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.

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.