applying a systemic approach to identifying and satisfying the medical and social needs of children from different types of families could contribute to the most efficient use of available limited resources not only in the medical care of the child population, but also in the systems of insurance, social protection, and education. In light of the above, the presented research is relevant and timely.

Research objective: to present a scientific justification of methodological and organizational approaches to meeting the medical and social needs of the child population in the course of medical care.

Research tasks:

1. To develop a methodology for identifying the medical and social needs of the child population, taking into account contemporary conceptions of healthcare and the family as social institutions called upon to ensure the basic needs of the population in health protection.

2. To study the state of current legislation in the sphere of medical and social protection of the population and to provide a scientific justification for typologizing families according to their social protection, intensity of social stress, and mothers' readiness for childbirth and child-rearing.

3. To study the medical and social characteristics of children being raised in families under conditions of maximum social stress, psychological and social deprivation.

4. To assess the impact of the risk marker "Social Vulnerability of the Family" on indicators of child population health.

5. To study the medico-organizational and social-psychological aspects of meeting normative population needs in the course of maternal and child health services.

6. To conduct medical-statistical and medical-sociological profiling of the medical and social needs of disabled children in the course of medical care.

7. To examine the psychosocial aspects of the formation of medical and social needs of children with chronic pathology in the course of medical care.

8. To present a scientific justification for a programme for improving maternal and child health protection, based on a systemic approach to identifying and differentiating the medical and social needs of the child population in the course of medical care.

Scientific novelty and theoretical significance. The scientific novelty and theoretical significance of the research lie in the fact that for the first time: methodological approaches have been developed and tested for identifying, assessing, and satisfying the medical and social needs of children in the course of medical care; a scientific justification has been provided for typologizing families raising children by the risk marker "Social Vulnerability of the Family," intensity of social stress, taking into account the socio-psychological status of mothers in connection with childbirth;

- objective and subjective medical and social needs of different contingents of the child population have been clarified, along with the possibilities for their satisfaction in the course of medical care; a systemic approach has been applied for profiling needs, including medical-statistical (epidemiological), medical-sociological, and psychosocial profiling of needs and other methods;

- the basic principles and tasks of the activities of treatment-and-prophylactic institutions for maternal and child health protection have been developed, ensuring the satisfaction of the medical and social needs of the child population in the course of medical care, depending on the social protection of families; the goals and tasks of social and psychological services in the system of primary medical and sanitary assistance have been scientifically justified;

- measures directed at improving maternal and child health protection have been systematized, taking into account the typology of families by the risk marker "Social Vulnerability of the Family," intensity of social stress, and the socio-psychological status of mothers in connection with childbirth.

Practical significance and implementation. The practical significance lies in the fact that for the first time:

- methodological principles for clarifying the objective and subjective medical and social needs of different contingents of the child population have been proposed;

- a comprehensive programme has been developed that enables the typologization of families, as well as the selection of optimal approaches to identifying the medical and social needs of children using evidence-based medicine techniques. A "Family Social Protection Passport" has been developed, enabling the selection of children who are affected by the risk marker "Social Vulnerability of the Family"; a characterization of the main concepts and definitions has been provided that allows for the reduction of the probability of systematic errors arising during the selection of socially unprotected contingents; a medical and social characterization has been given of children being raised under conditions of maternal deprivation; a scientometric analysis of special legislative and other legal acts of social orientation has been conducted, and a quantitative assessment of the degree of social protection and satisfaction of basic medical and social needs of individual categories of families has been given; the role of family social protection in the formation of individual and population characteristics of children's health has been studied; the contemporary features of meeting normative needs of mothers in prenatal observation and in preventive observation of children, taking into account the influence of the risk marker "Social Vulnerability of the Family," have been studied; the features of the formation of medical and social needs of disabled children in the course of medical care have been studied; and the psychosocial aspects of the formation of medical and social needs of children with chronic pathology, depending on the severity of the disease, the presence of the risk marker "Social Vulnerability of the Family," and the degree of mothers' readiness for childbirth and child-rearing, have been presented.

The obtained systematized information on the features of the formation of medical and social needs of different contingents of children has formed the basis of a programme for improving maternal and child health protection.

The results of the work have been used in the preparation of a number of methodological and programme-targeted documents directed at improving medical care for mothers and children at the regional, territorial, and institutional levels in Pskov Oblast, Kaliningrad Oblast, Murmansk Oblast, the Republic of Karelia, and Saint Petersburg, as confirmed by corresponding acts of implementation.

The materials and methodological developments of the research have been used in 21 informational and methodological publications, including: in a manual for physicians "System of Organization of Medical Assistance to Children with Psychosocial Developmental Disorders Caused by Perinatal Factors" — Saint Petersburg, 2001 (approved by the Ministry of Health of the Russian Federation, protocol No. 1 of 21.02.2000);

- in an information letter "On Comprehensive Rehabilitation of Children Being Raised in Children's Homes of Saint Petersburg" — Saint Petersburg, 2003 (approved by the Ministry of Health of the Russian Federation, 03.03.2003, No. 13-16/12);

The materials of the dissertation are set out in the corresponding chapters of three monographs: "Contemporary Medical and Social Problems of Childhood Disability in Kaliningrad Oblast" (co-authored) — Kaliningrad, 1999; "Health of the Child Population of Buryatia and Ways of Its Improvement" — (co-authored) — Irkutsk, 1999; "Social and Organizational Problems of Pediatrics" — Moscow, 2003 (co-author of the chapter "Contemporary Aspects of the Formation of Children's Health and Measures for Its Preservation and Strengthening").

The results of the research are used in lectures for students, interns, clinical residents, postgraduates, and continuing professional development course attendees at the Saint Petersburg State Pediatric Medical Academy, and at the Saratov State Medical University.

Publications. On the topic of the dissertation, 62 scientific works have been published.

Dissertation work consists of an introduction, 7 chapters, a conclusion, findings, recommendations, a list of references, and appendices.