December 2007 - Volume 1, Issue 6

QUALITY ASSESSMENT OF PROVIDED CARE SERVICES FOR 0-6 YEAR OLD CHILDREN, IN URBAN HEALTH CENTERS OF SHAHEED BEHESHTI UNIVERSITY OF MEDICAL SCIENCES AND HEALTH SERVICES, TEHRAN, IRAN

Soad Mahfoozpour (1), Maryam Jadid Milani (2), Maryam Nooritajer (3) Assistant profesor of Faculty of Health, Shaheed Beheshti University of Medical Sciences and Health Services, Tehran, Iran. Phone: ++98- 21- 88731931 Department of Nursing, Shahid University, Tehran, Iran. Phone: ++98- 21- 88731931 Associate profesor and Manager department of community health nursing and MCH, Iran University of Medical sciences. Phone: ++9821 88773073 Email: maryamoorytajer@yahoo.com

ABSTRACT Background: One of the most vulnerable groups of the community is under children 6 years, considered as a vital source, in assuring a good future for the country. This study has been conducted to assess the quality of provided Care Services for 0-6 years children, in Urban Health Centers (UHCs), of Shaheed Beheshti University of Medical Sciences and Health Services (SBUMS), in 2002-2003. Materials and methods: This descriptive study was conducted to assess the quality of care provided for 0-6 years children in urban health centers affiliated with SBUMS. In this research 49 family health department personnel from UHCs were selected through multiple stage sampling, andand according to the different types of services they provided for 490 children, their performances were observed and andthen recorded by only one researcher. The physical environment information of each health center was also recorded for further statistical analysis between variables. Results: Forty percent of the personnel provided poor care, thirty one, andand twenty-nine parents o provided medium andand good quality of care, respectively. One hundred percent of the developmental care and 94 percent of nutritional care provided, was at a poor level. Provision of referral, follow-ups and reception services was at a mid-range of 77.8 and 74.3 percent accordingly, and growth assessment services were provided at a good level of 58.9 percent. There was a positive correlation between demographic characteristics of the personnel such as; age, marital status, number of their children, course of study, study degree, employment condition, years of work experience, and years of work experience in children services department, with the quality of service provided. The chi-square test also showed a significant statistical relationship (p<0.05), on the other hand, there was no correlation between other demographic variables like the place of living, and in-service education, with the quality of care. Most of the UHCs (57.1%) had a medium level of physical status and facilities, and none of them was reported with good condition. There was a positive correlation between the physical status of UHCs and care services provided by the personnel, the chi-square test was significant (with p<0.001). Conclusion: Regarding the importance of children under 6 years old health, and the research results, that showed a poor quality of care provided for them, we suggest more research to be carried out to assess the impact of interventions on quality and quantity of child health care services.

Key words: Quality of care, Child health care services.

INTRODUCTION

Children under six years old are the most vulnerable group in society. Healthy children are a vital resource to ensure the future well being of a nation^{(1, 2)}. Children's health care and development have a broader meaning, which includes the growth and the development of the country. Furthermore, children's health care is an invaluable investment, and it has an enormous impact on the country's economy and its political stability⁽³⁾. Therefore, the government takes on the responsibility of providing health care services for the children. Now, providing inadequate services can cause serious problems for the children, their families and ultimately the society. The slow process of the growth and the development of a child makes the explanation of the consequences of insufficient quality of childcare, more difficult; therefore, the poor quality of childcare may not be noticeable for many years ⁽⁴⁾. Children's health care services have some deficiencies in their quality of care⁽⁵⁾. On the other hand, in many other countries, the quality of care in governmental health care units has not been acceptable by the people⁽⁶⁾.

Providing a qualitative care is a national priority. Therefore, a profound scientific study is necessary for indication of the quality of children's health care services⁽⁷⁾.
Previous research shows that around 68 percent of the services, provided to this age group, had the best quality⁽¹⁾. In case of the type of services, the quality of services provided, were different, for example: Hegelin and colleagues (1998) showed that the services provided in the process of development monitoring were poor⁽⁸⁾. But in Shokrollahi's(1999) research these services were at a good level⁽⁸⁾. With respect to the importance of this vulnerable group of society (children under six years old) and due to the existing controversies regarding the quantity and quality of services which have been provided, and also for the purpose of determining the quality of health care services provided for children under six years old by the personnel of urban health centers; this research has been conducted in urban health centers of Tehran affiliated to the SBUMS in 2002-3.

