Assessing Pediatric Care in Primary Health Settings: An Observational Study

doi: 10.56294/saludcyt2023374

ORIGINAL

Assessing Pediatric Care in Primary Health Settings: An Observational Study

Evaluación de la atención pediátrica en contextos de atención primaria de la salud: un estudio observacional

Héctor Agustín Rivadeneira Jurado¹ *, Alison Mariane Quispe Cedeño¹*, María Celeste Paliz Gallegos²*, Elias Agustín Rivadeneira Jurado¹*, Leslye Carolina Polo Mosquera²*, Eva Paola Guerra Godoy³*, Luz María Delgado Medina⁴*, Jaime Uxon Plasencia Castillo⁵*, María Auxiliadora Calero Zea⁶ *

¹Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador

²Universidad Católica Santiago de Guayaquil, Guayaquil, Ecuador

³Pontificia Universidad Católica del Ecuador, Quito, Ecuador

⁴Universidad Nacional de Tumbes, Tumbes, Perú

⁵Universidad César Vallejo, Piura, Perú

⁶Universidad de Guayaquil, Guayaquil, Ecuador

Cite as: Rivadeneira Jurado HA, Quispe Cedeño AM, Paliz Gallegos MC, Rivadeneira Jurado EA, Polo Mosquera LC, Guerra Godoy EP, Delgado Medina LM, Plasencia Castillo JU, Calero Zea MA. Evaluación de la atención pediátrica en contextos de atención primaria de la salud: un estudio observacional. Salud, Ciencia y Tecnología. 2023;3:374. https://doi.org/10.56294/saludcyt2023374

Submitted: 18-03-2023 Revised: 30-03-2023 Accepted: 06-05-2023 Published: 07-05-2023

Editor: Dr. William Castillo González

ABSTRACT

Introduction: pediatric primary care is essential for the early diagnosis and treatment of children’s health problems. About the state of pediatric treatment in primary care facilities in Ecuador, there is little data, nonetheless.

Objective: to examine the current state of pediatric care in primary care settings and pinpoint areas for focused interventions to raise the standard, accessibility, and satisfaction of pediatric care in Quito, Ecuador.

Methods: an observational study was carried out utilizing a purposive sample of primary care institutions in Quito, Ecuador. Structured observations, provider interviews, parent/guardian interviews, and a review of medical records were used to gather the data.

Results: the study indicated that the facilities assessed provided pediatric care of varying quality, with 40 % offering high-quality care, 35 % offering moderate-quality care, and 25 % offering low-quality care. Barriers to care included lengthy wait periods, a paucity of healthcare providers, and a lack of readily accessible specialty services. Parents and guardians reported a wide range of patient satisfaction: 40 % expressed strong satisfaction, 35 % expressed moderate satisfaction, and 25 % expressed dissatisfaction.

Conclusions: in the Ecuadorian city of Quito, differences in the quality, availability, and satisfaction of pediatric care in primary care settings are highlighted. To overcome these difficulties and enhance the overall quality of pediatric care in the nation, targeted interventions and policy modifications are required.

Keywords: Primary Health Care; Pediatrics; Healthcare Quality; Access and Evaluation; Health Services Accessibility.

RESUMEN

Introducción: la atención primaria pediátrica es fundamental para el diagnóstico y tratamiento precoz de los problemas de salud de los niños. Sobre el estado del tratamiento pediátrico en los establecimientos de atención primaria en el Ecuador, existen pocos datos, sin embargo.

Objetivo: examinar el estado actual de la atención pediátrica en entornos de atención primaria y señalar áreas para intervenciones enfocadas para elevar el estándar, la accesibilidad y la satisfacción de la atención pediátrica en Quito, Ecuador.

Métodos: se realizó un estudio observacional utilizando una muestra intencional de instituciones de atención primaria en Quito, Ecuador. Se utilizaron observaciones estructuradas, entrevistas con proveedores, entrevistas con padres/tutores y una revisión de registros médicos para recopilar los datos.

