|Year : 2018 | Volume
| Issue : 1 | Page : 34-41
Prevalence, determinants, and health service utilization of ‘at risk’ under-five children attending a Family Health Center, Egypt 2017
Eman A Sultan1, Nagwa F Shokair1, Karima M Teba2
1 Department of Community Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
2 Resident Physician of Family Medicine, Ministry of Health, Egypt
|Date of Web Publication||7-Sep-2018|
Eman A Sultan
Department of Community Medicine, Faculty of Medicine, Alexandria University, Champollion Street, El-Khartoum Square, Azarita Medical Campus, Alexandria Egypt
Source of Support: None, Conflict of Interest: None
Background More than half of under-five child deaths are due to the diseases that are preventable and treatable through simple and affordable interventions. Owing to lack of resources, all under-five cannot be given equal time and attention. Therefore, ‘at risk’ concept has gained importance where health care is provided to all children., whereas children with high risk are given special attention.
Aim This study aims to determine the prevalence and identifying determinants of ‘at risk’ under-five children attending Rasheed Family Health Center and to determine the pattern of utilization of available health services.
Participants and methods This cross-sectional study included 300 under-five children with their mothers. Data were collected using an interviewing questionnaire including personal-social characteristics, obstetric history, and child characteristics. ‘At risk’ children were identified based on the recommendations of WHO Expert Committee and accordingly, the ‘at risk’ group was compared with those ‘not at risk’.
Results Results show that the prevalence of ‘at risk’ children among the studied group was 77.7%. The most frequent risk factors were recurrent or chronic gastrointestinal and/or respiratory tract infections followed by delay in receiving supplementary feeds, birth spacing less than 2 years and early lactation failure. Formula feeding and attacks of gastroenteritis were significant predictors of ‘at risk’ children. The main factors behind low utilization of the services were the long distance between home and the center, unpaved roads, and high costs of transportation, health care service, and medications.
Keywords: ‘At risk’ children, health care service utilization, risk determinants, under five
|How to cite this article:|
Sultan EA, Shokair NF, Teba KM. Prevalence, determinants, and health service utilization of ‘at risk’ under-five children attending a Family Health Center, Egypt 2017. Alex J Pediatr 2018;31:34-41
|How to cite this URL:|
Sultan EA, Shokair NF, Teba KM. Prevalence, determinants, and health service utilization of ‘at risk’ under-five children attending a Family Health Center, Egypt 2017. Alex J Pediatr [serial online] 2018 [cited 2018 Sep 26];31:34-41. Available from: http://www.ajp.eg.net/text.asp?2018/31/1/34/240743
| Introduction|| |
Children, one of the most vulnerable part of the population, face unusually high health risks as they grow. Children are the promise and future of every nation and the core of development .
Under-five children constitutes more than a tenth of Egyptian population. According to United Nations International Children’s Emergency Fund (UNICEF), they constituted about 11.5% of the total population in 2015. Fortunately, more than half of under-five child deaths are due to diseases that can be treated or prevented through simple and affordable interventions .
Since 1990, significant reduction in under-five deaths was noticed all over the world. According to the WHO, the number of under-five deaths worldwide has declined from 12.7 million in 1990 to 5.9 million in 2015 (nearly 16 000 every day compared with 35 000 in 1990). Under-five mortality rate is a leading indicator of the level of child health and overall development of a country. The global under-five mortality rate has dropped by 53%, from 91 deaths per 1000 live births in 1990 to 43 in 2015 .
Over the past 20 years, Egypt has made substantial progress in reducing maternal and child mortality. Yet, socioeconomic and geographical disparities in child survival still persist, particularly in rural Upper Egypt. Between 1990 and 2014, under-five mortality was reduced by 70% to become 27 child deaths per 1000 live births .
Strengthening health systems to provide simple affordable interventions to all children will save many young lives. However, owing to lack of resources and constraints of time, all under-five children cannot be given equal time and attention. Therefore, ‘at risk’ concept has gained importance where health care is provided to all children while children of high risk are given special attention. Identification of children at risk and associated factors will help for better delivery of maternal and child health care services ,.