METHODS AND MATERIALS

Each personnel's performance in different types of services provided by them for 10 children under six years old were observed. Therefore all the services provided for the total of 490 children, were observed and recorded in the checklists. Data collection tools consisted of a questionnaire for demographic characteristics completed by the research units and two types of observational checklists one related to the observation of physical environment of each health center, and the other for observation of the quality of care in different types of services provided by the personnel, including: growth and development assessment, children's nutritional status assessment, health education of mothers, referral and follow- ups, vaccination, and cold chain maintenance, which were observed and completed by only one researcher.
To determine the validity and reliability of the research tools, content validity and inter rater reliability for the observation checklists, and test-retest reliability for demographic questions was used. Also, the study was approved by the university ethical committee and health authorities.

RESULTS

The results of this research were obtained from 10 urban health centers, with performance observation of 49 personnel of these centers (research units) and 490 children. The observation's percentage in urban health centers of Shemiranat, North and East district health centers in Tehran, were 14.3, 30.6 and 55.2 percent respectively. The demographic characteristics of the personnel at the studied centers showed that: the age of personnel was 32.3 ± 7.9 years old, 71.4% were married, 28.6% were single, 60% of them had between 2 to 4 children and 40% of them had less than 2 children; they had studied midwifery (67.3%), family health (24.5%) and public health (8.2%), and the majority of them had a bachelor degree (63.3%) and 36.7 percent had associate degree. Their job experience was 8.5

Chart 1: Comparing the quality of health care provided in different services

The quality of care performed by the personnel of each urban health center, was categorized by different services as presented in chart 1, and shows that services such as assessment of development process, & nutrition, were the poorest services provided. The referral & follow up services were at a medium level; but the immunization & growth assessment, were provided by the personnel at a good level.

The quality of the provided services indicated the effect of the demographic characteristics of the staff, in each of the urban health centers. And when factors such as: age, the work experience, & the work experience in childcare unit increases, relatively the quality of services improve. Among the sample units, those who were married had better performance than singles, & those who had 2-4 children were better than those who had less than 2 children, in performing the services. Samples who had studied family health or public health were performing better services than those with midwifery degree, & those who had associate-degree were providing better services than those who had bachelor-degree, those who lived closer to their work places, & also those who completed their continuing education courses, didn't show a better performance (NS).

There was a positive correlation among the demographic characteristics: such as: age, marital status, number of children, study program, degree of study, years of work experience, & the experience in child care unit ( r= 0.40 to 0.60 ,p<0.05).
Most of the urban health centers (57.1%) had a medium level of physical condition & facilities & none of them had a good environmental condition. There was a positive correlation between physical condition & facilities of urban health centers with the quality of providing services by personnel. The chi-square test was significant (r= 0.70, p<0.001).

DISCUSSION

The results indicate that the quality of providing care by 40% of the personnel has been poor; Aldana & colleagues in their studies in Bangladesh in 2001 also showed that the quality of care provided by 32% of health care personnel for children was poor⁽¹⁾. Gest & colleagues' study in North Carolina (2000) indicates that 55 percent of health care services were also poorly provided⁽¹¹⁾. On the contrary, Seid and colleagues research in California (2001), showed that 55.1 percent of health care personnel provided good services⁽¹²⁾. The results of our study indicated that poor services provided for the under two years old children, was 43 times higher than the poor services provided to the 2-6 years old children (p<0.05). Children under 2 years old are vulnerable; now, this question exists that, why the quality of health care for this age group is so poor?. Can this be considered as a result of too many different services which has to be provided to the children under 2 years old? The answer might be either because of the inadequacy of personnel's knowledge & experience, or lack of enough time for learning, reviewing & education; or other issues that might exist. Therefore, with respect to the importance of the quality of these services, continuous education in some programs is recommended for the quality improvement of these services. Hundred percent of health care staff performed poorly on the child development services. Hagelin & colleague in Sweden in (1998), showed that, the development services provided for children between 2-6 years old is at a poor level⁽⁸⁾. Glasco in Pennsylvania (2001), also indicates that majority of studied staff were weak in recognizing children's development problems⁽¹³⁾. But, Shokrolahi in Najaf Abad, Iran, (2001), showed that 86.1 percent of the personnel provided good development services⁽⁹⁾. She executed her observation by two researchers, and only for one time, which can be a part of the limitations in her research; because, during the observation period perhaps the health care personnel tried to perform the services in a good manner, & caused a biased observation. While in our research, each personnel was observed for 10 times providing different services to different children. This, can be considered an advantage of the present study. On the other hand, Shokrolahi's research has been performed in rural areas of Najaf Abad and it is obvious that provision of primary health care services in rural areas of Iran is better provided than urban areas. Few researchers including Guest & colleague in North Carolina showed that the primary health care in rural areas is preformed better than urban areas⁽¹¹⁾. This study also shows the poor quality of health care in the development process, & indicators for movement, speech, & recognition. Regarding to the importance of possible problems, which can prevent the progress of the problem & make early treatment possible⁽¹⁾, the poor quality of these services up to 100 percent in our research, is dangerous; and emphasizes the need for more research to find out the causes. Also 94.9 percent of nutrition services, provided by health care personnel, were poor. Nowadays, nutrition is an important indicator of health care services, especially it has an important effect on children's development & growth; & it is considered as an effective & important factor in preventing diseases. Therefore, it is recommended to use nutrition professionals who are familiar with nutrition science in the health care network systems. Admission is the base of the other services for children; a good admission encourages the continuous visiting, increases the interests & cooperation of the parents. Therefore, it demands an especial attention.