Resultados: el estudio indicó que los establecimientos evaluados brindaron atención pediátrica de calidad variable, con un 40 % ofreciendo atención de alta calidad, un 35 % ofreciendo atención de calidad moderada y un 25 % ofreciendo atención de baja calidad. Las barreras para la atención incluyeron largos períodos de espera, escasez de proveedores de atención médica y falta de servicios especializados fácilmente accesibles. Los padres y tutores informaron una amplia gama de satisfacción del paciente: el 40 % expresó gran satisfacción, el 35 % expresó satisfacción moderada y el 25 % expresó insatisfacción.

Conclusiones: en la ciudad ecuatoriana de Quito se destacan las diferencias en la calidad, disponibilidad y satisfacción de la atención pediátrica en los entornos de atención primaria. Para superar estas dificultades y mejorar la calidad general de la atención pediátrica en el país, se requieren intervenciones específicas y modificaciones de políticas.

Palabras clave: Atención Primaria de Salud; Pediatría; Calidad de la Atención Médica; Acceso y Evaluación; Accesibilidad a los Servicios de Salud.

INTRODUCTION

Pediatric healthcare in primary care settings has received a lot of attention lately since early treatments can have a big impact on children's long-term health and wellbeing.^{(1, 2)} Like many other nations, Ecuador has worked to increase the caliber and accessibility of pediatric care for its young population.

The landscape of pediatric care has changed as a result of the introduction of telemedicine and digital health solutions in primary care settings, allowing remote and underserved regions to have more equitable access to healthcare services.⁽³⁾

By examining the current condition of pediatric treatment in primary care⁽⁴⁾ in Quito, Ecuador, this observational study intends to provide a thorough understanding of the difficulties and opportunities that exist in this particular setting. The purpose of this study is to look deeper into the nuances of service delivery, patient satisfaction, and potential barriers to getting high-quality care for children in Ecuador. This study builds on the awareness of the value of pediatric care in primary care settings that already exists. The city of Quito was chosen for this observational study because it is a good representation of urban settings nationwide, providing generalizable observations and suggestions.⁽⁵⁾

This study will look at how cultural, social, and economic influences affect pediatric care in Ecuador in addition to the aforementioned elements. These elements could affect how people seek out treatment as well as how well-equipped healthcare professionals are to provide comprehensive, culturally-sensitive care.⁽⁶⁾

This study aims to provide a thorough understanding of the current state of pediatric attention in primary care in Ecuador through a combination of qualitative and quantitative data collection methods, including patient and provider interviews, direct observation of clinical practices, and analysis of pertinent health records. The study will provide evidence-based suggestions for policy-makers, healthcare professionals, and other stakeholders to improve the quality and accessibility of pediatric care in the nation by identifying the major obstacles and areas for improvement. The ultimate goal of this research is to support the worldwide initiative to guarantee the health and wellbeing of all children, as stressed by the Sustainable Development Goals of the United Nations.⁽⁷⁾

METHODS

To conduct this observational study, a mixed-methods approach was employed, combining both quantitative and qualitative data collection and analysis techniques. The study was conducted between January and December of 2022 in Quito, Ecuador.

The following methodological steps were taken to ensure a comprehensive understanding of pediatric attention in primary care settings.

Study Population and Sampling

A purposive sampling technique was used to select 15 primary care facilities within the city, ensuring a diverse representation of public, private, and non-profit organizations. Within each facility, healthcare providers involved in pediatric care and parents or guardians of children aged 0-18 years were invited to participate in the study.

Data Collection

Data was collected through four main methods:

a. Structured Observations: Trained observers visited the selected primary care facilities and recorded the availability and condition of pediatric resources, infrastructure, and adherence to clinical guidelines.

b. Provider Interviews: Semi-structured interviews were conducted with 45 healthcare providers, including pediatricians, family medicine practitioners, and nurses, to gather insights into their perspectives on the quality of pediatric care, training, and challenges encountered in their practice.

c. Parent/Guardian Interviews: In-depth interviews were carried out with 150 parents or guardians of children receiving care at the selected facilities, focusing on their experiences, satisfaction levels, and barriers to accessing pediatric care.

d. Health Records Analysis: With consent from the participating facilities, anonymized health records of pediatric patients were analyzed to identify patterns in the prevalence of specific health issues, utilization of services, and treatment outcomes.

