Abstract
Objective. To describe both the direct and the indirect costs of illness in a closely followed cohort of toddlers attending day care centers (DCCs) in Québec, Canada.
Methods. Fifty-two DCCs participated in the study. Parents were invited to fill in a calendar on which they would indicate the occurrence of colds, diarrhea, and vomiting, in addition to any actions taken with respect to this occurrence. The participating parents were called biweekly to report the information. The costs reported in this article are based on a period of 6 months of follow-up. The direct costs included medication and visits to a physician whereas indirect costs included alternative care provided by a family member, a babysitter, or an employed parent who missed work.
Results. Two hundred seventy-three toddlers were followed from 35 to 182 days during the study period. During a 6-month period, the adjusted average costs per child for medication and consultation were $47.47 (standard deviation [SD] = 52.76) and $49.10 (SD = 51.34), respectively, whereas they amount to $11.51 (SD = 51.19) for care by a babysitter, $35.68 (SD = 94.74) for care by a family member, and $117.12 (SD = 210.29) for a parent missing work (when using opportunity cost). The overall adjusted average total costs per child incurred to the parents and society was $260.70 (SD = 301.25).
Conclusions. The originality of this study was to comprehensively include all costs associated with the care of an ill child attending DCCs. Future research should aim at finding economical ways to decrease illness frequency in toddlers attending day care centers and subsequently the costs they incur.
Two wage-earner families have become the single largest employee group in the United States.1 Because of this and other societal trends, services offered by day care centers (DCCs) are becoming increasingly needed. On January 7th, 1998, President Bill Clinton proposed the largest child care investment in the history of the United States ($20 billion throughout a 5-year period) to improve the quality, safety, supply, and affordability of child care to all American parents.2 The government of Québec allocates US $174 791 833 per year for child care services.3
The financial output of families for day care for children younger than 15 years of age has been estimated at more than US $14 billion per year which, on an individual basis, represents 6% of a family's income.4 However, these costs underestimate somewhat the total costs of child care because it is well-known that children in day care become sick more often,5–13 therefore imposing additional costs on families and society. Respiratory illnesses are the major cause of illness and absence from child care outside the home14 and often result in parental absenteeism from work as well as alternative costs and medication costs, among others.1,,15,16
To date, estimates of costs associated with common infections (diarrhea and colds) in young children have been based either on survey data17,,18 or on longitudinal studies in which the actions taken by parents were obtained from cross-sectional questionnaires6,,19 or a small subsample of the study population.20 As such, these cost estimates have included many assumptions and may be subject to some biases. In particular, there has been no comprehensive longitudinal study covering most actions (and their respective costs) taken by parents with respect to an ill child who attends DCC. The objective of this study was therefore to propose a methodology for estimating and describing both the direct and the indirect costs of illness in a closely followed cohort of toddlers attending DCCs in Québec, Canada.
METHODS
Setting
One or two toddler groups (between 18 to 36 months of age) in each of 52 DCCs in the province of Québec, Canada, participated in a randomized field trial of a comprehensive hygiene program aimed at reducing microbial contamination. The trial was conducted between September 1, 1996 and November 30, 1997. Children were followed until they were moved to an older group of children or until they left the DCC. As of March 1, 1997, 1064 children have been followed in the study. The costs reported in this article are based on information provided in a baseline questionnaire and in the 6-month period preceding randomization of DCCs into intervention groups.
Baseline Questionnaire
The director and/or educators of each DCC were asked to give the parents of toddlers in the study groups a package including a letter of information/invitation, a baseline questionnaire on sociodemographic factors, a consent form, and a prestamped return envelope addressed to the project director (H.C.). In the letter of information/invitation the parents were invited to participate in the study by filling in a calendar during the 15-month period of the trial. The parents were asked to fill in the baseline questionnaire whether or not they intended on participating in the trial. The questionnaire was pretested, translated into English, and then back-translated into French. It included four sections on: 1) demographic factors of the child, 2) health of the child in the past 4 weeks and the actions taken if the child was sick, 3) family environment, and 4) sociodemographic factors of the parents.
