PEDIATRICS Vol. 106 No. 1 July 2000, p. e12
ELECTRONIC ARTICLE:
Quality of Care of Children With Chronic Diseases in Alexandria,
Egypt: The Models of Asthma, Type I Diabetes, Epilepsy, and
Rheumatic Heart Disease
Received Jun 15, 1999; accepted Feb 7, 2000.
,,,,
,
From the * Department of Medical Statistics, Medical Research
Institute, Alexandria University, Alexandria, Egypt; Department of
Pediatrics, Alexandria University, Alexandria, Egypt; § Department of
Biostatistics, High Institute of Public Health, Alexandria University,
Alexandria, Egypt; Oxford University, Oxford, England; and ¶ Mario
Negri Institute, Milan, Italy.
Objectives. To evaluate the quality of care delivered to children suffering from index chronic diseases using specific indicators of health care delivery and to study the predictors of suboptimal quality of care (SQC) and its outcome on children.
Design. Over a 9-month period, guidelines for optimal care
were formulated. A specific questionnaire for every studied chronic
disease was prepared in collaboration with the clinicians in charge of the diseased children (66% pediatricians and pediatric specialists and
34% adult specialists). The clinicians were asked to write the details
of daily practice, ie, how these children were managed on a routine
basis as well as in an emergency situation. A cross-sectional study was
conducted over a 4-month period and included 953 children suffering
from bronchial asthma (BA), childhood epilepsy (CE), type I diabetes
mellitus (IDDM), and rheumatic heart disease (RHD). A systematic random
sample of children was selected from children visiting the ambulatory
settings of all children's hospitals. Every fourth child was selected
on 2 randomly chosen days each week, while all diseased children
admitted in the hospital settings of the children's hospitals during
the study were included. A general form describing the impact of the diseases on the child was
prepared. A network of clinicians was created in all children's
hospitals; seminars were held during which the content validity of the
questionnaire was tested. Items were evaluated for their internal
consistency using the Cronbach 
. According to the degree of adherence to the recent therapeutic
guidelines concerning selected indicators of the quality of care
specific to every disease, children were categorized as receiving optimal quality of care or SQC. These indicators were: the use of
inhaled bronchodilators in acute asthmatic attacks in mild asthma and
the use of the prophylactic drugs (inhaled sodium cromoglycate or
inhaled beclomethasone) in moderate to severe chronic BA in between
acute asthmatic attacks; compliance with antiepileptic drugs in
epileptic children; regular performance of self-monitoring of blood
glucose and/or urine testing in diabetic children; and compliance with
prophylactic antibiotics in children suffering from RHD.The records of the outpatient clinics for ambulatory and hospitalized
cases were reviewed to assess the degree of compliance with the
prescribed management before the index visit. Sociodemographic characteristics and health care system-related
predictors of SQC were analyzed via stepwise logistic regression analysis.The impact of illness on the child was assessed by 7 items which were:
dependence on parents in domestic activities, level of activity
compared with peers, mood compared with peers, level of socializing,
degree of discomfort attributable to illness, level of physical
disadvantage, and urinary incontinence. Factor analysis with Varimax
rotation was performed on items related to the impact of illness.Parental satisfaction with care was rated as excellent, very good,
fair, or poor. Information on school outcome was obtained by asking the
caretakers whether the child was able to attend school regularly
despite his sickness. Scholastic achievement was also rated as
excellent, very good, good, and acceptable. Parents were asked whether
the child had ever repeated a grade because of his sickness.
Setting. Ambulatory and hospital settings of all children's hospitals in Alexandria, Egypt.
Results. Only 52% of mild asthmatics were given inhaled bronchodilators during acute attacks and 6.84% of moderate to severe asthmatics were taking prophylactic drugs (inhaled sodium cromoglycate and/or inhaled beclomethasone) between acute attacks. Similarly, only 53 of 134 (39.6%) of diabetic children were regularly performing self-monitoring of blood glucose and/or urine testing. In contrast, in epileptic children, 121 of 173 (69.9%) were judged as being compliant by their managing clinicians and more than two thirds 82/123 (66.7%) of children with RHD were compliant with the secondary prophylactic antibiotic.Predictors of SQC were younger age of the child (in BA and CE), lower maternal education (in BA and IDDM), charged medication (in BA, IDDM, and RHD), suburban residence (in moderate to severe BA), lower paternal education (in CE), and management in health facilities other than university hospital (in IDDM). Regarding the outcome of chronic diseases on children, factor analysis revealed 2 factors (physical and psychosocial impact) that explained 41.5% of variance with moderate adequacy (Kaiser-Meyer-Olkin test of sampling adequacy = .67). Dependence on parents in domestic activities, urinary incontinence, physical disadvantage, and the degree of discomfort attributable to illness were all aggregated into the physical impact factor, whereas the level of socializing, mood, and the level of activity compared with peers were aggregated into the psychosocial impact factor. There was a strong association between the severity of psychosocial impact and the quality of delivered care in CE and RHD, as well as between the parental satisfaction with care and the quality of delivered care for the 4 index diseases. However, there was no significant association between the severity of physical impact or school performance parameters and the quality of delivered care (apart from grade repeating in RHD).
Conclusions. With respect to the declared primary goal of the study, the most interesting findings could be summarized as follows:
- Cultural and economic factors are the primary predictors of SQC for childhood chronic diseases.
- Noncompliance to medication reflects the quality of delivered care in terms of defective health education rather than problems in the availability of medications in the local market as in many other developing countries or problems in the access to pharmacy or health services.
- Parental satisfaction with care seems to be a reliable marker of the quality of health care delivery regardless of the educational level of the community. Therefore, it could be used as a sensitive marker for the quality of health care even in developing countries.
- Chronic diseases have a profound impact on children, especially those belonging to the lower socioeconomic levels of the society, their scholastic performance, and the health care system.
- Regular monitoring of the health system performance is warranted, along with emphasis on health education programs for caretakers of children with chronic diseases. quality of care, chronic diseases, outcome.