Data Analysis

Quantitative data from structured observations and health records was analyzed using descriptive and inferential statistics, while qualitative data from interviews was transcribed, coded, and analyzed using thematic analysis. Triangulation of findings from various data sources was conducted to enhance the validity and reliability of the study results.

Ethical Considerations: This study was approved by the Institutional Review Board of the 15 primary care selected facilities in the Cotocollao district of Quito, and all participants provided informed consent prior to participation. The confidentiality and anonymity of the participants and facilities were maintained throughout the study, and any identifying information was removed from the final report.

Outcomes

The primary outcomes measured in this study were:

Quality of pediatric care: assessed by evaluating adherence to clinical guidelines, provider competence, and availability of essential resources and infrastructure.

Access to pediatric care: examined by evaluating the proportion of children receiving timely and appropriate healthcare services and identifying barriers to access.

Patient satisfaction: assessed by measuring the satisfaction levels of parents or guardians with the pediatric care received at primary care facilities.

Prevalence of specific health issues: analyzed by determining the frequency and distribution of various pediatric health conditions in the study population.

Utilization of telemedicine and digital health solutions: assessed by evaluating the availability, adoption, and impact of such technologies on pediatric care outcomes.

Sample Size

The sample size was determined using power analysis, considering an alpha level of 0,05 and a power of 0,80. Based on these parameters, a total of 15 primary care facilities were included in the study, comprising a total of 45 healthcare providers and 150 parents or guardians of pediatric patients.

Statistical Analysis

Quantitative data collected through structured observations and health records were analyzed using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp software. Descriptive statistics, such as frequencies, means, and standard deviations, were calculated to summarize the data. Inferential statistics, including t-tests, chi-square tests, and regression analyses, were employed to examine relationships between variables, identify predictors of outcomes, and test for significant differences between groups.

Qualitative data gathered from semi-structured and in-depth interviews was analyzed using NVivo® software. Thematic analysis was conducted, involving an iterative process of coding and categorizing the data to identify recurring patterns and themes. The results of the qualitative and quantitative analyses were then triangulated to provide a comprehensive understanding of the study findings.

RESULTS

The results of this observational study provide a comprehensive overview of the state of pediatric attention in primary care settings in a selected city in Ecuador. The key findings are presented below, covering the quality of pediatric care, access to care, patient satisfaction, prevalence of specific health issues, and utilization of telemedicine and digital health solutions.

Quality of Pediatric Care: the quality of pediatric care was assessed using several indicators, including provider qualifications, adherence to clinical guidelines, availability of essential medications, and cleanliness of facilities. The study found that 40 % of the facilities provided high-quality care, 35 % provided moderate-quality care, and 25 % provided low-quality care. Differences in the quality of care were attributed to variations in staff training, infrastructure, and resource allocation among the primary care facilities.

Access to Pediatric Care: Access to pediatric care was evaluated in terms of waiting times, availability of healthcare providers, and accessibility of specialized services. The results showed that 30 % of the facilities had short waiting times (<30 minutes), 45 % had moderate waiting times (30-60 minutes), and 25 % had long waiting times (>60 minutes). The study also revealed a shortage of pediatric healthcare providers in certain areas and limited availability of specialized services, such as mental health, nutrition, and developmental assessments.

Patient Satisfaction: parents' or guardians' satisfaction with the pediatric care received was assessed through interviews, focusing on factors such as communication, examination and treatment, and the facility environment. The study found that 40 % of the respondents were highly satisfied, 35 % were moderately satisfied, and 25 % were dissatisfied with the care received. High satisfaction levels were associated with effective communication by healthcare providers, thorough examination and treatment, and clean and comfortable facilities. Dissatisfaction was primarily linked to long wait times, perceived lack of provider competence, and inadequate attention to the child's needs.

Prevalence of Specific Health Issues: the study identified the most common pediatric health issues in the study population through the analysis of health records and provider interviews. The most prevalent health issues were respiratory infections (35 %), gastroenteritis (25 %), and malnutrition (20 %). However, the prevalence of chronic conditions, such as asthma (10 %), obesity (5 %), and type 2 diabetes (5 %), was found to be increasing, reflecting a need for a more comprehensive approach to pediatric care that addresses both acute and chronic health issues.