Longitudinal Data Collection
Parents who agreed to participate in the trial were telephoned fortnightly and asked what they had recorded on the calendar. The study illnesses were limited to colds, diarrhea, and vomiting. The definitions used for these illnesses were identical with the ones used in a previous study on child illnesses conducted in Montréal, Canada in 199021 and were defined as follows.
Cold
Cold was defined as the presence of nasal discharge (runny nose) accompanied by one or several of the following symptoms: fever, sneezing, cough, sore throat, ear pain, malaise, irritability. An upper respiratory tract infection (URTI) was defined as the presence of a cold for 2 consecutive days.
Diarrhea
Diarrhea was defined as the presence of twice the normal number of stools or a change in the consistency of stool to watery.
Vomiting
Vomiting was defined as the abrupt ejection of partially digested food from the stomach.
The definition of the three study illnesses were written on the top of each calendar page. Each page had 14 columns (corresponding to the days of 2 weeks) and eight rows (three rows for the study illness [cold, diarrhea, and vomiting], and five rows starting by the following statement “because of the above symptom(s) in the child, it was necessary to”: buy medication, consult a physician, engage a babysitter to care for the child, engage a family member to care for the child, miss work [indicate the number of hours missed]). At the bottom of the calendar the parents were asked to indicate the name and the cost of each medication bought. The calendar was formatted as a grid where the parents could easily check the appropriate box for each day (Appendix 1).
The proportion of time with a cold was computed, for each child, as the total number of days with cold symptoms divided by the number of days of follow-up and then multiplied by 100. Similarly, the proportion of time with diarrhea and the proportion of time with vomiting were computed. If a child had a combination of the three symptoms, s/he was counted in each of the three groups.
Absence From the DCC Because of a Study Illness
Day care educators were also given calendars to indicate the occurrence of illness, the days each child was expected to attend DCC (especially for part-time children), and absences with their causes when known. Data from both the parents and the educators were linked to assess the number of days of absence and their cause. An absence was considered to be caused by illness if: 1) the educator declared the child was absent because of a study illness, or 2) the educator declared the child was absent because of an illness or an unknown cause and the parents declared for the same day that the child had study illness(es). The numbers of days a child should have attended the DCC was computed using the data from the educators. The overall proportion of absence was computed as the sum of days of absence divided by the sum of days each child should have attended the DCC. Data from educators were only available for the first 5 months of follow-up (September 1, 1996 to February 1, 1997), therefore, the proportion of absence was computed for this period only.
Evaluation of the Costs
Both direct and indirect costs were ascertained. All costs are reported in US dollars. On January 2, 1997, one Canadian dollar was equivalent to 0.73 American dollars.22 These costs are only descriptive and are not the equivalent of costs attributable to day care attendance.
Direct Costs
Direct costs included medication and visits to a physician.
Medication
The medications were divided into prescription drugs and over-the-counter (OTC) drugs. For each medication, the price declared by the parent was used as the actual cost. This procedure was used because there is a large variation in costs of both prescription and OTC drugs between regions and different drugstores. For summary statistical purposes, if the price of a specific medication was missing the average price (if more than four observations available per region) or the price set by the government, adding a pharmacy fee, was used23 or, for OTC drugs, the lowest price reported by two drugstore chains by region was used. Throughout, pediatric formulations were used. Some medications were bought during an illness-free period. These were nonetheless included because some parents might have continued the treatment after the symptoms disappeared and some may have stored OTC drugs for later use in relation to the study illnesses (eg, cough syrups, analgesics, etc).
Visit to a Physician
All visits to a physician, be it for a first or a follow-up visit, were included. In the baseline questionnaire, 48 parents declared taking their child to a physician within the previous 4 weeks because of a cold. A weighted cost for an average visit to a physician was computed by taking into account the type of physician (general practitioner or pediatrician) and type of setting (hospital emergency department, private clinic, community clinic). In Québec, the government sets the fees for medical care. The fees attributed to each visit were those for a first visit.24,,25 The weighted cost for an average visit was set at $20.16.
