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Indian Journal of Community Medicine

Quality of Child Health Services at Primary Care Level (Rural Vs Urban) in Lucknow District

Author(s): M. Agarwal, M.Z. Idris, N. Ahmed

Vol. 29, No. 4 (2004-10 - 2004-12)

Abstract

Objectives: To compare the quality of urban and rural primary level child health services.

Design: Cross sectional study.

Setting: Rural and urban primary care health facilities of Lucknow district.

Subjects: Children under 5 years of age, attending child clinics.

Methods: We observed 325 children attending child clinic at primary health facilities; of these 214 were from rural area and 111 from urban area. A total of 9 health facilities were observed. Structure and process attributes of quality were assessed through a checklist and observations respectively. Quality was measured against national standards of practice guidelines.

Result: Both rural and urban centers were reasonably good with regard to the structure aspect of quality of care. However, both were poor when it came to technical aspects of quality. Overall, quality of childcare services was of average grade. Quality of diarrhea control services, ARI treatment was poor at all centers while that of immunization services was of good grade at all centers.

Conclusion: There is need to equip the health providers with the supplemental training to promote and ensure accurate identification, management of childhood diseases and strengthening of caretakers as far as counseling skills are concerned.

Key Words: Quality of health services, Primary care, Child health

Introduction

Every year some 12 million children of developing countries die before they reach their fifth birthday; many during the first year of life. Seven in ten of these deaths are due to acute respiratory infections, diarrhea, measles, malnutrition, or a combination of these. The global burden of disease indicates that these will continue to be major contributors to child mortality, unless significantly greater efforts are made to strengthen access to optimum quality of primary health care delivery through motivated and proficient health care providers.

In India, all health programs have overwhelmingly emphasised quantitative aspect of services delivered. A close look at the evaluation of MCH and Family Planning services reveals that in quest to chase targets the concept of quality health care has been neglected. However, in recent years, substantial efforts have been made to improve the quality of care in public sector through Reproductive and Child Health Program.

Quality1 is defined by Institute of Medicine as, "the extent to which health services for individual and population increases the likelihood of desired health outcomes and are consistent with current professional knowledge". Three separate but related activities constitute much of the current work on quality: practice guidelines, quality assessment, and quality improvement. Quality assessment determines the extent to which actual practice is consistent with a particular indicator of quality, such as adherence to practice guidelines.

Building on a conceptual framework proposed by Donabedian2 three major aspects of care could be evaluated: the structure of care delivery system, the process by which care is delivered and outcome of care. Structure of the care delivery system includes material, human, financial and organisational structure; process of care includes both technical and interpersonal dimensions and principally captures the content and method by which health providers deliver services to their patients. Outcome of care indicates the effects of care on the health status of population or patients (morbidity and mortality).

Keeping in view the conceptual framework proposed by Donabedian, the present study attempts to assess the quality of delivery of childcare services at primary care level and to identify the weakness so that appropriate measures may be taken to provide responsive and effective care to each and every child.

Methodology

The study was undertaken at various primary health care levels in Lucknow district. A multistage stratified random sampling was used for the selection of health care centers based on the guidelines of primary health care mangement advancement program by Aga Khan Foundation.

All the primary health care delivery units were statified for urban and rural areas. At first stage one block level PHC from the rural area and one maternity center (MC) from the urban area was randomly selected from a single frame of all primary health care facilities within Lucknow district. At the second stage, two additional PHCs attached to block level PHC and two health posts from already selected maternity centers were included. At the third stage only one sub center from each of the selected PHCs was randomly chosen for the study, as no equivalent counter part of sub center was present at urban area. A set of ten beneficiaries for each service were randomly selected from each of the health facility in rural as well as urban area. The sample thus consisted of 6 rural health centers and three urban health centers. A total of 325 children(0-6 years) attending child clinics were observed; of these 214 were from rural area and 111 from urban area.

Assessment of Service Quality

The present study mainly focus on the assessment of the process of service delivery by determining whether services are provided according to established norms for quality care. The process attributes were measured through observation of service delivery encounters between providers and clients. The checklists were made up largely of lists of task that providers are expected to carry out in clinical assessment (history and physical examination), treatment, and health education. The service quality checklist were made up of `yes' and `no' questions. The questions were phrased so that all `no' responses indicate potential problems.

Structure attributes of quality were also assessed using a checklist based on various characteristics, e.g. general infrastructure, availability of basic equipment and availability of drugs and vaccines.