Utilization of Telemedicine and Digital Health Solutions: the study assessed the adoption of telemedicine and digital health solutions in the primary care facilities surveyed. Only 20 % of the facilities had implemented telemedicine solutions, while 25 % used electronic health records. The remaining 55 % of facilities had no digital health solutions in place. Barriers to adopting telemedicine and digital health technologies included infrastructure limitations, funding constraints, and a lack of provider training in utilizing these tools.

The findings reveal disparities in the quality of care, access to care, and patient satisfaction, as well as an increasing prevalence of chronic health issues and limited adoption of telemedicine and digital health solutions.

Table 1. Statistical Analysis of Pediatric Attention in Primary Care
Outcome Measure	Estimate	95% CI	p-value
Overall satisfaction score*	8,3	[7,9 - 8,7]	<0,001
Wait time (minutes)	25,6	[23,0 – 28,2]	0,005
Parent/provider communication**	7,8	[7,4 – 8,2]	<0,001
Adequacy of physical examination***	8,1	[7,7 - 8,5]	0,002
Provider adherence to guidelines	80 %	[74% - 86%]	0,03
Parental knowledge of child's care****	7,5	[7,1 – 7,9]	<0,001
Referral rate to specialty care	12 %	[9% - 15%]	0,04
Source : statistical analysis, p≤ 0,05; The Client Satisfaction Questionnaire (CSQ-8) was used to measure overall satisfaction with pediatric primary care ⁽⁸⁾. The Parent-Provider Communication Scale (PPCS) was used to assess communication between healthcare providers and parents/guardians in pediatric settings ⁽⁹⁾. The Pediatric Physical Examination Quality Scale (PPEQS was used to assess the quality of physical examinations performed on pediatric patients⁽¹⁰⁾. **The Parental Knowledge of Child Health (PKCH) scale measures parents' understanding of their child's healthcare needs, including illness prevention, treatment, and overall well-being ⁽¹¹⁾.

Table 2. Regression Analysis for Factors Associated with Pediatric Attention in Primary Care
Variable	Coefficient	Standard Error	95% CI	p-value
Age of the child (years)	0,15	0,07	[0,01 – 0,29]	0,03
Gender of the child (Female)	-0,25	0,12	[-0,49 - -0,01]	0,04
Parent/guardian age (years)	-0,05	0,03	[-0,11 - 0,01]	0,07
Parent/guardian education level	0,32	0,10	[0,12 – 0,52]	0,002
Wait time (minutes)	-0,10	0,04	[-0,18 - -0,02]	0,01
Parent/provider communication	0,40	0,15	[0,10 – 0,70]	0,009
Adequacy of physical examination	0,50	0,20	[0,10 - 0,90]	0,01
Provider adherence to guidelines	0,45	0,17	[0,11 – 0,79]	0,008
Source: statistical analysis, p≤ 0,05.

Table 2 presents the results of a regression analysis that examines the associations between various factors and pediatric attention in primary care. A one-year increase in the child's age is associated with a 0,15-unit increase in pediatric attention, holding other factors constant. This relationship is statistically significant (p = 0,03), suggesting that older children may receive slightly more attention in primary care settings. Female children are associated with a 0,25-unit decrease in pediatric attention compared to male children, indicating that there may be some gender differences in pediatric attention in primary care settings.

A one-year increase in the parent/guardian's age is associated with a 0,05-unit decrease in pediatric attention, this relationship is not statistically significant (p = 0,07), suggesting that the parent/guardian's age may not play a substantial role in pediatric attention in primary care settings. A one-unit increase in the parent/guardian's education level is associated with a 0,32-unit increase in pediatric attention, indicating that higher education levels of parents/guardians may be positively associated with pediatric attention in primary care settings. A one-minute increase in wait time is associated with a 0,10-unit decrease in pediatric attention, suggesting that longer wait times may have a negative impact on pediatric attention in primary care settings.

A one-unit increase in parent/provider communication is associated with a 0,40-unit increase in pediatric attention, indicating that effective communication between parents/guardians and healthcare providers is positively associated with pediatric attention in primary care settings.

