Peer-reviewed article

Structural and interagency influences on mandated health assessments for children in out-of-home care in Sweden: a qualitative study of child protection services workers.

Van Agthoven G, Otterman G, Knez R, Makoroff K, Korhonen L · 25 Sept 2026

Abstract

Background Children in out-of-home care (OOHC) have significantly poorer physical, mental and dental health than their peers. In Sweden, child protection services (CPS) are required to initiate health assessments (HAs) when a child is placed in OOHC. Despite this statutory requirement, fewer than half of eligible children undergo an HA. Factors influencing implementation remain poorly understood. Methods This qualitative study explored CPS caseworkers'change experiences of initiating and coordinating HAs for children placed in OOHC in Sweden. Five semi-structured focus group discussions were conducted with 18 CPS caseworkers. Participants were recruited nationwide through purposive snowball sampling. Data were analysed using reflexive thematic analysis, applying a decision-making ecology framework to interpret individual, organisational and interagency influences. Results Four interrelated themes captured factors influencing implementation across the HA pathway: (1) Ideally, we do it for the child (initiation); (2) Negotiation and uncertainty (scheduling); (3) What we request is not always what we receive (conduct); and (4) Variable reporting and the challenge of closing the loop (reporting and follow-up). Across all phases, CPS caseworkers assumed a de facto coordinating role to compensate for fragmented interagency structures. Conclusions From the perspective of CPS caseworkers, organisational and interagency factors influenced HAs across the assessment pathway. Fragmented routines and unclear responsibilities may reduce their usefulness for care planning and follow-up. Strengthening shared ownership and improving assessment, reporting and follow-up processes may support implementation. HAs may be most useful as part of a broader pathway of assessment, referral, care planning and follow-up.