Indirect Costs
Indirect costs included the cost of alternative care used when a child was ill. Alternative care included care provided by a family member (other than the parents), by a babysitter, or by an employed parent who missed work. These alternative care events were counted when they occurred during the time the child was reported to have one of the study illnesses.
Cost of an Employed Parent Missing Work to Care for a Sick Child
We calculated the value of lost parental working time according to two alternative methods proposed in the literature: the replacement cost method and the opportunity cost method.26,,27 In the replacement cost method, the lost time of parents was valued as the amount that parents would have to pay a day care caregiver to look after their child using the average wage of an occasional caregiver without specialized training in the region of the DCC.3 The total cost of lost work time was then calculated by multiplying the reported numbers of hours lost by these hourly earnings. Given the high level of educational attainment of parents in this sample, the replacement cost method is likely to be a quite conservative estimate of the lost value of work time by parents. In the opportunity cost method, we valued the lost time as the opportunity cost, or the value of the time in its best alternative use. Based on the theory of the labor supply, this opportunity cost is represented by the parents' lost wages.28 Therefore, in the opportunity cost method, full-time working parents had their lost time valued at the average hourly earnings for full-time workers in Québec of the same gender and educational attainment.29 Hourly wages were computed assuming that a work year corresponded to 49 weeks of work at 40 hours per week for full-time workers. The study population is similar to Québec's working population with respect to hourly wages. In the baseline questionnaire, the parents were asked who usually misses work when the child is sick and cannot attend DCC and was used to compute the opportunity cost. If the parent usually missing work was not working full-time, the replacement cost method was used.
Cost for Care Provided by a Family Member (Other Than the Parents)
The replacement cost method was used. The average hourly wage paid to an occasional caregiver without specialized training for each region was used to approximate the cost of care provided by a family member.3 The total cost per day was calculated as the hourly wage multiplied by 8 hours.
Cost for Care Provided by a Babysitter
This cost was estimated in the same way as for care provided by a family member.
Statistical Analysis
Averages, standard deviations (SD), medians, and first and third quartiles of the frequency of actions taken and their costs are reported. Parents could enter or leave the cohort at any time during the reporting period. Therefore, the number of days of reporting could vary. Only parents followed for a total of at least 35 days are included in this analysis. The frequency of actions taken and all costs were adjusted by the number of days of follow-up for each child. For example, the adjusted number of medications bought equals the crude number of medications bought divided by the number of days of follow-up for that child multiplied by 182 days (number of days of follow-up for the 6 months). The assumption is that the frequency of medication taken during the number of days of follow-up would remain constant throughout the 182 days. (In fact, this assumption will probably not introduce a big difference given that the median number of days followed was 168 of the 182 total days [see Tables 1A and B].)
Sociodemographic Description of the 273 Study Children and Their Parents
The agreement between information provided by parents in the baseline questionnaire and information provided by parents during the longitudinal follow-up concerning alternative care was assessed using a κ value.30
Ethics
The study was approved by the Montreal General Hospital Ethics Review Committee and the Cité de la santé de Laval Ethics Review Committee. Each child received a confidential study α-numeric code. The two telephonists were given only the child's code and the phone number of the parents.
RESULTS
Parents of 277 toddlers attending 48 DCCs participated in the reporting period between September 1, 1996 and March 1, 1997, among whom 273 children were followed for at least 35 days, 265 being followed during the fall and 266 followed during the winter. Two hundred and fifty-eight children were followed both during the fall (September 1 and November 30, 1996) and the winter (December 1, 1996 and March 1, 1997). The characteristics of the 277 participating parents did not differ from the characteristics of the 102 parents who filled in the baseline questionnaire but did not take part in the reporting follow-up in all sections of the questionnaire (data not shown). Overall, 379 parents had answered the baseline questionnaire as of March 1st.
Description of the Study Children and Families
Tables 1A and 1B show the sociodemographic factors of the 273 study children and their families.