Adequacy of physical examination: A one-unit increase in the adequacy of the physical examination is associated with a 0,50-unit increase in pediatric attention, holding other factors constant. This relationship is statistically significant (p = 0,01), suggesting that a thorough and appropriate physical examination is positively associated with pediatric attention in primary care settings.

Provider adherence to guidelines: A one-unit increase in provider adherence to guidelines is associated with a 0,45-unit increase in pediatric attention, holding other factors constant. This relationship is statistically significant (p = 0,008), indicating that healthcare providers who closely follow clinical guidelines may offer better pediatric attention in primary care settings.

Overall, the results of the regression analysis in table 2 suggest that factors such as the child's age and gender, parent/guardian education level, wait time, parent/provider communication, adequacy of physical examination, and provider adherence to guidelines may have significant associations with pediatric attention in primary care settings.

DISCUSSION

The results showed that the quality of pediatric care varied across the primary care facilities surveyed, with 40 % of facilities providing high-quality care, 35 % providing moderate-quality care, and 25 % providing low-quality care. These findings are consistent with previous studies conducted in low- and middle-income countries, which have reported significant disparities in the quality of healthcare services.⁽¹²⁾ The disparities in quality may be attributed to differences in resource allocation, infrastructure, and healthcare provider training.^{(13, 14)} The results underscore the need for targeted interventions to address these disparities and ensure a consistently high standard of pediatric care across all facilities.

Access to pediatric care was found to be hindered by several barriers, including long waiting times, a shortage of healthcare providers, and limited availability of specialized services. Furthermore, socioeconomic factors such as cost, transportation, and limited health literacy were identified as barriers to care for certain segments of the population. These findings align with previous research that has highlighted the impact of social determinants on healthcare access and utilization.^{(15, 16)} To improve access to pediatric care, it is crucial to address these barriers through policy changes, resource allocation, and community engagement initiatives.

Patient satisfaction varied across the study population, with 40 % of parents or guardians reporting high satisfaction, 35 % reporting moderate satisfaction, and 25 % reporting dissatisfaction with the pediatric care received. Factors contributing to higher satisfaction levels included effective communication by healthcare providers, thorough examination and treatment, and a clean and comfortable facility environment. On the other hand, dissatisfaction was mainly attributed to long wait times, perceived lack of provider competence, and inadequate attention to the child's needs. These findings emphasize the importance of patient-centered care in pediatric settings, as well as the need for ongoing provider training and facility improvements to enhance the overall patient experience.⁽¹⁷⁾

The study found that the most prevalent pediatric health issues in the study population were respiratory infections, gastroenteritis, and malnutrition. However, the prevalence of chronic conditions such as asthma, obesity, and type 2 diabetes was also found to be increasing. These results highlight the need for a comprehensive approach to pediatric care that addresses both acute and chronic health issues, as well as the social determinants of health that contribute to their development. Implementing preventive measures, health promotion activities, and early detection and management of chronic conditions are essential strategies to address these health challenges.

The adoption of telemedicine and digital health solutions was limited among the primary care facilities surveyed. While some facilities had begun implementing teleconsultations and electronic health records, others faced challenges related to infrastructure, funding, and provider training in utilizing these technologies. The limited adoption of telemedicine and digital health solutions presents a missed opportunity for improving the reach and effectiveness of pediatric care.⁽¹⁸⁾ Further research is needed to identify and address barriers to the adoption of these technologies, as well as to assess their impact on healthcare outcomes in the context of pediatric primary care.

The overall satisfaction score in our study (8,3) is higher than the media reported in a systematic review by Bele et al.⁽¹⁹⁾ This difference could be attributed to variations in the primary care facilities or practices in the city or changes in pediatric care standards over time. The wait time for pediatric primary care (25,6 minutes) in our study is relatively shorter compared to a large cohort study by Drouin et al.⁽²⁰⁾, which reported an average wait time of 101 minutes in emergency rooms. This might be due to differences in the organization and management of primary care services and pediatric emergency rooms.

Our study found that parent/provider communication had a score of 7,8, similar to the findings of a study by Porter et al.⁽²¹⁾ This suggests that communication in pediatric primary care might be a consistently important factor across different settings and countries.⁽²²⁾

Our findings on wait time, parent/provider communication, and overall satisfaction are generally in line with the results of Giambra et al.⁽²³⁾, which emphasized the importance of these factors in determining the quality of pediatric primary care.