Scientists have defined ‘high risk’ factors for the ‘at risk’ approach strategy. Thirteen risk factors were selected as per the recommendations of the WHO expert committee that include: (a) birth weight less than 2500 g; (b) twins; (c) birth order of five or more; (d) birth spacing less than 2 years; (e) present weight less than 70% of reference standard; (f) early lactation failure and artificial feeding before 6 months; (g) major congenital anomaly; (h) history of death of greater than two siblings within 12 months of age; (i) death of either or both parents; (j) children with chronic or recurrent gastroenteritis and/or recurrent respiratory infections (recurrent infections mean greater than 5–6 episodes of infections per year); (k) mother working outside for more than 8 h; (l) delay in giving supplementary feeds, that is, more than 6 months; and (m) mid-arm circumference less than 12.5 cm .
Several interacting factors affect the utilization of health facilities. Among these, type of family, social class, and literacy status are of vital importance. Other equally significant determinants are distance involved from medical center, attitude of the service provider, quality of health needs, and health awareness of the beneficiaries ,.
The current study aims to measure the prevalence of ‘at risk’ under-five children attending Rasheed Family Health Center, to explore different risk factors that can contribute to ‘at risk’ under-five children and to determine the extent and factors affecting the utilization of available health facilities by the mothers of the ‘at risk’ children.
| Participants and methods|| |
The cross-sectional design was adopted. The study was conducted in Rasheed Family Health Center, Behiera Governorate, Egypt. All under-five children with their mothers attending Rasheed Family Health Center during the study period were included. The sample size was calculated using Epi Info 7 (developed by Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, US) at 5% margin of error, using 95% confidence level and 75% prevalence of at risk under-five children concluded in a previous similar study in India . The minimum appropriate sample size was estimated to be 289 children. To increase the power of the study, 300 children were included in the study. The field work was conducted over a 4 months period from March to June 2017.
Objectives and types of information to be obtained were explained to participants’ mothers and their informed consents were taken. Confidentiality of data was ensured. Official approvals for the implementation of the study were obtained from Ethical Committee of the Faculty of Medicine, Community Medicine Department, Under Secretary of the Ministry of Health and Population in Beheira Governorate and the Director of Rasheed Family Health Center, Egypt.
Data were collected using an interviewing questionnaire that included personal and social characteristics, obstetric history, and child characteristics. Identifying ‘at risk’ children was based on the recommendations of WHO Expert Committee  and accordingly, the ‘at risk’ group was compared with those not at risk.
According to the frequency of the visits of the studied mothers to the health care facility, those with a frequency of one or two visits/year were considered as having low utilization while those with a frequency of three or more visits/year were considered as having high utilization.
Data were analyzed using SPSS, version 20 (SPSS Inc., Chicago, Illinois, USA) . Data are presented as numbers and percentages for categorical variables, mean, and SD for continuous variables. For testing associations between qualitative variables, the χ2, Fisher’s exact and Monte Carlo tests were used. Data were tested for normality using Kolmogorov–Smirnov test. Independent sample t-test was used to compare the means of normally distributed quantitative variables between the two studied groups, whereas Mann–Whitney test was used for abnormally distributed quantitative variables. Multiple regression analysis was performed to identify the factors affecting ‘at risk’ under-five children.
All results were interpreted at the 5% level of significance.
| Results|| |
[Table 1] describes the distribution of under-five children by their risk status according to sociodemographic characteristics. The highest proportion (84.2%) of ‘at risk’ children was among families with low income with statistically significant difference (P=0.036). Significantly higher percentage of children attending Day Care Centers (DCCs) were at risk compared to those not attending DCCs (P=0.01). Moreover, children living in overcrowded houses (CI>2) were more likely to be at risk than children living in less crowded houses with statistically significant difference (P=0.016).
|Table 1 Distribution of all studied under-five children by their risk status according to sociodemographic characteristics (Rasheed Family Health Center, 2017)|
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With respect to the reproductive health characteristics of mothers of the studied children, [Table 2] demonstrates that all children (100%) whose mothers had infections during pregnancy, were at risk compared to 77.5% of those whose mothers did not have infections during pregnancy with no significant difference. Significantly higher proportion of the children whose mothers received medications during pregnancy were at risk than those children whose mothers did not receive medications during pregnancy (P=0.005).
|Table 2 Distribution of all studied under-five children by their risk status according to their mothers’ reproductive health characteristics (Rasheed Family Health Center, 2017)|
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Health-related characteristics of the studied children are portrayed in [Table 3].Significantly higher proportion of children who were the result of undesired pregnancy were at risk (P=0.022). Children who were breast fed were less likely to be at risk than those children who were formula fed. This difference was statistically significant (P= 0.001). Children who had more than five attacks of respiratory tract infections were significantly more prone to be at risk (P=0.001). Similarly, children who had more than three attacks of gastroenteritis over the past year were significantly more prone to be at risk (P<0.001).