Frequency of Illness
The average percentages of time with cold, diarrhea, or vomiting were 23.4% (SD = 17.0), 2.3% (SD = 3.6), and 0.9% (SD = 1.4), respectively, for average durations of illness episodes of 12.1 days (SD = 13.4), 3.0 days (SD = 2.6), and 1.6 days (SD = 0.8), respectively. Median durations were 8.4, 2, and 1 day, respectively.
Frequency of Absence Because of Illness
The 273 children attended DCC a total of 18 551 days during the first 5 months of follow-up. During this time, there were 502 days of absence associated with study illnesses. The corresponding overall proportion of absence was 2.7%. Most absences were because of only one study illness (86.1%). The proportion of absence was higher in the 2 winter months (December, January) compared with the 3 fall months (3.5% vs 2.2%).
Evaluation of the Costs
The crude and adjusted frequencies of actions taken by the parents per child and season are reported in Table 2. The most frequently used alternative care was identified for each child. A lack of agreement between the information in the baseline questionnaire and the actual follow-up was noted for all types of action with κ values ranging from 0.15 for care provided by a family member to 0.24 for care provided by a babysitter, and with a value of 0.20 for parents that declared usually missing work.
Crude and Adjusted* Mean and Median Number of Times Per Child the Parents Had to Buy Each Type of Medication, Consult a Physician, Ask a Babysitter to Care for the Child, Ask a Family Member to Care for the Child or Miss Work, and the Adjusted Number of Work Hours Missed, by Season in Québec, Canada (September 1996–March 1997)
Table 3 shows the crude and adjusted costs resulting from cold, diarrhea, and vomiting in this group of toddlers.
Crude and Adjusted* Median and Average Direct and Indirect Costs ($) Per Child of the Different Actions Taken by Parents Because of URTI, Diarrhea, and/or Vomiting for a 6-month Follow-up Period (September 1996–March 1997)
Direct Costs
Medication
Overall, 248 (90.8%) parents had to buy at least one medication for their sick child, among whom 213 (78.0%) bought OTC drugs and 182 (66.7%) bought prescription drugs. The parents bought a total of 975 medications, 441 prescription drugs and 534 OTC drugs, among which the cost for 204 (20.9%), 115 (26.1%), and 89 (16.7%), respectively, were missing and subsequently imputed. Among OTC drugs, the vast majority were analgesics (n = 228; 42.7%) and cough syrups (n = 212; 39.7%) and only 18 (3.4%) were associated with gastrointestinal symptoms. The prescription drugs were mainly antibiotics (n = 342; 77.6%), and an important proportion was for asthma treatment (n = 80; 18.1%). Although OTC drugs were bought more frequently, they cost less than prescription drugs, with adjusted means of $12.44 and $35.03 per child for 6 months, respectively (Table 3). Although season did not have a significant effect on the adjusted number of times prescription drugs were bought, their costs were significantly higher in winter compared with fall (difference = $16.47; 95% CI = 6.99,25.95). There was no such difference for OTC drugs (difference = $−0.15; 95% CI = −2.21,1.92).
Consultation With a Physician
Overall, 202 (74.0%) parents consulted a physician at least once corresponding to an overall adjusted cost per child for 6 months of $49.10 (SD = 51.34; Table 3). There was no significant difference in cost between the seasons ($22.55, SD = 33.23, during the fall and $23.66, SD = 29.08, during the winter).
Indirect Costs
Costs because of missed working hours: replacement costs and opportunity costs methods were used to show the difference between a very conservative method of attributing a value to the working hours missed (replacement cost method) and a method more closely reflecting the real cost value (opportunity cost method). The adjusted averages per child for 6 months were $63.43 (SD = 101.30) and $125.35 (SD = 226.65) for the two methods, respectively, with corresponding medians of $13.79 and $22.44, respectively. Which method is used to assign values for missed working hours has an important impact on the estimation of the overall average and median costs. Both approaches are presented here in order for the reader to select that method which best reflects personal preferences or local situations.