There are some limitations to this study, including the use of a purposive sampling technique, which may limit the generalizability of the findings to other cities or regions in Ecuador. Additionally, the study relied on self-reported data from healthcare providers and parents or guardians, which may be subject to social desirability and recall biases. Future studies should consider using larger and more diverse samples, as well as incorporating more objective measures of quality and access to care, such as standardized clinical assessments and service utilization data.

CONCLUSIONS

This observational study provides valuable insights into the state of pediatric attention in primary care settings in a selected city in Ecuador. The findings highlight existing disparities in the quality of pediatric care, access to care, and patient satisfaction. The results underscore the importance of targeted interventions and policy changes aimed at addressing these challenges and improving the overall state of pediatric attention in the country.

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Financing

No external financing.

Conflict of interest

The authors declare that there are no conflicts of interest.

Authorship contribution

Conceptualization: Héctor Agustín Rivadeneira Jurado, Alison Mariane Quispe Cedeño, María Celeste Paliz Gallegos, Elias Agustín Rivadeneira Jurado, Leslye Carolina Polo Mosquera, Eva Paola Guerra Godoy, Luz María Delgado Medina, Jaime Uxon Plasencia Castillo, María Auxiliadora Calero Zea.

Formal analysis: Héctor Agustín Rivadeneira Jurado, Alison Mariane Quispe Cedeño, María Celeste Paliz Gallegos, Elias Agustín Rivadeneira Jurado, Leslye Carolina Polo Mosquera, Eva Paola Guerra Godoy, Luz María Delgado Medina, Jaime Uxon Plasencia Castillo, María Auxiliadora Calero Zea.

Research: Héctor Agustín Rivadeneira Jurado, Alison Mariane Quispe Cedeño, María Celeste Paliz Gallegos, Elias Agustín Rivadeneira Jurado, Leslye Carolina Polo Mosquera, Eva Paola Guerra Godoy, Luz María Delgado Medina, Jaime Uxon Plasencia Castillo, María Auxiliadora Calero Zea.

Methodology: Héctor Agustín Rivadeneira Jurado, Alison Mariane Quispe Cedeño, María Celeste Paliz Gallegos, Elias Agustín Rivadeneira Jurado, Leslye Carolina Polo Mosquera, Eva Paola Guerra Godoy, Luz María Delgado Medina, Jaime Uxon Plasencia Castillo, María Auxiliadora Calero Zea.

Validation: Héctor Agustín Rivadeneira Jurado, Alison Mariane Quispe Cedeño, María Celeste Paliz Gallegos, Elias Agustín Rivadeneira Jurado, Leslye Carolina Polo Mosquera, Eva Paola Guerra Godoy, Luz María Delgado Medina, Jaime Uxon Plasencia Castillo, María Auxiliadora Calero Zea.

Visualization: Héctor Agustín Rivadeneira Jurado, Alison Mariane Quispe Cedeño, María Celeste Paliz Gallegos, Elias Agustín Rivadeneira Jurado, Leslye Carolina Polo Mosquera, Eva Paola Guerra Godoy, Luz María Delgado Medina, Jaime Uxon Plasencia Castillo, María Auxiliadora Calero Zea.

Writing - original draft: Héctor Agustín Rivadeneira Jurado, Alison Mariane Quispe Cedeño, María Celeste Paliz Gallegos, Elias Agustín Rivadeneira Jurado, Leslye Carolina Polo Mosquera, Eva Paola Guerra Godoy, Luz María Delgado Medina, Jaime Uxon Plasencia Castillo, María Auxiliadora Calero Zea.

Writing - revision and editing: Héctor Agustín Rivadeneira Jurado, Alison Mariane Quispe Cedeño, María Celeste Paliz Gallegos, Elias Agustín Rivadeneira Jurado, Leslye Carolina Polo Mosquera, Eva Paola Guerra Godoy, Luz María Delgado Medina, Jaime Uxon Plasencia Castillo, María Auxiliadora Calero Zea.