|Table 3 Distribution of all studied under-five children by their risk status according to their health-related characteristics (Rasheed Family Health Center, 2017)|
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The prevalence of ‘at risk’ children among the studied group was 77.7%. [Figure 1] shows the distribution of ‘at risk’ categories among ‘at risk’ children. The most frequent risk factor observed was recurrent or chronic gastrointestinal tract (GIT) and/or recurrent respiratory tract infections (40%) followed by delay in receiving supplementary feeds (24.7%), birth spacing less than 2 years (22.7%), early lactation failure (17%), and then those with mid-upper arm circumference less than 12.5 cm (10.3%). 41.6% of the ‘at risk’ under five (41.6%) children had only one risk, 36.5% had two risks, whereas those with three risks and four or more risks represented 14.6 and 7.3%, respectively.
|Figure 1 Distribution of different risk categories among ‘at risk’ children (Rasheed, 2017). Responses are not mutually exclusive.|
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[Table 4] shows multivariate logistic regression analysis performed to identify significant factors associated with being ‘at risk’. On the basis the findings of the univariate analysis, eight variables were introduced for the binary logistic regression (crowding index, family income, DCC attendance, taking medications during pregnancy, undesired pregnancy, child feeding, recurrent respiratory tract infections, and number of attacks of gastroenteritis). Results showed that formula feeding and attacks of gastroenteritis were proved to be significant predictors of ‘at risk’ children after controlling the other factors. Children who were formula fed were five times more prone to be ‘at risk’ than breast fed ones (odds ratio=5.26). Those having attacks of gastroenteritis were three times more prone to be ‘at risk’ than those without (odds ratio=3.31) after controlling other factors.
|Table 4 Results of logistic regression analysis for the variables predicting the risk status among children attending Rasheed Family Health Center, 2017|
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[Table 5] describes the pattern of utilization of child health care facilities by mothers of the studied under-five children.
|Table 5 Pattern of utilization of child health care facilities by mothers of all studied under-five children (Rasheed Family Health Center, 2017)|
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| Discussion|| |
‘At risk’ refers to infants and young children who are physically, medically, or psychologically in danger of failing to thrive and also includes children who are affected by diverse economic, environmental, and geographical factors. The principles of ‘risk approach’ involve identification of risk factors relevant to the local situation, screening population for ‘at risk’ children and providing the extra care in proportion to their need according to the risk management plan .
The current study is aimed to determine the prevalence and to identify determinants of ‘at risk’ under-five children attending Rasheed Family Health Center, Egypt as well determining the pattern of utilization of available health services.
Results of the current study showed that more than three quarters (77.7%) of studied under-five children were at risk. This result was more than the prevalence reported by Avachat et al.  and Sharma et al.  where the prevalence of ‘at risk children’ was 54.75 and 65.7%, respectively.
The most frequent risk factor observed in the current study was recurrent or chronic GIT and/or recurrent respiratory tract infection (reported in 40% of studied children). Similarly, in a study by Bhasin et al. , chronic gastroenteritis and/or respiratory infections were reported in 35.3%. This finding may be possibly due to unfavorable environmental conditions, indoor and outdoor pollutions exposure, parental smoking, large family size, overcrowding, poor socioeconomic conditions with malnutrition, early socialization, as well as young children mix with other children in families or nursery .
Results of multivariate logistic regression analysis revealed that formula feeding and attacks of gastroenteritis were proved to be significant predictors of ‘at risk’ children after controlling the other factors. This result could be justified by the proven relation between lack of exclusive breastfeeding and gastroenteritis where exclusive breastfeeding is among the proven prevention measures that can significantly reduce the burden of diarrheal diseases . Moreover, Gale et al. , in 2012 concluded that compared with breastfeeding, formula feeding is associated with altered body composition in infant.
Access to adequate health care is among the factors suggested to be associated with child mortality; improved access holds great potential for a significant reduction in under-five death in developing countries. Theory and corresponding frameworks indicate a wide range of factors affecting access to health care, such as traditionally measured variables (distance to a health provider and cost of obtaining health care) and additional variables (social support, time availability, and caregiver autonomy) . In the current study, the reasons for low utilization of the services were the long distance between home and the center, unpaved roads, and increased costs of transportation, health care service, and medications.