Alternative Care
Overall, 60 parents (22.0%) asked a family member to take care of the child at least once, 25 (9.2%) asked a babysitter to take care of the child at least once, and 142 (52.0%) had to miss work at least once. The adjusted average costs per child for 6 months for alternative care provided by a family member and a babysitter were $35.19 (SD = 94.52) and $11.59 (SD = 49.16), respectively. The large standard deviations are attributable to the small number of parents that had to ask babysitters or a family member to care for their child.
Total Costs
Total costs using replacement cost and opportunity cost are also presented in Table 3. There is approximately a $35 difference in the average total costs when comparing the crude to the adjusted cost per child estimation. Whether replacement cost method or opportunity cost method is used, the indirect costs associated with parents' working hours missed contribute to at least one third of the total cost. Costs associated with consultation with a physician comes second, closely followed by the costs of medication.
DISCUSSION
This is a first attempt to comprehensively evaluate costs incurred by parents and society in caring for an ill toddler who attends day care. The originality of this study rests on the exhaustive reporting of all actions taken by parents in caring for their ill child, including weekends, rather than being limited to actions taken only if the child did not attend the DCC during the week19,,20 or actions based only on parent's recall.6,,10,17
For feasibility reasons, neither a total population nor a completely random sample of DCCs could be selected and recruited. Nonetheless, our study design permits generalization of our results for DCCs having more than 40 places and may be pertinent for all sizes of DCCs. The sociodemographic factors of parents responding to the questionnaire were similar to those of parents participating in the follow-up. According to the 1996 Canadian census, the overall percentage of single parent families is 15.9% in Québec, which is similar to the 15.4% found in our study population.31 The study parents were more educated than Québec's general population of full-time workers.29 Two American studies noted a similar trend when comparing parents of children in DCCs to parents of children staying at home, the former were found to be more educated.10,,32
The proportion of time with an illness was similar in both seasons and comparable to previous estimates.13,,32 The proportion of absence was higher during the winter. This may be related to the severity of the illnesses during the winter season. The proportion of absence associated with cold symptoms, diarrhea, and/or vomiting (2.7%) was considerably higher than the 0.56% documented in the only other study reporting absences from DCCs in Québec.14 There may be several reasons for this including the young age of the children followed in our study,21 the source of information (parents instead of staff),14 season,33 and the methodology used to compute the exact number of days of potential attendance in our study.
Although medication use in various countries may differ, it is still interesting to compare our results to what has been reported elsewhere. Few other longitudinal studies have focused on antibiotic or prescription drug use only.6,,12,15,2034–36 In Sweden, the reported average number of antibiotic purchases was 1.05 throughout a 9-month period for 2- to 3-year-old children.35 In Finland, estimates of 0.53 throughout a 2-month period12and 2 per child-year15 for children less than 36 months were obtained. Although the indications for antibiotic prescriptions may vary in time and locality, our estimate (2.03 prescribed drugs per child throughout a 6-month period) compares well with the observed frequency of antibiotic treatment for toddlers attending DCCs in Scandinavian countries where the climate is similar. In addition, our estimates are adjusted for the duration of follow-up, which may explain some of the discrepancy with the other estimates. Presser,17 based on the 1981 Child Health Supplement of the National Health Interview Survey, reported that 46.4% of 2-year-old children attending DCCs had a medicated respiratory illness in the past 2 weeks. This agrees with the average number of medications bought during our follow-up period (4.46 drugs per child throughout a 6-month period), including both prescription and OTC drugs, the vast majority being associated with cold symptoms. The high prescription drug usage might show that some physicians may inappropriately prescribe antibiotics to children.
Two-thirds of the medication costs are from prescription drugs, primarily represented by antibiotics. Only one-third of the costs are from OTC drugs but their inclusion in cost estimates is essential because it best represents the behavior of many parents. Moreover, these drugs are not covered by the usual drug insurance programs and are thus paid directly by parents. As for prescription drugs, some attempts have previously been made to estimate their costs for the treatment of minor illnesses. The two previously published estimates of costs per child associated with prescription drugs (including antibiotics) are $5.90 per month6 and $8.60 per year.20 Our estimate ($5.84 per month) would agree with the former amount where the cost of prescription drugs was obtained directly from the pharmacy charts.