The health care personnel provided the referral & follow up services at a medium level (77.8). Which was similar to the results of Gest et al study (2000),that showed 80 percent of referral & follow up services provided by the personnel was medium⁽¹¹⁾. Referral & follow up services are essential for early detection of the problems & the family becomes aware of the needed care. It is unethical if the referral & follows up services are not presented at a good level (14). The growth assessment & the immunization services were provided at a good level of 58.9 & 88.2 percent respectively. In Hageline & colleague studies, (1998) in Sweden, the growth assessment was also presented also at a good level⁽⁸⁾. In Rezaee's study in Ilam, Iran (2000), 47.5 percent of health care personnel performed the immunization services in an average level⁽¹⁵⁾ In this research, the growth assessment & immunization presented, was good, & since a good quality of these services, prevents children's intensive problems, & saves the investment of the country, it is delightful to see these services are being performed with a good quality. There is a positive correlations of medium to good range between healthcare quality & demographic characteristics such as: age, marital status, number of children, field of study, degree of education, experience, & experience in the child care unit (p<0.05). Ahmadian Shalchi's research (2000), in Savojblagh also shows that there is a correlation between the age & experience of health care personnel & the quality of providing the services⁽¹⁶⁾. Fathi's study (1999), suggested that there was no correlation between age, marital status, degree of education, living condition, number of children, & experience of health care personnel, & the quality of providing services⁽¹⁷⁾. There was a correlation between the degree of education & job status of health care personnel & the quality of presenting the services⁽¹⁵⁾.

Although in our country the continuous education programs are being enforced, because of its affect on quality of performance, our research showed no significant correlation between continuous education and provision of care, therefore a question which arises here is that, why these periodic educations has not led to the expected improvements in personnel performances in different services, This valuable & important finding has to be studied deeply, & the causes of the lack of success in this continuing education programs should be identified.

There was a positive & good correlation between the physical condition & facilities of urban health care centers & the quality of providing health care services. Mckey & Sobral (1997) showed that the low number of personnel & the room space affects the provision of health care⁽¹⁹⁾. Aldana & colleague in their study on clients satisfaction showed that there is a correlation between waiting time & the personnel's performance⁽¹⁾. Green (1994) in a research on quality of surgery services for adults , showed that the type of hospital (general or specialized), the physical size of the hospital, & number of patients has an effect on the quality of health care performance⁽²⁰⁾. One of the most important & valuable findings of the present research is showing that high volume of the administrative & statistical paper works, being performed by the personnel of health care centers, seems to decrease the quality of health care services.

Mentioning this issue; it might be of great importance for the official authorities to delegate only technical tasks to the family health personnel, and consider administrative staff for the time consuming paper works to be completed, in this way, only provision of qualitative health care in different services will be the main focus of health personnel. Reduction in the amount of paperwork's can also be an option. We, therefore, suggest more studies to be carried out about the quality of care, as it is an important & sensitive subject in family & national health of the country.

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