Quality of services was scored on the basis of percentage of activities performed correctly as per the checklist for each content of child health services. Percentages for differnt activities at each unit were pooled and then divided by number of activities/facilities to obtain overall grading of centers. The grading of the child health services for each of the center was done using 5 points scale.

Quality Score Rank Grade
80+ 5 Very Good
61-80 4 Good
41-60 3 Average
21-40 2 Poor
0-20 1 Very Poor

Results

Physical Infrastructure

It was observed that out of nine health centers overall physical infratructure was best available at maternity center. The situation at sub-centers was found to be very dismal. Only 16.6% centers in rural area had adequate waiting space in comparison to (33.3%). Facility of separate room for consultation was totally absent in rural areas and at health posts. Auditory and visual privacy during examination was available in 22.2% centers of urban and rural areas. Overall 55.5% centers had electric supply and in rural area only 16.6% centers had toilet facility. Availability of basic equipment, drugs and vaccine was reasonably good in all urban and rural centers. However availability of IEC material was more (50.0%) at rural centers in comparison to urban centers (33.3%). None of the centers in both areas had measuring tape and cup/spoons to administer ORS. Gloves and MCH cards were scarcely (16.6%) available in the rural centers. Antibiotics were not at all available at health posts.

In almost all the cases a single sterilized needle and syringe was used. Children were given all the needed vaccinations. Vaccine were applied at the right level and vaccine was used correctly with ice pack. In rural areas, no patient was reminded that child could be immunized even if she/he is ill and less than 50% of caretakers were explained about importance of completed vaccination schedule. In urban areas 26.7% clients were reminded of this. Of all the centers, immunization services were provided best at the maternity centers. No client was encouraged to ask any question.

Almost all the clients (more than 90%) were asked about duration / frequency of stools. ORS solution was prescribed to 92.-% clients but only 54.0% clients were recommended safe home treatment with ORS. Moreover, no client was told about signs of dehydration and danger signs. No client was asked for presence of blood/ mucus in stools, and very few (<10.0%) were asked for presence of vomiting and fever.

Table II shows that almost all the clients were inquired of duration of cough but none of them was asked about past respiratory problems and past treatment if any. No mother was told about signs of severe ARI and importance of giving extra fluid to child ruing illness.

Age of all the children was measured correctly. Very few children (<5.0%) were referred for nutritional counseling and very few mothers were explained importance of breast-feeding. No urban client was told importance of breast-feeding, balanced diet, purpose of growth monitoring, and advised regarding day/ time for next weighing. Correct plotting of weight, use of growth charts for explaning child's growth to mothers and recommending for child feeding and care was done more in case of rural clients than the urban clients.

The scoring and ranking of all the centers in table III shows that overall availability of physical infrastructure was poor at all centers. Availability of vaccines/ drugs scored very good for all the centers. Quality of childcare services was of average grade. Quality of DDC, ARI was poor while that of immunization services was of good grade in all the centers rural as well as urban centers except PHCs. Quality of immunization and DDC services was better at maternity centers when compared to other centers.

Discussion

It was observed that child health services of government health facilities were availed more by rural clients than by urban clients. It may be due to urban clients' preference for private practitioners as far as their child's health is concerned. It is only for immunization services they look for the services of government health centers.

The study showed that in spite of satisfactory structural attributes in all the centers, neither rural nor urban providers were offering an adequate quality of care from the technical point of view, although urban providers were performing better.

Table I: Quality of Diahrrea Disease Control Services

Service Elements Rural
N=39
Urban
N=26
'P'
Medical History
Duration/Frequency of Stools 100.0 92.3 0.1
Consistancy of Stools 17.9 7.69 0.2
Presence of Blood/Mucus 0.0 0.0 -
Presence of Vomiting 2.6 0.0 0.3
Presence of Fever 10.3 7.6 0.7
Physical Examination
Assessed General Status (Alerrt/Lethargic) 30.8 38.4 0.5
Pinch Skin 38.5 46.1 0.5
Weighed Child 0.0 0.0 0.0
Classification and Treatment
Determined the Degree of Dehydration 35.9 61.5 0.03
Prescribed ORS solution 92.3 92.3 -
Recommended Safe Home treatment with ORS 48.7 61.5 0.3
Refrained from using Antibiotics 61.5 100.0 <0.0
If child dehydrated administered ORS immediately or was referred  n=2 100.0 - -
Education
Told how to prepare ORS 71.8 65.3 0.2
Told how much and how often to give it 71.8 50 <0.05

Told Appropriate Feeding Practices during Diarrhea

33.3 11.5 0.02
Told Client about at least 3 signs of Dehydration 0.0 0.0 -
Told Client at least 2 danger sign for the Referral 0.0 0.0 -
Ask the Client if she had any questions 0.0 0.0 -