The costs for prescription drugs were higher in winter than during the fall. This may indicate that the doses were higher or that the type of drugs prescribed changed in winter. This could be an indication of more severe illnesses during winter, as already suspected because of the higher proportion of absence.
The high frequency of visits to a physician observed in our study (2.4 visits per child during a 6-month period) compares well to what has been reported previously for populations of infants and toddlers who are covered by a prepaid medical insurance plan (3.0 diagnoses per child throughout a 7-month period)6 and infants and toddlers attending municipal DCCs in Finland (4.2 visits per child-year).20 In the latter study, the estimation of visits to a physician was based solely on a subsample of the study population (180 absences in 8 DCCs) and on parent's recall. In the study by Bell,6 the exact number of visits to a physician was assessed from the medical charts of the insurance group and are thus probably accurate. Our estimate of cost ($8.18 per child-month) was considerably lower than the one reported by Bell ($19.72 per child per month)6 and closer to the one reported by Nurmi20 ($149 per child per year in Finland). In Québec, as in Finland, the health care system is public and there are no fees to parents associated with a visit to a physician per se. In addition, the fees for a visit to a pediatrician are lower than those for a general practitioner—and are substantially lower than those found in the United States—which explains the lower costs found in our study. Only fees for a first visit were used, excluding any possible hospitalization fees, costs for more complicated laboratory tests, or transportation costs to the clinic. Our cost estimates probably underestimate the true total cost for the medical care of an ill toddler attending DCC.
We presented two methods for estimating costs associated with working hours missed by parents. The opportunity cost method is already quite conservative because it only attributes a higher wage to full-time workers. This method based the estimate of hourly wages on Québec's population of full-time workers, 52% having children and 4.6% being from a single-parent family.29 This method uses the exact number of hours missed by parents, which allows for a more precise estimate of the costs. Costs associated with missing working hours remain the principal component of the total costs, as already observed in previous studies.6,18–20
The costs associated with caring for an ill child by a family member have been neglected in previous studies. Because the time these caregivers spend in caring for the child could be used for market work, nonmarket or household work, or leisure (an economic good), the cost of illness must reflect the economic loss of these alternative activities. As care by a family member represents a significant element of alternative care for two-wage earner families, omitting their costs will lead to a serious underestimate of the costs of illness. Based on the National Longitudinal Survey of Labor Experience conducted between 1979 and 1984 in the United States, 7.1% of the grandmothers were considered as the secondary caregivers (providing an average 11.4 hours of care per week).37 Similarly, 5.5% of parents participating in our 1996 to 1997 study who usually asked a family member to care for their ill child during the follow-up period. Cost estimates therefore should include alternative care provided by family members.
Only in two previous studies have costs associated with the care of an ill child by a babysitter been assessed.19,,20 Our estimate of 3.6% of parents who declared using exclusively a babysitter for alternative care falls between estimates of 1% from the United States and 7.6% from Finland, respectively.19,,20The Helsinki study reported a cost of $154 per child-year for care provided by a babysitter that is considerably larger than our estimate of $23.18 per child-year. However, the Helsinki estimate was based on the assumption that the babysitter had the same income as the mothers, which overestimated the true value. In addition, basing a cost analysis on a cross-sectional questionnaire only partially reflects the variations of day-to-day living. In our study, there was poor agreement between what the parents declared in the baseline questionnaire compared with what was actually being done during the follow-up period. The answers in the baseline questionnaire may perhaps indicate what actions the parents would have preferred to take rather than those they actually did take. This suggests that results from studies assessing indirect costs associated with alternative care should best be obtained from longitudinal studies.