Several studies emphasized the importance of cost as an access barrier. In Gambia  and Ghana , 20 and 36% of caregivers of ill children, respectively, did not attend health centers because of health service cost. As the majority of studies focus on the impact of user fees, other costs acting as a barrier to health care access are overlooked: costs including transportation, accommodation, medications and other supplies, such as food  are known to be important. A study in Ghana found that indirect costs of health care to be 2–3.6 times higher than direct costs .
| Conclusion|| |
- The prevalence of ‘at risk’ children was 77.7% of the studied sample at Rasheed Family Health Center, Egypt.
- The most frequent risk factor observed was recurrent or chronic GIT and/or respiratory tract infections followed by delay in receiving supplementary feeds, birth spacing less than 2 years and early lactation failure.
- Formula feeding and attacks of gastroenteritis were significant predictors of ‘at risk’ children.
- The main factors behind low utilization of services were the long distance between home and the center, unpaved roads, and high costs of transportation, health care service, and medications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Juliet OK. Evaluation of child health care services in health facilities in nsukka urban of enugu state [M Sc thesis]. Nsukka: Department of Health And Physical Education, University of Nigeria; 2007. p. 12.
World Health Organization (WHO). Children, reducing mortality. Geneva: WHO; 2016; 6.
Ministry of Health and Population (Egypt), El-Zanaty and Associates, and ICF International. 2015. Egypt Demographic and Health Survey 2014. Cairo, Egypt and Rockville, Maryland, USA: Ministry of Health and Population and ICF International. p. 102. Available from: https://dhsprogram.com/pubs/pdf/FR302/FR302.pdf
Bhasin SK, Pandit K, Kapil U, Dubey KK. Prevalence of ‘at risk’ factors in under five children. Indian Pediatr 1994;31:1537–1538.
Avachat SS, Phalke VD, Phalke DB. Epidemiological correlates of under-five children at risk: a study in the field practice area of rural medical college, loni. Health Popul Perspect Issues 2009;32:73–77.
World Health Organization (WHO). Risk approach for maternal and child health care: Offset Publication. WHO: Geneva 1978; 39.
Dutta PK, Choudhury TKG, Kumar B, Ganguly SS. Utilisation of health services by high risk children under five in a slum area. Health Popul Perspect Issues 1984 7:148–158.
Budimelli S, Chebrolu K. Prevalence of at-risk under-five children in a south Indian village. J Evolut Med Dent Sci 2015;4:16667–16671.
IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.
Winzer MA. Children with exceptionalities in canadian classrooms 8th ed. Ontario: Pearson Education Canada 2007.
Avachat SS, Phalke V, Phalke D. Epidemiological correlates of under-five children at risk: a study in the field practice area of rural medical college, Loni. Health and Population Perspectives and Issues 2009;32:73–77.
Sharma S, Gupta B. Prevalence of ‘At Risk’ under-five children in a rural area. Ind J Community Med 2005;30:30–31.
Bhasin S, Pandit K, Kapil U, Dubey K. Prevalence of at risk. Factors in under five children. Indian Paediatr 1994;31:1537–1539.
Kavle JA, Flax VL, Abdelmegeid A, Salah F, Hafez S, Ramzy M et al.
Factors associated with early growth in Egyptian infants: implications for addressing the dual burden of malnutrition. Matern Child Nutr 2016; 12:139–151.
Abdel-Hafeez EH, Belal US, Abdellatif MZM, Naoi K, Norose K. Breast-feeding protects infantile diarrhea caused by intestinal protozoan infections. Korean J Parasitol 2013;51:519–524.
Gale C, Logan KM, Santhakumaran S, Parkinson JRC, Hyde MJ, Modi N. Effect of breastfeeding compared with formula feeding on infant body composition: a systematic review and meta-analysis. Am J Clin Nutr 2012;95:656–669.
Rutherford ME, Mulholland K, Hill PC. How access to health care relates to under-five mortality in sub-Saharan Africa: systematic review. Trop Med Int Health 2010;15:508–519.
Menon A. Utilization of village health workers within a primary health care programme in The Gambia. J Trop Med Hyg 1991;94:268–271.
Hill AG, MacLeod WB, Joof D, Gomez P, Walraven G. Decline of mortality in children in rural Gambia: the influence of village-level primary health care. Trop Med Int Health 2000;5:107–118.
Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994;38:1091–1110.
Asenso-Okyere WK, Dzator JA. Household cost of seeking malaria care. A retrospective study of two districts in Ghana. Soc Sci Med 1997;45:659–667.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]