Table II: Quality of Respiratory Tract Infection Treatment

Service Elements Rural N=55 Urban N=25 'P'
Medical
Presence/Level of Fever 64.3 52.0 0.3
Duration of Cough 92.9 100.0 0.3
Any H/o (Past) respiratory problems 0.0 0.0 -
Any Treatment Administered 0.0 0.0 -
Physical Examination
Counted Respiratory Rate 14.3 52.0 0.001
Took Temperature 0.0 0.0 -
Auscultated Chest 10.9 12.0 0.8
Treatment
Classified Child by severity of Illness 16.1 60.0 <0.0
Administered Antibiotics for Pneumonia/Otitis media (n=4) 100.0 - -
Refrained from using Antibiotics for Cold 55.4 52.0 0.6
Administered Cough Mixture 17.8 13.3 0.1
Education
Explained How to Administer medicine 92.8 100.0 0.03
Told Mother about at least 3 signs of severe ARI 0.0 0.0 -
Told Mother to give extra fluid (breast Feeding during illness) 0.0 0.0 -
Told Mother to return for further consultation if childs condition worsens or does not improve 0.0 0.0 -
Asked the Client if she had any question 0.0 0.0 -

Table III : Rating of Quality of Services

  Score (rural) Rank (Urban)  
PHC SC Total MC HP Total Grand Total
Structural Attributes
Physical Infrastructure 50 5 28 100 42 61 39
  (3) (2) (2) 5 3 4 (2)
Basic Equipment 64 56 60 77 58 64 61
  (4) (3) (3) 4 3 4 (4)
Drugs/Vaccine 100 81 91 100 83 89 90
  (5) (5) (5) 5 5 5 (5)
Overall 71 47 60 92 61 71 63
  (4) (3) (3) 5 4 4 (4)
Services
Immunization 55 66 61 88 77 79 66
  (3) (4) (4) 5 4 4 (4)
DDC 32 38 55 49 27 35 35
  (2) (2) (2) 3 2 2 (2)
ARI 37 22 33 40 25 32 32
  (2) (2) (2) 2 2 2 (2)
GM 48 39 50 22 37 27 38
  (3) (2) (3) 2 2 2 (2)
Overall 43 41 45 64 42 43 43
  (3) (3) (3) 4 3 3 (3)

Immunization Services

During the study it was observed, only (30.0%) rural clients were advised about the importance of completing vaccination schedule in comparison to 73.3% among urban clients. Only 8.8% clients were told that vaccination could be done even during illness and only two third clients were reminded about next visit. Similar to this Gulati et al3 have reported that a greater proporation of mothers of rural as compared to that of urban areas were ignorant of the benefits of immunization. They also found that most frequently encountered obstacle during immunization in rural, as well as urban clients were discontinuation of vaccinations by them during illness. Aswar et al4 also reported mothers were not knowing the importance of immunization & immunization schedule. Hence there is need to educate the mothers regarding importance of immunization and visit for next dose should be emphasized at every visit. Streefland5 et al found that in India most health workers were unable to define the contraindications to vaccination. Side effects of immunization and their management were explained to 56.7% rural and 83.3% urban clients. However, in such cases also, only fever as a side effect was emphasized upon and for its management "paracetamol" was often provided by the health provider. This is in line with Streefland5 et al studies, which reported that information on side effects is given only when a mother comes with her first child for vaccination, and there was confusion about nodule formation in respect of BCG vaccination.

Lack of communication between provider and clients might threaten the continuity and coverage of immunization programme and promote the growth of pools of unvaccinated and partially vaccinated children. Providers should be trained to make full use of all opportunity available at contact with the parents to give required information.

Diarrhoea Disease Control Services The most vital aspects of DDC case management eg., education on appropriate feeding, increase fluids, proper preparation and administration of ORS and danger signs for immediate care seeking were often neglected by the health providers in rural as well as urban settings.

CDD6 surveys also have shown concern about low quality treatment practices and reported inadequate assessment of status of dehydration, observed error in the performance of health providers while determining severity of dehydration in children. The study suggested that health workers were lacking in technique of classifying the illness and health education and so missed the opportunity to educate mothers on various diarrhea case management issues which in long run can change thecommunity practices, awareness and can save the life of many children in future.

Acute Respiratory Infection Services

It was observed that danger signs of severe ARI and method of administrating extra fluid during illness were told to none of the clients. Bojalil7 et al found that 27.5% health workers were counseling mothers properly, 35.0% indicated 1-2 danger signs and 20.0% did not know about any danger signs.