The average total cost of caring for an ill child estimated in our study ($260.96 per child throughout a 6-month period) is lower than what has been reported in the literature. In Finland, the annual cost of caring for ill children attending municipal DCCs was $2572 per child under 3 years of age. However, this study included underutilization of DCCs as an indirect cost ($952) and it assumed that mother's absenteeism was always a full day of work (ie, no part-time absenteeism [$1140]).20 By including the DCC costs as part of the incremental costs, they seem to have double counted the costs attributable to the DCC. This explains a large part of the difference in the results. In our study, we limited incremental costs to costs of treating illness at home (medical expenses and indirect costs of parental/babysitter/family care) and we considered the exact number of hours missed from work. Our total costs are therefore closer to those found in Bell's6 study ($369.84 per child throughout a 7-month period) where hospitalizations were included as a cost, but OTC drugs and alternative care provided by a family member or babysitter were not.6
We computed the costs as a result of the care of toddlers in DCCs based on attributable risks of illnesses reported in other studies. In our study, we obtained an incidence rate of 6.1 URTI per child throughout a 6-month period (data not shown) that costs, on average, $260.96. This is equivalent to a cost of $43.13 per episode of URTI. If we assume, based on Fleming's9 study, that the relative risk of URTI is 1.6 for toddlers attending DCC compared with children cared for at home, the latter would have 3.8 URTI per child-year. The corresponding incidence rate difference is 2.3 episodes per child-year. Thus, there would be $99.20 (2.3 × $43.13) additional costs for toddlers attending DCCs. In Québec, from March 25 to 29, 1996, there were, on average, 3440 children age one year and 8792 children age 2 years in DCCs.3 If we assume that half the children age 1 year are actually 18 months old and older, there would be 10 512 toddlers aged between 18 and 36 months in licensed DCCs in Québec. This would correspond to an additional cost of $1 042 779 for the 6 fall and winter months for parents and society to care for an ill child attending DCC in Québec, Canada. Haskins18also estimated the additional costs to parents and society for the 7.2 million American children under 5 years of age attending child care and arrived at a figure of $1.8 billion per year ($250 per child-year). Although this estimate is based on several assumptions and various sources, it very closely approximates the additional costs we would extrapolate for Québec's population of children in day care (99.20 × 2 = $198.40 per child-year).
Estimating costs associated with illness in children attending DCC is challenging. We have proposed a methodology, using Québec as an example, to comprehensively include all costs incurred by both the parents and society. Developing better methods to estimate costs will contribute to improve cost-effectiveness analysis of potential hygiene programs aimed at reducing the frequency of infectious diseases in DCCs.
ACKNOWLEDGMENTS
Funding for the study was provided by Rhône-Poulenc Rorer Canada Ltd. Support was also received in the form of personnel awards to Hélène Carabin and Theresa W. Gyorkos (National Health Research and Development Programme) and to Theresa W. Gyorkos, Lawrence Joseph, and Jean-Paul Collet (Fonds de la recherche en santé du Québec) and to John Penrod (Montreal General Hospital Research Institute). The pharmacies Jean Coutu and Pharmaprix provided the missing costs for medications. Expert consultations with the Office des services de garde à l'enfance (the Québec government's day care regulatory body) were managed by Collette Boucher, Marie-Patricia Gagné, and Louise Rosso.
The following individuals provided essential support: Caroline Gendron, Valérie Desrosiers, Marc-Antoine Godin, Hanna Zowall, Alejandra Irace-Cima, Serge Benayoun, Christian Klopfenstein, Nabila Haider, Pierre Payment, Yvan St-Pierre, Patrick Bélisle, Lucie Blondeau, Louis Coupal, Sylvie Marchand, and Lora Tombari. This research would not have been possible without the sustained involvement and commitment of the children's parents and the day care educators and directors. Lastly, we appreciate the participation of the children who provided a constant source of surprise, happiness, and inspiration.
Footnotes
- Received March 18, 1998.
- Accepted August 13, 1998.
Reprint requests to (H.C.) Wellcome Trust Centre for the Epidemiology of Infectious Diseases, University of Oxford, Oxford, 0X1 3PS, United Kingdom.
- DCC =
- day care center •
- URTI =
- upper respiratory tract infection •
- OTC =
- over-the counter •
- SD =
- standard deviation
REFERENCES
- Copyright © 1999 American Academy of Pediatrics
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