In the present study, 57.5% of the clients were asked to refrain from taking antibiotics for mild ARI. NFHS8 in U.P. found that children were most often treated with antibiotics or cough syrup. A home remedy was used in less than 10% cases.

The reasons why health workers perform badly needs to be investigated and ways held to be found to improve their performance. It needs to be established whether the problem is lack of knowledge or whether workers are not able to translate knowledge into appropriate practices.

Growth Monitoring

There was remarkable correspondence in the results obtained in our study and studies of Gopaldas9 and Gopalan et al10 where also AWWs proved to be competent in weighing of children and in plotting of growth data. Our study was corroborated by CARE11 findings that only one-third ANMs and 40% AWW discussed the nutritional grade with the mother. Gopaldas in their study observed that mothers of children in normal channel of growth were not offered any advice on nutrition and care. Maximum attention was given to grade III and IV. As with all other MCH services, health eduation was the weakest link. As a result, proper growth monitoring and assessment of nutritional status of children is hampered.

During the study, it was observed that none of the clients was encouraged to ask any query to clear their doubts / problems and no efforts were made on the part of providers to know that whether clients understood the information. Lack of communication between provider and patients leads to inadequate gathering of information during consultation - leading to incorrect diagnosis, inadequate treatment and explanation and inadequate understanding on part of client and thus inadequate follow up of instructions.

Conclusions

It was seen that physical facilities and basic facilities were adequate in rural as well urban centers. However, in both the areas the qulity of service delivery process was poor. Of the four child health care services, which were evaluated (DDC, ARI, GM and immunization), two services viz, DDC and ARI were found to be of poor grade. It is necessary to increase the coverage and outreach of child care services to achieve the desired IMR & child mortality rate. However, as this study and other studies in this area show, that the quality of clinical management is poor and there is lack of proper health eduation / information with the clients. This has been a major obstacle in reducing IMR etc. Due to absence of complete information, the clients are unable to make full and proper use of available services and as a result, in spite of availablility of physical infrastructure, no favorable impact of child health care services is seen on the status of child's health.

Therefore, there is an imperative need to equip the health providers with the supplement training to promote and ensure accurate identification and management of childhood diseases and strengthening of caretakers as far as counseling skills are concerned. There is also a need to for reviewing training modules to ensure that they are conducive to high level of quality of care and at the same time, it is important not to forget the basics.

References

  1. Lohr K (Ed). Medicare : A Strategy For Quality Assurance, Vol I Washington DC, National Academy Press, 1990.
  2. Donabedian A. Explorations in Quality Assessment and Monitoring, Vol. 1 : The defintion of quality and Approaches to its Assessment. Ann Arbor. Mich, Health Administration Press, 1980.
  3. Gulati N, Sahgal K, Gogia V and Jain BK. Factors Influenicing Immunisation Status Of Urban And Rural Children In New Delhi. Indian Journal of Community Medicine 1990; 15(4) : 180-184.
  4. Aswar NR, Deot PG, Kale KM, Bhawlakar JS, Dhaye VR. Socio-Medical correlates of missed opportunities for Immunisation. Indian J Public Health 1999; 43 (4) : 148-51.
  5. Steerfland PH. Chowdhury AMR, Jimenez R. Quality Of Vaccination Services And Social Demand For Vaccinations In Africa And Asia. Bulletin of World Health Organisation 1999; 77(9): 722-30.
  6. CDD. Health Facility Survey, Child Health Development Report, WHO / CHD / 98.5 1996-97.
  7. Bojalil R, Guiscafre H, Espinosa P. et al. A Clinical Training Unit For Diarrhea And Acute Respiratory Infections. An Intervention For Primary Health Care Physicians In Mexico. Bulletin of World Health Organisation 1999; 77(11): 936-943.
  8. National family health survey, Uttar Pradesh (1999) : Preliminary Report NFHS-2 (1998-99). AC Nielsen Research Services Pvt. Ltd., New Delhi, IIPS, Mumbai.
  9. Gopal Das T. How well trained is the field level Aganwadi Worker in detecting growth retardation and Faltering in the `Under Sixes'? Indian Pediar 1998;25:41-46.
  10. Gopalan C. Use of Growth charts for Promoting Child Nutrition. New Delhi, Nutrition Foundation of India, Special Publication Series 2, 1985, pp 1-12.
  11. CARE. Integrated Nutrition and Health programme, Baseline survey report, Uttar Pradesh. State Institute of Health and Family Welfare Lucknow, Uttar Pradesh, 1997.

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